Vaginal oestrogen

Vaginal oestrogen is a hormone replacement therapy (HRT) medicine that contains the hormone oestrogen. It's used to treat the vaginal dryness and irritation that can happen during the menopause.

Menopause is when your periods stop due to lower hormone levels. It usually affects women between the ages of 45 and 55, but it can happen earlier. It affects anyone who has periods.

The fall in the amount of oestrogen your body produces can cause symptoms. Using vaginal oestrogen can help dryness and irritation but it will not treat other symptoms of the menopause such as hot flushes, mood swings or problems sleeping (insomnia).

Vaginal oestrogen comes as a tablet, pessary, cream, gel or ring that you insert into your vagina. Using oestrogen inside the vagina only is called local HRT.

Usually, if you take or use oestrogen you must also use a progestogen alongside it, to protect your womb. But with vaginal oestrogen, little of the medicine gets into the rest of your body, so you do not need to take progestogen.

If vaginal oestrogen is not enough to treat your symptoms, you can also use a higher dose of HRT.

Vaginal oestrogen is only available on prescription, except the brands Gina (vaginal tablets) and Ovesse (vaginal cream) which you can buy from a pharmacy.

Other brands of vaginal oestrogen include Vagifem and Vagirux vaginal tablets, Estring vaginal ring, Imvaggis pessaries, Blissel vaginal gel and Estriol vaginal cream.

If you're approaching the menopause and have symptoms (perimenopause) or have already gone through the menopause (post-menopause) you can usually use vaginal oestrogen.

Vaginal oestrogen is not suitable for everyone. To make sure it's safe for you, tell a doctor or specialist nurse if you:

• have ever had an allergic reaction to oestrogen or any other medicine
• have ever had breast cancer, are having tests for breast cancer, or are at high risk due to family history
• have ever had any other type of cancer
• have vaginal bleeding with no known cause
• have ever had a blood clot in a vein (thrombosis), such as in the legs (deep vein thrombosis) or the lungs (pulmonary embolism)
• have or have recently had a problem caused by blood clots blocking the arteries, such as a heart attack, stroke or angina
• have liver problems
• could be pregnant
• have a rare inherited condition called porphyria
• have diabetes
• have high blood pressure
• have migraines or severe headaches

Your dose of vaginal oestrogen depends on the type of medicine you're using:

• vaginal tablets (Gina, Vagifem, Vagirux) – insert 1 tablet a day for 2 weeks, then 1 tablet twice a week
• a vaginal ring (Estring) – insert 1 vaginal ring into the vagina for 3 months
• vaginal gel (Blissel) – insert 1 dose of gel a day for 3 weeks, then 1 dose twice a week
• vaginal pessaries (Imvaggis) – insert 1 pessary a day for 3 weeks, then 1 pessary twice a week
• Estriol vaginal cream – insert 1 dose of cream a day for up to 4 weeks, then you can reduce your dose gradually depending on symptoms, for example to 1 dose twice a week
• Ovesse vaginal cream – insert 1 dose of cream a day for 2 weeks, then 1 dose twice a week

Using vaginal oestrogen tablets

1. Wash your hands and get yourself into a comfortable position. You can either stand up or lie down.
2. Open the pack and remove the applicator. The tablet should already be inside it.
3. Hold the applicator so one finger can press the applicator plunger.
4. Insert the applicator carefully into your vagina. You can do this either standing up or lying down. Try to insert about half of the applicator and only go as far as you're comfortable with.
5. Press the applicator plunger until you feel it click. This lets you know that the tablet has been released. The tablet will then attach itself to your vaginal wall.
6. Gently remove the applicator and throw it away.

Using vaginal gel

Your gel will come in a tube. It will also come with a plunger and a small, empty tube (cannula) to help you insert the gel.

