Jul 19, 2018

Interview Transcript

Dr. Jones: There's a problem that is very common in women after menopause. It can cause significant discomfort, it's very easy to treat with a medication that's widely available and low-tech, and it's really, really expensive. What's going on? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is about vaginal health on The Scope.

Announcer: Covering all aspects of women's health. This is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Estrogen, my favorite hormone, is the primary hormone that keeps the vaginal skin healthy and elastic. The tissues in the vagina and the lower part of the urethra, the tube that comes out of the bladder are very sensitive to low doses of estrogens made naturally in women of reproductive years. Having these tissues be healthy and elastic is important for comfort during sexual intercourse, is important for the normal microbiome of the vagina, and helps women from getting too many urinary tract infections.

After menopause, women who don't take hormonal therapy with estrogen, and that's the majority of women actually, often find they have a sense of dryness or burning in the vaginal area. They may have painful intercourse. They may have more urinary tract infections. And the good news is the treatment is easy. Estrogen applied in very small doses to the vagina with the cream, a little pill, a suppository, or even a ring placed in the vagina that slowly releases small amounts of estrogens locally.

A big study that followed 50,000 women over 10 years, looked at these women who used local natural estrogen after menopause and compared their health outcomes to women who didn't use any estrogens. There was no increase in the risk of breast cancer, heart disease, or blood clots, diseases that can be slightly associated with postmenopausal estrogens taken in larger doses for hot flashes.

So what's the problem? It's a common problem, and it's a low-tech, easy fix. Now, if I wanted to take estradiol, my natural hormone, by pill for hot flashes, I could go to Walmart and get a 90-day supply for $10. If I wanted to use the same hormone vaginally, prepared to be absorbed by the vagina and this isn't rocket science, drug technology, it will cost $520 depending on how the estradiol is delivered. Now, $520 is the upper end, $300 is the lower end.

So what is the reason that the pharmaceutical industry puts such high prices on vaginal estradiol? It's because they can. Even women who might have a drug plan with their insurance might have to pay a lot for these drugs, much more than they would for oral contraceptives or birth control pills or oral estrogen. Drugs to treat sexual health for women like the estradiol products are frequently placed on a higher formulary tier, meaning you're going to have to pay a large percent of the list price. Although it may be covered by the insurance company, the amount that they might pay would be little.

The problem caused by vaginal atrophy, thinning of the vagina and the urethra are not only sexual. Women can have discomfort with some sports like bike riding, and they might have more urinary tract infections. Not only are the prices high, but they're going up, even doubling over the past five years, and the technology is not new.

The company that made the little vagina estrogen pill dropped the dose in half because the lower dose did a good job, but the price wasn't lower and it still keeps going up.

A new product just approved by the FDA with the rather odd, but sort of cute name called Imvexxy, it'll be available in July of 2018 and provides estradiol at a very low dose, the lowest of any product and could have made a big hit on the market if they'd priced it at a level that most postmenopausal women could afford. This drug is being priced about the same high cost as the other products. There is another product the FDA approved for vaginal atrophy, which isn't an estrogen, but is another naturally occurring hormone, DHEA comes in a vaginal suppository, and it's really expensive too.

So some women are turning to Europe or Canada to get these medications at a more reasonable price, even though it won't be covered by insurance, and it may not be strictly legal to import it. Also, many pharmacies that compound hormones with creams are selling the products at lower cost, but they aren't under the same control with respect to quality and consistency that the FDA approves manufacturers are.

So what is a woman to do? First of all, if you're a postmenopausal woman and having trouble with painful intercourse or symptoms of dryness or burning in the vaginal area or frequent urinary tract infections, you should talk to your clinician. They can easily check and make sure the problem is vaginal atrophy associated with low estrogen and not something else that might be treated in another way.

Speak up. If enough women complain to their insurance companies, maybe the word will get back to manufacturers. If your local compounding pharmacy can make vaginal estrogen at the correct low dose, that's an option. And this is the only situation where I actually recommend this particular option. There are some companies that are making these products generic, which will bring the price down a little bit, but not as low as the technology would suggest. They can keep the price up because they can.

Talk to your clinician about other options that might be available for your symptoms if you cannot afford vaginal estrogens or choose not to take them. Don't suffer, there are choices. Speak up, be heard. And thanks for joining us on The Scope.

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