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Ask an Expert: Q&A – September 2022

Ask An Expert: Q&A | For health professionals
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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.

Answering your question for this edition of 'Ask an Expert: Q&A' is Jean Hailes gynaecologist & Medical Director Dr Elizabeth Farrell AM.

Question 1

I have a patient who came to see me last week from another clinic for an MHT script. Age 52, LMP > 12 months ago.

To my dismay, I discovered that she has been on unopposed oestrogen (Estraderm patch 25) with an intact uterus for 6 months.

No PV [per vaginal] bleeding, good control of menopause symptoms. I changed her to an oestrogen + progesterone regimen.

My question is, given she has had no PV bleeding, should she have an ultrasound to check endometrium?

Elizabeth Farrell

Answer

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

Thank you for your question. It is of concern that patients are being prescribed oestrogen alone when they still have a uterus.

Sometimes the reasons for being on combined oestrogen and progestogen are not explained clearly to the patient so she may cease the progestogen if there are unpleasant side effects, thinking it is safe to do so.

There are two pathways: initially cycle her progestogen for three months to have a withdrawal bleed then continue with continuous therapy, or initially perform an ultrasound to check the endometrial thickness which, if less than 4mm, start continuous progestogen. If the endometrium is greater than 4mm, then cycle the progestogen for three months and recheck endometrial thickness. Always recommend the ultrasound be performed immediately postmenstrual when the endometrium is thin.

Question 2

My question is about the use of MirenaTM IUD and COCP (for example, Valette) together in a young woman with endometriosis. Can patients be left on hormonal IUD and COCP? If yes, for how long?

Answer

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

If endometriosis has been proven by laparoscopy, then postoperative management is by hormonal suppression to treat symptoms of pain and suppress growth of endometriosis cells that may still be present.

The aim is to reduce the risk of recurrence, or delay recurrence.

In some cases, ovulation also needs suppression as well as endometrial thinning, requiring both an oral contraceptive and a MirenaTM IUS. If adenomyosis is also present, the use of the MirenaTM IUS will suppress the adenomyotic cells.

If the individual’s symptoms are controlled, then these treatments should continue unless the individual wishes to become pregnant or have a trial off the hormones. It is most likely that if you discontinue the treatment, symptoms may return, and a recurrence may occur earlier.

Working with the individual’s gynaecologist will assist in providing optimum treatment for your patient.

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