Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders Essay

Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders Essay

Response to Chidinma

Midlife can be a vulnerable period for physical and psychological conditions, particularly for women going through the menopause transition. A study by El Khoudary et al. (2019) found that women in midlife experience a range of physical and psychological symptoms associated with the menopause transition. The study surveyed over 2,000 women between the ages of 40 and 65 and found that the most common physical symptoms were hot flashes, night sweats, and vaginal dryness. At the same time, the most common psychological symptoms were mood changes, irritability, and difficulty sleeping.

It is important to note that menopausal symptoms vary in terms of race and ethnicity. For example, Williams et al. (2022) examined the differences in menopause symptoms between women from different ethnicities and geographical locations. The study found that women from certain ethnicities, such as African-American and Hispanic women, were more likely to report severe symptoms of menopause compared to women from other ethnicities (Williams et al., 2022). In contrast, women from certain geographical locations, such as Japan and Southeast Asia, were less likely to report severe symptoms of menopause than women from other parts of the world.

A study published in the Journal of the American Medical Association in 2017 examined the health risks associated with menopause. The study found that women going through the menopause transition are at increased risk for heart disease, stroke, and osteoporosis. The study also found that low estrogen levels and other aging-related changes, such as weight gain, can increase the risk of these health problems. Santoro et al. (2021) emphasize the importance of symptom recognition and management during the menopause transition, especially the need for healthcare providers to be aware of the symptoms that can be attributed to endocrine changes during the menopause transition and to provide personalized care that addresses the unique concerns and risk factors of each patient.

Several health concerns for the patient, including obesity, family history of breast cancer, menopausal symptoms, and hypertension, each have potential implications for the patient’s overall health and requires careful management and monitoring. Obesity is a significant risk factor for breast cancer, particularly in menopausal women. According to Kolb and Zhang (2020), obese women are more likely to develop breast cancer and have worse disease outcomes than non-obese women. Therefore, weight management should be a priority for the patient, and lifestyle modifications such as increased physical activity and dietary changes are recommended. Perimenopausal symptoms, such as hot flashes, night sweats, and genitourinary symptoms, are common and can significantly impact the patient’s quality of life.

Healthcare providers should consider the use of hormone therapy or non-hormonal therapies, such as selective serotonin reuptake inhibitors (SSRIs), for the treatment of vasomotor symptoms. Genitourinary symptoms may be managed with the use of topical estrogen therapy, vaginal lubricants, or other medications. Hypertension is a common health concern for many individuals, and management typically includes lifestyle modifications, such as dietary changes and increased physical activity, as well as the use of antihypertensive medications.

In the case of a patient who is already taking antihypertensive medication, healthcare providers may consider adjusting the medication regimen and adding additional medications to achieve better blood pressure control. Given the patient’s family history of breast cancer, yearly mammograms are recommended for breast cancer screenings. The patient should also undergo yearly pap smears to monitor any changes related to her previous ASCUS diagnosis.

In addition to the non-pharmacological interventions mentioned above, several pharmacological options are available for managing hot flashes in women. Hormone therapy (HT) is the most effective pharmacologic therapy for managing hot flashes, and it is the preferred treatment for healthy women aged 50-59 years (Stuenkel, 2021). However, the use of HT is associated with risks such as breast cancer, stroke, and venous thromboembolism; thus, women with a history of breast cancer or a high risk of breast cancer, as in the case study, should avoid HT in treating perimenopausal symptoms (Stuenkel, 2021).

In the case study provided, the patient is experiencing moderate to severe hot flashes, which are affecting her daily life. As such, menopausal hormone therapy (MHT) may be a viable option for symptom relief, provided that there are no contraindications. However, given the patient’s family history of breast cancer, careful consideration must be given to the potential risks associated with MHT, as estrogen therapy has been linked to an increased risk of breast cancer. Similarly, women with a history of CHD, VTE, or stroke, or those at moderate or high risk for these complications, may also not be good candidates for MHT due to the potential risks associated with hormonal therapy.

 If MHT is deemed inappropriate or not preferred by the patient, nonhormonal pharmacotherapy options such as SSRIs, SNRIs, anti-epileptics, clonidine, oxybutynin, and centrally-acting drugs may be recommended. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are also effective in reducing the frequency and severity of hot flashes. Clonidine, a centrally acting alpha-2 adrenergic agonist, is another option for managing hot flashes, especially in women with a contraindication to HT or who do not tolerate other medications (Paciuc, 2020).

