Dyspareunia Case Study
Individual Case Study #1
Individual Case Study #1
Assigned Scenerio
A 47 year old woman presents to the clinic. She has been menopausal but can 't deal with the hot flashes anymore. Recently she started to have pain during intercourse. She is Caucasian, 5 '6", and weighs 152 pounds. She is a gravida 2, para 2, NSVD x 2, no complications. You learn in her history that she had breast cancer and had a successful lumpectomy 7 years ago. Her vitals today are 148/82, 76, 22, 97.9
Potential Working Diagnosis: 2 points
This patient is previously known to be experiencing menopause per the description. The differential diagnoses will focus on her new onset symptom of dyspareunia. Although dyspareunia is common in relation to vaginal dryness …show more content…
and atrophy in menopause, differential diagnoses will be considered because this complaint began recently. Many women with hypothyroidism or hyperthyroidism may present with similar symptoms related to menopause such as hot flashes and dryness (Natural Standard, 2013). It is recommended to rule Thyroid Disease out when seeing a new patient with menopause related symptoms (Schuiling & Likis, 2013). Based on the information provided, treatment will be focused on both vasomotor instability and vaginal discomfort during intercourse, both classic presentations of menopause.
Potential Working Diagnoses: * Vaginal Atrophy related to Menopause * Bacterial Vaginosis * Vaginal Candidiasis * Trichomoniasis * Atopic Vaginitis * Vaginismus * Thyroid Disease
What lifestyle alterations could you recommend? (7 pts)
Stress management may be important to discuss with the patient. Education should be provided about the impact of stress on increased menopausal symptoms. In addition, her blood pressure is elevated. This should be addressed while asking about current stressors and discussing a plan to decrease the stress in her life. In order to find an individualized approach to stress management, the patient should be introduced to interventions including exercise, meditation, deep breathing, taking baths, reading, having a massage, spiritual activities, and social support. Pacing respiration in the form of yoga breathing can help reduce hot flashes and stress, and should be explained to the patient if she is comfortable with this practice (Schuiling & Likis, 2013). Blood pressure should be reassessed at follow-up in addition to reviewing improvement of symptoms.
Diet should be reviewed with the patient to assess for possible benefit of dietary modifications. Avoiding certain foods and dietary substances can help to decrease frequency and severity of hot flashes. Some dietary changes to discuss with the patient would include eliminating intake of refined sugars, caffeine, spicy foods, and alcohol (Schuiling & Likis, 2013). If the patient is unable to avoid these foods, she should consider only consuming them in moderation.
While discussing dietary changes, it would be beneficial to recommend that the patient increase water intake to reduce symptoms and balance the loss of fluid due to increased perspiration. Increasing water intake, particularly cold water, can decrease her symptoms of hot flashes as well as dryness (Schuiling & Likis, 2013). Instruction would include drinking six to eight glasses of water per day. Discussing issues such as incontinence and nocturia can help guide the patient in planning what time periods are best to increase fluids. If she experiences nocturia, it would be best to limit the increased fluids to earlier in the day, while women with incontinence may want to avoid fluid intake during occasions when access to restrooms may be limited (Schuiling & Likis, 2013).
The patient’s choice of clothing can reduce the discomfort related to hot flashes. She should be instructed to avoid wearing turtle necks and confining fabrics such as polyester and silk. Instead, breathable fabrics such as cotton or linen should be encouraged. It may be helpful for the woman to prepare for temperature changes by wearing layers so that she may remove them as needed during hot flashes (Schuiling & Likis, 2013).
Aside from clothing choices, other recommendations should be given for keeping core body temperature low. By avoiding long periods in warm environments, she can avoid intense hot flashes. Some tips include sleeping on cotton sheets, carrying a cool water bottle, carrying a small fan, cool showers before bedtime, and keeping a cool pack under pillow to flip throughout the night (Gibbs, 2013).
Smoking cessation can be helpful if this is part of the patient’s social history. Smoking can increase the incidence of hot flashes (Gibbs, 2013). Smoking cessation is linked to improvement of all menopausal symptoms aside from vaginal dryness. It is also important to address the connection between smoking and cardiovascular disease as she is presenting with an elevated blood pressure.
Exercise can offer many benefits to women experiencing menopause. Increasing her physical activity can help reduce hot flashes as well as increase libido (Natural Standard, 2013). Other benefits that she may experience include improvement in mood, energy, cardiovascular and muscle health, and sleep (Schuiling & Likis, 2013). Daily moderate intensity exercise should be recommended for at least thirty minutes a day (Natural Standard, 2013). Increased Body Mass Index (BMI) is also associated with more frequent hot flashes (Gibbs, 2013), so maintaining a healthy weight can help prevent worsened symptoms as well as improve overall health. The patient has a BMI of 24.5, which is in the normal weight category of 18.5–24.9 (U.S Department of Health and Human Services, 2013). Diet and exercise can help her maintain this BMI as menopause may influence weight gain.
