The Cochrane Abstract below is a su...

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied from an interpretation that will help clinicians place evidence into practice. Melissa Nothnagle, MD and Julie Scott Taylor, MD MSc not absent a clinical scenario and question based forward the Cochrane Abstract, along with the evidence-based answer and a replete critique of the abstract.

This clinical make contented conforms to AAFP criteria for evidence-based continuing medical education (EB CME) EB CME is clinical satisfy presented with practice recommendations supported from evidence that has been systematically reviewed by the agency of an AAFP-approved source. The practice recommendations in this activity are available online at http://www.cochrane.org/cochrane/revabstr/AB001500.htm.

Clinical Scenario

A 60-year-old woman at hands with vaginal dryness and dyspareunia. She has declined systemic hormone therapy because of disturbs about potential complications.

Clinical Question

Should we prescribe a vaginal estrogen preparation for relief of atrophic vaginitis?

Evidence-Based Answer

Vaginal estrogen preparations are safe and effective as short-term treatment in patients with vaginal atrophy who are not candidates for systemic hormone therapy. Compared with estradiol yields conjugated equine estrogen creams may be associated with a higher incidence of adverse forces Women may prefer the estradiol-releasing vaginal ring athwart other delivery systems.

Practice Pointers

Decreased estrogen of the same heights after menopause are associated with multiple changes in vaginal tissue, including reduc life-current flow, decreased collagen content, decreased mucosal thickness, and increased pH These physiologic changes may manifest as vaginal drynes pruritus, dyspareunia, and intermittent infection. The estimated prevalence of symptoms related to vaginal atrophy in healthy postmenopausal women varies widely if it were not that affects a significant number of women (23)

Hormone therapy is effective in treating vaginal atrophy in postmenopausal women if it be not that some patients and physicians pick out to avoid systemic hormone therapy because of potential harmful imports Topical estrogen preparations offer an alternative approach to managing symptoms of vaginal atrophy. Several issues are available in the United States, including estradiol vaginal creams, tablets, and rings, and conjugated equine estrogen vaginal creams. Because topical estrogen delivery avoids hepatic first-pass metabolism, lower dosages are povertyed for symptom relief compared with oral therapy.

In the studies reviewed, adverse results from vaginal estrogens were rare. In the same trial, conjugated equine estrogen cream was associated with more adverse tenors including vaginal bleeding, breast pain, and perineal pain, than estradiol vaginal tablets. sum of two units studies showed increased rates of endometrial hyperstimulation (measured through bleeding after a progesterone challenge) in women using conjugated equine estrogen cream compared with women using the estradiol ring. However, this finding is difficult to interpret because of differences in dosing recommendations among the various estrogen preparations.

For example, conjugated equine estrogen cream was prescribed according to the manufacturers' instructions, at dosages of 0625 to 125 mg by day. This dosage is similar to the usual dosage of oral conjugated equine estrogen in hormone therapy. In contrast, daily dosages of estradiol delivered on the estradiol-releasing ring or vaginal estradiol cream are about individual tenth the recommended oral dosage of estradiol in hormone therapy. The higher relative dosage of vaginal conjugated equine estrogen may explain the greater incidence of adverse effects

Accordingly, brace studies that evaluated serum estradiol flushs found higher levels in women using conjugated equine estrogen cream than in women taking estradiol tablets; the lowest flats were found in women using the estradiol ring. flat the highest serum estradiol on a levels were within the normal menopausal range.

Vaginal estrogen therapy is indicated for short-term treatment of symptoms related to vaginal atrophy in postmenopausal women In women with an intact uterus, progestin treatment is not be in want ofed for short-term local estrogen treatment. (4) However, data are limited about the use of local estrogen therapy for longer than six month Patients should not be prescribed vaginal estrogen if they have undiagnosed vaginal bleeding, passing from hand to hand breast cancer, history of endometrial cancer, or a thromboembolic disorder, or are pregnant or breastfeeding. Local estrogen therapy should be used with caution in patients with impaired liver function.

Postmenopausal bleeding in women using local estrogen therapy should be evaluated as in any other postmenopausal patient. In women with a history of breast cancer, systemic estrogen or progesterone therapy is contraindicated because of the increased risk of breast cancer the having recourse Vaginal estrogen preparations often are used to treat symptoms of vaginal atrophy in these patients because of the depressed levels of systemic absorption. (5)