A Patient with Menopausal Syndrome

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This is a common presentation to the internists where middle-aged women present with vague, non-specific symptoms of generalized unwell being with headache, flushing, chest pain, body ache and symptoms of insomnia and irritability. They usually undergo numerous investigations without any fruitful results. A diagnosis can be obtained by taking proper history of oligomenorrhoea of recent onset. Many times there is the history of oophorectomy along with hysterectomy. The diagnosis is further substantiated by the presence of elevated level of FSH. Many of the symptoms are quickly relieved by judicious use of HRT, antihypertensive, short course of antidepressants and counselling. Diagnosis is clinical; however elevated FSH may provide some clue.

Diagnosis Menopausal Syndrome

  • Hot flushes
  • Episodic sweating
  • Insomnia
  • Depression
  • Mood swings
  • Vaginal Dryness
  • Somatic symptoms
  • Loss of memory
  • Impaired memory
  • Sexual Dysfunction

Management postmenopausal symptoms

Until recently, HRT was very popular as they are quick in relieving postmenopausal symptoms.

Conjugated oestrogen (Premarin 0.625 mg daily) is commonly used for this purpose. symptom relief it also has a bone conserving effect and helpful in In addition to quick prevention of osteoporosis in late ages. However, unopposed effect of oestrogen has a carcinogenic effect on uterus. So it should be used with progesterone while using in patients with intact uterus. Moreover, it increases the incidence of breast cancer, regular follow up with yearly mammography is essential. It is always prudent to get a thorough gynaecological checkup including cervical smear and mammography before commencing HRT.

Typical schedule of HRT:

⦁ Oestrogen (0.625 mg) — daily: in patients with hysterectomy.
⦁ Oestrogen (0.625 mg) — day 1 to day 21 + Medroxyprogesterone (2.5 mg) day 14 to day 21 : in patients with intact uterus. This regime will cause cyclical bleeding.
However, following the publication of HERS study where oestrogen was shown to increase cardiac mortality in the Pt year in patients with angina, as well as other side effects like hypertension, increased incidence of DVT, this regime has fallen into disrepute.

Problems of HRT:

Although HRT was Popular and considered to be cardio-protective few decades ago in publication of the report of HERS study as well as other observational studies, have
indicated many adverse effects of HRT and subsequently, the use has declined considerably.

Problems found with HRT with Oestrogen:

  • Endometrial carcinoma in case of unopposed use of oestrogen in patients with intact uterus [increased by 3 folds if used in short-term for 1-5 years] sequential use of progesterone offsets this risk, although increases the risk of breast carcinoma.
  • Deep Vein Thrombosis
  • Breast cancer, if used for more than 5 years. Addition of progesterone increases the risk.
  • Increased risk of coronary artery disease.

Problems encountered in patients on oestrogen containing HRT:

  • Breast carcinoma
  • Increased DVT
  • Increased IHD
  • Increased pulmonary embolism
  • Increased hypertension

Other contraindications of oestrogen:

  • Active liver disease
  • Unexplained vaginal bleeding
  • Gallbladder disease
  • Severe hypertriglyceridemia

Those who are severely affected by postmenopausal flushing it can be used as short-term (2-3 months) without much of a problem (In selected cases it can still be used as long-term).

Other drugs:

  • Tibolone is a newly available synthetic hormone which can be used assubstitute
  • . It does not have any adverse effect on the breast or uterus.
  • SERM (Selective Estrogen Receptor Modulator): Raloxifene (60 mg daily) can be used as a substitute for HRT. It has estrogenic actions on bone and anti-estrogenic actions on the uterus and breast. So it does not have any adverse effect on breast or uterus. It is partially effective for prevention of osteoporosis. Unfortunately, it does not help to reduce the postmenopausal symptom of flushing.
  • other drugs for flushing: When hormones cannot be used, one should look for other drugs. Few drugs can be tried e.g. Clonidine (100microgram
  • daily). It can cause dryness of mouth and abrupt withdrawal may cause problems. Anti-depressant drugs particularly SSRI (Fluoxetine) may be tried with mixed results. Of late, newer group of antidepressants like venlafaxine has also been used with partial success.

General Management

Good nutritious diet containing calcium is essential. Control of blood pressure with appropriate medication will also be required. While treating with HRT, migraine may be aggravated and HRT should be discontinued. With appropriate management and counselling, most of the patients will go back to normal life within 5-6 months.

Practical Approach:

  • In postmenopausal local symptoms like vaginal dryness, local oestrogen may be used.
  • In severe symptomatic postmenopausal symptoms like flushing, sweating etc, very short-term oestrogen may be used without any concern. However if the symptoms present and HRT needed for more than 1 year, gynaecological opinion will be needed.
  • If the patient hashysterectomy
  • , oestrogen may be continued for a longer period. In patients with
  • intact
  • uterus, cyclical oestrogen and progesterone may be considered for some time (although long-term use may increase the risk of breast cancer).
  • Longer-term use of oestrogen particularly incombination
  • of progesterone increases the risk of breast cancer specifically in patients with family history of breast cancer, BRCA1 & BRCA2 gene positivity.

From clinician point of view, very short-term use in symptomatic patients may be considered, longer-term use that is beyond 6 months should be contempt only after consultation with gynaecologists. Other ways of combating the postmenopausal symptoms need to be considered as well.

For flushing:

  • Venlafaxine
  • Gabapentin
  • Clonidine

For osteoporosis:

  • Bisphosphonates
  • Raloxifene (BERM)
  • Smoking cessation
  • Adequate calcium intake

Main Points

  • Any non-specific symptoms of unwell being along with insomnia, flushing, depression and irritability in a middle-aged woman, menopausal syndrome should be thought of.
  • Good history taking along with estimation of FSH will obviate the need of many unnecessary expensive tests.
  • HRT quickly improves the menopausal symptoms and can be used for a short term.
  • Long term HRT should be used with caution.
  • Tibolone and raloxifene does not have adverse effect on breast and uterus.
  • Raloxifene helps in prevention of osteoporosis but not in postmenopausal flushing.
  • Clonidine, fluoxetine and venlafaxine sometimes help alleviate some of the postmenopausal symptoms.

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