Topical Estrogen Cream Research Articles

Success of Treatment Modalities for Labial Fusion: A Retrospective Evaluation of Topical and Surgical Treatments

Study Objective Standard treatment for girls with labial fusion has included topical estrogen cream, manual separation, or surgery. Side effects may limit the use of topical estrogen. Betamethasone has recently shown efficacy at separating labial fusion. Local irritation and inflammation may be an initiator of labial fusion. No adverse effects of betamethasone treatment have been documented. Long-term side effects are unknown. This study compares therapies for conservative management of labial fusion for efficacy and focuses on the response rate, time to separation, recurrence, and side effects of treatment. Design A retrospective chart review. Participants One hundred fifty-one prepubertal girls, mean age 3 years (range 0.25-8.75 years) diagnosed with labial fusion. Main Outcome Measures To investigate the incidence of related symptoms, length of topical estrogen or betamethasone treatment, side effects, rate of successful separation, rates of recurrence, percentage requiring surgery, and postoperative outcomes in patients with labial adhesion who underwent treatment. Results Of 151 patients with labial adhesion, 11 (7.3%) presented with urinary frequency, 30 (19.9%) with urinary tract infections, 13 (8.6%) with vaginitis, and 19 (12.6%) with post-void dripping. When compared to patients treated with betamethasone (1.3 months), patients treated primarily with premarin took nearly twice as long (2.2 months) for resolution of their adhesions. Rates of recurrence were lower for patients receiving betamethasone therapy. Side effects for estrogen therapy included breast budding and vaginal bleeding, and for betamethasone, local irritation was reported. Some patients went on to surgery and experienced recurrence after surgery. Conclusion Initial comparison of topical estrogen and betamethasone treatment of labial fusion suggests that betamethasone may separate fusion quicker with less recurrence and fewer side effects than topical estrogen therapy.

Index of Suspicion

Index of Suspicion

Topical vaginal oestrogen cream used for treatment of burn injury of vaginal mucosa after misapplication of 100% acetic acid in a perimenopausal woman: A case report

Three to five per cent acetic acid is commonly used in the field of gynaecology for colposcopic examinations of the cervix. It gives an 'acetowhite' effect that may assist clinicians in identifying neoplastic areas. A perimenopausal woman was treated with acetic acid for abnormal Pap smear report (cervical intraepithelial neoplasia 1). During application, the patient complained of burning sensation of vagina and vulva. The vagina was saline-irrigated after realising that the acetic acid had not been diluted. Following this incident, the patient was seen weekly and treated with conjugated vaginal oestrogen cream. The patient recovered and the vagina mucosa healed within two weeks. Acetic acid is corrosive and may cause vagina bleeding. Oestrogen cream can be used in an attempt to minimise the adverse reaction and speed the healing process.

Sexual Function in Chronic Kidney Disease

Endocrine abnormalities are common in patients with chronic kidney disease (CKD) and lead to sexual dysfunction, anemia, hyperparathyroidism, and altered mineral metabolism. Common clinical problems include disturbances in menstruation in women, erectile dysfunction in men, and decreased libido and infertility in both sexes. Organic factors tend to be prominent and are related to uremia and other comorbid illnesses. Psychological factors and depression may exacerbate the primary problem. Alterations in the hypothalamic-pituitary axis are seen early in CKD and tend to worsen after patients start dialysis. Hypogonadism plays a dominant role in male sexual function, whereas changes in hypothalamic-pituitary function predominate in female sexual dysfunction. In patients on dialysis, treatment strategies include optimizing dose of dialysis, correction of anemia with erythropoietin, and correction of hyperparathyroidism. Successful kidney transplantation may restore normal sexual function, especially in younger patients.

Estrogens and Urinary‐Tract Infection

The effects of estrogen on the risk of urinary-tract infection (UTI) in women has been the subject of many studies in both humans and experimental animals. Often, these studies have come to seemingly contradictory results: some have suggested an increased risk attributable to estrogen and others that estrogens may be preventative. In part, this confusion arises because the physiological effects of estrogen on different anatomic parts of the urinary tract differ depending on the specific effect and the outcome measured. For example, in the absence of estrogen, the periurethral and vaginal microflora, which is usually predominated by hydrogen peroxide-producing lactobacilli and few Escherichia coli, changes dramatically to a flora with few or no lactobacilli but many E. coli [1]. This change in flora is associated with a markedly increased risk of recurrent E. colibladder infections. In a randomized, placebo-controlled trial of topical intravaginal estrogen cream in such women, both the reestablishment of the normal lactobacillus-dominant vaginal flora and reduced rates of UTI were demonstrated in estro-

Significance of Topical Estrogens to Labial Fusion and Vaginal Introital Integrity

