prescription for Estring (NHS) - plus cream?

[HappyCheesy]

I have a prescription for Estring, which so far is going OK. It is mainly for urinary symptoms and I much prefer it to having to apply something daily or a couple of times a week. But I am still getting some dryness/itching, and I have read that some women on estring also use a cream/gel. The GP said no, it's either/or, and if I want cream, then that's a different prescription and I use it bi-weekly instead, not just as an occasional top-up for issues. I can't find anything in official guidance that says you can have both at the same time, even though anecdotally, it sounds like people do. Even if you buy it at the pharmacy - I think there is at least one type available - it goes on your GP record, and I don't want her to stop prescribing the estring (I think it's more expensive, and she didn't seem that keen on it in the first place). And if I do find something that says it's OK to have both, which cream/gel would be best for occasional, external use?

Also the information on estring says it can be used for up to 2 years only. I think, from reading about it, that this is mainly because it hasn't been tested for longer term. The same thing is true of the cream/gel preparations, but those now say that long-term use should be fine. But the estring advice hasn't similarly been updated to say that it can be used for longer if it's helping, even though it's also a local oestrogen. I'm getting ahead of myself here, but I don't want to only be able to use it for another year and half and then have to stop. I again can't find any official information that suggests it could be up to the provider to continue the prescription if appropriate. And my GP is very hot on following rules, so would not go off-piste. So at some point before the two years is up, I'd like to find some official guidance that says it can be continued in some cases. Any links?

Have you tried googling using the phrases that are needed here to find any info?

I'm pretty sure the same applies to all vaginal estrogen treatments - that there are no long term studies on use. However, what was changed some years ago was the advice on using progestogen now and then (eg once a year) to see if the womb lining had built up and needed to be shed. The guidance does now say this is not necessary.

I've used the cream for 20 years with a consultant gynaecologist.

There is guidance that vaginal treatment should be used as long as necessary or symptoms will return.

To give another side to this- if this was privately prescribed and the consultant had any concerns about your womb lining, they would arrange a scan to check it.

That is always an option but of course it's not cheap.

You can buy Ovesse over the counter and I'm not aware that they inform your GP.

There is no reason why you can't use both. One year of vaginal estrogen is the same as 1 day of estrogen on HRT.

Unfortunately, some GPs go 'by the rules' because they don't have the deeper knowledge to make individualised prescribing.

She is very much 'by the rules'.

Yes I have been googling, but I'm not finding the official rules that allow it, just plenty of anecdontal descriptions of what other people have been able to get prescribed, and/or private prescriptions. That's why I hoped others here might have found some links. All the official guidance (NICE etc) that I've come across just lists the different preparations as alternatives. Nothing seem to say you can use both. Nothing says you can't, either, but she will want specific guidelines to allow it.

I even googled whether pharmacies inform the GP, but apparently they do (for Ovesse). For Blissel (?) a gel, which sounded milder, they don't even prescribe, only the GP, which seems a bit counter-intuitive.

I'm not worried that there would be consequences of long term use, but if the prescribing information specifically says 'up to 2 years', which it still does for the estring, then she will stick to that. The other forms of vaginal oestrogen don't now say that (even though long term evidence is equally lacking), but the estring does, from the manufacturer's leaflet. So I'm sure she'll stick to that, even though it sounds like it is more a 'covering themselves' type of warning because of lack of research, rather than any particular reason.

So I'm just looking for official information that would allow these things; I'm comfortable enough with their use, but would like to continue to have the GP prescription for them rather than eventually needing to go private.

I don't think you will find what you're looking for as it doesn't exist.

I'd focus on finding a different GP to be honest.
It seems ridiculous that she may not consider why there is a 2- year limit (lack of research or the possible but unproven risk of hyperplasia) when the simplest solution if she is worried is to send you for a scan.

You could try googling the British Menopause Society and the International Menopause Society on the key words as they produce guidance.
Have you tried Google Scholar and used words like 'long term use of Estring'?

Or, if she is intransigent, you may have to find a private GP who deals in menopause, which would be cheaper than a consultant, and get them to prescribe.

I'm not aware of a pharmacy taking anyone's details and passing onto a GP- are you sure of that?

I'm not sure of it, no. Just what I googled, suggests that the pharmacist is supposed to record it and send it to your GP for the records (eventually). I don't know if this actually happens in practice. Has anyone actually done this, and do you have to give your NHS details? Of course the GP might be happy enough if I do just buy it over the counter, as she wouldn't be going counter to any rules that way.

If anyone has got their GP to prescribe both, it would be useful to know what, if any, prescribing guidance they used - did you go for cream or gel, and which kind, and did the dose/info about applying it specify that you were using it alongside the estring? (i.e., not internally, so don't need the normal dose/instructions for that). Or do they just prescribe it as if it were the only thing you were using, including the internal application?

