Posted: May 1st, 2025

(2) peers Discussion replies wk 7

1st peer: Week 7 Case Scenario 1

Table 1

Define:

Perimenopause

The transitional phase occurs approximately age 48-55 before menses ceases permanently.

Menopause

When menses cease for 12 consecutive months. This occurs on average at the age of 51 in women.

Postmenopause

Postmenopause occurs after menopause has been confirmed and symptoms are caused by decreasing estrogen and progesterone levels (Alexander, 2023).

S/S menopause

Cause -How does it occur/ how does it relate to menopause

Recommendations

Example: Decrease libido

Lower levels of testosterone

Having a conversation with a partner sets the mood.

Hot flashes

Vasomotor symptoms are caused by hormonal deficiencies. Hot flashes impact the quality of life. Hot flashes occur on average for 3-4 minutes and make women feel self-conscious in social situations due to the effects of facial flushing. This symptom can last for 1 to 6+ years and is reported to last 15 years in 10% to 15% of postmenopausal women (Peacock et al., 2023).

Wearing cotton clothing, having a fan nearby, and using air conditioning and cold beverages are comfort measures. Hormone replacement therapy is also an effective option for women without risk factors such as a familial history of reproductive cancers (Peacock et al., 2023).

Night sweats and Sleep Disturbance

Night sweats are caused by estrogen deficiencies which cause vasomotor symptoms and sleep disturbances. Women commonly report trouble falling asleep, waking throughout the night, and feeling unrested (Peacock, et al., 2023).

Sleeping with cotton sheets and sleepwear in a well-ventilated room with a fan or air-conditioning and no stimulus. HRT with estrogen and progesterone can significantly decrease sleep disturbances for women without contraindications for treatment (Peacock et al., 2023).

Irregular menses

Fluctuations and a decline in estrogen contribute to irregular menses (Peacock et al., 2023).

Keeping a diary of symptoms and a calendar of when periods occur can help women feel more in control of irregular menses (Peacock et al., 2023).

Mood swings or irritability

Fluctuations and a decline in estrogen contribute to mood swings and irritability (Peacock et al., 2023).

Cognitive behavioral therapy, counseling, and SSRIs are often prescribed to alleviate these symptoms (Peacock et al., 2023).

Vaginal dryness

Fluctuations and a decline in estrogen contribute to vaginal dryness and atrophy (Peacock et al., 2023).

Localized estrogen therapy with vaginal rings, creams, or tablets has been shown to enhance blood flow and reverse vaginal atrophy (Peacock et al., 2023).

Barbara is a 48-year-old female who complains her menstrual cycle has recently become irregular, and she is experiencing hot flashes and vaginal dryness. She has also noticed a decrease in her desire for sex lately. She has been married to a man for 20 years, is in a stable relationship, and has two daughters ages 16 and 18. She is otherwise healthy with an unremarkable medical history. Her pregnancy test is negative. Her Pap smear and STI panel are all negative.

Demographic Data

: 48-year-old Caucasian female.

Subjective

Chief Complaint: “Irregular menses, hot flashes, decreased libido, and vaginal dryness.”

HPI:The patient presents today with multiple symptoms of irregular menses, decreased libido, hot flashes, and vaginal dryness that began six months ago. The patient reports the severity of each of these symptoms as “6/10”, affecting her “quality of life’ and “ causing painful sex with her husband.” The hot flashes occur intermittently on most days, decreased libido and vaginal dryness are “constant.” Alleviating factors for these symptoms are  “wearing cotton clothing, staying indoors with air conditioning and using lubricant jelly before sex.” The patient has tried over-the-counter “Estroven and Black Cohosh” with mild relief.

PMH: Hypothyroidism, well-managed with medication.

PSH:None

Family History:

Mother: age 76, no medical conditions.

Father: age 78, hypertension.

Siblings: Younger sister 46, no medical history.

Maternal Grandmother: deceased at 89, no medical history.

Maternal Grandfather: deceased at 74, DM2.

Paternal Grandmother: deceased at 90, no medical conditions.

Maternal Grandfather: deceased at 86, CVA.

Medications:

Levothyroxine 75 mcg tablet PO once daily in the AM 30 minutes before food.

Allergies: NKDA

Immunizations:COVID-19 x 3 9/2023, Influenza 9/2023, RSV 09/2023, TDAP 2019.

Health Maintenance:Pap with HPV Co-testing 06/2023, negative. Mammogram 08/2023, negative. Annual Physical Exam 08/2023. Dental exam 03/2024. Eye exam 08/2023 wears prescribed glasses for myopia.

Social History: The patient lives with her husband and two teenage daughters in a single-family home and works full-time as a school administrator. -ETOH, drugs, vaping and tobacco. The patient is in a heterosexual monogamous relationship with her husband of 20 years.

OB/GYN History: (G3P2T2A1) Menarche at age 13. The patient reports regular menses occurring every 28-30 days with a regular flow lasting 4-5 days, until three months ago. LMP 12/28/2023.The patient reports two uneventful vaginal deliveries and one miscarriage in 2014. The patient reports using the fertility awareness method as her birth control. The patient has no plans of becoming pregnant. The patient has had 3 sexual partners in her lifetime with no history of STIs. Pap with HPV Co-testing 06/2023, negative. Mammogram 08/2023, negative.

