Doctor Fail
After practicing medicine for almost 25 years, certain patterns become very clear. I’ve created all sorts of processes in the office to help prevent common bottlenecks that affect access to care for my patients. The one pattern that I can’t seem to mitigate is the fear of vaginal estrogen.
After menopause, 60% of women notice vaginal dryness and pain with intercourse. The one surprising symptom of menopause that people don’t know about is bladder irritability and urge incontinence. Many women complain about having to modify their activities to make sure they’re always near a bathroom, burning with urination, and leaking urine on the way to the toilet. They might also have frequent bladder infections, which can become more dangerous as we age. Most attribute this to childbirth or aging, and don’t realize that this is directly related to low estrogen. Genitourinary syndrome of menopause (GSM) is the medical term for genital, sexual and urinary symptoms caused by thinning of the muscles and lining of the bladder and vagina.
People often see urologists when these symptoms become debilitating and are prescribed anticholinergic medications like Ditropan or Myrbetiq. But these medications come with side effects that seriously decrease quality of life including dizziness, constipation, and dry mouth. Those little old ladies crinkling their candy wrappers at the theatre may be taking Ditropan. These medications don’t address the root cause of bladder irritability which in most cases is low estrogen. It turns out that a tiny dose of estrogen applied locally to the vagina will often fix these symptoms.
When most people think about taking hormone therapy in menopause they imagine swallowing a pill that increases estrogen levels in the blood. They’ve heard that menopausal hormone therapy (MHT, previously called HRT) increases the risk of cancer and stroke and they think that their little bladder problem isn’t worth having a stroke for!
To make matters worse, all estrogen products sold in Canada have big warning stickers that say “The Women’s Health Initiative (WHI) trial examined the health benefits and risks of oral combined estrogen plus progestin therapy (n=16,608) and oral estrogen-alone therapy (n=10,739) in postmenopausal women aged 50 to 79 years. The estrogen-alone arm of the WHI trial (mean age 63.6 years) indicated an increased risk of stroke and deep vein thrombosis in hysterectomized women treated with CEE-alone (0.625 mg/day) for 6.8 years compared to those receiving placebo. ”
When we prescribe estrogen to treat GSM, we don’t prescribe it by mouth and the amount of estrogen used is a much lower dose than the WHI study. Comparing low-dose vaginal estrogen to full-dose MHT is like comparing a handful of almonds to a dose of cyanide. They are not the same thing. The North American Menopause Society has been campaigning to have these black box warnings removed because they are just not appropriate to display on vaginal estrogen products.
Low-dose vaginal estrogen is such a tiny dose that it’s undetectable in blood tests. It doesn’t cause blood clots or strokes or cancer. It just helps your bladder and vagina work better. It’s also such a tiny dose that it doesn’t even affect the uterus. It’s the same hormone your body made for years and years to help keep you working at your best. The UK is way ahead of us in North America; you can buy vaginal estrogen over the counter there because it is safer than Tylenol.
Common misconceptions:
If you’re taking MHT/HRT (oral estrogen or the patch) you don’t need vaginal estrogen.
MHT often doesn’t improve genitourinary symptoms, so add some vag estrogen as well.
Vaginal estrogen is the same as MHT/HRT
As discussed above, vaginal estrogen won’t treat hot flashes or improve irritability. It only affects the genitourinary system.
Some physicians think that every post-menopausal woman should be using vaginal estrogen. I wouldn't go that far, but I do prescribe it for patients who are distressed by pain, irritation and urinary symptoms. I give them all a heads-up about the warning label and the fact that it is incorrectly applied to this product. Still, 90 percent of my patients fill the prescription and never take it.
The American Urological Association calculated the overall cost savings for vaginal estrogen treatment for women with recurrent bladder infections to be $1226 to $4888 annually per patient. How much are you spending on incontinence pads and pelvic physiotherapy? How much have you had to restrict your activity so that you’re always near a bathroom, and how has your sex life changed because of irritation and discomfort down there?
Agony is optional and vaginal estrogen is safe. Talk to your doctor.