RESPONSE 1B CN
Case Study 2
For this case study, a 46-year-old woman presents to the clinic with symptoms of hot flashes, night sweats, and genitourinary issues. She is here for her annual well women exam. She had felt well until one month ago. She has a family history of breast cancer. She has a history of HTN and ASCUS about five years ago on her pap. Other than that, pap smears have been WNL. She is up to date on yearly mammograms. Her home medications consist of Norvasc 10mg daily and HCTZ 25mg daily. Her blood pressure is elevated today at 150/90. She has regular menstrual cycles and her LMP was one month ago.
Based on the patient’s age and onset of symptoms, I believe this patient is experience symptoms associated with entering menopause. This stage in a women’s life can include hot flashes, night sweats, sleep disturbance, vaginal dryness, sexual dysfunction, and mood disturbance (Roberts & Hickey, 2016). Many of these symptoms interfere with a women’s quality of life. It is important to explain the natural changes that occur during menopause to the patient and to also explain ways to combat certain symptoms. Roberts and Hickey (2016) state that moderate dose estrogen-containing hormone therapy is currently the most effective treatment for many symptoms of menopause. While this may be true, the association between hormone replacement therapy and an increase in cancer risk has remained controversial. Estrogen itself can accelerate many types of cancer (La Vecchia, 2004).
Because the patient has a family history of breast cancer, it is important speak with the patient about risks associated with hormone replacement therapy. Current evidence does not conclusively eliminate hormone replacement therapy in breast cancer patients or patients with a family history of breast cancer (Fahlen, et al., 2013; Ugras, 2021). Where hormone replacement therapy has been shown to relieve menopausal symptoms and protect against osteoporosis and possibly heart disease in breast cancer survivors (von Shoultz & Rutqvist, 2005), concerns endure over the risk of breast cancer recurrence. Non-hormonal pharmaceutical approaches may be used as a second-line therapy for this patient’s symptoms of hot flashes, night sweats, etc., is she chooses not to opt for hormone replacement therapy.
If this patient were to opt in for hormone replacement therapy, there would be several choices consisting of estrogen pills, estrogen patch, topical estrogen, vaginal estrogen, estrogen/progestin, and progestin hormone therapy. I would place this patient on vaginal estrogen which comes in either a cream, vaginal ring, or vaginal estrogen tablets. This type of hormone replacement therapy focuses on the symptoms of vaginal dryness, itchiness, and burning or pain during intercourse (Suckling, et al., 2006). Depending on the patient’s concerns, this type of hormone replacement therapy would be a viable option. Estrogen pills could also be given which are the most common type of hormone replacement therapy. It is probably the most convenient type, given that it can be taken once a day without regard to food intake. I would have a conversation with the patient and go over the pros and cons of hormone replacement therapy. Cons would include increased risk of stroke, heart attack, and reccurent cancer. Ultimately, the patient would decide on the course of treatment related to hormone replacement therapy.
Fahlen, et al., (2013). Hormone replacement therapy after breast cancer: 10 year follow up of the Stockholm randomized trial. European Journal of Cancer, 49(1), 52-59.
La Vecchia, C. (2004). Estrogen and combined estrogen–progestogen therapy in the menopause and breast cancer. The Breast, 13(6), 515–518.
Roberts, H., & Hickey, M. (2016). Managing the menopause: An update. Maturitas, 86(2016), 53–58.
Suckling, J. A., Kennedy, R., Lethaby, A., & Roberts, H. (2006). Local estrogen for vaginal atrophy in postmenopausal women. Cochrane Database Systemic Review. Issue 4. Art. No.: CD001500. Pub2.
Ugras, S. K., & Layeequr Rahman, R. (2021). Hormone replacement therapy after breast cancer: Yes, No or maybe? Molecular & Cellular Endocrinology, 525, N.PAG.
Von Shoultz, E., & Rutqvist, L. E. (2005). Menopausal hormone therapy after breast cancer: the Stockholm randomized trial. Journal National Cancer Institute, 97(7), 533-535.
