The Magic of Hormones

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October 27, 2021

I believe the only true essential oil out there is vaginal estrogen. I bet you haven’t heard that one before. In fact, I think at age 45 every woman should go to her doctor and get at the very least 3 prescriptions. 

  1. Colonoscopy 
  2. Mammogram 
  3. A lifetime prescription for local vaginal estrogen.  

Now let me take you through my logic. 

When vulva owners are babies they have no hormones in their bodies. Think diaper rash, raw/irritated tissue, and constant leaking into diapers. The vulva is small, there are no labia minora and the opening to the vagina is teeny tiny. 

Then puberty hits. GASP. Suddenly hormones are raging, we become irritable and mean to our parents and our bodies change. Like a lot. Included in that change, is a significant change to our genitals. Women grow labia minora, their vaginal openings become pink, stretchy, and lubricating. 

The magic of hormones. 

But then around age 52 – often before, and sometimes after. The ovaries slowly stop making estrogen, progesterone, and testosterone. And that genital tissue, which is so rich in hormone receptors begins to feel the loss. 

That means the tissue goes back to being thin, raw, irritated. The opening narrows or shortens. The tissue dries out and loses the acidity it once had to fight infections. The whole microbiome changes which increases the likelihood of urinary tract infections (UTIs). 

Other symptoms include urinary frequency, urinary urgency, pelvic pain, pain with urination, vaginal dryness, and constipation. 

This condition is called GSM. Say it with me G-S-M. It stands for genitourinary syndrome of menopause. The lack of hormones after 50 causes significant genital and urinary symptoms. And they don’t magically get better or go away with time. In fact, they just keep getting worse. 

But all of this is not only treatable but dare I say it is PREVENTABLE. 

If we warned women that this was going to happen, we could stop the changes before they start. Hence why I said it’s the only essential oil and should be given early as prevention. Don’t start watering the garden after all the plants have wilted! 

____ 

Overwhelming data shows that local vaginal estrogen will prevent recurrent UTIs in peri and post menopausal women and it’s recommended by the American Urological Association (AUA) in their guidelines on recurrent UTI. 

Not only will vaginal estrogen decrease recurrent UTIs, but it will improve many lower urinary tract symptoms including frequency, urgency, and painful urination. It will also help improve arousal, lubrication and decrease painful penetration. 

The problem is that less than 7% of women with GSM are prescribed vaginal estrogen, and many who get the prescription don’t use it properly, can’t afford it, stop using it, or fear using it because of misinformation around mythical harm and inappropriate FDA boxed warnings. 

 But the crazy thing about this story is that vaginal estrogen is a local treatment. It’s TOTALLY safe for essentially all women. In fact, there are very few woman >50 who I wouldn’t recommend the use of local vaginal estrogen. Occasionally I need to pick up the phone and talk to her cancer doctor to discuss the fine print. 

There is no data. NO DATA. That local vaginal estrogen causes cancer, cardiovascular problems, stroke, dementia or any other issues.  In fact, studies with over 18 years of observational show safety. Even studies in women who have gynecologic cancers have no issues using local vaginal estrogens. I prescribe and encourage this therapy in my patients with breast cancer, a family history of breast cancer, and those who are worried about breast cancer. 

Let me give you a quick example. When I was pregnant my estrogen level was 3,000pg/ml at the same time my husband’s estrogen level was 25pg/ml. Menopausal women’s estrogen level is <5pg/ml and on vaginal estrogen it stays at <5pg/ml. There are many reasons why a women over 50 might want an estrogen higher than 5pg/ml but that is for another post. My point is local vaginal estrogen does not pose a risk to the amount of estrogen in your bloodstream. How is it going to grow a cancer, cause dementia or give you blood clots? It’s not, and it doesn’t

All hormones are not the same. 

A birth control pill has different risks then an IUD which have VERY different risks from a local vaginal estrogen.   

Starting local vaginal hormone therapy is easy to do. There are lots of options including inserts, gels, and rings. It may take up to 2-3 months to get maximal benefit (remember the tissue must heal which takes time) and it will only keep working if you keep using the therapy. 

Think to yourself. When can I stop brushing my teeth? When can I stop moisturizing my face? When can I stop wearing my seat belt? Never. The answer is never. 

Please talk to your doctor about vaginal hormones. Show them this blog post. Show them the table below for options. 

Pharmacologic treatments for GSM 

TreatmentProduct NameDose
Vaginal Cream

17-beta- estradiol creamEstrace, generic0.5-1gm daily for 2 weeks then 0.5-1gm 1-3x per week
Conjugated equine estrogens creamPremarin0.5-1gm daily for 2 weeks then 0.5-1gm 1-3x per week
Vaginal Inserts

Estradiol vaginal tabletsVagifem®, Yuvafem®10mcg inserts daily for 2 weeks and then 2x per week
Estradiol soft gel capsulesImVexxy® 4, 10 mcg inserts daily for 2 weeks and then 2x per week
DHEA (prasterone) inserts Intrarosa® 6.5mg capsules daily 
Vaginal Ring

17-beta-estradiol ringEstring® 1 ring inserted every 3 months
SERM

Ospemifene oral tabletsOsphena® 60mg tablet daily 

11 Comments

  1. L McKibben on October 28, 2021 at 3:41 am

    I like the lively writing and sound advice. Thank you.

  2. Carol Preston on October 28, 2021 at 9:49 am

    Who knew? Could have used this info 15 years ago. Should women over 70 bother?

    • Rachel S Rubin on November 2, 2021 at 1:01 pm

      absolutely! I have women who are 98 start this product to prevent UTI, vulvar irritation and pain with sitting! I have one patient who says “Dr. Rubin…it’s about wearing pants! I can wear pants again!”

    • Tara Allen, MD FPMRS on November 4, 2021 at 10:10 am

      Yes!! I’m a physician admirer of Dr. Rubin the author of this post. She is spot-on! Start now and don’t look back.

  3. joann urquhart on October 29, 2021 at 3:02 am

    Great information. It is shocking how few women know this very important information that we as doctors should be telling them.

  4. Mitra ayazifar on October 30, 2021 at 4:23 am

    Thank you for this valuable information.
    My oncologist was adamant that I could not have hormonal replacement after having surgical menopause post ovarian cancer. From your blog, and “you are not broken” podcast, I understand this may not be true.

  5. Rachel S Rubin on November 2, 2021 at 1:00 pm

    Thanks for reading!

  6. Rachel S Rubin on November 2, 2021 at 1:02 pm

    absolutely! I have women who are 98 start this product to prevent UTI, vulvar irritation and pain with sitting! I have one patient who says “Dr. Rubin…it’s about wearing pants! I can wear pants again!”

  7. Miriam Graham on November 2, 2021 at 8:27 pm

    Thank you for getting this important information about women’s vaginal health out there! Will help our patients with painful sex and those with mild urinary incontinence. Many patients are concerned about the CA risk–great job putting this into perspective and breaking it down!

  8. I Ali on November 4, 2021 at 1:18 pm

    Wonderful article! If post menopausal women are on hormone replacement therapy, does that improve vaginal dryness? Should they also be using vaginal cream?

    • Rachel S Rubin on November 8, 2021 at 1:48 pm

      Absolutely! Many women on systemic therapy still need local therapy to help their GSM symptoms. SO if you are on a systemic estrogen/progesterone therapy but have urinary symptoms, vaginal dryness, or a UTI. Then DEFINITELY get local therapy. No harm and no reason not to!

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