Case Scenario_ a 54-Year-Old African American Woman Reports Severe Hot Flashes (Printer-friendly)

8/12/2019 Case Scenario_ a 54-Year-Old African American Woman Reports Severe Hot Flashes (Printer-friendly)

1/13

10/13/13 Case Scenar io: A 54-Year-Old Afr ican Amer ican Woman Repor ts Severe Hot Flashes (pr inter-fr iendly)

www.medscape.org/viewarticle/765072_print 1/13

www.medscape.org

CME/CE Information

CME/CE Relea sed: 06/13/2012; Valid for credit through 06/13/2013

This activity has expired.

The accredited provider can no longer issue certificates for this activity. Medscape cannot attest to the timeliness of expired CME activities.

Target Audience

This activity is intended for primary care physicians, family practitioners, internal medicine specialists, physicianassistants, nurse practitioners, nurses, menopause specialists, obstetricians/gynecologists, pharmacists, reproductiveendocrinologists, and geriatricians.

Goal

The goal of this activity is to improve clinicians adoption of patient-focused dialogue in identifying and treating menopausalsymptoms, including vasomotor symptoms (VMS) and vulvovaginal atrophy (VVA).

Learning Objectives

Upon completion of this activity, participants will be able to:

1. Initiate discussion about menopause-related symptoms with perimenopausal and postmenopausal women2. Identify and rule out other potential causes of VMS or VVA menopausal symptoms that might necessitate

treatment3. Discuss the efficacy , safety, benefits, and risks of available options for the treatment of menopause-related

symptoms4. Develop culturally sensit ive dialogue regarding racial, ethnic, and attitudinal differences with menopausal women

about their symptoms5. Engage in conversation about individualized treatment plans for patients experiencing menopause-related

symptoms

Credits Available

Physicians - maximum of 0.75 AMA PRA Category 1 Credit(s)

Nurses - 0.75 ANCC Contact Hour(s) (0.75 contact hours are in the area of pharmacology)

All other healthcare professionals completing continuing education credit for this activity will be issued a certificate of participation.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Accreditation StatementsFor Physicians
http://www.medscape.org/


2/13



The North American Menopause Society (NAMS) is accredited by the Accreditation Council for Continuing MedicalEducation to provide continuing medical education for physicians.

The North American Menopause Society (NAMS) designates this enduring material for a maximum of .75 AM A PRACategory 1 Credit(s) . Physicians should claim only the credit commensurate with the extent of their participation inthe activity.

For Nurses

Medscape, LLC is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center'sCommission on Accreditation.

Awarded 0.75 contact hour(s) of continuing nursing education for RNs and APNs; 0.75 contact hours are in the area of pharmacology.

Accreditation of this program does not imply endorsement by either Medscape, LLC or ANCC.

Contact This Provider

For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above.For technical assistance, contact [email protected]

Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicabilityand acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on the title page; physicians should claim only thosecredits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete theactivity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit , youmust receive a minimum score of 70% on the post-test.

Follow these steps to earn CME/CE credit*:

1. Read the target audience, learning objectives, and author disclosures.2. Study the educational content online or printed out.3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score

as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it.Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can printout the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.
mailto:[email protected]:[email protected]


3/13



Faculty and Disclosures

As an organization accredited by the ACCME, Medscape, LLC, requires everyone who is in a position to control the

content of an education activity to disc lose all relevant financial relationships with any commercial interest. The ACCMEdefines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months,including financial relationships of a spouse or life partner, that could create a conflict of interest.

Medscape, LLC, encourages Authors to identify investigational products or off-label uses of products regulated by the USFood and Drug Administration, at first mention and where appropriate in the content.

The North American Menopause Society (NAMS) is committed to ensuring balance, independence, and objectivity in all of its educational activities. Faculty, planners, managers, and other individuals who are in a position to control the content of this activity are required to disclose any real or apparent conflict of interest they may have as related to the content of thisactivity. All identified conflicts of interest are thoroughly reviewed and resolved by NAMS. Complete disclosure statements

are listed so that participants may evaluate the objectivity of the presentations.

CME Author(s)Martha K. Richardson, MD, FACOG

Assistant Clinical Professor, Department of Obstetrics and Gynecology, Harvard Medical School; Director, MenopauseConsultation Service, Harvard Vanguard Medical Associates, Boston, Massachusetts

Disclosure: Martha K. Richardson, MD, NAMS, FACOG, has disclosed no relevant financial relationships.