Staying sexually active can help control symptoms of vaginal dryness and vaginal discomfort (Natural Standard, 2013). The patient may be hesitant due to her discomfort with intercourse, but will be introduced to other options to ease this discomfort. Utilizing the interventions discussed later, along with remaining sexually active can ease the dryness and discomfort. Sexual discomfort can also be worsened by atopic irritation. Vaginal discomfort can be decreased by avoiding personal hygiene products containing scents and irritants such as soaps, powders, spermicides, deodorants, and perfumes (Dynamed, 2013).
What tests would you offer or perform? What objective data would you gather? (7 pts)
Vitals: Vital signs and BMI will be evaluated. If BMI was elevated, weight loss could be discussed to decrease menopausal symptoms. There is concern related to her elevated blood pressure. If this is not an ongoing issue there should be follow-up evaluation.
General appearance: Emotional state and alertness should be assessed. Menopause may cause decreased energy. If hot flash occurs during visit, skin changes may be observed. Redness may be noted to chest and face (Dynamed, 2013).
Skin: Dryness of skin can be a pertinent positive of menopause as well as hypothyroidism (Schuiling & Likis, 2013).
Thyroid: Palpating the gland and isthmus with absence of abnormal enlargement will help rule out Thyroid diseases (Schuiling & Likis, 2013).
Inspection and palpation of external genitalia: Assess for erythema, rashes, discharge, or discoloration.
Erythema would be present for atopic vaginitis and possibly Candidiasis. Supportive findings for vaginal include dryness, thin vaginal tissue, loss of labial fat pads, narrowed vaginal opening, or less distinct labia minora (Dynamed, 2013). Upon insertion of index and third fingers into vagina to assess vaginal wall, Vaginismus would present with intolerance to penetration and possible contractions. Tolerance to penetration with lubricated insertion contraindicates Vaginismus. Absence of vaginal discharge would help rule out Bacterial Vaginosis, Candidiasis, and Trichomoniasis (Schuiling & Likis, …show more content…
2013).
Speculum Exam: Carefully performed with well lubricated speculum. Examination should be done slowly and as the patient feels comfortable (Schuiling & Likis, 2013). Pertinenet positives for vaginal atrophy would include decreased vaginal elasticity and rugal folds, shortened vagina, pale epithelium, pelvic relaxation, and decreased cervical secretions (Dynamed, 2013). Cycstocele, rectocele, or uterine prolapse may present with menopause related vaginal atrophy (Dynamed, 2013). Further assessment for absence of abnormal discharge can help rule out Bacterial Vaginosis, Candidiasis, and Trichomoniasis (Schuiling & Likis, 2013). Table 1
Diagnostic Lab Tests Diagnostic Lab Test | Rationale | Vaginal cytology | Vaginal Atrophy would show prevalence of parabasal cells and decreased superficial cells. b | Vaginal pH Normal: 3.8-4.2a | Vaginal Atrophy would show pH >5bBacterial Vaginosis: >4.5Vaginal Candidiasis: Usually <4.5 Trichomoniasis: >4.5a | NaCL Wet Mount Normal: Presence of lactobacillia | Vaginal Atrophy would show lack of lactobacilli. b Rule out:Bacterial Vaginosis: >20% clue cells presentVaginal Candidiasis: pseudohyphae (mycelic) and/or budding yeast Trichomoniasis: Protozoa, motile and flagellated. Presence of WBCs. a | Thyroid Stimulating Hormone | Normal levels would rule out Thyroid Diseasec |
Source: aCenters for Disease Control and Prevention, 2010; bDynamed, 2013; cSchuiling & Likis, 2013
What non-hormonal medications (supplements or herbals) and alternative therapies could you recommend? (7 pts)
Vaginal lubricants can provide significant relief of the patient’s complaint of dyspareunia. This symptom is likely caused by a decrease in vaginal secretions. Many water based lubricants can be found over the counter such as K.Y personal lubricant, Astroglide, Lubrin, and Moist Again. She should be advised against using oil-based products, including Vasoline, because these can actually cause injury to the vaginal tissue and are difficult to remove (Schuiling & Likis, 2013).
Vaginal moisturizers may be considered if the vaginal dryness is causing daily discomfort aside from during intercourse. This should be discussed with the patient. If vaginal dryness is a daily issue, a vaginal moisturizer such as Replens or K.Y Long Lasting Vaginal Moisturizer, should be recommended. The patient should be taught about the difference between lubricants and moisturizers. Moisturizers replenish and help maintain fluids for longer relief, while lubricants offer short term relief (Schuiling & Likis, 2013).
Research shows that the isoflavones in soy are a type of phytoestrogen which can produce similar effects to estrogen in the body. This can help relieve many menopausal symptoms including the patient’s current complaints of hot flashes, vaginal dryness. Although soy is considered safer than estrogen therapy in breast cancer survivors, there is not enough research to fully determine its safety (American Cancer Society, 2013). Foods containing soy may be discussed with the patient such as tofu, soymilk, and soy beans. If soy is used for treatment, this patient should be closely monitored as breast cancer is a highly hormone sensitive type of cancer (National Center for Complementary and Alternative Medicine, 2012).
