menopause
Doctor Information
Mrs Margaret Chessington, age 48
PMH:
Chronic lower back pain
Right inguinal hernia repair 2009
Osteoarthritis both hands
Medication:
Naproxen 250mg BD
Paracetamol 1g QDS
Amitriptyline 25mg ON
No known allergies
Last consultation over 6 months ago
PMH:
Chronic lower back pain
Right inguinal hernia repair 2009
Osteoarthritis both hands
Medication:
Naproxen 250mg BD
Paracetamol 1g QDS
Amitriptyline 25mg ON
No known allergies
Last consultation over 6 months ago
Patient Information
Mrs Margaret Chessington, age 48
Opening line: I’d like something for these awful hot flushes
History: You have been having hot flushes for about 8 months, up to 20 times a day. There is no warning and half the time you are at work with a client - it is very embarrassing. You get them at night too, and sometimes you are drenched in sweat.
If asked only: Your last period was 4 months ago, and it seemed normal. Prior to this you periods have been irregular, with breaks in-between of anything between 4-10 weeks. You have had No bleeding after intercourse, no intra-menstural bleeding, no abnormal discharge or vaginal dryness. Your husband says you are irritable and snappy, much more than you ever were. Your mood is good generally but sometimes you just burst into tears for no apparent reason. You don't feel you are depressed however. You have not noticed any urinary nor vaginal symptoms. Your libido isn't what it used to be, much to your other half's annoyance. You have a high pressured job, and find that your memory isn't quite what it used to be recently.
No history of breast cancer or VTE/stroke.
Social History
You live with husband Ian, daughter Sam, and son Jonah. You have never smoked and drink a glass of wine a few nights a week. You work as an accountant and spend most of the day with clients. You can not find any time to exercise.
PMH
Longstanding lower back pain
Hernia repair
Arthritis in hands
No recent MI / Angina
Medication
Naproxen 250mg bd
Paracetamol 1g qds
Amitriptyline 25mg nocte
No Known Allergies
Ideas: You are assuming this is the menopause, and you talked with some of your friends and searched on google, but there are so many different treatment options you don't know where to start. You suspect you will need a blood test to diagnose it.
Concerns: Some of your friends have mentioned HRT but you are scared to take it as you don't want breast cancer ( you googled HRT and read about breast cancer risk). You also have some concern over the memory loss at work, is this to be expected with menopause?
Expectations: You did want to start HRT, since your friends seem so much better on it, but you are now in two minds due to the breast cancer risk, and you would like to hear about the alternative options.
In this case; if the Doctor explains the risks to you in a logical and easy to understand way, and they explain that due to your age, there is no appreciable increased risk of breast cancer, then you will happily start the HRT.
Opening line: I’d like something for these awful hot flushes
History: You have been having hot flushes for about 8 months, up to 20 times a day. There is no warning and half the time you are at work with a client - it is very embarrassing. You get them at night too, and sometimes you are drenched in sweat.
If asked only: Your last period was 4 months ago, and it seemed normal. Prior to this you periods have been irregular, with breaks in-between of anything between 4-10 weeks. You have had No bleeding after intercourse, no intra-menstural bleeding, no abnormal discharge or vaginal dryness. Your husband says you are irritable and snappy, much more than you ever were. Your mood is good generally but sometimes you just burst into tears for no apparent reason. You don't feel you are depressed however. You have not noticed any urinary nor vaginal symptoms. Your libido isn't what it used to be, much to your other half's annoyance. You have a high pressured job, and find that your memory isn't quite what it used to be recently.
No history of breast cancer or VTE/stroke.
Social History
You live with husband Ian, daughter Sam, and son Jonah. You have never smoked and drink a glass of wine a few nights a week. You work as an accountant and spend most of the day with clients. You can not find any time to exercise.
PMH
Longstanding lower back pain
Hernia repair
Arthritis in hands
No recent MI / Angina
Medication
Naproxen 250mg bd
Paracetamol 1g qds
Amitriptyline 25mg nocte
No Known Allergies
Ideas: You are assuming this is the menopause, and you talked with some of your friends and searched on google, but there are so many different treatment options you don't know where to start. You suspect you will need a blood test to diagnose it.
Concerns: Some of your friends have mentioned HRT but you are scared to take it as you don't want breast cancer ( you googled HRT and read about breast cancer risk). You also have some concern over the memory loss at work, is this to be expected with menopause?
