Q. A 45-year-old patient of mine has menorrhagia with flooding and clots (a transvaginal ultrasound was normal). She has been taking norethisterone 5mg twice daily from day five to 22, which is controlling her periods.
She stopped after four months, but all the symptoms returned. She started taking the norethisterone again and has been on this treatment for 18 months.
She has tried the Mirena coil but this has not helped. Are there any problems with continuing the norethisterone?
You mention a transvaginal ultrasound, so I am making the assumption the woman has been investigated for possible causes and nothing (for example fibroids) has been found. It might be worth considering a clotting screen in case she has a clotting disorder.
You say the patient has tried the Mirena coil, but do not say for how long, she should have given it at least six months.
Interestingly, norethisterone is not considered to be particularly effective for menorrhagia, being greatly surpassed by tranexamic acid. Nevertheless it clearly works for this patient, and I do not see a problem with continuing the norethisterone if she is happy.
However, if she does not smoke and does not have other risk factors for cardiovascular disease or any other contraindications, she might want to consider the combined Pill, which would combine contraception, bleeding control and ease of use.
Dr Anne Szarewski, clinical consultant and honorary senior lecturer at the Cancer Research UK Centre for Epidemiology, Mathematics and Statistics, London.
Q. What is the recommended regimen for chronic cough in children, after ruling out asthma and bacterial chest infections?
Chronic cough is not uncommon in paediatric practice. When taking the history, ask about duration of the cough and whether it is worse during the day or night, its relationship to exercise and meals, and whether it is paroxysmal or not. Check for associated features such as face redness or vomiting.
Does the child have any problems related to ears, throat and sinuses?
Ask about frequency, consistency, greasiness or floating of stools.
Has the child had any chest infections, and if so, how often, how long do they last and was hospital needed? Has the child had any other infections?
The examination will include plotting weight and height on a growth chart and checking for finger clubbing and chest deformity. Examination should include ENT, cardiovascular and chest examination as well as abdominal palpation to exclude hepato- or splenomegaly.
Include an FBC, an immunoglobulin test, a chest X-ray and possibly a sweat test.
Cough variant asthma is the most common cause. Other causes include subacute infections, usually diagnosed from the history and a chest X-ray.
Whooping cough syndrome is milder than whooping cough and is caused by viruses and other micro-organisms.
Immunoglobulin deficiency is another possibility, particularly IgA and IgG subclass deficiency.
Always consider gastro-oesophageal reflux in an infant.With a post-nasal drip and chronic tonsillar disease, an ENT referral is needed.
Cystic fibrosis is a diagnosis not to be missed. Remember that 15 per cent of such patients do not have pancreatic deficiency and so do not fail to thrive.
Rarer causes include bronchiectasis and congenital lung abnormalities, and immotile cilia and ciliary dyskinesia.
Dr Nawfat Sharief, consultant paediatrician at the Basildon Hospital.