Perimenopause and Menopause Health Assessment

Date

15/05/2024 10:30

Patient Details

Name: Sarah Louise Jenkins

Date of Birth: 12/08/1974

Age: 49 years

Address: 42 Eucalyptus Drive, Camberwell, VIC 3124

Contact Number: 0412 345 678

Reason for Assessment

The patient presented for a comprehensive perimenopause health assessment due to a 6-month history of worsening vasomotor symptoms, sleep disruption, and cycle irregularity impacting her daily functioning and work performance.

Medical History

Past Medical History: Mild intermittent asthma, Iron deficiency anaemia (resolved 2021), Migraine without aura

Surgical History: Laparoscopic appendicectomy (2005), Lower uterine segment caesarean section (2010)

Medications: salbutamol (Ventolin®) 100 mcg INH PRN, colecalciferol (Ostelin®) 1,000 IU PO OD, magnesium glycinate 300 mg PO nocte

Allergies: Penicillin (maculopapular rash)

Family History: Her mother developed osteoporosis at age 68 and had a hip fracture at age 75. Her father has hypertension and hyperlipidaemia. There is no family history of breast, ovarian, or endometrial cancer, nor any history of venous thromboembolism.

Social History: She works full-time as a high school teacher and lives with her husband and two teenage children. She is a life-long non-smoker, consumes 2–3 standard alcoholic drinks on weekends, and denies recreational drug use.

Menstrual History and Menopausal Symptoms

Menstrual Cycle Details: Her menstrual cycles were previously regular at 28-day intervals lasting 5 days, but over the past 8 months have varied between 21 and 45 days with moderate flow. Her last menstrual period commenced on 02/04/2024.

Menopausal Stage Assessment: The patient is clinically assessed as being in late perimenopause (STRAW+10 stage -1).

Symptom Checklist

• Vasomotor Symptoms: She experiences moderate-to-severe hot flushes 4–5 times daily and drenching night sweats 3–4 nights per week.
• Psychological Symptoms: She reports mild-to-moderate irritability, increased low-level anxiety, and subjective "brain fog" characterised by word-finding difficulties at work.
• Sleep Disturbances: She has moderate sleep maintenance insomnia, waking 2–3 times per night secondary to night sweats with difficulty returning to sleep.
• Genitourinary Symptoms: She reports mild vaginal dryness over the last 3 months, with occasional superficial dyspareunia, but denies urinary urgency, frequency, or recurrent urinary tract infections.
• Musculoskeletal Symptoms: She notes mild morning stiffness in her small hand joints and knees lasting less than 15 minutes, with no known history of low bone density.
• Sexual Health: She experiences reduced libido, which she attributes to chronic fatigue and mild insertional discomfort.
• Other Symptoms: She reports generalized daytime fatigue and occasional non-specific headaches, distinct from her previous migraines.

Physical Examination

General Appearance: Well-groomed, alert, normotensive appearance, in no acute distress.

Blood Pressure: 124/78 mmHg

Heart Rate: 72 bpm, regular

Weight and BMI: 68 kg, BMI 24.8 kg/m²

Clinical Examination Findings: Dual heart sounds with no murmurs, chest clear to auscultation bilaterally, and abdomen soft and non-tender with no palpable masses. Bilateral breast examination revealed normal fibroglandular tissue with no palpable discrete masses, skin tethering, nipple retraction, or axillary lymphadenopathy. Pelvic examination showed mild vulvovaginal atrophy with pale mucosa, normal cervix, and a small, mobile, non-tender anteverted uterus with no adnexal tenderness.

Investigations

Pathology Results: Recent blood tests from 05/05/2024 showed normal thyroid function (TSH 1.8 mIU/L), normal ferritin (65 mcg/L), fasting glucose 4.9 mmol/L, total cholesterol 5.1 mmol/L (LDL 2.9 mmol/L, HDL 1.6 mmol/L, triglycerides 1.3 mmol/L), and normal liver and renal function. Hormone levels were not ordered as diagnosis is clinical based on age and symptom profile.

