Abstract
IMPORTANCE: Low-dose vaginal estrogen (VE) is a safe and effective treatment for genitourinary syndrome of menopause (GSM). The frequency of VE prescribing for GSM is unknown. OBJECTIVE: To evaluate VE prescriptions among women with GSM and to identify clinical phenotypes associated with VE claims. DESIGN, SETTING, AND PARTICIPANTS: This is a retrospective, population-based cohort study of a 20% random sample of Medicare fee-for-service beneficiaries enrolled in Parts A, B, and D from 2006 to 2018. Women aged 66 years and older with a diagnosis indicative of GSM were included. Exclusion criteria included diagnoses of breast and/or endometrial cancer within 6 months of GSM diagnosis. Data analysis was performed from October 2023 to June 2024. EXPOSURE: Diagnosis indicative of GSM. MAIN OUTCOMES AND MEASURES: The primary outcome was the proportion of women with a VE prescription claim (cream, ring, or tablet) during the follow-up period, from first GSM diagnosis to the end of Medicare enrollment or the study period. To quantify associations between patient characteristics and the likelihood of VE claims, univariable and multivariable logistic regression analyses were conducted. RESULTS: A total of 1 838 732 women with at least 1 GSM-related diagnosis were identified (median [IQR] age, 74 [69-81] years; median [IQR] follow-up, 8 [4-10] years). VE prescriptions were filled by 165 530 women (9.0%) at a median (IQR) of 15 (2-46) months after diagnosis. Older women (adjusted odds ratio [aOR] for >86 years vs 66-70 years, 0.59; 95% CI, 0.58-0.60) and those with higher Charlson Comorbidity Index scores (aOR for score ≥5 vs 0, 0.67; 95% CI, 0.66-0.69) were less likely to have a VE claim. When comparing GSM symptom groups, women with recurrent urinary tract infections were least likely to have a VE claim (aOR vs local sexual symptoms, 0.54; 95% CI, 0.46-0.64). Women with vulvovaginal symptoms (aOR, 2.70; 95% CI, 2.45-2.97) and GSM multimorbidity (aOR, 15.91; 95% CI, 14.41-17.57) were most likely to have a VE claim. CONCLUSIONS AND RELEVANCE: In this large cohort study, 9.0% of female Medicare beneficiaries with a diagnosis indicative of GSM filled a VE prescription. Younger and healthier beneficiaries and those with GSM multimorbidity were more likely to fill a VE prescription. The majority of patients with GSM symptoms, including dyspareunia, vulvovaginal atrophy, and recurrent urinary tract infections, did not fill a VE prescription. Improving patient and practitioner education, revising the diagnostic code schema to capture the full breadth of symptoms, and validating GSM clinical phenotypes will help facilitate care and enhance our understanding of symptoms in research studies.