The two years thing might be a harder issue to solve, but at least it's not an immediate one. If it comes to it, I could consider a private prescription, but they are expensive, and I prefer the GP to know about it as well. Maybe by then the guidance will be updated. I don't think anyone is actually concerned about the long term use, but it seems that the official product description hasn't changed - and for many GPs, they probably are happy to prescribe anyway. But if the formulary says 2 years, mine wiill definitely stick to it.

I'd turn it round the other way and ask your GP to find the advice and speak to a specialist on your behalf.

There is info online , from 20 years ago, but it says what you already know and what I've said- that women can continue to be prescribed vaginal treatments and if there is any concern there can be a 'challenge' by giving a low dose of progestogen to see if the womb lining sheds.

This has been changed since 2005 when that advice applied, but your GP could do that for you if she's worried.

I'd either try buying it now and seeing what happens, or changing your GP- why stick with her if she's not open to what's best for you? Or at least refer you to a consultant for their input.

Hi OP,
I've just just started using estring on a trial at my gp menopause experts suggestion. I'm also using ovestin on my clitoris and around that area because as I understand it the estring only works inside.
So far I love it. It appears to have given me the vagina I had as a 30 year old 😁

I should maybe also add I'm also prescribed everol 50 patch and micronised progesterone.

thank you - I'm glad to know that it's possible and also that it seems to be helping! My GP said the estring should just help everything, but I am not convinced, and think some cream might help too. Did she suggest prescribing the ovestin, or did you have to ask for it?

I don't have systemic HRT yet either, as she wants me to wait for tests before she will prescribe that (I've been waiting for 18 months!). But hopefully within the next six months I can maybe start that too.

I was already on ovestin but mentioned I was having to get up in the night for a wee which was a pita so she suggested trying the estring. I'd been on systemic hrt for about 8 months at that point.

I was a bit dubious about the estring at first because I was expecting it to be a bit smaller but so far it's great.

If you're over 50 you can buy ovestin from boots over the counter.

Having to wait 18 months to try hrt is quite frankly taking the piss. I'm sorry your GP is so lacking OP x

yes i was wondering about buying over the counter, but I read online that they send the information to your GP record (which I know is good, as they need a complete record, but I don't want her to stop the estring as a result).

I thought it would be smaller too. People apparently don't have to remove them for sex etc, which surprises me. Not an issue for me, but I can't imagine how things would fit. Maybe I don't have it high enough up, as I can feel it easily with my finger. But I don't particularly feel it the rest of the time. I struggled getting it in, but that's for other reasons, and partly why I don't really want the other types of cream with pessaries or tablets or whatever that require application much more frequently. I would like to keep using this I think, and for more than 2 years if it seems to help in the end (bit too soon to tell how the urinary symptoms are, but they sound similar to yours, plus leaking with exercise and urgency).

It's waiting for some hospital tests that seems to be the issue, scans and appointments that seem to have months waiting lists for each step of the process. I'm pretty sure there wouldn't be any bar to HRT, but she wants to be sure I guess.

@HappyCheesy If you look on the website for Ovesse it tells you which shops stock it- I think Tesco is one and Boots. I think all you need do is answer a few questions when you buy it which are are you over 50 and post menopause. I'm not aware of any requirement to take your personal details and inform your GP.

(I get mine on prescription..)

If you're leaking , vaginal estrogen alone won't sort that. The best thing is to see a women's physio, privately, and have an assessment of your pelvic floor and be shown how to do exercises to help.

What is going on so you're waiting for scans and tests that mean your GP is waiting for results before she might prescribe HRT?

That's not usual at all. It sounds nonsensical to be honest.

I also wonder, if she's so black and white, if she stops prescribing vaginal estrogen cream after 2 years?

the estring was recommended for the leaking and urgency, as I have been doing pelvic floor exercises and they said my pelvic floor is ok. I don't suppose the estrogen will solve it entirely but I hope it might help. I'm waiting for some heart tests before starting hrt but routine appointments and scans have very long waiting lists.

I suggest you find another GP- yours sounds useless.
Is she very young and inexperienced or older and not up to date?

Having to wait for some tests (for 18 months?) before starting HRT is ridiculous.

What are the tests for? Are you suffering with menopausal symptoms and are needing HRT? If so, why are you waiting 18 months for 'tests'?

There will be no research into long term use of vaginal estrogen and it's unlikely the leaflets will change. The top consultants in the UK have been pushing for years to get the leaflets changed anyway- because they list all the side effects of HRT even though vaginal creams etc are not systemic HRT.

You have to take control of this yourself. Buy the cream, stop worrying if your GP finds out, insist you get HRT now if you need it and if she refuses you need to see another GP or change to a different practice.

Who said it would work for leakage? If this is your GP she doesn't know what she's talking about. It may well help urgency. It won't repair a pelvic floor.

