A 52-year-old woman comes to the office because she has not been sleeping well. For the past year, the patient has had no difficulty falling asleep, but has frequent sleep interruption and often awakens with her sheets soaked in sweat. She now has worsening fatigue that is affecting her ability to focus at work. The patient has not been sexually active in the last 6 months due to vaginal dryness and painful intercourse. She has no chronic medical conditions, and her only procedure has been a laparoscopic hysterectomy in her 40s for symptomatic uterine leiomyomata. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 116/78 mm Hg and pulse is 70/min. BMI is 24 kg/m². Pelvic examination shows pale, thin vulvovaginal tissues and a narrow vaginal introitus. The vaginal cuff is intact and without lesions. The remainder of the physical examination is normal. Which of the following is the most appropriate therapy for this patient's symptoms?

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Explanation: 11ec25c8_d9c9_a34b_bc81_cf13a731499e_MD0003_00 Menopause occurs at a median age of 51 and is due to decreased estrogen production. It can present with sleep disturbance, worsening fatigue, and hot flashes, as in this patient. Painful intercourse due to vaginal dryness is also common. Diagnosis is usually clinical; on examination, vaginal atrophy (ie, pale, narrowed introitus) may be present due to hypoestrogenism. Management of menopausal symptoms depends on the severity of vasomotor symptoms (ie, hot flashes). Mild hot flashes that do not interfere with daily activities are managed with lifestyle modification (eg, wearing layers, weight loss). In contrast, this patient has moderate to severe vasomotor symptoms (eg, awakening with sheets soaked in sweat) that may benefit from pharmacotherapy. In patients with no contraindications to estrogen, menopausal hormone therapy (MHT) is first-line treatment. Patients with an intact uterus require estrogen-plus-progesterone MHT (eg, estrogen-progestin pills), which decreases the risk of endometrial cancer associated with unopposed estrogen (Choice B). In contrast, patients without a uterus (eg, prior hysterectomy) can receive estrogen-only MHT (eg, transdermal estrogen patch), which is preferred in these patients because estrogen-plus-progesterone MHT has a small increased risk of breast cancer with long-term (>3-5 years) use. (Choices A, C, and D) In patients with contraindications to estrogen (eg, breast cancer, venous thromboembolism), second-line treatment for vasomotor symptoms is paroxetine, a selective serotonin reuptake inhibitor that is typically well tolerated. In patients who have no relief from paroxetine or who cannot take paroxetine (eg, current tamoxifen use), clonidine or gabapentin may be used. However, these medications can be associated with intolerable side effects, including hypotension (clonidine) and headache/dizziness (gabapentin). Educational objective: In menopausal patients with moderate to severe vasomotor symptoms (ie, hot flashes), first-line treatment is with menopausal hormone therapy. Patients with a uterus require estrogen-plus-progesterone therapy. In contrast, patients without a uterus require estrogen-only therapy (eg, transdermal estrogen patch). References: Hormone therapy and other treatments for symptoms of menopause. (http://www.ncbi.nlm.nih.gov/pubmed/27929271) Hormonal and nonhormonal treatment of vasomotor symptoms. (http://www.ncbi.nlm.nih.gov/pubmed/25681847)

A 52-Year-Old Woman Comes to the Office Because She Has