General Gynaecology Intake

Subjective:
Chief Complaint:
Persistent hot flashes, insomnia, difficulty with weight loss, surgical menopause, severe bilateral hip pain.

History of Present Illness:
Linda Parker presents for evaluation of persistent vasomotor symptoms and weight management concerns in the context of a complex gynecologic and orthopedic history. She reports a history of hot flashes and significant insomnia, with difficulty maintaining sleep, which began during the perimenopausal period. She notes a strong family history of menopausal symptoms, with both her mother and grandmother affected. In early 2022, she initiated low-dose oral estrogen therapy for menopausal symptoms, but experienced irregular adherence, including missed doses and subsequent doubling of doses. Approximately four months after starting estrogen, she developed two weeks of abnormal uterine bleeding, which prompted further evaluation. Endometrial biopsy revealed endometrial hyperplasia, and she subsequently underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy in September 2022. Pathology identified an early-stage endometrial neoplasm, for which she did not require adjuvant chemotherapy or radiation. She has been under regular surveillance with gynecologic oncology since surgery, with no reported recurrence.

Following surgical menopause, she continued to experience vasomotor symptoms, mood disturbances, and insomnia. She trialed medical cannabis edibles for symptom management, which improved her sleep but was discontinued due to employment-related drug testing. She continues to report severe hot flashes and poor sleep quality. She denies any history of breast cancer or genetic predisposition to gynecologic malignancy, as genetic testing for cancer susceptibility genes was negative in both herself and her mother. She also reports a history of progressive osteoarthritis, with bilateral knee replacements in 2024 and ongoing severe bilateral hip pain attributed to familial osteoarthritis and congenital bony overgrowth. She denies any history of bone-on-bone degeneration or traumatic joint injuries. She reports difficulty with weight loss since her orthopedic surgeries, with a shift in adipose distribution from the hips and buttocks to the abdomen. She expresses a desire to lose 30 to 40 pounds in preparation for planned hip replacement surgery. She has a remote history of an ovarian cyst in late adolescence, which was surgically managed. She has no other significant medical or surgical history aside from the aforementioned procedures.

Obstetric History:
She has a history of a single pregnancy, which was electively terminated. She has no history of multiple pregnancies. No complications or other obstetric events are reported.

Gynaecological History:
She experienced menarche at age 12. Her menstrual cycles were regular until the onset of perimenopause in her mid-40s, with menopause occurring between ages 45 and 47. She experienced significant vasomotor symptoms, including hot flashes and insomnia, during the perimenopausal transition. She has a remote history of an ovarian cyst in late adolescence, which was surgically managed. She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy in September 2022 for endometrial hyperplasia with early-stage endometrial neoplasm. She has no history of hormone replacement therapy after cancer treatment and no history of recent estrogen exposure after oophorectomy. She has no reported history of fibroids, polycystic ovary syndrome, endometriosis, or sexually transmitted infections. Her last Pap smear was prior to her hysterectomy, with no abnormal results reported. She has used low-dose oral estrogen therapy for menopausal symptoms prior to her cancer diagnosis.

Past Medical History:
She has a history of endometrial hyperplasia and early-stage endometrial neoplasm, diagnosed in 2022. She has a history of progressive osteoarthritis, with bilateral knee replacements in 2024 and ongoing severe bilateral hip pain attributed to familial osteoarthritis and congenital bony overgrowth. She has a remote history of an ovarian cyst in late adolescence. She has no history of hypertension, diabetes, thyroid disorders, or other chronic medical conditions. She has not required chemotherapy or radiation after her hysterectomy. She has no other health issues or surgeries other than orthopedic surgery and hysterectomy. She has not received cortisone injections for joint pain. She has no history of breast cancer or estrogen/progesterone sensitive cancers. She has previously used low-dose oral estrogen therapy for several months in 2022 prior to her cancer diagnosis.

Past Surgical History:
She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy in September 2022 for endometrial hyperplasia with early-stage endometrial neoplasm. She had bilateral knee replacements in March and May 2024 for severe osteoarthritis. She has a remote history of ovarian cyst removal in late adolescence. She has not experienced surgical complications. She is planning for bilateral hip replacement surgery due to severe osteoarthritis and congenital bony overgrowth.

