NURS 6521 WOMEN’S AND MEN’S HEALTH, INFECTIOUS DISEASE, AND HEMATOLOGIC DISORDERS

Case Study

A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms. She has a history of HTN. She complains of hot flushing, night sweats, and genitourinary symptoms. She had felt well until 1 month ago and presented to her gynecologist for her annual GYN examination and to discuss her symptoms. She has a history of ASCUS about 5 years ago on her pap; other than that, Pap smears have been normal. Home medications are Norvasc 10mg QD and HCTZ 25mg QD. Her BP today is 150/90. She has regular monthly menstrual cycles. Her LMP was one month ago.

Treatment Regimen

After analyzing the symptoms, I concluded that the patient is experiencing peri-menopausal symptoms. For many people, menopause begins around age 45 though the onset of symptoms varies across different people. She is undergoing the early stages of menopause which is a stage that begins with experiencing changes in the uterus, breasts, increased fat deposit, and the urogenital tract undergoing several changes such as a shrinking cervix, and reduced muscle tone in the pelvic area. At that age, the level of estrogen production is low hence, leading to hot flashes and night sweats. Therefore, her treatment regime will focus on taking into consideration the patient has Hypertension already. Hormone therapy will be eliminated and prescribe vaginal cream that would help her manage genitourinary symptoms such as vaginal dryness and dyspareunia (Yoo et al., 2020). Mood changes and hot flashes are common symptoms of menopause hence the patient will be prescribed low-dose antidepressants such as venlafaxine and sertraline. Besides, herbal treatment has been proven to be effective in managing vasomotor symptoms hence the patient can be prescribed black cohosh which helps in reducing many menopausal symptoms (Mahady, et al., 2002).

As people continue to age, their bones become weak and this increases their chances of suffering born fractures. Therefore, the patient will be given vitamin D supplements to the increase production of estrogen which reduces with age and reduces cases of bone fractures.

During the clinical interview, I realized that the patient is taking Norvasc 10 mg and hydrochlorothiazide (HCTZ) 25 mg. I would advise her to discontinue taking Norvasc since the drug acts as a calcium blocker hence leading to hypertension and besides, its side effects increase menopause symptoms. Since she has hypertension, I would recommend that she takes lisinopril 20 mg daily. This should help alleviate the flushing that the patient has been experiencing (Li et al., 2016). Additionally, the patient has a history of ASCUS, hence I will advise her to continue with her PAP smear exams. With her blood pressure being high currently, and the fact that she is taking Norvasc, she will be encouraged to stop Norvasc but increase the HTCZ dosage to 50mg daily. The patient is expected to come regularly for assessment and examination of the drugs and symptoms.

NURS 6521 WOMEN’S AND MEN’S HEALTH, INFECTIOUS DISEASE, AND HEMATOLOGIC DISORDERS

Patient Education Strategies

Patient education has become an effective strategy to influence patients’ behavior to start living a quality life. The patient will be educated on ways to maintain weight through diet modification, become physically active, and practice relaxation as one way to reduce the severity of menopause symptoms and chances of getting breast cancer (Paterick et al., 2017). The patient will be educated about things she needs to avoid such as the use of exogenous hormones to reduce getting breast cancer going to her family history (Stuenkel et al., 2015). All this information will be passed to the patient through her patient portal which is deemed the best instructional method for her as she can access the information from the comfort of her home.

References

Li, R. X., Ma, M., Xiao, X. R., Xu, Y., Chen, X. Y., & Li, B. (2016). Perimenopausal syndrome and mood disorders in perimenopause: prevalence, severity, relationships, and risk factors. Medicine, 95(32).

Mahady, G. B., Fabricant, D., Chadwick, L. R., & Dietz, B. (2002). Black cohosh: an alternative therapy for menopause?. Nutrition in Clinical Care, 5(6), 283-289.

Paterick, T. E., Patel, N., Tajik, A. J., & Chandrasekaran, K. (2017, January). Improving health outcomes through patient education and partnerships with patients. In Baylor University Medical Center Proceedings (Vol. 30, No. 1, pp. 112-113). Taylor & Francis.

Manson, J. E., & Kaunitz, A. M. (2016). Menopause management—getting clinical care back on track. N Engl J Med, 374(9), 803-6.

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.

