Vasomotor Symptoms of Menopause
The patient is a 46-year-old female who weighs 230lb. she has a family history of breast cancer and her yearly mammograms are up to date. She has a history of hypertension. She presented with complaints of night sweats, hot flushes, and genitourinary symptoms. She reports having been feeling well till a month ago when she visited her gynecologist for her annual checkup. She had previously done a pap test 5 years ago which revealed ASCUS. She is on Norvasc 10mg QID and HCTZ 25mg QID. Her blood pressure was 150/90mmHg and reports having regular menses. Her last menstrual period was one month ago.
The patient has different needs that need to be addressed. Firstly, the patient is perimenopausal. Menopausal vasomotor instability is characterized by hot flushing is a sensation of heat that is caused by cutaneous vasomotor dilation and compensation by a decrease in core body temperature for a few minutes. Menopausal women experience hot flushing and night sweats with heightened anxiety (Thurston, & Joffe, 2017). These are common symptoms experienced by almost every woman although they subside after a few years. The principal mechanism is thermoregulatory changes in the hypothalamus and decreased level of estrogen. The genitourinary symptoms are due to a menopausal condition known as atrophic vaginitis. The low level of estrogen brings about urinary, genital, and sexual complaints is over half of perimenopausal women (Roberts, & Hickey, 2016). Therefore, the patient needs to be educated more on menopause and its effects even though she has had regular menses in the recent past.
Another health need in this patient is elevated blood pressure. She had a BP measurement done on the visit which revealed that her blood pressure had not been adequately controlled. She also had a result of atypical squamous cells of undetermined origin in her previous checkup with a family history of breast malignancy. She needs to be educated more on cervical and breast malignancies and the need for repeated cytology and yearly pap smear tests (Roberts, & Hickey, 2016).
The management of this patient will be all rounded. Pharmacological therapy coupled with lifestyle modifications. The patient is already taking Norvasc and Hydrochlorothiazide for hypertension. The blood pressure however has not been adequately maintained. Therefore, changing the dosage would be appropriate for this patient rather than using different medications. Changing the frequency from QID to BD will also be effective. Vasomotor instability can be managed by SSRIs and SNRIs are the ideal drug of choice for reducing the frequency and severity of hot flushes and night sweats. Escitalopram, citalopram, paroxetine, and venlafaxine are the most effective drugs (Roberts, & Hickey, 2016).
According to Carroll et al., (2017), Paroxetine mesylate under the brand name Brisdelle, is approved for moderate and severe hot flushing by the FDA and can be given at 7.5-12.5mg per day. However, it is associated with drug interactions with other CYP2D6 substrates such as tamoxifen due to its nonlinear pharmacokinetics. Therefore, for people using drugs that are metabolized by these cytochromes, paroxetine will reduce their mean serum concentration. It improves the quality of life, improves sleep, reduces interferences from vasomotor instability, and does not cause sexual issues when used for this condition. Common side effects expected include; fatigue, somnolence, weight gain, dry mouth, and gastrointestinal symptoms. These effects are dependent on dose and therefore, it is appropriate to use the low dose of 7.5mg for at least a week. Gabapentin at 600-900mg per day reduces hot flushes and night sweats while clonidine at 0.1mg per day reduces the elevated blood pressure. Escitalopram is tolerated well but has variable effectiveness in patients (Roberts, & Hickey, 2016).
Hormonal therapy is also effective in this condition. Estrogen is the hormone used in combination with progesterone. Tilobone, a hormone supplement, can also be used. It reduces the effects of vasomotor instability by 80%. However, according to Hill et al., (2016), it is associated with many risky side effects. This patient has a family history of breast cancer; therefore, hormonal therapy is less ideal for the management of this patient. However, vaginal estrogen is not systemically absorbed and can avoid endometrial hyperplasia while treating genitourinary syndrome of menopause. It is available as creams, tablets, and rings. Vitamin supplements and herbal medicine have been used to manage the symptoms. Black cohosh, evening primrose oil, phytoestrogens, dehydroepiandrosterone, and vitamin E have proved to be effective (Hill et al., 2016).
The patient will need to be educated on other strategies to help with the reduction in frequency and severity of symptoms. According to Avis et al., (2019), other methods may include; encouraging layered clothing to control core body temperature by removing some clothes off and maintaining cool room temperature. Dietary modifications may also contribute to alleviating these symptoms. Avoiding alcohol consumption, decreasing the intake of caffeine, and avoiding spicy meals will go a long way. Eating a balanced diet that includes cold drinks and reducing emotional stress also contribute. A diet rich in fruits and vegetables and low in saturated fat is essential. Increasing fiber intake while limiting salt to less than 2.5g will also help. A good calcium diet due to the increased fracture risk with the use of paroxetine and a lot of fluid intake with avoidance of tea will reduce triggers of hot flushes (Thurston, & Joffe, 2017).
Physical exercise regularly, especially aerobic exercises, weight-bearing, and stretching activities and the weight loss coupled with the other methods is also essential. The patient should avoid smoking helps with reducing the severity of hot flushes. Hypnosis and acupuncture are rare methods but are effective in combination with others. She also needs to be informed about her blood pressure levels and the lifestyle changes needed for managing it. Monitoring of her blood pressure should be taught to this patient. Counseling on regular screening for cervical and breast malignancy should be done. Yearly mammography and pap smear are recommended for such patients. Follow up and regular visits should be scheduled for this patient (Avis et al., 2019).
References
Avis, N. E., Levine, B. J., Danhauer, S., & Coeytaux, R. R. (2019). A Pooled Analysis of Three Studies of Non-Pharmacological Interventions for Menopausal Hot Flashes. Menopause (New York, NY), 26(4), 350.
Carroll, D. G., Lisenby, K. M., & Carter, T. L. (2017). Critical appraisal of paroxetine for the treatment of vasomotor symptoms. International journal of women’s health, 7, 615.
Hill, D. A., Crider, M., & Hill, S. R. (2016). Hormone therapy and other treatments for symptoms of menopause. American Family Physician, 94(11), 884-889.
Roberts, H., & Hickey, M. (2016). Managing the menopause: an update. Maturitas, 86, 53-58.
Thurston, R. C., & Joffe, H. (2017). Vasomotor symptoms and menopause: findings from the Study of Women’s Health across the Nation. Obstetrics and Gynecology Clinics, 38(3), 489-501.