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[CLKD]

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 .........

[Wrensong]

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

[Ann B]

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

[Wrensong]

No problem Ann.
Wx

[Wrensong]

Bumped for SaraS

[Ann B]

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?

[Wrensong]

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

[CLKD]

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.

[Ann B]

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   

[Wrensong]

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

[Ann B]

All good stuff Wrensong.  Thanks for painstakingly answering each of my questions.

Ann

[Wrensong]

No problem Ann.  I wish there was more certainty in what I can say.
Wx

[Ann B]

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

[Flossieteacake]

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.

[CLKD]

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 ?