Yoo, T. K., Han, K. D., Kim, D., Ahn, J., Park, W. C., & Chae, B. J. (2020). Hormone replacement therapy, breast cancer risk factors, and breast cancer risk: a nationwide population-based cohort. Cancer Epidemiology, Biomarkers & Prevention, 29(7), 1341-1347.

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Enjoyed reading your post, I read Norvasc leads to HTN and its side effects increase menopause symptoms. I am not sure I read it correctly but wanted to add this, Norvasc, a calcium channel blocker slows the rate at which calcium passes into the heart muscle and into the vessel walls. This relaxes the vessels. The relaxed vessels let blood flow more easily, lowering blood pressure. Calcium Channel Blockers are used to control high blood pressure (hypertension), chest pain (angina), and irregular heartbeats (arrhythmia). www.texasheart.org. Links to an external site.Some side effect of calcium blockers is flushing which can be a symptom of menopause such as hot flashing.

Also, the underlying pathogenesis of amlodipine protection includes reduced apoptosis and inhibition of mPTP opening by preventing calcium overload and increasing renal blood flow and glomerular filtration rate by blocking the L-type calcium channels. It is often used to preserve kidney function in Diabetes. Yin, Zhou & Zou (2020) I was a dialysis nurse for years and our Nephrologist always managed our CRF patients who usually were diabetic with Norvasc to help preserve kidney function and to help with HTN.

Reference:

https://www.texasheart.org Links to an external site../heart-health/heart-information-center/topics/calcium-channel-blockers

Yin, Wen-jun and Zhou, Ling-yun and Li, Dai-yang and Xie, Yue-liang and Wang, Jiang-lin and Zuo, Shan-ru and Liu, Kun and Hu, Can and Zhou, Ge and Chen, Lin-hua and Yang, Hui-qing and Zuo, Xiao-cong (2020). Protective Effects of Amlodipine Pretreatment on Contrast-Induced Acute Kidney Injury And Overall Survival In Hypertensive Patients. Frontiers in Pharmacology, Vol 11 DOI10.3389/fphar.2020.00044

Your discussion was very insightful. Just to piggyback on what you said, the patient is probably experiencing premenopausal symptoms evident by hot flash, night sweats, and genitourinary symptoms. According to Smail et al. (2019), menopause is the period from when a woman has stopped menstruating for a period of twelve conservative months. Smail 2019 explains that during this time there is drop in the production of the ovarian hormones’ estrogen and progesterone leading symptoms and diseases like vaginal infections, increased risk for osteoporosis and cardiovascular diseases, sleep disorders, mood alterations, hot flashes, depression, and urinary tract infections. Roberts & Hickey (2016) also discusses that during menopause common findings such as genitourinary syndrome of menopause, sleep disturbances, vasomotor symptoms (VMS), and mood disturbances are common.

Treatment Regimen Choice or Pharmacotherapeutics Recommendation

To control the patient blood pressure and the patient’s obesity, I will encourage patient to keep to current medication prescription regimen, make lifestyle changes, and monitor blood pressure reading regularly. VMS treatments would be based on how disturbing the symptoms are (Roberts & Hickey, 2016). Currently the most effective treatment for VMS is moderate dose estrogen-containing hormone therapy (HT), and that also improves vaginal dryness (Roberts & Hickey). They also explain that to help reduce VMS, SSRI such as escitalopram is a reasonable first choice since it is well tolerated. I will prescribe transdermal estradiol patch, spray, or gel. The patch will be applied to the skin of the trunk, or the spray to apply once daily to the forearm or the gel to apply once daily to one arm, from the shoulder to the wrist or to the thigh (Rosenthal & Burchum, 2018). when used for VMS, escitalopram reduces the frequency, severity and improves quality of life, improves sleep, and does not cause sexual dysfunction (Rosenthal & Burchum). Transdermal formulations range of estrogen absorption is from 14 to 60 mcg/24 hr, depending on the product employed (Rosenthal & Burchum).

Patient Education Strategy Recommendation

To help with the patient’s VMS, I will educate the patient on eating heart healthy food such as whole grains, vegetables, fruits, and maintain a normal level of vitamin D and Calcium (McCance & Huether, 2019). To manage the patient’s weight, I will encourage her to reduce the amount of processed foods, reduce salt intake, avoid or limit alcohol consumption, maintain a healthy weight, manage stress level and regular exercise weekly at least for thirty minutes daily (McCance & Huether). Maintain good sleep pattern by avoiding caffeine, engage in bedtime relaxation rituals such as stay away from bright lights to reduce things that can cause excitement before bedtime and avoid eating large meals for at least two hours before bedtime (Fujimoto, 2017). Fujimoto also explains that keeping to regular health maintenance such as pap smear test, mammograms, breast self-examination, cholesterol screening. Also, I will encourage the patient to take flu shot annually.