Expectations: You did want to start HRT, since your friends seem so much better on it, but you are now in two minds due to the breast cancer risk, and you would like to hear about the alternative options.
In this case; if the Doctor explains the risks to you in a logical and easy to understand way, and they explain that due to your age, there is no appreciable increased risk of breast cancer, then you will happily start the HRT.
Examination Findings
Pulse 73 regular
Blood pressure 133/87
BMI 31
Blood pressure 133/87
BMI 31
Mark scheme
Data Gathering
|
Positive Indicators
Organised and systematic data gathering of symptoms and past history Competent examination of patient Able to interpret history and identify examinations |
Negative indicators
Makes assumptions about the history rather than taking detailed history Fails to examine patient or incompetent examination Unable to interpret findings |
Clinical Management Skills
|
Positive indicators
Makes an appropriate diagnosis Discusses management options, gives written advice Informs patient about the risks of HRT and offers non HRT treatments Makes arrangement for follow-up |
Negative Indicators
Unable to make a diagnosis Orders blood tests to confirm diagnosis Does not discuss or share options for treatment Fails to make follow-up arrangements |
Inter Personal Skills
|
Positive indicators
Discusses agenda, ideas and concerns Offers chaperone Explains in appropriate language Sensitive to patient's feelings |
Negative indicators
Fails to discuss agenda, ideas and concerns Fails to offer chaperone Uses jargon in explanation No sympathy shown |
Management
Explanation:
The menopause is your last period, but it is often used to describe the period leading upto this. As you get older, your ovaries stop producing eggs, and you therefore have less of the hormone oestrogen. This can cause lots of different symptoms for example hot flushes, sweats, mood changes, and changes to your periods. Often the symptoms pass without needing treatment, but there are several options available to improve how you feel.
As described above the 'menopause' is often used by people to describe the period of hormonal change that occurs around the end of reproductive life. In reality, the menopause can only be diagnosed retrospectively once a woman has been amenorrhoeic for 12 months. The 'perimenopause' is the technical term used to describe the time leading up to the last period.
About 8/10 women will experience symptoms around their menopause. Premature menopause describes the cessation of periods before the age of 40.
Symptoms are common in the perimenopausal / menopausal period.
8 in 10 complain of vasomotor symptoms - hot flushes, sweating.. These usually last around 2-5 years although can last up to 10 in some women. 30% have urinary/vaginal symptoms (dryness, itching, dyspareunia). Other notable symptoms include sleep disturbance, mood changes (which can include memory problems), loss of libido and others such as thinning of the hair and skin.
The diagnosis is clinical and not based on investigations. However, consider other conditions that can cause similar symptoms, e.g. endocrine conditions, psychological disorders, or even pregnancy! - Remember that in women under the age of 50, there is still a possibility of becoming pregnant for two years after the last period. This falls to one year in those over the age of 50.
Assess by asking about periods - frequency, heaviness, or if stopped, how long for. Then assess her symptoms and their effect on her quality of life, and consult her about her expectations. Often in practice, many women have heard of HRT, but are unclear as to exactly what it's used for, and what it does.
Management:
This is a very large topic heading, so we won't attempt to cover everything here, just the major points. For a really detailed approach to management that is heavily referenced, please read the NICE CKS recommendations
Lifestyle: regular exercise, light clothing and using fans/open windows, weight loss. Look for possible triggers such as caffeine, alcohol, stress and try and reduce these. For cognitive symptoms, good sleep hygeine and exercise may help.
Non-HRT: trial of SSRI such as paroxetine, citalopram or venlafaxine, especially for vasomotor symptoms (unlicenced). A 2-4 week trial of clonidine can also be used for this (licenced). Most find clonidine uneffective, reducing hot flushes by around 1-2 a day.
You should not recommend herbal or complementary therapy because there are less stringent controls over quality, and the safety and efficacy is not known.
HRT:
First consider the risks and benefits.
For combined HRT there is a small increased risk of breast cancer, myocardial infarction, venous thromboembolism and stroke.
Contraindications:
Pregnancy and breast-feeding.
Undiagnosed abnormal vaginal bleeding.
Venous thromboembolic disease.
Active or recent angina or myocardial infarction.
Suspected, current or past breast cancer.
Endometrial cancer or other oestrogen-dependent cancer.