Lubna L Pal, MBBS, MRCOG, MSc

Hardware/Software Requirements

To access activities, users will need:

A computer with an Internet connection.Internet Explorer 7.x or higher, Firefox 4.x or higher, Safari 2.x or higher, or any other W3C standards compliantbrowser.

Adobe Flash Player and/or an HTML5 capable browser may be required for video or audio playback.Occasionally other additional software may be required such as PowerPoint or Adobe Acrobat Reader .
http://get.adobe.com/reader/http://office.microsoft.com/en-us/powerpoint/http://get.adobe.com/flashplayer/


4/13



Associate Professor, Obstetrics , Gynecology, and Reproductive Sciences, Yale University School of Medicine; Director,Program for Reproductive Aging and Bone Health, Yale Reproductive Endocrinology, New Haven, Connecticut

Disclosure: Lubna L. Pal, MBBS, MRCOG, MSc, has disclosed no relevant financial relationships.

Hugh S. Taylor, MD

Professor, Obstetrics, Gynecology, and Reproductive Sc iences; Chief, Reproductive Endocrinology and Infertility;Director, Reproductive Endocrinology and Infertility; Yale School of Medicine, New Haven, Connecticut

Disclosure: Hugh S. Taylor, MD, has disc losed no relevant financial relationships.

Editor(s)Emilie McCardell

Scientific Director, Medscape, LLC

Disclosure: Emilie McCardell has disclosed no relevant financial relationships.

Christin Melton

Clinical Editor, Medscape, LLC

Disclosure: Christin Melton has disc losed no relevant financial relationships.

CE Reviewer Dominique Brooks, MD

Disclosure: Dominique Brooks, MD, has disclosed no relevant financial relationships.

Nurse Planner Laurie E. Scudder , DNP, NP

Nurse Planner, Continuing Professional Education Department, Medscape, LLC; Clinical Ass istant Professor, School of Nursing and Allied Health, George Washington University, Washington, DC

Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.

From Medscape Education Ob/Gyn & Women's Health

Case Scenario: A 54-Year-Old African American Woman Reports
http://www.medscape.org/womenshealth


5/13



Lubna L. Pal, MBBS, MRCOG, MSc

Background

Ms X, a 54-year-old African American woman, says she has been having trouble sleeping and experiencing severe hot

flashes. She is 5 ft 3 in tall, weighs 249 lb, and has a history of hypertension and high cholesterol. Her family historyincludes diabetes and cardiovascular disease (CVD) -- her mother had a venous thromboembolism at 52 years of agefollowing a serious car accident. Her chart lists her last menstrual period as having occurred 5 years ago, and she statesthat she is "tired of having the hot flashes."

In a discussion of Ms X's symptoms, she confirmed that the hot flashes were very uncomfortable but demurred whenasked whether she was having any other symptoms. During a follow-up discussion, she was told that some womenexperience vaginal dryness at this time of life, and she was then asked directly, "Are you having any discomfort withintercourse?" Ms X admitted having "some" vaginal and urinary symptoms.

Hot flashes, night sweats, and symptoms of urogenital atrophy (ie, vaginal dryness, dyspareunia, dysuria, and apredisposition to urinary tract infections) commonly accompany reproductive aging. [1,2] At first glance, this clinical pictureis typical for menopausal syndrome. In the SWAN study, investigators are following a multiethnic cohort of reproductivelyaging women as they transition from premenopause into menopause. Keeping in perspective that the median age of natural menopause for the SWAN cohort is 51.4 years [3] and our patient's age and symptom spectrum, we can presumeshe is at the very least in late perimenopause and perhaps even in the early postmenopausal phase (Table 1). [2]

Table 1. STRAW Stages of Menopause

FMP = final menstrual period; STRAW = Stages of Reproductive Aging Workshop; UAS = urogenital atrophysymptoms; VSM = vasomotor symptoms.

Adapted from Harlow, et al. [2]

Although the patient's urogenital symptoms seem tolerable, her vasomotor symptoms (VMS) are more severe anddominate the clinical picture. Prompt evaluation and action are warranted because the symptoms this relatively youngwoman has been experiencing appear to be adversely affecting her quality of life (QOL).

