Re: Is vaginal estrogen unnaposed?
From: Garry E. Siegel, M.D. (garrys@mindspring.com)
Wed Feb 25 20:22:42 2009
Fascinating. I use Vagifem a ton but if you are finding success with a
small amount of Estrace, then that may be worth a try. Your comment
about the introitus is sage.
Garry
At Wed, 25 Feb 2009, Joanne Bulley, MD wrote:
>
>One of last year's ABOG articles was on Vagifem (25mcg QD X 2 weeks
>followed by 25mcg twice weekly).
>
>Endometrial biopsy done at start and at 1 year. I recall one case of
>endometrial hperplasia at start - no treatment and 0 cases of any
>abnormality of endometrium at 1 year. Conclusion : that dose (eg
>Vagifem and by similarity Estring) does NOT need any progestin
>protection of endometrium.
>
>I have not looked at the package insert recently - but recall from >/10 years ago: serum estradiol "peaked" at a a very low level in those
>first 2-4 weeks then dropped to marginally higher than negligible.
>
>As far as the estrace or premarin cream: *I think* but could be wrong
>that the cream facilitates some of the absorption.
>
>However, when I use topical estrogen for atrophy: the problem nearly
>100% appears to be introital as the site that creates symptoms - so why
>use it in the upper vagina with the applicator that no one wants to wash
>anyway?
>
>I treat with Estrace cream only (use 17-Beta-Estradiol because that is
>the molecule the ovary/granulosa cells make and the vaginal epithelium
>has the receptors for). Why use Premarin with the various equine
>estrogens - some of which are not metabolized by human enzymes?
>
>I have the woman use - massage in - twice daily X 2 weeks, once daily
>"until function is normalized" then 1-3 times a week til feels good
>enough that she forgets to use it. Total exposure is minimal.
>
>I did have one woman call and say she had horrible breast tenderness
>after a few weeks --- turns out she was using a full applicator (4 gms?)
>daily! Her vaginal atrophy symptoms were 100% resolved. I had her stop
>use, come in and again I instructed her carefully that she should have
>been using a "pea to lima bean" size dose of the Estrace! Anymore I
>usually give a sample tube - and tel them to watch me THROW out the
>applicator - very expilicit instructions!
>
>Joanne
>
>At Wed, 25 Feb 2009, Rafael Haciski wrote:
>>
>>Vaginal absorption is excellent, but variable. When I need to push to
>>the limit, I will monitor with serum E2 levels. As long as levels are
>>low I am not concerned about uterine stimulation.
>>
>>1 gm twice weekly will not do much to the levels. If I need a bigger
>>bang, I may push to as much as daily, but then watch levels. If high,
>>drop down.
>>
>>Sent from my iPhone
>>
>>On Feb 25, 2009, at 18:02, Ronald Ainsworth <ainsron@sbcglobal.net>
>>wrote:
>>
>>> I had always heard the same thing Art said, decreased absorption as
>>> the epithelium matures.
>>>
>>> --- On Wed, 2/25/09, Richard Chudacoff <rchudacoff@mylinuxisp.com>
>>> wrote:
>>>
>>>> From: Richard Chudacoff <rchudacoff@mylinuxisp.com>
>>>> Subject: RE: Is vaginal estrogen unnaposed?
>>>> To: "Multiple recipients of list OB-GYN-L" <ob-gyn-l@mail.obgyn.net>
>>>> Date: Wednesday, February 25, 2009, 1:20 PM
>>>> I always thought it was the other way around; as the
>>>> epithelium thickens,
>>>> there is an increase in vascularization, which increases
>>>> the absorption
>>>>
>>>> Richard Chudacoff, MD, FACOG
>>>>
>>>> -----Original Message-----
>>>> From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On
>>>> Behalf Of art
>>>> fougner, md
>>>> Sent: Wednesday, February 25, 2009 12:25 PM
>>>> To: Multiple recipients of list OB-GYN-L
>>>> Subject: Re: Is vaginal estrogen unnaposed?
>>>>
>>>> Dan
>>>>
>>>> As the vaginal epithelium thickens in response to E cream,
>>>> the
>>>> absorption decreases a bit ... an interesting feedback
>>>> loop.
>>>>
>>>> Art
>>>>
>>>> At Wed, 25 Feb 2009, R. Daniel Braun wrote:
>>>>>
>>>>> --000e0cd4872e1edd6a0463c3d788
>>>>> Content-Type: text/plain; charset=windows-1252
>>>>> Content-Transfer-Encoding: quoted-printable
>>>>>
>>>>> On Wed, Feb 25, 2009 at 11:07 AM, Christopher Jones
>>>> <christopj@msn.com>wrote:
>>>>>
>>>>>> I just diagnosed a postmenopausal woman with
>>>> endometrial adenocarcinoma.
