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.

Jean Hailes endocrinologist Dr Sonia Davison

Ask an Expert: Q&A – April 2022

Questions answered by Dr Sonia Davison, endocrinologist (pictured)

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

Q: I have a 65-year-old patient with moderate symptoms of hot flushes and nights sweats. She has been on continuous MHT for last 7 years as patches. Recently she was told about her high breast density. As she is still symptomatic, is it safe to continue her MHT? In view of her dense breasts, which MHT will be more suitable?

A: from Jean Hailes endocrinologist Dr Sonia Davison

The high breast density and long-term hormone therapy both increase her breast cancer risk. Any additional risk factors such as family history of breast cancer would further increase her risk.

My preference would be to try to wean and cease the hormone therapy and opt for a non-hormonal medication for control of vasomotor symptoms (SSRI / SNRI / gabapentin or clonidine).

Cognitive behavioural therapy or hypnotherapy may also be useful.

Elizabeth Farrell

Ask an Expert: Q&A – February 2022

Question answered by Dr Elizabeth Farrell, Medical Director and gynaecologist (pictured)

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

Q: I'm wondering whether I should refer my patient for specialist Gynae review or repeat co-test in 12 months. My 29-year-old patient presents with recent vaginal discharge. On speculum exam appeared like thrush, positive for Candida on high vaginal swab. Cervical ectropion. Co-test - HPV other, cytology negative (endocervical cells present). The recommendation on the pathology report was for referral to specialist however Cervical Screening Guidelines say referral if unexplained and persistent abnormal vaginal discharge. Should I only refer if her symptoms persist after treating the Candida infection?

A: from Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell

If your 29-year-old patient has had one smear result with HPV non 16/18 +ve with negative cytology in the present of endocervical cells and no other abnormality then the CST co-test is repeated in 12 months.

If there is any concern re abnormal bleeding then referral to a gynaecologist with a prior vaginal ultrasound would be appropriate.

If the candida infection is treated satisfactorily there is no indication for referral. However if her candida was recurrent and not responding to treatment adequately then referral to a vulval specialist, either gynaecologist, dermatologist or GP with special interest, would be indicated.

Q: I have a 37-year-old female with POI in the context of radiation exposure as a child. She is currently on Estalis Continuous (50/140). She has concurrent osteopenia as she had many years of taking no HRT. I would like her to be on a topical oestradiol dose of equivalent to 100 mcg but there is no combined topical formulation I am aware of. She would prefer not to have withdrawal bleeding, so I am interested in a continuous regimen. I am concerned there is not enough data for Prometrium 100 mg nocte when on the high dose of oestradiol. Would Medroxyprogesterone be an option? She does not want to have a Mirena. What else would you recommend? I considered Kliogest (2 mg oestradiol/1 mg norethistrone) as well. I know the COCP can be used in POI, but transdermal is better for bone health. Her BMI is 26. On another note, she has noted a patch of grey pubic hairs. Could this reflect the insufficient oestradiol replacement? I am checking thyroid and vitamin B12.

A: from Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell

POI is treated with high dose therapy usually the equivalent of Oestradiol 75 ug patch or greater with the corresponding progestogen until around the age of expected menopause. There are a number of possibilities all of which DO NOT have data, with increasing dose of oestrogens requiring increased progestogen.

Increase the dosages by having:

1. 2x patches Estalis™ continuous patches
It may be better to use Estalis continuous 50/250™. Place them side by side and change at usual time of every 3½ days. You could try ringing for an authority for the increased quantity of patches.

OR

2. Estradiol patches 75 –100 ug patches or estradiol gels + oral progestogen.

Ideally oral progesterone would be prescribed however there is no data on higher doses or being used vaginally. Using 200 mg orally nightly may be sufficient but is expensive for some women. It is used vaginally in IVF satisfactorily. However, it is used “off label“ vaginally in menopause women using 100 mg vaginally at night for the higher doses of oestrogen but experts not are all in agreement to recommend it because of the lack of data.

Norethisterone acetate or medroxyprogesterone acetate could be used but we are tending to prescribe less because of their small increase in breast cancer risk and possible VTE risk.

Monitor for both side effects, breakthrough bleeding and check endometrial thickness after the first 6 months on the regimen to establish the appropriate endometrial suppression by the progestogen.

The greying of her pubic hair may represent years without oestrogen or may be genetic.

Elizabeth Farrell

Ask an Expert: Q&A – January 2022

Question answered by Dr Elizabeth Farrell, Medical Director and gynaecologist (pictured)

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

Q: I am looking after a lady with some menopausal flushing and sweats in her mid-40s, she is taking POP [progesterone-only pill]. Can I use topical MHT alongside POP? Is this enough progesterone for endometrial protection?

A: from Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell

The issues your patient has is that she has flushing and sweating in the perimenopause but I assume is still menstruating as she is on the POP. The dose of POPs are usually very low and are not considered sufficient for standard doses of oestradiol e.g. oestradiol patch 50ug or oestradiol 2mg oral tablet. By topical HRT I assume you mean either transdermal patches or gels.

