wk 7 discussion replies

1.CaseScenario 1

Table 1

	Define:
	Perimenopause	“Period preceding final menstrual period by 8–10 years, usually occurring between 48 and 55 years of age” (Alexander, 2027).
	Menopause	“Point in time occurring 12 consecutive months after natural cessation of menses, 51 years” (Alexander, 2027).
	Postmenopause	“Period following menopause, commonly associated with symptoms attributable to waning estrogen and progesterone levels” (Alexander, 2027).

	S/S menopause		Cause -How does it occur/ how does it relate to menopause		Recommendations
	Example: Decrease libido		Lower levels of testosterone		Having a conversation with partner, setting the mood
	Hot flashes	An effort to dissipate heat by means of vascular dilation (Alexander, 2017). Increased FSH and estrogen that is lowered.	Try to maintain a healthy weight, avoid spicy foods and alcohol, and dress in layers that can be easily removed (Alexander, 2017).
	Night sweats and Sleep Disturbance	Estrogen and progesterone can cause unpleasant temperatures (Casper 2024).	Wear loose fitting pajamas such as cotton, sip cold water through the night, exercise during the day (Casper, 2024).
	Irregular menses	Inconsistent levels of estrogen (Welt, 2024)	Hormone therapy such as estrogen or progesterone to balance the hormones (Welt, 2024).
	Mood swings or irritability	Falling of estrogen and progesterone can also cause serotonin levels to fall (Barbieri, 2024).	Exercise, diet, rest, and support from loved ones (Barbieri, 2024).
	Vaginal dryness	The body does not produce enough estrogen (Bachmann, 2024).	Vaginal moisturizers, lubricants, estrogen ring, and estrogen cream (Bachmann, 2024).

Barbara is 48-year-old female who complains her menstrual cycle has recently become irregular, and she is experiencing hot flashes and vaginal dryness. She has also noticed a decrease in her desire for sex lately. She has been married to a man for 20 years, is in a stable relationship, and has two daughters ages 16 and 18. She is otherwise healthy with an unremarkable medical history. Her pregnancy test is negative. Her Pap smear and STI panel are all negative.

Case 1

Subjective:

Chief Complaint: 48 y/o menstrual irregularity, hot flashes, and vaginal dryness.

HPI: 48 y/o female presents to the clinic for menstrual irregularity, hot flashes, and vaginal dryness. She admits to have experiencing hot flashes x4 months. Admits that the vaginal dryness has been increasing. Reports that the menstrual irregularity includes frequency of menstrual cycle lasting 4-5 days every 22 days vs 7 days every 28 days. Now that cycles are irregular menstrual cramps are a factor. Reports that her desire in sexual activity is decreasing. Endorses that because of experiencing low libido vaginal dryness is not of much concern in that department, but it is uncomfortable. She states that in times her occupation as a teacher can be stressful due to dealing with both children and parents on a day to day. She is happily married of 20 years with 2 daughters. Denies mood swings and sleep disturbance.

PMH: Unremarkable

LMP: 01.2024

Age of Menopause:

Pregnancies: 2

Miscarriage: 0

Past Surgical Hx: No Surgical Hx

Allergies: NKA

Family Hx:

Daughter, 16, Alive

Daughter, 18, Alive

Husband, 49, Diabetes

Mother, 67, Alive, Hypothyroidism

Father, 69, Alive, HTN

Maternal Grandmother, 90, Alive, Breast Cancer

Maternal Grandfather, 91, Alive, CKD

Paternal Grandmother, 93, Alive, Liver Disease

Paternal Grandfather, 95, Alive, Parkinson’s

Social Hx:

Married – 20 years

Occupation – School Teacher

Alchohol – 1 glass of wine per week

Tobacco Use – No hx of smoking

Substance Abuse – No hx of substance abuse

Subjective Data:

