- Email: [email protected]
Clinical case scenarios
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EMAS2017 / Maturitas 100 (2017) 93–202
and tall Caucasian who retired from work as a teacher in her 60’s. She has recently been widowed and has no children. At assessment, she was found to be osteoporotic with both vertebral and her femoral neck bone mass being below 2.5 centile of the mean. She is otherwise fit, has no history of breast cancer, and has no significant medical problems. What options would you consider in the management of this patient? Her primary concern is that she recovers from her fracture and improves her mobility. Case #3 Corinne, 55 year old had a ductal carcinoma in situ (DCS) diagnosed at the age of 40 in her right breast and subsequently had a mastectomy and anxillary node dissection. Her anxillary nodes were negative. She received radiotherapy and was on Tamoxifen for five years. Follow up at 51 revealed a small recurrence and this was once again treated surgically and with radiotherapy. This time she was put on an Aromatase Inhibitors. In the meantime she had a TAH and BSO, since she was still having regular if heavy periods. Now four years later and still on AI’s she is complaining of severe hot flushes, severe joint pains, muscle aches and what she describes as the worse symptom, severe vaginal pains and dryness with recurrent vaginal infections. This, she has been told is the effect of Aromatase Inhibitors coupled with a surgical menopause (TAH and BSO). She has complete aversion to sex and as a result of her dyspareunia, and additionally a loss of libido. She finds it difficult to have sexual intercourse with her as yet fit husband. She has come to you asking for relief and management of her symptoms. Case #4 Phyllis is a 60 year old who had a late menopause at the age of 57 years. She subsequently had episodes of postmenopausal bleeding and hysteroscopy and D&C showed cystic hyperplasia. Phyllis has a high BMI of 38, is hypertensive and has a tendency to hyper insulinism. She was found to be hypertensive at her pre-operative assessment and put on anti-hypertensives. It was decided to carry out a TAH and BSO. Post surgery, she complained of dry skin, itching, vulval dryness and frequency and dysuria. She also complained of hot flushes for the first time ever. She also complains of joint pains, anxiety and lack of concentration. She has no significant family history and is asking for relief of her symptoms. http://dx.doi.org/10.1016/j.maturitas.2017.03.085 ATE6 Discussion of clinical cases Juan Blümel Universidad de Chile, Medicine, Santiago, Chile Background: Vasomotor symptoms are common during menopause and perimenopause; however, in some women, it may appear at earlier ages. Chief complaint: A 42-year-old woman with normal menstrual flow who has hot flushes and depressive mood. Main outcomes: Symptoms. Laboratory and imaging exams. Questions: Can she be a woman with climacteric symptoms or thyroid dysfunction? Can the symptoms be adverse drug effects or tumors? Are there other diagnostic options? List what you would like to know about her medical history, physical exam and laboratory and imaging diagnosis exams. What would be your treatment? What do the clinical guidelines say about the use of estrogen in women with regular menstrual periods?
Conclusions: Climacteric symptoms are frequent before menopause. A therapeutic test with transdermal estradiol should be attempted if symptoms impair the quality of life. Evaluate lifestyles and cardiovascular risk. We need a position statement of the scientific societies on this subject. http://dx.doi.org/10.1016/j.maturitas.2017.03.086 ATE7 Clinical case scenarios Mary Ann Lumsden University of Glasgow, Glasgow, United Kingdom Case #1 Premature Ovarian Insufficiency. A 23 year old girl from Iran presented to the Outpatients Clinic with amenorrhea of 10 months duration. She had a regular cycle prior to this. She complained of some hot flushing on close questioning otherwise was asymptomatic. She was engaged to be married. On investigation her FSH was 26IU/l and LH 18U/L. Her oestradiol was <70 IU/L. The case aims to discuss future management: 1. 2. 3. 4.
Repeat gonadotropin assessment initial focus on fertility Hormone replacement Long term consequences.
