Abstract
Mrs Jones is a 51-year-old woman who had been booked into an extra appointment at the end of a very busy day in general practice. She had been trying, without success, to arrange an appointment at the practice for four weeks. She was relieved finally to be able to see a doctor. Before calling her in, I noted that she had not seen me for over two years, although I had seen her sporadically over the past decade, mainly for contraception advice. The last time I had seen her was following the death of her father from a myocardial infarction.
Her main concern was that she thought she had early dementia. She was forgetting things and her short-term memory had significantly deteriorated over the past few months. She worked as a legal secretary and was finding it increasingly hard to work, despite making copious lists and constantly rechecking her work for errors. She was finding it difficult to concentrate and described a brain ‘fog’ that was worsening. She recognised that she was under quite a lot of stress because her mother (who has dementia) had recently moved into a nursing home. Her only child had also recently started at university and she was finding it hard to adjust to not having her at home any more.
On reviewing her family history, I learnt that her maternal aunt was diagnosed with dementia when she was 82 years old. Her father, brother and uncle all have cardiovascular disease. Her mother also has osteoporosis and was diagnosed with breast cancer when she was 74 years old.
Mrs Jones came with a notebook to write everything down as she explained she was likely to forget everything otherwise. I saw that she had been to the surgery on 14 different occasions over the past two years which I remarked was a large number for someone who was previously an infrequent attender at the surgery. We talked through the various problems she had had.
Palpitations
Mrs Jones saw a GP with a history of palpitations. These came on at various times during the day, usually when she was sitting still. They never occurred with exercise. She had no associated chest pain or shortness of breath and they usually only lasted a few minutes at a time. She sometimes felt very warm and her skin on her face flushed when she experienced these. She was concerned as her brother and father both died from cardiovascular disease when they were in their 40 s.
She was referred to a cardiologist and had an ECG, 24-h ECG, chest X-ray and echocardiogram which were all normal. Her blood tests including full blood count, renal function, liver function tests, cholesterol and thyroid function tests were all normal. No explanation had been provided.
Recurrent cystitis and increased frequency of micturition
Mrs Jones had seen a different doctor with urinary symptoms. She explained that these symptoms often lasted a few days but went on their own. She had submitted five different urine samples for urinalysis to the surgery. These had all been sent for culture to the local laboratory and only one had shown an Escherichia Coli infection which was treated with appropriate antibiotics. She had explained that she was needing to pass urine more frequently during the day and night and was less able to hold onto her urine, for example when coughing or sneezing.
She had been referred to an urologist and had a renal tract ultrasound, cystoscopy and CT renal tract undertaken which was normal. She was given advice about appropriate fluid intake and pelvic floor exercises and then discharged from clinic.
Low mood and possible depression
There were several consultations documented in her notes where she had presented with low mood and not feeling ‘herself’. She had described that she felt like an ‘old lady’ and was not enjoying life as much as she used to. She was more anxious than she used to be and sometimes was even worried about driving in her car. There were no obvious triggers for this and she had no financial or domestic stresses. Although missing her daughter, her problem was one of adjustment and she was not unduly distressed. She had no suicidal thoughts and kept saying to the doctors that she was not depressed but could not ‘shake off’ her low mood.
She was offered antidepressants numerous times and eight months before my consultation, she had finally agreed to take citalopram, 20 mg od. She explained that these had lifted her mood a little initially but made her feel less associated with reality and were giving her some night sweats. The decision was made for her to continue taking them as there was nothing else that she could take to help with these depressive symptoms.
Worsening severity and frequency of migraines
Mrs Jones had a history of intermittent migraines which were usually stress related. She usually had around 4–5 migraines a year, some with aura. She had been prescribed zolmitriptan to take early when a migraine was starting and this helped if she managed to take it in time. However, her migraines were lasting longer, sometimes for two days, and this meant that she was having days off work as she was finding the pain unbearable. She had been prescribed naproxen, codeine and tramadol as analgesia and then was referred for a neurology opinion.
She was subsequently seen at the migraine clinic and a magnetic resonance imaging (MRI) scan of her brain was undertaken which was normal. She was given propranolol to take as prophylaxis, but she found these made her too tired so she was then given topiramate. She experienced side effects with this medication including dizziness and weight loss so this was stopped after three months and her migraines returned.
Consultation with me
I thought menopause might provide a unifying diagnosis and as Mrs Jones was of typical age decided to ask her some more direct questions in order to see if this could apply. She told me that her periods had been rather scanty and irregular over the past six months. In addition, she had been experiencing night sweats even when she was not taking the citalopram and was having 8–10 hot flushes a day. She did not think this was relevant to tell any doctor because she knew that the menopause is a normal life event and not an illness. She admitted to not knowing much about the menopause.
When asked, she told me that her libido had reduced over the past year and she had only had sexual intercourse twice in that time. This is partly because it was very uncomfortable and painful but also because she had less desire, although she still loved her husband. She had never spoken to anyone about this before because she was too embarrassed.
She had put on around a stone in weight over the past few months and admitted to ‘comfort eating’ because she was feeling so low. She had stopped going to the gym or doing any exercise as she was constantly tired. She admitted to drinking more wine than she used to in the evenings to try and have a better night’s sleep and to lift her mood.
Obvious diagnosis when appropriate questions are asked
I thought the majority (if not all) of her symptoms were related to her changing hormone levels due to the perimenopause. I explained this and we had a long discussion about diet, exercise and lifestyle factors. I explained the benefits and risks of hormone replacement therapy (HRT), basing the information I gave her on the NICE guidance.
She wanted to do something to help herself and agreed to try HRT for three months. I gave her a prescription for transdermal 17β oestradiol patches and micronised progesterone to take cyclically at night. I also gave her patient information booklets on menopause and HRT.
She returned to see me three months later and she was a different person. She explained to me that within a few days of starting HRT, her flushing and palpitations had disappeared and her sleep improved. She found that she had far more energy and her mood was considerably better. In addition, the urinary symptoms no longer bothered her and she had only experienced one migraine since her previous consultation. This had occurred when she had been very tired.
Commentary
For the majority of women under 60 years, the benefits of taking HRT outweigh the risks. 1 Many women and healthcare professionals do not realise the variety of symptoms that can occur in the perimenopause and menopause. Around 25% of women have severe symptoms which can have a very negative effect on the quality of their lives.
It is important that the menopause is considered in primary care consultations. As outlined in the BMS Vision for Menopause Care in the UK, 2 all healthcare professionals should have basic understanding of menopause and should be able to ask the right questions as women may often not volunteer the information needed to make the correct diagnosis. Low estrogen levels can be associated with a greater future risk of heart disease and osteoporosis, and it is important that women know that there are beneficial health effects of taking estrogen in addition to HRT improving their symptoms.3,4
Sadly, there are still many doctors and healthcare professionals who are negative about the benefits of HRT and some are simply refusing to prescribe it. Some of this negativity stems from the poor reporting of the Women’s Health Initiative (WHI) study in 2002, which led to a global reduction in confidence about the use of HRT. Although this publication was 15 years ago, time has not really been a healer to the huge upset and anxiety regarding HRT and its perceived risks. One of the principal investigators from the WHI study, Robert Langer, has reiterated that it had been wrong to generalise the results from this study to all postmenopausal women, especially to those who take HRT for the relief of their symptoms.
There are now a variety of national and international guidelines which provide more evidence and support for the way we can help, educate and counsel women regarding their menopause and should give us more confidence in HRT prescribing.1,5,6