1. What other medical history questions should you ask? Have you been treated for menopause? No, I have not. What medications are you currently taking? I am not on any medications. Have you gotten a recent set of labs? I went to have my labs drawn by my PCP, but I don’t believe that my other labs got drawn. Do these labs include hormone levels? No. Have you utilized oral contraceptives? Yes, many years ago. I used to take an Oral Contraceptive.
2. What other social history questions should you ask? Do you practice safe sex? Yes, condom use. Do you practice stress relieving exercises? Yes, I attend a weekly cycle class.
3. What other family history questions should you ask? At what age did your mom start menopause? 44 Did she experience the same symptoms? Yes

• General/Constitutional:Admits to irregular menstrual cycle x4 months. Admits to hot flashes. Admits to low libido. Admits to vaginal dryness.Denies malaise, weakness, fever, or chills. Denies recent weight gains or losses of >20 pounds over the last 6 months.
• Cardiovascular:Denies chest discomfort, heaviness, or tightness. Denies abnormal heartbeat or palpitations. Denies shortness of breath, denies having to sleep elevated on 2 pillows or more, no swelling of the feet, no passing out or nearly passing out. Denies history of heart attack or heart failure.
• Respiratory:Denies cough, phlegm production, coughing up blood, wheezing, sleep apnea, exposure to inhaled substances in the workplace or home, no known exposure to TB or travel outside the country. Denies history of asthma, COPD/emphysema, or any other chronic pulmonary disease.
• Gastroinestinal:Denies nausea, vomiting, abdominal discomfort/pain. Denies diarrhea, constipation, blood in the stool or black stools. Denies hemorrhoids, trouble swallowing, heartburn or food intolerance. Denies history of liver or gallbladder disease. No recent weight gains or losses of > 20 pounds within the last year.
• Skin and Breasts:Denies rash, itching, abnormal skin, or recent injury. Denies breast pain, discharge, or other abnormality was reported by the patient.
• Genitourinary:Denies Abdominal pain/swelling. Denies Blood in urine. Denies Difficulty urinating. Denies Frequent urination. Denies Pain in lower back.Denies Painful urination
• Women Only:Admits to irregular menstrual cycle x4 months to 4-5 days every 22 days vs 7 days every 28 days. Admits to filling up 3 pads in 24 hours daily. Admits to hot flashes. Admits to low libido. Admits to vaginal dryness

• Mental Status/Psychiatric:Denies history of depression or anxiety. Denies difficulty sleeping, persistent thoughts or worries, decrease in sexual desire, abnormal thoughts, visual or auditory hallucinations. Denies history of psychosis or schizophrenia. Denies difficulty concentrating or change in memory.
• Up to date on all Immunization
• Endorses a male sexual partner of 20 years

Objective:

VS: BP: 108/72, HR: 67, RR: 18, Temp: 98.3,O2 Sat: 98%, HT 5’10 inches WT: 165lb

Physical Exam:

• General: Alert and Oriented x4, speaks clearly and comfortably throughout.
• RESP: lungs clear to auscultation bilaterally, no rales, wheezes, or rhonchi, nonlabored breathing, no use of accessory of muscles of respiration.
• CV: RRR
• BREAST: (-) erythema, (-) symmetric at rest, (-) symmetric with pectoral tension, (-) tender to palpation
• Urethral meatus: (-) lesions, (-) erythematous, (-) discharge, (-) tender
• Bladder: normal, (-) tender, (-) cystocele
• Vagina: (+) dryness, (-) moist (-) discharge, (-) lesions
• Cervix: (-) lesions, (-) discharge, (-) contact bleeding,
• Uterus: (-) enlarged (-) tender, (-) cervical motion tenderness
• Extremities: (-) edema
• DERM: skin warm and dry

Tests will order:

Pregnancy test – negative

Pap Smear – negative

STI Panel – negative

CBC – unremarkable

CMP – pending

Labs, progesterone, estrogen, and testosterone – pending results

• Pregnancy test to confirm the patient is not pregnant. Pap smear to confirm Vaginal dryness and it is time for routine Pap Smear. STI testing to rule out. A CMP will reveal thyroid function. Hormone labs are included due to lack of libido, hot flashes, vaginal dryness, and irregularity of menstrual cycles.