Her fear was that her fiancée would leave her but he said he would support her. She rejected ovum donation and HRT was then started. She will be regularly reviewed. Case #2 65 year old at high risk of cardiovascular disease. This patient attended the clinic complaining of severe hot flushing and sweats that were intolerable. She had been on HRT until 18 months previously but had been stopped by her GP because of her age. She had hypertension and was on an anti hypertensive and a statin. She was very overweight but did not have T2DM. She was desperate to restart her HRT. Issues for discussion. 1. Current data for women starting HRT at 65 but unknown impact of having been on it before. 2. Impact of symptoms of QoL and why so important. 3. Risk of MI, CVD episode and stroke 4. Transdermal versus oral Case # 3 Perimenopausal Bleeding A 48 year old African-American woman presents with heavy menstrual bleeding. Her periods last 7 to 10 days and are heavy for 3 with flooding and clots. She cannot leave the house. She has a regular menstrual cycle. She had 2 children by LSCS and is overweight. She has also had a previous myomectomy. She wishes to avoid surgery if possible. She has tried mefenamic acid and tranexamic acid without success. On examination the uterus is enlarged to 18 weeks size and ultrasound confirms the presence of at least 6 fibroids, the largest 8 cm in diameter and anteriorly. She has no menopausal symptoms as such. Issues for discussion are the possible treatment options. NOT Mirena Uterine Artery Embolisation Ulipristal acetate MRgHIFU Case # 4 Severe dyspareunia in a 35 year old who has breast cancer. She had a lumpectomy followed by radiotherapy 2 years previously and is currently on aromatase inhibitor. She also has severe joint pains and is feeling very low as a result.
EMAS2017 / Maturitas 100 (2017) 93–202
Issues for discussion. Impact and importance of symptoms. Full history. Physiology Possible treatment options – lubricants, moisturisers, etc Change to tamoxifen. Local oestrogen treatment.
121
Case 4 Unexplained exhaustion A 46 years old female school teacher, liking her profession, is completely exhausted by a normal day at school, without explanation, since about 2 months. Her cycles became irregular, she feels sometimes hot. http://dx.doi.org/10.1016/j.maturitas.2017.03.089
http://dx.doi.org/10.1016/j.maturitas.2017.03.087 ATE8 Clinical case scenarios Susan Davis Monash University, Melbourne, Australia Case #1 A 54 year old had the menopause 2 years ago and is now concerned about her flushes and her bones. Her mother and maternal aunt were diagnosed with breast cancer in their 70s and her mother had a hip fracture at 65 and has bad kyphosis She is worried about the risk of breast cancer if she takes HRT but also about the risk of developing osteoporosis. Mammogram 2016 unremarkable How would you advise and manage her? Case #2 A 49 year old woman went through menopause 2 yrs ago. Been seeing a GP who has been prescribing compounded hormone therapy. She has a syringe containing progesterone and uses a metered dose ea day according to the “Wiley protocol” She is using a biest lozenge and another cream containing DHEA and testosterone. She has come to see you as another GP has questioned her use of these medications and referred her to you. She is having night sweats. She hands you the results of the salivary tests she has had performed and seeks your opinion on her medication, the test results and the doses.
ATE10 Case scenarios Marije Geukes Reinier de Graaf Gasthuis, Delft, The Netherlands Poor concentration: The past few months a 52 years old female human resource manager has been struggling to keep her attention during performance interviews with employees. If she could only have a good night rest, as to regain her focus at work. http://dx.doi.org/10.1016/j.maturitas.2017.03.090 ATE11 Case scenarios Henk Franke Franke Consultancy Holding BV, Enschede, The Netherlands Case 1 A 50 year old woman works in a pastry factory. She suffers of frequent hot flushes which results in excessive sweetening. Her employer fires her because of this unhygienic situation. Case 2 A 48 year old female teacher became indecisive and depressed lately. She also suffered of menopausal symptoms. Her general practitioner thinks she suffers of dejection and advised her to take Seroxat and report herself sick.
http://dx.doi.org/10.1016/j.maturitas.2017.03.088 http://dx.doi.org/10.1016/j.maturitas.2017.03.091 Ask the Expert: How should employers treat menopausal women? Discussion of cases
ATE12
ATE9
Case scenarios
Cases scenarios Martin Birkhäuser Universitäts Frauenklinik, Bern, Switzerland Case 1 Hot flushes provoked by client contact A 52 years old female bank employee gets hot flushes as soon as a client approaches her desk. The phenomenon started 3 months ago. She panics more and more, just by thinking at her next client. Case 2 Climacteric depression A lawyer observes a progressive mood change in one of his assistants, a pretty married female bachelor of law, 54 years old. She looks sad, what is new for him. He fears a depression. What should/can he do? Case 3 Pollakisuria at work A 61 years old otherwise reliable female supermarket cashier leaves her box more and more frequently to go to the restroom, without explanation to the manager. Clients start to complain.
Herman Depypere Ghent University, Ghent, Belgium Everything came at the same time for Nathalie, her long awaited appointment as head of the department and her vasomotor symptoms. How to tackle both challenges? http://dx.doi.org/10.1016/j.maturitas.2017.03.092 Ask the Expert: Non-HRT, alternative and complementary therapies for menopause: Discussion of clinical cases ATE13 Clinical case scenarios Amos Pines Tel-Aviv, Israel Case 1 A 52-year healthy woman. Cessation of periods since one year. Suffers from 5-7 hot flushes during the day and once every night.