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Di Donato et al. (2019) found that vaginal estrogen therapy improved vaginal health and quality of life for women experiencing GSM symptoms. The randomized, double-blind, placebo-controlled trial included 302 postmenopausal women experiencing moderate to severe dyspareunia and vulvovaginal atrophy. Participants were randomized to receive either vaginal estradiol or a placebo twice weekly for 12 weeks. The results showed that women in the estradiol group experienced significant improvement in symptoms, as measured by the Vaginal Maturation Index, vaginal pH, and the Female Sexual Function Index, compared to the placebo group. The authors concluded that vaginal estrogen therapy is an effective and safe treatment option for postmenopausal women with GSM symptoms.

Another study published in the Journal of Obstetrics and Gynaecology Canada evaluated the safety and efficacy of vaginal dehydroepiandrosterone (DHEA) for the treatment of GSM (Labrie et al., 2016). The randomized, double-blind, placebo-controlled trial included 233 postmenopausal women with moderate to severe vulvovaginal atrophy. Participants were randomized to receive either a vaginal DHEA suppository or a placebo suppository daily for 12 weeks. The results showed that women in the DHEA group experienced significant improvement in symptoms, as measured by the Vaginal Health Index, compared to the placebo group. Labrie et al. (2016) concluded that vaginal DHEA is a safe and effective treatment option for postmenopausal women with GSM symptoms. Therefore, both vaginal estrogen therapy and vaginal DHEA therapy are effective treatment options for women with GSM symptoms who do not adequately respond to nonhormonal vaginal moisturizers and lubricants. However, healthcare providers need to assess each patient’s individual risk factors and medical history before recommending hormonal therapies.

Patient education is an essential component of healthcare that empowers patients to make informed decisions regarding their health. Patient education in menopause management is crucial in ensuring a woman’s quality of life before, during, and after the transition into menopause. As seen in the case study above, the patient presents with moderate to severe hot flashes, and understanding the available therapies and treatments is necessary. Patients with hypertension require proper education on medication use, possible side effects, and lifestyle modifications. Education regarding medication side effects is necessary to ensure patients are aware of possible adverse effects associated with prescribed medications. Regular cancer screenings are crucial in early detection and management. The American Cancer Society recommends yearly mammograms for women starting at age 40 and yearly pap smears starting at age 21 or within three years of becoming sexually active (Smith et al., 2019).

 References

Da Silva, A. S., Baines, G., Araklitis, G., Robinson, D., & Cardozo, L. (2021). Modern management of genitourinary syndrome of menopause. Faculty Reviews, 10, 25. https://doi.org/10.12703/r/10-25

Di Donato, V., Schiavi, M. C., Iacobelli, V., D’oria, O., Kontopantelis, E., Simoncini, T., Muzii, L., & Benedetti Panici, P. (2019). Ospemifene for the treatment of vulvar and vaginal atrophy: A meta-analysis of randomized trials. Part I: Evaluation of efficacy. Maturitas, 121, 86–92. https://doi.org/10.1016/j.maturitas.2018.11.016

El Khoudary, S. R., Greendale, G., Crawford, S. L., Avis, N. E., Brooks, M. M., Thurston, R. C., Karvonen-Gutierrez, C., Waetjen, L. E., & Matthews, K. (2019). The menopause transition and women’s health at midlife: a progress report from the Study of Women’s Health Across the Nation (SWAN). Menopause (New York, N.Y.), 26(10), 1213–1227. https://doi.org/10.1097/GME.0000000000001424

Kolb, R., & Zhang, W. (2020). Obesity and breast cancer: A case of inflamed adipose tissue. Cancers, 12(6), 1686. https://doi.org/10.3390/cancers12061686

Labrie, F., Archer, D. F., Koltun, W., Vachon, A., Young, D., Frenette, L., Portman, D., Montesino, M., Côté, I., Parent, J., Lavoie, L., Beauregard, A., Martel, C., Vaillancourt, M., Balser, J., Moyneur, É., & VVA Prasterone Research Group. (2016). Efficacy of intravaginal dehydroepiandrosterone (DHEA) on moderate to severe dyspareunia and vaginal dryness, symptoms of vulvovaginal atrophy, and of the genitourinary syndrome of menopause. Menopause (New York, N.Y.), 23(3), 243–256. https://doi.org/10.1097/GME.0000000000000571

Paciuc, J. (2020). Hormone therapy in menopause. Advances in Experimental Medicine and Biology, 1242, 89–120. https://doi.org/10.1007/978-3-030-38474-6_6

