Menopause Matters Forum
Menopause Discussion => Postmenopause => Topic started by: Ann B on July 24, 2023, 10:26:26 AM
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I had a surgical menopause 23 years ago, this necessitated low-dose transdermal oestrogen therapy.
I experienced and was treated for oestrogen-sensitive breast cancer 3 years ago, so the oestrogen therapy immediately stopped. I believe I now have VA which may be contributing to persistent high leucocytes in my urine, and 2 possibly 3 UTIs over the past 2 years.
My most recent UTIs were already resistant to a number of the popular UTI ABs.
I practice all the sensible precautions and am considering dealing with the foregoing through a multi-pronged strategy ie probiotics, d-mannose, vit c, and possibly the lowest dose of vaginal oestrogen pessary. I am a bit apprehensive regarding the latter because my low-grade BC tumour was classified as +8 oestrogen sensitive.
I utilised a nomogram regarding my personal risk for recurrence and opted not to take any endocrine therapy, essentially to avoid effects that I am now experiencing due to lack of oestrogen.
I would be most interested to hear from those who have experienced BC and are using vaginal oestrogen, and what their regime is to deal with VA and UTIs, as well as general advice.
There is additional background information in my other post regarding urine p.h.
Ref. https://pharmaceutical-journal.com/article/news/vaginal-oestrogen-therapy-in-breast-cancer-may-not-be-linked-with-recurrence
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Quality of Life!
Vaginal atrophy mimics repeated urine infection-type symptoms really really well. If a urine sample is sent to a Lab to be grown for bugs and returns 'no growth' then VA treatment should be offered. It is such a small amount of active ingredient that it really should not impact on breast tissue etc..
The idea is to use the appropriate prescribed VA treatment for 2-3 weeks initially then as necessary: some require every night, others can get symptoms under control then use every 3rd and 5/6th night.
Personally I would use VA treatment. My breast disease was treated in the 1990s and my GP didn't hesitate to prescribe 'ovestin'.
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Many thanks for the quick reply CLKD.
I absolutely agree with QOL, which is why I took ERT for 20 years after my surgical menopause, and opted not to have Tamoxifen post BC.
Re VA mimicking a UTI, you may be on to something. I was on holiday in France when my symptoms of a UTI flared. I presented a urine sample to a local French lab. The report was bacteria not significant, but extremely high for leucocytes. When I returned to the UK and still experiencing significant discomfort, I requested a urine test (with difficulty) and once again it came back even higher in leucocytes at 1076/ul, but bacteria only 4/ul as per the French report. Nevertheless, the GP prescribed 7 days Nitrofurantoin. I thought along the same lines as you, and because the irritation was also intermittent during the day. I delayed taking the AB, and sought advice from a private uro/gyn to clarify if I had in fact a UTI. He said yes, and take the AB. Given the foregoing, I remain unsure!
I would add that I experienced UTI symptoms approximately 8 weeks earlier and was treated with 3 days of Nitrofurantoin. The urinalysis indicated bacteria 24/ul and leucocytes (pus cells) 289/u/l. I assumed (now perhaps incorrectly) that the 3 days of Nitrofurantoin had been insufficient to eradicate the UTI. However, curiously, since recently completing the 7 day course of AB the high leucocytes are no longer registering on the dipstick. They had been at the maximum when testing recently, and over the past 2 years. The GPs are not interested in high leucocytes, and I believe choose to classify them in the absence of bacteria, as sterile pyuria, which they ignore under the protocols.
Following your response and my own deductions, I am inclined to think that I have been misdiagnosed as having UTIs, and the issues I have been experiencing, including the high leucocytes stem from VA, which require to be addressed properly. That, therefore, takes me full circle, back to my post regarding vaginal oestrogen and BC.
I assume from your reply that you are a BC survivor and currently taking vaginal oestrogen?
I am hesitant following my 20 years of oestrogen therapy then having ER+ BC. I must say that I miss the benefits of the systemic ERT even though it was a very low dose.
If I was to proceed I would consider a 10mcg pessary. I would be interested in feedback on type and mode.
Given my fuller explanation do you believe we are still on the right track?
Thanks again.
