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[Hurdity]

I believe that Vagifem is not absorbed into the bloodstream, at least only a microscopic amount.

Did I read somewhere on this forum that the amount absorbed is something like the same as one HRT pill in a whole year?

I have seen women quote this but I'm not sure where it comes from! I would want to see the data personally.

Whatever it is, the research (from the manufacturer and possibly elsewhere) shows that oestrogen levels are maintained within the normal post-menopausal range once the loading period has been completed but there are no studies on the long term effects of Vagifem.

Nevertheless the BMS 2013 guidelines recommend long term use and without progestogen:

Section on Urogenital symptoms:

Low-dose vaginal estrogen preparations can be used long-term in symptomatic women as required, and all topical estrogen preparations have been shown to be effective in this context.

There is no requirement to combine this with systemic progestogen treatment for endometrial protection, as low-dose vaginal estrogen preparations do not result in significant systemic absorption.

However, there is little evidence to prove the safety of vaginal preparations beyond one year of use; clinicians should therefore aim to use the lowest effective dose for symptom control and counsel women regarding this.

Section on routes and regimens:

Low-dose vaginal estrogenic creams, rings, tablets and pessaries should be considered for all women with symptoms of urogenital atrophy.

Local estrogenic preparations and may be more effective than systemic therapy and can be used in conjunction with oral/transdermal HRT.

Indefinite usage is usually required as symptoms often return when treatment is discontinued – progestogenic opposition is not required as systemic absorption is minimal with estradiol and estriol preparations.

This is the paper - published 18 months ago and from which we have quoted extensively on here in the past: http://min.sagepub.com/content/19/2/59

It can be downloaded free and I would recommend anyone to do so, to have the information to hand!

Hurdity x

[scriv]

Is roughly 50mcg a week still the maximum safe limit though ?- this was the old 25mcg vagifem regime @ twice a week

50mcg a week is the limit which my GP still works towards... as 2x10mcg @ twice a week does not quite do the trick,  I have found 2x10mcg @ every 3 days works well for me, even though I do appreciate it would not be for everyone.

[babyjane]

10mcgs every other night works best for me and gives me 40mcgs one week and 30 the next, below the previous 50mcgs of the 25 dose. This gives me a continuous comfort rather than a larger dose less often.

I think ladies should be allowed to do what works best for them within the recommended guidelines.  My point was that all GPs should have the same information and be advising the same thing but they differ a lot.

[Evenstar]

That was an interesting read. I have just started with vagifem. My GP told me to use it every night for 14 days then once a week.   Sounds like that might not be enough then.   She did say she was happy for me to stay on it for as long as I liked though and could have a repeat prescription,
       Will see how I get on and maybe discuss using it more than once a week.

[babyjane]

My personal opinion is that 10mcg once a week will not be enough to prevent vaginal atrophy and you could lose all the benefit of your 2 weeks loading.  The information sheet that comes in the box says one tablet twice a week so that would be the standard dose.

I can't understand why some GPs want their ladies to use such a low dose of a topical oestrogen containing 10mcg when pills or patches contain 50 - 75 mcg or more and are absorbed systemically.  Am I not understanding something basic?

[Hattie]

I can't understand why some GPs want their ladies to use such a low dose of a topical oestrogen containing 10mcg when pills or patches contain 50 - 75 mcg or more and are absorbed systemically.  Am I not understanding something basic?

Isn't it because the topical oestrogen is unopposed in some cases.

[babyjane]

what does unopposed mean?

[Hattie]

Unopposed...

Sure someone will correct me but i take it to mean that you are putting oestrogen in your body but not the progesterone side of HRT to produce a bleed.

Some say that oestrogen from vagifem does go systemic - but maybe that is another argument.   

Hattie X

[Hurdity]

Hattie - you're right about the meaning of unopposed.

"Some say"..... There has never been any doubt that some oestrogen is absorbed into the blood-stream from vaginal oestrogen. As I said below in my previous post - all the research (that I am aware of) shows that oestrogen levels in women using topical (vaginal) oestrogen are maintained within the post-menopausal range and therefore using it is unlikely to cause thickening of the uterus lining.