Santoro, N., Roeca, C., Peters, B. A., & Neal-Perry, G. (2021). The menopause transition: Signs, symptoms, and management options. The Journal of Clinical Endocrinology and Metabolism, 106(1), 1–15. https://doi.org/10.1210/clinem/dgaa764

Smith, R. A., Andrews, K. S., Brooks, D., Fedewa, S. A., Manassaram-Baptiste, D., Saslow, D., & Wender, R. C. (2019). Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal for Clinicians, 69(3), 184–210. https://doi.org/10.3322/caac.21557

Stuenkel, C. A. (2021). Managing menopausal vasomotor symptoms in older women. Maturitas, 143, 36–40. https://doi.org/10.1016/j.maturitas.2020.08.005

Williams, M., Richard-Davis, G., Williams, P. L., Christensen, L., Ward, E., & Schrager, S. (2022). A review of African American women’s experiences in menopause. Menopause (New York, N.Y.), 29(11), 1331–1337. https://doi.org/10.1097/GME.0000000000002060

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Please reply to Chidinma post below:

Women’s and Men’s Health, Infectious Disease, and Hematologic Disorders

Midlife may be a vulnerable period for several physical and psychological conditions. The menopause transition starts at around 47 years and lasts 5–8 years on average. While the timing of menopause is relatively constant, both the nature and severity of symptoms vary substantially between women from different ethnicities and geographical locations for poorly understood reasons. Changes in the body in the years around menopause may increase the risk for certain health problems. Low estrogen levels and other aging-related changes, for example, weight gain, can increase the risk of heart disease, stroke, and osteoporosis. To manage menopause effectively and not overlook conditions that require different management, providers need to be aware of what symptoms can be attributed to endocrine changes during the menopause transition.

Patient’s Health Needs

According to the assigned case study, the patient weighs 230Ib and has a family history of breast cancer. She is most likely obese, depending on her height. Obesity is associated with a higher risk of developing breast cancer, particularly in postmenopausal women, and worse disease outcomes for women of all ages (National Institutes of Health, 2017). The patient presented with the classic symptoms of menopause, which include hot flushing, night sweats, and genitourinary symptoms. This is the patient’s primary concern. Vasomotor symptoms (VMS), “hot flushes,” or “night sweats,” are typical during the menopause transition and affect around 80% of women. Genitourinary symptoms may include, but is not limited to, genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria, and recurrent urinary tract infections. As estrogen levels decrease, the urethra and vaginal epithelium undergo degenerative changes causing urge incontinence, urinary frequency, dryness, urinary tract infections, and vaginal infections (Rosenthal & Burchum, 2021). The third health concern for the patient is hypertension, given that her current blood pressure is 150/90, although she is on antihypertensive medication. The patient in the assigned case study is experiencing symptoms of perimenopause. Her healthcare needs include treatment of perimenopausal symptoms, hypertension management, lifestyle modification for weight management, yearly mammograms for breast cancer screenings, and yearly pap smears for previous ASCUS.

Treatment Regimen

Vasomotor symptoms

Simple Behavioral Measures

Women with mild flashes (hot flashes that do not interfere with usual activities) usually do not need pharmacotherapy. Instead, simple behavioral measures, such as lowering room temperature, using fans, dressing in layers of clothing that can be easily shed, and avoiding triggers (such as spicy foods and stressful situations), can help reduce the number of hot flashes. Other potential options include weight loss, cognitive behavioral therapy (CBT), vitamin E, and hypnosis. Some providers recommend vitamin E to women with mild hot flashes because, at low doses, it is well tolerated and not associated with toxicity (Ziaei, Kazemnejad & Zareai, 2018).

Hormonal Options

Menopausal hormone therapy (MHT) is recommended for most women with moderate to severe hot flashes and no contraindications. Women with an intact uterus need estrogen and progestin, while those undergoing hysterectomy can receive estrogen only. The first step for women interested in MHT is to determine the potential risks for the specific individual. Most perimenopausal and recently menopausal women are good candidates for short-term hormone therapy for symptom relief. However, for women with a history of breast cancer, coronary heart disease (CHD), a previous venous thromboembolic event (VTE), or stroke, or those at moderate or high risk for these complications, alternatives to hormone therapy should be suggested.

Nonhormonal pharmacotherapy

For women with moderate to severe hot flashes who are not candidates for hormone therapy based on their breast cancer, CHD, or VTE risk and those who choose not to take MHT, the recommended treatment option is nonhormonal agents (Stuenkel et al., 2018). The best-studied agents with positive results include SSRIs, serotonin-norepinephrine reuptake inhibitors (SNRIs), anti-epileptics, clonidine, oxybutynin, and centrally-acting drugs. These drugs are also often tried in women who experience recurrent hot flashes after stopping MHT. The drug choice depends on whether the patient is taking tamoxifen, the pattern of hot flashes, and the presence of a mood disorder or sleep problem.

