Menopause Case Discussion

Scenario: 52 yo lady presenting with hot flashes

– History – 

  • CC:
    • Onset: first time? When? Sudden\gradual? Continuous\intermittent?
    • Timing? Frequency? Duration?
    • Site: upper chest and face?
    • Aggravating\relieving factors: hot weather?
    • Severity: wakes you up from sleep? Interferes w\ ADL?
  • Associated sx:
    • Constitutional: fever, fatigue, chills, loss of appetite, weight loss?
    • Vasomotor: hot flashes, night sweats, headache, trouble sleeping, nausea?
    • CVS: chest pain, SOB, palpitations?
    • Genital: itching, vaginal dryness\discharge\bleeding, painful sexual intercourse?
    • Urinary: dysuria, frequency, urgency, leakage, incontinence (w\ coughing, sneezing)?
    • MSK: bone\joint\muscle pain, recurrent fx, dry skin?
    • Psych: mood (irritable, loss of interest), memory, concentration?
  • Obstetric Hx:
    • Gravida? Para? Abortions? Living?
      • If prev: mode of delivery? Fetal\maternal complications?
  • Gynecological Hx:
    • Menstrual Hx: age of menarche? Regular\heacy periods? Intermenstrual bleeding?
    • Contraception use, IUCD?
    • Gynecological procedures, IVF\induction of ovulation?
    • Last pap smear, mammogram?
  • PMHx:
    • Diseases:
      • Chronic ds (HTN, DM\GDM, DLP)
      • Cardiac, hematological, liver ds
      • Malignancy (breast, uterine), infections
      • Gyn (STDs, PID, endometriosis, fibroids)
    • Medications: anticoagulants
    • Surgery, hospitalization, trauma
    • Allergies
  • FMHx:
    • Similar complaint?
    • Same diseases as in PMHx?
  • Social Hx:
    • Occupation, marital status, children?
    • Smoking, alcohol, recreational drugs?
    • Diet, exercise


– Counseling –

“I understand that you have been having symptoms of hot flushes and you wishes to discuss the possibility of hormone replacement therapy. I suspect that you are in a phase of life that is medically termed as the climacteric. This is a phase that women enter into, usually between the ages of 45 to 55, where they experience a range of symptoms which is due mainly to the marked reduction in a vital hormone in the female. This hormone is called Estrogen, and it is this hormone that will be looking to replace for you”

» First, recommend lifestyle changes:

  • Smoking cessation
  • Diet and exercise
  • Stay in chilly weather, wear cotton clothes


» Types of HRT?

  • Based on component:
    • Estrogen alone -> to hysterectomized women
    • Estrogen + progesterone -> to non-hysterectomized women (to reduce risk of endometrial hyperplasia)
  • Based on route:
    • Given systemically -> for hot flashes, osteoporosis
    • Given locally (vaginally) -> for vaginal dryness


» Contraindications of HRT?

  • Active liver disease
  • Thromboembolic disorders
  • Breast or endometrial ca
  • Undiagnosed vaginal bleeding
  • Cardiovascular or cerebrovascular disease
  • Relative CI: endometriosis, fibroids


  • Benefits of HRT?
    • Relief of vasomotor sx (hot flashes)
      • Notice improvement w\in 4 wks -> max therapeutic response by 3 mo
      • Should be used < 5 yrs
    • Improves UG sx + sexuality
    • Decreased risk of osteoporosis: prevents osteroporotic fx (hip and vertebral)
    • Decreased risk of colorectal ca (by 1\3)
    • Improves QOL: sleep, muscle aches, mood and depressive sx


» Risks of HRT? (which increase significantly after using HRT for > 5 yrs)

  • Endometrial hyperplasia and ca in non-hysterectomized women if estrogen was used alone
  • Breast ca: esp in nulliparous, high BMI, delayed first birth, FHx
  • VTE
  • Gallbladder disease: cholelithiasis


» Side effects of HRT?

  • Fluid retention, bloating, wt gain, breast tenderness, nausea, dyspepsia, headache, leg cramps, irregular breakthrough bleeding


» Alternatives to HRT?

  • Vasomotor: SSRIs (fluoxetine, paroxetine), SNRI (venlafaxine), Clonidine (a-agonist)
  • Osteoporosis: calcium, vit D, bisphosphonate, calcitonin, SERMs: raloxifene (selective estrogen reuptake modulator)
  • GU: estrogen creams, intra-vaginal sustained-release estradiol ring, estradiol vaginal tables


Download the PDF version: here

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