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.