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[matildamouse]

http://www.whria.com.au/wp-content/uploads/2016/08/HRT-Micronised-Progesterone-2016.pdf

I found this really easy to read and understand article highlighting a few aspects which are frequently discussed on this forum...please see the specific comments regards twice a week vaginal progesterone as well as alternative days of vaginal progesterone and minimum dosages considered safe etc. Also note the research to support this regimes.

Also note the comments on vaginal estrogen advised to be placed in ANTERIOR vagina to assist with bladder and vaginal atrophy issues. Also note the warning regards endometrial stimulation with posterior placement of vaginal estrogen. Made me worry whether the deep placement of Vagifem (as per applicator) can contribute to a thicker lining in combo with my estrogen patch.
 I find this a bit confusing with regards to Vagifem specifically as the applicator provided will ensure more of a posterior placement. My plan is in future to place the Vagifem not as deep as possible but try more of an anterior placement ( as advised in this article) and assess any positive changes to my bladder especially at night.

Any comments and thoughts on this article?

[matildamouse]

For those who do not have time to read the whole article, following are the extractions which caught my attention : (mP4 is micronized progesterone)

Recommended dosage of mP4 for women using E2 orally or transdermally:

Oral route
Cyclical: 200mg mP4 for twelve to fourteen days per month
Continuous: 100mg mP4 daily

Vaginal route
Alternate day: 100mg mP4
Sequential: 45-100mg for at least 10 days a month
Minimal dose: 100mg twice a week (more research needed; endometrial monitoring may be required)

Transdermal route
Not recommended

AND

Vaginal E2 should not be inserted deep into the vagina but rather delivered to the anterior vaginal wall. From a pharmacokinetic perspective, the vagina has two compartments. The posterior component has vascular and lymphatic connections with the uterus and so E2 placed in the posterior vagina, if used for long periods of time, could theoretically induce endometrial hyperplasia. The anterior compartment has connections with the urethra, clitoris and bladder9 and so placement of E2 in this region best reduces atrophic symptoms.

[Dancinggirl]

Very interesting matildamouse.
I use Vagifem and hope to be using it the rest of my life due to, predominantly, urethral burning, so this info was very appropriate for me. DG x

[Jenna]

http://www.whria.com.au/wp-content/uploads/2016/08/HRT-Micronised-Progesterone-2016.pdf

Also note the comments on vaginal estrogen advised to be placed in ANTERIOR vagina to assist with bladder and vaginal atrophy issues. Also note the warning regards endometrial stimulation with posterior placement of vaginal estrogen. Made me worry whether the deep placement of Vagifem (as per applicator) can contribute to a thicker lining in combo with my estrogen patch.
 I find this a bit confusing with regards to Vagifem specifically as the applicator provided will ensure more of a posterior placement. My plan is in future to place the Vagifem not as deep as possible but try more of an anterior placement ( as advised in this article) and assess any positive changes to my bladder especially at night.

Any comments and thoughts on this article?

Thank you for posting this, matildamouse.

As I have been using vaginal oestrogen (Estriol Cream) for approximately ten years now, reading this worries me a great deal.

I wonder whether ladies who have been prescribed vaginal oestrogen delivered by applicators should now be scanned for endometrial thickening.

[Wrensong]

Thank you for posting the link & helpful summary Matildamouse.  A very interesting article & easy to read.  Really unfortunate some of us find micronised progesterone makes us feel so dreadful, but the research is reassuring for those who get on well with it.  The Vagifem placement advice is food for thought & may help many women.  Thank you again.

[CLKD]

My GP never hesitated in prescribing treatment for VA.  I put it up as high as possible in the belief that the whole of the vagina needs to be kept as moist as possible - it was like razor blades up there!

Thanks for posting.  What do NICE suggest?

[matildamouse]

Good point CKLD.

I have noticed on the 2 nights a week I use Vagifem, I have minor uterine cramping a few hours later..since reading this article, I am now really worried regards this.

[Dancinggirl]

I don't think we should get too alarmed. I doubt that there is real concern over the uterus building as the Vagifem dose is half what its used to be and the NICE guidelines actually say that scans are unnecessary.
What I found interesting, is the placement of the Vagifem pellet for the benefit of the bladder - which many of us need. The dose is so tiny, it makes sense to me that placing it closer to the bladder would be beneficial for those of us who suffer with bladder and urethra pain and UTI type symptoms. Our uterus dose not need maintaining but our bladders definitely do.  Many of us have to use more than the 2 a week treatment, so perhaps it would be sensible to place some doses high up and some nearer the bladder?
The NICE guidelines say that it is only if bleeding should occur that a scan would be advisable - I wonder what the statistics show for long term use? The NICE guidelines also state that symptoms are very likely to return if treatment is stopped, - to me this implies that treatment should be used long term?
UTIs are common as we age - I wonder how many women get fewer UTIs if they are using local oestrogen? There is still a lot of research to be done to demonstrate the protective benefits of local oestrogen - I feel it should be routine for all women post meno.  DG x

[CLKD]

Luckily I 've never had cramps with Ovestin1mg although symptoms seem to return the next day  .  The GP would have to wrest the product from me 

[Hurdity]

Thanks for the link matildamouse - interesting that micronised progesterone is finally available in Aus!

