How Vaginal Oestrogen can help you
Firstly, it's important to understand that vaginal oestrogen is not the same as HRT. It will only target the vaginal/vulval/bladder areas and it comes in much, much lower doses than HRT. Also, if you are using HRT, you can also use vaginal oestrogen treatment. HRT alone may not be enough to tackle your vulvovaginal and/or bladder symptoms. If you're generally fit and well, you don't have to choose between the two.
Vaginal oestrogen is very low dose - it wont help with any other menopause symptoms such as hot flushes, aches and pains or mood changes.
It is safe for almost anyone to use with only a few exceptions. For those rare exceptions there are alternative options including non hormonal treatments such as the YES vaginal moisturisers and lubricants. If you have had cancer previously and you've been advised not to use vaginal oestrogen but your symptoms are impacting on your day to day life, please discuss this with your specialist as they may consider changing your current medication which could then allow you to use vaginal oestrogen.
Now that we've got all that out of the way....
What is Vaginal Oestrogen and how do you know that you need it?
Vaginal Oestrogen treatment includes a range of creams, gels, pessaries, vaginal tablets and vaginal ring which all contain a small amount of oestrogen and are inserted directly into the vagina or applied to the vulva. They help to target specific concerns affecting the vagina, vulva and/or the bladder. You might have more than one concern affecting any or all of these areas.
Symptoms can appear in the form of vaginal/vulval itching, vaginal dryness, frequent urinary or vaginal infections, burning, soreness, inflammation, swelling or painful sex - and the symptoms often occur around the time of the menopause. ( they can also arise during or after a pregnancy, from using certain types of contraception and also as a result of having cancer treatment )
A collection of these symptoms have been given the clinical diagnostic term as Genitourinary Syndrome of the Menopause although many people still call it Vaginal Atrophy while still acknowledging that symptoms don't just affect the vagina.
It's believed that up to 80% of all women will experience some of these symptoms in varying different degrees during their menopause.
Vaginal oestrogen can be used on it's own or alongside HRT. If you are generally fit and well, you do not have to choose between one or the other.
Whichever way you choose to use vaginal oestrogen, ideally it should be used in combination with non hormonal options like vaginal moisturiser and lubricants as this combined approach helps to support your vaginal health and to maintain relief. Consistency in using these treatments is key. The YES range of non hormonal vaginal products are rated highly among users and clinical advisors.
As there are a broad range of vaginal oestrogen products, finding the one which suits you personally in terms of practicality and efficacy can involve some trial and error.
Each will contain forms of the oestrogen hormone; Estradiol or Estriol which we produce naturally ourselves. Both these forms of oestrogen are quite similar but they vary in treatments formulation, and they tend to be produced in varying potencies at different times during our reproductive years.
Both these forms of oestrogen will fluctuate and decline as we move through the menopause.
Estradiol - the most potent form of oestrogen is made naturally in our ovaries, usually in good amounts during our reproductive years and it gradually declines as we move through the menopause. Its' starring role is in the regulation of the menstrual cycle and it helps with heart and bone health too.
We also naturally produce Estriol which is another form of oestrogen, and it's mainly dominant during pregnancy.
Estriol can be viewed as the weaker of the two forms, and in vaginal oestrogen products it tends to come in gel, cream or waxy pessary formulations while in the UK body identical Estradiol usually comes as a dry pessary/tablet ( such as Vagifem/Vagirux ) or within the vaginal ring ( Estring )
Both estradiol, and estriol levels weaken as we move through the menopause before production of both forms stops.
There is another form of oestrogen which we naturally produce across our lifetime and it's called Estrone. This is a weak form of oestrogen and it's the main form of oestrogen produced in very, very small amounts once we're post menopausal. It's produced from the adrenal glands and in fatty tissues and isn't potent enough to keep vulvovaginal and bladder symptoms away or have any significantly positive effect on our body overall.
How do you know if you need Vaginal Oestrogen?
Symptoms can be specific to the vaginal area on their own such as at the vaginal entrance or internally which causes pain, dryness or inflammation during or after sex, but they can also involve the bladder.
Some women notice that they're having to get up several times at night to pass urine or they might feel that they're having lots of cystitis symptoms which reocur and they feel they have to get antibiotics more often.
Sometimes the symptoms increase after you've had sex, or after sitting for long periods of time or even just from wearing tight clothing. Other's feel they develop an itch on the vulva and feel that it worsens at night time and that they can't help scratching to relieve this which then causes further soreness. Some also feel they are having frequent episodes of what feels like thrush.
Just to confuse things - others feel they often have a wet discharge but feel dry during sex.
Initial symptoms can be subtle and can come and go before becoming more of a permanent nuisance. They can vary in intensity and while some people manage them by non hormonal means such as lubricants or vaginal moisturisers, other people might find them much more troublesome and require some vaginal oestrogen treatment.
How do you decide what to use?
Vaginal oestrogen comes in a range of different formulations including gels, cream, dry pessaries, vaginal rings and waxy pessaries.