Another source of phytoestrogens is Black Cohosh. Black Cohosh has been shown to improve menopausal symptoms, including hot flashes and vaginal dryness (Natural Standard, 2013). The usual dosage for treatment of hot flashes is 20 mg tablet BID. The patient should be advised not to use for more than six months, as safety for longer than this duration is not determined. Although side effects are rare, she should be informed of the possibility of intestinal upset, headache, dizziness, hypotension, and pain in extremities (Schuiling & Likis, 2013). Although not contraindicated, Black Cohosh should be used with caution in this patient, as she is considered high-risk due to her history of breast cancer. The benefits of Black Cohosh are similar to that of estrogen therapy (Natural Standard, 2013).
Vitamin E, up to 800 international units per day is shown to produce small improvements in hot flashes (Schuiling & Likis, 2013). Although there may be some benefit with supplementation, according the Natural Standard (2013), there is a lack of evidence for exceeding recommended daily intake with supplementation unless there is a deficiency. The Patient may be educated about sources of vitamin E in foods such as fruit, green leafy vegetables, eggs, meat, nuts, grains, and various oils (Natural Standard, 2013).
Evening primrose oil can help relieve hot flashes, though some data has shown minimal benefit. Usual dosage is 3-4 grams PO daily, in divided doses. When advising a patient to take evening primrose oil, they should be taught about possible side effects of diarrhea and nausea (Schuiling & Likis, 2013). When discussing treatment options, it is important to considered that this herbal medication is contraindicated with anticonvulsants which can also be chosen as treatment (Natural Standard, 2013).
According to the National Center for Complementary and Alternative Medicine (2012), acupuncture can decrease the intensity and frequency of hot flashes. Acupuncture can also increase libido in menopausal women (NCCAM, 2012). If the patient chooses to pursue acupuncture she should be educated on importance of safety and sanitary use of needles. She should also be aware that if she had received radiation therapy during cancer treatment, those areas should be avoided during acupuncture (National Standard, 2013).
Hypnosis can also be beneficial in reducing hot flashes. Studies have shown a 68% decrease in hot flashes in women who were treated with hypnosis (Loibl, Lintermans, Dieudonné & Neven, 2011). Aside from relief of hotflashes, hypnosis can offer additional benefits in stress relief, sleep improvement, and well-being.
What hormonal or other synthetic medications could you recommend? (7 pts)
Although many women experience significant relief of symptoms from hormone therapy during menopause, a history of breast cancer makes this a possibly unsafe option for the patient. According to the American Cancer Society (2013), studies have shown that breast cancer survivors who used hormone therapy were at higher risk for developing new or recurrent breast cancer. Although estrogen has been more commonly known to be associated with breast cancer, other variations including progesterone treatment are also discouraged (American Cancer Society, 2013). When hormone therapy is being evaluated, it is important to know that only women without an intact uterus are candidates for estrogen therapy alone due to the risk of endometrial hyperplasia and cancer with unopposed estrogen (Schuiling & Likis, 2013).
If hormone therapy is still to be considered, progestins alone can provide reduction of hot flashes.
Medroxyprogesterone Acetate, a progesterone, can be effective when 500 mg is administered IM on days 1, 14 and 28 (Loibl, et al., 2011). Due to the unknown safety of progestins in breast cancer survivors, non-hormonal options should be considered for this patient due to her medical history (Schuiling & Likis, 2013). Hormonal treatment for the breast cancer survivor should only be considered if benefits are believed to outweigh the risk and non-hormonal treatments have been unsuccessful. In this situation, treatment should be closely monitored and implemented in collaboration with her oncologist (Loibl, et al., 2011). The patient should return within six to eight weeks for follow-up to evauluate relief of symptoms. Side effects that the patient may experience with hormone therapy include headache, bloating, mood changes, nausea, fluid retention, and breast tenderness (Schuiling & Likis,
2013).
Local hormone therapy can be effective for treating vaginal dryness which causes dyspareunia. Recent studies show that breast cancer recurrence is not associated with the use of local hormone therapy (Ray, Dell 'Aniello, Bonnetain, Azoulay & Suissa, 2012). A variety of local preparations such as creams, suppositories, and rings are available with low doses of hormones are available. When considering these treatments, it is important to be sure that the hormone is not a systemically absorbed treatment. The vaginal creams are more likely to result in systemic absorption than the vaginal ring or tablet. The vaginal ring, containing low doses of estradiol acetate, has proven to be effective in reducing hot flashes and relieving vaginal dryness. Estring (Pfizer), a vaginal ring, releases 7.5μg of estradiol each day. The patient should be instructed to change the ring every ninety days (Simon, 2011).
Vaginal tablets have proven to be the least likely to cause systemic absorption. Vagifem is a tablet which recently released a low dose of 10μg estradiol hemihydrate which has proven to be as effective as the ring with lower incidence of systemic absorption. The tablet should be placed in the outer third of the vagina, reducing absorption while still being effective. Tablets are the safest option for a breast cancer survivor because studies have shown systemic absorption to be nearly undetectable, while vaginal rings have shown systemic effects despite their low circulating levels (Simon, 2011). The patient should be aware that although the majority of evidence has found minimal relation, there is conflicting evidence of whether or not there is an association between local estrogen therapy and endometrial hyperplasia (Simon, 2011). Before choosing any hormonal treatment, including local treatment, the patient’s oncologist should be consulted.