The current NICE recommendations and those of the BMS, IMS etc are that vaginal oestrogen can be used indefinitely without using a progestogen because systemic absorption is extremely low and the doses used are also low. However most of the recommendations or position statements do say there is no evidence from trials of long-term use of this to back-up this recommendation - so I presume the evidence is anecdotal and observational as well as theroetically reasonable. As always any unusual or persistent pains, or abnormal or unexpected spotting or bleeding should be referred to a doctor.

I did not find that statement in the paper at all worrying! There was absolutely no evidence to back this up at all - just a theoretical possibility - and in any case how on earth can you determine where the Vagifem ends  up - I mean it could stick to either the anterior or the posterior wall (if that is what they are referring to). No studies even of vagifem application have looked at this as far as I know but look at the important clinical outcomes ie whether endometrial hyperplasia (or just thickening) occurred within the time-scale of usage, and also measured systemic oestrogen levels which remain within post-menopausal levels (on the low doses and when plumped up) according to trials.

If anyone has been using vaginal oestrogen (and is not using systemic HRT) for 5 years or more and is concerned then by all means suggest you ask your doc for a scan - on the understanding that no long term trials data exist, but in the absence of symptoms (pains, spotting) they may refuse.

Good idea sparkle - to ask about checking your fibroids and to get a scan! There is no evidence though, that fibroids are affected by local oestrogen, in fact my small fibroid shrunk over a couple of years even while using systemic HRT as well as Vagifem (hasn't been looked at recently).

I really would not worry at the moment. Noone is going to have to stop using it!! If you were all going to get endometrial thickening from local oestrogen then gyanes and docs would have noticed by  now and ordered more studies, as it's been around for some time. If the worst came to the worst and it was found to cause more thickening in more women then a progestogen course could be given to shed the lining say every one or two years ( as used to be recommended by some authorities - not in UK I don't think).

Relax

Hurdity x

[matildamouse]

Thanks everone for your input. Agree, Hurdity, going for a scan is the only way we will know for sure.

I am doing an experiment for myself now to NOT place my Vagifem as deep as possible to see if my bladders symptoms might improve with more of an anterior placement.

I use vaginal progesterone on alternative days and aim for a deep vaginal placement which this article also advise. Interesting that according to this article, the alternative day regime (vaginal) is one of the suggested regimes! And can actually result in atrophy of the endometrium as per research studies

[Wrensong]

I was also a bit confused by the use of "anterior" & posterior" in the article, but took this to mean front/back in relation to the rest of the body rather than trying to distinguish between which of the vaginal walls to stick it to!  I thought by anterior placement they meant shallow insertion, so the Vagifem would stick to the vaginal wall closer to the bladder, whereas with deep insertion (the full length of the applicator) it would end up more towards the posterior, if you get my drift!!

[Dancinggirl]

When using Utrogestan vaginally (where ever it is placed) it will often cause extra irritation to the bladder. Even used orally, many find their bladder is more irritated while on Utrogestan.
So matildamouse, your bladder issues may be more to do with using Utrogestan vaginally than anything else and using Vagifem closer to the bladder might help a bit but not as well as you hope.

DG x

[Cassie]

Without appearing dim how does one find the anterior or the posterior of the inner vagina! 

[dahliagirl]

Mmm - this has sent me googling anterior and posterior vagina and I have seen too many prolapse diagrams 

There is the posterior fornix.

If you throw away the idea that the vagina is a tube that leads up to the cervix and uterus, which is the picture from the school biology books, it helps.

The vagina is usually a sort of H shape as the front and back walls rest together, rather than an open tube.  It is angled towards the lower back rather than straight up, and the uterus and cervix meet it at an angle, as they are tilted towards the front (mostly, anyway - not always).  The fornix is the part of the vagina surrounding the cervix - so the posterior fornix is the part of the vagina that keeps going towards the small of the back, past the cervix, if you continue in a straight line.  I am assuming this is what is meant by the posterior vagina.  The top part of the vagina is very stretchy and if I put the vagifem straight up to the hilt, I am assuming this is where it ends up - nearer the rectum.

I have been putting it a little lower down near to where I think my urethra is (and I think there is a bit of mild prolapse going on there) as I was hoping it would help the dryness and itching which is lower for me.  It seems to help for me and feel better.  I hope I have been doing the right thing - the article is very helpful.