Monthly Q & A: Vaginal Dryness, Heart Disease & HRT

Q: Dr. Diana – I’m using vaginal estradiol for my vaginal dryness – like you recommended! But, do I also need to use Progesterone to protect my uterus?

Great question!  The answer depends on what type of vagina treatment you are using.  If it is a form of vaginal estradiol intended just for vaginal dryness, then NO progesterone is needed.

Examples of localized vaginal Estradiol treatments include:

Imvexxy vaginal suppositories, Vagifem vaginal suppositories, Premarin vaginal cream, Estrace vaginal cream, and Estring vaginal ring.

Other treatments such as vaginal Intrarosa suppositories or oral Osphena do NOT need additional progesterone therapy.

The one vaginal exception to this is a form of vaginal systemic (whole body) estradiol in ring form known as FEMRING – this delivers a much higher amount of estradiol to the vaginal tissues, which is then absorbed into the bloodstream.  This is known as “systemic” hormone therapy, which is absorbed into the bloodstream at much higher levels, helping with symptoms such as hot flashes and night sweats. When this FemRing is used, then a form of progesterone is needed to protect the lining of the uterus from becoming too thickened, leading to possible hyperplasia and precancerous changes. This is different from “localized” vaginal therapies described above which act just at that site – the vaginal tissues and surrounding tissues such as the bladder and urethra.


Q: Dr Diana - I’m so confused about hormone therapy.  My doctor tells me it can increase the risk of stroke/heart attack and that I shouldn’t be using it.  My friend just started it and is feeling so much better with her hot flashes and sleep problems.  What should I do?

The first thing is to sign up (as you already have!) to be a subscriber to Amazing Over 40.  I developed this site specifically for women like you who are struggling with the symptoms of perimenopause/menopause and feel alone in the decision-making process. 

Up-to-date, trustworthy and scientifically proven research is available for all to read and be educated to formulate the best plan for your symptoms.  Before starting any treatment, please be sure to discuss it with your physician.

To take or NOT to take Hormone therapy – that is the million-dollar question!

As with so many things in life, it comes down to the risks and benefits.  Do the benefits outweigh the risk?  And what are the true risks and benefits of HT?

Benefits:  There are more but these are the top ones!

  • Hot flashes
  • Night sweats
  • Sleep disruption/awakenings
  • Vaginal dryness/Pain with sex
  • Mood swings
  • Irritability
  • Brain Fog
  • Libido/Sexual Desire

Risks:  Heart Disease – Does HT increase risk for heart disease?

If you are more than 10 years past the age of menopause (average age = 51) then HT is NOT recommended for the reduction of heart disease and may increase your risk of developing a heart attack or stroke.

If you are less than 10 years from the onset of menopause and do NOT have a history of cardiovascular disease, then HT is cardio-protective and decreases the risk of heart disease.  Example, a healthy woman who is now 57 and went through menopause at age 50 is considered a candidate for HT to help prevent heart disease.  A woman who is 63 and went through menopause at age 52, is 11 years past menopause and would require more extensive work-up to see if she could take HT (lipid panel, carotid artery scan, and possible coronary calcium score) to help evaluate the extent of her cardiovascular disease risk (plaque formation in her carotid arteries and/or coronary arteries.)

Again, it is always recommended that you speak with your health care professional before starting any medications.

As we know, there are risks associated with HT, including increased risk of breast cancer, deep venous thrombosis and possible increased risk of dementia.  These will be discussed in next month’s Q & A, which will focus on the study that turned the hormone therapy world upside- down, the Women’s Health Initiative (WHI). 

In health and happiness,

Dr. Diana