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Ask an Expert: Q&A – May 2021

Ask An Expert: Q&A 18 May 2021
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'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 Payam Nikpoor, gynaecologist and urogynaecologist, and Dr Sonia Davison, endocrinologist.

Question 1

How many people who have a hysterectomy go on to have a vault prolapse?

Dr Payam Nikpoor

Answer

From Jean Hailes gynaecologist and urogynaecologist Dr Payam Nikpoor

Hysterectomy, an operation that involves removal of the uterus with or without adnexal structures including ovaries and/or tubes is carried out for different reasons and different routes.

Hysterectomy may be done vaginally or abdominally. The latter can be done via laparotomy or laparoscopic method. The indication may be uterine prolapse, fibroids, heavy menstrual bleeding not amenable to other treatments or malignancy.

The international urogynaecology association (IUGA) and international continence society (ICS) in their joint report on the terminology for female pelvic organ prolapse define vault prolapse as “descent of the apex of the vagina (vaginal vault or cuff scar after hysterectomy)”. The way vault prolapse is assessed during examination is by using pelvic organ prolapse quantification POP-Q system, which measures the descent of each compartment relative to hymen.

Vault prolapse occurs either due to failure to address the appropriate vault attachments during hysterectomy or due to weakening of tissues and these attachments that support the vault. Vaginal vault prolapse is often associated with other compartment defects (cystocele, rectocele, or enterocele), which makes it a challenging condition to treat.

The incidence of vaginal vault prolapse requiring surgery has been estimated to be 36 per 10,000 women. The risk of vault prolapse following hysterectomy is higher in women whose initial indication for hysterectomy was pelvic organ prolapse as opposed to other indications. Case series dating back to 1960 have identified the incidence of vault prolapse after hysterectomy ranging from 0.2% to 43%. Others have reported vault prolapse to follow almost 11% of hysterectomies performed for prolapse and almost 2% for other benign diseases. In 2010 a study from Austria estimated the frequency of vault prolapse requiring surgical repair to be between 6-8%.

There is a solid recognition in the field of gynaecology that adequate support for the vaginal apex is an essential component of a durable surgical repair for women with advanced prolapse. Because of the significant contribution of the apex to vaginal support, anterior and posterior vaginal repairs may fail unless the apex is adequately supported.

Primary prevention can be performed at the time of hysterectomy.

Whilst all women with vaginal vault prolapse benefit from conservative measures such as vaginal pessaries, physiotherapy and lifestyle modifications, surgical intervention remains integral in the effective management of some women with vaginal vault prolapse after hysterectomy who do not respond to conservative therapy or suffer from more advanced prolapse.

Question 2

Best options for increased facial hair in a 55 year-old woman? She is 5 yrs post ovary sparing hysterectomy. BMI 31, widespread OA no other medical issues no medications other than 2mg Progynova started 6 months ago for hot flushes.

Dr Sonia Davison

Answer

From Jean Hailes endocrinologist Dr Sonia Davison

Management:

a. Ensure that there is no biochemical androgen excess that may require further work-up

b. Cosmetic options – laser hair removal / IPL, waxing, electrolysis, threading

c. Medications – spironolactone, gradual increase in dose, up to 100mg bd, watching UEC and blood pressure

d. Other – whilst oral oestrogen is useful for increasing SHBG and therefore reducing free testosterone and may therefore be theoretically useful for reducing hirsutism, given her BMI she has an added VTE risk and I would favour transdermal oestrogen or weight loss

Question 3

I would like to ask about the use of HRT in a women with a known factor V Leiden deficiency, who has never had a thrombotic event, and is now suffering with a quite severe menopausal symptoms. I have just changed her Cipramil antidepressant to Efexor to see if this helps, but wanting to know if using a transdermal HRT could be considered?

Answer

From Jean Hailes endocrinologist Dr Sonia Davison

The decision to use MHT will depend on a range of factors, such as whether she is a heterozygote for Factor V Leiden mutation, or a homozygote, and whether there is a strong family history of VTE, if she is obese, or has other risk factors such as smoking or mobility challenges. My management of these women includes ensuring that a full hereditary thrombophilia screen has been performed (she could carry another genetic clotting mutation or other clotting risk marker), fully assessing their family history and past history, asking about OCP use and pregnancy history (i.e. how they managed with exposure to high levels of sex steroid hormones in the past), and asking about occupation (e.g. flight attendants on long haul flights are at higher risk of VTE).

I also ask these women to be assessed by a haematologist who has an understanding about women’s health and menopausal hormone therapy, so that the women can be advised about potential MHT use, but also how to manage situations such as surgery, travel, and screening of family members (especially children). If the haematologist considers that MHT could be used, transdermal MHT at the lowest dose to control symptoms would be ideal, hence avoiding first pass metabolism.

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