Gabapentin (Neurontin) is an anticonvulsant that is shown to significantly reduce hot flashes (Natural Standard, 2013). Dose should be initiated at 300 mg/day prior to bed, and increased up to 300 mg PO TID in 3-4 day intervals. The patient should be instructed to avoid antacids within two hours of taking, and discouraged from discontinuing abruptly as it should be tapered. Side effects to review with the patient include somnolence, dizziness, ataxia, fatigue, and weight gain (Schuiling & Likis, 2013).
Clonidine (Catapres), an antihypertensive, may reduce hot flashes. For this patient particularly, this medication may be considered as her blood pressure will require monitoring due to her current elevation. She should be prescribed 0.05-0.1 mg PO BID, although it is also available as a patch (Natural Standard, 2013). Side effects to make her aware of include dry mouth, drowsiness, dizziness, fatigue, constipation, urticara, insomnia, nausea, agitation, hypotension, and myalgia. Education must also include instructing her not to stop this medication abruptly, as it should be tapered when discontinuing (Schuiling & Likis, 2013).
When planning treatment for menopausal symptoms, particularly hot flashes, low dose anti-depressants may be beneficial. Venlafaxine (Effexor), a selective serotonin and norepinephrine reuptake inhibitor, has been shown to decrease hot flashes in menopause (Natural Standard, 2013). When starting the patient on Venlafaxine, it should be titrated up from 37.5 mg/day to 75 mg/day. Likewise, it should be titrated down when discontinuing. Patient education should include awareness that this medication cannot be taken with MAO inhibitors as it can interact. She should be aware that response is usually immediate. Side effects to discuss are nausea, vomiting, dry mouth, and decrease in appetite (Schuiling & Likis, 2013).
Anti-depressants in the selective serotonin re-uptake inhibitor (SSRI) class can also be helpful in reducing hot flashes in menopause. Fluoxetine (Prozac) provides an immediate response and should also be titrated up when initiating. The recommended dose is 20 mg/day, and should be tapered when discontinuing. The patient should be aware that use is contraindicated with MAO inhibitors, thioridazine, and warfarin due to potential interactions. Possible side effects to educate the patient about include asthenia, sweating, nausea, somnolence, inability to orgasm, and decreased libido (Schuiling & Likis, 2013). Another SSRI that is shown to decrease hot flashes is paroxetine (Paxil). Paroxetine shares the same contraindications, side effects, and tapering requirements as fluoxetine. Additionally, fluoxetine may cause weight gain and blurred vision (Schuiling & Likis, 2013). The patient’s weight should be taken into consideration, and guidance should be provided regarding exercise and diet if this medication is used. Titrating up upon initial therapy, the dosing should range from 12.5-25 mg/day (Schuiling & Likis, 2013).
References
American Cancer Society. (2013, February 26). Post-menopausal hormone therapy after breast cancer. Retrieved from http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-after-post-menopausal-therapy
Centers for Disease Control and Prevention. (2010). 2010 std treatment guidelines. Retrieved from http://www.cdc.gov/std/treatment/2010/toc.htm
DynaMed. (2013, January 15). Menopause. Ipswich, MA:EBSCO Publishing. Retrieved July 15, 2013, from http://web.ebscohost.com.ezproxy.midwives.org/dynamed/detail?sid=dd4685cd-0650-4a22-9dd8-b738cbfd81e6%40sessionmgr104&vid=4&hid=124&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=114698&anchor=top
Gibbs, T. (2013). Breast cancer survivors & hot flash treatments. Retrieved from http://www.menopause.org/for-women/menopauseflashes/breast-cancer-survivors-hot-flash-treatments
Le Ray, I., Dell 'Aniello, S., Bonnetain, F., Azoulay, L., & Suissa, S. (2012). Local estrogen therapy and risk of breast cancer recurrence among hormone-treated patients: a nested case-control study. Breast Cancer Research And Treatment, 135(2), 603-609. doi:10.1007/s10549-012-2198-y
Loibl, S., Lintermans, A., Dieudonné, A., & Neven, P. (2011). Management of menopausal symptoms in breast cancer patients. Maturitas, 68(2), 148-154. doi:10.1016/j.maturitas.2010.11.013
National Center for Complementary and Alternative Medicine (2012, February). Menopausal symptoms and complementary health practices. Retrieved from http://nccam.nih.gov/health/menopause/menopausesymptoms
Natural Standard (2013). Menopause. Retrieved from http://naturalstandard.com.ezproxy.midwives.org/databases/conditions/all/condition-menopause.asp?
