Abstract
‘I would be grateful to you for arranging to see Judith who would value your thoughts on how she might manage her perimenopause. I note that Judith is a scientist by trade… . Her case is quite complex…. She will doubtless describe it to you at great length’.
In the menopause clinic, the scenario above is not a problem provided that appointments are of an appropriate length. In the primary care setting, 10-minute appointments are undoubtedly the biggest challenge to manage menopause as unravelling the symptoms, assessing risk and negotiating a management plan can each easily take that amount of time. An appropriate outcome can be achieved with the use of information sources to read and assimilate before returning to continue the discussion in a double appointment. The skills needed are very much those of the general practitioner (GP), used to multisystem assessment. With some extended knowledge and more time even the more complex women can be helped.
Judith's referral was entirely appropriate as her GP had unravelled the complexity of her presentation, understood much of the risk assessment but was unable to discuss the options in sufficient detail to answer Judith's questions.
Judith was 48 and her problems fell into two broad groups: estrogen deficiency symptoms and heavy, painful and increasingly irregular bleeding. These had started to be a problem two and a half years before and it was six months before she had realized that they were linked. They were not quite classical however, as vasomotor symptoms did not predominate. Judith had no daytime flushes but was awake most nights with wakening followed by some degree of sweating. Troublesome soaking occurred only about once every two weeks. The sleep disturbance seemed independent of the sweating and had not been helped by a range of sleep hygiene techniques.
Judith was disturbed by her perception that her logic, memory and spelling had all deteriorated and she had some word finding difficulty. These were becoming a problem at work. Her most troublesome symptom however was mood change. She described being more anxious and irritable and had had a behavioural report at work that described her as ‘unwilling to compromise’. She told me that this was quite out of character and that whereas she had previously been logical and organized she was now tearful, disorganized and had started to lose self-confidence.
Questioning revealed irritative bladder symptoms in the premenstrual phase and one episode of coital incontinence which Judith had found to be acutely embarrassing. She was not aware of vaginal dryness and had only minor premenstrual breast tenderness.
Bleeding was however the second major problem. Judith's periods had been less than four weeks apart but had become more erratic and increasingly heavy with frequent clots, cramping and light-headedness. Following another distressing episode with blood running down her legs following a presentation, she had started taking time off work.
In the time honoured phrase, ‘something needed to be done’.
In the 1990s, Judith's chosen contraceptive method had been the multiple rod levonorgestrel subdermal implant (Norplant). This had stopped her periods but these returned as heavy and painful when the rods were removed. She was then told that she probably had adenomyosis and was treated with oral contraceptive pills, which she tolerated but did not greatly help the pain of withdrawal bleeding. Danazol had been helpful but she then needed contraception again and chose an etonorgestrel implant. This induced amenorrhoea and she was very happy with the method so had it replaced and continued for six years. The second implant was removed at the end of its licensed life, and having no sexual partner at the time, it was not replaced. In the subsequent three years her periods had progressively deteriorated to the current situation. Of interest Judith's mother had undergone hysterectomy at 45 for heavy painful periods.
Clearly we needed to come up with a plan that would address both issues so needed some more background information.
Judith was potentially still fertile and did have a contraceptive need. She had never been pregnant and given her irritable uterus (presumed adenomyosis), I had some caution about attempting to fit a levonorgestrel intrauterine system (IUS) as a firstline option. This would certainly have been a solution to the heaviness of bleeding but would not have taken control of her cycle and would have needed estrogen to be added.
There were no breast issues to raise apparent risk. The risks of extended exposure to estrogen were explained in great detail and fully understood, but did not apply as mean menopausal age had not been reached.
I was interested to hear that Judith had had colitis over 20 years before, which had been treated with steroids. This potentially raised the issues of absorption and steroid effects on bone density. While we had no objective measurement, estrogen would offer benefit for bone health as well as symptom relief.
Judith had a body mass index of 27 but no other vascular risk, did not smoke and ate a Mediterranean diet. Despite her age the UK medical eligibility criteria for contraceptive use would have placed her as category 2 for combined hormonal contraception with benefits outweighing risk.
Pills patches or the vaginal ring were on the table for discussion as they would be anovulatory, reduce bleeding and replace estrogen. An extended cycle regimen was an option with just four days break when breakthrough bleeding occurred.
While a hormone replacement therapy (HRT) regimen with a higher dose progestogen component could potentially have addressed both estrogen deficiency symptoms and bleeding control, it could not be guaranteed to be contraceptive and the endogenous cycle might break through.
We also discussed the use of another etonorgestrel implant which would be anovulatory but would need additional and probably cyclical HRT to relieve symptoms and regulate bleeding.
With all options offered that chosen by Judith was the oestradiol valerate/dienogest combined oral contraceptive. This is now licensed for heavy menstrual bleeding and having only two hormone free days was felt to offer the simplest solution to good cycle control, relief of symptoms and contraception.
I have just seen Judith after the first three months and she was delighted. Her sleep had initially improved rapidly, though had regressed a little and she was managing about five hours a night. She was sweating if she woke at night but this was mild and she was able to sleep again. She was slightly irritable before a bleed but was not sure if this was due to autosuggestion. Most importantly she was almost back to her old self and could concentrate, spell, have a difficult conversation and her renewed confidence had allowed her to take on a new and very satisfying position at work. She described spotting through the first pack, with two moderate and one missed bleed – nothing that was a problem and typical of the product.
The impression that we had is that for her, estrogen replacement was slightly suboptimal. This is plausible as the dose in this product varies through the cycle and the days of reported symptoms map to those with higher progestogen and lower estrogen dose. We have now embarked on fine tuning, adding a small dose of additional oestradiol just as we would with a conventional cyclical product and await the response.
We need to keep an open mind and be aware of all the options. For Judith, the choice of a levonorgestrel IUS and estrogen – which is what her GP thought I would suggest, was not the only strategy to offer.