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Hormonal Replacement Therapy Following TAHSO

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Case Scenario

Mrs Masroh, a 45-year-old lady underwent a Total Abdominal Hysterectomy and Bilateral Salphingo-opherectomy (TAHSO) about 6 weeks ago for a left ovarian tumour...

The surgery was uncomplicated and she recovers completely.

Over the last 2 weeks she has been complaining of hot flushes and irritability for the last 2 weeks. She does not have any urinary symptoms.

She is seeing you for her post-operative follow up

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Objectives

Correlate previous information with her current condition

Explain the results of labs and convey information for further care

Show ability to break news.

Be able to formulate a diagnosis for her new condition, exclude differentialsand suggest appropriate options of therapy taking into account currentmedical evidence.

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Further History

Establish rapport with patientElicit information to assess patient's condition following surgeryOverall wellbeingWound healingHer ability to function normallyHer eating, urinary and bowel habitsAny questions about sexual health and views of spouseAddresses new concerns or problems

Professional approach to patient and postoperative brief assessment

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Counselling

Explains to her that it means the tumor is benign

Informs her that the pelvic organs were removed in total though they are normal due to inability to confirm pre-operatively if the tumor is malignant

Confirms that this is probably best treatment option in view of age ( 45) and nature of disease (ovarian tumor)

No further definitive treatment is required since it is a benign disease

Interpretation of HPE report and explanation to patientDIAGNOSIS : LEFT OVARIAN CYSTASDENOMA. Right ovary, uterus and fallopian tubes are normal

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Counselling

Reiterates that removal of both ovaries would result in early symptoms of menopause

She will not have her menstruation and does not need to go for cervical screening

Her sexual function should not be affected if her desire is normal

On the other hand, her risk of osteoporosis and other related menopausal problems like vasomotor symptoms, vaginal dryness etc are high as she is stillYoung She would also have to be cautious about the bladder

Function and vault prolapse as evidence has shown that up to 30% of women suffers from incontinence or vault prolapse following a pelvic surgery

DIAGNOSIS : LEFT OVARIAN CYSTASDENOMA.Surgical Menopause and its effect

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Counselling

The symptoms of hot flashes and irritability could be vasomotor symptoms from depletion of oestrogen as a consequence of removal of ovaries/ menopause 1/3 of women suffer from menopausal symptoms of various degrees.

Suggest to rule out other conditions that may have similar presentation like hyperthyroidism or early sign of depression on by further assessment and investigation (though these are unlikely as she has 6 already be screened for co-morbid disease prior to operation)

Explain to patient about her new symptoms and possible options of therapy..

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Non pharmacological: stay active, highly nutritional intake, exercise, meditation, cold and frequent bathe.

Pharmacological: Hormonal or non hormonal.Hormonal i.e: oestrogen only drug (not need for addition of progestins) as her uterus is no longer present, is said to ease the symptoms quite immediately. It also has other benefits like reducing risk of osteoporosis, coronary disease, bladder instability etc.

Non hormonal drugs i.e. alpha blockers, herbal based like Remifemin could also help though evidence shows that it may help only about 60% of women.

If other differentials are ruled out, discusses options of therapy available for her menopause related symptoms…

Depending on the degree of symptoms, options like non pharmacological or pharmacological can be selected.

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Hormonal Therapy (HT) in

Vaginal spotting is not uncommon during the first few cycles but it would settle down gradually.

If the bleeding is heavy the progesterone should be given for last 21 days or the dose can be doubledContinuous bleeding >6 months requires ultrasound examination for endometrial thickness and endometrial biopsy.

Progyluton Premelle 2.5 Notes...Each calendar-pack

contains 11 white tablets of oestradiol valerate 2 mg & 10 light-brown tablets of oestradiol valerate 2mg & norgestrel 0.5 mg.

Some women may not have any spotting

All the 28 tablets contain conjugated estrogen 0.625 mg and medroxyprogesterone acetate 2.5 mg.

She should take the tablets daily without interruption.

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Minor problems:Oestrogen can cause nausea, vomiting, dizziness and vaginal spottingProgesterone can cause few problems like bloated feeling, acne, hirsutism, mood swings and depression. In these circumstances the progesterone dose can be reduced restricted to 7 to 10 daysLong term major complications include: Breast cancerThromboembolismMyocardial infarction, atherosclerosis

Side effect of HT?

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Thank you