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

Ask An Expert: Q&A 19 Jul 2021
Doctor with patient

'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 this edition of 'Ask an Expert: Q&A' is Dr Elizabeth Farrell, Jean Hailes gynaecologist and medical director.

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?

Elizabeth Farrell

Answer

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

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.

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?

MHT

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.

Do you have a women's health clinical question for one of our experts?

Go to 'Ask an Expert'