Imaging Results: Pelvic ultrasound performed on 06/05/2024 demonstrated a normal-sized anteverted uterus, an endometrial thickness of 4 mm, and normal bilateral ovaries with no adnexal pathology.

Other Investigations: Cervical Screening Test (CST) performed in November 2022 was negative for HPV. Bilateral screening mammogram completed via BreastScreen Victoria in January 2024 was normal (BI-RADS 1).

Assessment and Diagnosis

The patient is a 49-year-old female in late perimenopause presenting with moderate-to-severe vasomotor symptoms, sleep disturbance, mood changes, and mild genitourinary syndrome of menopause (GSM), with no absolute contraindications to menopausal hormone therapy (MHT).

Differential diagnoses considered and excluded via recent normal pathology include thyroid dysfunction and iron deficiency anaemia.

Management Plan

Algorithm Applied

The "Symptomatic Woman Assessment and Management Algorithm" and "Menopausal Hormone Therapy (MHT) Prescription Algorithm" from A Practitioner's Toolkit for Managing Menopause were applied.

Lifestyle Modifications

• Dietary Advice: Advised to maintain a Mediterranean-style diet rich in phytoestrogens, ensure dietary calcium intake of 1,000–1,200 mg daily, and reduce caffeine and alcohol intake to minimise vasomotor triggers.
• Exercise Recommendations: Recommended 150 minutes of moderate-intensity aerobic activity per week alongside progressive resistance and weight-bearing exercises twice weekly for bone and cardiovascular health.
• Stress Management: Discussed pacing strategies at work, mindfulness techniques, and cognitive behavioural strategies to manage perimenopausal anxiety and vasomotor bother.
• Sleep Hygiene: Advised to maintain a cool bedroom environment, use breathable cotton bedding, avoid screens for 60 minutes prior to bed, and maintain a consistent wake time.

Hormone Replacement Therapy (HRT) Discussion

• Benefits and Risks: Discussed that cyclical MHT is the most effective treatment for vasomotor symptoms, sleep improvement, and bone density preservation; explained that transdermal oestradiol with micronised progesterone carries no increased risk of venous thromboembolism, avoids cardiovascular risk, and has the lowest breast cancer risk profile compared to synthetic progestogens, while noting common transient side effects such as breast tenderness and irregular bleeding.
• Prescribed HRT Regimen: Commenced cyclic combined MHT consisting of estradiol (Estrogel®) 0.06% transdermal gel 1.5 mg (2 pumps) applied topically OD, combined with micronised progesterone (Prometrium®) 200 mg PO nocte for 14 days per calendar month (days 15–28).
• Patient Decision and Consent: The patient elected to commence transdermal estradiol and oral micronised progesterone and provided informed verbal consent after her questions were answered.

Non-Hormonal Therapies

Recommended a non-hormonal vaginal moisturiser (Replens®) 2–3 times weekly and water-based lubricant PRN for intercourse to manage mild GSM symptoms, with the option to add topical vaginal estriol if symptoms persist after 3 months of systemic MHT.

Referrals

No specialist referrals are required at this stage; discussed the option of a pelvic floor physiotherapist if genitourinary symptoms progress.

Screening and Prevention

Advised to continue routine 2-yearly mammograms via BreastScreen Victoria (next due January 2026) and 5-yearly Cervical Screening Tests (next due November 2027), with a baseline DEXA scan to be considered at age 50 given the maternal history of hip fracture.

Follow-up Plan

Scheduled a review appointment in 12 weeks (approx. 07/08/2024) to assess symptom response, treatment tolerability, bleeding pattern, and blood pressure, or earlier if side effects occur.

Patient Education

Provided written fact sheets from the Australasian Menopause Society (AMS) on Perimenopause, Menopausal Hormone Therapy, and Lifestyle Modifications, and clarified that MHT does not provide contraception, advising barrier methods or consideration of a hormonal IUD if contraception is desired.

MBS Item Numbers Considered/Applied

• Item 695 (Menopause and perimenopause health assessment, 20 minutes or more)