Managing Menopausal Symptoms: A Case Presentation and Treatment Plan

This presentation discusses the case of a 50-year-old post-menopausal woman experiencing hot flashes, insomnia, and vaginal dryness. It covers the problems encountered in menopause, goals of therapy, and available hormonal and non-hormonal alternatives. The presentation also includes a treatment plan, patient education, and monitoring therapy and follow-up.

MENOPAUSE
Managing Menopausal Symptoms

Case presentation: Emma Peterson
 50 year old post-menopausal woman
 Presented with two to three hot flashes per day with insomnia and vaginal dryness.
 Symptoms present for the past 3 months and wake her from sleep two to three times a week.
 Past medical history includes treatment for depression, GERD, hypothyroidism and
hypertension. She is on paroxetine, hydrochlorothiazide, omeprazole and Synthroid. She has a
family history of
 Vital signs were essentially normal
 Lab work done showed increased FSH levels of 87.8 mIU/ml

MENOPAUSE
The patient presents with symptoms of early menopause.
Problems encountered in menopause include
 hot flashes, headaches, tachycardia and night sweats (Freedman, 2014).
 Osteopenia and risk of osteoporosis with back and joint pain
 Depression, insomnia, and other psychological symptoms
 thinning of mucous membranes, vaginal dryness and bleeding
 soft issue atrophy including breast and skin.
The patient presented with hot flashes, night sweats, vaginal dryness and depression. Her
assessment shows normal breast appearance and labs show normal calcium but increased FSH
levels. Her menopause symptoms are not as severe.
Al-Safi & Santoro, 2014.

Goals of therapy
 Relieve menopausal symptoms
 Prevention of osteoporosis
 Improve and maintain post menopausal quality of life.
Before any medical therapy is initiated, the following non-drug therapies are helpful:
 Diet rich in soy proteins, vitamins and calcium
 Cessation of alcohol intake or smoking
 Weight bearing exercises including jogging and walking.
Stuenkel et al., 2014

Hormonal Therapy
The patient might benefit from hormonal therapy which has the advantage of reversing
menopausal symptoms including flashes, atrophy, pathological fractures and bone mineral loss
and return the patient to a better functional state.
The risks involved include
 Adverse drug reactions
 Increased risk of developing breast cancer, endometrial cancer and venous thromboembolism
 Increased risk of coronary heart disease and dementia.
Rossouw, Manson, Kaunitz, & Anderson, 2013.

Available hormonal therapies
The following are hormonal therapies available for the treatment of menopause:
• Conjugated estrogen and micronized estradiol
• Medroxyprogesterone
• Oral estrogen- conjugated equine estrogen
• Estrogen and cyclic progestin
• Continuous estrogen and progestin therapy.
• 17β estradiol implants and transdermal patches
• Percutaneous estrogen gel
• Conjugated equine vaginal cream
• Progestins
• Tibolone
These drugs are essentially serve to replace the hormones estrogen and progesterone that the body is no longer able
to produce due to ovarian failure.
De Villiers et al., 2013

Non- Hormonal Alternatives
To circumvent the risks associated with hormonal therapy, the following alternatives can be employed:
• Phytoestrogens (Moreira et al., 2014)
• Selective estrogen receptor modulators like raloxifene are tissue specific in action.
• Clonidine and paroxetine which reduces frequency and severity of hot flashes.
• Thiazides which reduce urinary calcium excretion.
• Supplementary calcium
• Supplementary vitamin D
• Bisphosphonates- etidronate and alendronate to prevent bone resorption.
• Fluoride to increase bone matrix.
• Calcitonin to prevent bone resorption
Lethaby et al., 2013

TREATMENT PLAN AND FOLLOW-UP

Therapeutic plan:
 Daily calcium 1 gm
 Vitamin D3 400 IU/day
 Conjugated estrogen 1mg/day
Duration of three to five years is recommended.
To monitor therapy, the following should be
assessed:
 Reduction in symptomatology through
history and physical examination. Menstrual
history, sexual history. Breast and
gynecological examination,
 BP measurement.
 Lab evaluation using FSH levels and
calcium levels. Bone mineral density scan,
mammogram and vaginal ultrasound.

Patient Education
To enhance adherence patient education is key. The patient should be educated on the benefits of
hormonal therapy, the risks she should look out for and alternative therapies incase of adverse reactions.
The patient should be encouraged to adhere to medication dosage, regiments and durations. This prevents
risks of adverse reactions.

Clinical Course.
The recommended duration of therapy for postmenopausal women below 60 years is less than 5 years.
Beyond 60, continuation is based on clinical balance between risk and benefits. Emma should therefore use
these therapies for at least 5 years while balancing the risks involved (Maki, 2013).
The choices of stopping therapy include either stopping abruptly or tapering down the dose. In the short
term, tapering down limits recurrence of symptoms but both methods have no effect on symptoms in the
long run.
Genital symptoms including bleeding are a contraindication to hormone therapy and HT change.
The women's health initiative study found out that hormonal therapy over a 5.2 year period present more
harm than benefits especially on cardiovascular risk and breast cancer risk (Manson et al., 2013; Boardman
et al., 2015).

References
De Villiers, T. J., Gass, M. L. S., Haines, C. J., Hall, J. E., Lobo, R. A., Pierroz, D. D., & Rees, M. (2013). Global consensus statement on menopausal
hormone therapy. Climacteric, 16(2), 203-204.
Al-Safi, Z. A., & Santoro, N. (2014). Menopausal hormone therapy and menopausal symptoms. Fertility and sterility, 101(4), 905-915.
Moreira, A. C., Silva, A. M., Santos, M. S., & Sardão, V. A. (2014). Phytoestrogens as alternative hormone replacement therapy in menopause: What is real,
what is unknown. The Journal of steroid biochemistry and molecular biology, 143, 61-71.
Boardman, H. M., Hartley, L., Eisinga, A., Main, C., Roqué i Figuls, M., Bonfill Cosp, X., ... & Knight, B. (2015). Hormone therapy for preventing
cardiovascular disease in post-menopausal women. Cochrane Database Syst Rev, 3(3).
Manson, J. E., Chlebowski, R. T., Stefanick, M. L., Aragaki, A. K., Rossouw, J. E., Prentice, R. L., ... & Wactawski-Wende, J. (2013). Menopausal hormone
therapy and health outcomes during the intervention and extended poststopping phases of the Women’s Health Initiative randomized trials.
Jama, 310(13), 1353-1368.
Stuenkel, C. A., Davis, S. R., Gompel, A., Lumsden, M. A., Murad, M. H., Pinkerton, J. V., & Santen, R. J. (2015). Treatment of symptoms of the menopause: an
endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 100(11), 3975-4011.
Lethaby, A., Marjoribanks, J., Kronenberg, F., Roberts, H., Eden, J., & Brown, J. (2013). Phytoestrogens for menopausal vasomotor symptoms.
Freedman, R. R. (2014). Menopausal hot flashes: mechanisms, endocrinology, treatment. The Journal of steroid biochemistry and molecular biology, 142, 115-
120.
Rossouw, J. E., Manson, J. E., Kaunitz, A. M., & Anderson, G. L. (2013). Lessons learned from the Women’s Health Initiative trials of menopausal hormone
therapy. Obstetrics and gynecology, 121(1), 172.
Maki, P. M. (2013). The critical window hypothesis of hormone therapy and cognition: a scientific update on clinical studies. Menopause (New York, NY),
20(6), 695.