General practice and primary healthcare for PLAB 1

A 52 year old woman has not had a period for 14 months. She has hot flushes several times a day, night sweats disturbing her sleep, and low mood. She has a uterus and no personal or family history of breast cancer or thrombosis. Her BMI is 24 and her blood pressure is 122/76 mmHg. She asks for a blood test to find out what is happening. What is the SINGLE most likely diagnosis?

1. Premature ovarian insufficiency Menopause symptoms with a raised FSH on two separate tests, under the age of 40, and it needs treatment rather than just watching. It does not fit 14 months without periods, with hot flushes, at 52.
2. Endometrial cancer Bleeding after the menopause, or a change in the bleeding pattern on HRT, and this must be checked out rather than just put down to the menopause. Here, 14 months without periods, with hot flushes, at 52 points elsewhere.
3. Genitourinary syndrome of menopause Vaginal dryness, soreness, pain during sex, and urine symptoms, all from a lack of oestrogen, and it does not get better on its own without treatment. But 14 months without periods, with hot flushes, at 52 does not point to it.
4. Hyperthyroidism/thyrotoxicosis Sweats, a racing heart, weight loss and anxiety, and it is the condition worth ruling out when the picture does not fit the usual pattern. That does not match 14 months without periods, with hot flushes, at 52.
5. Menopause/perimenopause correct Correct. Over 45, with more than twelve months without a period and classic hot flushes. That is the definition of the menopause, and no test does a better job than that.

The point: Diagnose the menopause by symptoms alone in a woman over 45, with no blood test needed. FSH (a hormone blood test) is only checked in women under 40 where an early menopause is suspected (premature ovarian insufficiency), and in women aged 40 to 45 with symptoms and a change in their cycle. HRT (hormone replacement therapy) means oestrogen plus a progestogen for any woman who still has a womb, because oestrogen on its own causes womb lining cancer (endometrial cancer). Oestrogen through the skin (a patch or gel) avoids the extra blood clot risk that comes with oestrogen tablets, and it is preferred for women with migraine, a higher weight, or a higher clot risk. HRT is not contraception. Premature ovarian insufficiency under 40 needs HRT or the combined contraceptive pill until at least the average age of menopause. This is treating a hormone shortage rather than picking a treatment for symptoms. Oestrogen cream or pessaries placed in the vagina, for symptoms down below, can be used for as long as needed and alongside HRT taken for the rest of the body.

Source: NICE NG23 — Menopause: diagnosis and management NICE · tier 1, national regulator or guidance

A 52 year old woman has not had a period for 14 months. She has hot flushes several times a day, night sweats disturbing her sleep, and low mood. She has a uterus and no personal or family history of breast cancer or thrombosis. Her BMI is 24 and her blood pressure is 122/76 mmHg. She asks for a blood test to find out what is happening. What is the SINGLE most appropriate initial investigation?

1. FSH on two occasions four to six weeks apart Used for a woman under 40 with a suspected early menopause, and for symptoms between the ages of 40 and 45. It does not fit 14 months without periods, with hot flushes, at 52.
2. DEXA bone densitometry A bone density scan, used for premature ovarian insufficiency or other risks for thin, weak bones (osteoporosis). But 14 months without periods, with hot flushes, at 52 does not point to it.
3. Thyroid function tests Rules out an overactive thyroid when sweats, a racing heart and weight loss are the main symptoms. Here, 14 months without periods, with hot flushes, at 52 points elsewhere.
4. Full blood count and ferritin Used for heavy bleeding around the perimenopause that is causing tiredness. That does not match 14 months without periods, with hot flushes, at 52.
5. No investigation; diagnose clinically over 45 correct Correct. FSH levels go up and down, and a normal reading here would be misleading. Testing risks a normal result being used as a reason to refuse her treatment.

The point: Diagnose the menopause by symptoms alone in a woman over 45, with no blood test needed. FSH (a hormone blood test) is only checked in women under 40 where an early menopause is suspected (premature ovarian insufficiency), and in women aged 40 to 45 with symptoms and a change in their cycle. HRT (hormone replacement therapy) means oestrogen plus a progestogen for any woman who still has a womb, because oestrogen on its own causes womb lining cancer (endometrial cancer). Oestrogen through the skin (a patch or gel) avoids the extra blood clot risk that comes with oestrogen tablets, and it is preferred for women with migraine, a higher weight, or a higher clot risk. HRT is not contraception. Premature ovarian insufficiency under 40 needs HRT or the combined contraceptive pill until at least the average age of menopause. This is treating a hormone shortage rather than picking a treatment for symptoms. Oestrogen cream or pessaries placed in the vagina, for symptoms down below, can be used for as long as needed and alongside HRT taken for the rest of the body.

Source: NICE NG23 — Menopause: diagnosis and management NICE · tier 1, national regulator or guidance

A 52 year old woman has not had a period for 14 months. She has hot flushes several times a day, night sweats disturbing her sleep, and low mood. She has a uterus and no personal or family history of breast cancer or thrombosis. Her BMI is 24 and her blood pressure is 122/76 mmHg. She asks for a blood test to find out what is happening. What is the SINGLE most appropriate immediate management?

1. Combined oestrogen and progestogen HRT correct Correct. She still has a womb, so a progestogen must be included. Oestrogen on its own would put her at risk of the womb lining thickening and turning into cancer.
2. Vaginal oestrogen Used for symptoms down below, and it can be used long term and alongside HRT for the rest of the body, since very little of it gets into the bloodstream. That does not match 14 months without periods, with hot flushes, at 52.
3. Refer under the two week wait Used for bleeding after the menopause, which is cancer until it has been ruled out. But 14 months without periods, with hot flushes, at 52 does not point to it.
4. Cognitive behavioural therapy for vasomotor symptoms and mood A talking therapy that genuinely helps with hot flushes and mood, and it is the first choice when HRT cannot be used or is not wanted. It does not fit 14 months without periods, with hot flushes, at 52.
5. Continue contraception for 2 years after the last period under 50 One year of contraception is needed if she is over 50. HRT is not contraception, and this is where unplanned pregnancies happen. Here, 14 months without periods, with hot flushes, at 52 points elsewhere.

The point: Diagnose the menopause by symptoms alone in a woman over 45, with no blood test needed. FSH (a hormone blood test) is only checked in women under 40 where an early menopause is suspected (premature ovarian insufficiency), and in women aged 40 to 45 with symptoms and a change in their cycle. HRT (hormone replacement therapy) means oestrogen plus a progestogen for any woman who still has a womb, because oestrogen on its own causes womb lining cancer (endometrial cancer). Oestrogen through the skin (a patch or gel) avoids the extra blood clot risk that comes with oestrogen tablets, and it is preferred for women with migraine, a higher weight, or a higher clot risk. HRT is not contraception. Premature ovarian insufficiency under 40 needs HRT or the combined contraceptive pill until at least the average age of menopause. This is treating a hormone shortage rather than picking a treatment for symptoms. Oestrogen cream or pessaries placed in the vagina, for symptoms down below, can be used for as long as needed and alongside HRT taken for the rest of the body.

Source: NICE NG23 — Menopause: diagnosis and management NICE · tier 1, national regulator or guidance