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My breast disease in 1990s was discovered by palpation, not mammogram. Whilst washing I found the lump, saw a private Consultant 10 days later - needle biopsy OUCH showed no problems. Even so he insisted that I underwent removal of the lump - no healtht breast has lumps ! - he told me after the 1st surgery "I had in my hand what I expected to find". I didn't know him well enough to say "You were lucky!" ::)
At histology 'changes were found at the margins' so he went in to the op site the following week, took more cells as well as lymph nodes. The drain site remains tender to touch.
I underwent a body scan, 4 weeks of radiation treatment and regular follow ups. Although the lump wasn't seen on mammogram initially I had 1 every 6 months, after 3 years it was back to annually for 3 years. 'Tamoxifen' almost killed me.
I chose not to take any preventive treatments as these drugs aren't guaranteed to prevent future disease. Also, why is HRT is so dangerous, aren't women who require treatments advised to have bilateral mastectomy :-\.
Sometimes VA can be so bad that surgical intervention is required to part the vaginal lips. Many find that sitting and walking is impossible which makes life miserable. I always think that 'the bus might creep up behind me ....... ' long B4 cancer returns if I use vaginal atrophy treatment. After the initial loading weeks U may find that twice a week is enough to keep symptoms under control.
There are moisturisers too: Yes and Sylc and I use KY Jelly around the vulva if it is itchy/dry.
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Thanks for your background story. :)
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I'm a lot older than most on here ::) so am more inclined to use what relieves the various symptoms ;-)
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Two related questions.
I haven't absolutely decided to use vaginal oestrogen, I am still mulling things over.
Which mode of delivery and which brand of vaginal oestrogen would you recommend?
I am a little apprehensive that using V.O. isn't straightforward for some.
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I personally would go for a cream so you can apply a tiny bit to see how you find it. I use Ovestin which is a cream. I apply it internally and to the outer area mixed with Yes moisturiser.
If you try a VA treatment and do not like it then it is okay as there are other options. It can take time to find one you get on with best. :)
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GPs usually prescribe 'ovestin' which is delivered with a washable applicator so that the correct dose is inserted each time; or 'vagifem', which I think is a pessary. These are designed to replace the oestrogen locally that the body loses as we age. The idea [I may have said already] is to insert every night for 2-3 weeks then see how comfortable the vulva/vagina is.
HRT can protect bones and heart. For those who can't take it, it is important to get as much info as possible to ease any symptoms.
Some require moisturisers such as 'sylc', 'yes' which won't replace oestrogen but can ease dryness and itchiness.
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Thanks for your replies.
Thankfully, I have never had a problem with dryness or itchiness. I want to avoid those and hope the treatment doesn't promote them.
I am, however, quite sensitive and fragile. Both the GP and a urologist said I have V.A.
I am reasonably convinced that V.A. is the cause of the persistent leucocytes in my urine, and UTI symptoms, which only V.O. may/will resolve. I cannot risk HRT due to +8 ER BC. I hope that 10mcg of vaginal oestrogen would pose a very minimal threat. However, the latest Danish research found that there was no recurrence with V.O. when also taking Tamoxifen. I have avoided endocrine therapy.
With the cream, how can you ensure a minimum dose of 10mcg? I have never seen either, but I assume there is a 10mcg sized pessary?
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I think the pessary is a specific dose as is the 'ovestin' which has a red line on the applicator. MayB put the product names into GOOGLE which may well show you the different ways of delivery.
I wish that I could remember the name of the surgeon who recommends HRT for patients who have had breast disease - >blames age< :-\
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I've searched and bumped the thread for you - 'what to do if you can't take oestrogen and are anxious' I think it's titled.
IN "all things menopause "
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I think the pessary is a specific dose as is the 'ovestin' which has a red line on the applicator. MayB put the product names into GOOGLE which may well show you the different ways of delivery.
I wish that I could remember the name of the surgeon who recommends HRT for patients who have had breast disease - >blames age< :-\
Avrum Bluming? - American Oncologist
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Ovestin comes with an applicator. It ensures you get the right dose. I think the dose is actually 1g.
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that's it Ann
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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.
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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?
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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.
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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.
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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
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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"
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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?
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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
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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.
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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
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Time that medics took this lack of information on board :-\. We shouldn't be left with a 'no' if there are opportunities.
