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Ask an Expert: Q&A

Our team of experts will answer questions you have about cases you see in your work and/or clinical practice, covering women’s health topics such as menopause, contraception, vulval disorders, pelvic pain, pelvic floor issues, incontinence, PCOS, endometriosis, MHT, health checks, mental health and more, across every life stage.

The Jean Hailes team includes general practitioners, gynaecologists, physiotherapists, endocrinologists, a naturopath, urogynaecologists, psychologists and dermatologists.

If you have a clinical question, please send it to hp.education@jeanhailes.org.au in 200 words or less.

Please bear in mind we may not be able to answer all questions we receive. Also, as our experts don’t know your patient and their specific medical history, please keep your questions as broad as possible.

Elizabeth Farrell

Ask an Expert: Q&A – July 2021

Questions answered by Dr Elizabeth Farrell, gynaecologist (pictured)

(To read answers, toggle the orange + button next to the questions below or click here)

Q: If a woman only wishes to use topical vaginal oestrogen therapy for vaginal atrophy, how safe is that and do I need to prescribe intermittent progesterone to protect her endometrium?

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

The vaginal oestrogen preparations that are available in Australia are low dose and do not appear to stimulate the endometrium.

There is some initial absorption of the oestrogen into the circulation when the vaginal epithelium is thin but this reduces to almost zero after some days once the epithelium thickens and, if used in an appropriate regimen as recommended, it can be used long term without the use of intermittent progesterone.

The data on Vagifem low™ 10ug vaginal tablets shows absorption of 1.14 mg oestradiol over a 12month period.

Q: I have seen a patient who has well-controlled epilepsy. She has menopausal symptoms and is considering taking MHT. She is taking Lamotrigine. Can you please let me know if there are any issues prescribing MHT for this patient?

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

There is very little data on epilepsy and MHT. The use of oral MHT has been studied but only in the short term and with small numbers. A study using Premarin™ and Provera™ appeared to increase seizures.

It is thought that transdermal oestrogen and oral progesterone is probably the most suitable in women who are unresponsive to nonhormonal therapies.

Q: I have a 63yr old postmenopausal patient who presented with the onset of ‘an uncomfortable vaginal entrance’ of sudden onset following an episode of pyelonephritis. She describes a ‘sensation of being aware of her vaginal entrance’, no itch, ‘just uncomfortable’. She continues with estradiol validate 1mg nocte which she has been taking since age 51yrs, reducing from 2mgs about three years ago. O/E vulval skin and vaginal walls thin, NOAD. Thin, white vaginal discharge, no odour, pH Normal. She states discharge can stain underwear on some days. Touching the inner aspect of labia minora and posterior fourchette provoke the sensation. She does practice good vulval hygiene and has been placing Vaseline on the area morning and night with relief. I recommended a course of vaginal Acijel application. Should I add vaginal oestrogen?

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

As there is evidence of vulvo-vaginal atrophy on examination and a discharge visible, I would first take a vaginal swab for micro and culture to exclude any bacteria or candida. I would also ask about sexual partners and if she has had a sexual health check.

I assume she has had a hysterectomy as you do not mention a progestogen.

Is it possible she has vulvodynia and the use of amitriptyline may be of benefit? She does get relief using Vaseline so continuing with that and reviewing her in a few weeks is an alternative.

If you have excluded any urethral, bladder, vulva or vaginal lesion or prolapse and your diagnosis is vaginal atrophy then the use of vaginal oestrogen would be appropriate as it will have a positive effect on the urethra and bladder base reducing her risk of recurrent urinary tract infections and hopefully her introital symptoms.

Elizabeth Farrell

Ask an Expert: Q&A – June 2021

Questions answered by Dr Elizabeth Farrell, gynaecologist (pictured)

(To read answers, toggle the orange + button next to the questions below or click here)

Q: Is there a connection with oestrogen therapy/MHT causing vaginal thrush, and what can be done about it? This is a common problem for many women.

