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[Sunnyangel]

In short, just around 5 weeks ago I began a loading dose of once daily estradiol vaginal tablets/pessaries for 14 days. This improved my symptoms (especially the bladder symptoms) a lot. I also used a prescribed Estriol cream daily on external sore areas.

At the end of the loading period of time, I went down to the prescribed 2x week. Very quickly, my symptoms started to return so, having read a widely on the Menopause Matters Forums, I could see that many other women have had the same problem and needed a higher dosage than initially prescribed.

My problem is that when I contacted my (female) GP to explain the situation, she said that I can have another loading dose but she will not approve more than twice a week usage and if I have further problems, she will assume that it isn't working for me and give me the Estradiol cream (which I don't especially want) instead as it may absorb better. Who knows where it goes after that as she couldn't answer that question?!!!

I am not happy with this as I explained how the symptoms were disrupting my life but she doesn't seem interested. I cannot see how she is ok to prescribe another loading dose but not happy to let me even try 3x week given the fact that some women are on systemic HRT and ALSO take topical oestrogen which, as we all know, has a miniscule amount of oestrogen compared to systemic treatments.

I feel very anxious about this and wondered if going to a private menopause clinic (I live near one) would enable me to see someone more expert in the field and to have a longer consultation. If I do that and they agree with me about increasing the dose, or suggested an alternative treatment, would they advise my local GP surgery that I needed an increased dosage and would the GP Practice then have to provide it or would I have to keep paying for it myself?

I don't want to have to do this at all, not least because it is very expensive, and as a person who has never had any repeat prescriptions and virtually no prescriptions at all throughout my entire life (I've been a very lucky woman!) I feel as though I've hardly overwhelmed the NHS but now I'm being let down in my hour of need as though my quality of life is unimportant just so long as it's not totally unbearable.

Please, ladies out there if you can answer any or all of my questions, I would be so grateful. I really can't see a way ahead right now.

[Minusminnie]

Not meaning to be picky but I think you meant Estriol cream not Estradiol cream in part of your post. Just for anyone reading.

You can get Estradiol cream in the US.
But not here in UK.

Reading recent posts eg Snowcat’s use of Estriol cream internally & externally seems to now be being advised after trying vagifem.

Could you try it to see if it works ? If you needed more Estriol cream it is sold in Boots under the name Ovesse and cheaper than buying Gina the vagifem equivalent.

[sheila99]

Sadly you're not the only one. I'm only allowed it twice a week too and if I have vagifem I'm not allowed estriol cream for the outside as well so I'm expected to be permanently in pain and incontinent. Your GP is the gatekeeper to medication and if they've been told to only prescribe the alloted amount in my experience that's what they'll do regardless of any medical indication to the contrary. You can try asking for a referral and you could complain to the practice manager. My referral resulted in a loading dose for 2 months and then back to twice a week so it was just kicking the can down the road. There are some recent posts on va you might look up, Ayesha has posted useful references that may help your case. You can go private but your GP doesn't have to follow their advice so might be worth asking them first, you can buy a lot of Gina and estriol cream for the price of the consultation. I had other meno symptoms as well uncontrolled by the NHS maximum dose of systemic hrt so I went private and now have enough systemic hrt  my symptoms have gone and 'down below' is back to normal without the need for local oestrogen. I am yet to hear if the NHS will fund it but I can guess the answer.
  And it bugged me too that I pay for everyone else's prescriptions but if I needed one I had to pay again.

[Sunnyangel]

Hi Minusminnie, you are quite right, I meant Estriol cream.

Sheila99, this experience is so depressing and lacking in any kind of sense. The amounts of oestrogen concerned are so tiny when compared to systemic HRT that it doesn't seem surprising that women with more severe symptoms should require a higher dosage. I don't think my GP will ever agree to increase the dose so I don't know what option I have other than to go private or live in discomfort. This decision making seems driven by finances.

Does anyone know if I asked my GP to be referred (assuming that the loading dose and back to 2x week fails again) would I then be able to ask for an increased dosage and have that covered by the NHS? How does it all work? Where would I be referred to? I'm confused.

