consultation request - gynecology

[Guest guest]

I was recently consulted by a patient and would like to get some

feedback from the rest of the group.

She and her husband have been trying to concieve for 7 months. They

have one child, who was conceived fairly easily (3 months) and was

born by cesarean a few years ago. In the interim, she was diagnosed

with lichen sclerosis and apparantly has significant dyspareunia

when not on meds. The meds that have been effective for her are

vaginal and vulvar estrogen (estring and estrace cream),

beclomethasone topically to the affected area, and amitryptaline at

doses of up to 50 mg q hs. She has been monitoring for days of

fertility using a Clearplan monitor, but not recording any other

fertility signs. She went off her medications when she was first

trying to conceive but found that the dyspareunia made it a

difficult proposition, so she was wanting to go back on her meds.

As a starter, I have asked her to observe and chart other fertility

signs including cervical mucous, and to return with a more complete

chart in about a month.

My concerns are manifold. First, I am concerned that the estrogen

might suppress ovulation, especially as it is being dosed daily and

not cyclically. Is there a way to dose this co-operatively with her

cycle and still have it be effective for her condition? How might

the vaginal estrogen supplement affect not only her mucous

production but also her ability to assess her mucous signs.

Secondly, my recollection of the tricyclic antidepressants are that

they are very drying to the system as a whole - is this something

that can be overcome using guafenesin, B6, and other mucous

enhancers?

Any other thoughts?

alicia huntley cnm msn