Vaginal Atrophy on Perineum

[salsamad]

Can anyone advise on best steps to take.
I’m have been using Ovestin (Estriol 0.1% cream) for a couple of years due to Vaginal dryness & recurrent UTIs. This has really helped me, however I’m now having sore/dry irritated skin on my perineum (just below vaginal entrance down towards anus) which is aggravated terribly with sex.
I don’t know if I should apply the Ovestin externally to this area, as you use a measured dose internally twice a week or if there’s anything else I could try.
Any advice really welcome.

Just apply the cream on the perineal area too. Yes it's 2 doses a week but it doesn't need to be exact, use a bit on your finger to spread on the sore area.
I would maybe use condoms until the cream has worked as semen may well be exacerbating things.

As above.

The estrogen in Ovestin is minute. (2 applications per week over a year is the same amount as 1mg of systemic estrogen- that's a daily dose for women on HRT)

You can use it externally too - that's the benefit.
Just use a pea-sized blob, as necessary.

You can also use more than 2 x a week if your symptoms get worse- just revert to every day for 14 days then back to twice a week.

I’ve always been told to use it externally as well as internally, and I use it 3 times a week. (Specialist at Newson health and nhs both said this was okay). I use Replens on the days I don’t use Ovestin - you can buy this or you can get it prescribed. It’s hormone free so you can use as much as you like. (I have sjorgens syndrome so I am extremely dry)!

Thanks everyone for your advice. Have managed to get an appointment to see my GP next week, so will ask about alternative hormone free cream I could possibly get on prescription.

Can I also ask how often you are using Ovestin (or similar) for and for how long?
My GP says I am to use it twice a week for three months but then four weeks with nothing (and I notice as these weeks progress my symptoms worsen - though the UTIs haven’t recurred.) This advice hasn’t changed in medical reviews I’ve had over the past two years.
I do have the Ovestin on repeat but if I start using the cream externally it will use my supply quicker and my GP may be reluctant to prescribe more……

'I do have the Ovestin on repeat but if I start using the cream externally it will use my supply quicker and my GP may be reluctant to prescribe more……'

It won't increase your use dramatically just use a pea sized amount from the applicator for the external area.

Lots of hormone free vaginal moisturisers available over the counter, no need to see a GP. Try 'Yes', seems to last longer than replens.

'My GP says I am to use it twice a week for three months but then four weeks with nothing'

This isn't anything I've heard of, I think your gp has made a mistake. It's daily for 2 weeks then twice or 3 times weekly thereafter. It's a tiny dose, no need for breaks of any kind.

Have you been checked for lichen sclerosus? In which case you’ll be given a steroid cream.

I’ve been on the Ovestin for over 2 years and the 3 months on/1 month off is how I’ve been told to use it (I did use it daily for a short period when I first started using it). The leaflet with the Ovestin suggests this is how it should be used/prescribed. (I’ve included a screenshot).
It does work for me and stopped the very worrying constant UTIs, which I did had to have a Cytoscopy for due to frequency & blood in urine.
Maybe now I need to use it externally and I should speak to my GP to see if this 3mths on/1 mth off is necessary as the actual dose is so low and some of my symptoms reoccur in the month off. Thanks again for your advice everyone.

How I hate the patient leaflets that come with topical estrogen cream and I'm not the only one! they're out of date and have a lot of incorrect detail related to systemic HRT re risk etc. This was mentioned on the Channel Four programme Sex, Myths and the Menopause (still available on All 4 last I looked). It also, really importantly, doesn't mention that we can also use it externally on the vulva - and the perineum - and the anus for some women. We have estrogen receptors there too and it can help.

Better to go by the NICE Menopause guidelines, I've screenshot the relevant bit which states that if stopped symptoms can return and if treatment isn't controlling symptoms it can be increased. Full guidelines here: www.nice.org.uk/guidance/ng23

A moisturiser can also help and for the vulva an emollient ointment which is thick is really good in helping protect and soften the tissue. No need to see a GP for it - just get it OTC or from Amazon. There's quite a few different brands such as Epaderm, Hydromol, Zeroderm, Diprobase etc. Replens can be the GP go to suggestion but has mixed results in working for some women but irritating others. YES products are kinder to the genital tissue. YES VM is a good vaginal; moisturiser and YES OB is oil based and a thinner alternative for the vulva to the emollient.

Current BMS tool for clinicians - no mention of taking a break thebms.org.uk/wp-content/uploads/2022/08/04-BMS-TfC-HRT-Guide-01-AUGUST2022-A.pdf

'Maybe now I need to use it externally and I should speak to my GP to see if this 3mths on/1 mth off is necessary as the actual dose is so low'
Yes tell them they've made a mistake, its crazy that qualified HCPs are getting the simple stuff so wrong. The daily for 2 weeks is the kind of 'loading dose' with the twice weekly afterwards maintenance/ therapeutic doses. To stop for a month would seem absolutely pointless and could well set you back painwise.

Remember it's a tiny dose. Many women take it daily continuously, I'm not suggesting you should of course but just for some perspective.

Thanks so much everyone and especially Over50andfab for those links. I will show them to my GP.

@salsamad Your Gp is incredibly out of touch and incorrect. Also I know that some consultants are pushing for that leaflet to be changed as it's not appropriate any more.

I've used it for 16 years, as often as needed, from a top meno consultant (he trains other drs and speaks at the British Menopause Society conferences.)

There is no need to take a break from Ovestin. How mad is that?
Would someone say stop using handcream for a month?

I use it continuously, no break and have done for years.

The amount of oestrogen in it is exceptionally low, so low that when I have cortisol blood tests (which usually require anything containing oestrogen to be stopped for 6 weeks prior to testing - for example systemic HRT or the combined pill) I can keep using Ovestin as the oestrogen is so low it doesn’t affect blood results. It’s enough to make a difference vaginally but that’s all! There’s no need whatsoever to stop it.

@salsamad You can buy Gina which is vaginal estrogen at a pharmacy now. It's like ovestin but a tiny pessary.

Some women use Gina (also known as Vagifem) internally and Ovestin externally.

If you are 50+ and already have vaginal estrogen from your dr, you will usually be able to buy Gina OTC (pharmacist has to ask a few questions.)

Ideally, you need to see your GP NOT to ask permission but to make them aware of the correct prescribing for this. Other women may be suffering from the incorrect prescribing.

Hope you find a way forward.