Increasing medical specialization has undoubtedly resulted in better outcomes for patients with denned conditions. The converse to this is the lack of a gener-alist opinion for the presentation that is less obvious. One of the functions of the menopause clinic is to stand back and look at the bigger picture: to make an experienced analysis of a multisystem presentation. We routinely integrate risks and benefits affecting different bodily systems and in this respect differ from most other specialities.Just under a year ago, I was asked by her general practitioner (GP) to think about Tracey who was 54. I was given selected hospital correspondence and results from the previous three years and Tracey had written reams about what had happened to her. I take the view that in such situations the more information the better.From this I gleaned:Twenty years previously, age 33, Tracey had developed menopausal flushes. Her mother had been prematurely menopausal in her 30s. No other explanation was identified and she was treated successfully with cyclical HRT.Sixteen years before, age 37, Tracey had changed to continuous combined hormone replacement therapy (HRT) in the form of 2 mg estradiol +1 mg norethister-one (Kliofem?, NovoNordisk). This was also effective and she had no obvious flushes or other menopausal symptoms.Three years before, age 51, Tracey had begun intermittently to bleed vaginally. This was more like discoloured discharge than a period but varied from pink to brown and occasionally red. The GP notes indicated that when examined her vagina had looked atrophic. Tracey had been advised to reduce the Kliofem and with that alteration, the blood loss had increased rather than reduced.
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