1. Wash your hands and remove the tube cap. If it's the first time you're using the tube, pierce the seal on the neck of the tube but do not use it if the seal is broken.
2. Insert the plunger into the cannula and screw the end of the cannula onto the neck of the tube.
3. Squeeze the gel into the applicator until it reaches the filling mark. The plunger will stop at that mark.
4. Unscrew the cannula from the tube and replace the cap on the tube.
5. Get into a comfortable position, either standing or lying down, and insert the end of the applicator into your vagina.
6. Push the plunger all the way down.
7. Gently remove the applicator. Throw the cannula away and rinse the plunger with warm and clean water so you can use it again.

Using vaginal pessaries

1. Wash your hands and get yourself into a comfortable position, either standing up or lying down.
2. Remove the pessary from its foil pack.
3. Standing up or lying down, gently insert the pessary as far into your vagina as you can.
4. Wash your hands. If you're using Vagirux, you can use the applicator again. If you're using Vagifem, throw the applicator away.

Using vaginal cream

1. Wash your hands and remove the cap from the tube. If it's the first time you're using the tube, pierce the seal on the neck of the tube but do not use it if the seal is broken.
2. Screw the end of the applicator onto the tube.
3. Squeeze the cream into the applicator to the red ring mark. The plunger will automatically stop at that mark.
4. Unscrew the applicator from the tube and put the cap back on the tube.
5. Get into a comfortable position, either standing up or lying down. Gently insert the applicator into your vagina and push the plunger as far as it will go.
6. Remove the applicator and take the plunger out of it. Wash the applicator and plunger in hot, soapy water so you can use it again.

Using a vaginal ring

1. Wash your hands then find a position you feel comfortable in, either standing up or lying down.
2. With one hand, squeeze the ring into an oval shape and gently push it into your vagina. Do this in the direction of upwards, backwards and towards the small of your back.
3. Wash your hands when you've finished.

You can use your vaginal ring for up to 3 months. After that, you'll need to remove it and replace it with a new one.

If your ring falls out, rinse it in lukewarm water and insert it back into your vagina.

If you're going to have sex, you can either leave the ring in place, or remove it if you find it uncomfortable.

You may notice that the ring shifts when you have a poo. If this happens, you can easily push the ring back into position with your finger. If you're constipated or know you're going to find it difficult to poo, it's best to remove the ring completely and then put it back afterwards.

You'll usually be recommended to take HRT for between 2 and 5 years to relieve symptoms but you may need to take it for longer, and there is no set limit on how long you can take it.

It's recommended that you speak to your doctor at least once a year, to check whether the benefits of using vaginal oestrogen still outweigh the risks.

No matter what form of vaginal oestrogen you use, never insert 2 doses at the same time. Never insert an extra dose to make up for a forgotten one.

If a doctor has advised you to use vaginal oestrogen regularly and you often forget doses, it may help to set an alarm to remind you. You could also ask a pharmacist for advice on other ways to help you remember to use your medicine.

Vaginal tablets and cream

Insert your missed tablet or dose of cream as soon as you remember.

Pessaries

If you forget to insert your pessary during your 3 weeks of daily treatment, skip the missed dose then insert your next pessary at the usual time.

If you forget to insert one of your 2 pessaries during your 1 week of treatment, insert the forgotten dose as soon as possible.

Gel

Insert your missed dose of gel as soon as you remember, unless it's been over 12 hours since your last dose. In this case, wait until the next one.

Inserting an extra dose of vaginal oestrogen is unlikely to harm you. If you're worried, talk to a doctor or pharmacist for advice.

These common side effects of vaginal oestrogen happen in more than 1 in 100 people. There are things you can do to help cope with them:

Headaches usually only last for a few days after you start using vaginal oestrogen as your body gets used to the medicine. Try taking a painkiller such as ibuprofen or paracetamol.

If headaches last longer than a week or are severe, speak to your doctor. You may need to change your dose or switch to a different type of HRT.

This is common for the first 3 to 6 months after starting HRT, but usually settles down.

If you get heavy bleeding or unexpected bleeding after you've been using vaginal oestrogen for 6 months, talk to your doctor.

