A 48-year-old lady presented with symptoms of headache insomnia, mood swings, body ache and a sense of being unwell. She also complained of occasional chest pain, fluctuating BP and a warm sensation around her head. Numerous investigations including CT scan of brain and symptomatic treatment came to nothing. The symptoms were interfering with her day to day activities. Examination revealed normal haemodynamic status BP 150/100 m/Hg rest of the examination NAD.

Investigations were essentially normal, Thyroid function was normal. FSH was markedly elevated, LFT and bone biochemistry were normal. ECG and X-ray chest - normal. USG whole abdomen - NAD [she had history of hysterectomy with intact ovaries for fibroid uterus - 5 years back]. Bilateral mammography - normal.

Diagnosis: Menopausal syndrome

This is a common presentation to the internists where middle-aged women present with vague, non-specific symptoms of generalised unwell being with headache, flushing, chest pain, body ache and symptoms of insomnia and irritability.

They usually undergo numerous investigations without any fruitful results. A diagnosis can be obtained by taking proper history of oligomenorrhea of recent onset.

Many times there is history of oophorectomy along with hysterectomy. The diagnosis is further substantiated by the presence of elevated level of FSH.

Many of the symptoms are quickly relieved by judicious use of HRT, antihypertensive, short course of anti depressants and counselling.

Management

Until recently HRT was very popular as they are quick in relieving postmenopausal symptoms.

Conjugated oestrogen (Premarin 0.625 mg) daily is commonly used for this purpose.

In addition to quick symptom relief it also has a bone conserving effect and helpful in prevention of osteoporosis in late ages.

However, unopposed effect of oestrogen has a carcinogenic effect on uterus. So it should be used with progesterone while using in patients with intact uterus. Moreover it increases the incidence of breast cancer (albeit small), regular follow up with yearly mammography is essential.

It is always prudent to get a thorough gynaecological check up including cervical smear and mammography before commencing on HRT.

Typical schedule of HRT will include-

1. Oestrogen (0.625 mg) - daily: in patients with hysterectomy

2. Oestrogen (0.625 mg) - day 1 to day 21 +

Medroxy progesterone (2.5mg) day 14 to day 21: in patients with intact uterus. This regime will cause cyclical bleeding.

or

3. Oestrogen (0.625 mg) + Medroxyprogesterone (2.5 mg ): daily  

Following the publication of HERS study where oestrogen was shown to increase cardiac mortality in the 151 year in patients with angina, as well as other side effects like hypertension, increased incidence of DVT, this regime has fallen into disrepute.

Problems encountered in patients on oestrogen containing HRT :

Breast carcinoma

Increased DVT

Increased IHD

Increased pulmonary embolism

Increased hypertension

Those who are severely affected by post menopausal flushing it can be used as short term (2-3 months) without much of a problem (/n selected cases it can still be used as long term).

Other drugs

Tibolone is a newly available synthetic hormone which can be used as substitute. It does not have any adverse effect on the breast or uterus.

SERM (Selective Oestrogen Receptor Modulator)

Raloxifen (60 mg)- daily can be used as a substitute for HRT. It does not have any adverse effect on breast or uterus.

It is partially effective for prevention of osteoporosis. Unfortunately it does not help to reduce the post menopausal symptom of flushing.

Other drugs for flushing - When hormones cannot be used, one should look for other drugs - few drugs can be tried - e,g.,

Clonidine (100 microgram) - daily. It helps in flushing. It can cause dryness of mouth and abrupt withdrawal may cause problems. Anti depressant drugs particularly SSRI (Fluoxetene) may be tried with mixed results.

Of late, newer group of antidepressants like venlafaxine has also been used with partial Success.

General management:

Good nutrious diet containing calcium is essential. Control of blood pressure with appropriate medication will also be required. While treating with HRT, migraine may be aggravated and HRT should be discontinued. With appropriate management and counselling most of the patients ill go back to normallife within 5-6 months.

Key Points

Any non-specific symptoms of unwell being along with insomnia, flushing, depression and irritability in a middle-aged woman, memopausal syndrome should be thought of.

Good history taking along with estimation of FSH, will obviate the need of many unnecessary expensive tests.

HRT quickly improves the menopausal symptoms and can be used for a short term.

Long term HRT should be used with caution.

Tibolonce and raloxifen does not have adverse effect on breast and uterus.

Raloxifen helps in prevention of osteoporosis but not in post menopausal fluxhing.

Clonidine, fluoxetene and venfaxine sometimes help alleviate some of the post menopausal symptoms.