Purpose One theory for labial fusion is low prepubertal estrogen levels. Topical estrogens remains the mainstay of therapy. Some patients require surgical lysis of the adhesion. Estrogen's action in regard to collagen may influence recurrent adhesions and adhesions that form after manual disruption or surgical separation. This study assesses the efficacy of topical estrogen to separate the labia, recurrence, and estrogen related side effects. Estrogens may have a role in vaginal healing in genital surgery. Materials and Methods Retrospective chart review of 109 girls from 3 months to 10 years old (mean 44 months) who had labial fusion. Data was collected on the length of topical estrogen treatment, rate of successful separation, rate of recurrence, percentage requiring surgery, and post-operative outcomes. Results Mean length of topical estrogen treatment was 3.7 months (range 0 to 36 months), with separation in 79% (85/107) of patients. Forty-one percent (44/107) had recurrence of labial fusion one to five times (range 2 to72 months). Surgery was required in 21% (22/107). Ten percent of patients (2/21) had recurrence of labial fusion post-operatively (age 6,10 years, at 1, 18 month post-operatively). Neither of these two patients was responsive to topical estrogen cream post-operatively and required a second surgical separation. Side effects of estrogen were minimal breast development in 6 children and vaginal bleeding in one child. Discontinuance resulted in resolution of side effects. Conclusion Topical estrogens were effective treatment for labial fusion. After surgical separation of adhesions there was a 10% recurrence rate. Estrogen therapy initiated after surgical failure was unsuccessful.

Treatment of Labial Fusion with Topical Estrogen Therapy

Twenty girls with labial fusion that covered at least 50% of the vaginal opening were treated with a topical estrogen cream. The cream was precisely applied to the fused area twice a day until the adhesions were totally lysed. After separation of the adhesions, a petroleum ointment (Vaseline) was applied twice a day to the labia minora for at least 1 month. The introital area was carefully rinsed twice each day before application of either the estrogen cream or the petroleum ointment. The mean age of the studied population was 13.2 months (range, 2 to 38 months). The mean duration of estrogen treatment was 2.4 months (range, 1 to 3.5 months). All patients were successfully treated. Five patients developed vulval pigmentation, which lasted for a mean of 1.5 months. One patient developed breast enlargement, which lasted for 1 month. The mean duration of follow-up was 3.1 months, and there was no recurrence of labial fusion during the period of follow-up. We conclude that treatment of labial fusion with topical estrogen therapy is safe and effective.

A cohort study of topical vaginal estrogen therapy in women previously treated for breast cancer

Objective: To estimate the risk of recurrence of breast cancer associated with the use of topical vaginal estrogen therapy in the management of vaginal atrophy in women previously treated for breastcancer.Methods: The study group comprised 1472 women with histologically confirmed breast cancer. In 69 of these subjects (4.7%) their only bothersome menopausal problems were vaginal symptoms.In these women, poorly absorbed topical vaginal estrogen cream or tablets were used. The response of these patients was compared with that of the rest of the database. A Cox regression analysis was performedusing sex hormone usage after diagnosis as a time-dependent covariate. Disease-free interval was the outcome measured. Results are expressed as a hazard ratio with 95% confidence intervals. The hazard rateis defined as the probability of disease recurrence or of a subject dying from breast cancer over the study period. A second analysis was performed adjusting for factors known to affect breast cancer prognosis.Results: Hormone usage was entered as a time-dependent covariate with disease-free interval as the outcome. Subjects who used a topical estrogen alone for menopausal symptoms had an uncorrected hazardratio of 0.30 (95% confidence interval (CI) 0.11-0.80, p = 0.02). The corrected hazard ratio was 0.57 (95% CI 0.20-1.58, p = 0.28). The hazard rate for a subject dying was not analyzed, asthere were too few numbers.Conclusions: Although the small numbers of this study preclude a definitive result, topical estrogen usage does not appear to be associated with an increased risk ofrecurrence of breast cancer.

The child with a vaginal discharge

This common gynaecological complaint may be caused by a specific infection or most commonly by a non-specific local irritation which establishes an inflammatory response which gives rise to the symptoms. The clinician must understand the normal physiology of the prepubertal vagina before embarking on the management of this problem. A careful history and examination should lead the clinician to a diagnosis in most cases. Bacteriological samples may be helpful and if a specific infection is recognized, appropriate antibiotic treatment should be given. Recurrent courses of antibiotics should be avoided. Detection of a sexually transmitted disease should mean a referral for investigation of sexual abuse. The majority of non-specific cases should be managed by improved hygiene, simple barrier creams, and occasionally, topical oestrogen cream. Parental reassurance is a part of the mainstay of treatment.