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

The vaginal microbiome (VMB) changes throughout life from birth, prepuberty, then to the reproductive years and lastly in the postmenopause. The postmenopause VMB is similar to the prepuberty stage with thin vaginal epithelium, an alkaline environment, low glycogen and lactobacilli growth. This picture is the result of low oestrogen.

Circulating oestrogen during the reproductive years and in the presence of systemic or vaginal oestrogen therapy in the postmenopause leads to increase in the vaginal epithelium and mucosal layer thickness with glycogen production and lactobacilli growth with the acidification of the vagina.

Candida in its various forms may be present in very small numbers in the vagina without causing an infection. Symptoms occur when the yeast grow to a significant number. The risk factors include both postmenopause systemic and vaginal oestrogen therapy, with added risks in diabetes, on systemic antibiotics and in immunosuppressed patients. In the woman with a vulval dermatoses who uses corticosteroid ointment, a superimposed candida infection may also exist.

Being aware of the “at risk” woman is important but always examine her vulva and vagina and take a swab to test for the cause of her symptoms before commencing treatment. Treat as appropriate with oral and topical antifungal preparations for an adequate period of time and review to assess the success of the treatment, visually and by repeat swab.

Q: I am a GP and we have been advising patients to wear cotton underwear for recurrent thrush on the basis of its breathability. Now we are led to believe that many new fabrics are breathable and wick away moisture. Should our recommendations be changing? Is there any evidence one way or the other? Bamboo claims to be breathable too.

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

Your question is a very interesting one because I cannot find research to show that cotton underwear is preferable to other forms, except that occlusive fibres increase the risk of contact dermatitis. Wearing breathable fabrics are recommended so therefore bamboo garments should be the same as cotton.

Dr Payam Nikpoor

Ask an Expert: Q&A – May 2021

Dr Payam Nikpoor, gynaecologist & urogynaecologist (pictured), and Dr Sonia Davison, endocrinologist

(To read answers, toggle the orange + button next to the questions below or click here)

Q: How many people who have a hysterectomy go on to have a vault prolapse?

A: from Jean Hailes gynaecologist & urogynaecologist Dr Payam Nikpoor

Hysterectomy, an operation that involves removal of the uterus with or without adnexal structures including ovaries and/or tubes is carried out for different reasons and different routes.

Hysterectomy may be done vaginally or abdominally. The latter can be done via laparotomy or laparoscopic method. The indication may be uterine prolapse, fibroids, heavy menstrual bleeding not amenable to other treatments or malignancy.

The international urogynaecology association (IUGA) and international continence society (ICS) in their joint report on the terminology for female pelvic organ prolapse define vault prolapse as “descent of the apex of the vagina (vaginal vault or cuff scar after hysterectomy)”. The way vault prolapse is assessed during examination is by using pelvic organ prolapse quantification POP-Q system, which measures the descent of each compartment relative to hymen.

Vault prolapse occurs either due to failure to address the appropriate vault attachments during hysterectomy or due to weakening of tissues and these attachments that support the vault. Vaginal vault prolapse is often associated with other compartment defects (cystocele, rectocele, or enterocele), which makes it a challenging condition to treat.

The incidence of vaginal vault prolapse requiring surgery has been estimated to be 36 per 10,000 women. The risk of vault prolapse following hysterectomy is higher in women whose initial indication for hysterectomy was pelvic organ prolapse as opposed to other indications. Case series dating back to 1960 have identified the incidence of vault prolapse after hysterectomy ranging from 0.2% to 43%. Others have reported vault prolapse to follow almost 11% of hysterectomies performed for prolapse and almost 2% for other benign diseases. In 2010 a study from Austria estimated the frequency of vault prolapse requiring surgical repair to be between 6-8%.

There is a solid recognition in the field of gynaecology that adequate support for the vaginal apex is an essential component of a durable surgical repair for women with advanced prolapse. Because of the significant contribution of the apex to vaginal support, anterior and posterior vaginal repairs may fail unless the apex is adequately supported.

Primary prevention can be performed at the time of hysterectomy.

