| Symptom | None | Mild | Moderate | Severe |
|---|---|---|---|---|
| Vaginal dryness | ☐ | ☐ | ☐ | ☐ |
| Vaginal irritation/itching | ☐ | ☐ | ☐ | ☐ |
| Pain during intercourse | ☐ | ☐ | ☐ | ☐ |
| Urinary urgency | ☐ | ☐ | ☐ | ☐ |
| Urinary frequency | ☐ | ☐ | ☐ | ☐ |
| Recurrent UTIs | ☐ | ☐ | ☐ | ☐ |
| Vaginal discharge | ☐ | ☐ | ☐ | ☐ |
Date: _________________ Next Follow-up: _________________
| Product | Strength | Frequency | Estradiol Dose |
|---|---|---|---|
| Vagifem® (tablet) | 10 mcg | 2x/week | 10 mcg/dose |
| Estrace® (cream) | 0.01% | 1-4 g daily → 2x/week | 100-400 mcg/g |
| Premarin® (cream) | 0.625 mg/g | 0.5-2 g daily → 2x/week | CEE 0.625 mg/g |
| Estring® (ring) | 2 mg | Every 90 days | 7.5 mcg/day |
| Femring® (ring) | 0.05 mg/24hr | Every 90 days | 50 mcg/day |
| Imvexxy® (insert) | 4 mcg, 10 mcg | Daily → 2x/week | 4-10 mcg/dose |
| Intrarosa® (insert) | 6.5 mg | Daily | DHEA 6.5 mg |
Note: CEE = Conjugated Equine Estrogens. Initial dosing is typically daily for 2 weeks, then maintenance 2x/week.