Tales from the menopause clinic: practice observed.

Helen was 36 when she was referred on to the menopause clinic by a hospital gynaecologist. She had daytime flushes, mood changes and breast tenderness, all of which had worsened since stopping co-cyprindiol on account of migraine. She had been diagnosed with polycystic ovaries at the age of 17 and had not had a period in the six months since the last withdrawal bleed. The letter suggested that her ongoing management would be better served by the holistic approach of the menopause clinic. Helen had two children aged 15 and 10 who had been conceived spontaneously and her husband had had a vasectomy. Contraception was not a problem we needed to address. The co-cyprindiol had been used purely to manage the polycystic ovarian syndrome (PCOS). Migraine had been occurring weekly when taking the co-cyprindiol with flashing lights but no scotoma or neurological loss to constitute aura. Its frequency had progressively increased and had worsened in the pill-free week. Since stopping, there had been no migraine, though headache had continued. Discussion revealed a further disadvantage in that Helen was increasingly having to wax her upper lip and had had electrolysis to the linea alba. Helen described her mood change as hideous being tearful, irrational and depressed. This was endorsed by her mother. To Helen this was the most troublesome of her symptoms. As she had no periods there was no premenstrual exacerbation but she could clearly identify her mood being worse at the times when both the hot flushes and breast tenderness were most pronounced. The working hypothesis was that these correlated with a degree of estrogen deficiency. Helen worked hard to maintain her BMI of 27.5 and exercised regularly; she was aware of the recommendation for a low glycaemic index diet and had already been prescribed metformin at 500 mg twice daily. Our starting tactic after much discussion was to use low-level transdermal estrogen to address the apparent estrogen deficiency symptoms with continuous cyproterone acetate (CPA) in the lowest available daily dose (25 mg – half of a 50 mg tablet). Cyproterone is structurally a progestogen with potent antiandrogen receptor activity. It is not licensed for this indication but potentially this would address both a need for endometrial opposition and the androgen excess of the PCOS. Continuous use was intended to avoid changing progestogen levels and avert bleeding. It was vital to avoid fetal exposure as the drug could prevent virilization, the vasectomy achieved this. Three months later, Helen reported having been well when using one measure of estradiol gel along with the CPA. She had no flushes and her breast tenderness disappeared. Following instruction she had increased to two measures of gel and had then developed migraine. She therefore stopped both and had a painful, heavy and prolonged withdrawal bleed. However, since then her flushes and breast tenderness had resolved and mood remained good. We wondered if she had in fact ovulated. Pragmatically she was advised to use no more than one measure of estradiol gel and then only if the mood symptoms returned. Endometrial protection would be addressed with CPA 25 mg daily for two weeks if she had not had a true period by three months. Helen used no estradiol and remained amenorrhoeic and so took the progestogen challenge. This made her mood feel premenstrual but there was no significant withdrawal bleeding and this was re-assuring. Over the next three months, Helen then had three spontaneous cyclical bleeds and needed no exogenous hormones. Time went by. Helen continued without flushes or mood problem. Breast tenderness and migraine were less of a bother, only being associated with a period. It appeared as though the original symptoms had sufficiently resolved. However, there is always a but. . .. Hirsutes and weight gain had become more of a problem despite the exercise. There were few options available but we decided to add spironolactone 100 mg for its antiandrogenic effect along with topical eflornithine cream. Spironolactone is unlicensed for this indication, but as before, detailed discussion, an informed decision and thorough documentation made this an option for specialist practice. The eflornithine irritated and was stopped, but the addition of the spironolactone does appear to have had a positive effect. Hair growth has reduced, weight has been lost, mood has remained buoyant and stable, there have been no flushes for some time and breast tenderness has been minimal and only linked to bleeding. In addition, Helen has only had two migraines. Menopause International 2011; 17: 155–156. DOI: 10.1258/mi.2011.011032