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Thanks for this references Wrensong. I will work my way through them.
All good comments.
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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.
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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
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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
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That's bothersome >:( - when ladies require advice.
VA is difficult to control as it mimics repeated urine infection-type symptoms - ABs will help but obviously don't replace the lost oestrogen. I think it depends on a) age when symptoms occur; b) how badly VA symptoms are affecting daily living; c) consideration of quality of Life. Regardless of any breast disease history.
It's early for me: I believe that there are non-oestrogen moistorisers which may give you relief without risks? 'yes', 'sylc', KY jelly .........
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Oh, sorry to know Dr Currie can't help at the mo, Ann. That is unfortunate.
Been doing a trawl this morning & there are a couple of papers here that might be of interest to anyone facing this very difficult situation. Ann, I'm sorry I haven't the expertise to interpret the fine detail, nor the time today to digest them fully, but have just scanned them & pulled out some extracts that seem pertinent, but please don't rely on this as it is not intended as a recommendation. Simply a bit more info that may or may not help with your dilemma. On the whole, I think what they have to say is reassuring, but I also feel this is a decision each woman who has undergone treatment for breast cancer can only make for herself.
Interestingly, the first paper mentions that placement (depth of insertion within the vagina) may influence how much gets into systemic circulation. You will need to read the detail in the paper, but it seems that shallower insertion may result in less systemic absorption. The research seems to have involved women with an intact uterus though & I believe, like me, you've said you've had hysterectomy, so whether not having an intact uterus may make a difference to our systemic absorption I don't know.
It also touches on what we were discussing about absorption diminishing over time as the condition of the vaginal mucosa improves in response to the local treatment.
Systemic estradiol levels with low-dose vaginal estrogens
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050796/
"Systemic estradiol absorption may be influenced by the placement of estradiol higher (as with an applicator) versus lower (as without an applicator) in the vagina . . . From this evidence, the authors recommended placing vaginal estrogens in the outer third of the vagina to reduce the risk of estradiol transport to the uterus. In addition, lower estradiol absorption was observed with softgel capsule vaginal inserts placed without an applicator (lower in the vagina) versus tablet vaginal insert of the same doses inserted with an applicator (higher in the vagina) in a head-to-head study. Taken together, these data support a difference in estradiol absorption depending on placement of an estrogen product in the vagina."
"Thickness of the vaginal wall due to response with estrogen treatment may affect systemic absorption of estradiol when estrogens are used locally in the vagina. Some studies that measured estradiol levels at different times after vaginal estrogen use showed that peak and/or average levels declined over time as vaginal wall thickness likely increased with treatment"
"Certainly, after longer-term vaginal estrogen treatment (12 weeks, 83 or 84 days, 52 weeks), levels of circulating estradiol were similar to those at baseline or with placebo"
"CONCLUSIONS
Our review of systemic absorption of estradiol with use of low-dose and ultralow-dose vaginal estrogen therapies found low to negligible amounts of circulating estradiol that may be influenced by product formulation and vaginal placement."
Systemic Effects of Vaginally Administered Estrogen Therapy: A Review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4354766/
Vaginal Estrogen and Breast Cancer
"For urogenital symptoms, the vaginal ring that provides 5-10 μg/day locally and results in no increased serum estradiol, even if an ultra-sensitive bio-assay is used, meets these requirements. If vaginal estradiol less than 25 μg twice weekly or vaginal estriol less than 0.5 mg twice weekly is administered, there is no associated increase in serum estrogen. Expert opinion suggests that oral and transdermal hormone therapy are currently contraindicated for at least some women with a diagnosis of breast cancer. However, vaginal estrogen may provide relief of vaginal symptoms without an increase in serum levels.
An exception to this situation, however, may exist in women taking aromatase inhibitors. A recent study reported that in women using aromatase inhibitors, baseline serum estradiol was less than 5 pmol/l (1.36 pg/ml). After 2 weeks use of Vagifem® vaginal estradiol tablets, serum levels reached a mean concentration of 72 pmol/l (19.6 pg/ml). This level fell to less than 35 pmol/l (9.5 pg/ml) at 4 weeks except for two women where the estradiol remained elevated. The authors concluded that Vagifem® may counteract estrogen suppression caused by aromatase inhibitors and should not be used with these agents."
