A 51-year-old woman presents to your office with questions about whether postmenopausal hormone therapy (HT) is “dangerous.” She heard this on the news and read about it in a women’s magazine. She denies hot flushes, irregular menses, emotional lability, or vaginal dryness. She has hypertension, but is otherwise healthy. Her family history is negative for breast cancer and cardiovascular disease.
According to data from the Women’s Health Initiative study, what advice should you give her?
Data from the Women’s Health Initiative randomized trial of estrogen and progesterone in healthy postmenopausal women found a 26% increase in the risk of breast cancer over a mean follow-up of 5.2 years. This trial confirmed the benefit of HT in prevention of osteoporotic fractures, but did not show a benefit in prevention of coronary heart disease. Routine use of postmenopausal HT for prevention of coronary heart disease is no longer recommended. Vaginal estrogen cream is safe and effective treatment for postmenopausal vaginal atrophy. Short-term use of HT (< 5 years) for relief of menopausal symptoms in a healthy perimenopausal woman remains a reasonable and highly effective option. In this woman without perimenopausal symptoms, however, treatment would be premature.
A 25-year-old white woman presents to your office for an annual examination. She is a G2P2 and had a bilateral tubal ligation after her last child was born (3 years ago). Her menstrual periods are regular; her LMP was 2 weeks before her visit. On review of systems she describes two to three headaches per month for the past year, usually unilateral and occasionally associated with nausea. The headaches last for several hours. She denies visual changes or other neurological changes when the headaches occur. She had migraine headaches in high school, but they stopped when she was about 20. She has not noted that foods, alcohol, stress, or fatigue trigger the headaches. Her headaches usually happen within the same several-day period and are not spread out over the month. Her last bout with the headaches occurred about 2 1 /2 weeks ago.
What is the most likely diagnosis?
This patient’s headache pattern is typical of menstrual migraines, occurring within several days of menses. She denies that fatigue or stress contributes to the headache; therefore, tension headache is not likely. She has no aura associated with the headache; therefore, classic migraine (migraine with aura) is not correct. Sinus headaches would not occur cyclically. Cluster headaches tend to occur in brief, sharp bursts and are more common in men than women. Migraine is precipitated by menstruation in 24% to 68% of women. Although this patient’s history points to menstrual migraine, before initiating treatment a headache diary should be recorded for 2 to 3 months to ensure that the migraines occur exclusively or primarily within 3 days of the onset of menses.
A 21-year-old woman complains of fatigue and difficulty swallowing. She describes the difficulty swallowing as a choking sensation that occurs randomly and not with eating. She denies fever, chills, nausea, or vomiting. She notes some difficulty sleeping at night. She is 28 weeks pregnant with her first child. You note that she is wearing long sleeves in warm weather to cover up bruising on her forearms; she also has a bruise on her left lateral thoracic area. How would you most appropriately introduce your concern about domestic violence?
Since a woman rarely spontaneously reports domestic abuse to her doctor, recognizing signs and symptoms of domestic abuse may be the only opportunity the physician has to intervene. It is also important to recognize the increased risk of domestic abuse during pregnancy. An abused woman can have vague physical symptoms, including headache, fatigue, insomnia, choking sensations, gastrointestinal complaints, and pelvic pain. Inviting the patient to discuss the situation in a caring and sensitive fashion will create a trusting environment and may encourage the patient to accept help. However, opening the conversation with a joke, or jumping to the conclusion that the patient’s spouse caused her apparent injuries, is not appropriate or effective. A compassionate and yet professional approach may open the door to help, even if the abused patient is unwilling to accept intervention at her first visit.
A 28-year-old nonsmoking woman presents to discuss birth control methods. She requests a contraceptive option that is not associated with weight gain. She and her husband agree that they desire no children for the next few years. Her periods are regular, but heavy and painful. She frequently stays home from work on the first day due to severe lower abdominal cramping and back pain. She changes her pad every 4 hours. This pattern of bleeding has been present since she was 15 years old. For a week before her period begins, she is uncharacteristically tearful, irritable, and depressed. These behavioral changes are beginning to affect her work relationships. Her physical examination reveals blood pressure 110/75, BMI 22, and moderate acne on her face and neck.
What recommendation will best address her mood, skin, and contraceptive needs?
While each of the options will provide contraception, only the combination pill fulfills all of her requests. Tubal ligation represents permanent sterilization and will not help her mood swings or dysmenorrhea. Progesterone-infused IUDs provide convenient and effective reversible contraception; they usually decrease menstrual flow and do not cause significant weight gain. IUDs, however, are not effective in treating acne or premenstrual dysphoric disorder (PMDD). Progesterone intramuscular injections are associated with weight gain. Condoms do not provide benefits beyond contraception and protection against sexually transmitted infections. The only FDA-approved contraceptive pill for PMDD is a drospirenone/ethinyl estradiol combination.
Four months after an unremarkable vaginal delivery, a previously healthy 34-year-old G1P1 develops fatigue, dyspnea on minimal exertion, and paroxysmal nocturnal dyspnea. She is no longer breastfeeding. Physical examination reveals a fatigued appearing woman, with normal heart sounds and bibasilar crackles in her lungs. She has no evidence of lower extremity edema, calf tenderness, or ascites. Echocardiogram shows global systolic dysfunction without hypertrophy; her ejection fraction is 40%.
Which of the following statements regarding her condition is correct?
By definition, peripartum cardiomyopathy is cardiac dilatation and dysfunction of unexplained cause occurring during the last trimester of pregnancy or within 6 months of delivery. Half of patients will completely recover normal cardiac size and function. However, further pregnancies in women with persistent left ventricular dysfunction frequently produce increasing myocardial damage and increased mortality, and patients should be counseled to avoid future pregnancies. Treatment is the same as for other types of dilated cardiomyopathy and includes salt restriction, angiotensin-converting enzyme inhibitors, beta-blockers, diuretics, and/or digitalis for symptomatic treatment. Intravenous immunoglobulin therapy has shown some benefit in small studies, but has not been established as first-line therapy.
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