Local estrogen benefits of postmenopausal women with dyspareunia: data confirming what clinicians already know!

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The more things change, the more they stay the same. Gonadal hormonal use continues to evoke strong scientific and public debate. Controversies regarding its use span decades, exemplified by the 1960s when not only were the pros and cons of hormonal contraception caught up in polarized debate by many medical, nonmedical, and religious groups, but also hormonal use in menopause was strongly debated as well.
Standard textbooks read by most medical students, and Ob/Gyn residents and attendings, such as the one by Thomas Green published in the early 1970s, clearly told its readers regarding menopause that “… the psychologic components of the symptoms of the ‘change of life’ is usually of greater importance than hormone replacement therapy.” Not only was hormonal use minimalized, but Dr. Green went on to note that, “At times sympathetic explanation and reassurance must be fortified by judicious and temporary use of sedatives and tranquilizers, but these should be discontinued as soon as fears and anxieties are allayed and the patient has been encouraged to meet and adjust realistically to her changing environment by finding new interests and activities.” And Dr. Green goes on further to say, “The majority of gynecologists continue to adhere to the concept that the menopause is a normal, physiologic event and that estrogen therapy should not be used indiscriminately nor for more than a year or two in the management of the minority of women who require it.”1 …and this is how early practitioners were schooled on hormones and menopause.
Dr. Green's advice was, however, in sharp contrast to Robert Wilson's and his spouse, Thelma Wilson, who reported that estrogen replacement therapy should be considered for all women and be a long-term treatment.2 The benefits of this hormonal intervention, as they noted, were the prevention of atrophy and disease of the cardiovascular system, bone and joints, sexual function, and even intellectual ability and psychologic wellness. Of course, as would be expected, Green debated this concept with the statement, “… estrogens have no effect whatsoever on the inevitable changes in skin, hair, weight distribution, muscle tone, libido, etc., induced by the aging processes …. nor maintain the perpetual bloom of youth.”
If and when estrogen was prescribed for atrophic vaginitis (formerly referred to as senile vaginitis), unlike Wilson who recommended it indefinitely, Green cautioned that it should be used for up to 30 days and then stopped. In Green's textbook, Gynecology: Essentials of Clinical Practice,1 when addressing atrophic vaginal changes, which at that time were said to include symptoms of vulvar and vaginal burning and soreness, occasional pruritus, vaginal discharge and bleeding, a 30-day course of Dienestrol cream, Premarin cream, or stilbestrol suppositories was recommended.
During these early years of estrogen use, dyspareunia from vulvovaginal atrophy usually was either not specifically mentioned or mentioned briefly in instructional materials. In fact, gynecologists often received information about gonadal hormones and menopause/postmenopause, including the treatment of vulvovaginal atrophic changes, from industry-produced material. One of the most prolific educators during the early years of hormonal therapy was Ayerst laboratories, the distributors of conjugated equine estrogens (Premarin).3 And even then, the topic of dyspareunia was merely alluded to in a discussion of atrophic vaginitis, as noted in one of the publications produced by their company. The treatment recommended in this monograph was to prescribe a locally applied estrogenic cream, ointment, or suppository with or without concomitant systemic estrogen treatment.

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