Menopause Matters Forum
Menopause Discussion => All things menopause => Topic started by: jorainbow on October 24, 2023, 06:21:32 AM
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Ive been prescribed vagifem twice a week with no loading dose. This is due to a March 21 biopsy showing 'mild endometrial hyperplasia '. Oct 21 and March 22 were disordered proliferative endometrium and clear respectively, without any treatment. I struggled with both the mirena and more recently utrugestan vaginally combined with only 1 spray of lenzetto so I've decided to go without either for the tine being. I asked for vagifem as that is one of the most impacting symptoms.
Do you have to have the loading dose?
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Not necessarily. It will depend on how dry the vulva and vaginal areas are. Of course, it's such a small amount once the 2-3 weeks loading period is done, that any concerns of triggering disease can be put to rest.
Who prescribed 'vagifem'?
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The menopause consultant prescribed it this way I am assuming because of the past hyperplasia issue though I was under the impression it doesn't go systemic.
I'm gathering all my information, scans etc and going private as I'm beyond with trying to get answers from him.
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Ah a menopause consultant may not be au fait with prolapse etc. ::)
Who did the biopsy, mayB ring for advice?
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Thanks CLKD there's no prolapse just dryness
Same team so I'll ask their secretary when i request all the info.
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I've just started on Vagirux for VA, which I believe is an equivalent dose. My GP said I could do loading doses, but as I've been sensitive to hormones, she would leave this with me.
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I've just started on Vagirux for VA, which I believe is an equivalent dose. My GP said I could do loading doses, but as I've been sensitive to hormones, she would leave this with me.
Thanks. I might just do that instead!
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Ultimately you will end up deciding for yourself what dose you will take. VA with time only gets worse and the symptoms are impossible to tolerate once it gets to the chronic stage. It all becomes quality of life in the end, the reason the treatment is for life.
Its why some GP's leave it to the patient as it is a very safe form of topical HRT.
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I'm currently using it every other night. My GP said I could use it every night if necessary. But everytime I read a different view of usage, I start worrying again. I've been using ovestin externally nightly for about 6 weeks and am now noticing a difference with plumping up. It's hard knowing what's ok though with so many different views
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Thanks Jules. It seems my meno consultant will only allow twice weekly due to past hyperplasia despite me finding another letter where it says it isn't systemic. It is incredibly confusing
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Quality of Life Girls 8)
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That's the problem Jules,what works for one doesn't necessarily work for another,always best to talk to a Dr.Like you, I was using it every other night but when I read negative things it panics me :-\
And did you stop using it that frequently?
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Yes I did,just didn't know what to believe any more BUT my VA has settled down,can still be uncomfortable when doing the old wham bam thank you mam lol but apart from that I've been ok but again everyone is different,so please don't stop using it just because of my panicky brain,mostly I've heard it is very safe x
I admit, I have stopped googling or reading anything other than on here. I was on twice a week and I had an internal exam and the doctor told me how thin the vaginal walls were, she said it would have been worse without any vagifem, she also said i had some fusion externally, it wasn't good to hear, so I increased it and started using ovestin externally. I was prone to UTIs and she said unless i use vagifemfor life i would still get them. I don't get discomfort with sex now but I'm still worried about using estrogen at all.
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Hi jorainbow, we discussed the situation with systemic absorption of vaginal oestrogen on Ann B's thread on vaginal oestrogen post breast cancer a few months ago. I've just posted on that thread again so it's back up in current pages if you'd like to look at it. It's quite long so I'll paste in some extracts below in case you don't have time to check it out . . .
In the initial weeks of use, some of the ostradiol in Vagifem does go into systemic circulation. 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.
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.
There are some articles & extracts here:-
Position Statement for Management of Genitourinary Syndrome of the Menopause (GSM)
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."
The following 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.
It also touches on 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."
Jorainbow I think the advice on lower placement may be particularly relevant for you.
I hope there's something helpful in this.
Wx
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tnx - so women who have undergone breast surgery may still be at risk :-\ of triggering oestrogen dominant disease.
So far I haven't had problems fortunately but others who underwent more rigorsous treatment? Criky, it's a Mine Field. :'(
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Right, that's concerned me with the frequency I use and placement. What the heck do you do?
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CLKD, that's why we were trying to thrash it out in Ann B's thread. But what we found ultimately seemed reassuring & I think the take home is in the extracts towards the end of my last post above:-
"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."
Wx
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Out of interest, and considering the change of advice, how many women on here are using more than twice a week and how many using externally too? Am I in the minority?
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Jules, I use Vagifem 5 nights a week with the weak 0.01% Estriol cream externally (& systemic HRT). I can't get by with less. I think the general medical consensus is that vaginal oestrogens are very safe for long term use, but I'm not sure what the answer is to minimising initial systemic absorption in terms of the loading phase. We wondered on Ann B's thread whether avoiding consecutive nightly use for 2 weeks as is usually prescribed might simply prolong the duration of systemic exposure as that would likely mean it would take longer for the condition of the vaginal mucosa to improve to the "barrier" stage.
Wx
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Jules, I use Vagifem 5 nights a week with the weak 0.01% Estriol externally (& systemic HRT). I can't get by with less.
Wx
Similar then but I'm not on systemic HRT. It's hard to get the balance isn't it.
