EXPLANATION MENOPAUSE HX + HRT COUNSELLING Menopause Hx 1) Name, Age (if < 45 = premature ovarian failure) 2) PC: Amenorrhoea + Duration

n 3) Menstrual Hx: y LMP ascertain stage of menopause (pre-, peri- or postmenopausal)  > 6 months = menopause  < 6 months = climacteric y Age of menarche y Bleeding pattern y ?Early menopause 4) Elicit menopausal symptoms: Physical Psychological (depressive symptoms) y Hot flushes y Irritability/anxiety/mood swings y Night sweats y Insomnia y Vaginal dryness y Short-term memory impairment y Dyspareunia y Lack of concentration y Loss of libido y Loss of self-confidence y Urinary frequency y Depression y Tiredness 5) Effects of symptoms on: personal & domestic life and occupation 6) PMH: y Hormone-dependent cancer breast/endometrial cancer y VTE y CVS heart/stroke y Undiagnosed vaginal bleeding y Any risk factors for CVS? Hypertension/smoking/diabetes/obesity y Any risk factors for osteoporosis? Endocrine problems/Steroid-use 7) FH: y Breast/endometrial/bowel cancer linked BRCA1 and 2 genes y VTE y CVS heart/stroke y Osteoporosis y Alzheimers ( risk with menopause) 8) Elicit other risk factors for CVS: y Smoking y Hypertension y Sedentary lifestyle y Diabetes y Obesity 9) Gynae Hx: y Surgical menopause hysterectomy? y Fibroids/endometriosis? hormone-dependent 10) Contraception Hx: y Ask if on Progesterone-only pill, IUS/IUD, implanon hormone-based

HRT Counselling: 1) Check understanding of patient and how much they already know about menopause and HRT 2) Correct any misunderstanding 3) Explain what is menopause? normal event that occurs in every women average age in UK = 51 years. This is average, some are early/late however. < 45 years = premature menopause 4) Explain what is HRT? combination of hormones(oestrogen + progesterone) normally present in the body taken upon menopause to mimic the normal pattern of release in body to avoid adverse effects of menopause. Oestrogen taken alone will risk of endometrial cancer. 5) Discuss types of HRT available: y Oral oestrogen 12-days of progesterone  Daily use pill  Can be taken any time of day  Cheap  Well-tolerated  E2:oestrone 1:2 (reverse of physiological ratio in body)  S/E:  induce liver enzymes review dose - thyroxine therapy  risk of VTE 3.5/10000 a year y Transdermal oestrogen 12-days of progesterone  Lipid soluble avoid 1st pass metabolism in liver  E2:oestrone 2:1 (normal physiological ratio)  Reach therapeutics plasma level in 4 hours y S/C implantation  Implanted in lower abdo  Only for patients post-hysterectomy oophorectomy in UK  Treats menopausal symptoms & bone loss y Tibilone  Synthetic steroids  Oestrogenic, progestogenic and androgenic properties  s/e: androgenic effect (hirsutism) + libido y Local oestrogen vaginal cream/pessary  For women with genito-urinary symptoms or systemic delivery of oestrogen is hazardous (breast cancer) 6) Benefits of HRT y Short-term:  Symptomatic relief stops hot flushes and night sweats within weeks  Psychological symptom relief y Long-term:  Protects against bone loss osteoporosis and pathological fractures  risk of CVS disease  problems with urogenital atrophy  risk of bowel cancer 7) Side-effects: (first few weeks of taking HRT) y Weight gain + Mastalgia (progesterone effect) y Return of bleed (can be distressing to some women)

y Nausea/Headaches 8) Risks of HRT (long-term) y VTE risk from 1.5 to 3.5 per 10 000/year (ten teachers) - risk from 3 per 1000 to 7 per 1000 women over a 5 year period (patient.co.uk) y Breast cancer - 19 extra cases of breast cancer in women taking combined oestrogen/progesterone HRT for 10 years compared to women not taking HRT - 5 extra cases of breast cancer in women taking oestrogen-only HRT for 10 years compared to women not taking HRT - Risk falls back to normal a few years within stopping HRT y Endometrial and ovarian cancer if taking oestrogen-only HRT

HISTORY MENORRHAGIA DDx: (to keep in mind while taking history) y Local anatomical Regular bleeding: fibroids, endometrial/cervical polyp, adenomyosis, endometriosis Irregular bleeding: endometrial/cervical carcinoma, ovarian tumour, chronic PID y Systemic thyroid, haematological disorder e.g. von Willebrands, warfarin therapy y Unexplained - dysfunctional uterine bleeding (DUB) 1) Name, Age (>40 risk of fibroids), Ethnicity (Afro-Caribbean risk of fibroids) 2) PC + Duration of problem 3) Menstrual Hx: y Age of menarche y Duration of cycle + Bleeding days y Regular/Irregular cycle y No. of sanitary towels/tampons used per day + Double padding? y Passing any clots or flooding? y 1st day of LMP y Post-coital bleeding (PCB)? Intermenstrual bleeding (IMB)? y Post-menopausal bleeding (PMB) if relevant to age 4) Associated symptoms: y Pain during periods (dysmenorrhoea) y Feeling tired/fatigued (anaemia due to losing blood) y Urinary symptoms dysuria (large fibroid pressure effect) y Bowel symptoms constipation (large fibroid pressure effect) 5) Gynae Hx: y Last smear date, results, any previous abnormalities? y Vaginal discharge 6) Sexual & Contraception Hx: y Dyspareunia

y Type of contraception IUD specifically 7) Obs Hx: (perhaps can wait till later because not really related to menorrhagia?) y Been pregnant? y No. of pregnancies? y Any complications? y TOP/Miscarriage 8) PMH: y Bleeding diathesis? y Thyroid problems? y Cancer? cervical, endometrial 9) FH: y Fibroids? y Bleeding diatheses? y Thyroid problems? y Cancer? cervical, endometrial 10) DH: y Warfarin/Heparin? y Recent antibiotics can interact with OCP leading to onset of normal erratic menstruation 11) SH: y Smoking y Alcohol