I repeat what I said below ( in green - quoted from BMS paper) that no long term studies have been carried out on long term vaginal oestrogen use (maybe beyond 3 years? - can't quite remember), but long term use is still recommended due to the minute quantities absorbed.

Evenstar/babyjane - yes the instructions as you see are for twice a week maintenance. I agree you may well lose the benefit of the two week loading if you only use once a week. I would definitely use it twice a week following loading - there is no reason not to.

Also in fact paradoxically you could end up with more systemic absorption if you use it less than the recommended amount/frequency! This is because the loading period plumps up the vaginal lining which then seems to resist systemic absorption. Without the right amount of oestrogen the lining could thin again and more will be absorbed!

There was talk about amounts of oestrogen. It is difficult to compare excatly - because for example patch oestrogen contains more estradiol than the dosage given.

Here is an example: 50 mcg Estradot patch is a patch containing 0.78 mg estradiol (= 780 mcg) and designed to deliver estradiol into the bloodstream at a rate of 50 mcg per day. This means that over 3.5 days that the patch is on, less than a quarter (175 mcg) is actually absorbed

10 mcg Vagifem is just that - 10 mcg in total!! There is no info on the leaflet about the release rate because that is not important in this context - as systemic absorption is not the aim (although it has been studied). Even if all of it was absorbed (which it won't be) that would be approx 2.9 mcg per day, but as with the patch some will be lost.

That was just for illustration to give you an idea of the amounts we are talking about!

Sorry if that was a bit of a digression but thought it was relevant as dosage etc has been mentioned...

Hurdity x

[babyjane]

Although I had to read through your post a few times Hurdity I found it very informative so thank you for taking the time.

I am not concerned about my Vagifem, been using it for 4 years now and am on every other night making 70mcg over a 2 week time frame.  It keeps me comfortable and I have not had thrush, cystitis or BV throughout my time on it.  that really counts for something for me personally.  I do not have a womb so am not concerned about the progesterone question. If I forget my regular night I can certainly feel the difference the following day.

I do agree that some is absorbed as within a couple of months of starting it my bra size went from a B cup to a C cup and has stayed there ever since.  I have never been a C cup in my life, not even when I was breastfeeding so some oestrogen clearly gets through.

[Dancinggirl]

I had my private appointment with an excellent gynaecologist yesterday and I asked him about the long term use of local oestrogen.  He did say that the risks are very small and the drug companies do have to cover their backs regarding the long term use of local oestrogen - you can just imagine the fall out if one or two women developed womb cancer having used local oestrogen for over 2 years. Needless to say most GPs are going to stick to the party line when prescribing local oestrogen for the same reason. This gynae did suggest it might be advisable to have a course of progesterone after the two years and possibly once a year, to see if there was anything to shed.  In the absence of regular scans, that the NHS is unlikely to fund, this would be the safe option.
DG x

[Hattie]

I had my private appointment with an excellent gynaecologist yesterday and I asked him about the long term use of local oestrogen.  He did say that the risks are very small and the drug companies do have to cover their backs regarding the long term use of local oestrogen - you can just imagine the fall out if one or two women developed womb cancer having used local oestrogen for over 2 years. Needless to say most GPs are going to stick to the party line when prescribing local oestrogen for the same reason. This gynae did suggest it might be advisable to have a course of progesterone after the two years and possibly once a year, to see if there was anything to shed.  In the absence of regular scans, that the NHS is unlikely to fund, this would be the safe option.
DG x

Thanks for posting this DG - i went privately in 2010 to the top gynae in our area and was prescribed vagifem 'for life' with little other explanation - only by finding discussions on this site was i able to find out anymore about vagifem.

Nothing was mentioned about scans or regular progesterone.

Hattie X

[babyjane]

so from this information does this mean that women who do not have a womb do not have any reason not to use it long term?

[Hurdity]

It is only some gynaes that recommend an annual or biennial "progestogen challenge" but as far as I remember this wasn't mentioned as an option in the BMS 2013 recommendations. It is not suggested in the current NICE guidelines on HRT but as Dancinggirl says some gynaes might suggest it as a precaution.

Yes babyjane I would say that's exactly it!

Hurdity x

[babyjane]