Abstract
Tracey has featured in all of my menopause teaching in the last year.
I am prepared to confess that Tracey is not a single patient. Tracey is composite and represents women seen every day in primary care. She has family problems, an unsympathetic husband and is stressed at work. Although she does go to the surgery when called in for screening and chronic disease management (which gets their boxes ticked), she is generally undemanding. She would not have considered making an appointment to discuss menopause. She would have assumed that it is her lot in life and her mother will have told her that she just had to get on with it. Her mother had no help even though she found it difficult, and Tracey has seen newspapers saying hormone replacement therapy (HRT) is bad for you.
Tracy is not a woman who would be seen in a specialist menopause clinic. She would not seek help, could not afford to pay and even if a NHS service did exist in her area, the referral would not be made. Tracey would continue in primary care and that is why it is so important that her menopause-related issues are first recognised, secondly assessed and finally options offered that are explained so that she can make an informed choice about what she wants to do.
Tracey has three children. The eldest is now 26 and away working in London. The middle boy had problems with drugs and is a constant worry. Her younger daughter has two children of her own who Tracey helps to look after. Her daughter is a single mother and has to work. Tracey opted for early shifts in a factory so that she can pick the grandchildren up after school. Work is repetitive and boring, and her supervisor (she feels) is out to get her. When she gets home, she turns to the biscuit tin for comfort, finds herself helping the grandchildren to finish their tea and then cooks and eats with her husband. She does not smoke but likes a drink as it is about the only positive thing in her life. She has a glass of wine while cooking, one with her meal and a third while watching the TV. She is on her feet most of the day but does not move much and sits and knits in front of the TV in the evening. She never has exercised and would not have thought of starting now.
Tracey comes to see the practice nurse for a check-up – her body mass index reached 41, and three months ago, she was formally diagnosed as having Type II diabetes. She has been prescribed metformin 500 mg twice a day but does not like taking it as it upsets her bowel.
Primary care is under pressure, but whether this scenario, a routine smear, or a presentation with coping difficulties I would challenge colleagues to think about menopause. It could be contributing to the situation. Do not immediately turn to blood tests and get her out of the door but rather ask a few questions.
Tracey is 51 which is about the median age for spontaneous menopause in the UK. The first issue faced is identifying where she has got to in menopause transition. She has a 52 mg levonorgestrel intrauterine system (LNG IUS) in place. This one was inserted three and a half years ago and she had two before that. Tracey has not had a period for 10 years and does not miss bleeding. She had the first device fitted when her general practitioner decided that she had become too fat to prescribe her the pill. Without it, her periods were heavy and took some time to settle even after the first LNG IUS was placed.
Tracey should be asked about the range of typical menopause-related symptoms and how they affect her. The clinician should not simply assume that night time sweating is due to poor diabetic control. Not sleeping at night could be attributed to stresses and might be eased by the alcohol, but waking for no apparent reason, particularly if bathed in sweat or followed by sweating, could very plausibly be related to estrogen deficiency. Tracey may blame her low mood on her situation and her fuzzy brain on the wine and tedium of life, but they may not be the only contributing factors. She should be asked about bladder function and vaginal dryness. Irritative bladder symptoms may be difficult to disentangle from diabetes-related polyuria, but vaginal dryness is related to estrogen deficiency. Low interest in sex could be blamed on the lack of attractiveness of her husband who has also gained a lot of weight or tiredness or lack of opportunity and these will certainly contribute, but there may be a hormonal component.
This shows how easy it is to blame symptoms on something else and decide that Tracey is unsuitable for HRT as her cardiovascular risks are high. However, the cardiovascular risks do not preclude. Tracy’s blood pressure is acceptable at 130/82. Diabetes is not a contraindication and is not made worse by HRT (indeed there may be an improvement in insulin sensitivity). She does not smoke, but her weight will significantly increase her venous thromboembolic risk. This would lead to the suggestion that if she did choose HRT, a non-oral delivery route would be preferred, but it does not mean that she cannot have HRT. Tracey can be informed that standard doses do not raise her blood clotting risks any higher than they already are, and it may help to explain how much of a difference her weight does make to this.
Tracey says that she is worried about breast cancer as her aunt had this. Her aunt however was diagnosed at 68 and no-one else in the family has been affected: she can therefore be reassured that it is very unlikely that she has a higher risk than average. She was not a close (first degree) relative and was 68. For genetic risk to rise significantly, a single affected relative needs to be a sister or mother and less than 40 at diagnosis. That Tracey is 51 makes her genetic risk additionally unlikely as cancers linked to susceptibility genes tend to present early. Tracey has not yet had a first NHS Breast screening program mammogram so she should be encouraged to attend when called. Tracey needs to know that being obese raises her risk of being diagnosed with breast cancer and so does her alcohol consumption. She can also be told that the size of this risk is significant and HRT does not appear to make this situation any worse. Why is this different to blood clots where everything multiplies? The simplest answer is to say that for blood clots, the different factors work in different ways, and for breast cancer, these factors are working in the same way and there is only so much growth effect that can happen. The hormones are very unlikely to initiate breast cancer – they are more likely to promote the cancer which is already present in a small number of women.
The HRT options currently available to Tracey are very simple – patches or gel. Tracey can be offered the choice. She has adequate endometrial protection from the LNG IUS, and although the license for endometrial protection in the UK is for four years, expert opinion and clinical guidance support its use for five. It will then need to be replaced if that is how she chooses to protect her uterus. Tracey can be told that being overweight and being diabetic increase her risk of endometrial cancer even without HRT and the LNG IUS is already protecting against this.
Tracey can reasonably be offered HRT. This is very likely to make her feel better and should help her to sleep, help her flushing, ease her bladder and make sex comfortable again. She should not be offered antidepressants as there is no clear evidence that she is depressed and these could make some of her symptoms worse. She should be told about herbal options and can then make her choice. HRT would offer bone protection and reduce coronary artery disease as a bonus. It would not make her diabetes worse or make her put on weight. She has little to lose and much to gain. However, it is important that she understands what risks that being obese, inactive and drinking are for her.
Three months after deciding to try some patches and being prescribed a 50 µg/day twice weekly brand, she is very much happier and has not bled. She has thought about all the things that her weight was affecting and not bought any more biscuits and taken to walking to collect the grandchildren and bring them home. She only has one glass of wine in the evening and finds that neither her work place supervisor nor her husband are as irritating as they were. In fact, she has persuaded her husband that they will go on a diet together and for a walk at the weekend.
By making one small difference to this woman, she has started to accept the need to look after herself and is taking responsibility for her own health. With encouragement and support, she may get to the point that the metformin is not necessary, can wear smaller clothes sizes, feel better, look better and go out. Her risk profile and her costs to the health service reduce. As she is pivotal to the health of her family, potentially these effects will magnify.
Risks are relative and not doing something for this apparently high-risk woman may be worse than addressing menopause if it is impacting on her. All too often primary care denies such help and our task when educating both colleagues and patients is to dispel the myths and assess women holistically. Ten-minute appointments are a challenge, but it can be done and all members of the team contribute to this.