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 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.

I feel this 46-year-old, 230lb woman is experiencing perimenopause. During perimenopause, you experience symptoms such as hot flashes, night sweats, and vaginal dryness.  This occurs prior to menopause with menstrual irregularities, hot flashes, and night sweats and continues until menopause starts or 12 months of amenorrhea occurs (Delamater, & Santoro, 2018).  It appears that up to 80% of women experience VMS during perimenopause, increasing over the transition from early to late menopausal transition (Delamater, & Santoro, 2018) Treatment for her symptoms would be hormone therapy, but she is not a candidate for this since she has a history of breast cancer in her family. “Estrogen and progesterone also promote the growth of some breast cancers, which are called hormone-sensitive (or hormone-dependent) breast cancers. Hormone-sensitive breast cancer cells contain proteins called hormone receptors

Links to an external site. (estrogen receptors Links to an external site., or ERs, and progesterone receptors

Links to an external site., or PRs) that become activated when hormones bind to them. The activated receptors cause changes in the expression of specific genes, which can stimulate cell growth” (Delamater, & Santoro, 2018) Other treatment alternatives are hypnoses, cognitive behavioral therapy, yoga, meditation, and others to help reduce symptoms.  There are also herbal products supplements, and vitamins (Johnson, Roberts, & Elkins, (2019). Anti-depressant medications such as SSRIs and SNRIs have been shown to reduce symptoms of perimenopause. Brisdelle (paroxetine mesylate) is an SSRI antidepressant. It’s the only antidepressant that’s FDA-approved for treating hot flashes (Johnson, Roberts, & Elkins, 2019). I would like her to start this medication and follow up in several weeks to see if this is helping with her symptoms.

I would also recommend some dietary changes and have a dietician work with her since she is overweight and has hypertension. I would recommend increasing her Norvasc to 20 mg QD and her Hydrochlorothiazide to 50mg QD and have her monitor her blood pressure daily to see if it starts to trend down. I would educate her on the need to exercise daily and eat a healthier diet with protein at each meal with more fruits and vegetables than carbohydrates. I would also order blood work for hormone levels and a plasma glucose (FPG) test, a hemoglobin A1c (A1c) test, and an oral glucose tolerance test (OGTT). She has a lot of risk factors for diabetes and some of her symptoms could be from unstable blood sugar (Niddk.Nih.gov, 2022).