Nowadays, it is commonly believed that intravaginal estrogen is safer as compared to oral estrogen but there is scarce evidence to support this belief (Cameron, 2003). Low dose of intravaginal estrogen is required as it bypasses first pass metabolism. Therefore, it can be postulated that it will have lesser systemic side effects but the main concern is that continuous exposure can lead to endometrial hyperplasia.
A recent review showed that seven clinical and epidemiological studies revealed no significant increase in the risk of endometrial hyperplasia or cancer associated with use of intravaginal estrogen (Cameron, 2003). Only a few studies in the review reported endometrial hyperplasia but in those studies higher doses of intravaginal estrogen were used. It was further concluded in the review that estrogen tablets and low-dose estrogen rings are the safest HRT as reported by the clinical trials conducted so far.
The Cochrane review compared different intravaginal forms of estrogen HRT (Suckling, 2003). This review concluded that all of the forms (creams, tablets, rings, etc) are affective in relieving vaginal atrophy symptoms but vaginal rings and tablets pose a lesser risk of developing endometrial hyperplasia and caner compared to intravaginal cream. Intravaginal rings and tablets even showed lesser side effects in all the trials compared to intravaginal estrogen creams.
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