Balance risk against benefit with cream

Dear Dr. Roach: In a recent column, you addressed the costs of vaginal Premarin but did not mention the risks associated with stroke and dementia. Do you consider these risks to be of importance? — J.S.B.

Hormone replacement increases risk of blood clotting. This can certainly lead to increased risk of stroke, and pulmonary embolism.

The dementia association is more complex. Estrogen appears to reduce dementia and heart disease when started early, at menopause, but it increases dementia and heart attack risk when started 10 years or more after menopause. On the other hand, estrogen reduces colon cancer risk but increases breast cancer risk.

However, all of these risks are from systemic estrogen. Low-dose vaginal estrogen probably has very little or no systemic risks. That said, a woman with a history of an estrogen-sensitive cancer should discuss her risk with her oncologist. Women with a history of blood clots should likewise discuss their risk.

I received quite a bit of advice from women who use estrogen cream. I wanted to pass on advice from one woman whose physician sent her to a compounding pharmacy that made estradiol cream at a small fraction of the cost of the brand name. Another woman found that she did not need the entire dispenser to relieve symptoms. I appreciate the advice from readers living through the issues I write about and pass on the information when I can.

Several readers wrote about what they describe as inhumane conditions of horses used in the manufacture of Premarin (the name comes from PREgnant MARe urINe). I recommend estradiol as first choice from a medical perspective, as it is the bioidentical human hormone. Synthetic estradiol is made with soy or yams as a starting material, which I confirmed from the manufacturer.