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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.

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.