Tales from the clinic.

Two countries/two services/two cases from each These tales from the clinic focus on cases from primary care and from a tertiary referral service in secondary care. The cases from secondary care describe less common conditions, but for all women with lack of estrogen, irrespective of the underlying cause, management in a specialist service offers the benefits of a multi-disciplinary team approach, including psychological support. We hope to raise awareness of all potential causes of estrogen deficiency in younger women, including those with POI and the potential benefits associated with early recognition and treatment. POISE, a long-term, NIHR funded, multicentre UK study, aims to determine whether the combined pill or hormone replacement therapy, has the best impact on bone health (primary outcome) in women with premature ovarian insufficiency (POI). It is due to commence very soon. Premature ovarian insufficiency refers to ovarian failure resulting in hypoestrogenism and amenorrhoea before the age of 40. The incidence is estimated to be between 1.1% to 3.7%, although this may be an underestimate, due to reliance on self-reporting. There is no doubt that in practice, POI is under diagnosed, despite excellent guidelines and toolkits. This can lead to poor health outcomes and a significant adverse effect on quality of life. Two cases from Dr Karen Soffe, a GP with a special interest in Women’s Health from the Republic of Ireland: I am a GP working in a small town in the west of Ireland. I have been working to improve my skills in the management of women through their post reproductive years for many years now. I set up a menopause clinic 5 years ago and am currently working towards validating this work by gaining the advanced PPMC certification. One of the more frustrating aspects of establishing a menopause service has been the number of women presenting in their 50’s with osteoporosis, severe urogenital atrophy, mental health issues and a high risk of cardiovascular disease. These women have in fact untreated premature ovarian insufficiency. The under diagnosis of POI in Ireland is exacerbated by several factors. Infertility services are largely provided by private clinics who operate on a self-referral basis and GPs are often unaware that patients have had fertility treatment. This is particularly true of women using egg donation. There is often no follow up provided for patients and as they do not require contraception, this potential clinical interaction with their general practitioner is also lost. Cancer care in children is provided by either one of two stand-alone tertiary service level paediatric hospitals. The clinical records of survivors of childhood cancers over time may be lost as a result of relocation and changing GPs. Sometimes patients don’t even disclose it as part of their past medical history. Historically, an entire generation of GP’s had a negative opinion of Hormone Replacement Therapy (HRT) and very little experience of prescribing it. As a result, many of these women, even if they had presented, would have had poor advice regarding HRT as a treatment option. These two anonymised cases, described with the patients consent, highlight some of the difficulties experienced by patients and the potential patient benefits to be gained by better education of General Practitioners and the wider primary health care team.Case 1 LW, a 35-year-old type 1 diabetic, presented to me with an acute medical issue while I was providing emergency cover in another clinic. As part of the medical history, I asked her the date of her last menstrual period. She said she had been amenorrhoeic for over 10 years. I noted from her file that she had had two previous FSH levels >35 IU/l, as part of routine bloods, dating back seven years. On further discussion she told me that she had been referred to a gynaecologist ten years previously, when her periods had stopped and was prescribed the combined pill (COC). She was under the impression that this was to “regulate her periods”. Shortly afterwards, she was diagnosed with type 1 diabetes and sent to see an endocrinologist, who advised her to stop the pill, as it was unsafe in people with diabetes (although UKMEC 2).