So let’s back up. Way up.
People are scared of estrogen. People don’t understand estrogen. People hate estrogen. People love estrogen.
We have a lot of emotions towards estrogen.
Estrogen can help with vulvovaginal issues. So how do you know what kind of estrogen to use? That is a really big question. Estrogens can be given orally, via a gel, with a patch or topically.
Oral, gel and patch estrogens are meant to be absorbed throughout your whole body. That is considered “systemic” absorption. That is body system wide. Topical estrogens are to be applied to the vulvovaginal tissue. They are typically only absorbed “locally”. This means that the estrogen isn’t going to affect your body outside of the vulvovaginal tissue. The tricky thing is that there are some women who have sensitive nervous systems. These women do notice more systemic absorption of topical estrogens. They might notice mood irritability, breast tenderness among other body changes.
One thing you must know: Just because you are using systemic estrogen does NOT mean you are getting an adequate amount at your vulvovaginal tissue. Many, many women need topical hormones on their vulvovaginal tissue IN ADDITION TO the systemic estrogen they are using. Most doctors don’t understand this.
Orals, gels and patch estrogen = systemic estrogen = changes body wide
Topical creams applied to the vulvovaginal tissue = localized estrogen = changes in vulvovaginal tissue (but can be body wide for some)
So, there’s that.
Now if we look just at localized estrogen we can answer some more questions. There are lots of different companies making localized estrogen. You may have heard of names like: Estrace, Premarin, Vagifem and now there is an oral pill called Osphena that is supposed to target only vulvovaginal tissue. And there are more names that I’ve not listed. There are three different types of estrogen found in the human body. The type of estrogen used in these creams can differ. Each estrogen, regardless of type, needs to be transmitted to vulvovaginal tissue through a base. So, all estrogens are mixed with a base. What we’ve got here now is different types of estrogens and different bases. We’ve got a confusing situation. We’ve almost got too many options.
Too many options. It’s true. But, when you go to your doctor, it might not seem that way. It might seem as if there is only one or two options and those are called Estrace and Premarin. Doctors get lots of free samples of Estrace and Premarin. I’m going to talk about only three topical options because if I talked about any more I might type forever and have to rename this entire blog Blog About Pelvic Pain and Also A Lot About Topical Hormones – But, Men, I Have Stuff For You Too, I Promise and oddly enough – that url was taken…. Who knew?
Let’s talk about Estrace.
Estrace is estradiol + propylene glycol.
Estradiol is the estrogen and propylene glycol is the base.
Estradiol is is bio-synthetic. It is very much like what our own body produces. It is a very helpful estrogen. It is a very powerful estrogen. It is my favorite type of estrogen for women to apply topically to the vulvovaginal tissue.
Propylene glycol is an alcohol base. So…if you already have issues at the vulvovaginal tissue – say you already have pain and are seeing your doctor to resolve this pain, then applying alcohol (albeit with a good estrogen) to your vulvovaginal tissue might actually burn.
When it burns…ah, let’s talk about when you’ve been prescribed Estrace and it burns. Oy. A lot of times a doctor will tell you to keep using the Estrace if it burns, but a lot of times patients just give up. Because it burns. Because they went to the doctor to get relief from the burning in their vulvovaginal tissue and were prescribed a topical hormone that created more burning in their vulvovaginal tissue. Doctors will often say, well, if you’re really deprived of estrogen at the vulvovaginal tissue, then the estrogen alone will burn. And, they are right – if your vulvovaginal tissue is super duper incredibly out of this world unbelievably deprived of estrogen. Just touching it to apply anything at all can hurt. But, for the most part, if your vulvovaginal tissue is super deprived of estrogen and you give it estrogen (without also introducing alcohol), then it will feel pretty decent to good to really nice a lot of the time. I think that doctors think that the estrogen is burning because they are largely unaware that they are issuing estrogen with an alcohol base. I think that, honestly, is the main problem.
The way you get around that is by compounding the estradiol in a very gentle base. There are tons of bases out there with really exciting names. But, I like to keep it simple. I like plain old coconut oil as a base. It’s good for your, it’s anti-microbial and I haven’t met anyone that it irritates. (Actually, one person was irritated by it and they ended up using Slippery Stuff as their base.) The point is, there is a base option out there for the very sensitive vulvovaginal tissue. The downside of this option is that insurance doesn’t pay for compounded topical hormones. Insurance doesn’t get it. The other thing is – you have to advocate for yourself and ask your doctor for this. They aren’t going to jump right to it most of the time, but they have probably heard of the idea of a compounded topical hormone.
Let’s talk about Premarin.
Premarin is made from pregnant horse’s urine.
Pre(gnant) + Mar(e) + (Ur)in(e) = Premarin
This is not bio-synthetic…because it’s from a horse. It’s considered a conjugated equine estrogen (CEE). This means that it is a horse estrogen that has been converted to a form that can be used by the human body. The implications of this are that the estrogen sticks to your body’s estrogen receptors very aggressively and it’s affects last for a really long time. The other part of this is that our body doesn’t metabolize these estrogens in the same way that it would metabolize something that is more bio-synthetic. For some women, this has been really problematic. You can google it and find lots of crazy stories.
Nevertheless, Premarin is heavily marketed to physicians and it is heavily used by physicians. It’s not my first choice, by any means, but it’s one choice and for some people it’s better than nothing at all – if they can tolerate it.
That’s the basics. The basics of the basics.
If you have questions or comments, please leave them anonymously in the comment section below or email me at Sara@Sullivanphysicaltherapy.com