A 53-year-old woman comes to the office for a routine annual examination. Her last menstrual period was 2 years ago. The patient has hot flashes throughout the day. She awakens several times each night drenched with sweat. The patient has tried weight loss and over-the-counter medications to manage these symptoms, but they have not improved. She has hypertension and type 2 diabetes mellitus controlled with diet and exercise. The patient's mother had a bilateral hip replacement after a fall at age 77. Blood pressure is 124/80 mm Hg and pulse is 76/min. BMI is 28 kg/m². Cardiopulmonary examination is normal. On pelvic examination, the uterus is small and nontender, and there are no adnexal masses. The extremities have 2+ peripheral pulses. HbA1c is 6.9%. Which of the following is an indication for systemic estrogen/progestin replacement therapy in this patient?

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11ec25c8_d267_6164_bc81_bf91bae7e5b9_MD0003_00 Menopause, absent menses for 12 months, occurs at a median age of 51 when the loss of ovarian function leads to hypoestrogenemia and its sequelae: vasomotor symptoms (eg, hot flashes, night sweats, sleep disturbances), vulvovaginal atrophy, and osteoporosis. Management of hot flashes depends on symptom severity and patient risk factors. Patients with mild symptoms that do not interfere with daily activities are managed with lifestyle modification (eg, wearing layers, weight loss). Severe hot flashes typically require pharmacologic therapy, and hormone replacement therapy (HRT) is the first-line treatment (Choice E). The only current indication for HRT is vasomotor symptoms in women age <60 who have undergone menopause within the past 10 years. HRT was previously used for chronic disease prevention, but it is no longer recommended in the prevention of coronary heart disease or osteoporosis due to the associated risks of HRT (eg, thromboembolism) (Choices A and C). Contraindications to HRT include a personal history of coronary heart disease, thromboembolism, transient ischemic attack or stroke, breast cancer, and endometrial cancer. Patients with contraindications to HRT are typically managed with nonhormonal therapy (eg, selective serotonin reuptake inhibitors). (Choice B) HRT is not indicated for endometrial cancer risk reduction. The estrogen component of HRT treats menopausal symptoms, but if unopposed (ie, no progesterone), it can result in endometrial proliferation and hyperplasia. Therefore, in patients with a uterus, HRT with a progestin component is required for endometrial protection. Educational objective: Hormone replacement therapy is indicated in the treatment of vasomotor symptoms (eg, hot flashes, night sweats) in women age <60 who have undergone menopause within the past 10 years. References: Managing the menopause: an update. (http://www.ncbi.nlm.nih.gov/pubmed/26921929) Hormone therapy for relieving postmenopausal vasomotor symptoms: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/26838086)

A 53-Year-Old Woman Comes to the Office for a Routine