Osce Counselling on hormonal replacement therapy following TAHBSO

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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 differentials
and suggest appropriate options of therapy taking into account current
medical evidence.

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Further History
Establish rapport with patient
Elicit information to assess patient's condition following surgery
Overall wellbeing
Wound healing
Her ability to function normally
Her eating, urinary and bowel habits
Any questions about sexual health and views of spouse
Addresses 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 patient
DIAGNOSIS : 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 still
Young 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
doubled
Continuous 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 spotting
• Progesterone 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 days
Long term major complications include:
• Breast cancer
• Thromboembolism
• Myocardial infarction, atherosclerosis
Side effect of HT?

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Thank you