A 52-year-old woman comes to the emergency department with left leg pain and swelling. She is a commercial truck driver and first noticed the swelling 3 days ago. The patient initially attributed the swelling to a long haul truck ride as she often gets mild "puffiness" of her ankles by the end of the day. However, the swelling has persisted and now involves her entire left leg below the knee. She has discomfort with walking but no chest pain, palpitations, syncope, or difficulty breathing. The patient has a history of hypothyroidism and hypertension and takes levothyroxine and hydrochlorothiazide. She has also been on menopausal hormone therapy using estrogen-progestin for intractable hot flashes. She smokes a pack of cigarettes daily and drinks 2 beers each night. Temperature is 37.2 C (99 F), blood pressure is 134/89 mm Hg, and pulse is 78/min. BMI is 31 kg/m². Extremity examination reveals a normal right leg and pitting edema and warmth over the left lower leg. ECG shows normal sinus rhythm, and chest x-ray is normal with no infiltrates. Serum creatinine level is 0.7 mg/dL. Duplex ultrasound of the lower extremities reveals noncompressibility of the left popliteal and femoral veins. The patient is started on rivaroxaban and scheduled to follow up with her primary care physician. She is counseled on smoking cessation and agrees to enroll in a smoking cessation clinic. The patient is also informed that her current menopausal hormone therapy (MHT) increases her risk of venous thromboembolism. She is concerned about experiencing hot flashes again. Which of the following is the most appropriate recommendation for treatment of this patient's menopausal symptoms?

Question

Quizplus · Accepted Answer

Explanation: Hot flashes occur in >80% of women in the perimenopausal and early menopausal period. Manifestations largely arise due to estrogen withdrawal, and treatment with menopausal hormone therapy (MHT) can palliate symptoms significantly. Although healthy patients who receive MHT in the decade following menopause are at minimal risk for adverse outcomes, the rates of stroke, breast cancer, and venous thromboembolism (VTE) are mildly increased. The development of VTE while on MHT usually necessitates a cessation of hormone therapy as the benefit of continued treatment does not outweigh the risk of recurrent, potentially life-threatening VTE. The most common alternate treatments are selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram) or serotonin-norepinephrine reuptake inhibitors (eg, venlafaxine). Although the exact mechanism for how these medications improve hot flashes is currently unknown, 50%-70% of women who receive this therapy have a reduction in symptoms. (Choice A) SSRIs are not typically associated with an increased risk of deep venous thrombosis (DVT) and are a safe alternate therapy for those who develop DVT while on MHT. (Choice B) MHT should be discontinued, and this patient should receive 3-6 months of anticoagulation. Patients rarely need lifelong anticoagulation unless they have recurrent DVT or malignancy. (Choice D) Raloxifene is a breast cancer treatment for post-menopausal women due to estrogenic effects on bones and anti-estrogenic effects on the breasts and uterus. Raloxifene may increase (not decrease) the risk of hot flashes and is associated with an increased risk of VTE. (Choice E) Estrogen-only MHT also increases DVT risk and should not be used as a substitute in those who develop DVT while on combination (estrogen plus progestin) MHT. Educational objective: Patients who develop venous thrombosis while on menopausal hormone therapy (MHT) should discontinue MHT and begin an alternate treatment such as a selective serotonin reuptake inhibitor or a serotonin-norepinephrine reuptake inhibitor. References: Nonhormonal management of menopause-associated vasomotor symptoms: 2015 position statement of The North American Menopause Society (http://www.ncbi.nlm.nih.gov/pubmed/26382310)

A 52-Year-Old Woman Comes to the Emergency Department with Left