Case Study Number Two
In this week’s discussion, I chose case study number two. A 46-year-old, 230 lb. woman with a family history of breast cancer. She is up to date on yearly mammograms. She has a history of hypertension. She complains of hot
flushing, night sweats, and genitourinary symptoms. She had felt well until one month ago, and she presented to her gynecologist for her annual gynecological examination and discussed her symptoms. She has a history of ASCUS about
five years ago on her pap. Other than that, Pap smears have been regular. Home medications are Norvasc, 10 mg every day, and HCTZ 25 mg every day. Her blood pressure today is 150/90. She has regular monthly menstrual cycles. Her
last menstrual period (LMP) was one month ago.
Menopause is the constant cessation of menstruation after the loss of ovarian follicular activity. In the United States, the median age at the beginning of menopause is 51 years but may vary significantly from 40 to 58 years. Symptoms
of vasomotor instability may include hot flashes, night sweats, sleep, and mood disorders and indicate early estrogen loss (DiPiro et al., 2016). In addition to menopausal symptoms, estrogen production loss leads to critical metabolic
changes, including effects on body composition, cognition (central nervous effect), lipids, vascular function, and bone metabolism (Rosenthal & Burchum, 2016). The menopause transition is associated with a significant increase in central
abdominal fat leading to an average weight gain during the five lb. menopause transition (DiPiro et al., 2016). Menopausal hormonal therapy (MHT) has three primary benefits: suppression of vasomotor symptoms (hot flashes, night
sweats), prevention of urogenital atrophy, and prevention of osteoporosis and related fractures (Rosenthal & Burchum, 2016). In the study of Kim et al. (2020), their findings suggest that underlying disease and timing of initiation should be
carefully considered before starting therapy in postmenopausal women
Treatment
As with any drug, prescribing decisions require weighing the benefits and risks. The patient has updated mammograms, and pap smears have been normal. I would start the patient to start on MHT. The candidate patient for MHT
must be informed of known risks potential for endometrial hyperplasia, endometrial cancer, breast cancer, and cardiovascular thromboembolic events) (Rosenthal & Burchum, 2018). I would consider a combination MHT of Estradiol (E) +
drospirenone (DRSP). A study by Park et al. (2017) highlights that greater than 85% of Korean patients experienced improved menopausal symptoms on drospirenone 2mg/estradiol 1 mg MHT. The results from their surveillance study
confirm the efficacy and safety of DRSP 2 mg/E2 1 mg tablet. Continuous combined MHT is more acceptable than traditional cyclic therapy (DiPiro et al., 2016).
Patient Education
As a provider, it is essential to educate patients. It may be beneficial to increase the dosage of HCTZ if the blood pressure remains elevated. Thiazides promote tubular reabsorption of calcium and decrease osteoporosis risk in
postmenopausal women. Patients should not take contraindications of MHT with a history of deep vein thrombosis (DVT), pulmonary embolus, or conditions such as stroke or myocardial infarction (MI) that occurred secondary
to a thromboembolic event. For women who choose to taper slowly, again, there are two basic options, referred to as “dose tapering” and “day tapering.” Dosing is done every day with dose tapering, but the daily dose’s size is gradually
reduced. If severe symptoms recur following a dose reduction, further reductions should be postponed until symptoms improve. As the daily dose is reduced, the daily dose remains unchanged, but the number of days between doses
increases gradually, starting with a dose every two days, then every three days, and so on. Whichever method is used, whether the dose is decreasing or daily, only the estrogen dose must be reduced (Rosenthal & Burchum, 2018).
The benefits of short-term therapy (less than five years) to treat menopausal symptoms. To keep risk as low as possible, MHT should be used in the lowest dosage and for the shortest time needed to accomplish treatment goals
(Rosenthal & Burchum, 2018).
References
DiPiro, J., Talbert, R., Yee, G., Matzke, G., Wells, B., & Posey, M. L. (2016). Pharmacotherapy: A Pathophysiologic Approach, Tenth Edition (10th ed.). McGraw-Hill Education / Medical.
Kim, J.-E., Chang, J.-H., Jeong, M.-J., Choi, J., Park, J., Baek, C., Shin, A., Park, S. M., Kang, D., & Choi, J.-Y. (2020). A systematic review and meta-analysis of effects of menopausal hormone therapy on cardiovascular diseases.
Scientific Reports, 10(1), 20631. https://doi-org.ezp.waldenulibrary.org/10.1038/s41598-020-77534-9
Park, B. R., Park, H. N., Jung, J. B., Lee, E. S., Kim, J. S., Choi, G. Y., Lee, J. J., & Lee, I. S. (2017). efficacy and safety of drospirenone 2 mg/17-estradiol 1 mg hormone therapy in Korean postmenopausal women. Obstetrics &
Gynecology Science, 60(2), 213. https://doi.org/10.5468/ogs.2017.60.2.213
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