I'm sorry there is so much to get to grips with & wish it were more straightforward for us all.
Wx
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Hi Wrensong
That is all very good and relevant information.
I really appreciate the time you have given to providing these references and information.
Hopefully, this will certainly assist in my decision on whether to take vaginal oestrogen.
Ann x
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No problem Ann.
Wx
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Bumped for SaraS
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I have had a quick unsuccessful look online regarding the initial loading phase for vaginal oestrogen. Is it absolutely necessary?
In order to reduce this initial surge that goes systemic, can VE be gradually introduced and build up slowly and thus be contained locally?
Has anyone tried this?
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Ann, I think the topical oestrogen goes systemic all the while the vaginal mucosa are in poor condition i.e. before their restored integrity is sufficient to provide something of a barrier. I imagine taking the loading phase more gradually might simply prolong the leaching of topical oestrogen into systemic circulation but I really don't know for sure. If you would be less concerned at the idea of smaller amounts going systemic with each application spread over time, to avoid a bigger hit in the initial weeks from the usual 2 week nightly loading, I can see how that might feel more reassuring. But I haven't seen any studies where slower introduction was used. Hopefully someone else will come along with better knowledge. This is where the advice of a good Menopause Gynae like Dr Currie would be invaluable.
Wx
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I don't know whether any studies have been done on the loading period: I have been told that, because I no longer require regular 'ovestin', that when reloading it might cause problems with uptake. But I don't believe in using a product unless necessary, i.e. I wouldn't take 'nurofen' unless I had a headache.
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Ann, I think the topical oestrogen goes systemic all the while the vaginal mucosa are in poor condition i.e. before their restored integrity is sufficient to provide something of a barrier. I imagine taking the loading phase more gradually might simply prolong the leaching of topical oestrogen into systemic circulation but I really don't know for sure. If you would be less concerned at the idea of smaller amounts going systemic with each application spread over time, to avoid a bigger hit in the initial weeks from the usual 2 week nightly loading, I can see how that might feel more reassuring. But I haven't seen any studies where slower introduction was used. Hopefully someone else will come along with better knowledge. This is where the advice of a good Menopause Gynae like Dr Currie would be invaluable.
Wx
That's a valid point you have made Wrensong.
It may also be very individualised ie dependent on the fragility or otherwise of the vaginal tissue, which in turn corresponds to the degree of V.A. so may be difficult even for an expert to provide a generalised answer.
However, if there is a correlation between dose level and speed of tissue renewal, then would it be better to commence with a higher loading dose to make that phase shorter, then drop down to a lower maintenance dose?
What happens to those who are given a higher dose pessary or cream, do they arrive at the end of loading quicker? Conversely do those on say 10 mcg take much longer?
This is a bit of a conundrum, and should maybe be more specifically tailored to the individual following assessment of the degree of V.A. rather than a
general shotgun approach. Perhaps a bit too idealistic considering what's available on the NHS and the paucity of post-menopause experts.
The uro/gyn suggested that I should take the V.E. for 3 months every year, but surely this would result in intermittent relapsing tissue and an annual systemic loading surge. I can only think that was his response to pacify the BC team and also minimise oestrogen risk for an ER-positive BC survivor. It seems to be 'swings and roundabouts'.
Ann
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Ann,
However, if there is a correlation between dose level and speed of tissue renewal, then would it be better to commence with a higher loading dose to make that phase shorter, then drop down to a lower maintenance dose?
I really don't know, but that question had gone through my mind when writing my last post to you. And of course that's the recommended way for general use (i.e. among women with no BC history). I don't know that anyone has addressed the situation for former BC patients needing to use topical HRT.
I'm conscious too, that some authorities say that in susceptible women BC can begin at times of transition (I think Dr Bluming mentions that in the paper you posted), suggesting that hormonal instability can be a catalyst. And that makes me wonder whether a slow drip drip of one of the lower dose Estriol creams might be favourable over the bigger hit you'd get in initial weeks from the stronger Vagifem. I think it was Dr Helen Briggs who favoured the Estriol creams over Vagifem for women with a BC history in an article I read & think I may have posted or quoted from on here the other day. Sorry can't see my earlier posts as I write this, I've posted a lot recently & my menopausal memory is not that good.
