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Posted: October 31st, 2023
A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms. She has a history of HTN. She complains of hot flushing, night sweats, and genitourinary symptoms. She had felt well until 1 month ago and she presented to her gynecologist for her annual gyn examination and to discuss her symptoms. She has a history of ASCUS about 5 years ago on her pap, other than that, Pap smears have been normal. Home medications are Norvasc 10mg qd and HCTZ 25mg qd. Her BP today is 150/90. She has regular monthly menstrual cycles. Her LMP was 1 month ago.
Discuss the case study scenario above,and explain the type of treatment regimen you would recommend for treating your patient, including the choice or pharmacotherapeutics you would recommend and explain why. Be sure to justify your response. Explain a patient education strategy you might recommend for assisting your patient with the management of their health needs. Be specific and provide examples.
Support your work using 5 APA reference to support your treatment of choice and disussion.
The patient’s presentation indicates she is experiencing menopausal symptoms including hot flashes, night sweats, and genitourinary symptoms at 46 years old (Nelson, 2017). Her family history of breast cancer and history of ASCUS on pap smear five years prior also warrant further investigation and treatment. Given her symptoms, medical history, and the fact that she is still menstruating regularly, the most appropriate initial treatment would be pharmacotherapy with hormone therapy (HT). HT has been shown to effectively relieve vasomotor symptoms associated with menopause like hot flashes and night sweats in 90% of patients (Santen et al., 2014). It also offers protection against risks like osteoporosis and cardiovascular disease that can increase during and after menopause (Rossouw et al., 2002).
I would recommend starting the patient on a low-dose estrogen and progestin combination therapy medication like Prempro or Activella. Combination HT containing both estrogen and progestin is the standard for women with a uterus to prevent endometrial hyperplasia and cancer caused by unopposed estrogen (Nelson, 2017). It also effectively treats vasomotor symptoms. Given her history of hypertension controlled with Norvasc and HCTZ, starting with a low dose and monitoring her blood pressure is prudent (Santen et al., 2014). We could titrate the dose up gradually as tolerated to gain maximum symptom relief.
Close monitoring during the first year of HT is important to assess treatment effectiveness and watch for any side effects or changes in her health (Santen et al., 2014). Follow up in 3 months would allow us to evaluate response to therapy, perform a pelvic exam, and order relevant screening tests like a mammogram and pap smear based on her risk factors and history (Nelson, 2017). Continuing annual exams and screening tests are recommended for the duration of HT use per menopause guidelines (Santen et al., 2014).
In educating the patient, I would explain the treatment rationale for HT in relieving her symptoms and long term health protection based on her risks (Rossouw et al., 2002). Discussing potential side effects like breast tenderness or a potential increase in vaginal bleeding would allow her to feel informed (Nelson, 2017). Recommending lifestyle modifications to reduce modifiable risk factors could offer additional relief and reassurance (Santen et al., 2014). Close follow up provides an opportunity for her questions to be addressed and adherence reinforced.
Rossouw, J. E., et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. Jama, 288(3), 321-333.
Santen, R. J., et al. (2014). Postmenopausal hormone therapy: an Endocrine Society scientific statement. The Journal of clinical endocrinology and metabolism, 99(11), 3931-3958.
Nelson, H. D. (2017). Menopause. The Lancet, 389(10090), 746-758.
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