Vaginal Estrogen–a High Risk Medication in the Elderly?

There is a wonderful expression used by the French when referencing an older woman. She is “a woman of a certain age” (une femme d’un certain age) Recently. a patient who fits in that category, began suffering from vaginal dryness causing burning and pain. This is impacting her sexual function as well as being just plain uncomfortable. So I prescribed a vaginal estrogen which serves to increase the vascularity in the area and “plump” up the cells. This improves things in general and reduces the discomfort of sexual activity. Her insurance company, a prominent one in our city, requested that I obtain a Prior Authorization but still denied payment for the prescription because it is a “high risk medication in the elderly.”

Oral estrogens are high risk in the elderly, defined as over 65, increasing the risk of stroke, breast cancer and memory problems. This woman is not at all elderly in the sense of being infirm. She walks daily, volunteers weekly, travels widely, has an active sexual life with her husband and could no doubt run circles around half the people involved in the denial of her medication. The lowest cost vaginal estrogen preparation costs about $168 a tube and there isn’t a generic alternative.  In an article published in the American Journal of Obstetrics and Gynecology in 1981, there was NO systemic absorption with low dose vaginal estrogen.(1) A study in 1983 published in the Journal of Clinical Endocrinology and Metabolism showed essentially no changes in the systemic markers of estrogen.(2) While I suspect that no one at the insurance company is maliciously denying claims,  did their pharmacy committee bother to do its homework regarding the difference between vaginal estrogen and oral meds?

Low-dose topical estrogen is significantly safer in women over the age of 65 than oral preparations. This should be a choice between a patient and her doctor NOT a “member” and her insurance company.

1. American Journal of Obstetrics and Gynecology. 1981 Apr 15; 138(9):967-8. – See more at: http://www.popline.org/node/385377#sthash.kkgLZIvI.dpuf
2.Biological Effects of Various Doses of Vaginally Administered Conjugated Equine Estrogens in Postmenopausal Women http://press.endocrine.org/doi/abs/10.1210/jcem-57-1-133

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