Tuesday, January 31, 2023
First a quick summary of Vaginal Oestrogen.
Vaginal Oestrogen is used to treat Vaginal Atrophy (VA) with/without Urogenital Atrophy (UA) in menopausal women.
Vaginal Atrophy is when reduced Oestrogen levels in the body, due to the menopause, cause inflammation, drying and thinning of the vaginal walls. Symptoms include vaginal discomfort, dryness or pain during sex and sometimes increased cases of thrush.
Urogenital Atrophy is when these same reduced Oestrogen levels in the body also cause inflammation, drying and thinning of the external genital area including the urethra (the hole you urinate from) and the vulva.
Symptoms are similar to VA - dryness, discomfort and itching but this time on the outside of the vagina, the vulva, labia, perianal area and forward towards the clitoris.
You might also find that you need to wee more often as the bladder and urethra walls weaken, this can be most noticeable at night, or find that you’re experiencing an increased number of urinary tract infections (UTIs) as conditions inside the urethra change and allow bacteria to flourish.
All Vaginal Oestrogen products are used in a similar way, with daily dosing for a few weeks when you start treatment then reducing to one dose twice weekly. If you are moving over to a new Vaginal Oestrogen from another, you can continue to use it twice weekly in place of your previous product as you had done before, providing there has been no treatment break.
Theoretically the amount of Oestrogen in these products is not enough to be absorbed into the bloodstream and cause symptoms such as breast tenderness, nausea and other hormonal symptoms, or to relieve whole-body menopausal symptoms such as brain-fog, mood swings or migraines amongst others.
That said, medicines are standardised and we are not. If you are feeling uncomfortable using your current Vaginal Oestrogen and are experiencing these symptoms beyond the first couple of weeks then you should speak to your prescriber and consider trying an alternative product.
You should if you want to, but we do not insist on it before we prescribe for you. Our doctors carefully assess each consultation and will prescribe Vaginal Oestrogen if they believe it is best for you, they also provide tailored advice with every order. Speak to us if you would like more information.
Estriol is a weaker form of Oestrogen so these products are often considered gentler than those which contain the stronger form of Oestrogen - Estradiol.
Although chemically this is the case, many women find that they suit one type of Oestrogen more than the other, regardless of this variation in strength.
Ovestin contains Estriol 0.1% in a smooth, oil-based white cream which is applied internally using the included applicator.
One applicator dose of Ovestin delivers 500mcg of Estriol and each tube contains 30 doses.
Ovestin is one of the more commonly prescribed Vaginal Oestrogen products in the NHS, this is because it has been around for a long time (since the 1980s) and is often the most cost-effective choice for NHS prescribing.
The biggest benefit of Ovestin is that it can be used both internally to treat VA and externally to treat UA. You use the applicator for internal treatment and can apply externally using your fingers.
All vaginal Oestrogen products leak from the vagina after use, especially Ovestin and Blissel, usually during the night. Due to the creamy formulation Ovestin is often reported as one of the messier options.
Blissel Gel is a newer product. It is a clear, colourless, water based gel containing Estriol and is applied internally using an included applicator.
One applicator dose of Blissel delivers 50mcg of Estriol and each tube contains 30 doses.
Blissel is the lowest dose Estriol product that is not a pessary.
The benefits of Blissel Gel include the water-based formulation, this can be more beneficial for women who find oil-based cream too thick, irritating to their skin or find that it takes longer to dry and remains sticky when used externally.
For this reason, Blissel could be a more convenient choice for an Oestrogen product used externally for Urogenital Atrophy (UA) as it is less sticky and dries quicker.
This water-based gel also has a moisturising effect on the vaginal tissues which can make it both more comfortable to use and help the symptoms of VA improve, particularly vaginal dryness.
All vaginal Oestrogen products leak from the vagina after use, especially Ovestin and Blissel, usually during the night. As the only water-based product, Blissel is reported as the least messy.
The water-based formulation also technically makes Blissel condom-compatible. I would recommend using your vaginal Oestrogen after sex anyway, but worth a mention in case it’s important to you. Oil-based cream like Ovestin can damage latex condoms (and diaphragms) reducing their strength.
Imvaggis is an Estriol pessary.
Pessaries are small, vaginal tablets or capsules containing medicine, some bulking ingredients (to fill out the pessary and make it large enough to be easily used vaginally) and usually a cream or wax-based ingredient which causes it to melt and release the medicine at body temperature.