Active liver disease with abnormal LFTs.
Uncontrolled hypertension.
Porphyria cutanea tarda
However it is very effective in treating vasomotor symptoms of menopause, as well as mood disturbance and vaginal symptoms. It is protective against osteoporosis, but should not be given primarily for this reason.
The risks of combined HRT are outlined below: (RR=relative risk AR=absolute risk)
Coronary events:
VTE:
Stroke
Breast Cancer (only applies to women OVER the age of 50)
Oestrogen only HRT does not appear to be linked with an increased risk of breast cancer, and is associated with a small increased risk of VTE, stroke and endometrial Ca. In this particular case, with the patient being under 50, taking HRT untill the age of 50 is not known to increase the risk of breast cancer.
Which HRT to give?
Essentially there are four categories that women may fall into:
If a woman is perimenopausal, cyclical HRT is better as it mimics the patient’s own cycles. If a woman has an intact uterus, cyclical combined HRT should be used, as oestrogen only HRT would put them at higher risk of endometrial cancer. Without a uterus, oestrogen only HRT is suitable.
Follow up three monthly until stable, then annually.
For postmenopausal women (12 months period free, or age>54), the same principle applies - with uterus, give combined, without a uterus, give oestrogen only. The main difference is that HRT can be given continuously in this group. Again, follow up three monthly until stable and then annually.
HRT has many available delivery routes, it is usually best to start with oral preparations. Patches avoid first pass metabolism, so is better for women who experience side effects on oral preparations, women who have liver disease, women who are at increased risk of thromboembolism, women taking enzyme inducing medication, or even those who suffer from migraines.
Remember that HRT is NOT a contraceptive. One option can be a hormone IUS with oestrogen supplementation on top, the other can be a POP with combined cyclical HRT. Do not give a POP with oestrogen only HRT, as it does not provide enough endometrial protection.
Swapping from cyclical to continuous HRT: This is a subject where no clear guideline exists. Most accept it is safe to try swapping after 12 months of cyclical HRT, however 'Guideliness' suggest waiting until the age of 54, as by then 80% of women will have cessation of ovarian function [see link below].
Links to excellent resources about HRT:
http://www.patient.co.uk/doctor/hormone-replacement-therapy-including-risks-and-benefits
https://www.rcog.org.uk/en/news/campaigns-and-opinions/hormone-replacement-therapy/
http://cks.nice.org.uk/menopause
Long term hormone therapy for perimenopausal and postmenopausal women: J Marjoribanks, C Farquhar, H Roberts, A Lethaby
http://www.guidelines.co.uk/obstetrics_gynaecology_urology_mm_hrt#.VE0gcvmsW1c
The menopause is your last period, but it is often used to describe the period leading upto this. As you get older, your ovaries stop producing eggs, and you therefore have less of the hormone oestrogen. This can cause lots of different symptoms for example hot flushes, sweats, mood changes, and changes to your periods. Often the symptoms pass without needing treatment, but there are several options available to improve how you feel.
As described above the 'menopause' is often used by people to describe the period of hormonal change that occurs around the end of reproductive life. In reality, the menopause can only be diagnosed retrospectively once a woman has been amenorrhoeic for 12 months. The 'perimenopause' is the technical term used to describe the time leading up to the last period.
About 8/10 women will experience symptoms around their menopause. Premature menopause describes the cessation of periods before the age of 40.
Symptoms are common in the perimenopausal / menopausal period.
8 in 10 complain of vasomotor symptoms - hot flushes, sweating.. These usually last around 2-5 years although can last up to 10 in some women. 30% have urinary/vaginal symptoms (dryness, itching, dyspareunia). Other notable symptoms include sleep disturbance, mood changes (which can include memory problems), loss of libido and others such as thinning of the hair and skin.
The diagnosis is clinical and not based on investigations. However, consider other conditions that can cause similar symptoms, e.g. endocrine conditions, psychological disorders, or even pregnancy! - Remember that in women under the age of 50, there is still a possibility of becoming pregnant for two years after the last period. This falls to one year in those over the age of 50.
Assess by asking about periods - frequency, heaviness, or if stopped, how long for. Then assess her symptoms and their effect on her quality of life, and consult her about her expectations. Often in practice, many women have heard of HRT, but are unclear as to exactly what it's used for, and what it does.
