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[Wrensong]

Ann, Ovestin cream & Vagifem pessaries contain 2 different forms of oestrogen.  Ovestin contains estriol which is a weaker form of oestrogen than the oestradiol in Vagifem but is said to have a special affinity for the urogenital tract.  As the other ladies have said Ovestin comes with an applicator for a measured dose.  There is also a weaker preparation of estriol cream, 0.01%, marketed as "Estriol cream" rather than branded Ovestin (0.1%), which some of us use on the vulva in conjunction with the 10mcg Vagifem oestradiol pessaries. 

Both creams come with applicators for internal use if that's the required mode of delivery for that patient & the measured dose of each actually provides the same amount of active ingredient despite Ovestin being a stronger formula than the one marketed as Estriol cream.   Sorry - it's a bit confusing, but I think the weaker Estriol cream is mainly just used externally as an adjunct to Vagifem.  The weaker Estriol cream is also much more expensive than Ovestin so less cost effective for internal use.

[Ann B]

Thanks Wrensong.  I appreciate your comments, and the knowledge on this site.

I am new to VO so it is a little confusing.  I will have to look at this in more detail in order to understand things better.

I looked at the potential side effects of these treatments and there were so many.  I used a slow-release Estraderm MX 25 patch for 20 years and was never aware of any side effects.  I think it released 25 mcgs of oestradiol per day through the skin.

10 mcg of Vagifem would represent 40% of that estraderm/Estradiol dose to be absorbed through the vaginal tissue.  With thin vaginal tissue having a rich blood supply, I don't understand how that 40% dose would not have some systemic effect, albeit at a lower dose.  There are ultra-low dose systemic patches like Menostar at 14 mcg oestradiol which is not far removed from 10 mcg.

It is quite complex.

Which of the vaginal oestrogens do the ladies seem to prefer?  Do they notice systemic effects?

[Ann B]

that's it Ann

Thanks CKLD.

I read sections of Dr Avrum Bluming's book.  I 'think' both his daughter and wife had breast cancer then went on to take HRT in line with his philosophy.  What he doesn't make clear is whether they are also using Tamoxifen, which as you will know is a breast protective SERM.  If I was taking Tamoxifen I would probably more seriously consider systemic ERT.  Following BC I decided not to take endocrine therapy due to QOL considerations due to the effects of even further systemic oestrogen ablation.

Dr Liz Reardon the former breast surgeon who had stage 3 breast cancer is the antithesis to Dr Avrum Bluming.  They are two different schools of thought on HRT following BC.

[Wrensong]

Ann, I agree it can be confusing.  If you want medical support to help you decide, I'd discuss it with your clinicians for expert input relevant to your own history as individual differences in BC type & variations in subsequent treatments can be important & although some menopause authorities are of the opinion that low dose vaginal oestrogen poses little risk as regards BC, it's only natural & I think sensible to be cautious with a personal history of ER+ BC.  If you've not already done so you may also like to have a look at Newson's Health's website for articles & podcasts relating to HRT after BC.  I've heard interesting interviews with several medics on the topic inc Prof Lesley Regan, Dr Tina Peers & various breast cancer specialists inc Dr Avrum Bluming, as well as reading his book when it first came out.

The systemic & vaginal products are not comparable in terms of overall effect on the body.  Although Vagifem pessaries contain 10mcg oestradiol per dose, the effect, after the initial loading period is said to be very localised.  The oft quoted comparison is that a whole year's use of Vagifem at the recommended dosing is comparable to just one oral dose of systemic oestradiol, though at what strength the oral I'm not sure. 

In the initial weeks of use, some of the ostradiol in Vagifem does go into systemic circulation & during that period some women do report systemic side effects.  For me on first starting Vagifem around 8 years ago, already several years postmenopause, this meant headaches every afternoon.  The initial systemic absorption is thought to be because the vaginal mucosa, when in poor condition from atrophy, provide less of a barrier than once improved following adequate oestrogenisation from the effects of the vaginal HRT.

Different women get on better with different vaginal oestrogens.  Some prefer the creams, some the pessaries.  I don't get on well with the creams when used internally but wouldn't be without the weaker Estriol cream for external use & find it very soothing in conjunction with Vagifem internally.

[Ann B]

Hi Wrensong.

Thanks again for your reply - all very pertinent.

The gyno/uro is suggesting taking Vagifem for 3 months every year, but from the official info you mention, that would expose me to a systemic boost every year in the loading phase.  It might be less of a potential threat if the Vagifem is taken continuously.

I was interested in your quote below.  Is there a link for that?

"The oft quoted comparison is that a whole year's use of Vagifem at the recommended dosing is comparable to just one oral dose of systemic oestradiol, though at what strength the oral I'm not sure".

Ann

[Wrensong]

Ann, yes I think you'd likely get repeated systemic exposure from vaginal oestrogen if you use annual short courses rather than the continuous method usually recommended.  I think your GSM is also less likely to be well controlled that way & could relapse during the periods without topical oestrogen.  But your urogynae is the expert on treating that part of the anatomy & he/she may have treated women in your position before.

As an example & please bear in mind this is only my personal experience, after an enforced break from vaginal oestrogens of 8 weeks, the blood tests I had coincidentally arranged at the end of the 2 week Vagifem re-loading period showed my systemic oestradiol had almost doubled on the value I'd been getting from my systemic (patch based) HRT.  We could think of no other explanation than that the increase was due to the cumulative load from the nightly 10mcg oestradiol in Vagifem. 

As estriol is a weaker form of oestrogen & it's not usual to test systemic estriol levels I have no idea what if any systemic effects may result during an initial loading with an estriol based vaginal HRT preparation rather than Vagifem.  Perhaps someone else will come along with knowledge on that.

Have you looked at the BMS website?  I see this morning they seem to have some podcasts on BC I haven't yet looked at.

Just about to go out but some links here I hope might help.  Sorry a bit rushed so hope I have the right comments attached to the right sources!

https://d2931px9t312xa.cloudfront.net/menopausedoctor/files/information/601/Been%20through%20breast%20cancer%20(with%20links).pdf

See p10 Helping your genital & urinary symptoms

& p12 Risks of vaginal oestrogens

https://balance-menopause.com/uploads/2021/10/GSM-for-BSSM-FINAL-version-with-links.pdf

"The dose of vaginal oestrogen is very low; for example, using 10mcg oestrogen pessaries regularly for one year is an
equivalent dose to just one 1mg of oestradiol HRT tablet."

https://thebms.org.uk/wp-content/uploads/2022/12/12-BMS-TfC-Fast-Facts-HRT-and-Breast-Cancer-Risk-NOV2022-A.pdf

"Managing vulvo-vaginal atrophy
• Vaginal moisturisers should be first-line management
• If refractory symptoms, ultra-low dose topical oestrogen can be considered
• Topical oestrogen should be avoided in the presence of an aromatase inhibitor"

[CLKD]

If you want to know whether the wife and daughter have used other medications after surgery, there maybe a web-site where you can ask the question. 

What's your biggest worry?  There are preparations that are non-hormonal which may help any of your symptoms?

[Wrensong]

OK, now had a chance to have a listen to Dr Paula Briggs on HRT after breast cancer in the BMS link below.  In those women who need vaginal HRT to manage GSM after BC she recommends (as I suggested in my earlier post) discussing this with the clinicians who know your history, i.e. breast surgeon, oncologist.  She also says that she would favour an estriol preparation over the stronger oestradiol in Vagifem & mentions some alternative hormonal meds for GSM such as Intrarosa/Prasterone which is a DHEA vaginal product.  But do have a listen.  The podcast is entitled "Post cancer treatments".

https://thebms.org.uk/publications/bms-tv/

Wx

[CLKD]

My oncologist told me 'no HRT for you' when I had my last appt in the 1990s.  From reading here and discussions with friends, it seems that this remains the general consensus.  It would appear that not many oncologists are prepared to push out the boat to see if VA treatments are actually likely to cause further disease.  I think too that it might depend on how much treatment and how this affected the patient as to whether they would be willing to take part in such 'trials'. 

