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Case 5

Menopause
A 51-year-old woman presents to her physician’s office complaining of mood swings, vaginal
dryness, and hot flashes for the past several months. She had a total abdominal hysterectomy 4
years ago secondary to uterine myomas.

QUESTIONS
What are the potential causes of this patient’s complaints?
What laboratory values would help confirm the diagnosis?
DISCUSSION
Given the patient’s age and symptoms, she is most likely going through menopause. It must be considered
that, as women age, their risk for thyroid disease increases. The most common complaints that will bring
a menopausal woman to her physician are hot flashes, irregular menses, vaginal dryness, mood swings,
and sleep disturbances. This patient has undergone a hysterectomy so has not experienced irregular
menses. Most women will begin to experience menstrual irregularities as the first sign of impending
menopause. The irregularities are quite similar to the menstrual irregularities experienced by adolescents.
The cessation of menses defines menopause. When a woman has had her uterus removed, the physician
relies on symptoms to make the diagnosis. Serum levels of follicle-stimulating hormone and luteinizing
hormone increase due to the loss of negative feedback from estrogen and inhibin from the ovary. In this
situation, these values help confirm the diagnosis of menopause. A maturation index from the vaginal
mucosa may be obtained to determine if the vaginal symptoms are caused by atrophy.

On further questioning, the physician discovers that the patient’s mother died from a pulmonary
embolus after surgical pinning of a fractured hip.

QUESTION
How will this information impact patient management?
DISCUSSION
This patient’s mother may have suffered a fractured hip secondary to osteoporosis. A family history of
osteoporosis is the strongest risk factor for the development of osteoporosis. This patient should be
advised of her increased risk of osteoporosis and instructed as to how she can decrease her risk and keep
her bones healthy. The health cost of osteoporosis is great. Over 10 billion dollars are spent every year
caring for men and women who have osteoporosis. For elderly patients who suffer a hip fracture, the rate
of morbidity is high. The mortality rate approaches 25% for women who have a hip fracture. The most
common cause of death for women undergoing hip replacement or pinning of a fracture is pulmonary
embolus. These elderly patients commonly have multiple medical problems complicating their recovery.

The physician discusses the use of estrogen replacement therapy, calcium supplementation, weightbearing exercise, and the avoidance of smoking and alcohol to decrease the patient’s risk of
osteoporosis. The patient refuses estrogen replacement therapy because she is afraid of increasing
her risk of breast cancer.

QUESTION
What other therapy should the physician offer this patient?
DISCUSSION
If the patient has already developed osteoporosis, she can be treated with alendronate sodium (Fosamax).
This is a new class of drugs that inhibits osteoclastic resorption of bone. It is approved for use in
menopausal women who have documented osteoporosis. This diagnosis can be made by demonstrating

osteoporosis on a dual-energy x-ray absorptiometry (DEXA) bone scan. Adequate calcium
supplementation is mandatory with this therapy. The patient should be advised to continue weight-bearing
exercise and to avoid alcohol and smoking.

Before leaving the physician’s office, the patient asks the physician to recommend an internist for
her. The physician gives the patient the name of an internist, explaining to her that all the routine
primary care screenings will be forwarded.

QUESTION
What other studies should be ordered before the completion of the visit?
DISCUSSION
This patient needs a screening blood pressure measurement, urinalysis, weight measurement, and a
screening cholesterol test. Total cholesterol and high-density lipoprotein are satisfactory. In addition, the
patient should have a rectal examination with stool guaiac. After the age of 50, all men and women should
have screening sigmoidoscopies performed every 3 to 5 years. Starting at age 65, all women should be
screened for thyroid disease with a thyroid-stimulating hormone. The patient should be reminded about
the need for yearly Pap smears and mammograms.

The patient returns 2 months later stating that she and her husband have not been able to have
intercourse due to severe pain. She is distressed by this and would like to resume a normal sex life.

QUESTIONS
What should the physician tell this patient?
What are the patient’s options?

DISCUSSION
Vaginal dryness is a common complaint in menopausal women. This dryness is due to a decrease or lack
of secretions. The pain with intercourse is due to the lack of lubricant as well as vaginal atrophy from
estrogen deprivation. Most patients will have significant relief from the use of a lubricant with
intercourse. Patients must be advised that continued sexual activity is necessary or the pain with
intercourse will worsen. A maturation index can be helpful to confirm vaginal atrophy. A careful
examination to diagnose vaginitis is mandatory. For those patients with severe atrophy who do not
respond to lubricant, a trial of oral or local Premarin therapy is indicated. Although there is systemic
absorption of Premarin cream applied to the vagina, the levels are much lower than with oral therapy.

The patient was willing to try the local Premarin and had complete resolution of her symptoms.
The patient returned 1 year later for her annual examination and was doing quite well. She has
had a normal sex life with her husband, and the hot flashes have tapered. The only complaint that
she has is mild bone pain in her back.

QUESTION
What could the physician recommend for this patient?
DISCUSSION
Bone pain is common in menopausal women. These symptoms commonly abate with estrogen
replacement therapy. The patient should be informed of this and should have a DEXA bone scan to check
for osteoporosis. If osteoporosis is diagnosed, the physician should suggest that the patient begin
estrogen replacement therapy. Because she has had a hysterectomy, the patient can take just estrogen
daily.