Management:
This is a very large topic heading, so we won't attempt to cover everything here, just the major points. For a really detailed approach to management that is heavily referenced, please read the NICE CKS recommendations
Lifestyle: regular exercise, light clothing and using fans/open windows, weight loss. Look for possible triggers such as caffeine, alcohol, stress and try and reduce these. For cognitive symptoms, good sleep hygeine and exercise may help.
Non-HRT: trial of SSRI such as paroxetine, citalopram or venlafaxine, especially for vasomotor symptoms (unlicenced). A 2-4 week trial of clonidine can also be used for this (licenced). Most find clonidine uneffective, reducing hot flushes by around 1-2 a day.
You should not recommend herbal or complementary therapy because there are less stringent controls over quality, and the safety and efficacy is not known.
HRT:
First consider the risks and benefits.
For combined HRT there is a small increased risk of breast cancer, myocardial infarction, venous thromboembolism and stroke.
Contraindications:
Pregnancy and breast-feeding.
Undiagnosed abnormal vaginal bleeding.
Venous thromboembolic disease.
Active or recent angina or myocardial infarction.
Suspected, current or past breast cancer.
Endometrial cancer or other oestrogen-dependent cancer.
Active liver disease with abnormal LFTs.
Uncontrolled hypertension.
Porphyria cutanea tarda
However it is very effective in treating vasomotor symptoms of menopause, as well as mood disturbance and vaginal symptoms. It is protective against osteoporosis, but should not be given primarily for this reason.
The risks of combined HRT are outlined below: (RR=relative risk AR=absolute risk)
Coronary events:
- RR: 1.89 at 1 year
- RR: 1.22 at 5 years.
- AR: 4/1000 at 1 yr,
- AR: 22/1000 at 5 yrs.
VTE:
- RR: 4.28 at 1 year
- AR: 7/1000 at 1 yr
Stroke
- RR: 1.38 at yr
- AR: 18/1000 at 5 years
Breast Cancer (only applies to women OVER the age of 50)
- RR: 1.26 at 5 years
- AR: 23/1000 at 5 years.
- Before the age of 50,
Oestrogen only HRT does not appear to be linked with an increased risk of breast cancer, and is associated with a small increased risk of VTE, stroke and endometrial Ca. In this particular case, with the patient being under 50, taking HRT untill the age of 50 is not known to increase the risk of breast cancer.
Which HRT to give?
Essentially there are four categories that women may fall into:
- Perimenopausal with uterus
- Perimenopausal without uterus
- Postmenopausal with uterus
- Postmenopausal without uterus
If a woman is perimenopausal, cyclical HRT is better as it mimics the patient’s own cycles. If a woman has an intact uterus, cyclical combined HRT should be used, as oestrogen only HRT would put them at higher risk of endometrial cancer. Without a uterus, oestrogen only HRT is suitable.
Follow up three monthly until stable, then annually.
For postmenopausal women (12 months period free, or age>54), the same principle applies - with uterus, give combined, without a uterus, give oestrogen only. The main difference is that HRT can be given continuously in this group. Again, follow up three monthly until stable and then annually.
HRT has many available delivery routes, it is usually best to start with oral preparations. Patches avoid first pass metabolism, so is better for women who experience side effects on oral preparations, women who have liver disease, women who are at increased risk of thromboembolism, women taking enzyme inducing medication, or even those who suffer from migraines.
Remember that HRT is NOT a contraceptive. One option can be a hormone IUS with oestrogen supplementation on top, the other can be a POP with combined cyclical HRT. Do not give a POP with oestrogen only HRT, as it does not provide enough endometrial protection.
Swapping from cyclical to continuous HRT: This is a subject where no clear guideline exists. Most accept it is safe to try swapping after 12 months of cyclical HRT, however 'Guideliness' suggest waiting until the age of 54, as by then 80% of women will have cessation of ovarian function [see link below].
Links to excellent resources about HRT:
http://www.patient.co.uk/doctor/hormone-replacement-therapy-including-risks-and-benefits
https://www.rcog.org.uk/en/news/campaigns-and-opinions/hormone-replacement-therapy/
http://cks.nice.org.uk/menopause
Long term hormone therapy for perimenopausal and postmenopausal women: J Marjoribanks, C Farquhar, H Roberts, A Lethaby
http://www.guidelines.co.uk/obstetrics_gynaecology_urology_mm_hrt#.VE0gcvmsW1c