EMAS2017 / Maturitas 100 (2017) 93–202
and tall Caucasian who retired from work as a teacher in her 60’s. She has recently been widowed and has no children. At assessment, she was found to be osteoporotic with both vertebral and her femoral neck bone mass being below 2.5 centile of the mean. She is otherwise fit, has no history of breast cancer, and has no significant medical problems. What options would you consider in the management of this patient? Her primary concern is that she recovers from her fracture and improves her mobility. Case #3 Corinne, 55 year old had a ductal carcinoma in situ (DCS) diagnosed at the age of 40 in her right breast and subsequently had a mastectomy and anxillary node dissection. Her anxillary nodes were negative. She received radiotherapy and was on Tamoxifen for five years. Follow up at 51 revealed a small recurrence and this was once again treated surgically and with radiotherapy. This time she was put on an Aromatase Inhibitors. In the meantime she had a TAH and BSO, since she was still having regular if heavy periods. Now four years later and still on AI’s she is complaining of severe hot flushes, severe joint pains, muscle aches and what she describes as the worse symptom, severe vaginal pains and dryness with recurrent vaginal infections. This, she has been told is the effect of Aromatase Inhibitors coupled with a surgical menopause (TAH and BSO). She has complete aversion to sex and as a result of her dyspareunia, and additionally a loss of libido. She finds it difficult to have sexual intercourse with her as yet fit husband. She has come to you asking for relief and management of her symptoms. Case #4 Phyllis is a 60 year old who had a late menopause at the age of 57 years. She subsequently had episodes of postmenopausal bleeding and hysteroscopy and D&C showed cystic hyperplasia. Phyllis has a high BMI of 38, is hypertensive and has a tendency to hyper insulinism. She was found to be hypertensive at her pre-operative assessment and put on anti-hypertensives. It was decided to carry out a TAH and BSO. Post surgery, she complained of dry skin, itching, vulval dryness and frequency and dysuria. She also complained of hot flushes for the first time ever. She also complains of joint pains, anxiety and lack of concentration. She has no significant family history and is asking for relief of her symptoms. http://dx.doi.org/10.1016/j.maturitas.2017.03.085 ATE6 Discussion of clinical cases Juan Blümel Universidad de Chile, Medicine, Santiago, Chile Background: Vasomotor symptoms are common during menopause and perimenopause; however, in some women, it may appear at earlier ages. Chief complaint: A 42-year-old woman with normal menstrual flow who has hot flushes and depressive mood. Main outcomes: Symptoms. Laboratory and imaging exams. Questions: Can she be a woman with climacteric symptoms or thyroid dysfunction? Can the symptoms be adverse drug effects or tumors? Are there other diagnostic options? List what you would like to know about her medical history, physical exam and laboratory and imaging diagnosis exams. What would be your treatment? What do the clinical guidelines say about the use of estrogen in women with regular menstrual periods?
Conclusions: Climacteric symptoms are frequent before menopause. A therapeutic test with transdermal estradiol should be attempted if symptoms impair the quality of life. Evaluate lifestyles and cardiovascular risk. We need a position statement of the scientific societies on this subject. http://dx.doi.org/10.1016/j.maturitas.2017.03.086 ATE7 Clinical case scenarios Mary Ann Lumsden University of Glasgow, Glasgow, United Kingdom Case #1 Premature Ovarian Insufficiency. A 23 year old girl from Iran presented to the Outpatients Clinic with amenorrhea of 10 months duration. She had a regular cycle prior to this. She complained of some hot flushing on close questioning otherwise was asymptomatic. She was engaged to be married. On investigation her FSH was 26IU/l and LH 18U/L. Her oestradiol was <70 IU/L. The case aims to discuss future management: 1. 2. 3. 4.
Repeat gonadotropin assessment initial focus on fertility Hormone replacement Long term consequences.
