Abstract
Menopause technically refers to the very last menstrual bleed. It would be easy to assume that the cessation of periods means that issues specific to women are over. There are clinicians who take this view. For some women, however, problems are only just beginning. The loss of ovarian function has an impact on a range of body systems, and this can have a very great effect over many years. A broader view is required.
Susie is 49. Her husband works for an international company, and she has spent most of the last 15 years abroad. She had taken longer to conceive her third child who is now 11 and had infrequent periods for a couple of years after she stopped breast feeding. She has now not had a period for eight years. She was not particularly troubled by hot flushes at the time and was advised in the Netherlands that nothing needed to be done. She has not been offered any hormone treatment.
During these years, Susie has developed a very troublesome arthropathy that remains undiagnosed. The joints of her hands are swollen, distorted and painful though not red and she has back pain. This has been treated by a variety of anti-inflammatory agents – including methotrexate without evident benefit. She is currently taking naproxen to ease the pain and stiffness with gastroprotection.
I was asked to see her by her GP. The presenting problem was a lack of libido, but the GP was not sure anything could be done at this point in time. As the tale unfolded, it was clear to me that this was just one part of a much more complicated picture. Susie still does not have bothersome flushes. She occasionally wakes with sweating, but this would not be intrusive enough to treat. Generally, however, she feels dreadful: she constantly aches, her mood is low though she is able to function, she feels angry and irritable, she is forgetful and has lost any sense of being feminine. She blames this mostly on her situation: a move back to the UK, the stress of dealing with frail elderly relatives and the fact that her marriage is on the rocks. She is drinking three bottles of wine (or more) a week for consolation.
It transpired that she has not had intercourse since the birth of her last child and cannot contemplate intimacy. Her last smear test was intolerably uncomfortable. There is great tension within the marriage.
Susie has some urinary urgency and frequency but copes with this and has no breast symptoms. She is active and exercises regularly, eats a healthy diet with adequate calcium and does not smoke. Her body mass index and blood pressure are both within the normal range, but she has recently had palpitations identified as ectopic beats but not treated. The significant family history is that her mother had multiple fractures including hip fracture.
So, although a lack of libido was the reason for initiating the assessment, I can see potential mood effects, cognitive effects, joint pain, vaginal dryness and bladder irritability as symptoms that might be attributable to the estrogen deficient state. There is clearly a raft of situation and relationship issues that potentially are highly relevant to the lack of libido. These do need to be addressed but may not be amenable to modification.
What had not been picked up by the rheumatologists was a risk of osteoporosis. With a parental history of hip fracture, high alcohol consumption and inflammatory arthropathy FRAX suggests that she has a 10-year fracture risk of 11%. The National Osteoporosis Guidelines Group (NOGG) guidance is that treatment should be initiated – even without a bone mineral density assessment. We agreed, however, that this was indicated to provide a baseline and guide treatment decisions and duration.
Estrogen would undoubtedly be the management option of choice for Susie’s fracture risk and in the process could potentially have additional value for her symptoms. It might even improve the sense of femininity. If intimacy were to be considered, it is important to restore vaginal comfort and lubrication. Additional vaginal treatment will not add risk.
As the uterus is intact opposition is needed. There is no evidence of previous progestogen intolerance and combined oral contraception had been taken without problems in the past. We have discussed the options and agreed that continuous combined patches would be used. Non-oral delivery will mitigate any potential concerns regarding thrombotic risk given the palpitations.
We agreed that Susie will start at half the standard dose (to deliver 25 mcg/day) as she has been deficient for some time, and this will reduce any tendency to symptoms that may arise from abrupt change such as headache or breast tenderness. This level of replacement has evidence of effect on bone density (14 mcg is licensed for this use in older women in the US). The intention is, however, to increase after 6–8 weeks to a full patch to be used twice a week. This should have full therapeutic effect on bone density. In addition, she will use 0.1% estriol cream daily to the vagina for two weeks and then twice a week.
I am hoping that our discussion will empower Susie to begin a conversation with her husband about their relationship and stresses. She is aware that the hormone replacement will take time to have an effect, and she needs to be realistic about how much can be achieved and when she may notice a difference. If she feels better in herself coping will become easier and perhaps this will reduce some of the tensions. If the very least I have achieved is to prevent future fractures, I will be pleased. I hope, however, that the broader view has addressed very many more issues and will allow her to get her life back on track after what is essentially a lost decade.