. A 60-year-old woman presents with complaints of pain during intercourse. She describes the pain as sharp and constant during sexual activity, and there is a lack of lubrication. This discomfort is very bothersome to her because she wishes to continue an active sex life. She underwent surgical menopause at age 44 due to uterine fibroids and heavy bleeding. She used oral estrogen until age 50; she has used no hormonal therapy since then. On physical examination you note significant urethral and vaginal atrophy.
Which of the following is the best treatment option for this patient?
This patient has dyspareunia or pain during intercourse. She has been postmenopausal for many years without hormone (estrogen) replacement. A commercial lubricant would be helpful for vaginal dryness but will not treat the underlying cause of her urogenital atrophy, which is hypoestrogenemia. She has no other symptoms of menopause (such as vasomotor symptoms or sleep disturbance) that impair quality of life. Therefore oral estrogen is not required. She denies depressive symptoms. The best treatment option for this patient is to treat the underlying disorder of urogenital atrophy with topical estrogen applied to the vagina. A commercial lubricant could be used as needed, but would be in addition to the vaginal hormone cream. Though sildenafil has been shown to be efficacious in the treatment of antidepressant-associated sexual dysfunction, it is not FDA-approved for use in women. Nothing on examination suggests fungal vaginitis.
A 43-year-old woman presents to your office because of musculoskeletal pain and weight gain. Over the past 6 months, she has noted generalized aches and pains of muscles and joints, fatigue, and poor sleep quality. She admits to wanting to stay in bed rather than socialize with her friends and family. She denies fever, night sweats, morning stiffness, joint redness, blood loss, easy bruising, or daytime somnolence. Physical examination reveals normal BMI, normal thyroid, normal cardiovascular examination, normal joints, and no tenderness to palpation. CBC, TSH, ESR, ANA, rheumatoid factor, electrolytes, liver enzymes, and kidney function tests are normal. She wants pain control.
Which treatment is most likely to relieve her symptoms?
This patient is suffering from the emotional and physical symptoms of depression. Her weight gain is due to her sedentary lifestyle. Initiation of an antidepressant is the most appropriate pharmacologic management, either with a selective serotonin reuptake inhibitor, or with a serotoninnorepinephrine reuptake inhibitor. The SNRI may provide more relief from her physical symptoms than SSRI therapy. Opiate therapy for the pain of depression is inappropriate and exposes the patient unnecessarily to potential addiction. Steroids are not clinically indicated. DMARDs are reserved for specific rheumatologic diseases, not nonspecific musculoskeletal symptoms.
You are reviewing your office records as part of a performance review mandated by an insurance company. One criterion is appropriate to use of low-dose aspirin for prevention of heart attack or stroke. According to the United States Preventive Services Task Force recommendations,
which of the following patients should be treated with low-dose (81 or 162 mg daily) aspirin?
The USPSTF strongly recommends the use of low-dose aspirin for women age 55 to 79 for ischemic stroke reduction when the potential benefit outweighs the potential harm. It also strongly recommends the use of low-dose aspirin in men between ages 45 and 79 to reduce the risk of myocardial infarction when the potential benefit outweighs the potential harm. The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 years or aspirin for myocardial infarction prevention in men younger than 45 years. There is insufficient evidence that the use of aspirin for primary prevention of cardiovascular events in men and women over the age of 80 exceeds the potential harm of GI hemorrhage from aspirin use.
Click to expand