MENOPAUSE MISUNDERSTOOD

 

I have moved to a first-world country now, and I see a totally different demographic of patients with new problems. Women are well educated and way more fit and active in their fifties than women in third-world countries. I came across a woman in her sixties who is still working in a law firm with a demanding job, and she was experiencing a bit of brain fog; her GP put her on HRT to improve her memory. What is the first thing that comes to our mind, in elderly women with memory loss, perhaps this could be the beginning of dementia, or the normal forgetfulness with aging. She presented to us with unscheduled vaginal bleeding and decided to stop her HRT. Her hysteroscopy, dilatation, and curettage showed uterine atrophy and no hyperplasia. She claimed the HRT did not make a difference

The most shocking thing I witnessed was a patient in her forties, who presented to the gynae clinic with an extensive psychiatric history of bipolar disease, with extensive medical treatment, previous admissions to psychiatric ward and even a session of Electroconvulsive therapy (ECT).  she was in her fourties, still menstruating, and was asking if going on HRT will improve her psychiatric condition! She was hoping she could even try to reduce or stop her psychiatric treatment. I reassured her that she has to continue her treatment with her psychiatrist. She is menstruating and not menopausal yet, and the real indication for HRT is severe hot flashes that decrease the quality of life and sleep, etc. I explored some of the side effects and the contraindications, such as a history of thromboembolic disease, stroke, ischemic heart disease, or estrogen-dependent malignancies. 

We have had an ambulatory gyneacology unit in the department since 2024. The referrals to the department are mainly women with heavy menstrual bleeding or post menopausal bleeding. Other services, such as coil insertion, are also offered. Patients have analgesia, and in cases of post menopausal bleeding or unscheduled bleeding on HRT, women are triaged to attend within 2 weeks. When women start HRT, and they experience some vaginal bleeding, we usually still classify them as post menopausal bleeding. The biggest worry in this situation is endometrial hyperplasia or malignancy. One of the non-invasive tools for this is a transvaginal ultrasound to assess the endometrial thickness. The British Menopause Society indicated that the endometrial thickness varies in women on HRT, with the higher ET limit of 7mm in women on a sequential regimen and 4 mm in women on a continuous regimen being accepted. If the endometrial thickness is increased or difficult to visualize, an urgent hysteroscopy and endometrial sampling are mandatory. 

Most clinicians offering HRT understand the importance of progestogens along with estrogen in women with a uterus. The challenge is calculating the optimal dose of an oral or vaginal progestin and ensuring patients adhere to it. 

Women with unscheduled bleeding with HRT with these major risk factors for endometrial carcinoma should be prioritized for hysteroscopy and endometrial sampling. These include: A BMI more than 40, lynch syndrome, being on HRT for more than five years, and inadequate use of progesterone. Minor risks for endometrial cancer are Diabetes, a BMI of 30-39, and a history of polycystic ovaries. 

Mirena coil is a good option to ensure a good endometrial progesterone supply without systemic side effects. We need to ensure the Mirena coil is in the correct position; if it is more than 2cm from the fundus of the uterus, it will not be protecting the endometrium. 

Using oral HRT preparations or Mirena coil as the progesterone component ensures more amenorrhea and less unscheduled vaginal bleeding. Using the fixed oral combined estrogen and progesterone ensures adequate dosing. We need to ensure our patients are up to date with their cervical smears, and if there is evidence of vaginal atrophy, to supply them with topical estrogen. 

APPRECIATION

 

I am under a lot of pressure at work, and it is affecting my mental health. It is the 8th of March, and the weather is still as frosty and cold as January, crushing my expectations that spring is near. I have downgraded my winter clothes to lighter jackets with no gloves, and I am not able to cope with the cold weather when I go out in the mornings. My baby girl started school in the middle of February, and I am having a terrible case of the flu again, after recovering from a chronic cough that lasted three months. On top of the new and difficult work environment, absenteeism has been prominent during the time colleagues were writing the Royal College exams. Not to mention the world leaders have decided to start a new war and bomb each other. With the instability in the Gulf countries, the fuel and grocery prices will go up. Here I am trying to be positive about life. and make a list of the things I am grateful for. 

I am grateful I actually have a job right now. This is the job I got so excited about last year may when I had the interview and broke the news to my parents, and started applying for a work permit, visa, and getting tickets for Ireland.  We are back to basics. We are grateful to have a job and a stable income to put food on the table. The demographic of patients has changed here; they are well taken care of, and I find it very rewarding compared to South Africa, where every day we had to save patients from critical conditions such as severe cardio-respiratory distress, sepsis, or haemorrhage. 

I cannot put a price on the feeling of safety we have staying in Ireland. There is no constant fear of an armed robbery, hijacking, or a gun attack. I often walk to work while on a video call with my mother.  In other countries, phones go missing in public. I remember when I worked in one of the government hospitals in Johannesburg, there was an incident in ED where one of the patients started assaulting a male nurse, and another patient pulled out a gun, to defend the nurse! I love my morning and evening walks to work,  thanks to a safe community. 

We appreciate the change of seasons, and we are eagerly waiting for the beautiful spring and summer to arrive. Hoping to spend more time in nature with friends and Aryana. Most of my career and study difficulties have occurred in winter. I remember when I was in university back home, I had not submitted my research proposal, and I was in crisis before the start of the internship. I was very stressed out, while mom and Cyrus were in South Africa, every morning before going to the university, I would have an episode of crying at the breakfast table. 

I love seafood, and Ireland is a country where we can get a good supply of fish and prawns. I am in love with Salmon. My favourite meal of the week is baked salmon fillets in the oven with a healthy side of vegetables. My daughter is also a great fan of seafood and prawns. I am planning to cook more sophisticated dishes on weekends when I  have time, it is more fun and rewarding than eating out. 

I am happy that my little girl is going to day care. It was weighing on my heart all these months she was at home. hopefully the school will help her pick up more skills and learn to be more vocal. Immigration is hard, but we are slowly settling in and getting used to our new environment. I enjoy the slower pace of life in our small city. There is no hectic traffic or morning rush to day care. My husband and the transport lady take care of the day care drop off and pick up while I focus on getting to work.