ROS:

General: Reportsweight gain of 5 lbs in the last 3 months. Denies fever and/or chills.

Cardiovascular:Denies edema, chest pain, palpitations, irregular rate, rhythm, murmurs, gallops, or rubs.

Respiratory:Denies shortness of breath, dyspnea, wheezes, rales or cough.

Gastrointestinal:Denies constipation, diarrhea, distention, pain, hernias or masses.

Genitourinary:Denies frequency, urgency, dysuria, and nocturia.

Breasts/Reproductive:Denies lumps or masses or swollen lymph nodes breasts during self-breast exams in the shower. Reports vaginal dryness and burning with intercourse and irregular menses.

Integumentary: Reports hot flashes beginning in January 2024, and occurring daily at irregular intervals, lasting for 3-4 minutes. Denies rashes, excoriation, or lesions.

Objective

Physical Examination:

Vital Signs: BP 112/76, HR 78, RR 18, O2 99%, Temp 98.4 F, Weight 145 lbs, Height 5’7”, BMI 22.7 (healthy weight).

Constitutional/General Appearance: In no acute distress, well developed, alert, and oriented.

Cardiovascular:Regular rate and rhythm, -edema, murmurs, gallops, or rubs.

Respiratory:Clear to auscultation bilateral, no wheezes or rales.

Gastrointestinal:Bowel sounds x 4, no guarding, distention, hernias, or masses.

Genitourinary: No signs or symptoms of infection.

Breasts/Reproductive:No dimpling, retraction of the nipple, nipple discharge, asymmetry of the breasts, or abnormal pigmentation. No masses were palpated.  Vaginal odor, – abnormal discharge. Wet Mount – whiff test,- clue cells, -hyphae, or motile organisms. Ph 4.5 normal.

External Genitalia Exam: External genitalia intact with no excoriations or lesions and normal hair distribution.

Speculum exam: Os is multiparous with no abnormalities. -odor, -abnormal discharge.

Bimanual exam: No adnexal tenderness or cervical motion tenderness.

Integumentary:Skin is warm, dry, and intact with no lesions, purport, ecchymoses, or excoriation.

Neurological:CN nerves are intact. DTRs intact.

PCOT:Urine pregnancy test, Pelvic Exam, Wet Mount.

Assessment

/Diagnosis

Presumptive Diagnosis:

N95.9 Menopausal and perimenopausal disorder, unspecified.Physiologic perimenopausal and menopausal symptoms occur due to ovarian hormone depletion and occur between the ages of 44 and 58 years of age in most women (Cash, 2024).

Pertinent +: The patient is 48 years of age and experiencing symptoms of irregular menses, hot flashes, decreased libido, and vaginal dryness which are characteristic of perimenopause.
DDX:

E07.9 Disorder of thyroid unspecified-Thyroid disorders can cause weight gain, irregular menses, cold or heat intolerance, skin dryness, and fatigue which can contribute to low libido (Cash, 2024).Pertinent +:The patient has a history of hyperthyroidism. Pertinent -:The patient has hypothyroidism which causes cold intolerance and the patient is experiencing hot flashes.

2. Z34.90 Pregnancy-Pregnancy causes primary amenorrhea. Pertinent +: The patient has not had menses for three months and uses the fertility self-awareness method as her birth control.

PLAN

Treatment

Plan

Diagnostic Labs: HCG, CBC, CMP, TSH and Free T4, lipids, Vitamin D, FSH, estradiol, LH. Transvaginal ultrasound to evaluate for uterus abnormalities (Cash, 2024).

Pharmacologic:Discuss the risks and benefits of hormone replacement therapy to reduce hot flashes, vaginal dryness, low libido, and other symptoms of perimenopause. For patients without any risk factors such as having a family history of breast, uterine or ovarian cancers, liver disease, or thromboembolic events, and who are 60 years and younger and menopause is expected within 10 years, the benefits may outweigh the risks. The Women’s Health Initiative (WHI) has evidence that HRT can reduce risks of cardiovascular disease among patients who start HRT within 10 years of menopause (Lega et al., 2023), HRT is typically used for 5 years, but individual health considerations, patient risk profile, and preferences should be considered before discontinuing therapy. HRT comes in many forms such as transdermal patches, creams, pills, and IUDs. Estrogen and progesterone are recommended for the treatment of moderate to severe vasomotor and vaginal atrophy symptoms in women with an intact uterus. Alternatively, antidepressants can provide relief from vasomotor symptoms when HRT is contraindicated or not desired (Lega et al., 2023).

If the patient desires HRT:

Premarin estrogen therapy 0.625 mg/day tablet PO once daily (90 tablets with 6 refills).

Provera progesterone 5-10 mg tablet PO once daily is added to the estrogen for the first 10-14 days of the month (90 tablets with 6 refills) (Cash, 2024).