[Ayesha]

Your GP is not up to date on the recommended dosage of topical oestrogen, It's up to you to demand more, I know it feels like bloody Oliver Twist asking for more!!
Some links to give you assurance and ammunition in getting the topical oestrogen you require to be comfortable.
BTW, I am not on systemic oestrogen but I am allowed by my GP to have daily Vagifem and Estriol cream without any problems whatsoever!

https://bssm.org.uk/wp-content/uploads/2023/02/GSM-BSSM.pdf

A recent post from Dr Currie
"The dose increase for vaginal estrogen tablet as mentioned is reasonable because of the following--
Many years ago, we had a preparation Vagifem 25mcg--every night for 2 weeks then twice weekly. When it was taken off the market, we then used the lower dose Vagifem 10mcg (Vagirux is the same)--nightly for 2 weeks then twice weekly. So the maintenance dose of Vagifem 25 provided 50mcg of estradiol over a week, for which there was no concern about significant circulating absorption affecting the womb lining. Therefore, if needed, this can be achieved by using Vagifem 10 of Vagirux up to 5 times weekly. For many, twice weekly is enough and can be continued long term, for others using it 3 to 4 times weekly or maximum 5 times weekly works better.
If vulval and vaginal treatment needed, some find using the large volume estriol cream 0.01% applying half with a finger to the vulva and remainder into the vagina can be useful. However, other vulval conditions and sensitivity may need to be considered.
I hope that this is helpful."

[bombsh3ll]

I would ask for a referral to your local NHS menopause clinic due to suboptimal primary care treatment of GSM.

Whilst waiting, which can be up to 2 years depending on geography, you would probably be best buying what you need from an online pharmacy rather than going without.

I know it's rotten having to pay but sadly this tends to be the norm rather than a rarity with female hormone treatment - misogyny has always been rife within healthcare.

I have to pay for my combined pill Zoely, which the NHS doesn't fund in Scotland, but if I lived in England or Wales I could get it free.

Additionally, I don't know your medical history but is there a reason you aren't on, or pursuing, systemic HRT? This can also reduce (or if adequately dosed, eliminate) the need for vaginal estrogen.

[Minusminnie]

A recent post from Dr Currie

If vulval and vaginal treatment needed, some find using the large volume estriol cream 0.01% applying half with a finger to the vulva and remainder into the vagina can be useful. However, other vulval conditions and sensitivity may need to be considered.
I hope that this is helpful."

No mention of Vagifem as well.

[Ayesha]

Dr Currie's post in full to give context

"Re: Can I increase vagifem dose
« Reply #24 on: July 10, 2025, 09:28:21 AM »

A few points to pick up on on this discussion--
Vaginal estrogen is minimally absorbed, but we do not know the effects of using more than one preparation at a time, or using higher than licensed doses. As with HRT doses, if a licensed dose is not fully effective, then a different type could be considered but also the underlying problem may not be purely hormone related and review would be indicated.
The BMS consensus statement does not recommend adding preparations together--see  https://thebms.org.uk/wp-content/uploads/2024/04/09-BMS-ConsensusStatement-Urogenital-atrophy-MARCH2024-A.pdf
The dose increase for vaginal estrogen tablet as mentioned is reasonable because of the following--
Many years ago, we had a preparation Vagifem 25mcg--every night for 2 weeks then twice weekly. When it was taken off the market, we then used the lower dose Vagifem 10mcg (Vagirux is the same)--nightly for 2 weeks then twice weekly. So the maintenance dose of Vagifem 25 provided 50mcg of estradiol over a week, for which there was no concern about significant circulating absorption affecting the womb lining. Therefore, if needed, this can be achieved by using Vagifem 10 of Vagirux up to 5 times weekly. For many, twice weekly is enough and can be continued long term, for others using it 3 to 4 times weekly or maximum 5 times weekly works better.
If vulval and vaginal treatment needed, some find using the large volume estriol cream 0.01% applying half with a finger to the vulva and remainder into the vagina can be useful. However, other vulval conditions and sensitivity may need to be considered.
I hope that this is helpful."

