Transcript Journal Club

NYU Medicine Grand Rounds
Clinical Vignette
Gregory Katz
PGY-2, Internal Medicine
February 19, 2014
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 50 year old woman presenting with hot
flashes, sleep disturbances, and vaginal
dryness for 8 months
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient’s menarche was at age 15 and she
experienced irregular cycles of 5-6 weeks until several
months prior to presentation
•She has one daughter conceived via in vitro fertilization
•8 months prior to presentation, she began to experience
occasional hot flashes, sleep disturbances, and vaginal
dryness.
•At that time, she was prescribed estradiol vaginal tablets
without effect as well as an antidepressant that made her
feel “out of sorts”
•Her symptoms have persisted and now she also reports
increased irritability and decreased libido
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•GERD
•HLD
•Hallux abducto valgus deformity
•Past Surgical History:
•None
•Social History:
•Occassional alcohol, about once per week, no history of tobacco or illicit
drugs
•Works as a marketing consultant, married with one child
•Family History:
•Noncontributory
•Allergies:
•Allergic to penicillin, unknown reaction
•Medications:
•Lorazepam 1mg at night as needed for sleep
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: well appearing, in no acute
distress
•Vital Signs: T: afebrile BP: 118/68 HR: 78
RR: 12 and O2 sat: 99% on room air
•The remainder of the physical examination
was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: within normal limits
•Basic Metabolic panel: within normal limits
•Hepatic panel: within normal limits
•Estradiol: less than 15 (normal: less than 30 for
menopause, 30-400 for premenopause)
•Follice stimulating hormone: 12.4 (normal: 25.8-134
postmenopause, 5-21 premenopause)
•Lutenizing hormone: 5.4 (normal: 14.2-52.3 post
menopause, 5-25 premenopause
•Prolactin: 6.7 (normal: 2-2)
•Total testosterone 7 (normal: 15-70)
•Free testosterone 0.5 (normal: 0.3-1.9)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•Papanicolaou stain: no evidence of cervical
intraepithelial neoplasia
•Mammogram: within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• The patient was determined to be
undergoing menopausal transition
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Treatment Course
• The patient was started on a trial of continuous cyclic
hormonal therapy with transdermal estrogen twice
weekly and progesterone the first ten days of each
month
• 9 months later, the patient’s hot flashes had improved
but she continued to report vaginal dryness, decreased
libido, and poor sleep
• Topical vaginal estrogen was added to her treatment
regimen, with improvement in her vaginal dryness
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Menopausal transition
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS