Prescribing Trends for Vaginal Estrogen: What Role Do Urologists Play?

Objectives: Little is known regarding urologist prescribing patterns of vaginal estrogen (VE) since the American College of Obstetrics and Gynecology’s 2016 committee opinion on the safety of VE. Our aim is to assess VE prescribing trends for urologists participating in Medicare Part D and determine differences for those subspecialized in urogynecology and reconstructive pelvic surgery (URPS) from 2016-2018.

Methods: We queried the Medicare Part D Prescriber dataset from 2016-2018 to identify urologists who made claims for VE, including Vagifem, Estring, Estrace, and Yuvafem. Premarin was excluded because the database did not discriminate between oral and vaginal formulations. The American Board of Urology registry was queried to determine if urologists were board-certified in URPS. Claims and expenditure trends were analyzed using descriptive statistics as well as student’s t-test and one-way ANOVA.

Results: From 2016-2018, we identified 4,515 urologists with claims for VE, 625 of which were board-certified in URPS. During this time, the number of VE claims decreased from 56,777 to 27,362 for all urologists and from 12,011 to 7,309 for URPS urologists. Each year, URPS urologists had significantly more claims per provider than non-URPS urologists (42.9 vs 26.7, p< 0.0001 in 2016; 42 vs 27.7, p< 0.0001 in 2017; 30.1 vs 23.9, p=0.007 in 2018) (Figure 1).

The majority of the claims were for Estrace (84.7%), followed by Yuvafem (7.2%), Vagifem (6.2%), and Estring (1.9%). Compared to non-URPS urologists, URPS urologists had higher mean claims per provider for Estrace (40 vs. 27, p< 0.0001) but fewer mean claims per provider for Estring (19 vs 26, p=0.0006) with no difference for Vagifem or Yuvafem.

For all urologists, mean spending per claim per urologist increased for Estrace (p < 0.0001) and Estring (p < 0.0001) but decreased for Yuvafem (p < 0.01) from 2016-2018. However, there was no difference in mean spending per claim per urologist between URPS and non-URPS urologists for any VE product during the study period.

Conclusions: The overall number of VE claims made by urologists participating in Medicare Part D decreased from 2016 through 2018. URPS-certified urologists made more VE claims than non-URPS urologists, despite similar cost per claim. These findings may be reflective of referral patterns or the impact of fellowship training in URPS on how urologists treat genitourinary syndrome of menopause.

Figure 1: Mean number of vaginal estrogen claims made by urologists participating in Medicare Part D, stratified by URPS sub-specialty board certification; URPS=urogynecology and reconstructive pelvic surgery