Menopause/Perimenopause GP MBS

Perimenopause and Menopause Health Assessment Date: 01 November 2024 Patient Details: Name: Sarah Jones Date of Birth: 12/03/1968 Age: 56 Address: 12 Acacia Avenue, London, SW1A 0AA Contact Number: 020 7946 0000 Reason for Assessment: Patient presents today for a comprehensive assessment of perimenopausal symptoms, including hot flushes, sleep disturbances, and mood changes. She is seeking guidance on managing these symptoms and understanding her options for hormone replacement therapy. Medical History: Past Medical History: Hypertension, managed with Lisinopril 10mg daily. No other significant medical conditions. Surgical History: Appendectomy in 1985. Medications: Lisinopril 10mg daily, Vitamin D 1000 IU daily. Allergies: No known allergies. Family History: Mother had a history of osteoporosis; father had a history of cardiovascular disease. Social History: Non-smoker, drinks alcohol occasionally (1-2 units per week), works as a teacher, lives with her husband, good support system. Menstrual History and Menopausal Symptoms: Menstrual Cycle Details: Irregular periods for the past 18 months, with cycles ranging from 28 to 45 days. Last menstrual period was 3 months ago. Menopausal Stage Assessment: Perimenopause. Symptom Checklist: - Vasomotor Symptoms: Experiencing hot flushes several times a day, moderate severity, and night sweats 2-3 times a week. - Psychological Symptoms: Reports mood swings, occasional anxiety, and difficulty concentrating. - Sleep Disturbances: Difficulty falling asleep and staying asleep, waking up frequently during the night. - Genitourinary Symptoms: Reports mild vaginal dryness. - Musculoskeletal Symptoms: Reports occasional joint pain. - Sexual Health: Reports decreased libido. - Other Symptoms: None reported. Physical Examination: General Appearance: Alert and oriented female, appears her stated age. Blood Pressure: 130/80 mmHg. Heart Rate: 72 bpm. Weight and BMI: Weight 70 kg, Height 165 cm, BMI 25.8. Clinical Examination Findings: Cardiovascular and respiratory systems unremarkable. Abdomen soft, non-tender. Breast examination normal. Pelvic examination deferred due to patient preference. Investigations: Pathology Results: FSH 45 IU/L, LH 38 IU/L, Oestradiol 25 pg/mL, TSH normal, Lipid profile normal. Imaging Results: DEXA scan scheduled. Other Investigations: None. Assessment and Diagnosis: Patient is experiencing perimenopausal symptoms, including vasomotor, psychological, and sleep disturbances. Diagnosis: Perimenopause. Differential diagnoses considered: Thyroid dysfunction, depression. Management Plan: Algorithm Applied: Utilised the algorithm for managing perimenopausal symptoms from "A Practitioner’s Toolkit for Managing Menopause". Lifestyle Modifications: - Dietary Advice: Advised to maintain a balanced diet rich in calcium and vitamin D, and to limit caffeine and alcohol intake. - Exercise Recommendations: Recommended regular moderate-intensity exercise, including weight-bearing activities. - Stress Management: Recommended relaxation techniques, such as deep breathing exercises and mindfulness. - Sleep Hygiene: Advised to establish a regular sleep schedule, create a relaxing bedtime routine, and ensure a comfortable sleep environment. Hormone Replacement Therapy (HRT) Discussion: - Benefits and Risks: Discussed the benefits of HRT in managing menopausal symptoms, including symptom relief and potential benefits for bone health. Discussed the risks, including increased risk of breast cancer, cardiovascular events, and venous thromboembolism. Informed patient of the importance of regular breast screening. - Prescribed HRT Regimen: Patient opted to start HRT. Prescribed transdermal oestrogen patch (50 mcg) and cyclical progesterone (Utrogestan 100mg orally for 14 days each month). - Patient Decision and Consent: Patient provided informed consent for HRT. Non-Hormonal Therapies: Recommended a vaginal moisturiser for vaginal dryness. Referrals: Referral to a gynaecologist for further assessment and management. Screening and Prevention: Recommended annual mammograms and cervical screening as per national guidelines. DEXA scan scheduled to assess bone density. Follow-up Plan: Review in 3 months to assess response to HRT and monitor for any side effects. Patient Education: Provided education on perimenopause, HRT, lifestyle modifications, and potential side effects. Provided written information on menopause management. MBS Item Numbers Considered/Applied: 36, 5000, 5020