Vaginal oestrogen: why one maintenance dose does not fit everyone

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Vaginal oestrogen: why one maintenance dose does not fit everyone

Why are we so comfortable with the idea that one maintenance dose of vaginal oestrogen should suit almost everyone? Some women use vaginal estradiol twice a week and feel completely transformed. Others use it exactly as prescribed and are still living with dryness, burning, urinary symptoms, recurrent UTIs or pain with sex.

Receptor biology is complex. Oestrogen receptor expression varies between women and between tissues, and androgen receptors are abundant throughout the vulva, vestibule, urethra and pelvic floor. Genetics, years of oestrogen deprivation, inflammation, tissue remodelling and the vaginal microbiome can all change how someone responds.

A changing maintenance dose

Many of us trained when Vagifem contained 25 micrograms of estradiol. Twice weekly meant 50 micrograms each week. When the formulation changed to 10 micrograms, many women effectively had their routine dose reduced to 20 micrograms a week. Some do fine on that dose. Lots do not.

Local vaginal oestrogen has minimal systemic absorption and an excellent safety profile for the vast majority of women. Treatment decisions may need additional discussion for women with a history of hormone-sensitive breast cancer, alongside their oncology team.

This does not mean everyone should automatically receive more. It does mean that twice-weekly treatment should not always be seen as a ceiling rather than a starting point. The goal is healthy tissue, symptom relief and the freedom to sit comfortably, exercise without discomfort, have sex if wanted, and stop planning life around bladder symptoms.