Take Care of Your Rose:

What Pissed-Off Grannies with Vulvas Can Do

This is the third part of my series on Genitourinary Syndrome of Menopause.
Here are the links to Part 1 and Part 2.

In 1845, Columbat de l’Isere wrote an early description of what is now called Genitourinary Syndrome of Menopause, or GSM:
“The postmenopausal woman’s features are stamped with the impress of age and their genital organs are sealed with the signet of sterility… It is the dictate of prudence to avoid all such circumstances as might tend to awaken any erotic thoughts in the mind and re-animate a sentiment that ought rather become extinct.”

Thanks so much, Columbat, for that terrible advice. Because, as it turns out, seminal fluid contains a high level of estrogen; one of the best things we can do for our post-menopausal vulvas is to have lots of sex with men. And that just goes to show that taking care of ourselves can be joyful.

But sex alone cannot replace reasonably priced vaginal estrogen. The American pharmaceutical industry has run a pricing scam on estradiol for half a century and it needs to stop. Recently, some women have even turned to laser “rejuvenation” of the vulva, an unapproved and dangerous technique that is the subject of an FDA Warning. The greed of businesses large and small puts women in danger, and together we can help to change that.

First, we need to break the silence about GSM. While there is a well warranted public outcry about steep price increases in off-patent drugs like insulin and the EpiPen, little is spoken or written about estradiol and GSM. A June 2018 New York Times article quotes Dr. Lauren Streicher, the medical director of the Northwestern Medicine Center for Sexual Medicine and Menopause: “Women are not going to be rising up and saying, ‘My vagina is dry and I don’t want to pay 2,000 to 3,000 dollars a year.”
We won’t? Really? Why not? A friend in England who read the first two parts of this blog series just sent the price of estrogen cream via the UK’s National Health Service. It is—get this—UK# 4.00 a tube, or a little over five dollars. A British woman could literally buy a hundred tubes of estrogen cream for the retail price of one tube in the United States. It is well past time for American women to rise up and protest about the barriers to the health of our vaginas after menopause. We need to ditch toxic shame and raise our concerns out in the world of price fixing lawsuits, insurance companies, and manufacturers.

Here’s What Pissed-Off Grannies with Vulvas Can Do.

These are some ways to push back and make noise. Please let me know what you try and how it goes.

• Is your state one of the 44 that are suing drug companies for price fixing? If so, write to your attorney general and demand that estradiol cream be added to the lawsuit.
• If you use generic estradiol, let the manufacturer know that you will demand reasonable pricing of estradiol cream be part of the settlement.
• Find an independent pharmacy. Many of them can give you a lower price without insurance than you would get using your insurance at a major pharmacy chain. And be sure to let your big-name pharmacy know why you don’t buy there anymore.
• Consider the possibility of a cream compounded by an independent pharmacist. Under FDA regulations, a pharmacist is legally precluded from making a medication that is available as an FDA-approved product. But a different concentration? Sure, that’s legal. Will your pharmacy make it? They might; ask and see. And the more of us who get prescriptions from our doctors for a non-commercial concentration, the better.
• Talk with your insurance company. Tell them there is no rationale for your medication to be on a higher tier than birth control pills. It’s not the little blue pill; treating your GSM is about even more than sexual health.
• Even insurance sponsored by AARP covers a small part of the cost of this product that many of their members require. The good news is that AARP wants to hear from you about overpriced medications for seniors—let’s give them an earful about estradiol! The email address to reach the right person at AARP is in this article.
• If you live in the US and near the Canadian border, you may be able to investigate Canadian pricing as well.
• Talk with your friends about GSM, and if they use estradiol, spread the word by sharing these blog posts with them and on your social media channels. The share buttons on the left make this easy to do – do it NOW please.

Continue to educate yourself and your friends about treatment for women’s health after menopause.One avenue to explore is Hormone Replacement Therapy (HRT), the use of systemic hormones via pills or a patch.

