The patient, for this discussion will be named MJ. MJ is a 46-year-old, 230-pound woman with a family history of breast cancer and hypertension. MJ is up to date on yearly mammograms and presents with complaints of hot flashes, night sweats, and genitourinary symptoms. MJ has a history of ASCUS from about five years prior, but recent pap smears appear normal. Her current medications include Norvasc 10mg and HCTV 23 mg QD. MJ blood pressure is 150/90 at the time of the interview, states regular menstrual cycles with her LMP a month ago.
Due to MJ’s age, weight, and complaints of hot flashes, night sweats, and genitourinary symptoms, a diagnosis of menopause was given. Menopause can be best described as the last menstrual period indicating the end of menstruation and characterized as the decline or loss of estrogen (Roberts & Hickey, 2016). Estrogen production occurs in both males in females but more profoundly in females. In females, estrogen promotes female maturation and help regulate the activity of female reproductive systems (Rosenthal & Burchum, 2018). The typical onset of menopause is around 51-52 years, although 95% of women will enter menopause between the ages of 45-55 years (Rosenthal & Burchum, 2018). Symptoms of menopause include vasomotor symptoms, genitourinary symptoms, mental changes, bone loss, altered lipid metabolism. MJ stated she was having hot flashes and night sweats, which are vasomotor symptoms. The patient weight can also be a risk factor for her vasomotor symptoms. Previous studies indicated obesity to be protective against vasomotor symptoms but that ideology has changed (Thurston & Joffe, 2012). Genitourinary symptoms include vaginal dryness, vaginal burning, vaginal discharge, and genital itching (mayoclinic.org, n.d.). Since the urethra and the vagina have the highest concentrations of estrogen receptors, a decline in estrogen levels can lead to vaginal atrophy of the epithelium causing vaginal dryness as well as pain with intercourse (Rosenthal & Burchum, 2018). Due to clear and up to date mammograms, breast cancer was ruled out.
Regarding MJ’s previous history of ASCUS but with normal pap smears, cervical cancer was ruled out. ASCUS or atypical squamous cells of undetermined significance “are abnormal cells in the tissue that lines the outer part of the cervix and are the most common abnormal finding in a pap test,” according to cancer.gov (n.d.). Furthermore, they may be a cyst or polyp that is benign in menopausal women with low hormone levels.
A treatment regimen of hormonal therapy (HT) is suggested. HT consists of low doses of estrogen (with or without progestin) and is given to counteract the loss of estrogen during menopause (Rosenthal & Burchum, 2018). Progestin is sometimes added with estrogen to counterbalance estrogen-mediated stimulation of the endometrium. In the case of Lucy, estrogen- only can suffice for her HT. HT, when used in low doses, is the most effective treatment for vasomotor symptoms, aid vaginal dryness associated with menopause, and increase mood and libido (Mayoclinic.org, n.d.).The typical short treatment periods are three to four years at low doses are presumably safe, although reassessment at consistent intervals is well recommended. Due to Lucy’s family history of breast cancer, a complete and personalized risk profile will be needed as well as educating Lucy on the benefits and the harm of starting HT. If Lucy is found to be an acceptable candidate for HT, transdermal therapy is preferred by way of Estradiol (generic name) formulated transdermal patch. The strength of Estradiol is 14 mcg absorbed/day and used once weekly. MJ will be given direction to apply the patch upon her trunk area of her body (excluding breast and waist) changing application sites as ordered (Rosenthal & Burchum, 2018). Should she feel her family history of breast cancer leaves her susceptible to higher risks with HT, there are antidepressant therapies that can be used. They are not as effective but do have fair results treating vasomotor symptoms. The two antidepressants are escitalopram [Lexapro] & desvenlafaxine [Pristiq]. Lexapro is a selective serotonin reuptake inhibitor (SSRI), while Pristiq is a serotonin-norepinephrine reuptake inhibitor (SNRI).
As with the start of any therapy, the patient’s needs and expected outcomes will need to be taken into consideration. Patient education on the benefits, added risks, side effects, therapy time line of medication use, additionally available therapies as well as timely feedback is critical for safe treatment plans and positive patient care outcomes
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