Ellen is a 53-year-old woman requesting a repeat script for perindopril which she takes for hypertension. She is otherwise well, with normal lipids and fasting glucose done recently. She has a family history of breast cancer (mother had postmenopausal breast cancer).
Ellen’s blood pressure is 140/90 mmHg which is a little higher than previously recorded for her. She wonders if it is due to poor sleep. Her last menstrual period was two years ago and since then she has struggled with persistent hot flushes and night sweats. She says she does not wish to take any menopausal hormone therapy due to her family history of breast cancer, but prefers ‘natural approaches’, and has recently started taking a herbal supplement for menopause called Menopause Supplements Extra Strength Hot Flash Support, that she purchased online.
Communication and consultation skills
What communication strategies can you use to approach this consultation in a non-judgemental and empathic manner?
How would you approach this case if Ellen wanted to use a traditional medicine from her culture (such as Aboriginal, Torres Strait Islander, or Chinese) for hot flushes?
Non-judgmental and Empathic Approach:
- Active Listening: Start the consultation by actively listening to Ellen’s concerns and validating her experiences, especially regarding her sleep and menopause symptoms.
- Open-ended Questions: Use open-ended questions to allow Ellen to express her feelings and preferences about her treatment options.
- Empathy: Show empathy by acknowledging the challenges she faces with menopause and her concerns about hormone therapy due to her family history.
- Non-judgmental Attitude: Avoid making judgments about her choice of herbal supplements and her preference for natural approaches.
- Cultural Sensitivity: If Ellen prefers traditional medicine from her culture, respect her cultural beliefs and practices. Ask about her cultural background and any traditional remedies she might be considering.
- Education and Partnership: Provide information in a clear, respectful manner, emphasizing a partnership in her care decisions.
Clinical information gathering and interpretation
What additional history and examination do you need to assist Ellen in making an informed decision about the use of integrative medicine modalities for her hot flushes?
Additional History and Examination:
- Detailed Symptom History: Ask about the frequency, severity, and triggers of her hot flushes and night sweats.
- Sleep Patterns: Inquire about her sleep hygiene, patterns, and any potential sleep disorders.
- Menopausal Symptoms: Explore other menopausal symptoms she might be experiencing.
- Medication and Supplement Use: Obtain a detailed list of all medications and supplements she is currently taking, including dosages.
- Family History: Clarify the specifics of her family history of breast cancer, including age of onset and any other relevant cancers.
- Physical Examination: Conduct a thorough physical examination, focusing on cardiovascular and breast examination, given her family history.
Making a diagnosis, decision making and reasonin
What are the potential risks associated with the use of this supplement? Think about both direct and indirect risks.
How will Ellen’s family history and medical history influence the decision about whether this supplement is safe?
Potential Risks of the Supplement:
- Direct Risks: The herbal supplement might interact with her antihypertensive medication (perindopril), potentially affecting blood pressure control. The safety and efficacy of the supplement might not be well-established.
- Indirect Risks: The use of unregulated supplements might delay more effective conventional treatments. There is also a risk of contamination or incorrect dosages in supplements purchased online.
Influence of Family and Medical History:
- Breast Cancer Risk: Given her family history, any supplement or therapy that might have estrogenic effects could potentially increase her breast cancer risk.
- Estrogen’s Role in Breast Cancer:
- Hormone-Sensitive Cancers: Estrogen can promote the growth of hormone-sensitive breast cancers. Tumors that are estrogen receptor-positive (ER+) can grow in response to estrogen.
- Increased Risk: Prolonged exposure to estrogen, either endogenous (produced by the body) or exogenous (from external sources like hormone therapy or OCPs), is associated with an increased risk of breast cancer.
- Family History:
- Genetic Predisposition: A family history of breast cancer, especially in first-degree relatives, can increase an individual’s risk, and the use of estrogen-containing therapies in such cases may need careful consideration.
- Estrogen’s Role in Breast Cancer:
- Hypertension Management: The supplement could interfere with her blood pressure management, necessitating close monitoring.
