MENOPAUSE: PATIENT CASES
1. A healthy 50 year-old obese woman is currently going through menopause. She is
having hot flashes (~8 per day) and night sweats (~1 per night). Her girlfriend recently
started hormone therapy and suggested she try it. She has no significant medical
history, surgical history, or family history. Her physician is asking you about the efficacy
and safety of using hormone therapy in this woman. What recommendation would you
provide at this time? Be specific.
2. A healthy 52 year-old woman is currently going through menopause. She is having hot
flashes (~10 per day) and night sweats (~2 per night). She will not consider EPT and
would like to know about other options and how long she will “suffer”. Her other
medications include a multivitamin and ibuprofen prn for headache. What information
and/or recommendations would you provide at this time?
3. A 61-year-old postmenopausal woman, presents to her physician suffering from
unbearable vaginal dryness, itching, and pain during intercourse -- symptoms that were
not as severe during her last checkup 1 year ago and at that time caused no distress. She
reached menopause spontaneously at age 50 and has experienced no menopauserelated symptoms, including hot flashes. She does not have a personal or family history
of cardiovascular disease, breast cancer, or uterine cancer. A dual-energy x-ray
absorptiometry test to measure bone density 4 years ago was within normal ranges for
her age. Pelvic examination is unremarkable except for fragile vaginal mucosa
characterized by pallor, decreased elasticity, disappearance of rugae, and petechiae.
Vaginal secretions are scant and odorless. She has no complaints or signs that could
indicate a vaginal infection. Develop and assessment and plan for her vaginal symptoms.
4. A returning 45 year-old patient complains of depression, hot flashes, and difficulty
sleeping for the past 6 or 7 months. Relevant medical history includes migraine without
aura at age 37 years and normal Pap smear in last 12 months. She had a levonorgestrel
IUD placed at 43 years, has 2 children, and has been married for 12 years. She does not
smoke and drinks 1-2 alcoholic beverages on weekend days.
5. CC: “I have been having hot flashes for the past few months, and I just can’t take it
anymore.”
HPI: Emma Peterson is a 50-year-old woman who reports experiencing 2-3 hot flashes
per day, occasionally associated with insomnia. She also states she is awakened from
sleep, soaked by night sweats, about 2-3 times per week needing to change her pajamas
and bed linens. Her symptoms began about 6 months ago, and over that time, they have
worsened to the point where they have become very bothersome. She states that her
mother was prescribed hormones for this, but she is hesitant to take them because she
has heard that the medication may not be safe.
PMH: Depression; GERD; HTN; hypothyroidism
FH: Mother died of stroke at age 67; father died of lung cancer at age 62. Has one
brother, 52, and one sister 48 who are alive and well, but both with HTN.
SH: Married, mother of 2 healthy daughters ages 21 and 25. She is a RN in a neighboring
physician’s office. She walks on her treadmill 3 times/week and follows a dieticiandesigned low-cholesterol diet. She does not smoke and occasionally drinks a glass or
two of red wine with dinner.
Meds: Hydrochlorothiazide 25 mg by mouth once daily; omeprazole 20 mg by mouth
once daily; paroxetine 20 mg by mouth once daily; levothyroxine 75 mcg by mouth once daily.
All: NKDA
ROS: (+) hot flashes, night sweats and insomnia, vaginal dryness. (-) weight gain,
constipation. LMP was 8 months ago.
Physical Exam
Gen: WDWN female in NAD
VS – BP 128/78, P 78, RR 15, Wt 76 kg, Ht 5’6”
Skin – warm, dry, no lesions
HEENT, Neck/lymph nodes, lungs, CV, Abd – all normal findings
Breasts – equal in size without nodularity or masses, supple, nontender
Genit/Rect – Pelvic exam normal except (+) mucosal atrophy; stool guaiac (-)
MS/Ext/Neuro – normal, expected findings
Labs: TSH 2.46 mIU/L; total cholesterol 205 mg/dL; LDL 116 mg/dL; HDL 545mg/dL;
triglycerides 220 mg/dL; serum creatinine 0.7 mg/dL; FSH 42 IU/L
Other: Pap smear and mammogram normal
Assessment: 50-year-old, symptomatic postmenopausal woman exploring treatment
options.
Questions
a. What are the presenting signs and symptoms of menopause being experienced by
Emma?
b. What are the goals of therapy for Emma’s menopausal symptoms?
c. What non-drug therapies may be recommended for Emma?
d. What drug, dosage form, dose, schedule and duration would you recommend for
Emma and why?
e. What would you recommend for Emma’s monitoring plan?
f. What if....
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one of Emma’s sisters had ER+ breast cancer?
Emma had a calculated LDL of >160 mg/dL and uncontrolled hypertension?
6. Theresa Hart is a 53-year-old who presents complaining of dyspareunia and reduced
libido. As a result of this, she and her husband have not had sexual intercourse in more
than 4 months. Prior to menopause (her LMP was about 13 months ago), TH describes
their sex life as ‘vibrant’. She is quite distressed by this and is seeking your assistance.
She is an otherwise healthy 54 yo female. She does note the occurrence of rare (< 1
time/week) vasomotor symptoms. Her mother is alive and well (has HTN) at age 78; her
father died from an MI at age 74. She has 2 older sisters (ages 55 and 56); both alive and
well.
Questions
a. What therapeutic options exist for Theresa?
b. What treatment option would you recommend (drug, dose, route, etc.) for Theresa?
c. How would you monitor the treatment plan for efficacy and side effects?