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Case 679: I've got the flushes
Authors and Affiliations
Dr Wei How Lim,
Lyell McEwin Hospital, Adelaide
Dr Alphonse Roex,
School of Paediatrics and Reproductive Health,
University of Adelaide This case illustrates a common presenting symptom of menopause and the
medical practitioner's initial approach to the diagnosis and management of the problem, including a
brief overview on hormone replacement therapy.
Case Overview
Learning Objectives
The learning objective for this case include:
Understand
the basis of menopause
Understand
the common symptoms of menopause
Understand
the appropriate investigations of menopause
Understand
hormone replacement therapy †“ its benefits and risks
Question 1 : MS
Question Information:
Mrs McDonald is a 49-year-old woman who presents to her general practice with a three month history
of intermittent sensation of warmth over her upper chest, accompanied by some sweating. She is
otherwise in good health, with no significant medical or surgical history. She smokes five cigarettes a
day and enjoys a glass of whisky every now and then. Friends said that she might be experiencing
'men-o-pause', but she just laughed it off as she has not stopped seeing men yet.
The doctor suspects that her friends could be right and she may indeed be perimenopausal. It will be
important to obtain other pieces of information from the history to substantiate this diagnosis.
Question:
Which of the following will help make this diagnosis?
Choice 1: Genitourinary history Score : 1
Choice Feedback:
Correct. Vaginal dryness and dyspareunia are common complaints of women experiencing menopause,
mainly due to oestrogen deficiency. There can also be an increase in the presence and severity of
symptoms of incontinence. The presence of these symptoms may support the diagnosis. They do not
usually appear for at least three months after the onset of other menopausal symptoms.
Choice 2: Menstrual history Score : 1
Choice Feedback:
Correct. Menopause is defined clinically as 12 months of amenorrhoea in a woman over age 45 in the
absence of other biological or physiological causes[1]. The cessation of her menstrual periods would
make this diagnosis likely.
Choice 3: Developmental history Score : -1
Choice Feedback:
Incorrect. The developmental history is irrelevant as this patient†™s age fits into the normal period of
menopausal onset.
Choice 4: Family history Score : 0
Choice Feedback:
Incorrect. The patient†™s age fits into the normal period of menopause onset, so any family history is
irrelevant in aiding the diagnosis of menopause. However a family history exploring risk factors such as
breast cancer, osteoporosis or cardiovascular disease may be relevant.
Choice 5: Reproductive history Score : -1
Choice Feedback:
Not correct. There is a tendency for women who never had children to have earlier menopause, but this
piece of information is not diagnostic.
Question 2 : MS
Question Information:
Mrs McDonald's periods ceased 12 months ago and before that they had been quite regular. She has
also been having trouble sleeping recently. She puts this down to symptoms from a recent urinary tract
infection, as well as feeling the blues with her oldest daughter about to leave home. She has also
noticed some discomfort around her breasts and the wrinkles around her lower face to be more
prominent.
On examination she looks well and has a BMI of 28. Her blood pressure is 130/84 mmHg and pulse
rate 80/min. No abnormalities are found on examination of her face, chest, breasts and abdomen.
Mrs McDonald wonders if there are any tests she might require.
Question:
Which of the following would be appropriate?
Choice 1: Thyroid stimulating hormone Score : 0
Choice Feedback:
Incorrect. In some circumstances hyperthyroidism might be an important differential diagnosis to
exclude as the symptoms can mimic those of menopause. However, in Mrs McDonald's case she does
not have any weight loss, tremor, eye signs, resting tachycardia or any other symptoms or signs that
might suggest hyperthyroidism.
Choice 2: Electrocardiogram Score : -1
Choice Feedback:
Incorrect. There is little to suggest from Mrs McDonald's story or physical findings that her symptoms
are cardiac in origin.
Choice 3: Follicle stimulating hormone (FSH) Score : 0
Choice Feedback:
Incorrect. The diagnosis of menopause is usually made clinically. Measurement of FSH would only be
indicated if there was some diagnostic doubt on clinical grounds. Increased FSH levels point at low
ovarian oestradiol production and the levels of this hormone are often increased in early menopause.
Measurement of FSH may assist in the diagnosis of menopause especially in patients younger than 45
or where menopausal symptoms are not immediately apparent.