What happens to those who are given a higher dose pessary or cream, do they arrive at the end of loading quicker? Conversely do those on say 10 mcg take much longer?
10mcg is the only dose for vaginal oestradiol tablets/pessaries (Vagifem & its equivalents - Vagirux, Gina) as far as I know. The 2 Estriol creams (Ovestin 0.1% & Estriol 0.01%) are a weaker form of oestrogen than oestradiol & their measured doses for internal application contain the same amount of active ingredient (estriol hormone). There's Estring too & the DHEA product - Prasterone/Intrarosa which I think Dr Briggs may also have mentioned.
How quickly any woman responds I think will depend on degree of deterioration of the GU tissues before commencing vaginal HRT & on other individual factors.
The uro/gyn suggested that I should take the V.E. for 3 months every year, but surely this would result in intermittent relapsing tissue and an annual systemic loading surge.
Yes that was also my feeling when we discussed that earlier. But I don't know for sure & as I think I said, he's the expert on matters urogynae & may have treated women in your situation before. Could you perhaps contact him & put your concerns to him? He may have a colleague with greater knowledge he could liaise with.
Do you know how soon Dr Currie will be in a position to answer emails? I think her view on your dilemma might be very helpful.
Wx
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All good stuff Wrensong. Thanks for painstakingly answering each of my questions.
Ann
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No problem Ann. I wish there was more certainty in what I can say.
Wx
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I have gone and done it!
I commenced daily Ovestin two days ago. I have to take it every night for two weeks then switch to Vagifem two to three times per week.
Thus far I now have outer area redness and irritation, with a slight itch, not so bad inside. I suppose this is to be expected until my tissues adjust.
I felt compelled to take the vaginal oestrogen due to a current 'actual UTI'. I held off on the Nitrofurantoin for about a week, then for the first time in two years saw an indication of nitrites on the test strip.
Now I also need to explore d-mannose. I have bought it but don't know how and when to take it yet. I have three and a half days to go with the Nitrofurantoin.
I really hope I can get on top of my UTI-type symptoms. I have been gradually more affected since I discontinued Estraderm patches in March 2020.
Ann
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I am glad you have started the Ovestin as I think it is really going to help you. I hope the irritation stops soon for you.
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Let us know how you get on. I have used 'ovestin' successfully for years, after the 14 nights loading, including a smear around the outer labia when necessary. I've never moved to 'vagifem' internally. If 'ovestin' works, why change ?
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Thanks Flossieteacake and CLKD
Having read about the benefits, I am feeling quite positive that this could be the solution I have been looking for.
I find that the Ovestin cream is not as messy as I had anticipated. You are right CLKD if Ovestin remains a positive experience, why switch?
I am interested to know what dosing you are comfortable with, and whether you had initial irritation. The irritation is not that bad, just something new that I didn't have before. I don't want to add any undue complexity or substances, but should I use Sylk or similar now, or wait and trust things will settle down?
It all seems fairly straightforward, but I would be happy to have any tips regarding sterilising the applicator or whatever. Considering previous UTI-type symptoms, I have a thing about the applicator being as sterile as possible.
Ann
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I have been using 'ovestin' for several years without problems. The applicator can be cleaned in warm soapy water using a baby bottle brush, 10 at a time obtained from Amazon. The brush in turn gets washed under hot water. Do U have a plastic box with a lid, in which to put applicator and brush in?
Initially it was the 2 weeks loading then every 3rd and 6/7th nights. When I feel the symptoms niggling I put a dose up in the afternoon, take 2 nurofen to ease the nip as the urine flow shuts off and another dose in the evening: for 5-6 days.
I've never experienced any irritation internally, any drying on the vulva/labial area is treated with a smear of 'ovestin' or KY Jelly. If the skin is thin then the applicator may cause the body to be aware of insertion, once the vaginal walls begin to plump up, any irritation should ease.
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Thanks CLKD
All good information and tips.
The Amazon baby bottle brush is a good idea.
Ann
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Yes great idea. I am going to look for some online now.
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Ann B, I've only just caught up with this thread today. I'm sorry about the UTI, but so glad to know you've been able to make a decision about the treatment. Having earlier this year been without vaginal oestrogen for 8 weeks (contraindicated post-hysterectomy) & developed urinary retention after routine catheterisation & a persistent UTI requiring multiple courses of antibiotics, it's a situation I never want to be in again.