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Agreed Jules & as others have said it seems to be quite individual how much we need on a long term basis. I actually feel better using both vaginal preparations every night, not just 5 nights, but my systemic oestradiol levels have been quite low (poor absorption) so that won't have been helping GSM symptoms. Actually my last post to you was misleading & should have said Vagifem 5 nights a week, Estriol cream externally every night. I used to have 2 nights free of both but have fairly recently begun using the cream every night.
I'm really sorry if the links & extracts worried you Jules, it absolutely wasn't my intention to alarm anyone. I'd just hoped the articles would help explain why we get some initial systemic absorption & give pointers re placement to minimise any possible effects on the uterus given jorainbow's situation.
Wx
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Wrensong thanks for this information, I was looking yesterday for latest research on the use of topical oestrogen.
I use Vagifem every day with Ovestin. I remember reading an Australian research paper where it was recommended not to place the Vagifem pessary too high up to prevent it going systemic but from reading the research you have posted, once the body has healed enough the systemic effect becomes less and less.
Anyway, its reassuring reading as far as I am concerned and the benefits of Vagifem/Ovestin far outweigh the horrible symptoms of VA which I found impossible to live with.
Ann B's thread
https://www.menopausematters.co.uk/forum/index.php/topic,66941.0.html
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Ayesha I'm glad you found it helpful/reassuring. I think the majority of women have no need to worry at all, it's just in special circumstances where we are rightly asking sensible questions I personally like to look for research to help me become more informed.
Wx
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:thankyou:
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Ayesha, thank you for linking Ann B's thread. I'm not sure how coherent it is as I believe some posts from around mid-Aug are missing, lost during that period when there were server problems. I didn't reread the whole thread this morning, but remember being dismayed that some stuff I'd posted with links that had taken some time to compile was lost!
Wx
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Its quite ok. It's useful to know and I might stop pushing the pessary so high. I've been using vagifem ir equivalent for over a year now.
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My consultant prescribed provera every 6 months for 10 days when I was on vagifem. It gave me a bleed twice a year and shed the lining.
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Hi guys i found this thread interesting as ive been useing ovestin for over a year now thankfully with my gynos blessing for every 2nd day.which is working for me. I do agree with the application queries as i find if i use the applicater i get lower back pain i think from the higher insertin but systemically it last longer i can go 3-4days without ovestin.
If i use with finger insertiin just inside and outside ive found to be alittle more comfortable if that makes sense no lower back pain..ovestin for me i can honestly say has been a god send for my aches and pains ,headaches,and bladder issues.My gyno has done tests and said we are all different and there is no real proof of damage being done from this low dose so im happy with that for now.im 60 and on nothing but ovestin but for now that suits me 🙂
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Ayesha, thank you for linking Ann B's thread. I'm not sure how coherent it is as I believe some posts from around mid-Aug are missing, lost during that period when there were server problems. I didn't reread the whole thread this morning, but remember being dismayed that some stuff I'd posted with links that had taken some time to compile was lost!
Wx
Yes I remember now when the site went down and a number of posts disappeared which was very frustrating as a lot of good information went with it.
It's good to keep looking out for the latest research as knowledge is power and hopefully posts in Ann B's thread will still be helpful.
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OK, so had time to reread the BSSM Position Statement for Management of Genitourinary Syndrome of the Menopause (GSM) I posted earlier & here are some more extracts (with the link again) that are particularly relevant to our discussion & may give further reassurance to anyone who is worried:-
https://balance-menopause.com/uploads/2021/10/GSM-for-BSSM-FINAL-version-with-links.pdf
"The frequency of using these preparations can be increased in women who have persistent symptoms as the doses of these preparations are very low."
"Women using vaginal oestrogen – even in the long term – do not need to take progestogens or progesterone or have their endometrial thickness measured."
"after regeneration and cornification of the vaginal skin, increased systemic levels of oestrogen are not seen and they remain below postmenopausal levels."
And this next link is from the BMS (highlight of final point mine). Though it makes no mention of increasing dose beyond the manufacturer's recommended minimum if necessary to control symptoms, it's worth bearing in mind, that with Vagifem the original dose was 25mcg twice weekly, before the reduction to the 10mcg size they come in now, which is why many of us have been given the go ahead to use 5 x 10mcg a week.
https://thebms.org.uk/wp-content/uploads/2022/08/04-BMS-TfC-HRT-Guide-01-AUGUST2022-A.pdf
• When vaginal and/or bladder symptoms of urogenital atrophy predominate, vaginal oestrogen alone can be used.
• Vaginal oestrogen may also be required in addition for some women taking systemic HRT.
• Estradiol – Vaginal tablet: Vagifem 10, Ring: Estring (changed 3 monthly)
• Estriol - Ovestin (0.1%) and Gynest (0.01%) creams, Imvaggis pessary 0.03mg, Blissel 50 micrograms vaginal gel
• Tablets and creams should be used nightly for 2 weeks (3 weeks for pessary and gel) and then twice weekly.
Twice weekly maintenance doses can be continued long-term; symptoms frequently recur on cessation of therapy. Systemic
absorption is minimal and progestogen is not required.
Lynne888My consultant prescribed provera every 6 months for 10 days when I was on vagifem. It gave me a bleed twice a year and shed the lining.
that's interesting your having been prescribed occasional courses of MPA to reduce any lining build up. Can I ask were there unusual reasons for this in your case?
Wx