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[Grangravy]

I've found it difficult to find out exactly which product is the strongest, when it comes to Vagifem and the creams.

I know that Ovestin cream is stronger than Gynest, and although some say the applicator delivers a smaller dose of Ovestin, does that really mean you get the same dose from either product?

Also, I presume that one vagifem tablet delivers 10mcg, but is that the same as using one dose of cream, given that they are a different hormone?

I noticed from the 'burning club' thread that Dr. Currie hadn't condoned using more than the stated dose of vagifem (because that would be against the licensing agreement) and not mixing products i.e. vagifem inside and cream outside.

When the company stopped the 25mcg vagifem, they said it was because studies showed 10mcg x 2 weekly provided equally good results as 25's, but I don't know many that would agree with that.

I'm all for using what works best, but if someone would just spell out accurately which product is the strongest - life would be so much easier.

[dahliagirl]

I think they are all very much the same dosewise.

Estring is a higher dose - nearer the old vagifem.

The wording on the vagifem study did not say that 10mg worked as well as 25mg, but instead something woolly, to the effect that they both had an effect and that reducing to 10mg was in line with the 'smallest effective dose for the shortest time' that was going on, after the publication of the MWS/millennium study in the early 2000s.  I am sure that someone like Hurdity will know for sure.

[dahliagirl]

Yes - they were a nice halfway house between the tablet pessaries and the cream.

I have never tried the cream, but my experience of antibiotic cream is that it all falls out when you stand up in the morning. 

[Hurdity]

Hi Grangravy

As dahliagirl said the studies did not show they worked the same - I did look it up in detail at the time and have just hunted for the post I made as it would take ages to read it all again!

This is the post I wrote:

http://www.menopausematters.co.uk/forum/index.php/topic,23071.msg350814.html#msg350814

"I don't think they actually said that 10 mcg is as effective as 25 mcg. What they said was that trials showed that 10 mcg was effective - which is totally different.

Here is the company's response in their FAQs about the discontinuation of the 25 mcg dose:

Does Vagifem® 10μg work as well as Vagifem® 25μg?
Vagifem® 10μg has undergone rigorous approval procedures in North America and the EU, where clinical data demonstrated the efficacy of the product in treating symptoms of vaginal atrophy.8

The rationale was to use what they say was the lowest effective dose.

The paper that quotes all of this is called:

Efficacy and safety of ultra-low dose Vagifem (10 mcg) (Chollet 2011)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3234898/

Regarding efficacy - this is what the conclusion of one study involving 230 women found:

Vaginal tablets with 25 mcg and 10 mcg improved VVA [vulvovaginal atrophy] by decreasing vaginal pH and increasing maturation of the vaginal epithelium. These improvements were greater with the 25 mcg than with the 10 mcg which was to be expected.

However another study goes on to just look at the effect of 10 mcg compared to placebo (309 women) and found significant differences from placebo for various measures such as cells and pH, but that is not to say this difference is going to be felt by nor equally by all women. Basically it's a fudge. If the same study had also included women using 25 mcg they would have found an increased effect similarly to the study above, but the study was designed to test whether 10 mcg was effective - and within the limitations of that trial - it was.

No doctor can possibly conclude from this, that the 10 mcg dosage is going to work for all women."

Notwithstanding the ongoing debate about 10 mcg vs 25 mcg, the standard dose for estradiol (Vagifem), and the different estriol creams are designed to do the same job at the standard dose. The amount of estriol you get from the two different preparations is exactly the same, but obviously you have to use 10 times more Gynest than Ovestin. Yes it is very unfortunate they discontinued the pessaries - I still have some of these left, but use Vagifem when on my cycle. I phoned the manufacturers at the time to ask why and they said it was an old-fashioned product!!! Duuhhh!

Estriol and estradiol both work to reduce VA by doing all the right stuff physiologically - plumping up tissues/cell growth, and changing ph of vagina. There are two different types of oestrogen receptor in the vagina - alpha and beta and estriol has greater affinity for B receptors, but less affinity compared to estradiol for alpha receptors.

It's a matter of preference which one you use - but they are designed to do the same job.

In terms of doubling up or deviating from the (now-reduced) licensed dose, the new NICE Guidelines suggest that this can be undertaken with GP consultation from a specialist.

"If low-dose vaginal oestrogen does not relieve symptoms of urogenital atrophy, consider increasing the dose after seeking advice from a healthcare professional with expertise in menopause"

http://www.nice.org.uk/guidance/ng23/resources/menopause-diagnosis-and-management-1837330217413

My GP (gynae specialism) is happy to prescribe cream ( the 0.01%) along with Vagifem. The weaker cream is good for rubbing on the border between external and internal that perhpas Vagifem does not reach.

The only difference is the Estring which is much stronger - and delivers approx the same amount of estradiol as 2 x 25 mcg Vagifem., so can;t see why this is permitted and not the other.

Hope this helps 

Hurdity x