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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