Ask an Expert: Q&A – February 2022

Question 1

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?

Answer

From Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell AM (pictured)

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.

Question 2

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.

Answer

From Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell AM (pictured)

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. Oestradiol patches 75 –100 ug patches or oestradiol gels + oral progestogen.

Ideally oral progesterone would be prescribed however there is no data on higher doses or being used vaginally. Using 200mg 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 100mg 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.