Severe Hot Flashes

Posted: 06/13/2012


6/13


7/13



Table 3. Building a Problem and Risk Profile for Ms X

Obesity-Related Concerns[10,11,12,13-16]

Hypertension and Cardiovascular Risks[12,17,18]

Menopause-Related Concerns[1,19]

CVDEndometrial, breast, or bowelcancer VMS

StrokeThromboembolism

CVDLower bone mineral densityStroke

Increased bone resorptionPoor QOLUrogenital atrophy andsequelae

DiscomfortUTI

VMS

CVD = cardiovascular disease; QOL = quality-of-life; UTI = urinary tract infection; VMS = vasomotor symptoms.

Our patient's body habitus, preexisting diseased vasculature, and race increase her risk for cerebrovascular accidents andcardiovascular events. [10-12] The SWAN investigators reported that African American women disproportionately experiencemore frequent and more severe menopausal VMS than women of other races. [3] They also found that overweight andobese women were more likely to report VMS compared with their leaner counterparts. Ms X's race and excess weightmay therefore contribute to the severity of her VMS. [3,13-19,20-25] Factors such as a sedentary lifestyle and tobacco use,

if applicable, could exacerbate our patient's symptoms and further escalate her risk for CVD and stroke. [13,22]

An inquiry into the social history of a patient with menopausal symptoms should solicit information about modifiablehealth risks, including exposure to or use of tobacco, use of alcohol and recreational substances (cocaine and methadoneuse have been associated with bothersome VMS), and indulgence in any other toxic habits. [13,22-24] It is also important toinquire directly about issues that affect QOL, such as sleep, cognition, physical function, and sexuality, so as to quantifythe overall burden of the patient's symptoms on her well-being.

Optimizing Symptom Control for Ms X

Until fairly recently, systemic oral estrogen replacement therapy was viewed as the optimal strategy for managing VMS in

symptomatic women and is still considered the most effective of the available therapeutic options.[1]

Prior to 2002, oralestrogen would have been considered a first-line treatment for managing bothersome VMS in patients like Ms X,particularly if the patient was deemed at risk for CVD. [25] In addition to controlling symptoms, systemic estrogen useduring menopause was universally thought to confer cardioprotection; indeed, a large body of literature implied better vascular health and reduced CVD risk among menopausal women who used estrogen. [25,26]

In the past decade, however, new data have redefined our perceptions and reshaped the place for hormonal therapy inmenopausal medicine. [27,28] A succession of randomized controlled trials brought the potential health risks of hormonaltherapy, along with its benefits, to the forefront. [28,29] As a consequence of this evolving appreciation, successful effortswere undertaken to expand the repertoire of effective nonhormonal strategies for treating common menopausal symptoms.Today's clinicians have several effective options to consider to help alleviate bothersome menopausal symptoms. [30-43]

Systemic Estrogen Replacement Therapy

Although systemic estrogen is highly effective at relieving menopausal symptoms, its benefits must be carefully balancedagainst its risks for each patient (Table 4). [1,28,44-46] Systemic estrogen use in menopausal women increases the risks of thromboembolism, stroke, and even CVD. [1,28,44] These vascular phenomena, although uncommon, may be particularlyrelevant for women who, like our patient, are obese and have preexisting diseased vasculature. A recent study by Gastand associates suggests a relationship between VMS and covert vascular dysfunction, [22] adding fuel to our concerns for Ms X's vascular health.

Table 4. Benefits and Risks Associated With Menopausal Hormonal Therapy


8/13



Benefits of HT Risks of HT

Symptom control

Reduces VMSReduces urogenital symptoms: vaginal dryness,dyspareunia, dysuria, UTIsImproves moodImproves sexuality

Other

Reduces risk of vertebral and nonvertebralfracturesReduces risk of colon cancer

Vascular

Increases thromboembolism riskIncreases stroke riskIncreases risk of myocardial ischemia

Cancer

Increases risk of endometrial cancer (estrogenalone)Increases risk of breast cancer (especially estrogencombined with progesterone)May increase risk of lung cancer May increase risk of ovarian cancer

Neurocognitive

No protection against aging-related neurocognitivedecline

May increase risk of dementia

Other

Increases risk of gallstonesIncreased risk of incontinence

HT = hormonal therapy; UTIs = urinary tract infections; VMS = vasomotor symptoms.Data from The North American Menopause Society [1]; Rossouw JE, et al [28]; Hulley S, et al [29]; Renoux C andSuissa S [44]; Greiser CM, et al. [45,46]

Although a family history of spontaneous thromboembolism could indicate an underlying genetic predisposition, a case of

thromboembolism that was circumstantially provoked -- as appears to have been the case with our patient's mother -- islikely not relevant. Ms X should thus be reassured in this context.