Assessment:

Diff Dx:

E28.2: Polycystic ovary syndrome

The pertinent positives includes irregular menstruation and heavy periods

The pertinent negatives includes low libido and hot flashes

R/O Dx: Pelvic exam, blood tests, pelvic US

N73.9: Female pelvic inflammatory disease, unspecified

The pertinent positives includes irregular menstruation and spotting.

The pertinent negatives vaginal discharge and pain

R/O Dx: Pelvic US and MRI

Final Diagnosis:

E28. 310 Symptomatic premature menopause

The Pertinent positive includes hot flashes, vaginal dryness, low libido, and menstrual irregularity.

The Pertinent negative includes mood swings and sleep deprivation

Plan:

Treatment Plan: The treatment plan for menopause depends solely on the labs drawn for hormone levels. This will tell whether hormone replacement will be a good option. Vaginal dryness, hot flashes, and irregular menstrual cycle indicate low estrogen. Low libido indicates low testosterone. Treatments can include hormone replacement therapy, cognitive behavioral therapy, and bioidentical hormones. The route of the medication of estrogen can either be a skin patch, implants, tablets. The route of progesterone includes a patch, IUD, implant, or tablets. Testosterone is used to help restore libido. When lab results return we can then start you on estradioL 0.0375 mg/24 hr semiweekly transdermal patch, 1 patch twice weekly and Testosterone 5mg/24 hours transdermal weekly. In the meantime while waiting on lab results starting herbal medications will help such as Black Cohosh and Red Clover.

Education: Menopausal period can start between the ages of 45 to 55 (Martin, 2024). There are three stages of menopause. The first stage is perimenopause, the second is menopause, and the 3rd is postmenopause. Estrogen, progesterone, and testosterone are all hormones needed to help control how our body functions. As we age hormones can become imbalanced due to menopause. This can have direct effect on lifestyle habits, environmental conditions, and certain glandular malfunctions. Taking hormone replacement therapy can reduce risk of heart disease. A decrease of estrogen and of testosterone is seen, once the lab results return we can then start you on estradiol 0.0375 mg/24 hr semiweekly transdermal patch, 1 patch twice weekly and Testosterone 5mg/24 hours transdermal weekly. If hormone replacement is not on the table, then alternative methods may be used. Cognitive behavioral therapy can lower one’s mood and anxiety. It is important to keep follow up appointments every 3 months to make sure that symptoms are well under control and if the HRT needs adjusting. Herbal remedies may also be used such as Black Cohosh and Red Clover. These both help with hot flashes, night sweats, and vaginal dryness. Exercise, controlling stress levels, and lifestyle changes are extremely important. Improving eating habits will help immensely, eating green leafy cruciferous vegetables will help with symptoms and overall wellness. Take this one day at a time. It is important to have a support system throughout this time.

Referral/Follow-up: f/u after lab results to start on possible hormone therapy.

Recommend scheduling an appointment every 3 months to recheck hormone levels.

2. Case Scenario 1

Table 1

Define:

PerimenopausePerimenopause is the transitional period before menopause. Perimenopause, or the menopausal transition, encompasses that period of time during which physiologic changes mark progression toward a woman’s final menstrual period (FMP).Menopause

Postmenopause

Menopause is technically identified as a point in time following 12 consecutive months of amenorrhea occurring in response to normal physiologic changes in the hypothalamic–pituitary–ovarian (HPO) axis.

Postmenopausal is commonly applied to any woman after menopause, the postmenopausal period technically refers to the first 5 years after menopause. Hormonal fluctuations are common during this period.

S/S menopauseCause -How does it occur/ how does it relate to menopauseRecommendationsExample: Decrease libidoLower levels of testosteroneHaving a conversation with partner, setting the mood

Hot flashes

Hormone replacement or lifestyle modifications including diet (eliminate sugar, caffeine, spicy foods, chocolate, alcohol) and exercise. Wearing light clothes can also help especially when sleep.