Whilst all women with vaginal vault prolapse benefit from conservative measures such as vaginal pessaries, physiotherapy and lifestyle modifications, surgical intervention remains integral in the effective management of some women with vaginal vault prolapse after hysterectomy who do not respond to conservative therapy or suffer from more advanced prolapse.

Q: Best options for increased facial hair in a 55 year-old woman? She is 5 yrs post ovary sparing hysterectomy. BMI 31, widespread OA no other medical issues no medications other than 2mg Progynova started 6 months ago for hot flushes.

A: from Jean Hailes endocrinologist Dr Sonia Davison

Management:

a. Ensure that there is no biochemical androgen excess that may require further work-up

b. Cosmetic options – laser hair removal / IPL, waxing, electrolysis, threading

c. Medications – spironolactone, gradual increase in dose, up to 100mg bd, watching UEC and blood pressure

d. Other – whilst oral oestrogen is useful for increasing SHBG and therefore reducing free testosterone and may therefore be theoretically useful for reducing hirsutism, given her BMI she has an added VTE risk and I would favour transdermal oestrogen or weight loss

Q: I would like to ask about the use of HRT in a women with a known factor V Leiden deficiency, who has never had a thrombotic event, and is now suffering with a quite severe menopausal symptoms. I have just changed her Cipramil antidepressant to Efexor to see if this helps, but wanting to know if using a transdermal HRT could be considered?

A: from Jean Hailes endocrinologist Dr Sonia Davison

The decision to use MHT will depend on a range of factors, such as whether she is a heterozygote for Factor V Leiden mutation, or a homozygote, and whether there is a strong family history of VTE, if she is obese, or has other risk factors such as smoking or mobility challenges. My management of these women includes ensuring that a full hereditary thrombophilia screen has been performed (she could carry another genetic clotting mutation or other clotting risk marker), fully assessing their family history and past history, asking about OCP use and pregnancy history (i.e. how they managed with exposure to high levels of sex steroid hormones in the past), and asking about occupation (e.g. flight attendants on long haul flights are at higher risk of VTE).

I also ask these women to be assessed by a haematologist who has an understanding about women’s health and menopausal hormone therapy, so that the women can be advised about potential MHT use, but also how to manage situations such as surgery, travel, and screening of family members (especially children). If the haematologist considers that MHT could be used, transdermal MHT at the lowest dose to control symptoms would be ideal, hence avoiding first pass metabolism.

Elizabeth Farrell

Ask an Expert: Q&A – April 2021

Questions answered by Dr Elizabeth Farrell, gynaecologist (pictured)

(To read answers, toggle the orange + button next to the questions below or click here)

Q: Amongst the antidepressants, is there one that has better efficacy in managing hot flushes?

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

Non-hormonal therapies, such as the antidepressants, are prescribed when there is a contraindication to MHT or when a woman prefers not to take MHT.

Venlafaxine is the most studied antidepressants but other SNRIs and SSRIs are also effective.

Paroxetine or fluoxetine should not be prescribed in women on tamoxifen because they interfere with the metabolism of tamoxifen and may reduce its efficacy.

My recommendation is to start with an antidepressant then add gabapentin if there is an inadequate response.

Escitalopram 10-20mg daily is my first choice because it has been shown to reduce vasomotor symptoms up to 60% and have no impact on sexual function but improves quality of life. All of the non-hormonal therapies will reduce symptom within 4 weeks using the recommended dose compared to MHT which will take up to 6 weeks to get a maximal response. If there is none or only some benefit then introduce one of the other medications such as gabapentin or clonidine.

Review your patient after 4 weeks on the recommended dose to assess if further treatments are needed.

Non-prescriptive therapies available which may help are cognitive behavioural therapy, hypnotherapy and possibly acupuncture.

