Case 5 A 52-year-old woman who has not been able to control her temper recently

 Case 5 A 52-year-old woman who has not

been able to control her temper

recently

Mrs Caroline Britain, a 52-year-old business executive, has

noticed that over the last few months she has

not been able to control her temper in difficult meetings

and becomes red and flustered. This has become both

embarrassing for potential clients and senior management.

Her secretary who has worked for her for over 10 years has

heard gossip around the office. She feels she has to broach

the subject when Mrs Britain walks out of a very important

meeting for the company after shouting at a client. Mrs

Britain receives a verbal warning because of her actions.

After Mrs Britain discusses this distressing event with her

secretary, she attends her GP. She admits to marital

problems secondary to difficulties with sex and sleeping

because of sweating.

What is your differential diagnosis?

• Anxiety/depression

• Menopausal symptoms

• Thyroid dysfunction

What do you need to elicit from

the history?

History of complaint

• Presence of hot flushes/night sweats and subsequent

requirements, e.g. showering overnight, changing night

wear or bed clothes

• Duration of symptoms

• Amenorrhoea or irregular/less frequent periods

• Vaginal bleeding or discharge

• Presence of palpitations, anxiety, diarrhoea

• Difficulty in getting to sleep or waking at night and

unable to get back to sleep

• Extent of marital difficulties including sexual issues

such as dysparunia, aparunia

Associated symptoms

• Urinary symptoms: frequency or dysuria

• Bowel symptoms: diarrhoea and abdominal pain

Menstrual history

• Last menstrual period (LMP) and regularity of periods

Screening history

• Mammogram result

• Smear history

• Presence of significant venous varicosities in lower

limbs

Obstetric history

• Parity, type of delivery and complications

Medical history

Any previous history of hypertension, osteoporosis,

ischaemic heart disease, strokes, hysterectomy, gynaecological malignancy, previous endometriosis, previous/present breast cancer, thrombotic episodes (e.g.

pulmonary embolism, deep venous thrombosis).

Family history

Ask about the presence of hypertension, ischaemic heart

disease, osteoporosis, thyroid dysfunction, breast/gynaecological cancer and thrombotic episodes.

Drug history

Ask about non - prescribed and prescribed medication.

Mrs Britain explains her LMP was 10 months ago and since

then she has had difficulty sleeping because of hot flushes

and night sweats. Sometimes she has to shower three or

four times a night to cool down. This has led to marital

difficulties because of the constant

Obstetrics and Gynaecology: Clinical Cases Uncovered.

By M. Cruickshank and A. Shetty. Published 2009 by Blackwell

Publishing. ISBN 978-1-4051-8671-1.48 Part 2: Cases

PART 2: CASES

disruption of getting up at night and her reduced libido. She

finds intercourse is painful and can precipitate the hot fl

ushes and sweats. The lack of sleep has caused her

difficulty to cope at work.

She has two grown-up children; both delivered uneventfully

and she has never had any gynaecological operations. Both

her smears and mammograms are up to date and have been

normal. She has noticed some urinary frequency and

‘stinging’, but it is intermittent and no urinary infection has

been identified from culture despite several samples being

tested. Mrs Britain does admit that this mainly occurs after

trying to have intercourse which is painful on entry and during

intercourse. She has found it less painful with a lubricant that

she bought over-the-counter. The night sweats are the main

problem affecting her quality of life as she cannot function

properly during the day because they disturb her sleep

pattern. She did try some homeopathic preparation from the

local health shop, but it did not work, so she stopped taking it

3 months ago.

What would you look for on physical

examination?

General examination

• Tired appearance

• Presence of flushing/sweating during consultation

• Presence of goitre

Vaginal examination

First you need to look for the presence of atrophic

change. There may be petechial haemorrhages around

the vulva, inside the vagina or on the cervix. These

may cause bleeding during the examination and you

need to inform her that this is present. Sometimes the

presence of petechial haemorrhage only occurs with the

examination (even though you are being gentle) and

indicates atrophy. If she has had previous vaginal bleeding, a transvaginal ultrasound scan to assess endometrial

thickness and possible endometrial biopsy may be

required. A bimanual pelvic examination should be performed if possible to exclude any enlargement of the

pelvic organs or indeed pain on palpation in case

dual pathology is present. The use of a lubricant and an

appropriately sized speculum is important given the

presence of dysparunia. In addition, remember your

communication skills during the procedure and ensure

that Mrs Britain can stop the examination if she finds it

too painful.

To summarize your findings so far, Mrs Britain, a 52-year-old

woman with 10 months of amenorrhoea, has been

experiencing hot flushes and night sweats. These have

impacted on both her personal and working life. She has

dysparunia which has caused sexual problems with her

husband, negatively affecting her mood.

On examination, Mrs Britain appeared tired, has no goitre

and experienced several noticeable flushes throughout the

15-minute consultation. She does have atrophic changes

within the vagina, but no provoked bleeding on

examination. There are no pelvic masses and her uterus is

normal sized and mobile. The main discomfort was found

on insertion of the speculum, even with sufficient

lubricant.

