A 35-year-old woman comes to the office due to hot flashes. Her last menstrual period was a year ago, and she began having hot flashes 4 months ago. The patient's symptoms have become progressively worse and are starting to interfere with sleep and normal daily activities. Medical history is notable for Hodgkin lymphoma, for which she underwent treatment with chemotherapy and radiation 18 months ago. Family history is unremarkable. The patient lives with her husband and 2 children, and underwent a tubal ligation after the delivery of her second child 5 years ago. She does not use tobacco or alcohol. Current medications include calcium and vitamin D supplements. Blood pressure is 110/70 mm Hg and pulse is 80/min. BMI is 19 kg/m². Physical examination, including breast and pelvic examination, is unremarkable. Laboratory results show a normal complete blood count and basic metabolic panel. LH is 25 mU/mL (normal, 3-20 mU/mL) and FSH is 56 mU/mL (normal, 0.8-13 mU/mL). Bone density using DXA reveals a Z-score of -2.5 at the lumbar spine and -1.7 at the hip. Which of the following is the most appropriate treatment for this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_bed2_f7b1_8f63_5d32c0b0d240_MD0005_00 This patient has amenorrhea with low estrogen, elevated FSH, and hypoestrogenic symptoms. This is consistent with primary ovarian insufficiency (POI), which is a common complication of cancer treatment with chemotherapy and radiation therapy. In addition, she has low bone density as evidenced by a low (age-adjusted) Z-score on DXA. Patients with POI can rapidly lose bone mass, leading to an increased risk of fragility fractures. In the absence of specific risk factors (eg, history of breast cancer), most patients with POI should receive oral or transdermal estrogen therapy, which should be combined with a progestin in women with an intact uterus to reduce the risk of endometrial cancer (Choice B). Estrogen therapy can relieve hypoestrogenic symptoms (eg, hot flashes, vaginal dryness) and minimize bone loss. Estrogen replacement should be continued until the average age of normal menopause, around age 50. Postmenopausal estrogen/progesterone therapy is associated with significant risks (eg, venous thromboembolism, coronary heart disease), but the absolute risks are substantially lower in young patients with POI, and the benefits far outweigh the risks for most patients. (Choices A and E) Bisphosphonates (eg, risedronate) are commonly used in the management of postmenopausal osteoporosis. Calcitonin is occasionally used as a second-line agent. However, neither of these medications has been studied extensively in osteoporosis due to POI, and neither would alleviate this patient's hypoestrogenic symptoms. (Choice D) Raloxifene is a selective estrogen modulator. It stimulates estrogen receptors on bone cells to improve bone density and is used to treat postmenopausal osteoporosis. However, it has antagonistic effects on other estrogen-responsive tissues and can worsen the hypoestrogenic symptoms in this patient. Educational objective: Primary ovarian insufficiency is a common complication of cancer treatment. Patients can experience hypoestrogenic symptoms (eg, hot flashes) and rapid bone loss. Treatment includes oral or transdermal estrogen therapy, which should be combined with a progestin in women who have an intact uterus. References: Premature ovarian failure: clinical presentation and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25681846)

A 35-Year-Old Woman Comes to the Office Due to Hot