I'm a health care provider who has been shocked by the meteoric rise of the cost of vaginal estrogen preparations, which alleviate intense menopausal vulvovaginal dryness and irritation. This is a problem that can persist indefinitely after the menopausal hot flash phase is done. These preparations also improve urinary urgency and urge incontinence and also decrease the incidence of bladder infections that menopausal women are prone to. This is because the urethra, which is the tube going from the bladder to the outside world has estrogen receptors in it. Yes, these preparations also make intercourse more comfortable. Vaginal estrogen can treat these problems in much lower doses than is needed to control hot flashes and comes in different forms, including a cream, a little tablet that is inserted, and a ring. One has to be very careful of the dosing of especially the creams because too much absorption of the estrogen can cause cancer in the uterus, but with the right doses this risk is tiny. Other risks such as stroke are tiny also.
Back in the 1990’s and early 2000's I recall that a vaginal estrogen cream was under $40 per tube (3 months supply). There were generic 25 mcg forms of vaginal estradiol tablets (Vagifem was the brand name) that were in this price range, too. It seemed a little expensive at the time but not like it is now. Then someone did a very small study showing that the 10 mcg form of Vagifem is almost as helpful in reducing dryness as the 25 mcg form. So the 10 mcg form got a shiny new patent and the 25 mcg form was taken off the market and BOOM the price for Vagifem was rocketed upward. Now it is over $380 for a 3 months supply, or 12 pills since it is prescribed twice weekly. It is revealing to compare that to oral estradiol, a daily medication prescribed to menopausal women for a limited time for hot flashes, which is available retail at Walmart for $9/month. A 3 month supply of oral E2 costs $27 versus the vaginal around $380. So it costs twelve times (1200%)more for 3 month supply for the vaginal treatment versus oral.
Even crazier, though, the amount of estradiol (E2) in a single Vagifem tablet is 1/100 of the amount in a single tablet of generic oral E2. And since the 3 months supply of oral med is 90 pills whereas the vaginal supply is 12 pills, the vaginal form is 10,693 times more expensive per mg of estradiol than the oral. For Pete's sake, it's just a little tablet you put in the vagina. The applicator used to put the pill into the vagina has been around forever- no special technology there. So Vagifem got expensive and, guess what, the competing vaginal conjugated estrogen cream, a different vaginal estrogen preparation that's been around forever, also started shooting up. A third formulation, vaginal estradiol cream, is also obscenely priced now. And the Estring, too. No collusion there, eh? My patients' plans often did not cover the medication or went toward deductible or whatever. So when I prescribed any of these formulations I would warn them that many women had high out of pocket costs for them. Then invariably I would still get calls from patients saying that when they went to the pharmacy to fill my vaginal estrogen prescription the cost was even higher than I had said it would be, and they can't afford it and is there something else? Many menopausal women use vaginal estrogen to lessen general vaginal irritation or urinary symptoms and are not sexually active. They don't understand why they have to pay so much just for a little relief. Other menopausal women desire to continue the sexual aspect of their relationships, and some them (not all) find that lubricants are not enough. Then there is a subset of women who are in a marriage in which sex has ceased to be part of their life by mutual agreement, but their partner is newly prescribed Viagra or other medicine, and there is a new mismatch of goals. This latter group of women typically really need the relief from painful intercourse that vaginal estrogen can provide.
So now I too have aged and the worst of the hot flashes are behind me. Needing to address other issues, I asked my provider for a prescription for conjugated vaginal estrogen cream, 0.5 g twice weekly and went off to my local pharmacy to fill it. Even with my great insurance plan the price presented to me was $385 for a small 30 g tube! I wondered about personal importation from Canada since I have seen websites where the price is far lower. What about going to Canada to fill a rx personally? I found someone in Canada to help me look things up and did a little research. I found out that a prescription from an American doctor will not be filled by a brick and mortar Canadian pharmacy. (I have no idea how Bernie Sanders or Sherrod Brown were able to bring busloads to Canada to fill rx's). But one could go to a walk-in clinic and be evaluated for $60 and get a prescription. Conjugated vaginal estrogen cream 0.625g/mg at a certain pharmacy chain there costs $41 for a 3 months supply ($164/year). All added up, one could SAVE $284 for a 3 months supply or $1315 for a year's supply! At my local American pharmacy this would have run me $1540.
But there is a problem with doing this. I found out that it is illegal. The current American laws are such that it is not strictly legal to buy Canadian medications online or in person and use them on yourself in the US. It seems like at least personal importation should be legal. It is your own body, your own choice, your own risk, your own privacy. You are not selling anything to anyone else. The FDA could helpfully specify which countries have testing agencies and safer supply of medications. We are not the only country with a safer supply. If the US were so concerned about safety why is our vitamin and supplement industry completely unregulated? Why is such a high percent of our medications made in China of all places? Why did the Toxic Substance Control Act of 1976 allow the grandfathering of 62,000 chemicals, which could stay on the market without first assessing toxic impacts? These have still not been assessed. Why are we kept from knowing what is in an upstream local chemical plant that just leaked gadzillion gallons into the river?
Obviously it's about PHARMA profit. How come the competition between the two vaginal creams, the tablet and the ring has not driven the price of vaginal estrogen down? It didn't used to be this way. Something happened. They have chased each other up in price not down. Same with leukemia drugs, MS drugs, insulin, everything. Competition is not working.
Besides breaking up monopolies and stamping out collusion, we just so clearly need to be allowed to import, at least for ourselves. That will bring the prices down here. Real competition. Nothing else will. And don't get me started on the price of IUD's.