Menopausal Sx and HRT

Question 1

Flo (51F) presents with troublesome hot flushes and night sweats. She thinks she may be going through the menopause because her periods are now coming every six to eight weeks. Flo comes to see you with advice about the possibility of commencing hormone replacement therapy.

A 52-year-old postmenopausal woman complains of hot flushes and irritability. She wishes to commence HRT. How would you manage this situation? What are the risks and benefits of HRT?

Answer 1

Introductory
Flo is likely experiencing the menopause given the increasingly erratic menstrual periods and vasoactive sx.

Irregular PV bleeding red flags
- neoplasia
- polyps
- trauma

Goals
- targeted Hx/Ex/Ix, rule out red flag causes of irregular PV bleeding
- counselling re systemic MHT

Question 2

Menopausal sx and HRT - History

Answer 2

History
- PC: bleeding, how long irregular for, intermenstrual/post-coital, associated pain?, characterise impact on quality of life, impact on ability to work.
- sx: flushes, sweats, mood changes, vaginal dryness/atrophy, sleep disturbances
- ask about CIs for HRT: past VTE, stroke, MI, liver failure, significant breast cancer risk, has she had hysterectomy, age >60, SLE, uncontrolled HTN
- Menstrual hx: menarche, fam history, normal cycle regularity
- O&G history
- PMHx, any investigations
- medications, allergies

Question 3

Menopausal sx and HRT - Examination

Answer 3

Examination
- general appearance + vitals
- anthropometric

Question 4

Menopausal sx and HRT - Investigation

Answer 4

Investigation
Clinical diagnosis nil required

Question 5

Menopausal sx and HRT - Counselling

Answer 5

Counselling
- explain what HRT is

Types
- oestrogen only (only if had hysterectomy)
- combined
o cyclical (get breakthrough bleeding)
o continuous (no bleeding)

Risks
- breast cancer increased
- stroke increased
- VTE increased

Benefits
- reduces fractures
- reduces hip fractures
- reduces CRC
- reduces diabetes risk
- helps for vasomotor sx, not as good for vaginal dryness

Other medications for vasomotor sx
- SSRI’s
- SNRI’s
- Clonidine
- Gabapentin

Can use topical E2 creams for vaginal dryness.
- ovestin cream