Make sure you're applying the treatment carefully and using the applicator as described in the medicine pack. If the pain or itchiness do not improve after a week, check with your doctor as you may need to change to a different type of vaginal oestrogen.

If you have the symptoms of an infection (including raised temperature, urgent need to pee, local pain and itchiness), check with your doctor.

Try taking a painkiller such as ibuprofen or paracetamol for a few days. If the pain does not go away, check with your doctor.

Speak to a pharmacist or doctor if the advice on how to cope does not help and a side effect is still bothering you or does not go away.

Serious side effects from vaginal oestrogen are rare.

See your doctor if you:

• find a lump or changes in your breasts, especially dimpling of the skin, changes in the nipple or any lumps you can see or feel – this could be a sign of breast cancer
• experience any changes in vaginal bleeding after you have been taking oestrogen for more than a few months – this could be a sign of womb cancer

Call a doctor or call 111 for advice now if you have pain, redness or swelling in one of your legs – this could be a sign of deep vein thrombosis (DVT).

It's important to attend your breast screening (mammogram) appointments while you're taking HRT.

• you get a pain in your chest and breathlessness – this could be a sign of a blood clot in your lungs (pulmonary embolism) or heart problems
• have difficulty speaking, or moving your arm or leg, or your face has dropped on one side – this could be a sign of a stroke

Do not drive to A&E. Ask someone to drive you or call 999 and ask for an ambulance.

Bring all the medicines you take with you.

In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to vaginal oestrogen.

Call 999 now if:

• your lips, mouth, throat or tongue suddenly become swollen
• you're breathing very fast or struggling to breathe (you may become very wheezy or feel like you're choking or gasping for air)
• your throat feels tight or you're struggling to swallow
• your skin, tongue or lips turn blue, grey or pale (if you have black or brown skin, this may be easier to see on the palms of your hands or soles of your feet)
• you suddenly become very confused, drowsy or dizzy
• someone faints and cannot be woken up
• a child is limp, floppy or not responding like they normally do (their head may fall to the side, backwards or forwards, or they may find it difficult to lift their head or focus on your face)

You or the person who's unwell may also have a rash that's swollen, raised, itchy, blistered or peeling.

These can be signs of a serious allergic reaction and may need immediate treatment in hospital.

These are not all the side effects of vaginal oestrogen. For a full list, see the leaflet inside your medicines packet.

Vaginal oestrogen is not known to be harmful in pregnancy but if you think you might be pregnant, stop using it and talk to your doctor.

There is not much information about using vaginal oestrogen for HRT while breastfeeding. Most information comes from the use of other forms of oestrogen as a contraceptive.

If you're breastfeeding and need to use HRT, vaginal oestrogen is not usually prescribed, unless a specialist recommends it.

Talk to your doctor about non-hormonal preparations which might be more suitable while you're breastfeeding.

Using vaginal oestrogen is unlikely to affect your fertility.

Vaginal oestrogen does not act as a contraceptive.

Even if you think that you've gone through the menopause, there's a small chance that you could become pregnant. You're advised to use contraception for at least 1 year from your last period if you're over 50 years old and for 2 years if you're under 50 years old. Discuss this with your doctor or family planning practitioner.

Tell your doctor if you're:

• trying to get pregnant
• pregnant
• breastfeeding

It's unlikely that vaginal oestrogen will either affect how well other medicines work or be affected by taking other medicines.

There are several different herbal products sold to help relieve menopause symptoms. These include evening primrose oil, soya, red clover, black cohosh, ginseng and St John's wort.

All of these products might affect other medicine you're taking, so it's important to check with your doctor or pharmacist before starting to take them.

It's not possible to say that other herbal remedies and supplements are safe to take with vaginal oestrogen. They're not tested in the same way as pharmacy or prescription medicines. They're generally not tested for the effect they can have on other medicines.

Tell your doctor or pharmacist if you're taking any other medicines, including herbal remedies, vitamins or supplements.