Fab tip from CLKD about the bottle brushes :great:.
I think & hope you'll feel much better for the vaginal oestrogen in time. Do let us know how you get on.
Well done on taking the plunge. It takes some guts in this situation. :hug:
Wx
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At 73 and after using vagifem successfully for 4 years now terrible symptoms of VA it regularly and symptoms like uti Dr said had overactive bladder, but used more vagifem and it has got a little better, am seeing Dr soon after reading Dr Louise Newsomes book am going to ask for ovestin cream some oestrogen gel, and more vagifem, failing that Dr Newsome has clinics in London Bournmouth and I think Birmingham, she tailors treatment for you, and yes she thinks you can have topical hrt after cancer.
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Hi Wrensong and Decogirl50.
Thanks for your replies.
I held off reporting back until a little time had passed and I could gauge how my tissues were responding to the V.E.
I commenced with two weeks loading of Ovestin 0.5g per day. All went well. I followed CLKDs advice with the brush for cleaning the applicator. I found the brush for straw cleaning was the best fit.
I noticed during loading that my nipples became a little tender for a brief period, but my hot flushes continued, so obviously not too much systemically.
After the loading period and for convenience, I decided to try the Vagifem pessaries twice per week, and have been using them for the last 4 weeks. They are so much easier, and no concerns with applicator hygiene.
In addition and with the same frequency, I have been applying a tiny dab of Ovestin to the fourchette, because I had repeated tears there.
Thus far I have been really pleased with my feeling of vaginal comfort. I also obtained Sylk gel, but have not used it.
My nipple sensitivity stopped after the Ovestin loading period, but I have noticed that my hot flushes have very recently ceased. This worries me slightly because it could be indicative of some systemic oestrogen circulation.
For ease of use, I prefer the Vagifem, but in view of the hot flushes ceasing, (could be coincidental) I am now wondering if I should switch back to the weaker Ovestin. I have just been giving thought to this today.
Most positively, and one of the main reasons I considered taking the V.E, urine dipstick testing has been showing no leucocytes in my urine over the past week. This is a first. I have had very high levels of leucocytes for about 2 years. They would abate briefly following antibiotics, but then return. I am keeping my fingers crossed that they and UTIs will not return.
I would add that I am also taking a daily quality probiotic and cranberry capsule, so I may be muddying the water a little as to which is doing the trick.
Ann x
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Ann, thank you for the detailed update :).
Most positively, and one of the main reasons I considered taking the V.E, urine dipstick testing has been showing no leucocytes in my urine over the past week. This is a first. I have had very high levels of leucocytes for about 2 years. They would abate briefly following antibiotics, but then return. I am keeping my fingers crossed that they and UTIs will not return.
This is so good to know :).
I've also recently been trialling a new probiotic from a well respected manufacturer, marketed for women's GU health, but I'm watching for any possible worsening of bladder symptoms as there seems to be some thought that with IC, probiotics & fermented foods may aggravate the condition in some cases.
I hear you on your concern re a possible correlation between the stronger oestrogen product & the cessation of your flushes. I wonder whether this may be due to the initial systemic absorption we talked about, that's said only to occur to any significant degree until vaginal tissue integrity improves enough to form something of a barrier, but I understand why you're considering swapping back to Ovestin.
Please let us know how things go & I hope you will continue to feel better for the vaginal oestrogen.
Wx
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Hi Decogirl50 :welcomemm:. I hope it goes well with the GP. Please let us know how you get on.
Wx
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Good morning Wrensong
Thanks again for your reply.
You are probably correct about the loading period affecting the flushes. I have had a few since my last reply, so my tissues are probably improving. My breasts are not tender, which is a useful indicator. I have, therefore, decided to continue with the Vagifem for the moment.
The good news is that urine dipstick testing continues to show a complete absence of leucocytes, which is great.
I hope you get on with the new probiotic. I don't know if it is the probiotic or the cranberry pill, or the combination, but I have had quite a bit of abdominal pain and irritation over the past 3 days. I started a different cranberry pill around the same time, so that may be the culprit. I am going to exclude both of them for a few days then reintroduce them individually to determine which one may be having this effect.
