Practice observed.

Abstract

A 74-year-old lady attended my general practice surgery complaining that her urine was ‘pink’ and she had noted some vaginal bleeding. She was otherwise well and had no urinary or systemic symptoms to report other than ‘quite a lot of bruising on my bottom’. I know the lady well, she attends my Primary Care Menopause clinic for regular review as she is someone who has benefited from long-term use of estrogen replacement therapy (ERT). Having had a hysterectomy and bilateral oophorectomy in the past for fibroids she has remained on ERT ever since. Several attempts had been made over the years to withdraw hormone therapy (HT) but proved unsuccessful. There were frequent documented discussions assessing her risk profile, each time she opted to remain on ERT accepting any associated increased risks. At 74 she is extremely fit and active and a passionate equestrian. She is slim, a lifelong non-smoker with no history of hypertension or cardiovascular disease. The only history of note is osteopaenia detected on previous Dual X-ray absorpitometry scan. She continues to participate in regular breast screening and is on the lowest dose of transdermal estrogen required to control her symptoms. On closer questioning I discovered that she had just completed an adventurous horse trek over rough terrain and had been in the saddle for three days. Clinical examination revealed extensive bruising in the saddle region and inner thighs. There was spontaneous bleeding from the vaginal vault and vaginal mucosa; the vaginal walls were literally oozing blood. The vaginal vault was otherwise normal with no lacerations visible. Other than her ‘pink’ urine (frank haematuria), vaginal bleeding and impressive bruising she had no complaints and felt perfectly well. I reviewed her notes looking for clues and discovered that since her last review at the menopause clinic she had undergone investigation of a ‘dizzy spell’ and had been referred to the Stroke Clinic to exclude a transient ischaemic attack. The history was unconvincing and all investigations were negative (electrocardiography, computed tomography scan, cardiac echo, carotid Doppler scans, chest X-ray, biochemistry and haematology were all normal). It was concluded she had probably experienced a vasovagal episode. Nevertheless, she was advised to stop her ERT and commence antiplatelet therapy (clopidogrel) and a statin for preventive purposes (as per SIGN 108.) She explained that since stopping her ERT she had been feeling awful and started self-medicating with Gingko biloba having heard it was a ‘natural’ remedy for menopausal symptoms. Alarm bells immediately rang – I had been lucky enough to attend the 2011 British Menopause Society conference, which included a lecture on ‘alternative therapies for the menopause’. The speaker described the commonly used alternative therapies and highlighted possible interactions and cautions. From the lecture I remembered hearing that Gingko biloba is known to interact with and potentiate the antiplatelet activity of clopidogrel. I therefore advised her to discontinue the Gingko biloba immediately. A urine sample was sent to the laboratory for culture and sensitivity testing along with routine haematological and biochemical screening tests. At review a week later, the bleeding had stopped and most of the bruising had disappeared, her urine looked normal and urinalysis was negative. The previous urine test report confirmed the presence of red blood cells but no pus cells and culture was negative; all her blood test results were normal including renal function and cholesterol which was 4.8. This appeared to be a clear case of an ‘over the counter’ remedy interacting with prescribed medication and the problem resolved as soon as the interaction was suspected and the culprit stopped. Reflecting on this case I felt it highlighted several important issues that concern clinicians working in all fields of medicine not just menopause management: all prescribers need to be aware of the increasing use of ‘alternative’ and over-the-counter remedies and when taking a drug history should remember to enquire about all prescribed and non-prescribed ‘medications’. Both patients and doctors need to be educated about the danger of potential interactions of ‘non-prescribed’ products, which are often purchased from the Internet or supermarket removing the ‘safety net’ of a pharmacist. In the field of menopause management there are a multitude of alternative remedies in use as women seek to manage their menopause more ‘naturally’ so an awareness of the most commonly used products and their potential for interaction with prescribed medications is vital. Menopause International 2012; 18: 116–117. DOI: 10.1258/mi.2012.012021