A 52-year-old woman comes to the office due to "feeling hot all the time." She reports the sensation of heat starting in her upper body and spreading all over. She has had these symptoms for the past 10 months and is exhausted as they keep her awake most nights. Her last menstrual period was 8 months ago. The patient's other medical problems include hypothyroidism and gastroesophageal reflux disease, and her medications include levothyroxine and omeprazole. A mammogram performed last year was normal. She has had no surgeries; her family history is unremarkable. The patient does not use tobacco, alcohol, or illicit drugs.
Physical examination, including pelvic examination, is within normal limits. Laboratory findings, including TSH, are within normal limits.
Which of the following is the best therapy to relieve this patient's symptoms?

Question

A 52-year-old woman comes to the office due to "feeling hot all the time."  She reports the sensation of heat starting in her upper body and spreading all over.  She has had these symptoms for the past 10 months and is exhausted as they keep her awake most nights.  Her last menstrual period was 8 months ago.  The patient's other medical problems include hypothyroidism and gastroesophageal reflux disease, and her medications include levothyroxine and omeprazole.  A mammogram performed last year was normal.  She has had no surgeries; her family history is unremarkable.  The patient does not use tobacco, alcohol, or illicit drugs.
Physical examination, including pelvic examination, is within normal limits.  Laboratory findings, including TSH, are within normal limits.
Which of the following is the best therapy to relieve this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_97d9_981a_853d_ef9664b93f86_MD0002_00 This patient has symptoms of severe vasomotor instability (hot flashes) due to the menopausal transition. Hot flashes are sudden heat sensations in the face and upper chest that spread rapidly to other parts of the body. Patients with no history of breast cancer or cardiovascular disease are typically good candidates for hormone replacement therapy (HRT). Patients with an intact uterus (ie, no hysterectomy) are started on a short-term regimen of combined estrogen/progesterone to decrease the risk of endometrial hyperplasia or carcinoma. In contrast, patients with a previous hysterectomy (ie, no uterus) can be prescribed estrogen-only therapy (Choice A). HRT can be given for <5 years for patients who continue to have symptoms; most women remain on HRT for 2-3 years. Hot flashes stop spontaneously within a few years of onset in most women. Long-term HRT is no longer recommended for prevention of dementia, heart disease, or osteoporosis. (Choice C) Behavioral modifications, including dressing in layers, smoking cessation, and weight loss, are indicated in the management of mild hot flashes (ie, symptoms that do not interfere with daily activities). (Choice D) Phytoestrogens are plant-derived compounds with estrogenic properties that have a weaker estrogenic effect than natural and synthetic estrogens. There is no conclusive evidence that phytoestrogens help reduce hot flashes. (Choice E) Women with moderate-to-severe vasomotor symptoms who cannot take estrogen (eg, heart disease) or who continue to have symptoms after stopping estrogen therapy can be started on selective serotonin reuptake inhibitors (SSRIs) to reduce symptoms. Paroxetine is currently the only SSRI approved for treatment of hot flashes; however, it should not be used in patients on tamoxifen as paroxetine inhibits tamoxifen metabolism. Educational objective: Short-term (<5 years) hormone replacement therapy (HRT) is recommended for postmenopausal women with moderate-to-severe vasomotor symptoms. Combined estrogen/progesterone is the first-line treatment for patients with an intact uterus and no history of breast cancer or cardiovascular disease. HRT is not recommended for prevention of dementia, heart disease, or osteoporosis. __________ References: Estrogen and progestogen use in postmenopausal women: 2010 position statement of The North American Menopause Society. (http://www.ncbi.nlm.nih.gov/pubmed/20154637) Hormone therapy for relieving postmenopausal vasomotor symptoms: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/26838086)

A 52-Year-Old Woman Comes to the Office Due to "Feeling