When you start using vaginal oestrogen in cream,gel,pessary, dry tablet forms - you are advised to use it every night for around 2 weeks before reducing it down to twice weekly.
Vaginal oestrogen doesn't just tackle vaginal/vulval symptoms. When it's inserted into the vagina directly, it's absorbed through the vaginal walls and into the bladder opening and it gets to work on the bladder and urethral structures from there.
The treatments available
Estriol Cream ( used to be called Ovestin ) - a white cream which is usually inserted vaginally via an applicator which is set to allow you to only draw up a set dose each time you use it. You don't always have to insert it vaginally - if your discomfort is externally on the vulva for example, the cream can be used sparingly ( a pea size dose for example ) on the vulva or clitoris. Some people find using one of the dry vaginal tablets like Vagifem/Vagirux internally, and applying a minimal amount of estriol cream to any uncomfortable areas on the vulva - the be more effective for them.
Blissel gel - a clear gel which is inserted vaginally via an applicator which is set to allow you to only draw up a set dose each time.
Imvaggis pessaries - small, waxy pessaries which are inserted vaginally.
Vagifem/Vagirux - tiny dry tablets which are inserted vaginally. These tend to feel less messy for some people. Vagifem comes in pre loaded applicators while Vagirux comes with a re-usable applicator which you load yourself with small oestrogen tablets. This is a great alternative option to Vagifem as it's the same medication but uses much less plastic.
Estring - a flexible vaginal ring filled with oestrogen which stays put for up to three months and releases oestrogen daily.
Some people like the "no mess" aspect of a dry vaginal oestrogen tablet - like Vagifem/Vagirux.
Others might like the idea of the vaginal oestrogen ring which is replaced every 3 months compared to other products which need to be inserted twice weekly. Some might not like the idea of having something permanent situated in the vagina, so they prefer something they only need to apply or insert twice a week.
Twice weekly is the standard maintenance regime for vaginal oestrogen use when using creams, gels or vaginal tablets/pessaries but this can be increased by your GP or menopause specialist if twice weekly use is not relieving your symptoms.
If you've tried different vaginal oestrogens at varying doses without success, DHEA ( dehydroepiandrosterone and known as Prasterone/Intrarosa ) is a second line option. We naturally produce DHEA ourselves in the adrenal glands and levels decline naturally with age. It's a pre cursor to oestrogen and testosterone. In terms of treatment, it comes as a small, waxy pessary which is inserted vaginally. It contains palm oil which can be very soothing and the DHEA converts to oestrogen and testosterone once absorbed. It has been plagued by the dreaded manufacturing issues recently and is not always available.
Using vaginal oestrogen after breast cancer
This is still some contention relating to this although opinions and sensitivity to the plight are thankfully beginning to soften. Growing evidence is evolving to show that it is safe to use vaginal oestrogen after breast cancer.
Vaginal oestrogen has tended to not be advised for this group of women mainly due to particular treatments which many women will be using after their diagnosis and how these medications negate any oestrogen effect within the vagina.
Aromatase Inhibitors ( AI's ) for example will block the positive oestrogen effect from vaginal oestrogen treatments, but Tamoxifen will not - therefore - depending on the severity of the vaginal/vulval/bladder symptoms, your specialists may agree to switching you over from AI's to Tamoxifen and suggest a low dose vaginal oestrogen preparation which can provide that much needed relief, restore the vaginal health and potentially reduce recurring symptoms and the need for ongoing assessments and antibiotic/antifungal treatments which clinicians may look towards if vaginal oestrogen is off the table.
Non hormonal treatment options including vaginal moisturisers and lubricants are still advised as the first line treatment options for those with a history of breast cancer, although they may not be effective enough on their own, particularly for those who are using AI's.
If you are using Aromatase Inhibitors after breast cancer and you are struggling with vaginal, vulval or bladder symptoms please do speak to your GP about this as they can liaise with your specialists and ask whether a low dose vaginal oestrogen treatment could be trialled so see if that helps. If it does, it's a good idea to continue with the treatment as once you stop, your symptoms can return.
As with any medication, benefits and risks should be discussed with you and a decision can be based on shared decision making between yourself and your specialist clinician.
Which is the best?
As with finding any treatment that suits us the most - it's not unusual for someone to try one or two different types of vaginal oestrogen before they eventually settle on one that fits best because they feel it's been the most effective in relieving their main issues around their vaginal/vulval or urinary symptoms.
Some people might for example start off by using an oestrogen cream which is inserted into the vagina, and feel that it soothes the dry, inflamed vaginal tissues. Others might feel that the ingredients inflame their vaginal discomfort further. It really is all about finding the right product for you as an individual. Thankfully there are lots to choose from.
It's quite common to feel your inflammation/discomfort worsen when you first insert or apply any treatment to the vagina/vulva - whether that be vaginal oestrogen or a non hormonal moisturiser or lubricant. This is because the tissues are sore, inflamed and untreated.
However, what might initially sting or burn, can become more tolerable over time as the tissues begin to absorb the treatment, inflammation reduces and health is gradually restored.