Clinical management and therapeutic reasoning
What resources can you use to understand the risks and benefits of using this supplement, including information on herb–drug interactions?
What non-pharmacological strategies (including other integrative medicine modalities) can you suggest to Ellen to help her manage her hot flushes and general wellbeing after menopause? What if her main concern was poor sleep causing fatigue?
How can you monitor the safety of this supplement for Ellen?
Resources for Understanding Risks and Benefits:
- Reliable Sources: Use databases like the Therapeutic Goods Administration (TGA), National Center for Complementary and Integrative Health (NCCIH), and peer-reviewed journals.
- Herb-Drug Interactions: Refer to resources like the Natural Medicines Comprehensive Database or the Medscape Drug Interaction Checker.
Non-pharmacological Strategies:
- Lifestyle Modifications: Recommend regular physical activity, a balanced diet, stress management techniques, and maintaining a healthy weight.
- Cognitive Behavioral Therapy (CBT): Suggest CBT for managing menopausal symptoms and sleep disturbances.
- For Menopausal Symptoms:
- Cognitive Restructuring:
- Identify Negative Thoughts: Help the patient identify and challenge negative thoughts related to menopause, such as “I’m losing control” or “These hot flashes are unbearable.”
- Reframe Thoughts: Encourage reframing these thoughts into more positive or neutral ones, like “Hot flashes are uncomfortable, but I can manage them” or “This is a temporary phase.”
- Stress Management:
- Relaxation Techniques: Teach relaxation techniques such as deep breathing, progressive muscle relaxation, and guided imagery to help manage stress and reduce the frequency and severity of hot flashes.
- Mindfulness: Introduce mindfulness practices that focus on staying present and non-judgmental about menopausal symptoms.
- Behavioral Strategies:
- Pacing and Planning: Encourage patients to pace themselves and plan activities to avoid overheating, such as dressing in layers and staying hydrated.
- Trigger Identification: Help patients identify and avoid triggers for hot flashes, such as spicy foods, caffeine, and alcohol.
- Sleep Hygiene:
- Regular Sleep Schedule: Encourage maintaining a regular sleep schedule by going to bed and waking up at the same time every day.
- Sleep Environment: Advise creating a comfortable sleep environment, including a cool, dark, and quiet room.
- For Sleep Disturbances:
- Stimulus Control:
- Associate Bed with Sleep: Encourage using the bed only for sleep and sex, not for activities like reading or watching TV. If unable to sleep, advise getting out of bed and engaging in a quiet activity until feeling sleepy.
- Consistent Routine: Maintain a consistent bedtime routine to signal the body that it is time to sleep.
- Sleep Restriction:
- Limit Time in Bed: Initially limit the time spent in bed to the actual amount of time spent sleeping. Gradually increase this time as sleep efficiency improves.
- Avoid Naps: Advise against daytime naps, which can interfere with nighttime sleep.
- Cognitive Restructuring for Insomnia:
- Challenge Sleep Myths: Address and correct misconceptions about sleep, such as the belief that one must get 8 hours of sleep every night to function well.
- Manage Worry: Teach techniques to manage worry and racing thoughts at bedtime, such as setting aside “worry time” earlier in the day to address concerns.
- Relaxation Techniques:
- Progressive Muscle Relaxation: Teach progressive muscle relaxation to reduce physical tension and promote sleep onset.
- Breathing Exercises: Introduce breathing exercises to promote relaxation and reduce anxiety at bedtime.
- Paradoxical Intention:
- Reduce Performance Anxiety: Encourage the patient to stay awake and avoid trying to sleep, which can paradoxically reduce anxiety about not sleeping and promote sleep onset.
- Mind-Body Techniques: Propose techniques such as yoga, mindfulness, and acupuncture, which may help with hot flushes and general well-being.
Monitoring Safety:
- Regular Follow-ups: Schedule regular follow-ups to monitor her blood pressure, symptom progression, and any side effects from the supplement.
- Blood Tests: Periodically check for any abnormalities in liver and kidney function tests if she continues using the supplement.