Her fear was that her fiancée would leave her but he said he would support her. She rejected ovum donation and HRT was then started. She will be regularly reviewed. Case #2 65 year old at high risk of cardiovascular disease. This patient attended the clinic complaining of severe hot flushing and sweats that were intolerable. She had been on HRT until 18 months previously but had been stopped by her GP because of her age. She had hypertension and was on an anti hypertensive and a statin. She was very overweight but did not have T2DM. She was desperate to restart her HRT. Issues for discussion. 1. Current data for women starting HRT at 65 but unknown impact of having been on it before. 2. Impact of symptoms of QoL and why so important. 3. Risk of MI, CVD episode and stroke 4. Transdermal versus oral Case # 3 Perimenopausal Bleeding A 48 year old African-American woman presents with heavy menstrual bleeding. Her periods last 7 to 10 days and are heavy for 3 with flooding and clots. She cannot leave the house. She has a regular menstrual cycle. She had 2 children by LSCS and is overweight. She has also had a previous myomectomy. She wishes to avoid surgery if possible. She has tried mefenamic acid and tranexamic acid without success. On examination the uterus is enlarged to 18 weeks size and ultrasound confirms the presence of at least 6 fibroids, the largest 8 cm in diameter and anteriorly. She has no menopausal symptoms as such. Issues for discussion are the possible treatment options. NOT Mirena Uterine Artery Embolisation Ulipristal acetate MRgHIFU Case # 4 Severe dyspareunia in a 35 year old who has breast cancer. She had a lumpectomy followed by radiotherapy 2 years previously and is currently on aromatase inhibitor. She also has severe joint pains and is feeling very low as a result.
EMAS2017 / Maturitas 100 (2017) 93–202
Issues for discussion. Impact and importance of symptoms. Full history. Physiology Possible treatment options – lubricants, moisturisers, etc Change to tamoxifen. Local oestrogen treatment.
121
Case 4 Unexplained exhaustion A 46 years old female school teacher, liking her profession, is completely exhausted by a normal day at school, without explanation, since about 2 months. Her cycles became irregular, she feels sometimes hot. http://dx.doi.org/10.1016/j.maturitas.2017.03.089
http://dx.doi.org/10.1016/j.maturitas.2017.03.087 ATE8 Clinical case scenarios Susan Davis Monash University, Melbourne, Australia Case #1 A 54 year old had the menopause 2 years ago and is now concerned about her flushes and her bones. Her mother and maternal aunt were diagnosed with breast cancer in their 70s and her mother had a hip fracture at 65 and has bad kyphosis She is worried about the risk of breast cancer if she takes HRT but also about the risk of developing osteoporosis. Mammogram 2016 unremarkable How would you advise and manage her? Case #2 A 49 year old woman went through menopause 2 yrs ago. Been seeing a GP who has been prescribing compounded hormone therapy. She has a syringe containing progesterone and uses a metered dose ea day according to the “Wiley protocol” She is using a biest lozenge and another cream containing DHEA and testosterone. She has come to see you as another GP has questioned her use of these medications and referred her to you. She is having night sweats. She hands you the results of the salivary tests she has had performed and seeks your opinion on her medication, the test results and the doses.
ATE10 Case scenarios Marije Geukes Reinier de Graaf Gasthuis, Delft, The Netherlands Poor concentration: The past few months a 52 years old female human resource manager has been struggling to keep her attention during performance interviews with employees. If she could only have a good night rest, as to regain her focus at work. http://dx.doi.org/10.1016/j.maturitas.2017.03.090 ATE11 Case scenarios Henk Franke Franke Consultancy Holding BV, Enschede, The Netherlands Case 1 A 50 year old woman works in a pastry factory. She suffers of frequent hot flushes which results in excessive sweetening. Her employer fires her because of this unhygienic situation. Case 2 A 48 year old female teacher became indecisive and depressed lately. She also suffered of menopausal symptoms. Her general practitioner thinks she suffers of dejection and advised her to take Seroxat and report herself sick.
http://dx.doi.org/10.1016/j.maturitas.2017.03.088 http://dx.doi.org/10.1016/j.maturitas.2017.03.091 Ask the Expert: How should employers treat menopausal women? Discussion of cases
ATE12
ATE9
Case scenarios
Cases scenarios Martin Birkhäuser Universitäts Frauenklinik, Bern, Switzerland Case 1 Hot flushes provoked by client contact A 52 years old female bank employee gets hot flushes as soon as a client approaches her desk. The phenomenon started 3 months ago. She panics more and more, just by thinking at her next client. Case 2 Climacteric depression A lawyer observes a progressive mood change in one of his assistants, a pretty married female bachelor of law, 54 years old. She looks sad, what is new for him. He fears a depression. What should/can he do? Case 3 Pollakisuria at work A 61 years old otherwise reliable female supermarket cashier leaves her box more and more frequently to go to the restroom, without explanation to the manager. Clients start to complain.
Herman Depypere Ghent University, Ghent, Belgium Everything came at the same time for Nathalie, her long awaited appointment as head of the department and her vasomotor symptoms. How to tackle both challenges? http://dx.doi.org/10.1016/j.maturitas.2017.03.092 Ask the Expert: Non-HRT, alternative and complementary therapies for menopause: Discussion of clinical cases ATE13 Clinical case scenarios Amos Pines Tel-Aviv, Israel Case 1 A 52-year healthy woman. Cessation of periods since one year. Suffers from 5-7 hot flushes during the day and once every night.