Station 61
Amanda Bush
Age: 47 years old female
Full Case
Patient’s Data
Patient’s name: Amanda Bush
Age: 47-year-old female
Past medical history
- Generalised Anxiety Disorder (managed with CBT)
Drug and Allergy history
- Rigevidon (combined oral contraceptive pill)
Recent notes/consultation
- No significant recent consultations
Patient has booked routine telephone consultation to discuss concerns.
Patient's Story (Role player’s brief)
Patient’s Story
You are Amanda, aged 47. You have booked this consultation to discuss some new symptoms that have developed over the past two months. You have been experiencing excessive sweating, particularly noticeable at night, alongside persistent fatigue and unintended weight loss.
Symptoms Detail (Only disclose if asked):
The sweating occurs both during the day and most nights, often soaking your clothes and bed sheets. The fatigue is constant and does not improve with rest or sleep. You have lost approximately 5 kg over the last two months without any changes to your diet or activity levels.
You’ve had intermittent episodes of a racing heartbeat during this time, but you attribute this to your anxiety, even though you haven’t felt particularly anxious recently.
Menstrual and Hormonal History: You are currently taking the combined oral contraceptive pill (Rigevidon), and your periods remain regular and controlled. You have not experienced hot flushes, vaginal dryness, or any changes in your menstrual flow.
Social and Family History: You work full-time as a teacher and enjoy your role but have been feeling increasingly tired during the day. You do not smoke or drink alcohol. Your mother went through an early menopause. There is no family history of cancer or other significant medical conditions.
Ideas: You think the symptoms might be related to menopause.
Concerns: You’re worried about the possibility of early menopause, like your mother experienced, and the symptoms are beginning to affect your work as you feel tired all the time.
Expectations: You would like to have some blood test to check if you are going through menopause.
Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.
Marking Scheme
Data Gathering and Diagnosis
- Ask about the onset of symptoms
- Clarify whether the sweats occur during the day or just at night
- Ask about fever (to rule out infectious cause)
- Ask about fatigue, whether fatigue worsens with activity and whether symptoms are improving, worsening, or remaining unchanged
- Ask about any potential triggers for the symptoms (fatigue and night sweats)
- Ask about joint pains or the presence of any lumps or swellings (to rule out possible malignancy, particularly lymphoma)
- Ask about weight loss and quantify it (how much weight loss and over what period)
- Ask about menstrual history and whether periods are regular; explore menopausal symptoms such as hot flushes, vaginal dryness, irritability, reduced sex drive,
- Ask about palpitations, feeling hot when others are feeling cold, diarrhoea, neck swelling or discomfort (to explore hyperthyroidism)
- Ask about any family history of medical conditions including cancer, thyroid disorders, or early menopause
- Explore the impact of symptoms on daily functioning
- Take a social history including smoking and alcohol use
- Make a working diagnosis of likely hyperthyroidism while considering other differentials such as malignancy (e.g. lymphoma).
Example of explanation to patient
Amanda, you’re right to consider menopause as a possible cause for your symptoms like sweating and fatigue. However, since you’re currently on the combined oral contraceptive pill, it can mask the usual hormonal changes that occur during menopause, making it less likely to be the cause of your symptoms.
One possibility we need to consider is overactive thyroid. The thyroid is a gland that helps control how your body uses energy. If it’s a bit overactive, it can cause symptoms like weight loss, feeling very tired, sweating more than usual, and even a racing heartbeat, some of the things you’ve been describing.
Does that make sense so far?
That being said, it is also important to rule out more serious conditions, something like lymphoma, which is a type of cancer that can cause similar symptoms. I want to reassure you that I’m not saying you have got cancer, but it is important to also consider this while investigating the cause of your symptoms. Do you have any questions so far?
Management
Management
- Offer a face-to-face appointment to allow for physical examination, to check for lymphadenopathy, assess pulse and blood pressure, and consider ECG to evaluate for arrhythmias, especially considering her palpitations and the suspicion of hyperthyroidism. This is particularly important to rule out atrial fibrillation, which may be associated with Graves’ disease/thyrotoxicosis.
- Request urgent blood tests including FBC, U&Es, thyroid function tests, LFTs, HbA1c, CRP, and ESR.
- Explain that if blood results suggest an overactive thyroid, treatment would typically involve starting medication and referring to an endocrinologist (hormone specialist) for further management.
- Advise keeping a symptom diary to help identify patterns or potential triggers for the sweats.
- Recommend lifestyle strategies to manage fatigue, including pacing activities and maintaining good sleep hygiene.
- Arrange follow-up within 24–48 hours to review blood results and plan next steps.
- Advise seeking urgent medical attention if symptoms worsen or if she becomes more unwell in the meantime.
Learning point from this station:
The combined oral contraceptive pill (COCP) contains synthetic oestrogen and progestogen, which regulate the menstrual cycle and maintain stable hormone levels. Because of this, it can mask the typical hormonal fluctuations seen in natural menopause, such as declining oestrogen levels. As a result, menopausal symptoms like hot flushes, night sweats, or irregular periods may not be as apparent or may be absent altogether.
In natural menopause, ovarian function gradually declines, leading to reduced oestrogen production. This hormonal shift can cause vasomotor symptoms (e.g. hot flushes, night sweats), changes in mood, sleep disturbances, and genitourinary symptoms.
Therefore, in a woman on the COCP who presents with symptoms such as sweating, fatigue, and weight loss, menopause is a less likely explanation. In such cases, testing for follicle-stimulating hormone (FSH) is not useful, as the COCP suppresses natural hormone levels and makes FSH results unreliable. NICE guidance advises against using FSH to diagnose menopause in people on COCP for this reason.
This case highlights the importance of managing clinical uncertainty. A structured approach should be taken to explore other differentials, particularly hyperthyroidism, which is the most likely diagnosis in this scenario, as well as excluding serious pathology such as malignancy. Early identification, appropriate investigations, and safety netting are key.