Preventive and population health
What strategies can you use to facilitate shared decision-making?
What preventive strategies would you need to consider for Ellen that are specific to menopause?
How would your strategies be different if Ellen was an Aboriginal or Torres Strait Islander?
Consider how being in a rural location might affect accessibility to integrative medicine practitioners and complementary medicine products. How can you support your patients to access high quality complementary medicine care?
Shared Decision-Making Strategies:
- Decision Aids: Use decision aids to help Ellen understand the risks and benefits of her options.
- Clear Communication: Clearly explain the potential outcomes of different treatments, including no treatment.
Preventive Strategies:
- Bone Health: Discuss calcium and vitamin D supplementation and bone density screening.
- Cardiovascular Health: Encourage regular cardiovascular risk assessments and lifestyle modifications to mitigate risks.
Cultural Sensitivity for Aboriginal or Torres Strait Islander Patients:
- Cultural Support: Engage with Aboriginal and Torres Strait Islander health workers or liaison officers to provide culturally appropriate care.
- Accessibility: Consider the accessibility of services in rural areas and provide information on telehealth options if applicable.
Professionalism
How can you communicate effectively with complementary therapists/integrative medicine providers if Ellen decides to see one?
Where can you find reliable evidence on complementary medicines?
How would you approach this consultation if Ellen presents with a list of investigations that have been requested by a complementary therapist, so that the tests can be bulk billed?
Communicating with Complementary Therapists:
- Collaboration: Communicate openly with complementary therapists, sharing relevant medical information with the patient’s consent.
- Documentation: Document all discussions and decisions made in collaboration with complementary therapists.
Reliable Evidence on Complementary Medicines:
- Evidence Sources: Refer to the Cochrane Library, PubMed, and professional guidelines for evidence-based information on complementary medicines.
Approaching Requested Investigations:
- Critical Appraisal: Critically appraise the necessity and relevance of the requested investigations. Explain to Ellen the criteria for Medicare bulk-billing and the importance of evidence-based testing.
General practice systems and regulatory requirement
What regulatory issues do you need to consider if Ellen wants to see a complementary therapist?
What are the potential risks with the manner in which Ellen is purchasing this supplement (ie online)?
Regulatory Issues:
- Regulation Awareness: Be aware of the regulations governing complementary therapies in Australia. Ensure any practitioner Ellen consults is registered with appropriate professional bodies.
- Online Purchases: Advise Ellen about the risks of purchasing supplements online, such as the potential for counterfeit products.
Managing uncertainty
How will you approach the consultation if there is insufficient or inconclusive evidence for the integrative medicine modalities that Ellen wants to use?
How would you approach the consultation if there are safety concerns about the supplement Ellen wants to use?
What if Ellen is using a supplement a friend gave her, and can’t remember what it is called?
Insufficient Evidence:
- Transparency: Be transparent with Ellen about the limitations of evidence for certain integrative modalities. Discuss the potential risks and benefits and encourage shared decision-making.
Safety Concerns:
- Risk Communication: If there are safety concerns, communicate these clearly and provide alternative evidence-based options. Offer to monitor any potential side effects closely.
Unknown Supplements:
- Safety First: If Ellen is using an unknown supplement, advise her to discontinue its use until its safety and contents can be verified. Encourage her to bring any remaining product for evaluation.
Identifying and managing the significantly ill patient
How would you approach managing a patient who is very ill, for example, diagnosed with metastatic cancer or presenting with severe depression, and who wants to use integrative medicine modalities, either integrated with or as an alternative to conventional treatment?
Integrative Medicine for Severely Ill Patients:
- Holistic Approach: For patients with severe illnesses, adopt a holistic approach, integrating conventional treatments with complementary therapies if they are safe and evidence-based.
- Palliative Care: Work closely with palliative care teams to ensure comprehensive care that addresses physical, emotional, and spiritual needs.
- Clear Communication: Ensure clear communication with all members of the healthcare team, including any complementary therapists involved, to provide coordinated care.