Choice 4: Luteinising Hormone Score : -1
Choice Feedback:
Incorrect. LH detection is used in infertility treatment to predict the time of ovulation.
Choice 5: Mammogram Score : -1
Choice Feedback:
Incorrect. Universal mammography screening is recommended from age 50 unless there are risk
factors. Breast examination is normal and commencing hormone replacement therapy is not an
indication for early mammography.
Choice 6: Pelvic ultrasound Score : -1
Choice Feedback:
Incorrect. There is little to suggest that Mrs McDonald has any gynaecological pathology. If she had
abnormal vaginal bleeding, pelvic ultrasonography might be appropriate.
Choice 7: Prolactin Score : -1
Choice Feedback:
In this scenario, this hormone should only be tested if there are other clinical evidence of galactorrhoea
or loss of axillary and pubic hair, in absence of other symptoms.
Choice 8: 24 hr urine collection for catecholamines Score : -1
Choice Feedback:
Incorrect. It is most unlikely that the patient's symptoms of flushing and sweating are due to a
phaeochromocytoma. These patients usually have a much longer history and also have intermittent
palpitations and headaches.
Choice 9: Dual energy X-ray absorptiometry (DEXA) Score : -1
Choice Feedback:
Incorrect. The risk of osteoporosis increases after menopause and hormone replacement therapy may
offer benefits and reduce the risk of fractures. However the routine screening with a diagnostic test is
not indicated or recommended unless the patient has a strong medical history to suggest otherwise.
Question 3 : MS
Question Information:
For a patient of Mrs McDonald's age and together with her symptoms, no investigations are required to
confirm the diagnosis. Often FSH levels are measured (and would be elevated; consistent with
diminished oestrogen output from the ovaries), but this is usually a superfluous investigation. It certainly
would be appropriate to counsel the patient on mammographic screening, but this is for good overall
patient care and nothing to do with the diagnosis of menopause.
It is explained to Mrs McDonald that her symptoms are almost certainly menopausal in origin. Her
ovaries have stopped producing oestrogen and progestrogen, the lack of which are responsible for her
vaso-motor symptoms.
Question:
Which of the following treatment options would be appropriate?
Choice 1: Lifestyle advice Score : 1
Choice Feedback:
Correct. Initial interventions for management of menopausal symptoms should include lifestyle advice
such as exercise, weight reduction, stress avoidance, limiting intake of caffeine, cigarettes and alcohol
and wearing appropriate layered clothing that can be easily removed if hot flushes occur. Additionally,
there is some evidence that meditation, mindfulness training and cognitive behavioural therapy can all
aid in control of vasomotor symptoms.
Choice 2: Alternative therapies Score : -1
Choice Feedback:
Incorrect. There has not been any evidence based benefit shown using alterative remedies such as
black cohosh or phytoestrogens. Additionally, these therapies should be discussed as they can
significant interactions with other medications and important health risks for some patients (e.g. breast
cancer).
Choice 3: Non-hormonal medications Score : 1
Choice Feedback:
Correct. There are many medications such as clonidine, gabapentin, fluoxetine, paroxetine and
venlafaxine are all of benefit in reducing the frequency and severity of hot flushes whilst still avoiding
hormonal based therapy.
Choice 4: Hormone replacement therapy Score : 1
Choice Feedback:
Correct. Hormone replacement therapy will significantly aid in reducing Mrs McDonald†™s symptoms.
The correct type and duration should be based on her other health risk factors.
Question 4 : FT
Question Information:
Mrs McDonald returns to the clinic three months later, after having trialled conservative measures. She
is still experiencing ongoing hot flushes and sweats at night, and is now keen to pursue hormonal
replacement therapy.
Question:
Describe the three options and indicate which is most appropriate for Mrs McDonald.
Choice 1: null Score : 0
Choice Feedback:
1. Oestrogen only Menopausal symptoms are oestrogen deficiency symptoms. As such oestrogen is
the main hormone to be replaced. Otherwise known as unopposed oestrogen therapy, this is normally
given to women who do not have a uterus, as progesterone is only given to control uterine bleeding and
to prevent uterine cancer. Oestrogen replacement therapy only will increase likelihood of endometrial
hyperplasia and endometrial cancer.
