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[Bananarama]

Hi.  I posted recently re post meno bleed.  Investigations included biopsy and transvaginal scan.  I posted because the scan showed endo thickening of approx 12 mms including fluid.  I was really worried about this but after I received a copy of his letter to the GP I spoke to him and he said he wasn't particularly concerned and was more interested in what the biopsy showed.  Luckily this has come back as normal and he's booked me in for a hysteroscopy on Tuesday.  He phoned to confirm this but I didn't really ask whether he was removing a polyp or whether he would insert a Mirena coil to lessen the thickening.  I did briefly ask if he would be fitting a coil.  He said he didn't usually at my age (72) but if I wanted he would.  I know it involves progesterone.  I'm just worried if he doesn't then maybe I could have another bleed which is not what I want.  I know I will be able to speak to him on the day of the procedure but just wondered what you're views might be.  Also have severe VA and have been on Ovestin for about 12 years, firstly with the loading dose and then maintenance, then stopping for three months but I suppose I have been on continuous for at least five or six years now and had never had a scan.

Just wondered if anyone could advise.

[Taz2]

Hi Bananarama - I would think that as you are having a hysteroscopy then the polyp will be removed and there is no need for a hysteroscopy to insert a Mirena Coil. I'm so pleased that your result has come back as normal. It would be usual procedure to remove the polyp as they can sometimes turn cancerous I believe.

Good luck for Tuesday and please let us know how you get on.

Taz x

[Hurdity]

Hi Bananarama

Re the long term use of Ovestin: current guidelines are that "low dose vaginal oestrogen preparations can be used in symptomatic women and continued for as long as required. " (Quote from BMS 2016 updated recommendations on HRT). This paper goes on to say "However there is little evidence to prove the safety of vaginal preparations beyond one year. Clinicians should therefore aim to use the lowest effective dose for symptom control and counsel women regarding this".

Although adverse effects are very rare  - presumably there are instances when thickening can occur - so perhaps this could be the cause in your case of long term use?

Interestingly I was reading about what happens to the endometrium in post-menopause - ie why does it not continue to thicken in the presence of oestrogen - which continues to be made for the rest of our lives albeit at a much lower level? From what I read the theory was put forward ( can't remember if there was research to back this up) that the receptors became unresponsive to oestrogen and this led to true (rather than pathological) endometrial atrophy. Perhaps in very rare cases and in some women, or with prolonged use even of very low doses of vaginal oestrogen - this doesn't happen and some proliferation does occur? Hopefully your consultant will be able to enlighten you?

Re future bleeding - if your lining has thickened then the addition of any progestogen may cause bleeding. I know this is a side effect of the Mirena - so if you had one of these inserted then you could well bleed before the lining was completely shed. Also I would have thought a Mirena was "overkill" for what must have been a very slight thickening over many years (it has taken years to thicken to approx what it does during the menstrual cycle in a month!) - so would actually be too much progestogen.

If it were me I would prefer a course of tablets like norethisterone over say 3 months ( or whatever they normally do) until it had thinned and then suggest you have an annual scan just to check? This may still cause a bit of bleeding at first though.

I also read an early paper (but haven't had time to look up many more) suggesting that estriol (which Ovestin contains) was more likely to be absorbed systemically  - but this was in 2003 and has probable been superseded by more up to date research. Apologies for sounding a bit vague and not giving refs for this!

This has turned out to be longer than I intended but hope it's helpful!!

Hurdity x

[Hurdity]

PS have you thought of having the vaginal ring inserted ie the Estring? This might help with the VA if it is still severe. If your lining might have unusually thickened due to long term use of ovestin, then gynaes might want to supervise (ie regular scans) but hopefully they will anyway.

Hurdity x

[Bananarama]

Thankyou very much for your replies.  I'm going to add to my list of questions on Tuesday.  I'll update you when I know more.

[Bananarama]

Just to let you know I had the hysteroscopy yesterday under GA.  We decided to go for the Mirena coil with the option that it could be removed later if requested.   I did ask about breast cancer risks but I forgot to ask if I will now have periods.  Hope not.  After the hysteroscopy the gynae came to see me.  Everything was still a bit fuzzy but believe he said they did not find a cervical polyp.  Definitely have the Mirena.  Oh yes, I remember him saying that as I have been on Ovestin for approx 12 years on and off the Mirena with help lessen the endometrium thickening and allow me to continue was I have been with Ovestin as life is just unbearable without.

[Hurdity]

Thanks for the update Bananarama.

You won't have periods as such no - because you have a Mirena and are not taking oestrogen HRT. However as the lining has thickened then it may well shed intermittently at first until it has thinned ie you could get some bleeding or spotting - but it's not a period as such. Once the lining has thinned down - as I said in my previous post below, it may thin the lining too much so you will need to be vigilant about this. As you say it can be removed later.

I hope it all works out for you anyway

Hurdity x