Success of medical management of labial adhesions

BACKGROUND: The treatment of labial adhesions with topical estrogen has been reported to have a success rate between 88% and 89%, with almost 50% of these requiring some form of manual separation in the office. The purpose of this study was to evaluate the management of labial adhesions at the Hospital for Sick Children in Toronto, Canada.METHODS: A retrospective chart review of all patients with labial adhesions at the pediatric and adolescent gynecology clinic from 1993 until November 2000.RESULTS: A total of 251 patients were diagnosed with labial adhesion. Of these 168 (67%) were primary diagnoses and 83 (33%) recurrent. The age ranged from four months to sixteen years. All patients without urinary obstruction were treated with topical estrogen cream (Premarin® by Wyeth or Ortho® Dienestrol) BID for two to six weeks. Patients were re-evaluated every two weeks; the cream was discontinued once separation occurred. A total of 23 (9%) had surgical/mechanical separations performed; 3 for urinary obstruction, 4 because of maternal demands, 3 had reactions to the cream, 13 were medical failures. Children over six years of age were more likely to require surgical intervention despite prolonged medical therapy (up to 10 weeks). Medical therapy effected separation in 228 (91%); the treatment period was 2 weeks 94 (38%), 4 weeks 111 (44%), 6 weeks 21 (8%). Limiting the application of estrogen cream solely to the labial join minimized systemic estrogen effects. In 1996 preventive measures were taught after separation and this appeared to reduce recurrences.CONCLUSION: Surgery is rarely necessary for the management of labial adhesions if topical estrogen cream is used appropriately. Complete separation may take up to six weeks so perseverance may be necessary to avoid the potential complications from a surgical procedure. The older the child the greater the incidence of dense adhesions and risk of medical failure. Preventive measures may decrease the recurrence rate.

Labial Agglutination (LA) in Childhood: A Report of 241 Cases

Objectives: LA or fused labia minora are a common problem in prepubertal girls. Surgical separation under general anaesthetic, except in very young infants, has been recommended. Topical estrogen cream short course has been advocated as effective treatment: the best case-series presents 75 patients (Khanam W et al., Obstet Gynecol Surv, 1978;33:364–365). This study has been undertaken to confirm the effectiveness of the estrogen application in a large series of girls.

Childhood vulvovaginitis and vaginal discharge in general practice.

This study aims to examine the aetiology, clinical features and response to treatment of childhood vulvovaginitis in general practice. A longitudinal survey of consecutive premenarchal patients presenting with vulvovaginitis and/or vaginal discharge in the course of normal consultations with a general practitioner was conducted in a semi-rural, group general practice with 11,000 patients in Plymouth, UK. Forty-two premenarchal girls with vaginal inflammation or discharge were surveyed, with main outcome measures being clinical evaluation, microbiological assessment of urine and vaginal swabs, and patients' and parents' assessments of resolution and relapse of symptoms. Non-specific vulvovaginitis with mixed bacterial flora, associated with poor hygiene and atrophic vaginal mucosa, was the commonest cause; specific bacteria were found in 10 out of 42 cases, including six of Streptococcus pyogenes. No candida was isolated. Treatment with topical oestrogen cream was effective only with mixed infection, oral antibiotics were effective in both mixed and single organisms. No evidence of sexual abuse nor foreign body was found. Childhood vulvovaginitis is not uncommon in general practice, is usually associated with mixed growth of faecal organisms, and is seldom due to serious causes such as sexual abuse or foreign body.

The effects of exogenous estrogen on wound healing in dogs

Study Objective: To determine the efficacy of topical estrogen therapy in promoting the healing of genital injuries in prepubertal females.Design: Animal study.Setting: Pediatric and Adolescent Gynecology Clinic in Memphis, Tennessee.Participants: Four prepubertal dogs.Interventions: Four surgical incisions of predetermined length and depth were performed in a radial fashion into the vagina of each dog. Two dogs were treated with topical estrogen cream, and two dogs received no special wound care. Keyes punch biopsies were obtained at 3, 7, 14, and 21 days postoperatively. The biopsies were reviewed by a pathologist in a blinded fashion and graded as to the extent of inflammation and healing.Main Outcome Measures: The biopsies were reviewed by a pathologist in a blinded fashion and graded as to the extent of inflammation and healing.Results: Treated animals appeared to achieve a more complete resolution of the injury at 2 weeks when compared with untreated animals. Untreated dogs experienced a delay in the healing response.Conclusion: The findings of this study add support to the use of estrogen therapy in prepubertal girls with genital injuries.

Urethral prolapse in the premenarcheal female

Urethral prolapse in the premenarcheal female manifests as vaginal bleeding and a periurethral mass. In the past, the recommended management was surgical excision or cautery. However, conservative management has been shown to have excellent results. Five premenarcheal patients with urethral prolapse treated by conservative therapy are presented. Treatment regimen consisted of local hygiene with sitz baths, hexachlorophene soap, topical providone iodine and estrogen cream. There were no complications or recurrences. Surgery is not warranted in the treatment of urethral prolapse in the premenarcheal female. Medical management is equally effective and less traumatic in this age group.