2. Oestrogen and progestogen (cyclical) Apart from oestrogen, a cyclical progestogen is added for
women who are near menopausal and still menstruating. This is so as to give a more predictable
menstrual cycle than they would get on the next option.
3. Oestrogen and progestogen (combined continuous) A daily dose of oestrogen and progestogen is
given as a continuous regimen. This is preferred in older women (say 2-4 years post menopause) as
there is a good chance (80% after three months) of no vaginal bleeding with this regimen. Progestorone
is important as endometrial hyperplasia and cancer can occur after as little as six month of oestrogen
only therapy [1].
Another option for combined treatment would be insertion of an intra-uterine device containing
progestogen (eg a Mirena device) combined with oral oestrogen.
Synopsis
Menopause commonly occurs between the ages of 48-52 in Australian women. This patient presented
with hot flashes/flushes - perhaps the commonest presenting menopausal symptom.
The diagnosis of menopause is a clinical one and based on symptoms of hormone deficiency, viz:
hot
flushes
mood
swings
formication
joint
aches and pains
vaginal
GU
dryness
symptoms including urinary frequency
weight
gain
diminished
hair
dry
libido
loss
skin
memory
errors
Whilst most menopausal women do not require any form of hormone replacement, it may be
appropriate to offer therapy for control of menopausal symptoms and improve quality of life. It is
currently recommended as a short-term (no more than 5 years) for the management of moderate-tosevere vasomotor flushes(1).
The Women†™s Health Initiative (WHI) published in 2002 generated some controversy when it
showed that combined continuous hormone therapy significantly increased the risk of venous thromboembolism or coronary event, stroke and breast cancer. The only statistically significant benefits of this
therapy were a decreased incidence of fractures and colon cancer, with long-term use (2). The study
proved to have several flaws and a reappraisal of the WHI study showed that women who commenced
HRT under the ages of 60 did not show an increase risk of the diseases mentioned above (3).
Commencing HRT within 10 years in symptomatic women near menopause offers benefits and
protection that outweighs the risks and in most instances these symptoms do not require long term
treatment (3,4). Oestrogen is available for administration in other routes and have been associated with
fewer side effects (5). However long term observation studies have not been performed to support its
superiority to oral therapy. Tibolone (a selective tissue androgen estrogenic activity regulator) is as
effective in alleviating menopausal symptoms and preventing bone loss, has a greater positive effect on
sexual dysfunction and is associated with less vaginal bleeding (6). There also may be a role for drugs
such as escitalopram (a selective serotonin reuptake inhibitor) in the alleviation of the frequency and
severity of hot flashes (7).
References
1. http://www.uptodate.com/contents/treatment-of-menopausal-symptoms-with-hormonetherapy?source=search_result&selectedTitle=1%7E150
2. Writing Group for the Women's Health Initiative Investigations. Risks and Benefits of Estrogen Plus
Progestin in Healthy Postmenopausal Women JAMA 2002; 288: 321 - 333
3. Farquhar C, Marjoribanks J, Lethaby A, et al. Long term hormone therapy for perimenopausal and
postmenopausal women. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD004143.
4. MacLennan AH. HRT: A reappraisal of the risks and benefits. MJA. 2007; 186:643-646
5. Grady DG. Management of menopausal symptoms. N Engl J Med. 2006; 355:2338-47
6. Huang KE, Baber R. Updated clinical recommendations for the use of tibolone in asian women.
Climacteric 2010; 13:317-327 7) Freeman EW, Guthrie KA, Caan B et al. Efficacy of escitalopram for
hot flashes in healthy menopausal women. A randomised controlled trial JAMA 2011; 305: 267-74
7. www.ranzcog.edu.au/document-library/management-of-the-menopause.html Management of the
Menopause, RANZCOG Clinical Guidelines. Updated Nov 2014 Accessed 17/9/2016
Dr Sue Kennedy-Andrews and Dr Alphonse Roex kindly assisted with the writing of this case. This case
has been produced at the University of Adelaide. Support for its evaluation and peer review has been
provided by the Australian Learning and Teaching Council Ltd, an initiative of the Australian
Government Department of Education, Employment and Workplace Relations. The views expressed in
this case do not necessarily reflect the views of the Australian Learning and Teaching Council.
Adelaide
Dec 2011
Updated by Dr Amy Hercus, Sept 16