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[sheila99]

So my gp is firmly in the 'system says No' camp for VA treatment. I can have vagifem twice a week only and I can't have cream for the outside as well. I'm currently using vagifem (equivalent) every 2 days and am still incontinent when I walk and without daily estriol cream the end of my urethra is extremely painful. Rather than fight this battle I am wondering about increasing systemic hrt by enough that the va symptoms go. Any thoughts? Obviously the NHS doesn't support this view but is there a medical reason for it or just cost? I have a mirena so no liklihood of the lining building up. I need more than 100mcg so will need either to go private or a trip to somewhere I can buy it OTC (suggestions where to go?).
 Does anyone know what blood oestrogen has to be to prevent va?

[Ayesha]

If you have a systemic HRT regime that works the advice is that its best not to tinker with it as it might cause side effects, this is also Dr Currie's advice from reading one of her posts in the past. There is also no guarantee that your VA symptoms will ease, best to treat it as a separate thing.

Buy Estriol yourself, Ovesse from Boots for instance, buy extra Vagifem if you have to. It really is like banging your head against a brick wall, I am sure we are getting to the point that we will have to buy our own, from my own experience lately I really feel its going that way as its available to buy over the counter.

Your surgery have no knowledge of what is a crippling condition and I would be posting a copy of this document to them.
https://bssm.org.uk/wp-content/uploads/2023/02/GSM-BSSM.pdf

[CLKD]

Ignorant GP!  With no knowledge.  Buy the surgery a copy of Me and My Menopausal Vagina !!

Ask for a referral to a dedicated menopause clinic because there are waiting lists. I would be reporting this Practice to Dr Currie and the British Menopause Clinic, pronto.

MayB ask for written reasons why VA treatment is refused?  Would they refuse regular medications for heart/diabetes etc.?

Medical negligence in my opinion!

[Dotty]

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

This document states that you can use both treatments more frequently. Can you show this to your doctor ?

[sheila99]

Sorry I don't think I was very clear. On 100mcg I get meno symptoms - anxiety, insomnia, bad temper, flushes and hip pain. I have some gel from before I went on patches so have been using that but even on 125 the symptoms are better but haven't gone. So regardless of the va issue I need more systemic hrt. I'm struggling to understand why va is considered the only symptom you don't need more systemic oestrogen for. I haven't found anything that explains WHY va is treated differently to every other symptom.
I'll take the documentation in but I've already explained some women need more, I'm not convinced it will change their minds (and perhaps Newson's name on it doesn't help).

[CLKD]

I think it's plain ignorance!  Plus the leaflet in the box of VA treatments considered it to be HRT which is what medics read, rather than being aware of what treatments the vagina requires to remain healthy.

Let us know how you get on.  Whilst we shouldn't need to buy OTC at least we now have that option.

[Ayesha]

I would like to clarify here that the Position Statement in my link is published by the British Society For Sexual Medicine and Louise Newson is one of many names referenced in the document.

My previous surgery and my new surgery are in agreement with the words stated in the document and prescribe accordingly on an individual basis.
Because of the outdated leaflets that accompany the treatments it leads to a lot of confusion by medical professionals who know very little of the condition.

[bombsh3ll]

I think the NHS consensus is that systemic estrogen shouldn't be either prescribed or increased if VA is the only symptom.

I don't agree with that but I think the rationale is that local estrogen can be applied to the genitals whereas it cannot to the brain or other internal organs.

However, refusing to prescribe adequate vaginal estrogen to someone who either doesn't want or cannot access a therapeutic dose of systemic estrogen is not part of any guidance and is probably due to either ignorance or very local funding restrictions.

My personal view is that vaginal estrogen is akin to in work benefits, and that optimising systemic treatment should be the first port of call where possible, ie treat the whole, not just the hole.

That said there will always be some who need or want to use vaginal, and in most cases clinicians are more than happy to oblige in the belief that systemic is dangerous and anything that minimises this is a good thing.

From your point of view you can buy additional vaginal estrogen OTC should you wish. This is cheaper than seeing a specialist.

However if it were me I would see someone privately and get on a therapeutic dose of systemic estrogen.

Additionally there are studies from the 1990s by Dr Philip Sarrell and colleagues investigating the level of estrogen at which VA occurs.

They outlined a threshold of around 50pg/ml ( note US units), below which VA was prevalent, and at increasing levels above this it was less and less common.

I believe this corresponds to around 180mmol/L in UK units.

As thresholds of 250-300 have been established for bone protection, I personally believe the presence of VA should prompt a review of systemic treatment as it is suggestive of undertreatment in this regard.

Of course not everyone would choose to increase the systemic dose for multiple reasons, however there are many women chronically treating VA who are unware of its prognostic significance.

[sheila99]

Thanks all, I think I'll have to see a specialist anyway as I need more than a 100mcg patch so I might see what they say. An extra patch would be much easier vagifem every day which is probably what I need to stay dry. It's a bit worrying that my levels may not be high enough for bone protection so I'll get a blood test too. If the 180 figure is correct there'll be many women like me who think they're protecting their bones when they aren't.