References

Fujimoto, K. (2017). Effectiveness of coaching for enhancing the health of menopausal Japanese women. Journal of Women & Aging, 29(3), 216–229. https://doi-org.ezp.waldenulibrary.org/10.1080/08952841.2015.1137434

McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.

Roberts H., & Hickey, M. (2016) managing the menopause: An update. Maturitas, 86(2016), 53-58. Retrieved from https://www-sciencedirect-com.ezp.waldenulibrary.org/science/article/pii/S037851221630007X?via%3Dihub

Smail, L., Jassim, G., & Shakil, A. (2019). Menopause-Specific Quality of Life among Emirati Women. International Journal of Environmental Research and Public Health, 17(1). https://doi-org.ezp.waldenulibrary.org/10.3390/ijerph17010040

Menopause is a complex period of life which is associated with many physical and psychological changes and hot flushes are one of the most common bothersome symptoms related to menopause which has affected 85% of menopausal women with various frequency, severity and duration that needs to be addressed. Hormone replacement Therapy is considered one of the most effective treatments of choice to treat or manage these menopausal associated symptoms however there are exceptions that prevents its use. One of the example is the patient condition in the given scenario is compatible with exceptions that could prevent its use from using this treatment regimen that is Hormonal Replacement Therapy as patient in the given scenario is at risk for developing breast cancer due to her family history of breast cancer and prescribing her with HRT could potentially make her more prone to developing breast cancer and hence non hormonal based treatment regimen should be considered. Some of the non-hormonal based options include use of antidepressants such as SSRIs (paroxetine) and SNRIs and other one is the use of Gabapentin and Clonidine can also be used. Looking back at the patient scenario patient has a history of high blood pressure and is currently on amlodipine and Hydrochlorothiazide however patient still is experiencing high blood pressure and hence I believe addition of clonidine in the patient’s current drug therapy regimen, along with amlodipine and hydrochlorothiazide can be beneficial in achieving effective blood pressure control and reduction in adverse reactions. Adding Clonidine (alpha adrenergic agonist) to the drug therapy will be useful in controlling blood pressure as well as treating symptoms such as hot flashes that are related to premenopausal symptoms.

I think a lot of women; about 51% seek complementary and alternative medicine (CAM) for managing the symptoms associated with menopause as they consider it as safe and effective option with no risk associated with it, as it’s natural. However the majority of the women using CAM do not discuss it with their health care provider. Hence it is very important to reconcile their current medication list at each visit and educate patient on importance of informing their health care provider if they are using any alternative or complementary treatments such as plant estrogens, bioidentical hormones, black cohosh etc in managing their symptoms of menopause to prevent any adverse effects resulting from drug interactions.

References

Johnson, A., Roberts, L., & Elkins, G. (2019). Complementary and Alternative Medicine for Menopause. Journal of evidence-based integrative medicine, 24, 2515690X19829380. https://doi.org/10.1177/2515690X19829380

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2^nd ed.) St. Louis, MO: Elsevier.

Very insightful post and comprehensive assessment! Cognitive-behavioral therapy (CBT) could be an alternative treatment to overcome this patient’s perimenopausal symptoms. Zhang et al. (2019) have demonstrated that Cognitive-behavioral therapy helps lower menopausal symptoms, including hot flashes and excessive sweating, by attempting to alter unfavorable cognitive behaviors and patterns have recently demonstrated it. To lessen the sensations of hot flashes and night sweats, the patient should also practice meditation techniques, including progressive muscle relaxation and deep breaths (Zhang et al., 2019). According to Green and Furtado (2021), the patient could additionally attempt mindfulness-based stress reduction (MBSR), a type of mindfulness meditation that has been demonstrated to enhance mood and lessen menopausal symptoms. Cognitive-behavioral therapy and MBSR are non-pharmacological treatments that ought to be considered prospective choices with the patient as they might be helpful.

