II. Indications

III. Precautions

  1. Higher dose Topical Estrogens require concurrent Progesterone if Uterus intact (risk of Endometrial Hyperplasia)
  2. Lower dose Topical Estrogens do not require systemic Progesterone (in intact Uterus) if used <1 year
    1. Obtain Transvaginal Ultrasound (endometrial stripe) and Endometrial Biopsy if vaginal spotting or bleeding

IV. Preparations: High Dose Topical Estrogens

  1. Indicated for vasomotor symptoms AND Genitourinary Syndrome of Menopause (Vaginal Atrophy)
  2. Requires concurrent progesteron use
  3. Estradiol acetate vaginal ring (FemRing)
    1. Placed in vagina and replaced every 90 days
    2. Available as 0.05 and 0.1 mg/day rings
    3. Requires opposing Progesterone if Uterus intact (risk of Endometrial Hyperplasia)

V. Preparations: Low Dose Topical Estrogens

  1. Indicated for Genitourinary Syndrome of Menopause
  2. Estradiol Vaginal Ring (Estring)
    1. Placed in vagina and replaced every 90 days
    2. Available as 2 mg rings (releases 7.5 mcg estradiol per day)
  3. Estradiol Vaginal Tablet (Vagifem)
    1. Initial: One tablet intravaginally daily for 2 weeks
    2. Later: One tablet intravaginally twice weekly
    3. Available in 10 mcg and 25 mcg applicators
    4. May be safe at low dose, low frequency use despite history of Breast Cancer
      1. Low systemic absorption at low dose
      2. Requires Informed Consent regarding potential risks and lack of safety studies following Breast Cancer
      3. Pruthi (2012) Mayo POIM Conference, Rochester
  4. Estrogen Cream (Premarin or Estrace Creams)
    1. Premarin applied 0.5 to 2 grams daily
    2. Estrace applied 2-4 grams for 2 weeks, then reduced (0.1 mg estradiol per gram cream)

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Cost: Medications

femring (on 2/22/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
FEMRING 0.05 MG VAGINAL RING $403.32 each
FEMRING 0.10 MG VAGINAL RING $430.30 each
estring (on 6/1/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
ESTRING 2 MG VAGINAL RING $388.83 each
vagifem (on 1/18/2017 at Medicaid.Gov Survey of pharmacy drug pricing)
VAGIFEM 10 MCG VAGINAL TAB Generic $16.55 each

Ontology: Vagifem (C0592238)

Concepts Pharmacologic Substance (T121) , Steroid (T110)
English Vagifem, vagifem

Ontology: Femring (C1330276)

Concepts Hormone (T125) , Steroid (T110) , Pharmacologic Substance (T121)
English Femring