Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or follow-up for menopause
Specific symptoms (e.g., hot flashes, night sweats, vaginal dryness, sleep problems, mood changes)
History of Present Illness:
Onset, duration, frequency, and severity of menopausal symptoms.
Impact of symptoms on daily life and quality of sleep.
Any changes in menstrual bleeding patterns (irregularity, amenorrhea – absence of periods for 12 months).
Past Medical History:
Age at last menstrual period (LMP) to confirm menopause.
Underlying medical conditions (e.g., diabetes, hypertension) that may influence menopause or treatment options.
Surgical history, including hysterectomy or oophorectomy (removal of ovaries).
Family history of breast cancer or other hormone-related cancers.
Medications:
List all current medications, including any medications for menopausal symptoms (hormone therapy, antidepressants).
Social History:
Tobacco use (may worsen symptoms and increase health risks).
Alcohol intake (may worsen hot flashes).
Exercise habits (regular activity can improve mood and sleep).
Family History:
Family history of breast cancer, ovarian cancer, or endometrial cancer.
Physical Exam:
General examination: Assess vital signs for normal range.
Breast examination: To rule out breast masses or abnormalities.
Pelvic examination (if indicated): May be performed to assess vaginal health and rule out other causes of vaginal dryness or bleeding.
Laboratory Tests (not routinely required, but may be indicated in specific cases):
Follicle-stimulating hormone (FSH) level: Elevated FSH can confirm menopause, although not diagnostic on its own.
Thyroid function tests (TSH): To rule out thyroid disorders that can mimic menopausal symptoms.
Assessment:
Menopause: Based on age at LMP, menopausal symptoms, and exclusion of other causes, confirm or suspect menopause.
Severity of menopausal symptoms: Evaluate the impact of symptoms on the patient’s well-being.
Plan:
Management approach depends on individual needs and preferences:
Lifestyle modifications:
Regular exercise
Weight management
Dietary changes (limiting caffeine, alcohol)
Stress management techniques
Sleep hygiene practices
Non-hormonal therapies:
Lubricants and moisturizers for vaginal dryness
Sleep aids for sleep problems
Antidepressants for mood changes (if clinically indicated)
Hormone therapy (HT): Discuss the benefits and risks of HT with the patient, considering individual factors like medical history, family history, and symptom severity. If HT is chosen, select the appropriate type and dosage based on the patient’s needs (e.g., estrogen alone for women who have had a hysterectomy, combined estrogen and progestin for women with an intact uterus).
Complementary and alternative therapies (CAM): Discuss potential benefits and risks of CAM options (e.g., black cohosh, herbal remedies) and emphasize the lack of strong scientific evidence for their effectiveness.
Follow-up: Schedule regular follow-up visits to monitor symptoms, response to treatment, and bone health (bone density testing may be recommended in some cases).
Education:
Educate the patient about menopause, physiological changes, symptoms, and management options.
Discuss the importance of healthy lifestyle habits and potential benefits and risks of various treatment options.
Provide resources for menopause support groups or patient advocacy organizations.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Menopause is a natural transition, and management strategies should be individualized to optimize patient well-being and address specific concerns.