Case study - Emotional lability and sleep problems in a female teacher

Clinicians need to be prepared to look beneath the surface of a very general complaint, says Dr Sarah Gray.

(Photograph: Istock)

Laura is 52 years old and there is nothing of particular note in her medical summary.

She is concerned because she has become irritable and is struggling to cope with minor challenges. She teaches at a local secondary school.

She feels that the problem is worse because she is not sleeping and asks for sleeping tablets.

Reaching a diagnosis
Such a scenario is very common in primary care. It is crucially important that Laura's situation is explored in more detail because her story could present a variety of physical or mental health-related problems.

Among the list of potential differential diagnoses is menopause. Hormone-sensitive mood change is experienced by many women at menopause and often presents as irascibility or emotional lability. Given her age, it is reasonable to ask Laura about the pattern of her periods.

The most likely age for women in the UK to experience menopause is at about 52. Before then, the cycle length typically shortens and becomes erratic. This can take up to 10 years. The last menstrual bleed is impossible to define until there is one year's subsequent amenorrhoea.

Laura tells you that she has not had a period for six months and the one before that was three months earlier.

Night sweats
Ask her if she gets any daytime flushes or night sweats. These are not a universal experience but affect about three-quarters of women to some degree.

Falling estrogen levels are the most likely explanation in a woman with irregular menses. Flushes can occur before cycle regularity is lost, when detailed questioning will usually reveal the problem to be worse in the premenstrual phase.

Laura tells you that she feels a bit warm during the day but is really bothered at night and gets out of bed to cool off. Occasionally, she is so clammy that she changes her nightdress.

The GP should ask if it is always the sweating that wakes her. Research confirms that sleep disturbance is a menopausal symptom in its own right and can be debilitating. It usually follows a different pattern to that of depression and women describe becoming wide awake in the small hours with no apparent cause and variable difficulty in going back to sleep.

Laura tells you that sometimes it is the sweating that wakes her, but often she wakes and then begins to sweat.

Having initially satisfied yourself that there are no obvious pathological features to Laura's case, it is entirely reasonable to make a clinical diagnosis of menopause.

Having provided this explanation, it becomes easier to ask about the existence and extent of other estrogen deficiency problems, such as vaginal dryness, bladder irritability, sexual function and interest.

If the bleeding pattern is masked by interventions such as a levonorgestrel intrauterine system, it is reasonable for symptoms to be interpreted alone.

Gonadotrophin levels may support your clinical assessment but are not diagnostic. FSH should be raised on at least two occasions, ideally six weeks apart, for this to be consistent with ovarian failure.

Menopausal symptoms commonly appear before ovarian failure is established and women should neither be denied help because a single blood test is normal nor told that they can stop using contraception because one measurement is raised.

Laura accepts your explanation and then admits that she had wondered if this was the case but did not feel ready to grow old.

Laura needs time to contemplate and understand the physiological changes. It is worth pointing out that alcohol may exacerbate flushing and caffeine can aggravate sleep disturbance.

Exercise has been proven to help flushing, as well as cardiovascular and bone health. It is important to consider an adequate dietary intake of calcium because bone turnover will now be accelerated.

You can offer Laura patient advice leaflets, lend or recommend books and suggest reputable websites. You can also explain that there are various options available should she decide that more needs to be done.

  • Dr Gray is a GPSI in women's health in Truro, Cornwall
  • This article was originally published in MIMS Women's Health

Further resources

  • Rees M, Purdie D W, Hope S. The menopause: what you need to know (second edition). RSM Press, London, 2006
  • Currie H. Menopause: answers at your fingertips. Class Publishing, London, 2006

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