Risk quantification based on clinical assessment indicates that our patient has an enhanced risk for CVD and stroke,given her obesity, hypertension, and race. Although there is little doubt about the effectiveness of systemic estrogentherapy at relieving menopausal symptoms, this strategy's potential to cause harm to Ms X is deemed to outweigh themagnitude of benefit it might offer. In light of her innately increased risk for thromboembolism and stroke and therecognition that systemic estrogen use exacerbates these risks, menopausal hormone therapy should be considered asecond- or third-line strategy for Ms X, offered only if nonhormonal therapies fail to provide significant relief of her symptoms.

Nonhormonal Therapies and Topical Estrogen

Various studies have demonstrated the efficacy of a spectrum of nonhormonal s trategies against VMS (Table 5). [30]

Although we can reassure the patient regarding the potential for benefit observed with multiple nonhormonal strategies,nonhormonal approaches are uniformly less effective than systemic estrogen therapy at relieving VMS. The magnitude of benefit for nonhormonal strategies may also vary between individuals. Details concerning the Ms X's overall well-being,psychological parameters, and quality and quantity of sleep will be particularly meaningful in selecting the mostappropriate nonhormonal strategy.

Table 5. Potentially Beneficial Nonhormonal Treatment Strategies Investigated for Managing MenopausalSymptoms


9/13


10/13



If a trial of one or more nonhormonal strategies fails to provide this patient with substantial relief from bothersome VMS,systemic hormonal therapy remains an option. In recent years, studies have identified considerations that may helpmitigate the risks associated with systemic hormonal therapy, such as route of administration, dose, and hormoneformulation. [49-50] A reduction in the risk of thromboembolism that is associated with hormonal therapy may be achievedby administering estrogen via a transdermal route and by using lower doses of estrogen. [1] In the event that systemicestrogen therapy is deemed the most effective strategy for a patient like Ms X, one must keep in mind her innatelyenhanced risk for endometrial pathologies and the need to ensure adequate exposure of the endometrium to progesteronewhile she is receiving estrogen. [1] A trial of progesterone monotherapy, which adds only minimally to the risk of

thromboembolism, may be another option for managing VMS in select patients.[51]

Summary

This vignette has provided us with an opportunity to assess menopausal symptoms systematically in a 54-year-oldwoman in early menopause and to undertake systematic risk assessment and quantification to arrive at a managementalgorithm that adheres to the principle of "Do no harm." The goal of this exercise is to guide clinicians in identifying theoptimal strategies for menopause management so they can choose therapies that address a patient's symptoms yetpose minimal additive burden. The onus remains on clinicians to explore the breadth of symptoms beyond the presentingcomplaint so as to determine which treatment option is likely to offer the most benefit. In this obese and hypertensiveindividual, who has an enhanced risk of CVD and stroke, a nonhormonal strategy represents the safest first-line approach

for managing her severe hot flashes. Concomitant use of topical estrogen is encouraged to help mitigate symptoms thatare attributable to urogenital atrophy.

Identifying ancillary symptoms (ie, issues of sleep and of sexuality [52]) and their severity will guide clinicians caring for theaging woman in determining the optimal first-line strategy for managing VMS in their patients. Clinicians must familiarizethemselves with s trategies to mitigate estrogen-related risks, such as using a non-oral route of administration or loweringthe dose. Beyond the therapeutic interventions, lifestyle modification must be encouraged as a critical component of menopause management. In the event that nonhormonal strategies fail to improve the burden of menopausal symptoms inthis relatively young woman, judicious use of systemic hormone therapy remains an option to help improve her QOL.

5HIAA = 5-hydroxyindoleacetic acid ACTH = adrenocorticotrophic hormoneCBC = complete blood countCVD = cardiovascular diseaseFMP = final menstrual periodHIV = human immunodeficiency virusHT = hormonal therapyPPD = purified protein derivativeQOL = quality of lifeSNRI = serotonin norepinephrine reuptake inhibitor SSRI = selective serotonin reuptake inhibitor STRAW = Stages of Reproductive Aging WorkshopSWAN = Study of Women's Health Across the NationTSH = thyroid-stimulating hormoneUAS = urogenital atrophy symptomsUFC = urine-free cortisolUTI = urinary tract infectionVMA = vanillylmandelic acidVSM = vasomotor symptoms

References


11/13



1. The North American Menopause Society. The 2012 hormone therapy position statement of the North AmericanMenopause Society. Menopause. 2012;19:257-271. Abstract

2. Harlow SD, Gass M, Hall JE; for the STRAW + 10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. J ClinEndocrinol Metab. 2012;19:387-385.