I tend to experience fairly frequent intermittent abdominal pain, so neither of them may be responsible. I have been told by the GP (without any tests) that I probably have IBS. I know from an mri that I have diverticula in the sigmoid colon area, and that is where I feel the sharpest pain.
I have read that kefir is a good gut healer. I culture it, but then end up pouring it down the sink, because I find it can be constipating. I will have to try it again.
Decogirl50, I hope your VA symptoms have improved.
BW
Ann x
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Ann, I initially had symptoms when I started using vagifem. Some pelvic pain, then I had slight blood spotting so I stopped on gp advice. I then started again after US showed everything was ok, because I was having UTI symptoms. The second time I got breast pain. I stuck with it as sex was becoming painful. That's a year ago and I have no side effects at all and i use every other night, I'm also now using ovestin externally every night. I still have my night hot flushes though. I may try to swap my ovestin to the weaker one mentioned.
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Hi Jules
Thanks for relating your experience with the Vagifem. You are obviously getting the benefits.
I am currently taking 2 Vagifem pessaries per week, plus a pea size dab of Ovestin on the fourchette, After just 7 weeks ie, 2 weeks of Ovestin loading, then 5 weeks of Vagifem, I too feel the benefits. However, my hot flushes are still behaving differently. They are considerably less. In the past 2 weeks, I have also experienced a more bloated and distended feeling across my lower abdomen, with a sharpish pain around my sigmoid colon ie in the lower left quadrant. Was this like the pelvic pain you experienced? I wonder if anyone else has experienced this with Vagifem. Hopefully, others will comment. It could, however, be unconnected because I do frequently experience general discomfort in this area, although not quite so severe as it has been in the past few weeks.
Apparently, there have been repeated calls to rewrite the leaflets that accompany vaginal oestrogens because they are more related to systemic oestrogen side effects, and even then they have been criticised as being out of date. We therefore have to look for anecdotal experiences.
I can't really complain about my experience with Vagifem thus far. It is good that you no longer have any side effects.
Best wishes
Ann
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Hi Jules
Thanks for relating your experience with the Vagifem. You are obviously getting the benefits.
I am currently taking 2 Vagifem pessaries per week, plus a pea size dab of Ovestin on the fourchette, After just 7 weeks ie, 2 weeks of Ovestin loading, then 5 weeks of Vagifem, I too feel the benefits. However, my hot flushes are still behaving differently. They are considerably less. In the past 2 weeks, I have also experienced a more bloated and distended feeling across my lower abdomen, with a sharpish pain around my sigmoid colon ie in the lower left quadrant. Was this like the pelvic pain you experienced? I wonder if anyone else has experienced this with Vagifem. Hopefully, others will comment. It could, however, be unconnected because I do frequently experience general discomfort in this area, although not quite so severe as it has been in the past few weeks.
Apparently, there have been repeated calls to rewrite the leaflets that accompany vaginal oestrogens because they are more related to systemic oestrogen side effects, and even then they have been criticised as being out of date. We therefore have to look for anecdotal experiences.
I can't really complain about my experience with Vagifem thus far. It is good that you no longer have any side effects.
Best wishes
Ann
No my pelvic pain was like period pain. Your other sounds like IBS related, spasm in your colon. It's hard to decipher the aches and pains of getting older isn't it
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Another reassuring article, this time on vaginal estriol & serum hormone levels. So, relevant for Ovestin, Estriol 0.01% cream, Blissel, rather than the oestradiol in Vagifem & Estring.
https://www.informahealthcare.com/doi/full/10.1080/13697137.2023.2287624?src=recsys
Don't think I've posted this one here before. Hope not!
Wx
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Thanks, Wrensong for posting that positive study regarding E3 oestrogens.
Due to the ease of use and better hygiene of the disposable applicators, I opted for Vagifem, an E2. It is approximately 4 months and so far, the Vagifem has worked well for me. The primary issue of high-level leucocytes in my urine has completely ceased. I also have had no UTIs or vaginal discomfort.
There is some mention of E2 oestrogens in the study which I will have to read closely.
Best wishes
Ann
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:thankyou: 4 the update. It's the Trial and Error that can be so tiring ::)