What do you do next?

General and female health screening

First, both general and female health screening are

required if these have not taken place previously. Blood

pressure measurements are taken especially for those

who have a raised body mass index (BMI), treated hypertension or have a family history of hypertension or vascular disease. In addition to encouragement to participate

in general female population screening procedures such

as cervical smears or mammograms, it may be appropriate to teach the patient breast awareness (regular

self - examination). Any hormone replacement that is

commenced can reduce the clarity of identifying any discrete tumours so prior mammographic screening and

examination is beneficial for those over 50 years if this

has not been performed.

Do you need to do any investigations?

Serum samples such as follicle stimulating hormone

(FSH) are not always necessary for diagnosis of the

menopause. A raised FSH level (>35 IU/L) does not necessarily provide confirmation of menopause as women

who are perimenopausal can have fluctuating levels

dependent on the ovarian activity at the time of the blood

sample being taken. To clarify the diagnosis it can be

useful to perform a series of FSH levels in combination

with oestradiol levels. If the oestradiol level is consistently

low (<0.11 nmol/L) this is more indicative of failing

activity of the ovaries as FSH levels can be erratic and

wide ranging in the perimenopause.Case 5 49

PART 2: CASES

Although not always necessary, thyroid function screening could be considered as thyroid dysfunction can occur

at the perimenopause and diagnosis is hindered by menopausal symptoms. This investigation will be dictated

by history and examination (especially of the thyroid

region).

You can now review your findings

• BMI of 30

• BP 110/75mmHg

• Cervical smear: normal with routine recall advised.

• Mammogram: normal with routine recall advised.

• FSH 90IU/L and oestradiol less than 0.11nmol/L

• Normal thyroxine but raised thyroid stimulating hormone

(TSH)

Now review each differential diagnosis

Anxiety/depression

Although not completely excluded as a diagnosis, the

physical symptoms Mrs Britain describes are those of

vasomotor symptoms and are not associated with the

adrenaline/noradrenaline system.

Menopausal symptoms

This appears to be the most likely diagnosis given the

raised FSH and very low oestrogen in conjunction with

the present history of vasomotor symptoms and 10

months of amenorrhoea in addition to the presence of

vaginal atrophy (Box 5.1 ).

Thyroid dysfunction

This is unlikely at present to be a cause for her presenting

symptoms. However, this does require more investigation by further sampling (normally with samples 3 – 6

months apart) to identify any associated perimenopausal

thyroid dysfunction.

What treatment would you offer

this patient?

The use of treatments depends upon the patient, some

just need advice and reassurance, others cannot cope

with daily living activities (DLAs) and these are the

patients who should be offered some form of treatment.

The level of intrusion on DLAs will provide information

on the required treatment. If the symptoms are mild, an

over - the - counter preparation may be sufficient, but if

symptoms are significant a more medical approach is

necessary.

Herbal and homeopathic treatment

There are several preparations that are offered over - the -

counter to alleviate menopausal symptoms. None of

these preparations have been clinically tested other than

Red Clover™ (Novogen), although this used a dose double

that advised by the manufacturers. Red Clover is not yet

available on NHS prescription and requires self - funding

by the patient.

Many herbal preparations are known to affect intracellular activities within the body, notably co - enzyme p450,

or interact with prescribed medication (such as antihypertensives, hormonal treatments, tamoxifen and antidepressants; Table 5.1 ). Many menopause preparations

contain a combination of ingredients and patients should

be made aware of the information given by the

manufacturer.

Box 5.1 Effects of menopause

Short-term effects of menopause

• Hot flushes

• Night sweats

• Atrophic genitalia

Long-term effects of menopause

• Osteoporosis

• Atrophic tissues

Table 5.1 Warnings associated with menopausal

preparations*.

Herbal preparation Interaction/effect

St John’s wort HRT

Antidepressants

Contraceptive pills

Warfarin

Kava Liver function

Sage

Tamoxifen

Antihypertensives

HRT, hormone replacement therapy.

*There may be several unknown at present.50 Part 2: Cases

PART 2: CASES

Hormone replacement therapy

There are several different hormonal preparations of

HRT as well as different modes of administration (Table

5.2 ). The hormones required in the HRT preparation

are dependent upon the patient ’ s medical history.

Oestrogens are very effective in controlling vasomotor

symptoms.

In the case of Mrs Britain who still has a uterus, she

requires both oestrogen and a progestogen.

Progesterone

The progesterone will protect and control the growth of

the endometrium from the oestrogenic influence. There

are two ways of giving progestogens: on a sequential or a

continuous basis. The choice is dependent on the patient ’ s

duration of amenorrhoea and age. If a patient is at least 54

years old or has had at least 1 year of amenorrhoea, most

patients can be given an HRT with a continuous progestoKEY POINT

The use of herbal preparations is at the discretion of the

patient but you should guide and advise if the patient is

using any prescribed medication

KEY POINT

If the patient has had a hysterectomy only oestrogen is

required.

gen. This allows the patient to continue to experience

amenorrhoea. You need to advise that there may be light

intermittent bleeding in the first few months of treatment.