Schuiling, KD & Likis, FE. (2013). Women 's Gynelogical Health (2nd ed.), Burlingham, MA: Jones & Bartlett
Simon, J. (2011). Identifying and treating sexual dysfunction in postmenopausal women: the role of estrogen. Journal Of Women 's Health (2002), 20(10), 1453-1465. doi:10.1089/jwh.2010.2151
U.S Department of Health and Human Services. (2013). Standard bmi calculator. Retrieved from http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm
Individual Case Study #1
Assigned Scenerio
A 47 year old woman presents to the clinic. She has been menopausal but can 't deal with the hot flashes anymore. Recently she started to have pain during intercourse. She is Caucasian, 5 '6", and weighs 152 pounds. She is a gravida 2, para 2, NSVD x 2, no complications. You learn in her history that she had breast cancer and had a successful lumpectomy 7 years ago. Her vitals today are 148/82, 76, 22, 97.9
Potential Working Diagnosis: 2 points
This patient is previously known to be experiencing menopause per the description. The differential diagnoses will focus on her new onset symptom of dyspareunia. Although dyspareunia is common in relation to vaginal dryness …show more content…
and atrophy in menopause, differential diagnoses will be considered because this complaint began recently. Many women with hypothyroidism or hyperthyroidism may present with similar symptoms related to menopause such as hot flashes and dryness (Natural Standard, 2013). It is recommended to rule Thyroid Disease out when seeing a new patient with menopause related symptoms (Schuiling & Likis, 2013). Based on the information provided, treatment will be focused on both vasomotor instability and vaginal discomfort during intercourse, both classic presentations of menopause.
Potential Working Diagnoses: * Vaginal Atrophy related to Menopause * Bacterial Vaginosis * Vaginal Candidiasis * Trichomoniasis * Atopic Vaginitis * Vaginismus * Thyroid Disease
What lifestyle alterations could you recommend? (7 pts)
Stress management may be important to discuss with the patient. Education should be provided about the impact of stress on increased menopausal symptoms. In addition, her blood pressure is elevated. This should be addressed while asking about current stressors and discussing a plan to decrease the stress in her life. In order to find an individualized approach to stress management, the patient should be introduced to interventions including exercise, meditation, deep breathing, taking baths, reading, having a massage, spiritual activities, and social support. Pacing respiration in the form of yoga breathing can help reduce hot flashes and stress, and should be explained to the patient if she is comfortable with this practice (Schuiling & Likis, 2013). Blood pressure should be reassessed at follow-up in addition to reviewing improvement of symptoms.
Diet should be reviewed with the patient to assess for possible benefit of dietary modifications. Avoiding certain foods and dietary substances can help to decrease frequency and severity of hot flashes. Some dietary changes to discuss with the patient would include eliminating intake of refined sugars, caffeine, spicy foods, and alcohol (Schuiling & Likis, 2013). If the patient is unable to avoid these foods, she should consider only consuming them in moderation.
While discussing dietary changes, it would be beneficial to recommend that the patient increase water intake to reduce symptoms and balance the loss of fluid due to increased perspiration. Increasing water intake, particularly cold water, can decrease her symptoms of hot flashes as well as dryness (Schuiling & Likis, 2013). Instruction would include drinking six to eight glasses of water per day. Discussing issues such as incontinence and nocturia can help guide the patient in planning what time periods are best to increase fluids. If she experiences nocturia, it would be best to limit the increased fluids to earlier in the day, while women with incontinence may want to avoid fluid intake during occasions when access to restrooms may be limited (Schuiling & Likis, 2013).
The patient’s choice of clothing can reduce the discomfort related to hot flashes. She should be instructed to avoid wearing turtle necks and confining fabrics such as polyester and silk. Instead, breathable fabrics such as cotton or linen should be encouraged. It may be helpful for the woman to prepare for temperature changes by wearing layers so that she may remove them as needed during hot flashes (Schuiling & Likis, 2013).
Aside from clothing choices, other recommendations should be given for keeping core body temperature low. By avoiding long periods in warm environments, she can avoid intense hot flashes. Some tips include sleeping on cotton sheets, carrying a cool water bottle, carrying a small fan, cool showers before bedtime, and keeping a cool pack under pillow to flip throughout the night (Gibbs, 2013).
Smoking cessation can be helpful if this is part of the patient’s social history. Smoking can increase the incidence of hot flashes (Gibbs, 2013). Smoking cessation is linked to improvement of all menopausal symptoms aside from vaginal dryness. It is also important to address the connection between smoking and cardiovascular disease as she is presenting with an elevated blood pressure.
Exercise can offer many benefits to women experiencing menopause. Increasing her physical activity can help reduce hot flashes as well as increase libido (Natural Standard, 2013). Other benefits that she may experience include improvement in mood, energy, cardiovascular and muscle health, and sleep (Schuiling & Likis, 2013). Daily moderate intensity exercise should be recommended for at least thirty minutes a day (Natural Standard, 2013). Increased Body Mass Index (BMI) is also associated with more frequent hot flashes (Gibbs, 2013), so maintaining a healthy weight can help prevent worsened symptoms as well as improve overall health. The patient has a BMI of 24.5, which is in the normal weight category of 18.5–24.9 (U.S Department of Health and Human Services, 2013). Diet and exercise can help her maintain this BMI as menopause may influence weight gain.
