Case Study - Vaginal Dryness on Low E2 Dose

Transcript: I want to share a brief consult I had with a patient just today when she came to pick up her prescription. I asked her how things were going, and she said, “Oh, good.” So I followed up with, “How are you feeling?” That second question always opens the door. And it did.She said, “Well, to be honest… not very well.” She didn’t think the hormones were helping her vaginal dryness and discomfort. This is a 52-year-old woman who’s had a complete hysterectomy. Her ovaries are gone, so she’s no longer making any of her own estrogen. So we talked about it.She’s using a low-dose vaginal estradiol tablet twice a week, and she also takes a 0.2mg estradiol troche—basically a lozenge—under her tongue twice a day. She’s been on the same hormone dose for four years with no adjustments. And yet, she’s still dealing with vaginal dryness. That’s something that should be completely resolved with the right dose. She’s getting estrogen two ways—and that’s fine. We often dose estradiol vaginally every day to treat active dryness, then taper to twice a week for maintenance once symptoms resolve. But in her case, it hasn’t resolved—or if it did, it’s come back. I suspect the systemic dose she’s taking under the tongue is probably too low. And I think she needs to go back to daily vaginal dosing for a while to help restore the lining. That’s important—not just for comfort during intimacy—but because restoring the tissue also helps bring back normal secretions and lowers the pH to a slightly acidic range, which protects against urinary tract infections. Most women can eventually stop vaginal estradiol altogether once their systemic dose is dialed in. But some need to continue it for some time. Here’s the key point: when women and men understand exactly what each of their hormones is supposed to be doing, they get relief faster. They do better. Because they know how to advocate for their own care. And you have to do that.You can’t tell your practitioner “it’s not working” if you don’t know what “working” looks like.