Week 6 - Oncology and Menopause - Menopause, Pelvic Mass, Post-Menopasual Bleeding, Assessment of Cervix

Question 1

Patient 1 A 53 year old secretary who last had a period 2 years ago. Over the previous 3 years she has been experiencing hot flushes, night sweats and mood swings. She finds the hot flushes at work embarrassing and frequently has broken sleep due to night sweats. She had hoped that these symptoms would have settled by now. She is married, sexually active and uses condoms for birth control. What additional history would be helpful in establishing a diagnosis and why?

Answer 1

Try to elicit whether it could be to other causes eg depression or hyperthyroidism Any depressive symptoms such as low mood, difficult Any hyperthyroid symptoms - hot all the time, palpitations, tremor, proximal muscle weakness (eg climbing stairs)

Question 2

What is proximal muscle weakness due to hyperthyorisim known as?

Answer 2

Thyrotoxic myopathy (TM) is a neuromuscular disorder that develops due to the overproduction of the thyroid hormone thyroxine. Also known as hyperthyroid myopathy, TM is one of many myopathies that lead to muscle weakness and muscle tissue breakdown.

Question 3

Only do patient 2 on this card

Answer 3

• Phsyiological - symptoms suggestive of pregnancy, ie nausea, abdominal distention and breast enlarging
• Endocrine - does she have hyperprolactinaemia - ask about milk secretion, difficulty having sex, visual fileds?
• Gynaecological - consider PCOS - ask about hirsituism, acne, weight gain, pain in ovaries
• Premature ovarian failure - If you are under 40 and having no or very few periods you should be offered blood tests to measure your levels of FSH (follicle-stimulating hormone). You should be offered 2 blood tests for FSH,

Question 4

Patient 3 A 60 year old retired cleaner who had a total abdominal hysterectomy and bilateral salpingo-oophorectomy at the age of 47 due to fibroids and heavy periods. She has been taking oestrogen only HRT as a tablet since that time. She is sexually active and now finds this uncomfortable due to soreness at the vaginal introitus. What additional history would be helpful in establishing a diagnosis and why?

Answer 4

STI - ask about any discharge or warts, ulcers Ask if she has tried to discontinue from HRT - in most women HRT is only used during menopasue (on average lasts 4 years) Atrophic vaginitis - dryness, soreness, white discharge, bleeding

Question 5

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Answer 5

Blood pressure - want patient to have a normal BP before starting on HRT as it can cause increased BP and increase risks of VTE TFTs - make sure no hyperthyroidism

Question 6

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Answer 6

LH, FSH and oestradiol Prolactin levels TFTs Abdominal palpation and pregnancy test to exclude this cause of amenorrhea

Question 7

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Answer 7

BP as 60 and on HRT - want it to be normal if she were to continue Genital examaintion - not appearance and cause of discfomort HVS - for thrush

Question 8

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Answer 8

Patient 1 - post-menopausal and symptomatic - last had vaginal bleeding over 12 months ago (2 years) and is experiencing hot flushes, mood swings and night sweats

Patient 2 - premature ovarian failure- big cause of premature menopasue (<40 years) as she is 36

Patient 3 - post menopasual and symtpomatiic -had a TAH with BSO so past menopasua - also has symptoms of atrophic vaginitis

Question 9

Question 4 There are many symptoms attributable to the menopause. List any that you know.

Answer 9

Symptoms due to menopasua * Physical - atrophy of oestrogen dependent tissues - breasts, endometrium (can cause bleeding), dryness of vagina Hot flushes and sweats, weight gain and hair thinning, joint pain (osteoporosis) * Psychological - low mood, mood swings, irritability and anxiety, poor concentration and memory * Sexual - decreased libido and vaginal dryness

Question 10

Question 5 Patient 1 asks whether she may take hormone replacement therapy (HRT) to help her menopausal symptoms. Using the Tayside Menopause Guidelines what are the benefits for her of taking HRT and what are the risks (actual quantification not required)?