This woman obviously requires contraception so consider a Levonorgestrel IUD with the oestrogen. I would also exclude thyroid disease in this woman prior to commencing her on hormone therapy.

Vaginal or local/topical oestrogens for vaginal symptoms do not require progestogens.

Elizabeth Farrell

Ask an Expert: Q&A – December 2021

Questions answered by Dr Elizabeth Farrell, Medical Director and gynaecologist (pictured)

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

Q: In a menopausal woman who is on menopausal hormone therapy (MHT) and has side effects on Prometrium orally, is it acceptable to use the Prometrium capsules vaginally and if so, how frequently do they need to be used?

A: from Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell

Prometrium is micronised oral progesterone which is available in a 100mg capsule taken at night because of its somnolent properties. The product is registered as an oral preparation for menopause but there is a vaginal preparation available for IVF.

Using oral progesterone in the vagina is therefore "off label" usage and may equate to about double the oral dose. If the woman has side effects orally she may still have side effects with vaginal use.

The dose of Prometrium will depend on the dose of oestrogen used. A dose of oestradiol 50 micrograms patch then the usual daily oral dose of 100mg Prometrium nightly could be trialled every alternating night or three times per week vaginally. It is important to remember that this is "off label" usage.

References:

Q: I am a Nurse Practitioner/Women's Health Nurse working in primary care and my question is: if someone has had a hysterectomy and is on Estradot 25 micrograms patch twice weekly should they also be on progesterone?

A: from Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell

The role of menopausal hormone therapy (MHT) is to treat menopause symptoms (oestrogen) but at the same time to protect the endometrium (progesterone). With hysterectomy, the uterus is removed and therefore the woman has no remaining endometrium. Oestrogen alone is needed.

The only exception is in a woman with severe endometriosis who has had a hysterectomy with or without bilateral salpingo-oophorectomy and has menopausal symptoms. In these women a progestogen or progesterone with the oestrogen is appropriate.

Your patient who is on Estradot 25 micrograms patch and has had a hysterectomy, does not need progesterone.

Jean Hailes endocrinologist Dr Sonia Davison

Ask an Expert: Q&A – November 2021

Questions answered by Dr Sonia Davison, endocrinologist (pictured)

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

Q: Is it safe to continue with Tibolone 2.5mg daily in a 70 year-old? She has been on it since the age of 45 and had reduced to 1 tablet every second day but is having terrible hot flushes since stopping it 3 months ago. I cannot find an alternative explanation for her hot flushes. Would there be a safer/better alternative than Tibolone?

A: from Jean Hailes endocrinologist Dr Sonia Davison

This information page on Tibolone on the Australasian Menopause Society website goes through the benefits and risks of Tibolone in detail.

There is a slightly higher risk of stroke from the 60s, and an increased risk of breast cancer that increases with duration of use. My preference would be to try a non-hormonal treatment for controlling the flushes (see this information page), and trying to avoid a return to hormone therapy if possible.

Q: 51 year-old female using progesterone-only pill (POP) for contraception; amenorrhea on this for last 3 years; wishing to start menopausal hormone therapy (MHT) for vasomotor symptoms. As on POP, I cannot confirm if amenorrhea secondary to pill or now postmenopausal, hence difficult to advise on stopping contraception. Would it be best to use continuous MHT, oestrogen patch + micronised progesterone PLUS continue the POP for contraception, as I understand POP not approved for endometrial protection. Or is the combined progesterone use not advisable? Patient does not wish to have IUD.

A: from Jean Hailes endocrinologist Dr Sonia Davison

Please also refer to the answer and resources for Q2 on the October edition of Ask an Expert: Q&A below.

The probability of pregnancy is very slim but not zero. She still has the options of barrier contraception, vasectomy and tubal ligation if she doesn’t want to pursue a levonorgestrel IUD for contraception, whilst on combined MHT (of any type). My preference would be to combine any form of oestradiol with the levonorgestrel IUD in this situation; the risk of bleeding is minimised, contraception is provided, and the ‘set and forget’ convenience of the IUD means that there will be less worry for all concerned.

Jean Hailes endocrinologist Dr Sonia Davison

Ask an Expert: Q&A – October 2021

Questions answered by Dr Sonia Davison, endocrinologist (pictured)

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

Q: I am wondering whether Tibolone or transdermal oestrogen with micronised progesterone has the lowest breast cancer risk?

A: from Jean Hailes endocrinologist Dr Sonia Davison

There haven’t been any prospective studies directly comparing the breast cancer risk associated with Tibolone compared with body-identical combined menopausal hormone therapy (MHT). The only information we have is from cohort studies. A meta-analysis of cohort studies in The Lancet in 2019 reported on breast cancer risk with various forms of MHT. (Collaborative Group on Hormonal Factors in Breast Cancer. Type and timing of menopausal hormone therapy and breast cancer risk: individual participant meta-analysis of the worldwide epidemiological evidence. Lancet. 2019; 394:1159-68.) This meta-analysis reported that the breast cancer risk with Tibolone is lower than combined oestrogen and synthetic progestogenic MHT.

