symptoms of menopause

For this case study, we have a 46 year old female presenting with symptoms of menopause to include hot flashes, night sweats, and genitourinary dysfunction lasting one month. This patient has a history of hypertension (HTN), obesity, and atypical squamous cells of undetermined significance (ASCUS). This patient also has a family history of breast cancer but is up-to-date on her annual mammograms, which have been normal thus far. Hormone replacement therapy (HRT) is a treatment option used to address estrogen loss seen during menopause. HRT is typically comprised of low dosages of estrogen. There are two different medication regimens utilized by practitioners; one regimen consists of an estrogen-only therapy the other utilizes a combination of estrogen and progestin. The purpose of adding progestin during HRT is to address the excess stimulation of the endometrium caused by estrogen. This excess stimulation of the endometrium can lead to cancer and endometrial hyperplasia. This form of HRT is not an appropriate course of therapy in women who have had a hysterectomy. HRT improves the patient’s quality of life by decreasing vasomotor side effects. HRT also prevents urogenital atrophy and osteoporosis (Rosenthal & Burchum, 2021; Roberts & Hickey, 2016).

Studies indicate prolonged use (over ten years) of estrogen therapy (ET), especially in older adults, increases the incidence of heart disease, thrombosis, and stroke (Rosenthal & Burchum, 2021). Additionally, combination estrogen-progestin therapy (EPT) has been associated with an increased incidence of breast cancer. However, ET and EPT have been shown to reduce mortality rates when prescribed in lower doses, for an appropriate time frame (less than ten years), in women under 60 (Rosenthal & Burchum, 2021). Because this patient’s hypertension is not well controlled with her current medication regimen, she is at an increased risk for stroke and should not be placed on traditional HRT. This patient also has a family history of breast cancer, which is more reason for her not to be placed on an HRT even though she is closely monitored for breast cancer starting her on HRT is an unnecessary risk when there are other options available to manage her symptoms, This patient has a history of ASCUS which further contraindicates her taking an oral HRT. For these reasons, it would be more appropriate to start this patient on either an SSRI or an SNRI (Rosenthal & Burchum, 2021; Roberts & Hickey, 2016). If this medication regimen does not adequately reduce symptoms of hot flashes, either a dose adjustment or a medication change to gabapentin, pregabalin, or clonidine should be considered (Rosenthal & Burchum, 2021). If the patient’s genitourinary symptoms are strictly vulvar or vaginal, a topical estrogen-based cream could be considered as it is much safer than oral ET (Rosenthal & Burchum, 2021).

Colposcopic examinations in women over 40 are often unsatisfactory due to cellular alterations that occur with aging. Vaginal estrogen is useful for treating urogenital atrophy, urge incontinence, and recurrent urinary tract infections without inducing endometrial hyperplasia (Bruno et al., 2019). Premarin or Estrace are both creams that can be used to treat these conditions. Furthermore, this regimen is administered cyclically as a short-term therapy, significantly reducing the risk of the adverse effects associated with long term oral HRT agents (Rosenthal & Burchum, 2021). Utilizing HT does help to prevent osteoporosis but only while the patient is taking the medication. After discontinuation, bone mass decreases by 12% (Rosenthal & Burchum, 2021). This is problematic for many patients on HRT as they are often weaned off their hormone therapy at an age that bone density loss is the most dramatic. Alternative treatment options for this potential complication should be incorporated into the treatment plan. Alternatives include raloxifene, bisphosphonates, calcitonin, and teriparatide. Providers should also educate their patients about ensuring they get adequate amounts of vitamin D and calcium and weight-bearing exercises to prevent bone density loss (Rosenthal & Burchum, 2021).

For this patient, I would ask her to monitor her blood pressure for two weeks and bring in a written daily account to determine whether her blood pressure medication needs to be changed or if her current HTN is caused by stress or white coat syndrome. If her blood pressure remains elevated, I would discontinue the current regimen and try her on a combination HCTZ/Linsiopril 25-20mg daily. I would not start her on an HRT at this time. Instead, I would start her on escitalopram 10mg daily for a week and then increase to 20mg daily. I would prescribe 0.5 grams of Premarin intravaginally daily for 21 days, then off for seven days to be repeated for three months. I would follow up on the Premarin in 3 months and discontinue it as soon as symptoms improve. Finally, I would encourage the patient to incorporate weight-bearing exercises 2-3 times a week and prescribe a multivitamin that included calcium and at least 1000IUs of vitamin D daily to promote bone health (Rosenthal & Burchum, 2021; Drugs.com, 2021).

Reference

Bruno, M.T., Coco, A., Di Pasqua, S., & Bonanno, G. (2019). Management of ASC-US/HPV positive post-menopausal woman. Virology Journal, 16(39). https://doi.org/10.1186/s12985-019-1145-5

Drugs.com (2021). Drug interaction checker. Retrieved from https://www.drugs.com/interaction/list/?drug_list=1013-0,738-10576,1259-0,1661-0

Roberts, H., & Hickey, M. (2016). Managing the menopause: An update. Maturitas, 86(2016), 53-58. https://doi.org/10.1016/j.maturitas.2016.01.007

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.