>>>>>> Her only identifiable risk factor, if any, is a
>>>> history of premarin
>>>>>> cream unnaposed by progestins.
>>>>>>
>>>>>> My question is
>>>>>>
>>>>>> 1. Do you consider giving local estrogen without
>>>> progestins unnaposed?
>>>>>
>>>>> NO
>>>>>
>>>>> However, I wouldn't give vaginal estrogen to
>>>> someone who shouldn't take
>>>>> oral. The vaginal cream gets absorbed and enters the
>>>> blood stream and the
>>>>> doseage isn't controlled as well as it is with
>>>> oral.
>>>>>
>>>>>> 2. In your patients on local estrogen for
>>>> vulvovaginal symptoms, if you
>>>>>> give a progestin what is your protocol?
>>>>>>
>>>>>> Thanks
>>>>>>
>>>>>> Chris
>>>>>>
>>>>> --
>>>>> R. Daniel Braun, MD FACOG(L) ABMP CMTh
>>>>> Professor Emeritus
>>>>> Dept. of Obstetrics and Gynecology
>>>>> Indiana U. School of Medicine
>>>>>
>>>>> --
>>>>> R. Daniel Braun
>>>>>
>>>>> ¡°Science without Religion is LAME; Religion
>>>> without Science is BLIND"
>>>>> Einstein 1941
>>>>>
>>>>> --000e0cd4872e1edd6a0463c3d788
>>>>> Content-Type: text/html; charset=windows-1252
>>>>> Content-Transfer-Encoding: quoted-printable
>>>>>
>>>>> <br><br><div
>>>> class="gmail_quote">On Wed, Feb 25, 2009 at
>>>> 11:07 AM,
>>>> Christopher Jones <span dir="ltr"><<a
>>>> href="mailto:christopj@msn.com">christopj@msn.com</a>></span>
>>>> wrote:<br><blockquote
>>>> class="gmail_quote" style="border-left: 1px
>>>> solid
>>>> rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex;
>>>> padding-left: 1ex;">
>>>>> I just diagnosed a postmenopausal woman with
>>>> endometrial
>>>> adenocarcinoma.<br>
>>>>>
>>>>> Her only identifiable risk factor, if any, is a history
>>>> of premarin<br>
>>>>> cream unnaposed by progestins.<br>
>>>>> <br>
>>>>> My question is<br>
>>>>> <br>
>>>>> 1. Do you consider giving local estrogen without
>>>> progestins
>>>> unnaposed?</blockquote><div><br><br><br>NO<br><br>However,
>>>> I wouldn't give
>>>> vaginal estrogen to someone who shouldn't take oral.
>>>> The vaginal cream gets
>>>> absorbed and enters the blood stream and the doseage
>>>> isn't controlled as
>>>> well as it is with oral.<br>
>>>>> <br> <br></div><blockquote
>>>> class="gmail_quote" style="border-left: 1px
>>>> solid rgb(204, 204, 204); margin: 0pt 0pt 0pt 0.8ex;
>>>> padding-left:
>>>> 1ex;"><br>
>>>>> 2. In your patients on local estrogen for
>>>> vulvovaginal symptoms, if
>>>> you<br>
>>>>> give a progestin what is your protocol?<br>
>>>>> <br>
>>>>> Thanks<br>
>>>>> <br>
>>>>> Chris<br>
>>>>> <br>
>>>>> </blockquote></div><br>
>>>>> FACOG(L) ABMP CMTh<br>Professor
>>>> Emeritus<br>Dept. of Obstetrics and
>>>> Gynecology<br>Indiana U. School of
>>>> Medicine<br><br><br>R. Daniel
>>>> Braun<br><br> ¡°Science without
>>>> Religion is LAME; Religion without
>>>> Science is BLIND"<br>
>>>>> Einstein
>>>> 1941<br>
>>>>>
>>>>> --000e0cd4872e1edd6a0463c3d788--
>>>>>
>>>> --
>>>> art fougner, md
>>>> "May The Wings of Liberty Never Lose a Feather."
>>>> - Jack Burton
>
>--
>Joanne Bulley, MD
>solo gyn
>Keene, NH
>
--
Garry E. Siegel, M.D.
Private Practice
Roswell, GA
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