'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.
Answering your question for this edition of 'Ask an Expert: Q&A' is Dr Elizabeth Farrell AM, Jean Hailes gynaecologist and Medical Director.
I have a 20-year-old patient who suffers with migraines with aura so is not able to take the combined pill. This helped her period pain significantly. She is not sexually active and had a Mirena® for one year but unfortunately, she developed severe acne which improved after the removal of the Mirena® and a course of Roaccutane.
She gets significant pre- and during menses pain and also cyclical symptoms with painful bowel movements. I’m wondering if it’s worth trying her on [the POP] Slinda™. Much appreciated if you can help me with this patient.
From Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell AM (pictured)
Thank you for your question. My question to you is: has she been investigated for endometriosis? The presence of premenstrual and menstrual pain as well as cyclic bowel symptoms would alert me to consider endometriosis as her diagnosis and to check for any deep infiltrative endometriosis (DIE).
This young woman has the issues of dysmenorrhoea, cyclic symptoms and painful bowel movements which responded to use of the combined pill. However, because of her migraines with aura it is not recommended to be used. If her migraines were only during the non-active pills, then giving her a trial of continuous active pills without any break would be suggested.
Firstly, I would be investigating by having an ultrasound performed by an experienced gynaecological specialist, either gynaecologist or radiologist to exclude any DIE.
Secondly, for cycle control and suppression of ovulation Slinda™ may be worthwhile.
If her symptoms were not controlled, then referral to a gynaecologist with an interest in endometriosis would be recommended.
I have a patient aged 49, who we are starting on MHT. Her last period was between 9-12mo ago, she cannot exactly recall. She is not at all keen on the idea of having a regular bleed with a cyclical regime, thinking she has finished with periods! Are there any harms in starting on a continuous regime initially and changing to cyclical if she is bothered by onset of bleeding?
From Jean Hailes gynaecologist and Medical Director Dr Elizabeth Farrell AM (pictured)
I think your patient is very representative of many women we see, that once their periods cease, they don’t want to bleed ever again!
Starting a woman on a continuous regimen is perfectly reasonable, letting her know that she may have breakthrough bleeding because she is still perimenopausal or that breakthrough bleeding is a side effect of MHT within the first 6 months. It is important for your patient to realise that she needs to make a note in her diary of any bleeding and inform you at the next consultation.
There is no harm in commencing a continuous MHT regimen in the late perimenopause but the risk of bleeding is much higher because the ovary may still have some follicular activity.
If your patient starts to have regular breakthrough bleeding then changing to a cyclic regimen would be appropriate but also sending her for a transvaginal ultrasound to assess any ongoing ovarian activity and the endometrial thickness.
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