OR If the patient does not desire HRT:

Venlafaxine SSRI therapy 37.5 mg tablet PO once daily for one week and then 50 mg tablet once daily (37.5 mg 7 tablets with no refill and 50 mg 90 tablets with 3 refills)(Cash, 2024).

Non-Pharmacologic:Provide reassurance on the absence of menses and symptoms due to perimenopause hormone fluctuations and advise the patient on using birth control due to the possibility of getting pregnant due to the unpredictability of ovulation and menses Encourage a healthy diet rich in Vitamin D and Calcium daily. Encourage the use of glycerin-free, water-soluble vaginal lubricants. Wear cotton clothing, carry a fan and cold water, lower the air conditioning, and avoid caffeine, alcohol, and spicy foods which may trigger hot flashes. Encourage good sleep hygiene practices and adequate rest (Cash, 2024).

Patient Education:Menopause is a normal transition and health condition occurring in all menstruating females due to age-related changes and estrogen deficiency. Most women experience symptoms for several years before menopause which is indicative of perimenopause. Menopause is diagnosed when you miss 12 consecutive cycles in one year and you are no longer menstruating. Lower levels of hormones can alter the pH of your vagina and make you more susceptible to UTIs and BV infections. Stay hydrated, wipe front to back, use lubricant for sexual intercourse, and urinate before and after sex. Risks for osteoporosis and cardiovascular disease increase with menopause and having a healthy diet with calcium 1000 mg and Vitamin D 400 IU daily and performing weight-bearing exercises to reduce risks is recommended (Peacock et al., 2023). HRT therapy may increase your risk for stroke and cancer. Venlafaxine can cause headaches, nausea, dizziness, hypertension, and decreased libido. Report any abnormal bleeding to your healthcare provider and call 911 or go to the ED if you experience suicidal thoughts, visual changes, severe headaches that are unrelieved with NSAIDS, chest pain, shortness of breath, numbness or tingling, swelling in your legs, or severe pain You will need to have routine lab work to monitor your hormone levels (Epocrates, 2024).

Follow-Up/RTC:In 3 months discuss the efficacy of HRT and/or SSRI medications in improving symptoms and assess for adverse side effects.

Referrals: OB/GYN if any abnormal bleeding occurs (Cash, 2024).

Health Maintenance:Pap with Co-testing due 06/2028. Mammogram due 08/2024, Colonoscopy due at age 50. The annual Physical Exam is due 08/2024. Vision exam due 03/2025. Bone density scan for postmenopausal women younger than age 65. Healthy Diet and physical exercise education. Skin Cancer Prevention (USPSTF, 2023).

2nd peer: Case Scenario 1

Table 1(Casper, 2023; Alexander et al., 2023)

Define:
Perimenopause

Period prior to menopause, where hormones fluctuate. Lasts about 8-10 years, typically ages 48-55

Menopause

Period during menopause when the LMP occurs more than 12 months prior. No longer fertile/able to be pregnant. Typically ages 50-52

Postmenopause

Period after menopause until end of life. Typically age 52-death

Table 2(Casper, 2023; Alexander et al., 2023)

S/S menopause
Cause -How does it occur/ how does it relate to menopause
Recommendations
Example: Decrease libido
Lower levels of testosterone

Having a conversation with partner, setting the mood

Hot flashes

During menopause, estrogen levels decrease and FSH levels increase. Estrogen is a hormone that helps regulate the body temperature. The body counteracts this effect by vasodilating, causing hot flashes

Drink 8 glasses of water a day, wear layered clothing that’s easily removable, smoking cessation. Can take black cohosh

Night sweats and Sleep Disturbance

During menopause, estrogen levels fluctuate. Estrogen is a hormone that helps regulate the body temperature. So less estrogen means less regulation of temperature, leading to night sweats.

Hormone therapy, exercise, healthy diet, smoking cessation.

Irregular menses

During menopause, estrogen levels fluctuate. Estrogen helps regulate menses, so a fluctuating estrogen level fluctuates the menses as well

Hormone therapy with estrogen and progesterone, can take natural chaste tree berry

Mood swings or irritability

During menopause, estrogen and progesterone levels fluctuate. Estrogen and progesterone also impact serotonin levels, so a fluctuating hormone level will fluctuate the patients mood

Exercise, healthy diet, sleep/rest periods.

Vaginal dryness

During menopause, estrogen levels decrease. Estrogen helps keep the vaginal lining moist, so a decrease in estrogen, increases dryness

Lubricants, hormone replacement therapy, vaginal estrogen cream, pellets, oral medication.

Prompt:

Barbara is 48-year-old female who complains her menstrual cycle has recently become irregular, and she is experiencing hot flashes and vaginal dryness. She has also noticed a decrease in her desire for sex lately. She has been married to a man for 20 years, is in a stable relationship, and has two daughters ages 16 and 18. She is otherwise healthy with an unremarkable medical history. Her pregnancy test is negative. Her Pap smear and STI panel are all negative.