Answer 10

Benefits * Symptoms control * Reduced osteoporosis * Reduced bowel cancer * Symptom relief - eg vaginal dryness, flushes and sweats, insomnia and low mood * Cardioprotective Risks * Breast cancer * Gallbladder disease * VTE

Question 11

Q.6. Do you think patient 2 has the same risks and benefits of taking HRT as patient 1? If not, why Patient 2is aged 36 and has premature ovarian failure Patient 1 is aged 53 and went through menopause recently

Answer 11

Same benefits Patient 2 however has more risks if not taking the treatment - she will have significantly more risk from not taking HRT up to the usual natural age of the menopause ie 50-52. This is because she will have been exposed to no oestrogen for longer therefore increased risk of osteoporosis and bowel cancer

Question 12

Question 7 Patient 3 also asks whether she can continue taking HRT. Assuming the natural age of the menopause to be 50 and she, therefore, has been taking HRT for 10 years after the natural age of the menopause what are her current risks of continuing HRT?

Answer 12

Risks - Stroke, VTE, ovarian cancer

Question 13

Why is ovarian cancer a risk in the women aged 60 who has been on HRT for 10 years?

Answer 13

Those using HRT for >10 years have double the risk of ovarian cancer to non users

Question 14

HRT is not a contraceptive. How long should contraception be given in menopause?

Answer 14

For women aged 50 or over - contraception should be given for one year past the last natural period For woman aged 40-49 - contraception should be given for 2 years past the last natural period

Question 15

Different treatment courses of HRT are also available, depending on whether you’re still in the early stages of the menopause or have had menopausal symptoms for some time. The two types are cyclical (or sequential) HRT and continuous HRT. When are the different types given?

Answer 15

Cyclical or sequential HRT is given to perimenopasual women - ie they are going through menopause but still have periods (or are within 12 months of last period)

Continuous combined HRT is usually recommended for women who are post-menopausal. A woman is usually said to be post-menopausal if she has not had a period for a year.

Question 16

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Answer 16

Patient 1 - Continuous combined HRT tablets or patches, oestrogen only tablet with IUS Mirena coil, dietary advice, contraceptive advice (dont need contraception after 1 year if menopause after 50, need for 2 years if menopause 40-49) Patient 2- Sequential combined HRT tablets or patches, oestrogen only tablets with Mirena coil, dietary advice, contraceptive advice Patient 3 - Dietary advice, advice and leaflets about supplements, complementary therapies and herbal treatments, local vaginal oestrogen cream or tablets

Question 17

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Answer 17

Patient 1 - uterine fibroids Patient is having heavy bleeding, nullparous (could be due to subfertility thanks to fibroids), firm mass but mobile Patient 2 - benign ovarian cyst - feeling bloated but not affecting periods or pregnancies, also smooth Patient 3 - malignant ovarian tumour - age, nullparous, abdominal swelling + shifting dullness (ascites), firm, fixed mass P=0+1 - no pregnancies lasting longer than 24 weeks but one lasting shorter

Question 18

State which ultrasound, pathology and histology pictures should fit the different patients Patinet 1 - uteirne fibroids Patient 2 - benign ovarian cysts Patient 3 - maligannt ovarian tumour

Answer 18

Patient 1 - * Ultrasound B * Pathology A * Histology A Patient 2 * Ultrasound A * Pathology B * Histology C Patinet 3 * Ultrasound C * Pathology C * Histology B

Question 19

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Answer 19

Patient 1 - endometrial polyp - apart from bleeding fairly normal

Patient 2 - endometrial carcinoma - overweight, persistent bleeding, age, diabetes

Patient 3 - atrophic vaginitis - vaginal dryness and spotting

Question 20

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Answer 20

• Patient 1
  
  • * Hysteroscopy B
  • * Pathology B
  • * Histology C
• Patient 2
  
  • Hysteroscopy A
  • Pathology A
  • Histology B (overcrowded glandular cells, atypical hyperplasia)
• Patient 3
  
  • * Hysteroscopy C
  • *Pathology C
  • * Histology A

Question 21

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Answer 21

Patient 1 - high risk - has vulval warts and a vaginal discharge (points to HPV) and appropriate age group

Patient 2 - low risk - normal smears and asymptomatic

Patient 3 - high risk - post-coital bleeding (cervical carcinoma is said to be friable, breaks on contact), and offensive discharge

Question 22

What are risk factors for cervical carcinoma?

Answer 22

High parity High number of sexual partners (greater than 4) Prolonged pill use Smoking Early first coitus HPV

Question 23

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Answer 23

In patient 1 - CIN 3 - the dyskaryosis affects full thickness epithelium but doesntinvade stroma

In patient 2 - normal cytology and can see all layers of epithelium on histology

In patient 3 - acetowhite cervix, severe dyskaryoiss with keratin formation - keratinizing squamous carcinoma