Staying sexually active can help control symptoms of vaginal dryness and vaginal discomfort (Natural Standard, 2013). The patient may be hesitant due to her discomfort with intercourse, but will be introduced to other options to ease this discomfort. Utilizing the interventions discussed later, along with remaining sexually active can ease the dryness and discomfort. Sexual discomfort can also be worsened by atopic irritation. Vaginal discomfort can be decreased by avoiding personal hygiene products containing scents and irritants such as soaps, powders, spermicides, deodorants, and perfumes (Dynamed, 2013).
What tests would you offer or perform? What objective data would you gather? (7 pts)
Vitals: Vital signs and BMI will be evaluated. If BMI was elevated, weight loss could be discussed to decrease menopausal symptoms. There is concern related to her elevated blood pressure. If this is not an ongoing issue there should be follow-up evaluation.
General appearance: Emotional state and alertness should be assessed. Menopause may cause decreased energy. If hot flash occurs during visit, skin changes may be observed. Redness may be noted to chest and face (Dynamed, 2013).
Skin: Dryness of skin can be a pertinent positive of menopause as well as hypothyroidism (Schuiling & Likis, 2013).
Thyroid: Palpating the gland and isthmus with absence of abnormal enlargement will help rule out Thyroid diseases (Schuiling & Likis, 2013).
Inspection and palpation of external genitalia: Assess for erythema, rashes, discharge, or discoloration.
Erythema would be present for atopic vaginitis and possibly Candidiasis. Supportive findings for vaginal include dryness, thin vaginal tissue, loss of labial fat pads, narrowed vaginal opening, or less distinct labia minora (Dynamed, 2013). Upon insertion of index and third fingers into vagina to assess vaginal wall, Vaginismus would present with intolerance to penetration and possible contractions. Tolerance to penetration with lubricated insertion contraindicates Vaginismus. Absence of vaginal discharge would help rule out Bacterial Vaginosis, Candidiasis, and Trichomoniasis (Schuiling & Likis, …show more content…
2013).
Speculum Exam: Carefully performed with well lubricated speculum. Examination should be done slowly and as the patient feels comfortable (Schuiling & Likis, 2013). Pertinenet positives for vaginal atrophy would include decreased vaginal elasticity and rugal folds, shortened vagina, pale epithelium, pelvic relaxation, and decreased cervical secretions (Dynamed, 2013). Cycstocele, rectocele, or uterine prolapse may present with menopause related vaginal atrophy (Dynamed, 2013). Further assessment for absence of abnormal discharge can help rule out Bacterial Vaginosis, Candidiasis, and Trichomoniasis (Schuiling & Likis, 2013). Table 1
Diagnostic Lab Tests Diagnostic Lab Test | Rationale | Vaginal cytology | Vaginal Atrophy would show prevalence of parabasal cells and decreased superficial cells. b | Vaginal pH Normal: 3.8-4.2a | Vaginal Atrophy would show pH >5bBacterial Vaginosis: >4.5Vaginal Candidiasis: Usually <4.5 Trichomoniasis: >4.5a | NaCL Wet Mount Normal: Presence of lactobacillia | Vaginal Atrophy would show lack of lactobacilli. b Rule out:Bacterial Vaginosis: >20% clue cells presentVaginal Candidiasis: pseudohyphae (mycelic) and/or budding yeast Trichomoniasis: Protozoa, motile and flagellated. Presence of WBCs. a | Thyroid Stimulating Hormone | Normal levels would rule out Thyroid Diseasec |
Source: aCenters for Disease Control and Prevention, 2010; bDynamed, 2013; cSchuiling & Likis, 2013
What non-hormonal medications (supplements or herbals) and alternative therapies could you recommend? (7 pts)
Vaginal lubricants can provide significant relief of the patient’s complaint of dyspareunia. This symptom is likely caused by a decrease in vaginal secretions. Many water based lubricants can be found over the counter such as K.Y personal lubricant, Astroglide, Lubrin, and Moist Again. She should be advised against using oil-based products, including Vasoline, because these can actually cause injury to the vaginal tissue and are difficult to remove (Schuiling & Likis, 2013).
Vaginal moisturizers may be considered if the vaginal dryness is causing daily discomfort aside from during intercourse. This should be discussed with the patient. If vaginal dryness is a daily issue, a vaginal moisturizer such as Replens or K.Y Long Lasting Vaginal Moisturizer, should be recommended. The patient should be taught about the difference between lubricants and moisturizers. Moisturizers replenish and help maintain fluids for longer relief, while lubricants offer short term relief (Schuiling & Likis, 2013).
Research shows that the isoflavones in soy are a type of phytoestrogen which can produce similar effects to estrogen in the body. This can help relieve many menopausal symptoms including the patient’s current complaints of hot flashes, vaginal dryness. Although soy is considered safer than estrogen therapy in breast cancer survivors, there is not enough research to fully determine its safety (American Cancer Society, 2013). Foods containing soy may be discussed with the patient such as tofu, soymilk, and soy beans. If soy is used for treatment, this patient should be closely monitored as breast cancer is a highly hormone sensitive type of cancer (National Center for Complementary and Alternative Medicine, 2012).
