arrow-small-left Created with Sketch. arrow-small-right Created with Sketch. Carat Left arrow Created with Sketch. check Created with Sketch. circle carat down circle-down Created with Sketch. circle-up Created with Sketch. clock Created with Sketch. difficulty Created with Sketch. download Created with Sketch. email email Created with Sketch. facebook logo-facebook Created with Sketch. logo-instagram Created with Sketch. logo-linkedin Created with Sketch. linkround Created with Sketch. minus plus preptime Created with Sketch. print Created with Sketch. Created with Sketch. twitter logo-twitter Created with Sketch.

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 – 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.