3. Gold EB, Bromberg J, Crawford S, et al. Factors associated with age at natural menopause in a multiethnicsample of midlife women. Am J Epidemiol. 2001;153:865-874. Abstract

4. Shoupe D. Individualizing hormone therapy to minimize risk: accurate assessment of risks and benefits. Womens

Health. 2011;7:475-485.5. Izikson L, English JC III, Zirwas MJ. The flushing patient: differential diagnosis, workup, and treatment. J Am AcadDermatol. 2006;55:193-208. Abstract

6. Mohyi D, Tabassi K, Simon J. Differential diagnosis of hot flashes. Maturitas. 1997;27:203-214. Abstract7. Kojic EM, Wang CC, Cu-Uvin S. HIV and menopause: a review. J Womens Health. 2007;16:1402-1411.8. Miller SA, Santoro N, Lo Y, et al. Menopause symptoms in HIV-infected and drug-using women. Menopause.

2005;12:348-356. Abstract9. Cieloszyk K, Hartel D, Moskaleva G, Schoenbaum EE. Effects of hepatitis C virus infection on menopause status

and symptoms. Menopause. 2009;16:401-406. Abstract10. Rosenfeld HE, Tsokos M, Byard RW. The association between body mass index and pulmonary thromboembolism

in an autopsy population. J Forensic Sci. 2012. [Epub ahead of print]

11. Parkin L, Sweetland S, Balkwill A, Green J, Reeves G, Beral V. Body mass index, surgery, and risk of venousthromboembolism in middle-aged women: a cohort study. Circulation. 2012;125:1897-1904. Abstract12. Hurley LP, Dick inson M, Estacio RO, Steiner JF, Havranek EP. Prediction of cardiovascular death in racial/ethnic

minorities using Framingham risk factors. Circ Cardiovasc Qual Outcomes. 2010;3:181-187. Abstract13. Whiteman MK, Staropoli CA, Langenberg PW, et al. Smoking, body mass, and hot flashes in midlife women.

Obstet Gynecol. 2003;101:264-272. Abstract14. Haakinson DJ, Leeds SG, Dueck AC, et al. The impact of obesity on breast cancer: a retrospective review. Ann

Surg Oncol. 2012. [Epub ahead of print]15. Schmandt RE, Iglesias DA, Co NN, Lu KH. Understanding obesity and endometrial cancer risk: opportunities for

prevention. Am J Obstet Gynecol. 2011;205:518-525. Abstract16. Frezza EE, Wachtel MS, and Chiriva-Internati M. Influence of obesity on the risk of developing colon cancer. Gut.

2006;55:285-291. Abstract17. Gast GC, Pop VJ, Samsioe GN, et al. Vasomotor menopausal symptoms are associated with increased risk of coronary heart disease. Menopause. 2011;18:146-151. Abstract

18. Yazici S, Yazic i M, Korkmaz U, et al. Relationship between blood pressure levels and bone mineral density inpostmenopausal Turkish women. Arch Med Sci. 2011;7:264-270. Abstract

19. Crandall CJ, Tseng CH, Crawford SL, et al. Association of menopausal vasomotor symptoms with increased boneturnover during the menopausal transition. J Bone Miner Res. 2011;26:840-849. Abstract

20. Simpkins JW, Brown K, Bae S, Ratka A. Role of ethnicity in the expression of features of hot flashes. Maturitas.2009; 63:341-346. Abstract

21. Miller SR, Gallicchio LM, Lewis LM, et al. Association between race and hot flashes in midlife women. Maturitas.2006;20;53:133-143.