SOAP

Demographic Data

48-year-old/Female

Subjective

CC: Irregular menses

HPI:48-year-old female presents to office complaining of irregular menses. Patient states over the past 5-6 months her menses has become irregular lasting 7-14 days rather than her usual 3-5 days. Patient also states her menses is sometimes normal but other times is heavier. She also reports hot flashes, that worsen at night. Patient reports a decrease in libido and states she is now experiencing vaginal dryness.

Gyn Hx:G2P2, NSVD x2. LMP 04/01/24, reports this menses ended on 04/13/24. Patient has taken oral contraceptives in the past, but that was prior to when she married her husband. Patient has not tried or taken any other contraceptives since as her husband has had a vasectomy.

PMH/PSH: Denies any medical history. Denies history of STIs.

Medications:Denies any OTC or prescribed medications

Allergies: NKDA, environmental or food allergies

Immunizations: up to date

Preventive Health Maintenance:

Last pap smear: 03/22/24, WNL. No abnormal cells or STIs detected.

Family History:

Mother: hyperlipidemia

Father: denies

Maternal Grandmother: hypertension, hyperlipidemia

Maternal Grandfather: denies

Paternal Grandmother: hyperthyroid

Paternal Grandfather: unknown

Social History: Patient lives at home with her husband and her two daughters (aged 18 and 16). Patient is a homemaker. She reports she drives her children to school each morning and picks them both up as well. Patient reports she follows a Mediterranean diet. Patient reports exercising 5x/week either walking, hiking, or biking for about 1-1.5 hours. Patient reports occasional glass of wine with dinner 1-2x/week. Patient denies smoking tobacco, vaping products, or use of any illicit drugs. Patient identifies as heterosexual and has 2 lifetime partners, but has only slept with her husband for the past 20 years.

ROS:

General: Denies fever, weight loss. Reports hot flashes and night sweats

HEENT: Denies headaches. Denies eye pain, discharge, or erythema. Denies vision changes. Denies ear pain, discharge. Denies feeling of ear fullness or tinnitus.

Cardiovascular: Denies chest pain or palpitations. Denies swelling in the lower extremities

Respiratory: Reports shortness of breath when walking upstairs. Denies difficulty breathing, coughing, or wheezing.

Endocrine: Denies heat or cold intolerance. Denies polydipsia, polyphagia, or polyuria.

Gastrointestinal:Denies nausea or vomiting. Denies constipation or diarrhea. Denies difficulty swallowing. Denies black/tarry stools. Denies changes in bowel habits

Genitourinary: Denies urgency, dysuria. Reports frequency

Gynecologic: Denies any spotting or bleeding in pregnancy. Denies dysmenorrhea, dyspareunia, post-coital bleeding. Denies vaginal discharge, odor. Reports vaginal dryness.

Musculoskeletal: Denies fatigue or muscle weakness.

Integumentary (Skin/Breast): Denies new or changing moles, lesions, rashes, erythema. Denies breast sensitivity.

Hematologic/Lymphatic: Denies bruising or bleeding increases. Denies lymphadenopathy

Neurological: Denies numbness in extremities and face. Denies tingling or tremors in extremities.

Psychiatric: Denies anxiety, depression, increased stress, or suicidal ideation

Objective

Vital Signs:

Temp: 98.6 F, HR: 65, BP: 114/77, RR: 16, SpO2: 100%

Ht: 66 in, Wt: 135 lbs, BMI: 21.8

Physical Exam:

General: No acute distress

HEENT: No tenderness upon palpation. No mass/lumps palpated on head/neck. PERRLA. No discharge or edema on eyes. No discharge, edema, or erythema on TMs. Mucous membranes moist. No uvula deviation/tongue swelling. No goiter palpated.

Cardiovascular: Regular rate and rhythm. No gallops or murmurs auscultated. No swelling in the lower extremities noted. Radial and pedal pulses strong and equal +2 bilaterally. Capillary refill < 3 seconds.

Respiratory: Anterior lung fields and posterior lung fields clear to auscultation. No accessory muscle use noted.

Gastrointestinal: Bowel sounds normoactive in all 4 quadrants. No tenderness to palpation. No masses, hernias, bruits palpated. No hepatomegaly/splenomegaly palpated.

Musculoskeletal: Gait WNL. Muscle strength 5/5 in all extremities bilaterally

Integumentary: Skin is warm, dry. No diaphoresis noted. No rashes, lesions, irregular moles, erythema noted.

Lymphatic: No lymphadenopathy noted

Gyn:

Pelvic exam: External genitalia WNL. Vaginal mucosa dry, pale. No discharge, erythema, masses or lumps noted.

Breast: Breasts nontender. No dimpling, discharge, retraction, or erythema noted on bilateral breasts.

Neurological: A/Ox4. No numbness, tingling, tremors on face or extremities noted. Cranial nerves intact

Psychiatric: Mood and affect appropriate for age, situation. No auditory, visual disturbances

POCT:(Alexander et al., 2023)

Pregnancy test: Negative

Pregnancy test ordered as patient is still of reproductive age and is complaining of irregular menses. Any female of reproductive age with a menses within the past 12 months should be tested to rule out pregnancy. Additionally, any further testing ordered may require a rule out of pregnancy as well.

