HRT in a 51-Year Old Woman

A 51 year old woman who works as a real estate agent presents for an office visit with a chief complaint of severe vasomotor symptoms reporting, "I can't sleep through the night without being drenched in sweat. I have at least four hot flashes a day. Sometimes while I'm working with clients. I need some help. What do you think about hormone therapy? " Her LMP was approximately 13 months ago and she's without chronic health problems. 

When considering postmenopause hormone therapy, which of the following is the most accurate statement?

A. The use of hormone therapy post menopause is associated with a significant increase in cardiovascular and cancer risk.

B. The use of select low dose SSRIs for the management of vasomotor symptoms is as effective as hormone therapy.

C. Short duration lower dose hormone therapy offers an effective form of therapy for menopausal vasomotor symptoms.

D. Hormone therapy postmenopause offers an effective treatment for osteoporosis.

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Expert Fitzgerald faculty clinicians share their knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So if you're ready, let's jump right in.

Margaret Fitzgerald: A 51-year-old woman who works as a real estate agent presents for an office visit with a chief complaint of severe vasomotor symptoms reporting, "I can't sleep through the night without being drenched in sweat. I have at least four hot flashes a day, sometimes while I'm working with clients. I need some help. What do you think about hormone therapy?" Her LMP was approximately 13 months ago and she's without chronic health problems. 

When considering postmenopause hormone therapy, which of the following is the most accurate statement? 

A. The use of hormone therapy post menopause is associated with a significant increase in cardiovascular and cancer risk. 

B. The use of select low dose SSRIs for the management of vasomotor symptoms is as effective as hormone therapy. 

C. Short duration lower dose hormone therapy offers an effective form of therapy for menopausal vasomotor symptoms. 

D. Hormone therapy postmenopause offers an effective treatment for osteoporosis.

The correct answer is C. Short duration lower dose hormone therapy offers an effective form of therapy for post-menopausal vasomotor symptoms.

Where should you start? First determine what kind of a question this is given that we're being asked about a therapy for vasomotor symptoms. This is a plan question. 

A bit of background information. A series of shifts marks the life of a of a person who's been assigned female at birth. First, the person transitions from childhood to the reproductive years, then to the perimenopausal period, then to the menopausal and post-menopausal years. Each transition is normative, expected, and not a disease state. However, perimenopause and menopause are often symptom-producing conditions. something can produce symptoms without being a disease. 

Perimenopause is the time surrounding menopause. Its onset is marked by the beginning of symptoms of menopause and ends with the cessation of the menses. The average age for onset of perimenopause is about 40 to 45 years and this tends to occur earlier in people who are cigarette smokers. Menopause, when the final menstrual period occurs, marks another transition in reproductive life. By definition, menopause is when there's been no naturally occurring menstrual period for 12 months. In North America, the average age uh at menopause is 51.3 years. And that leaves many people live living for about a third maybe even more of their life in menopause. 

About 60% of all female individuals will consult a health care provider regarding perimenopausal and menopausal symptoms. This question focuses on a woman in me menopause who is having some severe vasomotor symptoms aka hot flashes and vasomotor symptoms will be reported in about 80% of individuals during perimenopause and menopause they can be quite debilitating causing disturbed sleep avoidance of social situations in which maybe a hot flash could occur interference with work just to name a few. 

As I mentioned, individuals will often seek help from a health care provider about minimizing vasomotor symptoms. And whereas um a myriad of different options are available for this, hormone therapy, usually in the form of an estrogen supplement, is likely the most commonly used and interestingly enough also the most effective therapy with an anticipated reduction in hot flashes by 80 to 95%. Of course, just like it is with all medications, HT as it's usually abbreviated for hormone therapy use poses certain risks. And by the way, I just want to remind you HT is the current terminology, not HRT or hormone replacement therapy because what's being prescribed in this situation is not an exact replacement of what has dissipated during menopause. So the correct term is HT not HRT. So, back to the issue at hand. With all medications, HT you use poses certain risks. However, recently the FDA changed the labeling on HT and the long-standing warnings about increased cardiovascular disease risk, dementia risk, and a number of other health problems have been removed particularly when we're talking about shorter term use of lower dose HT primarily for the treatment of vasomotor symptoms. 

