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Ask an Expert: Q&A – May 2022

Ask An Expert: Q&A | For health professionals 10 May 2022
AAE May 2022

'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 Jean Hailes gynaecologist & Medical Director Dr Elizabeth Farrell AM and Jean Hailes endocrinologist Dr Sonia Davison.

Question 1

Is it safe to give oestrogen-only MHT in women who have had subtotal hysterectomy (who still have cervical stump)?

I have a 53yo female who underwent a subtotal hysterectomy and unilateral oophorectomy in 2012 for pelvic pain and ovarian cysts – all benign.

She still has cervical stump present and is still having regular cervical screening.

She has been treated with MHT since 2020 and was taking both oestrogen and progesterone orally. She is now on Climara patches which are very effective, but she wants to cease the progesterone component. Is it safe to cease the progesterone in this patient?

Elizabeth Farrell

Answer

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

This is a very important question as women with subtotal hysterectomy are often dismissed as having had a hysterectomy, therefore assumed a total hysterectomy.

I have been unable to source any studies outlining the recommendations on the use of MHT following subtotal hysterectomy.

Many gynaecologists may diathermy the cervical canal to reduce the incidence of endometrial cells remaining at the time of the surgery but that is not a guarantee that all cells have been removed.

Because of the possibility of remaining endometrial cells in the cervical stump, combined therapy is suggested.

There are two suggestions for the longer term:

  1. Use the progestogen cyclically for about 3 months and see if there is a withdrawal bleed. If no bleed occurs then oestrogen alone therapy may be trialled.
  2. Tibolone has the actions of oestrogen, progesterone and testosterone and therefore does not stimulate any endometrium.

Asking your patient to have an ultrasound, if possible with a gynaecologist-run service, to measure the cervical stump and assess for any endometrial tissue, may also help in decision making.

Many thanks for this interesting and important question.

Question 2

I am trying to find some information on stopping MHT either oral or transdermal but can’t seem to find anything!

Is it better to wean the E2 or does it not really matter? How long does it take for symptoms to recur if they are going to? Obviously starting and stopping E2 is not ideal from a VTE risk (this stands for the COCP and I think is the same for MHT?) so how often and for how long would you usually advise a woman to cease E2 before deciding whether she should restart?

Jean Hailes endocrinologist Dr Sonia Davison

Answer

From Jean Hailes endocrinologist Dr Sonia Davison (pictured)

As a kindness I usually advise patients to very slowly wean hormone therapy, with a gradual reduction in dose, as clinically this can result in less rebound in vasomotor symptoms. However, the research suggests there is no difference between gradual reductions in dose, versus going ‘cold turkey’.

Women are very individual in their menopausal symptoms and in their response to coming off hormone therapy, so there are no ‘set’ answers, unfortunately.

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