TVUS: No cysts on ovaries, Uterus length WNL, no adnexal mass noted. No free-floating fluid in the cul-de-sac

TVUS ordered to visualize ovaries, uterus, and fallopian tubes to make sure no structural abnormality and no pelvic disease or syndrome is causing menses to be irregular.

Assessment

Working Diagnosis: (Mellor, 2023; Casper, 2023;

Menopausal and perimenopausal disorder, unspecified (ICD-10: N95.9):

Menopause and perimenopause typically occur in women around age 47. Early menopause is used to describe menopause in those younger than age 45. Perimenopause itself is a menstrual cycle change of equal to or more than 7 days in length. It may be accompanied by vasomotor symptoms. These symptoms include hot flashes, night sweats, irregular menses, mood swings, irritability, sleep disturbance, and vaginal dryness. Women may also experience vaginal atrophy, dyspareunia and sexual function, melasma, breast tenderness, alopecia, weight gain, and myalgias. Upon physical examination, the patient may be diaphoretic and the pelvic exam will reveal a pale or dry vagina. Laboratory testing, although unneeded for diagnosis may reveal high FSH and LH, low estradiol, AMH, and inhibin B.

Pertinent +/-: The patient is a 48-year-old female who reports hot flashes, night sweats, vaginal dryness, and change in her menses. Patient reports her menses has become irregular, lasting 7-14 days now instead of her usual 3-5 days. Patient denies mood swings, irritability, dyspareunia.

Differential 1: (Ross, 2023; Ross, 2024)

Hyperthyroidism, unspecified without thyrotoxicosis or thyroid storm (ICD-10: E05.9):

Hyperthyroidism can occur at any age but typically occurs in adulthood. It is more common in females than males. Symptoms include heat intolerance, diaphoresis, palpitations, tremors, weight loss, hair thinning, amenorrhea or oligomenorrhea, diarrhea, possible goiter, and mood changes. Upon physical examination, the patient may have a possible goiter, have conjunctival edema or eyelid lag. Laboratory testing may reveal a low TSH and high T3 and T4. Other laboratory data will reveal low HLD and LDL, and high SHBG, estradiol, and LH.

Pertinent +/-: The patient is a 48-year-old female who reports hot flashes, night sweats or diaphoresis, and change in her menses. Patient reports her menses has become irregular, lasting 7-14 days now instead of her usual 3-5 days. She denies palpitations, tremors, weight loss, diarrhea, and mood swings. Upon physical examination she did not have a goiter, any eyelid swelling or lid lag

Differential 2:(Barbieri & Ehrmann, 2022)

Polycystic ovary syndrome (PCOS) (ICD-10: E28.2):

PCOS is typically diagnosed in women of reproductive age. PCOS is a cycle of late menses followed by irregular cycles of menses. Other clinical symptoms include obesity, hirsutism, acne, male pattern hair growth and loss. Patients may also present with other metabolic issues, mood disorders or swings, and deepening of their voice. Upon diagnostic imaging with a TVUS, polycystic ovaries will be seen. Laboratory testing may reveal elevated testosterone, low SHBG, high 17-hydroxyprogesterone, and high AMH.

Pertinent +/-: The patient is a 48-year-old female who reports a change in her menses, now becoming irregular, lasting 7-14 days instead of her usual 3-5 days. Upon physical examination, the patient is not obese, her BMI is 21.8, she does not have acne, male pattern hair growth or loss, and no signs of hirsutism. The patient denies mood swings and denies change in voice. Upon her TVUS, no polycystic ovaries are seen.

Plan

Dx plan: (Ambikairajah et al., 2022; Casper, 2023; Mellor, 2023)

Labs: CBC, CMP, TSH, lipid panel, hormones (FSH, LH, estradiol, progesterone, AMH, Inhibin B)

CBC to look for anemia, CMP to look for electrolyte imbalance, TSH to rule out thyroid etiology for symptoms, lipid panel for baseline if possible hormone replacement is ordered as some hormone replacement therapies are contraindicated or can affect lipid levels. Hormones to determine levels if she is early perimenopausal state or late perimenopausal state. Although hormone levels are not required to diagnose perimenopause in women over the age of 45, I would still test for it.

FSH, LH are expected to be high

Estradiol, progesterone, AMH, inhibin B are expected to be low

Tx plan: (Martin & Barbieri, 2023; Vallerand & Sanoski, 2023)

Treatment for perimenopause and menopause includes hormone replacement therapy, so the patient would require Estradiol. The patient still has an intact uterus so progesterone is added for protection of uterus lining changes and to decrease risk of endometrial, ovarian and breast cancer.

