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page 7 | page 8 | page 9 | page 10 | page 11 | page 12 page 13 | page 14 | page 15 | page 16 page 17 | page 18 | page 19 | page 20 references | nursing assessment | patient handout table of contents | test CASE STUDY 1Perimenopausal WomanThis patient is a 45-year-old, nulligravida, professional woman complaining of memory loss, poor concentration, and unpredictable hot flushes that are troublesome during client meetings and during sleep. Her height is 5'6", weight is 135 lbs, she has an intact uterus and is a nonsmoker. Although her menstrual cycles are regular, the flow has become much lighter. Because a lab work-up shows normal FSH and estrogen levels, she has been told that she doesn't need HRT. She is sexually active and needs contraception. Among her questions are:
Nursing ManagementInitial treatment should be low-dose oral contraceptives (consider 20 µg OCs) to control hot flushes and provide contraception. A discussion of her lifestyle and dietary habits should be initiated. At 1-month follow-up the patient reported an improved sleep pattern, ability to concentrate, and less frequent hot flushes. Schedule routine follow-up for 1 year or prn.At age 48, and after 3 years on low-dose OCs patient questions her need for contraception. Her FSH level is >40 mIU/mL on day 7 of placebo on OCs, indicating a lack of fertility. Because day 7 is often on a weekend, the window of measurement can be expanded to day 5-8. Discuss changing her regimen to cyclic HRT (because she still has an active endometrium) with the goal of changing to continuous combined HRT in a couple of years. Discuss expected bleeding patterns and side effects.
CASE STUDY 2POSTMENOPAUSAL WOMANThis 57-year-old woman has an intact uterus, has no symptoms, and is in the office for routine care. She is a smoker, has not had a period for 10 years, and is otherwise healthy with no complaints. She is 5'6" and weighs 130 lbs. She has never considered HRT and has never received any counseling about it.
AssessmentPatient height has decreased within the last 2 years. She is 1" shorter than her maximum. When asked about sexuality she reports dyspareunia and vaginal dryness; she is not happy with these conditions. Her mother had a wrist fracture with a minor fall at age 65. The patient is taking a multivitamin and some herbal remedies. She has cut back to 3 cups of coffee a day. In discussing her own beliefs, she expresses fear of breast cancer with the use of HRT.
Nursing ManagementMany nurses and patients assume that if someone cannot take OCs (as would have been the case with a ³40-year-old smoker), then HRT is also contraindicated. In fact, this patient is a good candidate for continuous combined HRT. Her family history, loss in height, and smoking habit are risk factors for osteoporosis. Her early menopause at age 47 is suggestive of the effect of smoking. Consider a bone mineral density measurement to help convince the patient of the need for HRT. Educate her about the benefits of HRT (particularly osteoporosis prevention/treatment), the inadequacy of calcium alone for fracture prevention, and the lack of increased risk of breast cancer with HRT. Another area for discussion is the herbal remedies she is using.
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