Another source of phytoestrogens is Black Cohosh. Black Cohosh has been shown to improve menopausal symptoms, including hot flashes and vaginal dryness (Natural Standard, 2013). The usual dosage for treatment of hot flashes is 20 mg tablet BID. The patient should be advised not to use for more than six months, as safety for longer than this duration is not determined. Although side effects are rare, she should be informed of the possibility of intestinal upset, headache, dizziness, hypotension, and pain in extremities (Schuiling & Likis, 2013). Although not contraindicated, Black Cohosh should be used with caution in this patient, as she is considered high-risk due to her history of breast cancer. The benefits of Black Cohosh are similar to that of estrogen therapy (Natural Standard, 2013).
Vitamin E, up to 800 international units per day is shown to produce small improvements in hot flashes (Schuiling & Likis, 2013). Although there may be some benefit with supplementation, according the Natural Standard (2013), there is a lack of evidence for exceeding recommended daily intake with supplementation unless there is a deficiency. The Patient may be educated about sources of vitamin E in foods such as fruit, green leafy vegetables, eggs, meat, nuts, grains, and various oils (Natural Standard, 2013).
Evening primrose oil can help relieve hot flashes, though some data has shown minimal benefit. Usual dosage is 3-4 grams PO daily, in divided doses. When advising a patient to take evening primrose oil, they should be taught about possible side effects of diarrhea and nausea (Schuiling & Likis, 2013). When discussing treatment options, it is important to considered that this herbal medication is contraindicated with anticonvulsants which can also be chosen as treatment (Natural Standard, 2013).
According to the National Center for Complementary and Alternative Medicine (2012), acupuncture can decrease the intensity and frequency of hot flashes. Acupuncture can also increase libido in menopausal women (NCCAM, 2012). If the patient chooses to pursue acupuncture she should be educated on importance of safety and sanitary use of needles. She should also be aware that if she had received radiation therapy during cancer treatment, those areas should be avoided during acupuncture (National Standard, 2013).
Hypnosis can also be beneficial in reducing hot flashes. Studies have shown a 68% decrease in hot flashes in women who were treated with hypnosis (Loibl, Lintermans, Dieudonné & Neven, 2011). Aside from relief of hotflashes, hypnosis can offer additional benefits in stress relief, sleep improvement, and well-being.
What hormonal or other synthetic medications could you recommend? (7 pts)
Although many women experience significant relief of symptoms from hormone therapy during menopause, a history of breast cancer makes this a possibly unsafe option for the patient. According to the American Cancer Society (2013), studies have shown that breast cancer survivors who used hormone therapy were at higher risk for developing new or recurrent breast cancer. Although estrogen has been more commonly known to be associated with breast cancer, other variations including progesterone treatment are also discouraged (American Cancer Society, 2013). When hormone therapy is being evaluated, it is important to know that only women without an intact uterus are candidates for estrogen therapy alone due to the risk of endometrial hyperplasia and cancer with unopposed estrogen (Schuiling & Likis, 2013).
If hormone therapy is still to be considered, progestins alone can provide reduction of hot flashes.
Medroxyprogesterone Acetate, a progesterone, can be effective when 500 mg is administered IM on days 1, 14 and 28 (Loibl, et al., 2011). Due to the unknown safety of progestins in breast cancer survivors, non-hormonal options should be considered for this patient due to her medical history (Schuiling & Likis, 2013). Hormonal treatment for the breast cancer survivor should only be considered if benefits are believed to outweigh the risk and non-hormonal treatments have been unsuccessful. In this situation, treatment should be closely monitored and implemented in collaboration with her oncologist (Loibl, et al., 2011). The patient should return within six to eight weeks for follow-up to evauluate relief of symptoms. Side effects that the patient may experience with hormone therapy include headache, bloating, mood changes, nausea, fluid retention, and breast tenderness (Schuiling & Likis,
2013).
Local hormone therapy can be effective for treating vaginal dryness which causes dyspareunia. Recent studies show that breast cancer recurrence is not associated with the use of local hormone therapy (Ray, Dell 'Aniello, Bonnetain, Azoulay & Suissa, 2012). A variety of local preparations such as creams, suppositories, and rings are available with low doses of hormones are available. When considering these treatments, it is important to be sure that the hormone is not a systemically absorbed treatment. The vaginal creams are more likely to result in systemic absorption than the vaginal ring or tablet. The vaginal ring, containing low doses of estradiol acetate, has proven to be effective in reducing hot flashes and relieving vaginal dryness. Estring (Pfizer), a vaginal ring, releases 7.5μg of estradiol each day. The patient should be instructed to change the ring every ninety days (Simon, 2011).
Vaginal tablets have proven to be the least likely to cause systemic absorption. Vagifem is a tablet which recently released a low dose of 10μg estradiol hemihydrate which has proven to be as effective as the ring with lower incidence of systemic absorption. The tablet should be placed in the outer third of the vagina, reducing absorption while still being effective. Tablets are the safest option for a breast cancer survivor because studies have shown systemic absorption to be nearly undetectable, while vaginal rings have shown systemic effects despite their low circulating levels (Simon, 2011). The patient should be aware that although the majority of evidence has found minimal relation, there is conflicting evidence of whether or not there is an association between local estrogen therapy and endometrial hyperplasia (Simon, 2011). Before choosing any hormonal treatment, including local treatment, the patient’s oncologist should be consulted.