22. Gallicchio L, Miller SR, Visvanathan K, et al. Cigarette smoking, estrogen levels, and hot flashes in midlife women.Maturitas. 2006; 20;53:133-143.23. Tuchman E. Exploring the prevalence of menopause symptoms in midlife women in methadone maintenance

treatment. Soc Work Health Care. 2007;45:43-62.24. Ferri CP, Dunn J, Gossop M, Laranjeira R. Factors associated with adverse reactions to cocaine among a sample

of long-term, high-dose users in So Paulo, Brazil. Addict Behav. 2004;29:365-374. Abstract25. American College of Physicians. Guidelines for counseling post-menopausal women about preventive hormone

therapy. Ann Intern Med. 1992;117:1038-1041. Abstract26. Grodstein F, Manson JE, Colditz GA, et al. A prospective, observational study of postmenopausal hormone

therapy and primary prevention of cardiovascular disease. Ann Intern Med. 2000;133:933-941. Abstract27. Lukes A. Evolving issues in the clinical and managed care settings on the management of menopause following
http://www.medscape.org/medline/abstract/11119394http://www.medscape.org/medline/abstract/1443972http://www.medscape.org/medline/abstract/14732425http://www.medscape.org/medline/abstract/19592184http://www.medscape.org/medline/abstract/20878774http://www.medscape.org/medline/abstract/22291766http://www.medscape.org/medline/abstract/21127438http://www.medscape.org/medline/abstract/16239255http://www.medscape.org/medline/abstract/21802066http://www.medscape.org/medline/abstract/12576249http://www.medscape.org/medline/abstract/20124526http://www.medscape.org/medline/abstract/22394567http://www.medscape.org/medline/abstract/19002016http://www.medscape.org/medline/abstract/15879925http://www.medscape.org/medline/abstract/9288692http://www.medscape.org/medline/abstract/16844500http://www.medscape.org/medline/abstract/11323317http://www.medscape.org/medline/abstract/22367731


12/13



the Women's Health Initiative. J Manag Care Pharm. 2008;14:S7-S13. Abstract28. Rossouw JE, Anderson GL, Prentice RL, et al; W riting Group for the Women's Health Initiative Investigators. Risks

and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women'sHealth Initiative randomized controlled trial. JAMA. 2002;288:321-333. Abstract

29. Hulley S, Grady D, Bush T, et al; for Heart and Estrogen/progestin Replacement Study (HERS) Research Group.Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausalwomen. JAMA. 1998;280:605-613. Abstract

30. Nelson HD, Vesco KK, Haney E, et al. Nonhormonal therapies for menopausal hot flashes: systematic review and

meta-analysis. JAMA. 2006;295(17):2057-2071.31. Joffe H, Petrillo L, Viguera A, et al. Eszopiclone improves insomnia and depressive and anxious symptoms inperimenopausal and postmenopausal women with hot flashes: a randomized, double-blinded, placebo-controlledcrossover trial. Am J Obstet Gynecol. 2010;202:171.e1-171.e11.

32. Kalay AD, Demir B, Haberal A, Kalay M, Kandemir O. Efficacy of citalopram on climacteric symptoms.Menopause. 2007;14:223-229. Abstract

33. Loprinzi CL, Stearns V, Barton D. Centrally active nonhormonal hot flash therapies. Am J Med. 2005;118:118-123. Abstract

34. Fisher TE, Chervenak JL. Lifestyle alterations for the amelioration of hot flashes. Maturitas. 2012;71:217-220. Abstract

35. Daley AJ, Stokes-Lampard HJ, Macarthur C. Exercise to reduce vasomotor and other menopausal symptoms: a

review. Maturitas. 2009;63:176-180. Abstract36. Lethaby AE, Brown J, Marjoribanks J, et al. Phytoestrogens for vasomotor menopausal symptoms. CochraneDatabase Syst Rev. 2007;4: CD001395.

37. Barton DL, Loprinzi CL, Quella SK, et al. Prospective evaluation of vitamin E for hot flashes in breast cancer survivors. J Clin Oncol. 1998;16:495-500. Abstract

38. Innes KE, Selfe TK, Vishnu A. Mind-body therapies for menopausal symptoms: a systematic review. Maturitas.2010;66:135-149. Abstract

39. Borud E, White A. A review of acupuncture for menopausal problems. Maturitas. 2010;66:131-134. Abstract40. Lee MS, Kim JI, Ha JY, Boddy K, Ernst E. Yoga for menopausal symptoms: a systematic review. Menopause.

