Establishing good rapport MEMENPOUSE

ID( NAME-AGE-OCCUPATION-MARITAL STATE-PREGENENT OR NOT

Known case +duration ER OR opd case

Chief complain: AMENORHEA FOR 12 MONTHS IN WOMEN AGE MORE THAN 45

YEARS

HPi PSYCHOLOGIC SYMPTOMS

MENPOUSE SYMPTOMS

menopause may be asymptomatic Mood swings, depression and concentration difficulties are
psychologic symptoms that are associated with menopause.
vasomotor symptoms:
hot flashes, characterized by
sudden sensation of heat in the Sleep ddistarbance
upper body
perspiration Cognitive
flushing such as forgetfulness, difficulties with word retrieval, and
chills "brain fog"
clamminess MENESTRUAL HISTORY
anxiety Regularity –frequency –duration –volume of flow –
heart palpitations postmenopausal bleeding –post coital bleeding –dysmenorrhea –
night sweats age of menarche
sleep disturbance methods of contraception-HOW MANY CHILD –CS-or SVD
urogenital symptoms:
vaginal dryness Last screening
discharge CERVICAL –BREAST
itching history of conditions with known or possible
dyspareunia contraindications to hormone therapies5
sexual dysfunction breast cancer (including family history of breast cancer)
reduced libido endometrial hyperplasia or endometrial cancer
cardiovascular disease, including
Medication history deep vein thrombosis (DVT)
OCP pulmonary embolism (PE)
GNRH AGONIST arterial thromboembolic disease, such as
HRT myocardial infarction or stroke
factors associated with induced liver impairment or disease
menopause, protein C, protein S, or antithrombin deficiency, or other
hysterectomy thrombophilic disorders
radiation therapy gallbladder disease
chemotherapy hypertriglyceridemia
diabetes mellitus
hypoparathyroidism
constitutional symptoms LOW-LOA-FATIGUE-LN ENLARGMENT-FEVER-NECK STIFNESS –SKIN
RASH
Red flags Post menopausal bleeding

DDX OR causes

DDX OF HOT FLUSHES causes of secondary amenorrhea may include

• panic disorders1 • pregnancy
• hyperthyroidism1 • hyperprolactinemia
• pheochromocytoma1 • polycystic ovary syndrome
• carcinoid tumor1 • hypothalamic amenorrhea
• hypoglycemia in diabetes1 • primary ovarian insufficiency (POI)
• excessive caffeine intake • thyroid disorders, including hypothyroidism
(Maturitas 2011
Aug;69(4):338) •
• alcohol withdrawal
• autonomic dysregulation

Smoking Allergy

Trauma-travelling –contact with ill Contact with TB OR COVIED 19 PT ?when –Mosquito bite
patient
feeding history Obstetric and Menstrual history and contraception
Developmental history
Immunization history
Child neglect
PMHX Chronic dissese- Medication- Chronic dissese-hospitalization-
Previous similar illness
Genetic history- Same problem in family- Chronic dissesse
FAMILY HISTORY Be specific According to complain
age at onset of menopause
history of vasomotor symptoms

Social history • Substance abuse +herbal- Stress in family and work –Diet-
• smoking
• sleep patterns (increased sleep latency, decreased
sleep time)-exercise
ICEEDS ABUSE IN FEMALE –CHILD-OLD
I. affect on daily activities: affecting sleeping and
embarrassing her inwork . 4

Any added questions

Physical examinations:
VITAL signs +BMI OR GROTH CHART FUNDOSCOPY
+CVR assessment body mass index > 30 kg/m2 may increase risk of moderate-to-
severe hot flashe

GENERAL EXAM General lock-Thyroid-Lymph node –lower limp

Local focused Exam Pelvic

• perform genital exam to look for signs of vaginal
atrophy, such as2
o bleeding and fissures due to thinning of
vaginal epithelial tissues
o loss of subcutaneous fat in labia majora
§ narrowing of introitus
§ fusion of labia minora
§ shrinking of clitoral prepuce and
urethra
o decrease of vaginal secretions
o urogenital infection

Investigation
follicle-stimulating hormone (FSH):not rottenly recommended for diagnosis
• normal range
o child < 4 milliunits/mL
o reproductive period 6-10 milliunits/mL
o perimenopause 14-24 milliunits/mL
o menopause > 30-40 milliunits/m
Management
Clarify Explain to pt the physiological nature of
postmenopausal symptoms , 7
It will stop 3-4 years spontaneously
Reassurance ‫ﺗطﻣن ﻻ ﺗﺧﺎف اﺣﻧﺎ ﻣوﺟودﯾن ﻟﺧدﻣﺗك‬
 Diet –exercise
ADVICE See aafp tabele
For hot flashes
Non pharmacological o Avoidance of triggers (e.g., bright lights, predictable
emotional triggers)
o Environmental temperature regulation (e.g., using
fans)
For impaired sleep and/or hot flashes: exercise,
acupuncture, and relaxation techniques
Complementary and alternative medicine:
➢ No RCT evidence for efficacy of acupuncture,
yoga, Chinese herbs.
➢ Modest benefit of vit.E
➢ Mixed evidence for dietary phytoestrogens &
black cohosh

Prescription HRT
For atrophic vaginal
ü For healthy, peri/postmenopausal women with
symptoms: vaginal estrogen creams, moderate to severe vasomotor symptoms impacting
rings, or tablets (Estrogen therapy sleep, quality of life, or ability to function, and who
may reduce the incidence of UTIs and are within 10 years of menopause (or <60 years of
age), we suggest MHT (Grade 2B).
features of overactive bladder.) ü For most women, the benefits of MHT outweigh the
Depression risks (figure 1). Exceptions include women with a
Depression more than Hot flushes history of breast cancer, coronary heart disease
SSRI (CHD), a previous venous thromboembolic (VTE)
Hot flashes more than depression event or stroke, active liver disease, or those at high
MHT risk for these complications.
Depression and Hot flashes
MHT + SSRI + refer to a psych pharmacologist ü Standard recommendations for duration of use are
three to five years.
ü We no longer use MHT for the prevention of chronic
disease (osteoporosis, CHD, or dementia).
ü NON Hormonal therapy
ü paroxetine (an SSRI) 7.5 mg/day orally is the only
approved nonhormonal therapy for treatment of
menopause-related vasomotor symptoms
• Selective estrogen receptor modulators: tamoxifen,
ospemifene , and raloxifene
• Paroxetine: for vasomotor symptoms (i.e., hot flashes)
• Clonidine and/or gabapen
ü
Referral cognitive behavioral therapy

Observation Management of Long-Term Risks:

Or FU osteoporosis and CAD
Follow-up in 3 to 6 months after initiation of therapy
for menopausal symptoms is recommended to
determine the adequacy of the regimen and review
side effects. Once an appropriate regimen has been
established, the patient should be evaluated yearly
health promotion Prevention of osteoporosis
Screening tests for postmenopausal women • Smoking cessation, adequate vitamin D intake, and
are as regular weight-bearing exercise
follows: •
ü height and weight (periodically) For osteoporosis :
ü blood pressure (periodically) ü Advise on vitamin D intake (800-1000 IU per day)
ü vision (periodically) ü Recommend regular weight-bearing and muscle
ü mammography (40 to 49 years: strengthening exercise to improve agility, strength,
individualize posture, and balance and reduce the risk of falls and
according to risk; older than 50 years: fractures.
every 2 years) periodically if women on HRT ü Assess risk factors for falls and offer appropriate
ü Pap test (starting at 21 years every 3 modifications (eg, home safety assessment, balance
years and for women older than 30 training exercises, correction of vitamin D insufficiency ,
years, every 5 years if co-testing with avoidance of certain medications, and bifocals use when
human papillomavirus [HPV] is done appropriate
until the age of 65 years; Cardiovascular disease
ü colorectal (older than 50 This may be mediated by changes in cardiovascular
risk factors such as lipid profiles
years; frequency
depends on method
ü fecal occult blood test,
flexible sigmoidoscopy,
ü or colonoscopy),
ü BMD
ü fasting lipid profile (older
than 45 years of age;
every 5 years if previous
results were normal
HRT
Women over age 45 women between women under age 40
years the ages of 40 years
and 45 years
Ø diagnosis of the Ø diagnosis of Ø measuring FSH on
"perimenopause« the cycle day 3 in
change in menopause women with
intermenstrual is the same menstrual cycles
interval with as that for >10 to 15
or without women over IU/Lwomen with
menopausal 45 years, amenorrhea on a
symptoms except random day >30
Ø diagnose other causes of IU/L
menopause as 12 menstrual cycle Ø serum estradiol
months of dysfunction must ≥80 pg/mL
amenorrhea in first be ruled out Ø antral follicle
the absence of ü serum count (on
other biological human transvaginal
or physiological chorionic ultrasound)
causes gonadotropin Ø serum anti-
Ø A high serum FSH (hCG) müllerian
is not required to ü Prolactin hormone
make the ü thyroid-
diagnosis stimulating
hormone
[TSH]).
Hot flushes

Early symptoms

Vasomotor symptoms (Hot flushes)

classification:
(1)Not present
(2) Mild – Do not interfere with usual activities
(3) Moderate – Interfere somewhat with usual
activities
(4) Severe – So bothersome that usual activities cannot
be performed

*Mild symptoms may be treated with behavioral

modification, whereas more severe symptoms may
require pharmacologic therapy.
Treatment of Hot flushes
Genitourinary
Syndrome
§ First-line option
ü Vaginal moisturizer
Replens >> 3 times/week
§ Not improved
ü Low-dose
CannotVaginal
üOspemifene (severe Estrogen
arthritis,
(The•obesity,
All have
only vulvodynia)
similar
FDA-approved) or
prefer not to use a vaginal
effectiveness
>> OD POproduct
With food
 Examination
Done
Incomplete
Not done Full
½ mark
mark

Examiner
1. According to the scenario, how would you continue the consultation
(
II. Clarify the presenting symptom 4
III. Onset , trigger ( 2 months , no clear trigger ) 4
IV. Duration and frequency ( no specific timen , day and night last for 2-3
mints ) 4
V. Associated with ( palpitation , vaginal dryness , sleep disturbance ,
difficulty in concentration ) 4
VI. affect on daily activities: affecting sleeping and embarrassing her in
work . 4
Candidate
VII. Past medical hx : hypothyroidism 4
VIII. Past surgical : non 3
IX. Medicin and allergies : thyroxin 100mcg 4
X. Last screening : breast and cervical uptodate (8 months ago ) 4
XI. Ob/gyne hx : p6+0 all svd 4
XII. Family hx : unremarkable 4
XIII. Social hx : non smoker 3
XIV. Physical examination: unremarkable 4

Examiner
What will be your management ?

I. Explain to pt the physiological nature of post

menopausal symptoms , 7
II. It will stop 3-4 years spontaneously 7
III. Non pharmacological :wear light clothes , avoid
Mamagment
spicy hot food , use fan , drink cool liquid 7
IV. Regular exercise 7
V. Vitamin and soya milk has no rules 7
VI. Pharmacological : HRT ( pt refused ) 7
VII. Paroxetine. 7.5 mg will improve the symptoms
8

Total marks: %