Family History:
Her mother was diagnosed with stage IV ovarian cancer in her early 70s and has been in remission for nine years following prolonged chemotherapy. Her grandmother also had a history of osteoarthritis. There is no family history of genetic cancer markers.

Social History:
She is currently employed and lives with her husband. She does not use tobacco, alcohol, or illicit drugs. She previously used medical cannabis edibles for sleep and vasomotor symptoms but discontinued due to employment-related drug testing. She is focused on weight management and healthy dietary choices, with no processed foods in her diet. There is no reported exposure to domestic violence.

The Review of Systems:
Constitutional – She reports no fever, chills, weight loss, weight gain, night sweats, fatigue, or weakness.
Eyes – She reports no double vision, no blurry vision, and wears glasses.
ENT – She reports no hearing loss, dizziness, runny nose, nose bleeds, nasal septum deviation, or sore throat.
Integumentary – She reports no rashes, dry skin, or eczema.
Cardiovascular – She reports no chest pain, heart palpitations, or dizziness.
Respiratory – She reports no shortness of breath, no cough, and no wheezing.
Endocrine – She reports no known thyroid issues, no changes to appetite, no weight change, and no tiredness or lethargy.
Gastrointestinal – She reports no nausea, vomiting, diarrhea, or constipation. She denies problems swallowing, abdominal pain, or bloating.
Genito Urinary – She reports no dysuria, hematuria, frequency, or urgency.
Musculoskeletal – She reports no joint tenderness, redness, or swelling.
Neurological – She reports no headaches or weakness, and no history of seizures.
Psychology – She reports no changes in mood and no anxiety.
Hematology – She denies easy bruising.

Current Medications:
She takes meloxicam as needed for hip pain, tizanidine as needed for muscle relaxation, and gabapentin as needed for neuropathic pain. She takes a women's probiotic, flaxseed oil, and liquid vitamin D3. She is not currently taking any prescription medications on a regular basis except as needed. She does not use statins. She is not currently using medical marijuana.

Allergies:
She has no allergies to medications. She has a history of hypersensitivity to nickel, cobalt, and potassium chloride, manifesting as contact dermatitis. She has no other known allergies.

Gynecologic History:
She undergoes total abdominal hysterectomy with bilateral salpingo-oophorectomy in September 2022 for endometrial hyperplasia with early-stage endometrial neoplasm.
She has a remote history of ovarian cystectomy in late adolescence.
She initiates low-dose oral estrogen therapy for menopausal symptoms in early 2022, discontinued after diagnosis of endometrial hyperplasia.
She has no history of hormone replacement therapy after cancer treatment.
She has no history of recent estrogen exposure after oophorectomy.
She has negative genetic testing for cancer susceptibility genes.
She has no history of estrogen or progesterone sensitive cancers.
She has no history of sexually transmitted infections.
She has a single lifetime pregnancy, electively terminated.
She has regular gynecologic oncology surveillance post-hysterectomy, with no evidence of recurrence.
She has no current reproductive plans.

Objective:
Vital Signs:
Her weight is 291 pounds. Her height is estimated at 5 feet 9 inches. Her body mass index is 43. No other vital signs are documented.

Physical Examination:
General – Appears well, no obvious discomfort
ENT – No cervical lymphadenopathy, throat normal with no erythema or exudates.
Cardiovascular – Heart rate regular, S1S2 normal with no murmurs or added sounds, peripheral pulses easily palpable, equal and symmetric, normal capillary refill, no jugular venous distension, no carotid bruits, no central or peripheral cyanosis, no clubbing, no peripheral edema.
Respiratory – Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion.
Skin – No rashes, no dry skin, no skin infections
Breasts: Normal symmetrical appearance, no erythema, skin changes or tethering, no inverted nipples. Non-tender normal breast tissue on palpation with no palpable masses. Normal axillary lymph nodes on palpation.
Abdomen – Normal bowel sounds, abdomen soft and non-tender, no distension.
Genito Urinary – External genitalia normal, no inguinal adenopathy, normal pelvic examination
Musculoskeletal – No tender, swollen, warm, or erythematous joints. Normal range of motion in examined limbs, no muscle tenderness.
Neurological – Alert and oriented in time, space and person, normal gait, strength 5/5 in upper and lower limbs, cranial nerves 2-12 grossly intact, coordination intact.

