Last week I had the honor of speaking with NPR Here & Now co-host Robin Young about women's sexual medicine. Since the segment aired, we've received a flood of questions about local vaginal hormones--the risks and benefits of using them, how to access them, and how we can fight to make them the standard of care for the menopausal people who need them.
Here are some answers:
1. I've heard that hormones can lead to cancer. Is this true? If so, why do you still prescribe them?
Not all hormones are created equal, and not all hormone therapies come with the same risks. There are systemic hormones (sometimes called HRT), which can help with the hot flashes and night sweats associated with menopause. This means using pills, patches, gels, or rings containing estrogens and/or progestogens to supplement the body's decreased production.
There are also local vaginal hormones, which is what I discussed with Robin Young. Low dose hormones placed in the vagina don't significantly absorb into the bloodstream, and are miniscule in dose compared to the systemic treatments. So the risks of cancer, stroke or blood clots are nearly non-existent.
The benefits of local vaginal hormones, however, are plentiful. These include better lubrication, decreased pain with penetration, and decreased urinary frequency and urgency. Better yet, they prevent urinary tract infections. Not only can these treatments improve quality of life, I believe that they save lives. During menopause, the vagina becomes less acidic. Vaginal hormones acidify the vagina, which is so important in preventing infection.
Urinary tract infections are dangerous, especially in older adults. They can lead to kidney infections, sepsis, altered mental status, and death. By not talking about vulvovaginal health, we are perpetuating a culture of silence around not only sexual health, but also survival.
2. I'm having symptoms of Genitourinary Syndrome of Menopause (GSM), such as urinary frequency or urgency and vaginal dryness, burning, and irritation. What do I do?
Talk to your doctor. I envision a world in which GSM can be treated by all primary care providers, endocrinologists, dermatologists, colorectal specialists, oncologists, gynecologists, urologists, etc. In the meantime, to find a sexual medicine doctor like me go to ISSWSH.org, or find a certified menopause practitioner at menopause.org.
Your provider may recommend local vaginal hormones. These are different from systemic Hormone Replacement Therapy (HRT), which may also be recommended. Local vaginal hormones come in rings, suppositories, inserts, tablets, creams, and gels.
3. My vaginal hormones are expensive and inaccessible. How can I fix this?
I've found two ways to decrease medication prices for my patients. The first is GoodRx, which offers coupons for out-of-pocket medications and also has a pharmacy price comparison tool. To find the best prices, search your medication and zip code on goodrx.com. Then download, screenshot, or save the coupon that pops up. Have your provider send your prescription to the pharmacy that you choose, and remember to show the pharmacist your GoodRx coupon when you go to pick up your medications.
In addition to GoodRx, many of my patients use Mark Cuban's online pharmacy, Cost Plus Drugs. Cost Plus offers generic medications at low, transparent prices. To go through this pharmacy, have your provider send a prescription to Cost Plus Drugs that includes your email address in the notes. Create an account at costplusdrugs.com using that same email address and follow the prompts to get your meds delivered to your door.
4. How does my doctor write the prescription so I get cheap vaginal estrogen?
The cheapest option on the market right now is vaginal estrogen:
estradiol 0.01% cream
1 gram daily in the vagina for 2 weeks then 1 gram twice weekly forever
If you don't like creams - often the generic tablet inserts are covered by insurance:
estradiol 10mcg inserts
1 insert daily for 2 weeks then 1 insert twice weekly forever
Check out the Here & Now segment and explore my website and social media pages to learn more about what I do, including vaginal hormones, systemic hormones, GSM treatment options, pleasure, devices, quality of life, and survival.
International Society for the Study of Women's Sexual Health: isswsh.org
North American Menopause Society: menopause.org
Find a pelvic floor physical therapist: pelvicguru.com
Find a urogynecologist: voicesforpfd.org/find-a-provider