Genitourinary symptoms

First-line therapy for genitourinary syndrome of menopause (GSM) includes nonhormonal vaginal moisturizers and lubricants. Symptoms of vaginal dryness can be managed by regular vaginal moisturizing agents with supplemental use of vaginal lubricants for sexual intercourse (Edwards & Panay, 2018). These agents may improve coital comfort and increase vaginal moisture but do not reverse most atrophic vaginal changes. Thus, while vaginal moisturizers and lubricants are helpful for patients with mild symptoms, many patients will have persistent systems and require hormonal medications or other treatments. Vaginal estrogen therapy is a standard second-line treatment for GSM that does not adequately respond to moisturizers and lubricants. Vaginal estrogen is an effective treatment for symptoms of vulvovaginal dryness or discomfort (burning, itching, irritation), tissue fragility (this may result in postcoital bleeding or fissures), or dyspareunia.

Recommended pharmacotherapeutics

Menopause is an inevitable natural biological process in a woman’s life. For women who require relief from menopausal symptoms, various treatment options are available. The goal of therapy for treating menopausal symptoms is to control the occurrence or minimize the impact of these symptoms, which cause discomfort to a woman undergoing the menopausal transition. Providers must always consider the risk-benefit ratio, as many medications have adverse side effects. According to the assigned case study, the patient is obese, has hypertension, and has a family history of cancer. MHT is contraindicated in those with unexplained vaginal bleeding, active liver disease, previous breast cancer, coronary heart disease, stroke, personal history of thromboembolic disease, or known high inherited risk (Roberts & Hickey, 2016). Given that the patient is hypertensive, obese (which increases her risk for developing cancer), and has a family history of breast cancer, menopausal hormonal therapy will not be recommended.

Since the patient is a high risk for MHT, alternative options will be considered. In high-risk patients, some antidepressants, such as SSRIs or SNRIs, have been shown to relieve vasomotor symptoms of menopause (Freeman et al., 2019; Carpenter et al., 2019). I would recommend escitalopram (Lexapro) orally, an initial dose of 10mg once daily, and an increase to 20mg once daily after four weeks if symptoms are not adequately controlled. Escitalopram is a good first-choice drug for vasomotor symptoms as it is well tolerated and reduces vasomotor symptoms by about 50-60 percent (Roberts & Hickey, 2016).

Nonhormonal vaginal moisturizers and lubricants are the preferred approaches to initial therapy for genitourinary symptoms. For patients who are not adequately treated with vaginal moisturizers and lubricants, a short course of low-dose vaginal estrogen rather than systemic hormonal therapy is recommended. The preference for vaginal estrogen is based on its superior efficacy for genitourinary syndrome of menopause and the risks of systemic menopausal hormone therapy. A meta-analysis of 58 comparative studies of patients with urogenital atrophy found that patients’ report of symptom relief was significantly higher for vaginal versus oral estrogen therapy (Cardozo et al., 2018). Based on observational data, the reported efficacy rate is approximately 80 to 90 percent for vaginal therapy and 75 percent for systemic treatment (Simunić et al., 2018; Barnabei et al., 2018; Long et al., 2019). In addition, the increased risks of breast cancer and thrombosis with systemic estrogen and progestin compared with placebo were best demonstrated by the Women’s Health Initiative randomized trial; some of these risks vary depending upon whether a progestin is used in combination with estrogen (Rossouw et al., 2018).

Recommended Patient Education Strategy

Empowering the patient to actively participate in their care can improve patient satisfaction and outcomes. The patient’s healthcare needs include menopause management, hypertension management, lifestyle modification for weight management, yearly mammograms for breast cancer screenings, and yearly pap smears for previous ASCUS. Menopause education should be provided so the patient can know what to expect for the upcoming years. For many women, the symptoms associated with menopause can be a challenging experience Education on menopause management is essential as it creates awareness about the latest therapies and treatments available to guide women before, during, and after they transition into menopause. Being proactive about menopause can help ensure a woman’s quality of life long before the transition occurs.

