Menopause is not just “hot flashes”—it is a systemic hormonal shift that affects almost every organ system. For the emergency clinician, recognizing the symptoms of perimenopause and menopause is crucial for expanding the differential diagnosis once life-threatening conditions are ruled out. Dr. Pam Dyne joins us for a crash course on evaluating menopausal and perimenopausal patients in the ED.

The “Why”: Why Menopause Matters in the ED

The Mimic: Menopausal symptoms can mimic emergencies, including cardiac events, neurologic issues, and acute musculoskeletal injuries.
The “Nothing Bad” Trap: After a negative workup (e.g., for chest pain or abdominal pain), telling a patient “everything is normal” often leaves them without answers. Identifying menopause as a potential etiology provides patient-centered closure and a path to treatment.
Empowerment: Many medical providers are insufficiently trained when it come to menopause – ED clinicians can help patients advocate for themselves.

Physiology Refresher: When the Ovaries Retire

The Signal: Prior to menopause, the brain sends FSH/LH to the ovaries, and the ovaries answer with estrogen.
The Shift: In menopause, the ovaries “retire.” The brain keeps shouting (higher FSH levels), but the ovaries don’t respond.
Perimenopause: Hormones fluctuate wildly, cycles become irregular, and symptoms are often at their peak due to inconsistency.

Hormone Therapy (MHT): Debunking the Myths

A major barrier to treatment is the “mass hysteria” caused by the 2002 Women’s Health Initiative (WHI) study.

The Correction: Modern re-analysis shows that for healthy females under 60 and within 10 years of menopause, hormone therapy is extremely safe. (There are some exceptions, including females at high risk for certain cancers)
The Benefits: It has been shown to reduce all-cause mortality by 30% and has many potential health benefits, including lower the risk of Alzheimer’s, Parkinson’s, and osteoporotic fractures.

The Difficult Pelvic Exam: ED “Hacks”

Examining older female patients can be challenging for myriad reasons, including physical limitations and lack of proper ED pelvic exam gurneys.

The Upside-Down Speculum: If you can’t use stirrups, keep the patient flat on the bed. Turn the speculum upside down (handle facing up) so it doesn’t hit the gurney. Tip: Push down on the handle; don’t pull up like a laryngoscope.
Lateral Decubitus: Perform the exam with the patient on their side (top leg held up) if they cannot flex their hips.
Comfort: Use liberal lubrication and consider topical lidocaine gel.
The “Hidden” Problem: Always check for old/forgotten pessaries or fecal impaction in cases of pelvic pain or recurrent UTIs.

Clinical Pearls: Specific Presentations

1. Post-Menopausal Bleeding

Rule: Cancer until proven otherwise.
Workup: Speculum exam (confirm source) + Ultrasound (measure endometrial thickness) + Endometrial biopsy (usually outpatient).

2. Genitourinary Syndrome of Menopause (GSM)

Symptoms: Vaginal dryness, thinning tissue, pH changes, and recurrent UTIs (≥3 culture-proven UTIs in 12 months or ≥2 in 6 months).
ED Treatment: ED docs can and should prescribe vaginal estrogen cream. It is not absorbed systemically and is highly effective at preventing future UTIs.

3. Pelvic Organ Prolapse

Types: Cystocele (bladder), Rectocele (rectum), or Uterine prolapse.
Exam Tip: Symptoms are often gravity-dependent. If you don’t see the bulge while the patient is supine, ask them to bear down.

4. Musculoskeletal (MSK) Syndrome of Menopause

Presentation: atraumatic joint pain, tendinopathies.
Cause: Estrogen receptors are located throughout the MSK system; loss of estrogen leads to inflammation and ligamentous changes.

Key Takeaways for the ED Clinician

Keep menopause on your differential: Don’t dismiss vague aches, mood changes, or urinary issues in women aged 45–60 as “just stress.”
Look at the Problem: If a patient has pelvic pain or bleeding, do the exam. You might find a simple fix, like a forgotten pessary or local atrophy.
Connect to Care: If you suspect menopause is the culprit, point them toward menopause.org to find a certified practitioner.

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

Guest:

Dr. Pamela Dyne, Professor of Clinical Emergency Medicine and Chief Physician Wellness Officer at Olive View UCLA Medical Center

Resources:

North Americal Menopause Society (NAMS) – Menopause.org

UTIs and Estrogen: the Overlooked Link, By Ashley Winter, MD; Rachel Rubin, MD; and Howie Mell, MD, MPH. ACEP Now, February 16, 2022

American College of Obstetricians and Gynecologists (ACOG): Menopause

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Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.