183. What Would Cicero Do?

Understandably, my exam room explanations have undergone countless iterations and though perhaps smooth, may sound a little too polished, too rote.

For example, today 66 year old Sandra expresses concern about painful intercourse, and I explain that this is common due to menopausal changes: decreased estrogen leaves the vaginal surface dry, irritable, and less flexible.  I start to encourage her to consider a vaginal estrogen preparation, when she starts to interrupt me, but I won't let her, my prepared speech is too near it's conclusion to allow distractions, and concludes with the observation that the estrogen has no systemic side effects because it doesn't enter the circulation 

When I finish she resumes her objection.  It seems that a few years ago she tried a vaginal estrogen and within a few hours experienced breast tenderness, a clear indication of systemic absorption.  Furthermore her mother died of breast cancer, increasing her wariness about any form of estrogen.

I quickly backtrack, learning again that my primary role is not to provide fluent, persuasive explanations, but to listen, to guide the discussion with questions such as, is there a family history of beast or cancer, or have you used any hormone preparations in the past?