A 48-year-old woman comes to the office for a well-woman examination and a discussion about menopausal symptoms. She has experienced unpredictable and progressively worsening episodes of flushing, sweating, and anxiety that interfere with her occupational performance during the day and wake her from sleep at night. The patient has attempted to manage her symptoms by turning on the air conditioner in the winter and dressing in layers. Her menstrual cycles have become irregular, occurring every 28-50 days. The patient had a tubal ligation at age 40, and her postoperative course was complicated by lower extremity deep vein thrombosis. She does not use tobacco and does not have a personal history of breast cancer.
Blood pressure is 122/78 mm Hg, pulse is 72/min, and respirations are 17/min. The well-woman physical examination is unremarkable.
Which of the following is the most appropriate next step in management to reduce this patient's symptoms?

Question

A 48-year-old woman comes to the office for a well-woman examination and a discussion about menopausal symptoms.  She has experienced unpredictable and progressively worsening episodes of flushing, sweating, and anxiety that interfere with her occupational performance during the day and wake her from sleep at night.  The patient has attempted to manage her symptoms by turning on the air conditioner in the winter and dressing in layers.  Her menstrual cycles have become irregular, occurring every 28-50 days.  The patient had a tubal ligation at age 40, and her postoperative course was complicated by lower extremity deep vein thrombosis.  She does not use tobacco and does not have a personal history of breast cancer.
Blood pressure is 122/78 mm Hg, pulse is 72/min, and respirations are 17/min.  The well-woman physical examination is unremarkable.
Which of the following is the most appropriate next step in management to reduce this patient's symptoms?

Quizplus · Accepted Answer

11ec193a_97e3_351b_853d_975b4ad098ff_MD0002_00 Systemic estrogen-based hormone therapy is the most effective treatment for menopausal vasomotor symptoms, such as moderate to severe hot flashes. Unopposed estrogen therapy can increase the risk of endometrial hyperplasia and cancer, so it is appropriate only for women who have had a hysterectomy. This risk can be mitigated by the addition of a progestin (eg, combination patch, pill, or intrauterine device). However, all estrogen-containing regimens can increase the risk of venous thromboembolism and are contraindicated in women, such as this patient, with a history of deep vein thrombosis (Choices B and C). Estrogen is also contraindicated in women with a history of breast cancer, coronary heart disease, or active liver disease and is relatively contraindicated in those who smoke. For patients who cannot or prefer not to take hormonal therapy, alternate options include selective serotonin reuptake inhibitors (eg, paroxetine) and serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine). Hot flashes are mediated in part by serotonergic pathways, so blockade of these pathways provides symptomatic relief. Gabapentin is also beneficial but is associated with sedation and dizziness; it may be most useful in bedtime dosing for patients with predominantly nocturnal symptoms. (Choice A) Dopamine reuptake inhibitor antidepressants (eg, bupropion) are useful for smoking cessation and certain types of sexual dysfunction. However, they are not helpful for hot flashes. (Choice D) Certain plant-derived chemicals with estrogenic properties (phytoestrogens) have not shown significant benefits for hot flashes and have had mixed results for other menopausal symptoms. They appear to have a lower absolute risk than standard estrogen formulations, but it is not clear whether they have a more favorable benefit-to-risk ratio. Educational objective: Estrogen-based menopausal hormone therapy is contraindicated in patients with a history of venous thromboembolism, breast cancer, coronary heart disease, or active liver disease. Nonhormonal treatments include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and gabapentin. __________ References: ACOG Practice Bulletin No. 141: management of menopausal symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/24463691) Treatment strategies for reducing the burden of menopause-associated vasomotor symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/18439062)

A 48-Year-Old Woman Comes to the Office for a Well-Woman