Case study: Menopause

Nurse Practitioner, May 1999

Margaret was a 52-year-old woman, gr 4, p 4, whose periods had ceased 3 years previously. She had not soueht health care of any kind since that time.

She had experienced vasomotor symptoms but had convinced herself that she could "deal with them" and she used several herbal formulas purchased at a local health food store. She had done extensive reading about synthetic hormones, the alleged link between estrogen and breast cancer, and alternative treatments for menopause. She exercised regularly, worked full-time, did not smoke or use alcohol, and considered herself very healthy.

Margaret presented for care after learning that her mother, age 74, had severe osteoporosis and had recently broken a hip. Her mother had never used hormone replacement therapy (HRT); Margaret had reasoned that she would not need it either. However, her mother's injury and severe bone disease prompted Margaret to see her clinician for a well-woman exam.

Margaret's medical history included four normal births. Her husband had undergone a vasectomy. Margaret's gallbladder had been removed at age 46 with no complications. She had no serious or ongoing illnesses. The physical examination revealed an atrophic vagina, tiny uterus, and nonpalpable ovaries. A breast examination and mammogram were normal. Pap smear showed only atrophic changes. Bone density studies indicated osteopenia in the spine and nondominant hip.

Margaret was carefully counseled on the extent of her bone disease and the risk it presented. She adamantly refused treatment with conjugated equine estrogens, citing "horror stories" from her friends as well as a moral objection to using an animal product. She did not want to risk experiencing the adverse effects of vaginal bleeding, breast tenderness, or fluid retention.

After the discussion, Margaret was placed on the lowest available dose of oral esterified estrogens (0.3 mg) plus 200 mg of micronized progesterone daily. She was counseled to add soy products to her diet,29 maintain her intake of calcium and vitamin D, and engage in weightbearing exercise. Margaret experienced no untoward effects. After 1 year of therapy, her bone density study results had improved.

Discussion

Margaret was an informed consumer with definite ideas about what forms of treatment she would and would not accept. She understood her risks of osteoporosis and fracture.

Noncompliance with HRT is commonly caused by adverse effects (bloating, breast tenderness, and resumption of menses), fear of cancer (regardless of family history and other risk factors), and lack of understanding of the overall impact of declining hormone levels.24,26 By considering these factors and individualizing management, the clinician created a treatment plan that was consistent with the patient's needs and desires.