Ask an Expert: Q&A – July 2021

Question 1

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?

Question 2

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?

Answer

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.

Question 3

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?

Answer

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.