This treatment can be used instead of vaginal application of estradiol. In addition to the symptoms of GSM, systemically delivered hormones can help with more symptoms of menopause such as hot flashes, night sweats, mood swings and joint pain.
HRT was widely used before initial results of the Women’s Health Initiative suggested that HRT increased the incidence of breast cancer; at that point prescriptions plummeted.The Women’s Health Initiative was begun in 1991 to study the effects of estrogen on the three main causes of women’s significant illness and death after menopause: osteoporosis, cancer and cardiovascular disease. The study did not focus on quality-of-life issues such as hot flashes, which were the main reason women took HRT. The initial budget was $625 million for a 15-year study that enrolled over 200,000 women and garnered lots of attention in medical journals and the popular press. Early published results of the Women’s Health initiative have been criticized for overemphasizing statistically insignificant breast cancer risks while ignoring women’s quality of life. Further data collection and analysis showed a decrease in breast cancer in women treated only with estrogen (the form of HRT prescribed for women who have had hysterectomies). However, the risk of breast cancer did increase in women treated with estrogen plus progestin (the form of HRT often prescribed for women who still have a uterus), to limit chances of endometriosis.

Current medical journals give contradictory information about the risks and benefits of HRT. There seems to be consensus that HRT decreases the risk of fractures, which makes sense given that estrogen has a protective effect on bone density.
On the other hand, more recent analyses of multiple studies show increases in the risk of stroke and cardiovascular disease for women who take HRT.
It is telling that extended studies past the original Women’s Health Initiative showed no difference in overall mortality between women taking a placebo and women receiving HRT. This begs the questions:

• Why is overall mortality unchanged, if in fact HRT increases the risks of stroke and cardiovascular disease?
• What key factors in life expectancy are not accounted for?
• Should studies factor in the effect of estrogen on muscle mass, on improved sleep, on bone density, and what other criteria?
• And knowing that overall mortality is unchanged, how should women balance the slight increases in the risk of certain conditions against the improvements in quality of life when taking HRT?

Some journal authors advocate increased use of HRT, emphasizing the “needless suffering” women experience due to the backlash against HRT following the Women’s Health Initiative.  Others note that the greater the level of symptoms, the more relief HRT provides. Official positions of medical organizations range from discouraging any use of HRT to advocating its use for a limited time (e.g., five years), and only for newly menopausal women.
With all this contradictory information, ultimately each woman past menopause must make the decision whether to use systemic HRT or a local estradiol cream by educating ourselves and talking with our physicians, in light of our individual symptoms.

And one more factor to keep in mind: For American women, the cost of oral hormone replacement therapy is a fraction of the cost of estradiol cream. HRT can cost as little as $45 per year.

Women have a longer lifespan post-menopause than almost any other mammal, as discussed in my previous blog on the Grandmother Hypothesis. We deserve medical treatment that is based on science and we deserve medicine that is reasonably priced. According to IQVIA, a company that runs clinical trials and tracks drug sales, menopause related treatments totaled nearly three billion dollars in 2017. That means we women past mid-life are a huge market with a lot of power, if we speak up and work together.

Let’s make it happen.

To Learn More about the Topics in Part Three:

• FDA Warning about Unapproved Laser “Vaginal Rejuvenation”
• New York Times article cites reluctance of women to call for lower prices

Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women’s Well-Being and Lengthen Their Lives—Without Raising the Risk of Breast Cancer by Avrum Bluming, MD, and Carol Tavris, PhD

In Case You Missed It:
Part One: GSM Now That Trips Off The Tongue describes the causes and symptoms of GSM, how it is treated with vaginal estradiol cream, and quotes a Senate investigation of estradiol price fixing from half a century ago.
Part Two: Estradiol – The Scam What Am examines the “research” rationale for high estradiol prices, and why it doesn’t hold water. Then it explains why FDA approval of generic estradiol has not significantly improved the pricing for this product, and why even women with insurance pay so much for estradiol.