Read more & references:

Q: I have a question about MHT, I am a GP in Sydney. 57yr woman, menopause at 51yrs. No treatment at that time. No vasomotor symptoms but suffering from joint aches and pains, especially back and wrists. Can disturb sleep. Better in the morning then in the evening. Investigations for an inflammatory cause of arthritis negative. Raised cholesterol LDL 4.4, HDL 2.0. BP high normal range (137/93). CST, mammogram up to date. Ex-smoker quit 2005. Alcohol consumption within recommended ranges. Thinking about MHT and whether this would be effective for addressing joint aches. But now 6 years postmenopausal, developing some cardiovascular risk factors. Is MHT likely to be effective at relieving MSK symptoms of menopause? When is it too late to start MHT post menopause?

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

Joint aches and pains are very common menopause symptoms and may be present in about 50% of women that can impact on quality of life.

It depends when your patient’s symptoms commenced in relation to her final menstrual period, the closer to that time the more likely it is menopause related. If the symptoms have commenced in the last few years the less likely it will respond to MHT.

There is still debate about why aches and pains increase around menopause. Studies have shown increasing symptoms across and after the menopause transition whereas others have shown maximal symptoms in the perimenopause. In the Melbourne Women’s Midlife Health Project there appeared to be a correlation with high body mass index, negative mood and employment status. Aches and pains after the menopause were not always associated with radiological evidence of osteoarthritis.

Modification of lifestyle factors would be important to initiate first, such as weight loss, adequate exercise and stable mood. If not already done referral to a rheumatologist may help finding the cause.

MHT has been shown to reduce aches and pains. MHT is recommended to be commenced between 50-60 years of age or within 10 years of the final menstrual period if there are no contraindications or major risks. As your patient has developed cardiovascular risk factors it may not be appropriate to commence MHT, however, if her risk factors are under control, using a low dose transdermal therapy as a trial for a few months may be appropriate to see if she has any symptom relief.

Ask an Expert: Q&A – March 2021

Questions answered by Dr Elizabeth Farrell, gynaecologist and Dr Sonia Davison, endocrinologist

(To read answers, toggle the orange + button next to the questions below or click here)

Q: A woman with vasomotor symptoms consistently got migraines while on MHT. Escitalopram helped the hot flushes but seemed to exacerbate the night sweats. What are the options for non-hormonal treatment of vasomotor symptoms?

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

In women with migraines, oral oestrogens are contraindicated and transdermal oestrogens would be prescribed.

In your patient, the MHT exacerbated her migraines. Gabapentin added to escitalopram may be effective in reducing her night sweats. Gabapentin has been shown to be as effective in some studies as oestrogen.

It is prescribed at night, improving sleep and reducing hot flushes and night sweats.

Clonidine has also been studied and may be effective.

Read more:

Q: When Prometrium is used as continuous MHT, why is it advised to take it for 25 days out of 28 rather than continuously? Is there any concern with taking it continuously without the 3 day break?

A: from Jean Hailes endocrinologist Dr Sonia Davison

The rationale behind taking micronised progesterone for 25 days in a 28 day cycle is based on the likelihood of bleeding, and is also based on the clinical experience of European prescribers long-term.

Unscheduled bleeding or spotting is thought to occur more frequently in the atrophic endometrium associated with continuous micronised progesterone use, due to VEGF production and an increase in the number and size of new vessels within the endometrium.

If women avoid progesterone for 3 days per month this is less likely to occur.

Dr liz farrell facetime

Ask an Expert: Q&A – February 2021

Questions answered by Dr Elizabeth Farrell, gynaecologist and Dr Sonia Davison, endocrinologist

(To read answers, toggle the orange + button next to the questions below or click here)

Q: A 52 year-old woman with a past history of breast cancer (ER & PR + ve) currently on an aromatase inhibitor (letrozole). She presents with vaginal dryness and superficial dyspareunia. Is it possible to prescribe oestrogen cream to be applied vaginally? If not, what other treatment options are possible?

A: from Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell

With this woman it might be helpful to ask the following questions to help differentiate between an introital stenosis, an overactive pelvic floor or mainly an atrophic vagina.

  • Is the superficial dyspareunia on entry, or in the lower vagina?
  • Is there a barrier to penetration?
  • Is there any tearing or bleeding with penetration?
  • If penetration is possible, is it the vaginal dryness that causes the pain?