Night sweats and Sleep Disturbance

Irregular menses

Mood swings or irritability

Vaginal dryness

Vasomotor symptoms (VMS), also known as hot flashes or hot flushes, are described as sudden onset, intense feelings of warmth often involving the face, neck or chest, sometimes followed by a chill. The longstanding theory exists that VMS are related to the withdrawal of estrogen, specifically estradiol.
Trouble falling asleep, early awakening, and interrupted sleep can occur. In the Study of Women Across the Nation, 37% of women between the ages of 40 and 55 reported difficulty sleeping, with highest rates noted in Caucasian and Hispanic women. Sleep disturbances are strongly associated with vasomotor and psychological symptoms, in addition to stress- and health related lifestyle factors. With more severe VMS, a woman is more likely to report insomnia; however VMS alone do not explain all of the sleep changes during the transition. Hormone levels are not associated with sleep disturbances. Some sleep changes are related to aging: there is an overall reduced need for sleep (8 hours per night for younger women, 5–7 hours for older women), more frequent periods of brief arousal, and less time spent in sleep stages III (early deep sleep) and IV (deep sleep and relaxation). HFs and night sweats can further interrupt sleep.	Sleep aid such as melatonin or a medication can help. Sleep diary to see where the gaps are to make better sleep habits.
Irregular menstruation and early menopause may be affected by several factors, including, modifiable risk factors. Studies have shown that the changes in the female hormone levels are associated with health behaviors, obesity, and stress. Irregular menses are common during the perimenopause and may include alterations in flow or cycle length, missed periods, and increased or newly developing premenstrual symptoms.	Hormone replacement and eliminate modifiable factors such as smoking cessation, and diet. Reduce weight and reduce stress.
Hormone depletion associated with ovary failure results in mood swings and irritability. Menopause is associated with changes in the hypothalamic and pituitary hormones that regulate the menstrual cycle, menopause is not a central event, but rather a primary ovarian failure. At the level of the ovary, there is a depletion of ovarian follicles. The ovary, therefore, is no longer able to respond to the pituitary hormones, that is, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), and ovarian estrogen and progesterone production cease. The hormone depletion gives you mood instability and irrability.	Better sleep habits because loss of sleep can contribute to moodiness. Hormone replacement therapy. Diet and exercise can improve mood. Alternate complementary therapy can also be used to assist in treating mood instability such as acupuncture, reiki, herbal teas. Medications such as SSRI are also an option for treatment if severe mood changes.
Genitourinary syndrome of menopause (GSM) is a group of signs and symptoms associated with decrease in estrogen and other gonadal steroids, resulting in vulvovaginal atrophy. Urogenital changes will affect all women during the transition and after menopause. However, urogenital changes are not bothersome to all women. Atrophy of the vaginal epithelium causes vaginal dryness and dyspareunia, and can predispose women to urinary incontinence and recurrent urinary tract infections (UTIs). Depletion of hormones are the cause for vaginal dryness.	Hormone replacement- estrogen replacement. Lubricants can also be used. Both water-based lubricants and moisturizers can help to reduce the discomfort and dyspareunia experienced as a result of vaginal atrophy. Water-based, nonhormonal lubricants such as Astroglide, K-Y Personal Lubricant, Moist Again, Lubrin, and Intimate Options Personal Lubricant Mousse are available OTC. Lubricants can be used for daily discomfort and are most beneficial for reducing vaginal dryness and thereby increasing comfort during sexual activity. More severe dryness that causes discomfort when walking or sitting is best managed using long-acting vaginal moisturizers such as K-Y Long-Lasting Vaginal Moisturizer and Replens.

Demographics: 48-year-old Female

Subjective:

CC: “Irregular menses, hot flashes, vaginal dryness, low sex drive.”

HPI: 48-year-old female presents to the clinic for menstrual cycle has recently become irregular, and she is experiencing hot flashes and vaginal dryness. She has also noticed a decrease in her desire for sex lately.