Now, so you might be saying, well, well, why were those warnings there? They those former warnings arose from the results of the Women's Health Initiative, a study that was quite longitudinal and quite robust, often just abbreviated WHI. And the data for that study were collected primarily during the 1990s. The patient population and the medication options reflected in WHI generally older women and taking oral only higher doses of estrogen and progestin forms and they're really not representative of the contemporary options we have now like there are pills but there are patches there are aside from synthetic progestins there's micronized progesterone I mean, I could go on for hours about the differences between what was used in the WHI and what is being prescribed now for um females during menopause. 

At the same time, as we said with all meds, there are contraindications to its use. With HT, the more common absolute contraindications include unexplained vaginal bleeding. Many acute or chronic liver diseases in a history of thromboembolic disease including DVTs, ischemic stroke, pulmonary embolism, just to name a few. 

A breast cancer history, interestingly enough, is dependent on the type and the status of the disease. So it's not an absolute contraindication but it is something that before anyone should consider prescribing it, there needs to be a thorough history and likely consult with oncology prior to doing this. In addition, an additional note is in a person assigned female at birth who has a uterus, a progestin or progesterone should be prescribed with the estrogen in order to avoid endometrial hyperplasia and subsequent increased endometrial cancer risk. If a person assigned female at birth no longer has a uterus, then that person for hormone therapy can simply go on an estrogen form. 

With this information in mind, let's take another look at the question. A 51-year-old woman who works as a real estate agent presents for an office visit with a chief complaint of severe vasomotor symptoms, reporting, "I can't sleep through the night without um being drenched in sweat. I have at least four hot flashes a day, sometimes when I'm working with clients. I need some help. What do you think about hormone therapy?” Her LMP was approximately 13 months ago and she is without chronic health problems. 

When considering post-menopause hormone therapy, which of the following is the most accurate statement? 

A. The use of hormone therapy postmenopause is associated with significant increase in cardiovascular and cancer risk. This is incorrect and is reflected by the updating labeling on hormone therapy components. Indeed, the updated labeling reflects an observed reduced risk for cardiovascular disease uh with hormone therapy use. 

By the way, remember the boards are up to date on current therapies and you will sometimes people say, "Oh, no, no, no, no. The boards are like two or three sets of guidelines behind." No, they're not. They're up to date. So, whatever information would be on the boards would be reflected of this updated FDA advisory. 

B. The use of select low dose SSRI for the management of vasomotor symptoms is as effective as hormone therapy. Well, low dose SSRIs offer a degree of vasomotor symptom reduction. The reality is it's about 30 to 50% of HT's degree of relief. So this is incorrect because it's saying that low dose paroxetine which is actually FDA approved for this would be as effective as hormone therapy and that's simply incorrect. However, I will say the low dose SSRIs and select SNRIs do offer a reasonably priced non-hormonal option and that there are some people who would rather go a non hormonal option. That is something to um keep in mind. 

C. Short duration lower dose hormone therapy offers an effective form of an effective treatment for a menopausal vasomotor symptoms. This is of course the best answer. But you might be saying, well, where the heck did the breast cancer risk go that we've heard about with hormone therapy after menopause?  The North American Menopause Society emphasizes that care needs to be individualized like it is in any other condition, but they also state that in most the five-year breast cancer risk with hormone therapy is actually not significantly increased. And truthfully, whereas there is no set age where a woman should stop taking post-menopausal hormone therapy, the reality is most stay on it for maybe about 5 years. And so that is why menopause therapy guidelines usually will say quote short term but not say a time frame. That's what the correct answer here said. Um and one important part is with continue use of hormone therapy, the person taking this medication should be in ongoing care to make sure that there are not evolving contraindications to the use of the medication. 

D. Hormone therapy postmenopause offers an effective treatment for osteoporosis. This is incorrect and this might be almost what you would call a trap answer. And the reason is hormone therapy offers a degree of bone protection. What it best does is prevent rather than treat osteoporosis. The other part that I would look at this from a viewpoint of an exam question, the story of the question is about hot flash management. All of a sudden, option D introduces osteoporosis. Um, a woman sitting in your exam room drenched in sweat with hot flashes today is not worrying about osteoporosis. Trust me on that one. And so if you encounter an answer on the boards that's not clearly related to the purpose of the question, steer clear of choosing this. 

Key takeaway: practice evolves as evidence does. These changes will be reflected on the NP boards.

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