Examine the woman and check for introital stenosis, an overactive pelvic floor and any signs of fissuring of the posterior fourchette, or active bleeding due to severe vaginal atrophy.

Firstly, recommend vaginal moisturisers such as Replens™ and hyaluronic acid vaginal gels, which increase vaginal secretions, and also a lubricant. The lubricants, used at the time of intercourse, recommended are similar in acidity and osmolality to the vagina. Examples are Yes™, Astroglide™ or Pjur™. Oils such as olive oil or sweet almond oil may also be used.

Vaginal laser therapy has been trialled for vaginal dryness, but long-term safety and efficacy data is lacking. It is also expensive.

Refer her to a pelvic floor physiotherapist for relaxation therapy to reduce pelvic floor overactivity and introital stenosis.

Only after non-hormonal measures fail, discuss the use of low-dose vaginal oestrogen with the woman’s breast cancer team. There are no long-term studies on the use of low-dose oestriol or oestradiol vaginal products.

Q: Is there any risk to future fertility by women with PCOS managing their symptoms and family planning needs via hormonal contraception, especially combined estrogen-progestogen contraception options such as OCPs and Nuvaring?

A: from Jean Hailes endocrinologist Dr Sonia Davison

Studies have shown that the majority of women who wish to conceive will do so within a year of ceasing contraceptive medications. Hence women with PCOS who are on contraceptive hormonal measures can continue to use them for symptom or cycle control for as long as required.

If insulin resistance or weight excess are present, then a lower dose option is recommended, as these will be theoretically less likely to worsen insulin resistance. PCOS and its associated health issues, such as weight excess, anovulation, or hormonal imbalance, may provide extra challenges to conception, and age will also be a consideration.

Some women with PCOS will require assistance with fertility, hence it is advisable to discuss these issues with women well in advance of their pregnancy plans, and have adequate time to see how they progress off hormonal contraception. It would be ideal for women with PCOS to aim to conceive in their early 30s or younger, due to the extra fertility challenges they may encounter.

Dr Sonia Davison

Ask an Expert: Q&A – January 2021

Answered by Dr Sonia Davison, endocrinologist

(To read answers, toggle the orange + button next to the questions below or click here)

In women who cannot have the COCP but have started MHT, and also need contraception - how do we manage the oral progesterone (if Mirena is not used). Can POP be the progesterone component?

There is no data to support the use of progesterone only pills (POP) in combination with MHT oestrogen. Hence other contraceptive measures should be used (tubal ligation / vasectomy / barrier methods etc).

The Australasian Menopause Society MHT equivalents webpage states as a disclaimer:

  • Low dose progestogen-only contraceptive pills (Microlut (30mcg levonorgestrel), and Noriday (350mcg norethisterone) are used by some clinicians in various doses but there is limited data for dosages of these pills required for endometrial protection. 1 mg norethisterone was considered the minimum dose (cyclical or continuous) for adequate endometrial protection in the Cochrane Review (Cochrane Database Syst Rev. 2009 Apr 15;(2):CS000402).

How do you deal with bleeding side effects of MHT?

If women are perimenopausal with erratic periods, then a sequential regimen of MHT should ensure that they have a regular scheduled withdrawal bleed. Reassure women that any bothersome bleeding after initiation of MHT should settle in the first few months. If bleeding is still bothersome at this point then if on continuous MHT a trial of sequential MHT may be necessary, or investigation via transvaginal ultrasound to see if any pathology is evident e.g. a polyp. Some progestogens are better at controlling bleeding compared with others. Mirena may be a good option.

For Menopause resources for health professionals, visit this page of our website.

How to submit a question to Ask an Expert: Q&A

If you have a clinical question, please send it to hp.education@jeanhailes.org.au in 200 words or less.

Please bear in mind we may not be able to answer all questions we receive. Also, as our experts don’t know your patient and their specific medical history, please keep your questions as broad as possible.