Pharmacology discussion response
Provide recommendations for alternative drug treatments to address the patients pathophysiology. Be specific and provide examples.
This week’s patient is a 46-year-old female who is a 230lb woman with a family history of breast cancer; she is current on annual mammograms. The patient’s only noted history is Hypertension. The patient presents to the office today with hot flushing, night sweats, and genitourinary symptoms. The patient stated she had felt well until a month ago and is now when she made an appointment to discuss said symptoms with her gynecologist during her annual gynecological exam. The patient stated that her annual exams/ pap smears had been negative except for an ASCUS test result five years ago. The patients current medicaitions consist of Norvasc 10 mg daily, Hydrochlorothiazide 25 mg daily.Current blood pressure is 150/90. Her LMP was one month ago, and they are regular.
The patient shows signs and symptoms of menopause, including hot flashes, night sweats, and gentiuniary symptoms. According to the North American Menopause Society, NAMS, “Women in North America will likely experience natural menopause between ages 40 and 58, averaging around age 51.” Therefore, these symptoms are the most common. According to Deecher, “Vasomotor symptoms (VMS), commonly called hot flashes or flushes (HFs) and night sweats, are the menopausal symptoms for which women seek treatment during menopause most often. VMS is a form of temperature dysfunction that occurs due to changes in gonadal hormones. Normally, core body temperature (CBT) remains within a specific range, oscillating with daily circadian rhythms. Physiological processes that conserve and dissipate heat are responsible for maintaining CBT, and tight regulation is important for maintaining optimal internal organ function. Estrogens are known potent neuromodulators of numerous neuronal circuits throughout the central nervous system. Therefore, changing estrogen levels during menopause may impact multiple components involved in maintaining temperature homeostasis.”
Patients are typically treated with Hormone Therapy to decrease said symptoms; however, given the patient’s potential risk for breast cancer and ASCUS, it would be beneficial for the patient to utilize alternative therapy. According to Stubs, “Several nonestrogen pharmaceutical, or prescription, therapies have also been evaluated for hot flashes. These include clonidine, an alpha-adrenergic agonist, the anticonvulsant gabapentin, selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).” (Stubbs et al., 2017) Given the patient’s symptoms and past medical history, I would initiate an SSRI, paroxetine (Paxil) at 20 mg by mouth daily.
The patient is also exhibiting genitourinary symptoms. “These symptoms caused by a decrease in estrogen can include vaginal dryness during intercourse, urinary incontinence, or urgency. Most of these symptoms can be attributed to the lack of estrogen that characterizes menopause. Even though the condition mainly affects postmenopausal women, it is seen in many premenopausal women as well. The hypoestrogenic state results in hormonal and anatomical changes in the genitourinary tract, vaginal dryness, dyspareunia, and reduced lubrication, being the most prevalent and bothersome symptoms. These can greatly impact the quality of life (QOL) of the affected women, especially those who are sexually active. The primary goal of the treatment of GSM is to achieve the relief of symptoms. First-line treatment consists of non-hormonal therapies such as lubricants and moisturizers, while hormonal therapy with local estrogen products is generally considered the “gold standard.” Newer therapeutic approaches with selective estrogen receptor modulators (SERMs) or laser technologies can be employed as alternative options, but further research is required to investigate the viability and scope of their implementation in day-to-day clinical practice.” I would initiate a topical estrogen cream (Estradiol) applied in the vaginal canal to assist the patient with these symptoms.
In conclusion, the patient will have the following medications initiated: paroxetine (Paxil) and Estradiol. The patient will also need to be provided with education on all new medications dosages and routes and potential side effects, and the need to continue with annual pap smears, mammograms, and monthly self-breast exams.
References
Are we there yet? Navigate now with our guided menopause tour. How Will I Know I’m in Menopause? Menopause Stages, Symptoms, & Signs | The North American Menopause Society, NAMS. (n.d.). .
K;, D. D. C. D. (n.d.). Understanding the pathophysiology OF VASOMOTOR symptoms (hot flushes and night sweats) that occur In PERIMENOPAUSE, menopause, and postmenopause life stages. Archives of women’s mental health. https://pubmed.ncbi.nlm.nih.gov/18074100/.
M;, Y. T. U. H. T. M. I. (n.d.). Hormone replacement therapy in postmenopausal women. The journal of medical investigation : JMI. https://pubmed.ncbi.nlm.nih.gov/13678382/.
Stubbs, C., Mattingly, L., Crawford, S. A., Wickersham, E. A., Brockhaus, J. L., & McCarthy, L. H. (2017). Do SSRIs and SNRIs reduce the frequency and/or severity of hot flashes in menopausal women. The Journal of the Oklahoma State Medical Association, 110(5), 272274.
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