[sheila99]

Sadly there are many gps who hide behind the 'licensed dose' to refuse to prescribe more despite clinical need, for systemic as well as topical oestrogen. Until the licensed dose issue is sorted out many women will still have to suffer symptoms that could easily be controlled. I can argue with mine til the cows come home, it still makes no difference, the 'licensed dose' is all they'll prescribe.
  And we know perfectly well the effects of using higher doses, it means va is kept under control in the many women for whom twice a week is adequate. But the medical profession will never know because, just like testosterone, they have no intention of ever doing any research.

[Sunnyangel]

Thanks for advice so far everyone.

Bombsh3ell- I have not been on or ever requested HRT. There is no medical reason for this, I just managed to go through menopause without too many symptoms so I preferred to take nothing especially as at the time, there were a lot of media scare stories surrounding possible cancer links. I don't smoke, drink and am not overweight, I exercise sensibly- hardly ticking the boxes for lifestyle risks you might say! I'm years past when my periods stopped  and from what I read, if I've understood correctly, even if you take systemic HRT, you may need to take additional topical oestrogen anyway. I've also always preferred the idea of taking as little as possible. I doubt anyway that at my age (60) I would be offered HRT as an option even if I wanted it given that my GP won't even prescribe one extra estradiol vaginal tablet a week!

Ayesha- it seems like there is something of a postcode lottery at work here and it would be interesting to know which areas of the country seem to have a more informed approach to this whole issue.  Some women are easily prescribed what they need, others not so much. To be honest, I am concerned that if the situation develops so that  I have to go back and tell my GP that this second loading dose and subsequent 2x week Estradiol vaginal tablets aren't enough, she has effectively said that the dose will NOT be increased and she will instead prescribe oestrogen cream to be used internally to use in place of the tablets. How will help if it's only the same strength and to be used only with the same frequency? Is there something about the formulation that makes it more effective than vaginal tablets?  I don't want the estradiol tablets to stop being prescribed, I just want to try increasing the dose as I think that it would help, so I feel I will be running a risk if I go back again and complain as my GP seems pretty intransigent. The only other option I can think of is to buy additional Gina tablets OTC and increase my dose that way and just not contact the GP again, even though I will have to pay for those. I will feel uncomfortable about doing this. I am so annoyed by this impersonal treatment that seems to fly in the face of evidence with this 'one size fits all' approach. and basically an unwillingness to listen to the patient's experience.

[CLKD]

Sunnyangel - keep on with the prescription via the GP as well as buying what you require from a pharmacy, you may need to tell a white lie in order to get Gina though  .  U can then use as much as you require in order to remain comfortable! 

I can't understand why women have to fight, after all if this were diabetic or heart treatment would men/women need to fight?   

[Sunnyangel]

Yes indeed CLKD, it's hard to imagine a GP saying to someone with diabetes or a heart condition,' oh good, your treatment seems to be helping to make you feel more comfortable so now we'll decrease it massively in one fell swoop and you can see how you get along with that for the rest of your life.'  (BTW, no offence intended to anyone with those 2 problems which, I know may be extremely debilitating and serious)

[CLKD]

What is the British Menopause Society doing about these issues, it's not as though they are rare!  I believe that until women contact the Society, naming and shaming, very little will change the attitudes of medics. regarding what is essential treatment for many of us.

[Ayesha]

You could write a letter to your surgery quoting relevant paragraphs from the BSSM document, also Dr Currie's comment above on the dose of Vagifem allowed, up to five times weekly. Insist you want to stay on Vagifem, quote the saying, treatment for topical oestrogen is the equivalent to taking one systemic HRT tablet a year.

When I first started treatment when the two a week dose had no affect on symptoms, I was prescribed daily Vagifem by my then gynae GP who had no problems prescribing me this dose because she herself was on daily Vagifem.

It's a sad fact that to this day, if you say that its impossible for you to have intercourse with your partner you would most probably have no trouble getting what you want, this is the state of play when it comes to women's sexual health, we have to be very assertive and demand what is rightfully ours.

I hope one day your GP suffers the same fate as some of her patients, its a vile condition to live with when at the chronic stage and appropriate treatment is essential.

[sheila99]

Another approach would be to do as the GP suggests and try the estriol. I also think it's unlikely to be enough but sometimes if va is bad it does seem to be absorbed better. And it puts you in a stronger position to ask for an increase as you'll have tried all her suggestions.