Wash off any creams, moisturisers or gels the next morning, pat dry and apply some soothing emollient such as Epaderm Ointment, Hydromol or even something like Yes OB which is a plant oil personal lubricant. It can be very soothing and contains shea butter.
Some people find using a dry vaginal tablet such as Vagifem/Vagirux to tackle their vaginal discomfort and using a smaller amount of vaginal cream on any external areas of itch/soreness is the best combination for them to use and helps manage their vaginal/bladder/vulval symptoms more effectively.
Quite simply - what works for one person might not work for another. One particular dose or combination of treatments might be just what you need while others need something completely different.
We are all unique. YOU are unique and you should be heard and advised according to your own individual symptoms and needs.
There are several vaginal oestrogen products on the market and most are currently widely available on the NHS.
There are a range of hand held "vaginal rejuvination " devices marketed on social media channels which claim to restore your vagina back to how it used to be!
These, and other more potent laser devices are currently not backed by enough clinical evidence to show they work. They tend to be quite expensive and the National Institute of Clinical Excellence ( NICE ) advises that for now, their use should only be part of clinical trials. In short - save your money and don't fall for the hype.
You can talk to us about your concerns and the symptoms you're dealing with and we can go through available products with you and help enable you to make an informed decision.
If you'd like to do this, you can click on any of the Book a Consultation links on our website.
Our Top Tips and Resources
1.
First of all, don't spend ££££'s of your hard earned cash on countless products advertised online to help relieve vaginal/bladder or vulval burning/itching/soreness/frequent urine infections/vaginal infections that you've been dealing with. They wont give you back the oestrogen which you may be lacking in and causing you to develop these unpleasant and annoying symptoms - but regulated, licensed, body identical vaginal oestrogen will.
Instead of buying heavily marketed/advertised apparent cures online, please consider speaking with us or your GP about the symptoms you're seeing, how often you have them and what if anything you think is causing them ie: do they worsen after sex or after sitting for long periods or wearing tight jeans/knickers etc.
(ALSO - if you love a pair of skinny jeans or opaque/wooly tights in winter - consider buying them a size up to give you more room around the intimate areas, but still give you the look you love!)
2.
Switch from those lovely smelling shower gels and bath additives to an emollient wash such as Epaderm Ointment / Hydramol and use this to wash the intimate areas with. You can still wash the rest of your body with a nice shower gel but please keep it well away from your vagina/vulva. Simply scoop a blob of the product out, splash it with warm water and wash the vulva with it. Wash it off and pat dry. You can even apply a light layer of it afterwards to help you feel more comfortable across the day. Apply some before swimming to keep chlorine from having a drying effect on the vulval tissues even further. Was it off after your swim. Pat dry and reapply a light layer if you need it.
3.
Think about how often we use body lotions and moisturises to keep our face/skin moisturised and free from drying out - so why should we ignore our vagina - it's no different.
We LOVE the YES company for their range of non hormonal vaginal moisturisers and lubricants and they have some amazing products which help maintain moisturise in the vagina, retain this within the tissues there, help lubricate and coat the vaginal walls and keep the vulva comfortable so that sex is more do-able and YOU are more comfortable throughout the day!
You can buy Yes VM ( vaginal moisturiser ) or Yes OB ( oil based lubricant ) through our website ( see "Treatments we love" section at the bottom of this page ) and click to receive a 15% discount on your order! Yes also provide a more extensive range of products including a new coconut oil vaginal lubricant.
P.S If your YES OB lubricant becomes grainy, just pop the tube in a jug of warm water. This will melt the shea butter crystals. Pop the tube in the fridge and the product will return back to its original form.
4.
Purchase a washable vaginal moisturiser/lubricant applicator which allows you to squeeze the products into them and insert them deeper into the vagina as your finger often doesn't take the products far enough in. Amazon/Ebay are a good port of call for these. You can usually pull the plungers out and use warm water to wash them out afterwards. Insert your products at night to give them time to work on the vaginal tissues and vulva without ending up in your good knickers!
5.
We firmly believe a combined approach to managing vulvovaginal and urinary symptoms effectively is the way to go. If, despite using vaginal oestrogen and non hormonal treatments like moisturiser and lubricant, you are still seeing occasional flare ups of your symptoms - a women's pelvic health physio can really help you to manage how you respond to potential triggers such as stress or sex for example, and help you respond differently so that your symptoms don't worsen or become more prolonged than they have to be.
These specialists are worth their weight in gold and well worth investing in. Talk to us if you are looking for a referral as we can recommend someone to help.
Additional help and Resources
Have a read of one of many articles written on this specific topic by our very own Pearly Clark Brown:
https://www.practicenursing.com/content/clinical-focus/vaginal-symptoms-in-the-menopause-cause-impact-and-treatment-combination-options/
Click on this YES products link with a 15% Discount on us!
https://www.yesyesyes.org/YOUR_MENOPAUSE_NURSE
Vaginal Oestrogen after breast cancer clinical articles - https://jamanetwork.com/journals/jamaoncology/fullarticle/2811413
https://www.ajog.org/article/S0002-9378(24)01126-8/fulltext
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