A 54-year-old postmenopausal woman comes to the office to establish care. She feels well and describes her lifestyle as "overall healthy." The patient has a history of hypertension, osteopenia, and anxiety disorder. She went through menopause at age 49, during which time she experienced hot flashes, sleep disturbances, and mood swings. The symptoms have largely resolved except for occasional episodes of anxiety. The patient did not receive any therapy for her menopausal symptoms. Her current medications include valsartan, calcium/vitamin D, and paroxetine. She is married, works as a television news reporter, and does not smoke or consume alcohol. Family history is negative for coronary heart disease, stroke, cancer, and venous thromboembolism. Blood pressure is 128/76 mm Hg and pulse is 68/min. BMI is 29 kg/m². Physical examination is normal. Laboratory results are as follows: The patient says that her friends have been telling her about the "anti-aging" effects of hormone replacement therapy, and she would like to discuss initiating treatment. She asks for advice regarding the risks and benefits of combined estrogen/progesterone menopausal hormonal therapy (MHT). Which of the following is the most appropriate response regarding MHT in this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_bed2_5b70_8f63_fd6dffc52b6b_MD0005_00 Combination estrogen/progesterone menopausal hormone therapy (MHT), or estrogen alone for women who have had a hysterectomy, is the most effective treatment available for menopausal hot flashes. The use of MHT has declined following prospective trials (eg, Women's Health Initiative, Heart and Estrogen/progestin Replacement Study) that found an increased risk of stroke, coronary heart disease (CHD), breast cancer, and venous thromboembolism in women taking combination MHT. However, much of this risk is age-related; women age 50-59 have a lower risk of adverse effects, resulting in a more favorable risk-benefit profile compared with women age >60. In light of this, MHT can be safely used for a short period (3-5 years) in younger, low-risk women (ie, nonsmokers; no history of breast cancer, venous thromboembolism, or CHD). Prior to initiating therapy, patients should be advised of potential risks. In particular, the risk of ischemic stroke is increased in all age groups, although the absolute risk is small in women age <60. This increased risk is not eliminated by management of blood pressure or other traditional stroke risk factors. In addition, randomized studies have found no significant benefits of MHT on skin wrinkling. (Choice A) Combination MHT is associated with a lower risk of type 2 diabetes mellitus, possibly due to decreased insulin resistance. (Choice B) Unopposed estrogen is associated with an increased risk of endometrial cancer, an effect that is largely eliminated with combination estrogen/progesterone therapy. In contrast, the risk of breast cancer is increased with combination therapy (although it may be lower with unopposed estrogen). (Choice C) Both combined MHT and estrogen alone are associated with lower all-cause mortality in postmenopausal women age <60, a benefit that is not seen in women age >60. (Choice D) Combination MHT is associated with an increased risk of CHD in women age >60. This risk is significantly lower in women age <60 and those on unopposed estrogen. Educational objective: Combination estrogen/progesterone menopausal hormone therapy increases the risk for stroke, coronary heart disease, breast cancer, and venous thromboembolism. However, this risk is age-related, with a higher risk seen in women age >60. The risk of ischemic stroke is increased in all age groups, but the absolute risk in women age <60 is small. References: Menopausal hormone therapy for the primary prevention of chronic conditions: a systematic review to update the U.S. Preventive Services Task Force recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/22786830)

A 54-Year-Old Postmenopausal Woman Comes to the Office to Establish