Calla Lily Clinical Care

A Look at Three Common Medications That Can Be Delivered Intravaginally

Oct 28, 2024

Lara Zibners MD MMEd MBA
Co-Founder & Chairman

When one thinks about yeast infections, menopause and fertility support, the conversation usually revolves around pills or injections. But there’s a better, more targeted way to achieve results.

The era of blanket treatments is fading. I used to joke that medicine isn’t Burger King–you can’t just have it your way. Except, that’s exactly what is happening. Patients are being included (rightly so) in decision making. So if you know there is a better, more targeted, fewer side-effects, more reliable, less traumatic way to managing your condition, wouldn’t you want that? We’re highlighting three common medications that can be delivered intravaginally, rather than through a pill or an injection. Right to the source as they say. We’ll explain some of their benefits, use cases, and risks as well as the contexts in which this method is not only effective but also preferable.

1 – Antifungals for Yeast Infections

Science calls it vulvovaginal candidiasis (VVC).

I call it The Bakery.

Most of you know it as a yeast infection.

Whatever the name, VVC is the second most common cause of vaginal infection in the USA. 50-75% of all women experience it at least once in their lifetime and it’s miserable.

Yeast infections are caused by the proliferation of several species of yeast (most notably Candida albicans). Common symptoms include itchiness, abnormal discharge and a burning sensation.

Intravaginal antifungals offer a faster, more localized treatment option. For the majority of women who have experienced a yeast infection, medications such as clotrimazole or miconazole are probably familiar treatments because they are over- the-counter and advertised on TV. With these types of medications like Monistat, the treatment is delivered directly to the source of the infection and causes yeast cell death without having to circulate throughout the body.

The direct application not only hastens relief but also limits the body’s exposure to the medication which can cause other side effects.

Risks

The risks are low! Less than 10% of people who took clotrimazole experienced symptoms in a recent 2023 study.

Intravaginal antifungals may cause local symptoms such as irritation, burning and itching. (Which, by the way, are also the symptoms of a vaginal yeast infection, so it’s really hard to say what’s causing what.)

Use cases

Intravaginal antifungals are the best way to target a localized yeast infection, particularly if you experience adverse reactions to oral medication.
They are a better alternative than oral antifungals for pregnant and breastfeeding women. One study found that 150 milligrams or more of the oral antifungal fluconazole over the first trimester increased the risk of a newborn with a heart defect, compared to no exposure.

2 – Estrogen for Menopause Symptoms

Estrogen is a hormone that plays a vital role in not only sexual and reproductive health but also cardiovascular health and bone density.

Both men and women produce this hormone, but in women, production levels start to decline around menopause and cause symptoms such as:

Vaginal dryness and soreness
Vulval itching, redness, and soreness
Hot flashes
Pain during sexual intercourse
Pain during urination
The urge to frequently urinate

Vaginal estrogen is a type of targeted hormone replacement therapy (HRT) that increases estrogen levels in the vagina. This is particularly valuable for women who cannot take systemic forms that enter the whole body such as gels, pills or patches.

Local delivery of estrogen increases the amount of normal, clear vaginal discharge that would otherwise relieve vaginal dryness and irritation as well as promotes a healthy vulva and urethra.

Estrogen can be delivered vaginally via a cream, gel, ring or pessary (tablet).

Risks

In general, Estrogen-based HRT is pretty safe. (I take it proudly!) However, there can be associated side effects. The most severe complication can be development of life-threatening blood clots, particularly in women with certain genetic conditions, smokers and those with underlying health conditions.

Use cases

Intravaginal estrogen is suited to women that experience vaginal symptoms of menopause.

Since it is delivered in relatively low doses, intravaginal estrogen is also beneficial for those who have contraindications for oral HRT such as a history of breast cancer, blood clots, stroke, or heart disease.

NOTE: As long as you still have a uterus, you will need to take progesterone along with estrogen to protect yourself from the risk of endometrial cancer.

3 – Progesterone for Fertility Support

When it comes to fertility support, progesterone is front and center. (And down under!)

Intravaginal progesterone is commonly prescribed to women who are undergoing IVF treatment and other assisted reproductive techniques. To increase the odds of a pregnancy, progesterone creates an environment in the uterus conducive to the successful implantation of the egg.

The benefits of intravaginal progesterone delivery are similar to that of estrogen and antifungals. Namely, that the intravaginal route allows for more immediate and potent absorption of the hormone by the part of the body that requires it.

Intravaginal progesterone delivery may also be more convenient than the oral route for some women and less painful than viscous, injectable progesterone. I know. I went through 7 rounds of IVF, 5 of them with injected progesterone and it’s still something I remember vividly, and not in a good way.

Risks

As with all intravaginal drugs, there is always a risk of local irritation. Some women may experience bloating, nausea or other common GI side-effects but these are usually far less than experienced with oral formulations.

Use cases

Intravaginal progesterone is commonly used in assisted reproductive technologies such as IVF where support of the uterine lining is critical for the success of embryo implantation.

It’s also used in women with luteal phase abnormalities (where the uterine lining doesn’t grow thick enough to support a pregnancy) or other conditions where natural progesterone production is insufficient.

Why Intravaginal Delivery Matters

Intravaginal delivery of medical treatments is not only the preferred choice for a woman’s vaginal and reproductive area, it’s the most logical. Why wouldn’t you want medications delivered directly to the target with greater effectiveness and few side effects than necessary? It’s often safer, more convenient and more comfortable than the oral or injected alternatives.