Test Results:
Her blood counts are within normal limits. Her thyroid stimulating hormone is 1.4 mIU/L, which is within the optimal range. Body composition analysis reveals a weight of 291 pounds, body mass index of 43, intracellular water of 60.3 pounds, extracellular water of 39.7 pounds, muscle mass of 75.6 pounds, and fat mass of 154 pounds. Her body fat percentage is approximately 50%. Visceral fat level is elevated. Distribution of muscle and fat is symmetric across extremities. No discordance in upper and lower limb muscle mass.

Assessment:
Problem:

1. She presents with persistent vasomotor symptoms, including severe hot flashes and significant insomnia, in the context of surgical menopause following total abdominal hysterectomy with bilateral salpingo-oophorectomy for early-stage endometrial neoplasm. She continues to experience mood disturbances and difficulty with weight management, with a notable shift in adipose distribution to the abdomen. She has a history of progressive osteoarthritis with bilateral knee replacements and ongoing severe bilateral hip pain. There is no evidence of disease recurrence on surveillance, and she has not received hormone replacement therapy since her cancer treatment.

Differential Diagnosis:
She may be experiencing persistent menopausal vasomotor symptoms secondary to surgical menopause. Alternative considerations include sleep disturbance due to chronic pain from osteoarthritis, mood disorder related to hormonal changes, and metabolic syndrome contributing to weight gain and central adiposity. Less likely, but to be considered, are thyroid dysfunction or other endocrine abnormalities.

Plan:

• Orders and Referrals  
• Baseline laboratory panel including vitamin D, vitamin B12, and high-sensitivity C-reactive protein to assess nutritional deficiencies and systemic inflammation.  
• Hormonal levels evaluation to rule out unexpected endogenous hormone production.  
• Treatments  
• Continue vitamin D supplementation with instructions to take it with a meal for optimal absorption.  
• Magnesium glycinate supplementation recommended to support sleep, mood, and muscle health.  
• Consider initiating a compounded sublingual tirzepatide formulation for weight management, with counseling on gradual onset of effect and monitoring for adverse reactions.  
• No hormone replacement therapy initiated due to oncologic history.  
• Patient Education  
• Counseled on anti-inflammatory nutrition, prioritizing protein and non-starchy vegetables, and maintaining regular physical activity within orthopedic limitations.  
• Educated on the role of micronutrient supplementation and the importance of product quality.  
• Discussed risks and benefits of regenerative therapies and weight loss medications.  
• Follow Up  
• Follow up for laboratory review and ongoing symptom monitoring.  
• Continue regular gynecologic oncology surveillance every six months.  
• Further follow-up to be arranged based on laboratory results and response to interventions.  

Surgery Discussion:

• Purpose of the Surgery: The main objective of the total abdominal hysterectomy with bilateral salpingo-oophorectomy was to treat endometrial hyperplasia and remove an early-stage endometrial neoplasm. The surgery aimed to eliminate malignant and pre-malignant tissue, thereby preventing progression to advanced endometrial carcinoma and alleviating abnormal uterine bleeding. The anticipated benefits included disease eradication, avoidance of adjuvant chemotherapy or radiation, and reduction of future gynecologic cancer risk.
• Risks and Complications: Potential risks and complications of the surgery, as discussed, include but are not limited to perioperative bleeding, infection, injury to adjacent pelvic organs, thromboembolic events, and surgical menopause with resultant vasomotor symptoms, mood disturbances, and insomnia. There is also a risk of long-term sequelae such as pelvic floor dysfunction and changes in adipose tissue distribution.
• Alternatives: Alternatives to surgery that were discussed included serial endometrial biopsies every three months for surveillance of endometrial hyperplasia. Non-surgical management was declined by the patient due to the invasiveness and discomfort of repeated biopsies. No other non-surgical or less invasive alternatives were explicitly discussed.