Have a question about women’s health or menopause? Dr. Patricia Yarberry Allen may have the answer. Click here to send in your question to be posted on WVFC.

Question: I am 62 years old and have been divorced for years. I met a terrific guy about a year ago who has his own money and life. We are very much alike — he is adventurous, loves travel and works for himself. The problem is that he is six years younger and is a very sexually demanding partner.

Once I decided that this relationship had the qualities that suited me, I immediately visited my gynecologist. I never used hormone therapy and menopause never bothered me; I was too busy for that. But I had learned in my last sexual relationship that sex without local hormone therapy was uncomfortable.

My gynecologist started me on vitamin D oral supplements and a vaginal cream and then changed the regimen to Vagifem, a vaginal estrogen tablet that he said was bio-identical. I also use a lubricant during sex. It’s comfortable enough, but nothing like it was when I was in my 30s. Even with the Vagifem, I have to see my gynecologist frequently because of burning and pain. I am not comfortable letting my partner know that I have any symptoms.

At my last visit, the gynecologist reminded me to read the warning that comes in each box of Vagifem. I was shocked to learn that it could possibly increase my risk of endometrial and breast cancer. What should I do? I can’t have a relationship with this man without lots of sex, and I don’t want an increased cancer risk. – Holly

Dr. Pat: I don’t know whether to offer congratulations or commiserations. Lucky you, I think. Smart, financially independent, adventurous guy who likes sex. Then I read your letter carefully and wondered how much of this one-year relationship is sex-based. I don’t know lots of 22-year-olds who could take on this kind of sexual marathon for a year and not have complaints. It seems that it is time for you to discuss less frequent sexual activity so that you can have more joy in your sex life and less pain.

Let’s discuss your concerns. Vagifem provides a low dose (25 mcg) of estradiol locally to the vaginal epithelium. According to Novo Nordisk, the pharmaceutical firm that produces Vagifem, the tablet sticks to the tissue of the vaginal wall, allowing for gradual dissolution. Estradiol is released locally over a period of several hours.

The safety studies on Vagifem are not based on a large number of patients, nor do they cover years of observation. In the studies I reviewed to answer your question, however, the amount of systemic absorption of estradiol into the blood stream was low.

The ongoing safety studies of this form of genital estrogen will focus on systemic absorption and the impact on breast cancer risk and the development of endometrial cellular abnormalities. There have been rare reports of cellular change in endometrial tissue with Vagifem at the 25 mcg level, so all patients using this treatment must have their endometrial tissue carefully monitored on a regular basis.

The most recent study of vaginal estrogen tablets was reported in the January 2008 issue of Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists. This study compared the standard, 25-mcg dose of vaginal estradiol tablets to a lower dose of 10 mcg. The improvement in vaginal comfort was similar in both groups.

There is no perfect answer to your question of safety. I would suggest that you discuss the lower 10-mcg dose with your gynecologist. And it is important to find a way to share the information about your sexual comfort with your partner. This is now a relationship of over a year. You deserve to be heard and you deserve to be loved.

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Dr. Patricia Yarberry Allen,
director of the New York Menopause Center, is a gynecologist affiliated
with New York-Presbyterian Hospital and a board certified fellow of the
American College of Obstetrics and Gynecology. Have a question about sex, women’s health or the menopausal transition? Write to [email protected].