Stuck between a rock and a hard place.

[Wrensong]

So right CLKD, rock & hard place indeed.  The handful of breast surgeons I've spoken to on the topic have been open minded & pragmatic about HRT in the light of the difficulties menopausal women face after BC.  The only 2 oncologists I've spoken to have been divided in opinion, one (male) against any form of HRT inc vaginal, the other (female) saying she would not discourage her patients from using it if needed for QOL providing they are well informed & understand that there is simply too little known about the risks for anyone to advise with any certainty.
Wx

[CLKD]

Time that medics took this lack of information on board  .  We shouldn't be left with a 'no' if there are opportunities. 

[Ann B]

Thanks for this references Wrensong.  I will work my way through them.

All good comments.

[Ann B]

If you want to know whether the wife and daughter have used other medications after surgery, there maybe a web-site where you can ask the question. 

What's your biggest worry?  There are preparations that are non-hormonal which may help any of your symptoms?

Hi CLKD

I actually emailed both Dr Newson and Dr Bluming on the matter of not taking Tamoxifen after BC and the possibility of using systemic oestrogen.  Dr Newson did not reply but Avrum Bluming very kindly did.  He was willing to reply to the question in general terms.

You ask what my biggest worry is.  It is to do nothing, and experience the deterioration of my tissues due to VA which I suspect can result in recurrent UTIs and possibly my persistent high level of leucocytes.  I don't want to continue to take antibiotics and infections become resistant so that they are even more problematic as I get older. 

UTIs can lead to mental confusion in the elderly, and it is passed off by the medical profession as dementia or whatever.  From current personal experience, the GPs and medics operate from protocols that suggest ignoring pyuria and even ongoing bacterial infections in elderly women.   There is also increasing resistance to the different antibiotics for treating UTIs.  Their toolbox is becoming more sparse.

It is not that I have had a great many UTIs - only 2 in the past 2 years.  In May 2022 I had a UTI and was given only 3 days Amoxicillin.  3 days is now the standard protocol.  After 3 days I was still having symptoms.  I had to insist on a urine test.  The infection was still present, so had to be followed up with more days of Amoxicillin, to which I am now resistant!

Fast forward to May 2023.  I had repeat UTI symptoms.  Again there was resistance to lab testing.  I was given 3 days of Nitrofurantoin.  Due to my 2022 3 day experience I asked for a repeat urine test 14 days later, to check that the infection had gone. The GP flatly refused and dismissed the matter by saying elderly women would show positive for bacteria after treatment so there was no point.  After 2 weeks I became increasingly symptomatic and another GP subsequently prescribed 7 days Nitrofurantoin.

I have found that there is an antipathy from GPs to testing and treating for UTIs in mature women, and looking at the guidelines I can determine why!

I am very hesitant to resume systemic oestrogen or try vaginal oestrogen due to my BC experience.  I was absolutely convinced of the health benefits and low risk of low-dose transdermal oestrogen, so the BC was a shock and rude awakening.   I am therefore now super cautious and concerned over possible recurrence.  The GPs and medics are also quite hesitant over vaginal oestrogen for me.  Systemic seems to be an absolute no no!

So I feel I am between that classic rock and a hard place.  As Wrensong said I need to be comfortable and confident with any decision I make.

[Wrensong]

A final thought for this evening Ann, is that you might like to email Dr Currie, founder of this site, for her advice.  There is a small fee of around £30 I believe.
Wx

[Ann B]

A final thought for this evening Ann, is that you might like to email Dr Currie, founder of this site, for her advice.  There is a small fee of around £30 I believe.
Wx

Thanks Wrensong.  I checked.  There is a message from Dr Currie:  "unavailable at present due to high workload". 


Ann x