Vaginal atrophy and systemic HRT

[FergoMcFergFace]

I recently had a consultation at the menopause clinic at my NHS hospital to discuss HRT in the context of my family history of breast cancer. I was told with my history it was generally not recommended but if my symptoms were unmanageable, it was still an option.

I told the doctor (he was a trainee specialist not a gynaecologist) that my most problematic symptom was my vaginal/vulval soreness, for which I've just started using Estriol cream (still early days, not much relief yet).

He told me that systemic HRT does "absolutely nothing" for GSM symptoms, but that vaginal oestrogen was safe (which I already knew).

I've just read Jane Lewis's book Me and My Menopausal Vagina, and she describes seeing significant changes to her symptoms when she started systemic HRT.

I would absolutely be prepared to try HRT if there was a chance it would help support my vaginal health.

What are other people's experiences of HRT and their vaginal atrophy?

I found that systemic HRT wasn't fully effective on its own. I've since stopped using it and now only use topical and that is much more effective than the systemic was.

If I were you, I'd give the topical a few weeks to see before looking at the systemic again.

Same as above, the gels are best. I would try to find a qualified woman who can talk you through options in a friendly way as I find often it is easier to ask questions.

Systematic HRT did nothing for my atrophy. The treatment you have used has helped a little.
I also use moisturising pessaries called Balance Activ I buy off Amazon which have really helped me.
I would definitely get another opinion.

I used the oestrogen pessaries initially (this was about 2 years post menopause) and they definitely helped. I think if I had increased the dosage, they would have been even better.

However, I didn't have any contraindications and I moved to systemic HRT, which has made a massive difference. Everything is plumper and less dry and shrivelled and the horrible tugging sensation of all my reproductive organs shrinking has stopped. It has taken a while to get the dosage right but the improvements started almost immediately.

If you see a GP or even consultant gynae who has had menopause training that really helps.

Thanks, all.

I fully understand that local oestrogen is the most effective treatment for GSM and that a lot of women on HRT also need local treatment. I'll definitely be sticking with the Estriol (I'm two weeks in and feeling itchy, which I hope is just tissue healing and not an intolerance to the base).

My GP surgery won't prescribe HRT because of my family history, hence the referral to the menopause clinic. I was quite happy to put systemic HRT on hold as I feel I'm coping with the hot flushes quite well, and exercise has helped with anxiety and joint pain. Although since I've had this flare up of vaginal symptoms, exercise has completely gone out of the window, which hasn't helped at all.

Now I'm wondering whether I'm just putting up with more symptoms than I have to and I could really just do with a good dose of oestrogen! I feel like I put up with a lot of the worst symptoms during perimenopause, but two years on from my last period, I'm having hot flushes, itchy, dry skin, itchy ears. I can refer back to the clinic in the next 12 months if I need to.

I'm sorry you are having issues with this.
I'm afraid I'd disagree with the doctor as it's not so straightforward as he said.

Some women need both but there is no 'one fix suits everyone'.
Interestingly, 1 in 4 women need both- systemic and vaginal.

I started on Ovestin for around 6 months before adding systemic HRT (for other meno symptoms.)

I doubt systemic HRT on its own would be enough because if I get a bit lazy with using vaginal estrogen the symptoms start coming back.

My understanding is that systemic HRT may help a bit with issues like prolapse as it supports collagen throughout the body but don't quote me on that!

I'm more interested in your family history of BC and reasons not to use HRT.
One of the best breast specialists in the UK says that family history is only relevant if you have the BRACa gene and should have genetic testing if there are several women on your mother's side who had BC.

Are you willing to share what the family history is?
Genes account for 5% of breast cancer. The rest of often lifestyle, age or unknown reasons.

And if you are at high risk you can access annual mammograms either NHS or privately if that's an option.

@FergoMcFergFace What is the family history that your GP won't prescribe? Have you checked online what a strong history means?

Also, you can see a private menopause specialist who specialises in women at higher risk, and discuss with them- you don't have to wait a year or rely on the NHS.

If you can fund it you could see a private consultant within a month.
There are gynaecologists who are experts in exactly this- women who may benefit from HRT but with some family history.
Some of the NHS clinics are not at the same level of expertise, unfortunately.

@FergoMcFergFace I have been using estriol for nearly 2 weeks with your symptoms and today is the first day that I feel almost normal again so you do have to give it at least 2 wks. I nearly phoned the GP yesterday to arrange another urine test as convinced it was a UTI. The relief, I cannot tell you!
Re your itchy skin, ears etc. I had this and found an antihistamine a day helped. Loratidine inexpensive from online chemist.
Edited to add, I found it easiest to use at night before bed, after a shower (no soap or shower gel in the area) so that it worked all night and day.

@JinglingSpringbells I have no BRCA mutations but enough family history to mean I already have annual mammograms (mum and her sister both had breast cancer, post age 60 - plus some other relatives further back).

Yes, I've read the British Menopause Society's recommendations on family history considerations, and have read other evidence-based material. I'm not overweight, I've never smoked and I don't drink, so I feel that my risk is already mitigated to a degree.

Thanks - I've got some loratadine so I'll give that a go.

I've been using Estriol for two weeks too - although I've been dosing every other day (I had a really horrible experience with Blissel gel earlier this year so I wanted to go a bit more slowly). So I guess I've only taken half the amount that you have. I have to say, visibly, it has improved immensely! I think I may have an issue with overactive pelvic floor muscles because I've been subconsciously guarding against the pain for so long, so maybe a physiotherapist might be helpful for that. Oh joy. (Take me back to my 20s! 😩)

Really pleased you're getting some relief now.

I may be wrong but your mum and her sister don't count as risk factors.

The risk is one first degree relative at a young age, or 2 first degree relatives at any age. Your aunt is not a first degree relative.

The guidance at the moment is that using body identical estrogen and micronised progesterone for up to 5 years does not increase risk. There is also less risk using it sequentially rather than combined continuous.

For peace of mind if you can fund it I'd suggest seeing an expert- not a GP or a trainee consultant. There are plenty of experts and most do video consultations now.

A first degree and a second degree relative at any age means you're considered high risk. I've been assessed via Addenbrookes genetic services.

Ah, okay. I wasn't aware of that.

If you are near Cambridge I think there are several private menopause gynaecologists there (either working on their own or having set up small practices) or you're only an hour by train from London where there are lots of them!

I was the same as you, also had bc.
I too read Jillian Lewis book and I too also take HRT .
Junior Dr doesnt know what he’s talking about, as I believe during medical training covers about 30 minutes on menopause.
I have found Dr Louise Newson balance App invaluable to getting treatment I needed, took 3 long years to getting HRT.
i had horrific vaginal itching again took, years to get relief. Eventually got an appointment with Practice nurse, she took one look an I was given Audavate Ointment, all symptoms stopped over night.
I found the Balance app and still check in with it . You can long all your symptoms, also has a community you can post and as questions and covers every aspect of the menopause and getting the right treatment through NHS .

apps.apple.com/gb/app/balance-hormones-menopause/id1503345959