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rachelrubinmd.com
M E N O P A U S E E V E N T S E R I E S
How Vaginal Estrogen Therapy Can Reduce Risk of UTIs".
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
Dr. Rachel Rubin
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Estrogen Loss and Manifestation
of Health Risks Over Time
40 45 50 55 60 65 70 75+
Thacker HL. The Cleveland Clinic Guide to Menopause. New York, NY: Kaplan; 2009.
Age (years)
Development of subclinical disease
Estrogen
Secretion
Urogenital symptoms
Short-Term Symptoms Long-Term Symptoms
Hot flushes, sleep, mood
Osteoporosis
100-110 pg/ml
10-20 pg/ml
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Anatomy
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Hormones matter
estrogen and androgens
• Oral contraceptives
• Breast feeding
• Infertility treatments
• Menopause
• Oophorectomy
• Breast cancer treatments
– SERMS
– Aromatase Inhibitors
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Characterization of vaginal and vulvar vestibule
biopsies on healthy premenopausal women
Squamous epithelium
Lamina propria
Blood vessels
Collagen
Vaginal lumen
50 µm
Vaginal mucosae Vestibular mucosae
25 µm
Estrogen Receptor α
Vaginal mucosae Vestibular mucosae
25 µm
12 µm 12 µm
Androgen Receptor
Immunohistochemistry of androgen and estrogen receptors in the
vaginal vs vulvar-vestibule mucosae of the same patient.
• All the enzymatic machinery necessary to the conversion of
adrenal precursors such as DHEA into active sex steroids was
detected both in the vaginal and vulvar vestibule’s mucosae.
• Both the androgen and the estrogen receptors were expressed
in the vaginal and the vulvar vestibule’s mucosae
• As previously reported2, AR had a robust expression in the
vulvar-vestibule.
1. Bouchard C. Poster presented at the 19th world congress of Gynecologal Endocrinology, Dec. 2020 2. Palacios S, Menopause. 2020 Nov;27(11):1336-42
Exemples of cells positively-marked by the specific antibody
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Jin J. JAMA. 2017;317(13):1388
Portman et al, The journal of sexual medicine 11.12 (2014): 2865-2872.
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Prendergast Obstetrics and Gynecology Clinics, (2017). 44(3), 509-522.
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• Symptoms
• Survival
• Quality of life
WHY WHAT
• 4 options
• Safety & efficacy data
HOW
• Self-advocacy
• Resources for
providers
WHERE
• Price shopping
• Accessibility
4 Safe & Effective Local Vaginal
Hormone Therapies
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Genitourinary Syndrome
of Menopause
• Genital dryness
• Discomfort or pain
• Decreased arousal
• Diminished orgasm
• Irritation, burning, or itching of
the vulva or vagina
• Decreased elasticity
• Post-coital bleeding
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
• Pain with urination
• Urinary frequency
• Urinary urgency
• Urethral prolapse
• Recurrent urinary tract infections
• Urinary incontinence
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Estradiol Vaginal Cream
Estradiol 0.01%
Insert 1 gram vaginally every night for
2 weeks
Then decrease to twice weekly
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Estradiol Vaginal Inserts
Estradiol 10 mcg
Insert 1 tablet vaginally every night for
2 weeks
Then decrease to twice weekly
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Estradiol Vaginal Ring
Estradiol 7.5 mcg / day
Insert 1 ring vaginally every 3 months
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Intrarosa Vaginal Inserts
DHEA and palm oil
Insert 1 suppository vaginally every
night
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
Impact of Vaginal Prasterone on the Rate of
Urinary Tract Infections in GSM patients and
those with a History of Breast Cancer: A
Retrospective Cohort Analysis.
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But CANCER!!!!
Safety conversation.
Find out what they are most afraid of and drown them with data and
reassurance
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Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
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Estradiol Preparations and Maximum Annual Delivered Dose
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Boxed Warning
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CONCLUSIONS: The risks of cardiovascular disease and cancer were not elevated among
postmenopausal women using vaginal estrogens, providing reassurance about the safety of
treatment.
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Laser based therapy
is there consensus yet?
….of course not
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CO2 fractionated laser
Karram et al, OBG Manag. 2015; 27 (8): e1–e6.
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CO2 fractionated laser
• 1 month after laser: thicker epithelium with wide columns of large epithelial
cells rich in glycogen.
• reorganization of connective tissue, both in the lamina propria and the core of
the papillae
Karram et al, OBG Manag. 2015; 27 (8): e1–e6.
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Aromatase inhibitors
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Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
• International Society for the Study of Women’s
Sexual Health (ISSWSH)
⚬ isswsh.org
• The Menopause Society
⚬ menopause.org
Self-advocacy and resources
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Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
• Estradiol Cream, Inserts, and Tablets, generic
⚬ Any pharmacy, using insurance or a GoodRx coupon
⚬ CostPlusDrugs.com with a prescription
• Estradiol Ring, Estring
⚬ Any pharmacy, using insurance and/or savings card from estring.com
• Intrarosa
⚬ Any pharmacy, using insurance and/or savings card from intrarosa.com
Where can I get vaginal
hormones?
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• Can premenopausal women use this?
• Do I need progesterone?
• What if I have bleeding?
• When can I stop?
• What are the side effects?
• What if I get a yeast infection?
• What if I still have symptoms?
• Can I use this with systemic therapy?
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
FAQ
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• Sign up for our Menopause Group Visit Day
• October 13th 10-11:30am lecture, 1-4pm visits
• 1.5 hour lecture on menopause: the genitourinary system AND the
whole body
• Head the events page on rachelrubinmd.com
• Reach out to Sophia at office@rachelrubinmd.com to get scheduled.
Rachel Rubin, MD
Urologist & Sexual Medicine Specialist
Want a customized plan?
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