Abstract
A 74-year-old lady attended my general practice surgery complaining that her urine was ‘pink’ and she had noted some vaginal bleeding. She was otherwise well and had no urinary or systemic symptoms to report other than ‘quite a lot of bruising on my bottom’.
I know the lady well, she attends my Primary Care Menopause clinic for regular review as she is someone who has benefited from long-term use of estrogen replacement therapy (ERT). Having had a hysterectomy and bilateral oophorectomy in the past for fibroids she has remained on ERT ever since. Several attempts had been made over the years to withdraw hormone therapy (HT) but proved unsuccessful. There were frequent documented discussions assessing her risk profile, each time she opted to remain on ERT accepting any associated increased risks. At 74 she is extremely fit and active and a passionate equestrian. She is slim, a lifelong non-smoker with no history of hypertension or cardiovascular disease. The only history of note is osteopaenia detected on previous Dual X-ray absorpitometry scan. She continues to participate in regular breast screening and is on the lowest dose of transdermal estrogen required to control her symptoms.
On closer questioning I discovered that she had just completed an adventurous horse trek over rough terrain and had been in the saddle for three days. Clinical examination revealed extensive bruising in the saddle region and inner thighs. There was spontaneous bleeding from the vaginal vault and vaginal mucosa; the vaginal walls were literally oozing blood. The vaginal vault was otherwise normal with no lacerations visible. Other than her ‘pink’ urine (frank haematuria), vaginal bleeding and impressive bruising she had no complaints and felt perfectly well.
I reviewed her notes looking for clues and discovered that since her last review at the menopause clinic she had undergone investigation of a ‘dizzy spell’ and had been referred to the Stroke Clinic to exclude a transient ischaemic attack. The history was unconvincing and all investigations were negative (electrocardiography, computed tomography scan, cardiac echo, carotid Doppler scans, chest X-ray, biochemistry and haematology were all normal). It was concluded she had probably experienced a vasovagal episode. Nevertheless, she was advised to stop her ERT and commence antiplatelet therapy (Clopidogrel) and a statin for preventive purposes (as per SIGN 108.)
She explained that since stopping her ERT she had been feeling awful and started self-medicating with Gingko biloba having heard it was a ‘natural’ remedy for menopausal symptoms. Alarm bells immediately rang - I had been lucky enough to attend the 2011 British Menopause Society conference, which included a lecture on ‘alternative therapies for the menopause’. The speaker described the commonly used alternative therapies and highlighted possible interactions and cautions. From the lecture I remembered hearing that Gingko biloba is known to interact with and potentiate the antiplatelet activity of Clopidogrel. I therefore advised her to discontinue the Gingko biloba immediately. A urine sample was sent to the laboratory for culture and sensitivity testing along with routine haematological and biochemical screening tests.
At review a week later, the bleeding had stopped and most of the bruising had disappeared, her urine looked normal and urinalysis was negative. The previous urine test report confirmed the presence of red blood cells but no pus cells and culture was negative; all her blood test results were normal including renal function and cholesterol which was 4.8.
This appeared to be a clear case of an ‘over the counter’ remedy interacting with prescribed medication and the problem resolved as soon as the interaction was suspected and the culprit stopped.
Reflecting on this case I felt it highlighted several important issues that concern clinicians working in all fields of medicine not just menopause management: all prescribers need to be aware of the increasing use of ‘alternative’ and over-the-counter remedies and when taking a drug history should remember to enquire about all prescribed and non-prescribed ‘medications’. Both patients and doctors need to be educated about the danger of potential interactions of ‘non-prescribed’ products, which are often purchased from the Internet or supermarket removing the ‘safety net’ of a pharmacist. In the field of menopause management there are a multitude of alternative remedies in use as women seek to manage their menopause more ‘naturally’ so an awareness of the most commonly used products and their potential for interaction with prescribed medications is vital.
Most general practice computerized prescribing systems provide extensive warnings about every potential interaction of co-prescribed medications. Would a ‘pop up’ box reminding us to enquire about non-prescribed medications and warning of interactions be helpful, or prove to be one box too many?
Running a primary care menopause clinic, I am frequently involved in lengthy discussions assessing risk profiles with women on hormone replacement therapy (HRT) particularly those who opt to remain on treatment beyond the age of 60.
This lady had enjoyed many trouble-free years on low-dose transdermal ERT and was being appropriately monitored. Several attempts had been made to discontinue therapy but were unsuccessful as she felt ‘rotten’ when it was withdrawn. With her history of osteopaenia she was also benefiting from long-term bone protection as well as enjoying improvement in general wellbeing.
On reflection this lady was taken off a treatment from which she derived obvious benefit and hidden protection and was advised to take a treatment which also had associated risks (that do not appear to have been discussed and documented). Despite all investigations at the stroke clinic being negative, she was advised to commence medication for ‘preventive purposes’ and discontinue ERT - this not only increased her risk of future osteoporotic fracture and intracranial bleeding should she fall from a horse but left her feeling so miserable she went looking for alternative remedies to replace her ERT resulting in a dangerous interaction with the prescribed preventive medication!
In the post Women's Health Initiative/Million Women study (WHI/MWS) climate and continuing controversy surrounding HRT, I am acutely aware of the need to justify my reasons for prescribing HT particularly in older women, and suspect many other HT prescribers feel the same. I wonder if clinicians in other fields of medicine are as cautious and ensure all patients are fully counselled about the risk versus benefits of medications they prescribe to the same degree that HT prescribers do.
Nowadays there are numerous protocols and guidelines advising ‘cocktails’ of primary or secondary preventive therapy for patients diagnosed with, or considered ‘high risk’ of developing certain conditions - the clinicians at the stroke clinic were simply adhering to SIGN guideline 108. But is this always ‘best practice'? Has strict adherence to guidelines and protocols removed the option of applying a ‘bit of common sense'?
We must not become blinded by protocol and guidelines and lose touch with the importance of taking a ‘holistic’ view to prescribing and tailoring treatments to the individual. Perhaps it would be helpful to develop some form of ‘scoring system’ along the lines of World Health Organization-medical eligibility criteria (WHOmec) used in contraceptive prescribing to assist in a more quantitative assessment of the risk/benefit of prescribing HT with consideration of lifestyle factors, hobbies, extreme sporting activities or anything that might affect the risk benefit balance factored in?
So what happened in the end?
After much discussion and a few weeks of local vaginal estrogen she returned to report that life without ERT was not worth living. At 74 she wanted quality rather than quantity of life and quality improved on HT. I documented our discussion carefully as always and once again prescribed low-dose transdermal ERT. Before she left I reminded her to always wear protection - a riding hat of course!