Medications:

Estradiol 0.5 mg PO QD (90 tablets/ 3 refills)

Progesterone 200 mg PO for 12 days every 4 weeks (36 capsules/ 3 refills)

Side effects of Estradiol and Progesterone include hypertension, oily skin, weight change, amenorrhea or dysmenorrhea, breakthrough bleeding, vaginal discharge, mood swings, headache, and breast tenderness. Concurrent use with tobacco can increase risk of MI or venous thromboembolism. This medication, if taken alone can increase risk of endometrial, ovarian, and breast cancer. Continue taking both Estradiol and Progesterone together to decrease this risk. Best to take progesterone at bedtime as it may cause tiredness

Pt education: (Martin & Barbieri, 2023; Alexander et al., 2023, Mellor, 2023)

Every female goes through menopause, with the mean age of menopause being about 51. Many women start the transition to menopause at age 47-51. The reason menopausal symptoms occur is because our estrogen levels fluctuate, causing other processes of our body to fluctuate. The key to this transition period is to control symptoms as they are affecting your daily. Hot flashes, night sweats, vaginal dryness, the libido changes, and the irregular menses can be managed with oral estradiol and progesterone medication. However, you cannot take these medications for more than 5 years as they increase the risk of coronary heart disease, stroke, breast cancer, type II diabetes, and fractures. To continue management of vaginal dryness, water-based lubrication can be used or we can switch the route of estradiol to vaginal rather than oral which may help this symptom. Continue your Mediterranean diet and exercise daily as this positively impacts your overall health. For hot flashes, avoid triggers, wear layered clothing to be easily removed and dawned again. You can still get pregnant during the perimenopausal period. Although your husband had a vasectomy, continue utilizing protection with condoms for each sexual encounter.

Referral/follow up:

Follow-up in office in 6 weeks

Health maintenance: (USPSTF, n.d.)

Pap-smear: 03/2027

Mammogram: 03/2026Case Scenario 1Table 1(Casper, 2023; Alexander et al., 2023)Define:PerimenopausePeriod prior to menopause, where hormones fluctuate. Lasts about 8-10 years, typically ages 48-55MenopausePeriod during menopause when the LMP occurs more than 12 months prior. No longer fertile/able to be pregnant. Typically ages 50-52PostmenopausePeriod after menopause until end of life. Typically age 52-death Table 2(Casper, 2023; Alexander et al., 2023)S/S menopauseCause -How does it occur/ how does it relate to menopauseRecommendationsExample: Decrease libidoLower levels of testosteroneHaving a conversation with partner, setting the moodHot flashesDuring menopause, estrogen levels decrease and FSH levels increase. Estrogen is a hormone that helps regulate the body temperature. The body counteracts this effect by vasodilating, causing hot flashesDrink 8 glasses of water a day, wear layered clothing that’s easily removable, smoking cessation. Can take black cohoshNight sweats and Sleep DisturbanceDuring menopause, estrogen levels fluctuate. Estrogen is a hormone that helps regulate the body temperature. So less estrogen means less regulation of temperature, leading to night sweats.Hormone therapy, exercise, healthy diet, smoking cessation.Irregular mensesDuring menopause, estrogen levels fluctuate. Estrogen helps regulate menses, so a fluctuating estrogen level fluctuates the menses as wellHormone therapy with estrogen and progesterone, can take natural chaste tree berryMood swings or irritabilityDuring menopause, estrogen and progesterone levels fluctuate. Estrogen and progesterone also impact serotonin levels, so a fluctuating hormone level will fluctuate the patients moodExercise, healthy diet, sleep/rest periods.Vaginal drynessDuring menopause, estrogen levels decrease. Estrogen helps keep the vaginal lining moist, so a decrease in estrogen, increases drynessLubricants, hormone replacement therapy, vaginal estrogen cream, pellets, oral medication. Prompt: Barbara is 48-year-old female who complains her menstrual cycle has recently become irregular, and she is experiencing hot flashes and vaginal dryness. She has also noticed a decrease in her desire for sex lately. She has been married to a man for 20 years, is in a stable relationship, and has two daughters ages 16 and 18. She is otherwise healthy with an unremarkable medical history. Her pregnancy test is negative. Her Pap smear and STI panel are all negative.SOAPDemographic Data48-year-old/FemaleSubjective

CC: Irregular menses
HPI:48-year-old female presents to office complaining of irregular menses. Patient states over the past 5-6 months her menses has become irregular lasting 7-14 days rather than her usual 3-5 days. Patient also states her menses is sometimes normal but other times is heavier. She also reports hot flashes, that worsen at night. Patient reports a decrease in libido and states she is now experiencing vaginal dryness.
Gyn Hx:G2P2, NSVD x2. LMP 04/01/24, reports this menses ended on 04/13/24. Patient has taken oral contraceptives in the past, but that was prior to when she married her husband. Patient has not tried or taken any other contraceptives since as her husband has had a vasectomy.
PMH/PSH: Denies any medical history. Denies history of STIs.
Medications: Denies any OTC or prescribed medications
Allergies: NKDA, environmental or food allergies
Immunizations: up to date
Preventive Health Maintenance:
Last pap smear: 03/22/24, WNL. No abnormal cells or STIs detected.

Family History:

Mother: hyperlipidemia
Father: denies
Maternal Grandmother: hypertension, hyperlipidemia
Maternal Grandfather: denies
Paternal Grandmother: hyperthyroid
Paternal Grandfather: unknown

Social History: Patient lives at home with her husband and her two daughters (aged 18 and 16). Patient is a homemaker. She reports she drives her children to school each morning and picks them both up as well. Patient reports she follows a Mediterranean diet. Patient reports exercising 5x/week either walking, hiking, or biking for about 1-1.5 hours. Patient reports occasional glass of wine with dinner 1-2x/week. Patient denies smoking tobacco, vaping products, or use of any illicit drugs. Patient identifies as heterosexual and has 2 lifetime partners, but has only slept with her husband for the past 20 years.