Each Imvaggis pessary is only 30mcg of Estriol, making it the lowest estriol-containing product available in the UK. There are 24 pessaries in each pack.
Imvaggis pessaries are small, bullet shaped and waxy. They don’t come with any applicators, intended instead to be inserted manually, which makes them a more environmentally friendly choice.
The waxy exterior makes for a smooth application and this pessary delivers a little extra moisture for the vaginal tissues as it melts.
Ingredients in Imvaggis pessaries can damage and weaken the latex in condoms and can therefore impair their effectiveness.
Now let’s summarise the products which contain Estradiol as opposed to Estriol.
Although chemically Estradiol is around 8 times stronger than Estriol, many women find that one suits them better than the other. If you have tried one previously that hasn’t suited you well, it might be worth trying the other.
All Estradiol products are pessaries. Estradiol in cream or gel form is not available in the UK (at time of writing) but can be found elsewhere in the world.
Vagifem are very small tablet-like pessaries, 6mm in diameter each containing 10mcg of Estradiol. There are 24 pessaries in each pack with 24 applicators.
Vagifem pessaries are supplied already in the applicator and the applicators are each individually foil-wrapped. This means they are ready to go straight from the pack.
Benefits to using Vagifem include ease of use, the small tablet-like pessaries stick to the vaginal wall and release their dose of Estradiol. Because they don’t melt like some other types of pessary they are not so messy to use.
The main downside to using Vagifem (or any of the other pessaries) is that they really can only be used internally. As you settle with Vaginal Oestrogen you may find that the Vagifem starts to treat the symptoms of Urogenital Atrophy, but this is likely to take weeks to months.
If you’re looking for something to use both internally and externally, you might be better using Blissel gel or Ovestin cream.
Vagirux is a non-branded (generic) version of Vagifem.
Each tablet-like Vagirux pessary contains 10mcg of Estradiol and is also around 6mm in diameter. Each pack contains 24 pessaries and one applicator.
Vagirux pessaries are supplied with one single applicator in each pack, which you clean between uses which is more environmentally friendly than Vagifem. You should use a new applicator with each new pack of pessaries.
Gina is also another generic version of Vagifem.
Each tablet-like Gina pessary contains 10mcg of Estradiol and is also around 6mm in diameter. Each pack contains 24 pessaries and one single applicator.
The main difference with Gina is that it is available over-the-counter from pharmacies only, without a prescription. If you visited a high street pharmacy to purchase Gina, you would answer some questions with the Pharmacist about your VA/UA symptoms to ensure it is safe for you to use.
With an online pharmacy, we ask you to complete a short list of questions with your order for the same purpose.
Because there is no specialist prescriber involved when you buy Gina, the criteria for purchase is stricter than with a prescription product.
In real world terms, a woman might be refused Gina but would be able to have Vagifem or Vagirux prescribed by one of our team of online doctors.
The Estring is a soft, flexible silicone ring designed to be placed and worn at the top of the vagina, under the cervix, for 90 days at a time. Over these 90 days, a continuous dose of 7.5mg per 24 hours of Estradiol is released locally.
Estring is the equivalent of using 5 of the 10mcg Vagifem/Vagirux/Gina Estradiol pessaries each week so is the highest strength vaginal Estradiol product available in the UK.
The main benefits are ease of use, once the Estring is in place you don’t have to do anything for 3 months, although some women do prefer to take it out for sex.
An Estring can be fitted by a medical practitioner, like your practice nurse, if you prefer but it’s good to ask questions while she’s doing this should you want to take it out and replace yourself. It’s very soft and flexible and you shouldn’t feel it once it’s in place, similar to a tampon.
The Estring is very low-maintenance so can be a good choice for women who find cream/gel/pessary administration difficult or inconvenient. The Estring can also be a good option if you are experiencing prolapse and have a PVC ring pessary fitted as it will sit alongside and keep the vaginal tissues healthy.
So that’s our summary of Vaginal Oestrogens, I hope you’ve found it helpful, I’ve quite enjoyed putting it together.
Here is a quick comparison table that summarises the key features of each product.
Our clinical team, from our doctors to our support staff, all have an interest and expertise in the products we supply and we aim to be an extra support to your NHS or private menopause service so do reach out to us if we can help.
This is not personalised advice. To speak to one of our clinically trained team about finding the right treatment for you, email us at [email protected] or call us on 01295 262925.