Vaginitis: two common causes bacterial vaginosis and atrophic vaginitis

Townsend Letter for Doctors and Patients, August-Sept, 2005 by Tori Hudson, Leigh Kochan

Preparations
Estriol suppositories  Available in 1 mg and 2 mg. Common use--insert
                       one suppository daily for 2-4 weeks then twice
                       weekly maintenance
Estriol cream          Compounded formulation. Usual dose is 1 mg/gm.
                       Insert 1 gm daily for 2 weeks then twice weekly
                       as a maintenance dose.
Estrace cream          b-17 micronized Estradiol; 0.01% cream; 1 gm
                       1-3x/wk .1 mg per gram Consider start with 2-4
                       gm every day intravaginally for 2-4 weeks, and
                       then 1-2 gm for 1-2 weeks; maintenance dose
                       usually 1 gm 1-3x/week
Estring                Alpha estradiol; biologically inert liquid
                       polymer matrix with pure crystalline estradiol;
                       releases 7.5 mcg/24 h over 90 days
                       2 mg delivered over 90 days; replace ring every
                       90 days
Femring                Estradiol acetate 0.05 mg/24 h, 0.1 mg/24 h;
                       replace every for 3 months
                       * Due to dose and thus systemic effects, this
                       prescription requires adequate use of a
                       progestational agent in women with a uterus.
Ogen cream             Estropipate; 2-4 gm 1-3x/wk 1.5 mg/gm
Premarin cream         Conjugated equine estrogens 0.625 mg/gm of cream;
                       0.5 mg-2 gm 1-3 gm/week; applicator marked in 0.5
                       g intervals; absorbed slower than other estrogen
                       preparations and therefore a longer duration of
                       action
Vagifem                b-17 Estradiol vaginal tablets; a gel forms when
                       the tablet is in contact with the vagina; initial
                       dose of 1 tablet every day for 2 weeks, then
                       maintenance of 2X/wk
                       25 mcg in singe use applicator; 1 tab
                       2X/wk

Indications: vulvar and vaginal atrophy (Premarin and Vagifem are indicated for atrophic vaginitis; Femring is also indicated for moderate to severe vasomotor symptoms)

Though continued use has not been studied in long-term randomized controlled trials, most practitioners feel comfortable using these products, preferable in natural forms at the lowest possible dose, indefinitely, to maintain tissue integrity and to control symptoms. In addition, atrophic changes will return within four weeks after discontinuing estrogen therapy so continued use is often necessary

Adverse Effects

Common: headache, nausea, vaginal discomfort, vaginal candidiasis

Rare: vaginal trauma from the applicator if patient has severe atrophy

Dosing and administration: Daily dosing will achieve systemic concentrations; low dose, 1-3/weeks will achieve predominantly local effects

Drug interactions: See oral estrogens (except antibiotics and nicotine); interactions are based on extent of systemic absorption.