ROS:
General: Denies fever, weight loss. Reports hot flashes and night sweats
HEENT: Denies headaches. Denies eye pain, discharge, or erythema. Denies vision changes. Denies ear pain, discharge. Denies feeling of ear fullness or tinnitus.
Cardiovascular: Denies chest pain or palpitations. Denies swelling in the lower extremities
Respiratory: Reports shortness of breath when walking upstairs. Denies difficulty breathing, coughing, or wheezing.
Endocrine: Denies heat or cold intolerance. Denies polydipsia, polyphagia, or polyuria.
Gastrointestinal: Denies nausea or vomiting. Denies constipation or diarrhea. Denies difficulty swallowing. Denies black/tarry stools. Denies changes in bowel habits
Genitourinary: Denies urgency, dysuria. Reports frequency
Gynecologic: Denies any spotting or bleeding in pregnancy. Denies dysmenorrhea, dyspareunia, post-coital bleeding. Denies vaginal discharge, odor. Reports vaginal dryness.

1. Musculoskeletal: Denies fatigue or muscle weakness.

Integumentary (Skin/Breast): Denies new or changing moles, lesions, rashes, erythema. Denies breast sensitivity.
Hematologic/Lymphatic: Denies bruising or bleeding increases. Denies lymphadenopathy
Neurological: Denies numbness in extremities and face. Denies tingling or tremors in extremities.
Psychiatric: Denies anxiety, depression, increased stress, or suicidal ideation

Objective

Vital Signs:

Temp: 98.6 F, HR: 65, BP: 114/77, RR: 16, SpO2: 100%
Ht: 66 in, Wt: 135 lbs, BMI: 21.8
Physical Exam:
General: No acute distress
HEENT: No tenderness upon palpation. No mass/lumps palpated on head/neck. PERRLA. No discharge or edema on eyes. No discharge, edema, or erythema on TMs. Mucous membranes moist. No uvula deviation/tongue swelling. No goiter palpated.
Cardiovascular: Regular rate and rhythm. No gallops or murmurs auscultated. No swelling in the lower extremities noted. Radial and pedal pulses strong and equal +2 bilaterally. Capillary refill < 3 seconds.
Respiratory: Anterior lung fields and posterior lung fields clear to auscultation. No accessory muscle use noted.
Gastrointestinal: Bowel sounds normoactive in all 4 quadrants. No tenderness to palpation. No masses, hernias, bruits palpated. No hepatomegaly/splenomegaly palpated.
Musculoskeletal: Gait WNL. Muscle strength 5/5 in all extremities bilaterally
Integumentary: Skin is warm, dry. No diaphoresis noted. No rashes, lesions, irregular moles, erythema noted.
Lymphatic: No lymphadenopathy noted
Gyn:
Pelvic exam: External genitalia WNL. Vaginal mucosa dry, pale. No discharge, erythema, masses or lumps noted.
Breast: Breasts nontender. No dimpling, discharge, retraction, or erythema noted on bilateral breasts.
Neurological: A/Ox4. No numbness, tingling, tremors on face or extremities noted. Cranial nerves intact
Psychiatric: Mood and affect appropriate for age, situation. No auditory, visual disturbances
POCT:(Alexander et al., 2023)

Pregnancy test: Negative

Pregnancy test ordered as patient is still of reproductive age and is complaining of irregular menses. Any female of reproductive age with a menses within the past 12 months should be tested to rule out pregnancy. Additionally, any further testing ordered may require a rule out of pregnancy as well.
TVUS: No cysts on ovaries, Uterus length WNL, no adnexal mass noted. No free-floating fluid in the cul-de-sac

TVUS ordered to visualize ovaries, uterus, and fallopian tubes to make sure no structural abnormality and no pelvic disease or syndrome is causing menses to be irregular.

Assessment
Working Diagnosis: (Mellor, 2023; Casper, 2023;
Menopausal and perimenopausal disorder, unspecified (ICD-10: N95.9):
Menopause and perimenopause typically occur in women around age 47. Early menopause is used to describe menopause in those younger than age 45. Perimenopause itself is a menstrual cycle change of equal to or more than 7 days in length. It may be accompanied by vasomotor symptoms. These symptoms include hot flashes, night sweats, irregular menses, mood swings, irritability, sleep disturbance, and vaginal dryness. Women may also experience vaginal atrophy, dyspareunia and sexual function, melasma, breast tenderness, alopecia, weight gain, and myalgias. Upon physical examination, the patient may be diaphoretic and the pelvic exam will reveal a pale or dry vagina. Laboratory testing, although unneeded for diagnosis may reveal high FSH and LH, low estradiol, AMH, and inhibin B.
Pertinent +/-: The patient is a 48-year-old female who reports hot flashes, night sweats, vaginal dryness, and change in her menses. Patient reports her menses has become irregular, lasting 7-14 days now instead of her usual 3-5 days. Patient denies mood swings, irritability, dyspareunia.