When you said 'they' said your pelvic floor was okay is this your GP or have you seen a specialist women's physio? How was your pelvic floor assessed?

You don't need heart tests before starting HRT.
If you have eg palpitations, they are a common symptom of peri.
If it was a factor, that was urgent, you'd have the tests immediately.

I'm sorry- but you're being messed about by a very incompetent GP .
If you can, change GPs or pay to see a private specialist.

Sorry if I sound annoyed but it's on your behalf.
If you have to wait 18 months for some tests on your heart it can't be serious and more to the point, HRT actually protects the heart!

How old are you?

Hi, you definitely don't have give any details when you buy it over the counter, or at I didn't when I bought a tube in Boots. They just asked my age and emphasised that I should be getting in free on prescription.

I can say from experience that you can keep it in during sex. I have and I don't even notice it's there. Alternatively you can take it out, have sex and pop it back in after a quick wash in luke warm water.

I can feel mine with my finger, just about. But I can't feel it any other time. It's quite large so you'd need a massively long vagina not to be able to feel it with your finger (and it would be difficult to remove).

Could you afford a private menopause clinic for a consultation? That way you can get advice, probably ovestin cream and systemic hrt and once you're happy you can transfer to your GP for NHS care. A friend of mine did this and it worked well for her.

Alternatively there are a few places online you can buy hrt/ovestin cream privately eg Superdrug. You complete a medical history form first though so they can establish health risk.

As I understand it systemic hrt isn't recommended with a family history of oestrogenic cancers but non systemic hrt like estring, ovestin or intrarosa is fine.

I also tried intrarosa which I liked but its a pain having to use it every day.

The other thing I would recommend is a course of probiotics. I use Optibac 'for women'. Apparently lack of oestrogen causes a shift in the ph of the vagina from acid to alkali which makes thrush and uti's more likely.

If your GP likes to follow guidance, why is she not, if you have requested HRT?

The NICE guidance is that it's possibly not suitable for women with diagnosed active heart disease or a recent heart attack or blood clot.

If that doesn't apply to you, then you do not need to wait 18 months for routine tests on your heart ( ECG?) unless you're currently being treated by a cardiologist.

Obviously no one here knows your medical history.

It might help to look at the guidance and if you're asking for HRT, query your GP.

As I understand it systemic hrt isn't recommended with a family history of oestrogenic cancers

Family history is two first degree relatives (mum and sister) with breast cancer at an early age and in that case genetic testing is usually suggested.

The cardiology tests are not because of menopausal symptoms but other things (not just ecg), and she wants to wait for the results, which in theory is sensible, but in practice just means waiting a long time to have it confirmed that there likely isn't a heart issue.
I'll consider adding the probiotics too, that sounds like a good idea, and just buy the cream otc.
Changing GPs not that easy; I might try a different GP - it's mostly male doctors there who I don't know but they might well be more helpful.

Some surgeries have a womens health person. Either a dr or a practise nurse so you might do well to ask if they do when you change gp.

It's not sensible and far from it!

If you have symptoms linked to your heart you should be fast-tracked for tests and referred to a cardiologist.

The guidance on HRT is be cautions - as I posted above- with existing heart disease, heart attacks or a blood clot.
None of the applies to you.

The most important part is that HRT benefits the heart if it's started within 10 years of your last period. So the longer you wait, the clock is ticking.

Modern HRT does not damage the heart. It helps the arteries stop furring up and some elements of HRT can reduce blood pressure (eg micronised progesterone.)

I'm sorry but your GP is pulling the wool over your eyes. She's incorrect on so many points.

I have been referred and am in the process of tests. The waiting times here are insane; this is as fast tracked as it gets, without a life-threatening emergency. Each test has its own waiting time, and then a wait for the follow-up. Even when it's almost certainly nothing - in fact, that makes it take even longer, but they can't say for sure no heart disease or anything until I've had them. Luckily it's only about 3 years since last period. I would potentially rather start hrt than blood pressure drugs, which might also be on the cards, but waiting to see what the other tests show first. I'm not even totally sure I want hrt, but at some point I'd like to discuss it. There has been a lot of mixed research on dementia, particularly in those with genetic susceptibility, and some of the most recent research says that population (probably including me) might need to be careful, so i'm not rushing into it anyway, even though I do think there are other benefits that might be good for me.

There is no absolute evidence that HRT impacts on dementia.
My dad died from dementia and I'm not giving HRT any thought at all because the evidence is not there. Lifestyle factors like diet and exercise are more important in prevention.
HRT may well be protective given that more women than men die from dementia.

If you have menopausal symptoms that are affecting your quality of life, why not see a specialist for menopause, privately. They will be able to access if your heart symptoms are relevant, prescribe vaginal estrogen and also HRT. This could all be sorted within a month or so.

The cost is around £300 for a first appointment but the consultant can usually write to your GP with their recommendations for future prescriptions.