A 52-year-old recently menopausal female has developed hot flashes (or hot flushes) that she describes as severe. She currently takes no prescribed or over-the-counter medications and declines estrogen replacement therapy.
Which one of the following would be most effective for relieving this patient’s symptoms?
Correct Answer A:
Hot flashes have been shown to be most effectively treated with hormone replacement therapy (HRT). However, given the concerns regarding HRT, alternative strategies for managing hot flashes have been evaluated. Placebo-controlled trials have shown that vitamin E, soy protein, red clover, and black cohosh are not better or only slightly better than placebo in reducing hot flashes. SSRIs have been shown to be significantly more effective than placebo in relieving this symptom. Methyldopa has shown some benefit compared to placebo, but causes frequent side effects.
A 52-year-old woman undergoing menopause is complaining of vaginal pain during intercourse (without bleeding).
Your best initial treatment is:
Correct Answer B: Menopause officially “begins” when a (non-pregnant/lactating) woman experiences a lack of menses for a period of 1 year. The pathology is related to a reduction in estrogen levels (due to the degeneration of theca cells) and the resultant increase in FSH and LH (due to a lack of negative inhibition). Symptoms and sequelae of menopause can include: hot flushes, urogenital atrophy, osteoporosis, a reduction in breast size, skin thinning and mood or sleep disturbances. They should be treated individually where possible.
Estrogen cream (e.g. Premarin) is a local acting estrogen treatment which can relieve symptoms of urogenital atrophy such as painful intercourse (dyspareunia) and vaginal itching/dryness/bleeding.
→ Hormone replacement therapy (HRT) (choice A) is considered the first line treatment for symptoms of vasomotor instability (hot flushes, night sweats, sleep disturbances). HRT is not recommended for long-term use, except in limited circumstances where other therapeutic choices are found inadequate. They should be prescribed at the lowest effective dose for the appropriate duration.
→ Selective estrogen receptor modifiers (SERMs) (choice C) mimic estrogen-effects on bones without affecting breast and uterine tissue, i.e. they don’t increase the risk of breast or uterine cancer. They are approved for the treatment of osteoporosis and breast cancer.
→ Referral for sex therapy counseling (choice D) is a reasonable option to propose if initial or secondary treatments were ineffective and the couple was experiencing marital difficulties as a result.
→ Selective serotonin reuptake inhibitors (SSRIs) (choice E) have been proposed as an alternative to hormonal therapy for breast cancer survivors.
Key point:
Risk factors for cervical carcinoma includes all of the following, except:
Correct Answer D:
The cause of cervical cancer is not known, however, certain factors are believed to increase one’s risk of developing cervical cancer. Engaging in sexual activity at a young age is one such factor. The cells lining the cervix do not fully mature until the age of 18 and, therefore, are more susceptible to cancer causing-agents and viruses.
More than 90% of women with cancer of the cervix are infected with the human papilloma virus (HPV). HPV is the single most important factor for cervical cancer. HPV usually causes warts in the genital area. The viruses are passed from one person to another during unprotected sex. Having multiple sexual partners increases one’s risk of getting this cancer, because the greater number of sexual partners, the greater is the risk of acquiring HPV infection. Even if a woman has only one sexual partner, but the man has several partners, he is considered a "high-risk male" and can transmit HPV to the women.
Smoking is considered a risk factor, possibly because smoking causes some abnormal changes in the cells and these cells have a higher likelihood of becoming cancerous. There are also some statistical studies that have suggested that long-term use of oral contraceptives may put a woman at a slightly higher risk of developing this cancer.
Which one of the following is consistent with current recommendations?
Correct Answer C:
Cervical cancer screening is recommended every three years for all women starting at age 21 who are or ever have been sexually active.
The only nonsexual behavior that is consistently and strongly correlated with cervical dysplasia and cervical cancer is:
Cigarette smoking is the only nonsexual behavior consistently and strongly correlated with cervical dysplasia and cancer, independently increasing the risk two- to fourfold.
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