Questions: When did she notice that this started? Does anything alleviate symptoms? Does anything make is worse? I would ask about characteristics of the irregular menses, hot flashes, and vaginal dryness? On a scale from 1-10 with 10n being the worse rate her symptoms.

PMH: I would ask about past medical history?

Allergies: I would ask about allergies to medications.

Meds: I would ask her current list of medications.

FH: I would ask about family history of disease and cause of death. I would ask about menopausal history with her mother if known?

SH: Married for 20 years. She has two teenage daughters. I would ask what is her occupation? Does she smoke or regular alcohol drinker? Hobbies?

GYN: G2L2 When was her last LMP? Pap done unremarkable 10/23

ROS: Patient denies cough, congestion, or runny nose. Patient denies SOB, chest pain. Patient denies any weight gain, change in bowl habits. Patient denies urinary frequency or pain upon urination. Patient confirms hot flashes, irregular menses, vaginal dryness. Patient denies any bone pain, gait changes.

Objective:

Gen Appearance: List appearance as patient showed up in the clinic today.

Vitals: vitals would go here

Physical Assessment: Head: Normocephalic

Skin: pink dry, normal for ethnicity

Eyes: PERRL, symmetrical corneal light reflex, no drainage noted, and sclera is white.

Ears: pinas intact bilaterally without swelling or tenderness, Left and right TMs intact pearly grey

Nose: nasal mucosa pink and moist no lesions, nasal septum midline, no nasal discharge

Throat: oral mucosa pink and moist, tonsils 0+

Neck: full ROM, supple

Lymph: no cervical lymphadenopathy

CV: RRR, no murmurs, gallops or rubs

RESP: clear in all lung fields no adventitious sounds

ABD: soft round, no organomegaly or masses noted.

MS: normal gait and strength, muscle tension intermittently

Breast: no lump, or bumps noted. Nipple is appropriately positioned with no abnormalities.

Pelvic Exam: Vaginal dryness present, no abnormalities in structure noted.

Assessment:

Working Diagnosis: N95.9 Menopausal and Perimenopausal disorder, unspecified – irregular menses, hot flashes, and vaginal dryness include perimenopausal/ menopausal because she is still having her menses, they are just irregular.

Differential Diagnosis: 87.1 Abnormal level of hormones in specimens from female genital organs – The patient’s symptoms could be related to hormone depletion not necessarily perimenopause.

N93.9 Abnormal Uterine Bleeding –

Plan:

Diagnostic: TSH, CBC, estradiol, follicle-stimulating hormone (FSH), and luteinizing hormone (LH), (BUN), pelvic exam, -labs to see baseline and see if there is a need for immediate medication therapy or can she try non-pharmacologic measures first. With tracking hormone levels you can see if the non-pharm treatments are effective.

Pap smear (done with no issues)

STI- Panel Negative

Pregnancy test negative

Education: Discussed the natural progression of perimenopause and provided information about hormonal changes, lifestyle modifications, and potential treatment options.

Lifestyle Modifications: Advised the patient to maintain a healthy diet, engage in regular exercise, and manage stress to alleviate some of the symptoms associated with perimenopause. Abstain from- caffeine, sugar, chocolate, spicy foods, and alcohol. Importance of good night’s sleep. Discuss lubrication options for vaginal dryness.

Progesterone cream may be an option depending on lab values.

Hormone Replacement Therapy (HRT): Discussed the potential benefits and risks of HRT. Informed the patient that it can be an effective option for symptom management in perimenopause but may not be suitable for everyone. The decision to pursue HRT will depend on further discussion and the patient’s preferences.

Follow-up: Scheduled a follow-up appointment in six weeks to monitor the patient’s progress and discuss treatment options further.

Symptom Diary: Encouraged the patient to maintain a symptom diary to track the frequency and severity of hot flashes, night sweats, and mood swings, as this will help in assessing treatment effectiveness.

The patient was educated on the nature of perimenopause, treatment options, and the importance of maintaining good overall health. She was encouraged to contact the office if her symptoms worsened or if she had any concerns before her next appointment.