Investigations

Some investigations may be necessary to perform for diagnosis or to help in formulating a treatment plan.

Here are the most commonly used investigations and their indications.

The Pap smear and mammography should be mandatory routine screening investigations for all women over forty.

1. Pap smear

  • Every two years
  • If had previous abnormal smear (dysplasia or HPV changes) within the last two years
  • A vault smear every 2 years following hysterectomy if the woman has ever had an abnormal pap smear
  • If presents with abnormal vaginal bleeding.

2. Mammogram ± breast ultrasound

  • Every two years over the age of 50 years and probably between 40-50 years particularly if post menopausal
  • If any breast abnormality is found on examination.

The following investigations are not mandatory and should be chosen judiciously depending on the woman’s history and examination.

3. Hormone levels

FSH/Oestradiol levels:
  • Have limited use because of the variability day to day in the perimenopause (best taken in early follicular phase i.e. day three of cycle to assess reduced ovarian reserve. E2<150pmol/l with FSH>10IU/l).
  • On oral therapy are inaccurate and should not be used as a guideline for determining dosages.
  • Where there is doubt in diagnosis eg after hysterectomy with no subsequent menstrual marker.
  • FSH may be helpful in determining between premature menopause and secondary amenorrhoea in the under – 40 age group.
  • To track absorption where implant therapy is used, also with implant tachyphylaxis and where absorption with patch or gel use is concerned.
Testosterone levels:

May be appropriate when symptoms of loss of energy and sexual function.

 

  • Measure in the morning and after day seven of the cycle; include total sensitive testosterone, and Sex Horomone Binding Globulin (SHBG) and free testosterone to evaluate non – SHBG bound level. A “sensitive” testosterone level may reflect the androgen status more accurately.
Thyroid Stimulating Hormone :
  • Indicated where there are symptoms of thyroid dysfunction or palpable thyroid, which may manifest around the time of the menopause.

4. Lipid profile & fasting glucose

  • Especially if risk factors or family history

5. Coagulation studies

  • Where past history of thrombo-embolism, particularly if spontaneous and/or less than 40 years.
  • Where family history or known familial disorder.

6. Full blood examination, iron studies

  • Where abnormal bleeding, especially menorrhagia.

7. Vaginal ultrasound

  • To assess endometrial thickness where there is abnormal vaginal bleeding: >4-5mm thickness in the post menopausal woman requires endometrial sampling either by endometrial biopsy or hysteroscopy and curettage.
  • To exclude endometrial pathology such as polyps or submucous fibroids.
  • To exclude pelvic pathology such as ovarian cysts or fibroids.

Referral to a gynaecologist is appropriate for further investigations such as hysteroscopy and endometrial biopsy, where the ultrasound shows an increased endometrial thickening greater than 5mm in the post menopause, pelvic pathology or with any postmenopausal bleeding.

8. Bone Assessment

Bone Density:

There are different techniques for establishing bone density. The most reproducible form is the DEXA (dual energy X-ray absorptiometry), which scans both the lumbar spine and the femoral neck. The test is indicated:

Where there are major risk factors for osteoporosis:

  • eg strong family history, previous fracture, history of oral corticosteroid or thyroxine for the treatment of other illnesses.
  • Further biochemistry including calcium and 25 hydroxy vitamin D when osteopenia or osteoporosis is detected on bone density.
  • Urinary or serum bone turnover markers are still controversial, mainly used for experimental trials and are not recommended routinely.

9. Urodynamic Assessment

Where there is a history of stress and or urge incontinence, to determine the severity of the incontinence. The result will aid in planning and managing the symptom.

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