References

Debnath, N., Kumar, A., & Yadav, A. K. (2022). Probiotics as a biotherapeutics for the management and prevention of respiratory tract diseases. Microbiology and Immunology, 66(6), 277-291.

Green, S. M., & Furtado, M. (2021). Cognitive Behavioral Therapy for Sexual Concerns During Perimenopause: A Four Session Study Protocol. Frontiers in Global Women’s Health, 2, 744748.

Perimenopause is usually accompanied by several hormonal changes that may worsen the existing menstrual-related mood disorders(MRMDs). Some women experience depressive moods due to elevations of the ovarian hormones (Sander & Gordon, 2021). Although the case study has not presented any mood disorders, it will be necessary for the clinician also to bear this in mind.

Angelou et al. (2020) indicate that it is essential to note that for genitourinary treatment, always the first line of treatment is considered, and this is the use of lubricants and moisturizers before considering hormonal treatments with estrogen products. Also, new technologies that include selective estrogen receptor modules(SERMs) or laser technologies can be considered as the last resort. Intravaginal estrogen, such as tablets that contain an estradiol concentration of less than 50mcg, is an alternative to treating vaginal dryness, itchiness, and vaginal mucosa friability. However, as indicated by my colleague, hormonal therapy has risks, especially for the client in the case study since she has a history of breast cancer, hence should be thoroughly evaluated before being administered.

References

Angelou, K., Grigoriadis, T., Diakosavvas, M., Zacharakis, D., & Athanasiou, S. (2020). The genitourinary syndrome of menopause: an overview of the recent data. Cureus, 12(4). https://www.cureus.com/articles/29859#!/Links to an external site.

Sander, B., & Gordon, J. L. (2021). Premenstrual mood symptoms in perimenopause. Current Psychiatry Reports, 23, 1-8. https://link.springer.com/article/10.1007/s11920-021-01285-1Links to an external site.

From a personal standpoint, being age 60, overweight and having a family history of breast cancer, and being hypertensive, I can relate to this case study. I take HRT daily.

I recommend Compounded hormone therapy. According to Thompson, Ritenbaugh & Nichter (2017), this medication is a form of bioidentical hormone therapy that is individually formulated for patients by pharmacists. Popularly, the term “bioidentical” refers to prescription hormones that have “the same molecular structure as a hormone that is endogenously produced and circulates in the human bloodstream.” Bioidentical hormone therapy may be manufactured in standard doses by drug companies and sold under brand names such as Vivelle (estradiol) and Prometrium (micronized progesterone). Alternatively, it may be individually formulated for patients by compounding pharmacists as CBHT. CBHT is available in an array of delivery methods (e.g., capsules, patches, creams, sublingual lozenges or “troches,” and vaginal suppositories) and dose strengths, although common compounded formulations include estriol alone, “bi-estrogen” or “bi-est” combinations (estradiol and estriol), or “tri-estrogen” or “tri-est” combinations (estrone, estradiol, and estriol)—as well as progesterone, testosterone, and dehydroepiandrosterone (DHEA).

According to Dalal & Aganwal (2015), Systemic estrogen therapy is the most effective treatment available for vasomotor symptoms and the associated sleep disturbance. Healthy women in the perimenopausal transition who are experiencing bothersome hot flashes but still menstruating may benefit from oral contraceptives.

I would recommend for the patient have yearly mammograms and pap tests, a weight program, and monitor blood pressure and heart rate at home. Follow up in 3 months for repeat blood work to see the efficacy of therapy.

References:

Dalal, P. K., & Agarwal, M. (2015). Postmenopausal syndrome. Indian journal of psychiatry, 57(Suppl 2), S222–S232. https://doi.org/10.4103/0019-5545.161483 Links to an external site.

Thompson, J. J., Ritenbaugh, C., & Nichter, M. (2017). Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making. BMC women’s health, 17(1), 97. https://doi.org/10.1186/s12905-017-0449-0

From a personal standpoint, being age 60, overweight and having a family history of breast cancer, and being hypertensive, I can relate to this case study. I take HRT daily.

References:

Dalal, P. K., & Agarwal, M. (2015). Postmenopausal syndrome. Indian journal of psychiatry, 57(Suppl 2), S222–S232. https://doi.org/10.4103/0019-5545.161483 Links to an external site.

NURS 6521 WOMEN’S AND MEN’S HEALTH, INFECTIOUS DISEASE, AND HEMATOLOGIC DISORDERS