That paper also included very small numbers of women on body-identical MHT, and there was no statistically significant increase in breast cancer risk over 5 years, but there was beyond this timeframe. The direct answer to your question is that no-one really knows the exact answer! However, there are some excellent information sheets that may help on the Australasian Menopause Society website: Risks and benefits of menopausal hormone therapy; and Tibolone as menopausal hormone therapy.

Q: I have a 52 year-old patient who has asked if Slinda (Drospirenone progesterone-only pill) would be okay for her. She has a history of provoked venous thromboembolism (VTE). The manufacturer states that in trials there were no VTE events (10,000 pts), but trying to prescribe brings up a warning regarding VTE. Do you have any suggestions or guidance?

A: from Jean Hailes endocrinologist Dr Sonia Davison

I suspect that the warning comes up due to a combination of the patient’s age in the setting of prior VTE. Drospirenone progesterone-only pill (POP) is designed for, and has been tested in the reproductive age group, and its contraceptive use is recommended in that age group, although guidelines state that POPs can be used until age 55 years. There is some excellent information about other types of contraception on our website, including a health professional webinar that was conducted with colleagues from Family Planning Victoria, in 2021.

The Australasian Menopause Society has an excellent information page with a focus on women of perimenopausal or menopausal age.

Ask an expert 1

Ask an Expert: Q&A – September 2021

Questions answered by Dr Tanja Bohl, dermatologist

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

Q: A 75 year-old woman has had vulval pain for months with dyspareunia. Her main concern is loss of pleasure during sex. She is using Ovestin and KY lubricant without any improvement. She was previously using a corticosteriod cream. Examination reveals a white shiny vulva. I have referred her for a biopsy to rule out lichen sclerosis. What else can I do?

A: from Jean Hailes dermatologist Dr Tanja Bohl

I think what you have done is good. Please consider the following:

  • If you haven’t done so already take a swab for candida (low vaginal). I realise it’s not something you would normally associate with a 75 year-old postmenopausal woman, but I have been surprised with positive results before.
  • If the vulva is white all over I assume you are thinking lichen sclerosis or possibly hypertrophic lichen planus. It is good to avoid steroids until the biopsy is completed as it may interfere with the results.

The following things are for comfort and avoiding aggravating the vulva rather than specific treatment.

  • QV Intensive Body Moisturiser can be used as required, it won’t interfere with biopsy results. Often the vestibule is considered ‘inside’, so it’s important she parts the labia minora and gently cleanses and applies the ointment here. Dermeeze ointment is more runny but also good.
  • I would ask her to ‘walk me through’ how she cleans her vulva in the bath or shower and after going to the toilet. Again I find this of value – some women will say things like a non-scented, no-soap cleanser and when I run through it they apply it neat! I advise the use of salt water – tiny sprinkle of salt in a nozzle topped bottle – so she can sit on the toilet and squeeze it to cleanse and soothe. If it stings, there is too much salt. There are many variations on this theme, the main thing is to make it doable.
  • Cold compresses are useful but if she needs this for relief you should probably make a phone call to prioritise her appointment.
  • An antihistamine that sedates – Phenergan 10mg (occasionally 25mg) overnight is sometimes worth trying but again if she is very uncomfortable a referral should be a priority.
Jean Hailes endocrinologist Dr Sonia Davison

Ask an Expert: Q&A – August 2021

Questions answered by Dr Sonia Davison, endocrinologist (pictured)

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

Q: Can you give HRT [MHT] to women with a first-degree relative with breast cancer?

A: from Jean Hailes endocrinologist Dr Sonia Davison

An expert speaking on this topic at a previous World Congress on the Menopause in Vancouver discussed that a family history of breast cancer is not necessarily a reason to avoid hormone therapy use. The issue is one of risk. If there are other risk factors, such as dense breasts, or multiple close relatives with breast cancer, or BRCA1/2 gene mutations present (etc), breast cancer risk increases.

The Australasian Menopause Society has an information sheet dedicated to risks and benefits of MHT (menopausal hormone therapy), which details these risks further. There are also online tools for women to assess their overall breast cancer risk (even in the absence of MHT use).

The studies to date suggest that MHT regimens associated with the lowest risk of breast cancer contain progestogens that are close to endogenous progesterone (dydrogesterone and micronised progesterone).

Q: Is it safe to use vaginal oestrogen in a patient with past history of VTE?

A: from Jean Hailes endocrinologist Dr Sonia Davison

Past venous thromboembolism (VTE) is no contraindication to vaginal oestrogen use, as there is very little systemic hormone absorption. The pessary or cream are used nightly, vaginally, for 2 weeks, and then twice weekly thereafter.

Q: In a young woman who has had oophrectomy and colectomy for bowel cancer but no hysterectomy, will continuous combined transdermal MHT cause any bleeding?

A: from Jean Hailes endocrinologist Dr Sonia Davison

Whenever the uterus is present and hormone therapy is used, there is a risk of bleeding. Young women who have recently had periods are more likely to have bleeding when hormone therapy is introduced, even if the regimen is continuous combined MHT. It is also common to have bleeding within the first three months of hormone therapy use. If bleeding continues after three months of use, it is worthwhile changing to sequential progestogen use to plan for a regular withdrawal bleed.

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.