A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms
A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms
TuesdayApr 25 at 19:02pm
Case Study 2
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 she 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 1 month ago.
Recommended treatment regimen
- genitourinary symptoms
Genitourinary syndrome of menopause refers to a multitude of vulvovaginal, sexual and urinary symptoms associated with anatomical and functional changes in urogenital tissues, typically occurring with menopause and age-related depletion of sex hormones (Cucinella et al., 2022). Menopause typically begins at the age of 51 to 52 years of age but can occur as early as 45 and as late as 55 years of age. The initial phase of menopause begins with the irregularity of the menstrual cycle, eventually leading to the completion of ovulation. One of the side effects of entering menopause is the decline in estrogen levels, with the urethra and vagina having the highest concentration of estrogen receptors. Once the estrogen levels declines this leads to atrophy of the urethra which causes frequency and urgency in urination. Urethritis and urinary tract infections occurs due to the decrease in acidity (Rosenthal & Burchum, 2021).
Pharmacotherapeutics
As an advanced healthcare provider, I would explain to the patient that her symptoms could possibly be due to her entering the premenopausal phase but a clinical diagnosis of GSM will require a gynecologic examination. Treatment for GSM is based off the severity of symptoms. Moisturizers and lubricants, may be suitable for the management of mild symptoms or for women who are not candidate for hormonal treatments. Seeing that the patients continues to have a menstrual cycle every month regularly she does continue to make estrogen for there will be no need at this time to discuss estrogen replacement therapy.
There will need to be a thorough health assessment to discuss the patient’s genitourinary symptoms in more detail, such as if she is having genital symptoms that includes vaginal dryness or dyspareunia (pain during vaginal penetration), or urinary symptoms such as dysuria, frequency, nocturia and urinary incontinence.
2. history of ASCUS
ASCUS atypical squamous cells of undetermined significance, is diagnosed when the characteristics of cells are significantly more than inflammatory cell changes, but not enough to diagnose epithelial malignant lesions (Chenchen et al., 2019). Continue to remind the patient that its highly important for her to continue to obtain yearly pap smears
3. Blood pressure of 150/90 and weight of 230lbs
The patient’s blood pressure is on the higher end. As an advanced healthcare provider it would be important for me to be aware if this blood pressure is a trend for the patient or if it was just a one off thing. I would want to assess the patient for compliancy with her medications; asking her when was the last time she took her medication and remind the patient that her weight is a contributing factor in her high blood pressure.
Pharmacotherapeutics
Menopausal women have a higher risk of hypertension due to hormonal changes. Menopause is also associated with renin-angiotensin system activation, sympathetic activation, the increase of BMI, obesity and changes in body fat distribution, and type 2 diabetes. As an advanced healthcare provider I would need to keep an eye out for the patient’s blood pressure to see if there would need to be an adjustment in the patient’s current medication regimen.
There would be no change made at this time in patient’s blood pressure medications unless I noticed the continued trend in her pressure rising. At that time it would be decided to continued with a calcium channel blocker and thiazide diuretic or switch to a loop diuretic.
Patient education
As an advanced healthcare provider I would educate the patient on the DASH diet, the dietary approach to stop hypertension. The DASH diet is an a priori-defined dietary pattern recommended by the US Department of Agriculture’s dietary guidelines as a healthy dietary pattern for adults. The DASH diet consists mainly of high amounts of fruits, vegetables, nuts and legumes, low-fat dairy products and whole grains and low amounts of sodium, sweetened beverages, and red and processed meats. It has also been indicated to reduce the risk of developing type 2 diabetes, studies have also shown that adherence to the DASH diet affectively controls weight (Barak et al., 2015).
I would have the patient monitor her blood pressure daily, recording her pressure for the next month and to come back for a follow up appointment to determine if there would need to then be made an adjustment in her medications.
Natasha,
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Cucinella, L., Martini, E., Tiranini, L., Molinaro, P., Battista, F., & Nappi, R. E. (2022). Genitourinary syndrome of menopause: Should we treat symptoms or signs? Current Opinion in Endocrine and Metabolic Research, 26. https://doi.org/10.1016/j.coemr.2022.100386Links to an external site.
Chenchen Ren, Yuanhang Zhu, Li Yang, Xiaoan Zhang, Ling Liu, Zhaoxin Wang, & Dongyuan Jiang. (2019). Prognostic and diagnostic validity of p16/Ki-67, HPV E6/E7 mRNA, and HPV DNA in women with ASCUS: a follow-up study. Virology Journal, 16(1), 1–8. https://doi.org/10.1186/s12985-019-1251-4Links to an external site.
Xia Y, Liang C, Kang J, You K, Xiong Y. Obstructive Sleep Apnea and Obesity Are Associated with Hypertension in a Particular Pattern: A Retrospective Study. Healthcare (Basel). 2023 Jan 31;11(3):402. doi: 10.3390/healthcare11030402. PMID: 36766978; PMCID: PMC9913941.
Barak, F., Falahi, E., Keshteli, A. H., Yazdannik, A., & Esmaillzadeh, A. (2015). Adherence to the Dietary Approaches to Stop Hypertension (DASH) diet in relation to obesity among Iranian female nurses. Public Health Nutrition, 18(4), 705-712. https://doi.org/10.1017/S1368980014000822
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