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Ask an Expert: Q&A – February 2021

Ask An Expert: Q&A | For health professionals 23 Feb 2021
Hands up ask a question Ask an Expert 2

'Ask an Expert: Q&A' is a place for health professionals to ask our team of experts about cases seen in work and/or clinical practice.

Questions can cover a wide range of women’s health topics and will be answered by an expert in the multidisciplinary Jean Hailes health professional team. Read more about this series or learn how to ask a question here.

If you are not a health professional but have your own health question, visit our 'Ask Dr Jean' pages.

Answering your questions for February's edition of 'Ask an Expert: Q&A' is Dr Elizabeth Farrell, gynaecologist and Dr Sonia Davison, endocrinologist.

Question 1

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?

Dr liz farrell

Answer

From Jean Hailes gynaecologist and medical director Dr Elizabeth Farrell (pictured above)

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.

Question 2

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?

Dr Sonia Davison

Answer

From Jean Hailes endocrinologist Dr Sonia Davison (pictured)

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.

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