Practice observed.

Abstract

Rachel was referred in 2006. She was only 35 but already had a chequered gynaecological history. She had delivered four children (with depression in both antenatal and postnatal periods) but lost one from a cot death. She had a long history of pain attributed to pelvic inflammatory disease with removal of first one ovary and then attempted vaginal hysterectomy. Due to bleeding from iliac vessels an abdominal incision was needed. The remaining ovary was then removed. Prior to referral she had been prescribed hormone replacement therapy (HRT). The initial hospital prescription was an estradiol 50 mg/24 hour weekly patch but this did not suppress sweating and she assumed that because of this the patches did not stick. She had improved with 100 mg/24 hour patches but continued to have problems with adhesion. Her general practitioner (GP) then tried estradiol valerate (branded as Progynova) with which she complained of mood swings and was then changed to generic estradiol 2 mg, which she was still taking when I first met her. ‘Failure to settle on standard regimens’ is one of the referral criteria for the specialist menopause service and Rachel certainly met this. She was hot during the day and sweating with subsequent chills at night. Nights were very disturbed, she was tossing and turning, woken by the sweating and would frequently need to get up to pass urine. She was itchy and described moods that swung but were predominantly low. She was tearful, irritable and snapping at the family. Her concentration and memory were both poor and she survived by writing lists. Her vagina was dry and uncomfortable. She explained that all sexual interest and her sense of femininity had evaporated. In addition to vaginal discomfort she was slow to arousal. Sexual difficulty was the feature that most distressed her as she perceived it as threatening her relationship. Her breasts had shrunk and though she had lost the scourge of her periods she was generally tired and unhappy. Rachel was slim and fit and her vascular and breast risk profile were unremarkable. The treatment recommendation at the end of a long discussion was to try non-oral delivery of estradiol once more but using a different patch in the hope that this would help adhesion. I asked her to try the 100 mg/24 hour dose again. In addition, we would add testosterone. Having lost her ovarian source of androgens, deficiency was a possibility and the symptoms described appeared consistent with this. At the time patches licensed for women were not available so testosterone 1% gel (Testogel) was prescribed with advice to subdivide each sachet and use 1/7 daily such that each would last a week. Four months later her sweats had reduced but not gone, sleep had improved but remained broken, she remained irritable though overall mood had lifted and concentration was not quite as bad. Sex had occurred on one occasion, which was not uncomfortable. Rachel felt that she was very slow to achieve arousal. There was still significant patch irritation but the higher delivery of estrogen seemed to have helped. The next modification therefore was to stay with the non-oral route but change patches to gel in equivalent dose (Sandrena 1.0 g twice daily) and slightly increase the testosterone to 1/4 sachet daily. Four months on Rachel was coping with life and concentrating well enough to hold down a job. She was still flushing during the day and waking 2–3 times at night. She had not had sex for six months as she still lacked inclination and genital response. At that point the dose of both estrogen and testosterone were increased but with the proviso that I would need serum estimation of both hormones if the response was insufficient. By September 2007 (almost a year after we started to modify her HRT), Rachel was still experiencing daytime flushing. Her sleep was broken though not to the same extent. Her mood had lifted and she was more cheerful though still somewhat variable. Her urinary frequency was unchanged. Although she reported no vaginal dryness she remained disinterested in sex. As a positive element her skin irritation had settled. Our laboratory needs precise information on its request form before agreeing to measure serum estradiol and did not process the GP request. They did report serum follicle stimulating hormone (FSH) of 60.5 IU/L. Serum testosterone was supraphysiological at 11.0 nmol/L. The learning point from this is that if contemplating androgen replacement using anything other than the low dose patches I would now measure initial levels and monitor at each stage of modification. Clearly from Rachel’s perspective, estradiol remained under-replaced despite 3 1.0 g sachets daily and we Menopause International 2012; 18: 36–37. DOI: 10.1258/mi.2012.012003