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 confirm the menopause. What is the SINGLE most likely diagnosis?

1. Premature ovarian insufficiency Menopausal symptoms with raised FSH on two occasions under the age of 40, and it requires treatment rather than observation. 14 months of amenorrhoea with vasomotor symptoms at 52 raises it.
2. Endometrial cancer Postmenopausal bleeding, or a change in bleeding pattern on HRT, and it must be excluded rather than attributed to the menopause. 14 months of amenorrhoea with vasomotor symptoms at 52 demands exclusion.
3. Genitourinary syndrome of menopause Vaginal dryness, soreness, dyspareunia and urinary symptoms from oestrogen deficiency, and it does not improve without treatment. 14 months of amenorrhoea with vasomotor symptoms at 52 describes it.
4. Hyperthyroidism/thyrotoxicosis Sweats, palpitations, weight loss and anxiety, and it is the mimic worth excluding where the picture is atypical. 14 months of amenorrhoea with vasomotor symptoms at 52 makes it worth checking.
5. Menopause/perimenopause correct Correct. Over 45 with more than twelve months of amenorrhoea and classic vasomotor symptoms. That is the definition, and no test improves on it.

The point: Diagnose menopause clinically in a woman over 45 with typical symptoms, without any blood test. FSH is measured only in women under 40 where premature ovarian insufficiency is suspected, and in women aged 40 to 45 with symptoms and a change in cycle. HRT is oestrogen plus a progestogen for any woman with a uterus, because unopposed oestrogen causes endometrial cancer. Transdermal oestrogen avoids the additional venous thromboembolism risk of the oral route and is preferred with migraine, obesity or thrombotic risk. HRT is not contraception. Premature ovarian insufficiency under 40 needs HRT or the combined pill until at least the average age of menopause, and it is treating a deficiency rather than choosing a symptomatic therapy. Vaginal oestrogen for genitourinary symptoms can be used indefinitely and alongside systemic HRT.

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 confirm the menopause. What is the SINGLE most appropriate initial investigation?

1. FSH on two occasions four to six weeks apart For a woman under 40 with suspected premature ovarian insufficiency, and for symptoms between 40 and 45. 14 months of amenorrhoea with vasomotor symptoms at 52 indicates it.
2. DEXA bone densitometry For premature ovarian insufficiency or other osteoporosis risk factors. 14 months of amenorrhoea with vasomotor symptoms at 52 makes it appropriate.
3. Thyroid function tests Excludes thyrotoxicosis where sweats, palpitations and weight loss dominate. 14 months of amenorrhoea with vasomotor symptoms at 52 makes it prudent.
4. Full blood count and ferritin For heavy perimenopausal bleeding causing fatigue. 14 months of amenorrhoea with vasomotor symptoms at 52 makes it worthwhile.
5. No investigation; diagnose clinically over 45 correct Correct. FSH fluctuates and a normal value would be misleading. Testing here risks a normal result being used as a reason to deny her treatment.

The point: Diagnose menopause clinically in a woman over 45 with typical symptoms, without any blood test. FSH is measured only in women under 40 where premature ovarian insufficiency is suspected, and in women aged 40 to 45 with symptoms and a change in cycle. HRT is oestrogen plus a progestogen for any woman with a uterus, because unopposed oestrogen causes endometrial cancer. Transdermal oestrogen avoids the additional venous thromboembolism risk of the oral route and is preferred with migraine, obesity or thrombotic risk. HRT is not contraception. Premature ovarian insufficiency under 40 needs HRT or the combined pill until at least the average age of menopause, and it is treating a deficiency rather than choosing a symptomatic therapy. Vaginal oestrogen for genitourinary symptoms can be used indefinitely and alongside systemic HRT.

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 confirm the menopause. What is the SINGLE most appropriate immediate management?

1. Combined oestrogen and progestogen HRT correct Correct. She has a uterus, so a progestogen is mandatory. Oestrogen alone would expose her to endometrial hyperplasia and cancer.
2. Vaginal oestrogen For genitourinary symptoms, usable long term and alongside systemic HRT, with minimal systemic absorption. 14 months of amenorrhoea with vasomotor symptoms at 52 makes it right.
3. Refer under the two week wait For postmenopausal bleeding, which is cancer until excluded. 14 months of amenorrhoea with vasomotor symptoms at 52 makes it urgent.
4. Cognitive behavioural therapy for vasomotor symptoms and mood An effective non-hormonal option, and the first choice where HRT is contraindicated or declined. 14 months of amenorrhoea with vasomotor symptoms at 52 makes it reasonable.
5. Continue contraception for 2 years after the last period under 50 One year if over 50. HRT is not contraception, and this is where unplanned pregnancies happen. 14 months of amenorrhoea with vasomotor symptoms at 52 makes it necessary.

The point: Diagnose menopause clinically in a woman over 45 with typical symptoms, without any blood test. FSH is measured only in women under 40 where premature ovarian insufficiency is suspected, and in women aged 40 to 45 with symptoms and a change in cycle. HRT is oestrogen plus a progestogen for any woman with a uterus, because unopposed oestrogen causes endometrial cancer. Transdermal oestrogen avoids the additional venous thromboembolism risk of the oral route and is preferred with migraine, obesity or thrombotic risk. HRT is not contraception. Premature ovarian insufficiency under 40 needs HRT or the combined pill until at least the average age of menopause, and it is treating a deficiency rather than choosing a symptomatic therapy. Vaginal oestrogen for genitourinary symptoms can be used indefinitely and alongside systemic HRT.

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