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Case History

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Image not available. A 46-year-old woman complains of irregular heavy periods every four to six weeks over the past year and is flushing. She is using condoms for contraception and her family is complete.

What are the issues?

How should she be investigated?

What are the treatments?

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Background

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What are the issues?

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Image not available. Menopausal symptoms often start before menstruation stops and this patient would benefit from trying hormone replacement therapy (HRT). However, before then it is important to ascertain her contraceptive needs and to exclude pelvic pathology and to ensure that she is not anaemic.

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How should she be investigated?

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Evaluation begins with a detailed history focusing on menstrual patterns, subjective heaviness of loss (such as passage of clots) and vasomotor symptoms. An abdominal and pelvic examination is recommended. Cervical cytology should be up-to-date in accordance with local screening programmes. A full blood count is needed to determine the degree of anaemia.1 In a woman of her age there is no need to check follicle-stimulating hormone (FSH) levels. They fluctuate in the peri-menopause, will not predict when periods will stop and are not a guide to fertility status, as ovulation can occur in the presence of elevated FSH levels. However, it would be prudent to check thyroid function as thyroid disease is very common in women.2 Transvaginal ultrasound scanning (TVS) should then be used as a triage for further diagnostic evaluation (Figure 11.1). It will diagnose endometrial pathologies, including polyps and submucous fibroids, as well as other pelvic pathologies such as ovarian cysts. While endometrial thickness is an indicator of pathology in post-menopausal women, there are no such clear guidelines in perimenopausal women. The United Kingdom 'Royal College of Obstetricians and Gynaecologists Guideline Development Group' reviewed a number of studies involving pre-menopausal women and concluded that 10–12 mm represented a reasonable cut-off when using TVS as a method prior to more invasive procedures of endometrial assessment.3 Ideally, TVS should be performed after menstruation in the follicular phase of the menstrual cycle. Ultrasound can sometimes miss small polyps, particularly when performed in the late secretory phase when the endometrium is thicker. Endometrial sampling should be considered in this woman to obtain a histological diagnosis to exclude malignant and pre-malignant disease. This is usually undertaken without anaesthetic using a Pipelle sampler. However, if endometrial pathology such as an endometrial polyp is suspected, direct visualization with hysteroscopy is preferred and the lesion can then be removed. Of course if gross pelvic pathology such as large fibroids is found, she will need to be referred for consideration for surgery.

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Figure 11.1

Investigation of peri-menopausal menstrual symptoms.

Graphic Jump Location
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What are the treatments?

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Medical treatments are the first line if no gross pelvic pathology requiring surgery is ...

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