Mrs Britain has not had 12 months of amenorrhoea so she

will need to use an HRT that contains a sequential (cyclical)

progestogen and she will experience a withdrawal bleed.

Table 5.2 Types of available preparations for hormone

replacement therapy.

Mode of delivery Constituent hormones

Oral Separate or combinations of oestrogen

and/or progesterone

Transdermal Combinations of oestrogen and

progesterone or oestrogen only

Subcutaneous Oestrogen only

Testosterone only

Transvaginal Oestrogen only

Progesterone only

KEY POINT

If she was given a continuous progestogen, she could

experience very erratic and unacceptable bleeding as she

will still be producing some endogenous oestrogen from

her failing ovaries.

Mrs Britain has only ever taken tablets and is interested in

the different routes of delivery.

There are several ways in which HRT can be given and

this should be discussed with the patient and any medical

problems taken into account. Different modes of delivery

are beneficial for different patients. Mrs Britain has no

absorption problems and could easily be offered a range

of HRT delivery modes.

Transdermal preparations remove the first pass effect

through the liver and are suitable for women who cannot

swallow tablets or remember to take them. Women who

tend to forget to take regular medication may require

modes of delivery which require no thought on their part

such as the implant. Vaginal preparations can be used for

local vaginal symptoms. The main indicator is personal

choice and the beneficial effect on her symptoms.

KEY POINT

HRT needs to be used consistently and correctly for at

least 3 months before it can be considered ineffective.

Mrs Britain has no personal or family medical history

to suggest any form of HRT would be better for her

health, but first she wants to know about common

side-effects.

What are the common side-effects

of HRT?

On commencement, HRT can cause breast tenderness,

slight fluid retention and skin changes, but these normally settle down over 4 months.Case 5 51

PART 2: CASES

Mrs Britain has read a recent article

about HRT and she wants to know

about any risks

Counselling about the potential risks of HRT use is the

most important aspect of an HRT consultation. Over the

last decade, HRT use has declined because of negative

media coverage of studies reported in well - respected

journals. The crucial conclusions from these studies have

now been amended following reanalysis of the data. The

present understanding is that HRT should be used for

the shortest possible time at the lowest possible dose.

However, all women are individual and Mrs Britain may

require HRT for several years until she can cope without

it; in her case this would be her shortest possible time.

What risks should you discuss with her?

• Breast cancer. The main concern for women using

HRT is breast cancer which increases over time in most

women after the age of 50, but depends on the

type of HRT used and their own family and personal

history.

• Thromboembolic disorders. Mrs Britain, as in all

patients who are considering HRT, should be informed

of the slight increased risk of clotting (from 1 in 10,000

to 3 in 10,000).

• Hypertension. All patients should be reviewed for

blood pressure checks and symptom control.

Does Mrs Britain need to have her

hormone levels monitored?

She does not require further serum samples measuring

FSH and oestrogen and her replacement treatment

should be based on her symptoms. Some oestrogens used

in HRT are not measured by the assays used on serum

samples. As Mrs Britain is fit and healthy, 3 - monthly BP

checks are all that is required as well as symptom control.

Mrs Britain decides upon oral HRT and has no symptoms

at her 3-month review apart from some residual

intermittent dysparunia. On examination, the atrophic

changes have improved, with no pain on speculum

examination and she informs her GP she can have sex

without pain.

It is decided that her GP will review her annually to

identify the need for HRT continuation but provisionally

a plan is agreed with her to stop the HRT at 55 years on

a gradual basis. If HRT dosage reduction causes unacceptable vasomotor symptoms, then HRT will be continued and further reduction or cessation can be attempted

on a yearly bases with a deadline at 60 years of age.

HRT was the most appropriate option as her symptoms

were significantly affecting quality of life. On their

introduction, initial screening tests were undertaken to

prevent known complications of their use. She was given

adequate counselling about the possible risks of using

HRT. This should be directed and dependent on each

individual.

CASE REVIEW

This 52 - year - old woman was experiencing a reduction in

quality of life because of a poor sleep pattern caused by her

night sweats. She found that having hot flushes caused

distress at work and poor relationships were being developed

both at home and work because of her physical symptoms.

She had no past history and was up to date with health

screening. The clinical history suggested menopausal

symptoms but over - the - counter preparations had been

suggested previously and tried with no success.

KEY POINTS

• A progesterone is essential if the uterus is still in place as

unopposed oestrogen significantly increases the risk of

endometrial cancer

• FSH levels measurement is not necessary and a one-off

level does not confirm the menopause

• Oral HRT may not be the most appropriate preparation

• A patient considering HRT should be counselled on an

individual basis dependent on her family’s and her own

medical history

• Over-the-counter menopause preparations may not be

safe for some women and a full drug history should be

taken to avoid drug interactions

• Thyroid function tests can be influenced by changes in

oestrogen–progesterone levels

• HRT should be used at the lowest possible dose for the

shortest time on an individual basis