2009;16:602-608. Abstract41. Lipov EG, Joshi JR, Sanders S, et al. Effects of stellate-ganglion block on hot flushes and night awakenings in

survivors of breast cancer: a pilot study. Lancet Oncol. 2008;9:523-532. Abstract42. Freeman EW, Guthrie KA, Caan B, et al. Efficacy of escitalopram for hot flashes in healthy menopausal women: arandomized controlled trial. JAMA. 2011;305:267-274. Abstract

43. Joffe H, Soares CN, Petrillo LF, et al. Treatment of depression and menopause-related symptoms with theserotonin-norepinephrine reuptake inhibitor duloxetine. J Clin Psychiatry. 2007;68:943-950. Abstract

44. Renoux C, Suissa S. Hormone therapy administration in postmenopausal women and risk of stroke. WomensHealth (Lond Engl). 2011;7:355-361. Abstract

45. Greiser CM, Greiser EM, Dren M. Menopausal hormone therapy and risk of lung cancer --systematic review andmeta-analysis. Maturitas. 2010;65:198-204. Abstract

46. Greiser CM, Greiser EM, Dren M. Menopausal hormone therapy and risk of ovarian cancer: systematic review andmeta-analysis. Hum Reprod Update. 2007;13:453-463. Abstract

47. Balon R. SSRI-associated sexual dysfunction. Am J Psychiatry. 2006;163:1504-1509. Abstract48. Feighner JP. Cardiovascular safety in depressed patients: focus on venlafaxine. J Clin Psychiatry. 1995;56:574-579. Abstract

49. Mueck AO. Postmenopausal hormone replacement therapy and cardiovascular disease: the value of transdermalestradiol and micronized progesterone. Climacteric. 2012;15:11-17. Abstract

50. Renoux C, Dell'aniello S, Garbe E, Suissa S. Transdermal and oral hormone replacement therapy and the risk of stroke: a nested case-control study. BMJ. 2010;340:c2519.

51. Hitchcock CL, Prior JC. Oral micronized progesterone for vasomotor symptoms-a placebo-controlled randomizedtrial in healthy postmenopausal women. Menopause. 2012. [Epub ahead of print]

52. Nappi RE, Lachowsky M. Menopause and sexuality: prevalence of symptoms and impact on quality of life.Maturitas. 2009;63:138-141. Abstract
http://www.medscape.org/medline/abstract/19464129http://www.medscape.org/medline/abstract/22432811http://www.medscape.org/medline/abstract/8530334http://www.medscape.org/medline/abstract/16946173http://www.medscape.org/medline/abstract/17573406http://www.medscape.org/medline/abstract/20031346http://www.medscape.org/medline/abstract/21612355http://www.medscape.org/medline/abstract/17592922http://www.medscape.org/medline/abstract/21245182http://www.medscape.org/medline/abstract/18485819http://www.medscape.org/medline/abstract/19169169http://www.medscape.org/medline/abstract/20060667http://www.medscape.org/medline/abstract/20167444http://www.medscape.org/medline/abstract/9469333http://www.medscape.org/medline/abstract/19285813http://www.medscape.org/medline/abstract/22285470http://www.medscape.org/medline/abstract/16414336http://www.medscape.org/medline/abstract/17224858http://www.medscape.org/medline/abstract/9718051http://www.medscape.org/medline/abstract/12117397http://www.medscape.org/medline/abstract/18507508


13/13


Sponsored by The North American Menopause Society (NAMS) and Medscape, LLC.

Disclaimer

The material presented here does not necessarily reflect the views of Medscape, LLC, or companies that supporteducational programming on medscape.org. These materials may discuss therapeutic products that have not beenapproved by the US Food and Drug Administration and off-label uses of approved products. A qualified healthcareprofessional should be consulted before using any therapeutic product discussed. Readers should verify all informationand data before treating patients or employing any therapies described in this educational activity.

Medscape Education 2012 The North American Menopause Society and Medscape, LLC

Contents of Scenarios in Women's Health: Recognizing and M anaging Menopausal Symptoms [/viewprogram/32506]

1. Case Scenario: A 58-Year-Old Asian American Woman With Hot Flashes, Dyspareunia, and Cystit is[/viewarticle/765071]

2. Case Scenario: A 54-Year-Old African American Woman Reports Severe Hot Flashes[/viewarticle/765072]

3. Case Scenario: A 48-Year-Old Breast Cancer Survivor With Moderate to Severe Menopausal Symptoms[/viewarticle/765074]
http://www.medscape.org/viewarticle/765074http://www.medscape.org/viewarticle/765072http://www.medscape.org/viewarticle/765071http://www.medscape.org/viewprogram/32506

Documents

Case Scenario_ a 54-Year-Old African American Woman Reports Severe Hot Flashes (Printer-friendly)