Education regarding the side effects of SSRI drugs is critical. SSRI’s side effects can be minor to life-threatening; being aware of side effects associated with the drug is necessary (i.e., confusion, drowsiness, blurred vision, weakness, and suicidal ideation). Also, I will include instructions on topical estrogen use and the side effects of currently prescribed antihypertensives. She will be educated on fluid replacement while taking HCTZ. Dietary intake education should include a diet designed to reduce high blood pressure, for example, the DASH diet. A healthy diet combined with exercise can reduce weight and improve the patient’s overall outcome while promoting cardiovascular health. Patient education will include the importance of daily blood pressure monitoring and how to recognize signs and symptoms of hypotension. A yearly pap smear will be recommended owing to a previous ASCUS and yearly mammogram for breast cancer screenings.

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References

Barnabei, V. M., Cochrane, B. B., Aragaki, A. K., Nygaard, I., Williams, R. S., McGovern, P. G., Young, R. L., Wells, E. C., O’Sullivan, M. J., Chen, B., Schenken, R., Johnson, S. R. & Women’s Health Initiative Investigators (2018). Menopausal symptoms and treatment-related effects of estrogen and progestin in the Women’s Health Initiative. Obstetrics and Gynecology, 105(51), 1063–1073. https://doi.org/10.1097/01.AOG.0000158120.47542.18

Carpenter, J. S., Guthrie, K. A., Larson, J. C., Freeman, E. W., Joffe, H., Reed, S. D., Ensrud, K. E. & LaCroix, A. Z. (2019). Effect of escitalopram on hot flash interference: A randomized, controlled trial. Fertility and Sterility, 97(6), 1399–404 https://doi.org/10.1016/j.fertnstert.2012.03.001

Cardozo, L., Bachmann, G., McClish, D., Fonda, D. & Birgerson, L. (2018). Meta-analysis of estrogen therapy in the management of urogenital atrophy in postmenopausal women: Second report of the hormones and urogenital therapy committee. Obstetrics and Gynecology, 92(4), 722–727. https://doi.org/10.1016/s0029-7844(98)00175-6

Edwards, D. & Panay, N. (2018). Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? Climacteric: The Journal of the International Menopause Society, 19(2), 151–161. https://doi.org/10.3109/13697137.2015.1124259Links to an external site.

Freeman, E. W., Guthrie, K. A., Caan, B., Sternfeld, B., Cohen, L. S., Joffe, H., Carpenter, J. S., Anderson, G. L., Larson, J. C., Ensrud, K. E., Reed, S. D., Newton, K. M., Sherman, S., Sammel, M. D. & LaCroix, A. Z. (2019). Efficacy of escitalopram for hot flashes in healthy menopausal women: A randomized controlled trial. JAMA, 305(3), 267–274. https://doi.org/10.1001/jama.2010.2016

Long, C. Y., Liu, C. M., Hsu, S. C., Wu, C. H., Wang, C. L. & Tsai, E. M. (2019). A randomized comparative study of the effects of oral and topical estrogen therapy on the vaginal vascularization and sexual function in hysterectomized postmenopausal women. Menopause, 13(5), 737–743. https://doi.org/10.1097/01.gme.0000227401.98933.0b

National Institutes of Health. (2017). Obesity and adverse breast cancer risk and outcome: Mechanistic insights and strategies for intervention. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5591063/

Roberts, H. & Hickey, M. (2016). Managing the menopause: An update. Links to an external site.Maturitas, 86(2016), 53–58. https://doi.org/10.1016/j.maturitas.2016.01.007

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). St. Louis, MO: Elsevier

Rossouw, J. E., Anderson, G. L., Prentice, R. L., LaCroix, A. Z., Kooperberg, C., Stefanick, M. L., Jackson, R. D., Beresford, S. A., Howard, B. V., Johnson, K. C., Kotchen, J. M., Ockene, J. & Writing Group for the Women’s Health Initiative Investigators (2018). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women’s Health Initiative randomized controlled trial. JAMA, 288(3), 321–333. https://doi.org/10.1001/jama.288.3.321

Simunić, V., Banović, I., Ciglar, S., Jeren, L., Pavicić Baldani, D., & Sprem, M. (2018). Local estrogen treatment in patients with urogenital symptoms. International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics, 82(2), 187–197. https://doi.org/10.1016/s0020-7292(03)00200-5

Stuenkel, C. A., Davis, S. R., Gompel, A., Lumsden, M. A., Murad, M. H., Pinkerton, J. V. & Santen, R. J. (2018). Treatment of symptoms of the menopause: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology and Metabolism, 100(11), 3975–4011. https://doi.org/10.1210/jc.2015-2236

Ziaei, S., Kazemnejad, A. & Zareai, M. (2018). The effect of vitamin E on hot flashes in menopausal women. Gynecologic and Obstetric Investigation, 64(4), 204–207. https://do