• Differential 1: (Ross, 2023; Ross, 2024)

Hyperthyroidism, unspecified without thyrotoxicosis or thyroid storm (ICD-10: E05.9):
Hyperthyroidism can occur at any age but typically occurs in adulthood. It is more common in females than males. Symptoms include heat intolerance, diaphoresis, palpitations, tremors, weight loss, hair thinning, amenorrhea or oligomenorrhea, diarrhea, possible goiter, and mood changes. Upon physical examination, the patient may have a possible goiter, have conjunctival edema or eyelid lag. Laboratory testing may reveal a low TSH and high T3 and T4. Other laboratory data will reveal low HLD and LDL, and high SHBG, estradiol, and LH.
Pertinent +/-: The patient is a 48-year-old female who reports hot flashes, night sweats or diaphoresis, and change in her menses. Patient reports her menses has become irregular, lasting 7-14 days now instead of her usual 3-5 days. She denies palpitations, tremors, weight loss, diarrhea, and mood swings. Upon physical examination she did not have a goiter, any eyelid swelling or lid lag
Differential 2:(Barbieri & Ehrmann, 2022)

Polycystic ovary syndrome (PCOS) (ICD-10: E28.2):

PCOS is typically diagnosed in women of reproductive age. PCOS is a cycle of late menses followed by irregular cycles of menses. Other clinical symptoms include obesity, hirsutism, acne, male pattern hair growth and loss. Patients may also present with other metabolic issues, mood disorders or swings, and deepening of their voice. Upon diagnostic imaging with a TVUS, polycystic ovaries will be seen. Laboratory testing may reveal elevated testosterone, low SHBG, high 17-hydroxyprogesterone, and high AMH.
Pertinent +/-: The patient is a 48-year-old female who reports a change in her menses, now becoming irregular, lasting 7-14 days instead of her usual 3-5 days. Upon physical examination, the patient is not obese, her BMI is 21.8, she does not have acne, male pattern hair growth or loss, and no signs of hirsutism. The patient denies mood swings and denies change in voice. Upon her TVUS, no polycystic ovaries are seen.
Plan
Dx plan: (Ambikairajah et al., 2022; Casper, 2023; Mellor, 2023)
Labs: CBC, CMP, TSH, lipid panel, hormones (FSH, LH, estradiol, progesterone, AMH, Inhibin B)
CBC to look for anemia, CMP to look for electrolyte imbalance, TSH to rule out thyroid etiology for symptoms, lipid panel for baseline if possible hormone replacement is ordered as some hormone replacement therapies are contraindicated or can affect lipid levels. Hormones to determine levels if she is early perimenopausal state or late perimenopausal state. Although hormone levels are not required to diagnose perimenopause in women over the age of 45, I would still test for it.
FSH, LH are expected to be high
Estradiol, progesterone, AMH, inhibin B are expected to be low
Tx plan: (Martin & Barbieri, 2023; Vallerand & Sanoski, 2023)
Treatment for perimenopause and menopause includes hormone replacement therapy, so the patient would require Estradiol. The patient still has an intact uterus so progesterone is added for protection of uterus lining changes and to decrease risk of endometrial, ovarian and breast cancer.
Medications:
Estradiol 0.5 mg PO QD (90 tablets/ 3 refills)
Progesterone 200 mg PO for 12 days every 4 weeks (36 capsules/ 3 refills)
Side effects of Estradiol and Progesterone include hypertension, oily skin, weight change, amenorrhea or dysmenorrhea, breakthrough bleeding, vaginal discharge, mood swings, headache, and breast tenderness. Concurrent use with tobacco can increase risk of MI or venous thromboembolism. This medication, if taken alone can increase risk of endometrial, ovarian, and breast cancer. Continue taking both Estradiol and Progesterone together to decrease this risk. Best to take progesterone at bedtime as it may cause tiredness
Pt education: (Martin & Barbieri, 2023; Alexander et al., 2023, Mellor, 2023)
Every female goes through menopause, with the mean age of menopause being about 51. Many women start the transition to menopause at age 47-51. The reason menopausal symptoms occur is because our estrogen levels fluctuate, causing other processes of our body to fluctuate. The key to this transition period is to control symptoms as they are affecting your daily. Hot flashes, night sweats, vaginal dryness, the libido changes, and the irregular menses can be managed with oral estradiol and progesterone medication. However, you cannot take these medications for more than 5 years as they increase the risk of coronary heart disease, stroke, breast cancer, type II diabetes, and fractures. To continue management of vaginal dryness, water-based lubrication can be used or we can switch the route of estradiol to vaginal rather than oral which may help this symptom. Continue your Mediterranean diet and exercise daily as this positively impacts your overall health. For hot flashes, avoid triggers, wear layered clothing to be easily removed and dawned again. You can still get pregnant during the perimenopausal period. Although your husband had a vasectomy, continue utilizing protection with condoms for each sexual encounter.