Gabapentin (Neurontin) is an anticonvulsant that is shown to significantly reduce hot flashes (Natural Standard, 2013). Dose should be initiated at 300 mg/day prior to bed, and increased up to 300 mg PO TID in 3-4 day intervals. The patient should be instructed to avoid antacids within two hours of taking, and discouraged from discontinuing abruptly as it should be tapered. Side effects to review with the patient include somnolence, dizziness, ataxia, fatigue, and weight gain (Schuiling & Likis, 2013).
Clonidine (Catapres), an antihypertensive, may reduce hot flashes. For this patient particularly, this medication may be considered as her blood pressure will require monitoring due to her current elevation. She should be prescribed 0.05-0.1 mg PO BID, although it is also available as a patch (Natural Standard, 2013). Side effects to make her aware of include dry mouth, drowsiness, dizziness, fatigue, constipation, urticara, insomnia, nausea, agitation, hypotension, and myalgia. Education must also include instructing her not to stop this medication abruptly, as it should be tapered when discontinuing (Schuiling & Likis, 2013).
When planning treatment for menopausal symptoms, particularly hot flashes, low dose anti-depressants may be beneficial. Venlafaxine (Effexor), a selective serotonin and norepinephrine reuptake inhibitor, has been shown to decrease hot flashes in menopause (Natural Standard, 2013). When starting the patient on Venlafaxine, it should be titrated up from 37.5 mg/day to 75 mg/day. Likewise, it should be titrated down when discontinuing. Patient education should include awareness that this medication cannot be taken with MAO inhibitors as it can interact. She should be aware that response is usually immediate. Side effects to discuss are nausea, vomiting, dry mouth, and decrease in appetite (Schuiling & Likis, 2013).
Anti-depressants in the selective serotonin re-uptake inhibitor (SSRI) class can also be helpful in reducing hot flashes in menopause. Fluoxetine (Prozac) provides an immediate response and should also be titrated up when initiating. The recommended dose is 20 mg/day, and should be tapered when discontinuing. The patient should be aware that use is contraindicated with MAO inhibitors, thioridazine, and warfarin due to potential interactions. Possible side effects to educate the patient about include asthenia, sweating, nausea, somnolence, inability to orgasm, and decreased libido (Schuiling & Likis, 2013). Another SSRI that is shown to decrease hot flashes is paroxetine (Paxil). Paroxetine shares the same contraindications, side effects, and tapering requirements as fluoxetine. Additionally, fluoxetine may cause weight gain and blurred vision (Schuiling & Likis, 2013). The patient’s weight should be taken into consideration, and guidance should be provided regarding exercise and diet if this medication is used. Titrating up upon initial therapy, the dosing should range from 12.5-25 mg/day (Schuiling & Likis, 2013).
References
American Cancer Society. (2013, February 26). Post-menopausal hormone therapy after breast cancer. Retrieved from http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-after-post-menopausal-therapy
Centers for Disease Control and Prevention. (2010). 2010 std treatment guidelines. Retrieved from http://www.cdc.gov/std/treatment/2010/toc.htm
DynaMed. (2013, January 15). Menopause. Ipswich, MA:EBSCO Publishing. Retrieved July 15, 2013, from http://web.ebscohost.com.ezproxy.midwives.org/dynamed/detail?sid=dd4685cd-0650-4a22-9dd8-b738cbfd81e6%40sessionmgr104&vid=4&hid=124&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=114698&anchor=top
Gibbs, T. (2013). Breast cancer survivors & hot flash treatments. Retrieved from http://www.menopause.org/for-women/menopauseflashes/breast-cancer-survivors-hot-flash-treatments
Le Ray, I., Dell 'Aniello, S., Bonnetain, F., Azoulay, L., & Suissa, S. (2012). Local estrogen therapy and risk of breast cancer recurrence among hormone-treated patients: a nested case-control study. Breast Cancer Research And Treatment, 135(2), 603-609. doi:10.1007/s10549-012-2198-y
Loibl, S., Lintermans, A., Dieudonné, A., & Neven, P. (2011). Management of menopausal symptoms in breast cancer patients. Maturitas, 68(2), 148-154. doi:10.1016/j.maturitas.2010.11.013
National Center for Complementary and Alternative Medicine (2012, February). Menopausal symptoms and complementary health practices. Retrieved from http://nccam.nih.gov/health/menopause/menopausesymptoms
Natural Standard (2013). Menopause. Retrieved from http://naturalstandard.com.ezproxy.midwives.org/databases/conditions/all/condition-menopause.asp?
Schuiling, KD & Likis, FE. (2013). Women 's Gynelogical Health (2nd ed.), Burlingham, MA: Jones & Bartlett
Simon, J. (2011). Identifying and treating sexual dysfunction in postmenopausal women: the role of estrogen. Journal Of Women 's Health (2002), 20(10), 1453-1465. doi:10.1089/jwh.2010.2151
U.S Department of Health and Human Services. (2013). Standard bmi calculator. Retrieved from http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm