A 46-year-old, 230lb woman with a family history of breast cancer. She is up to date on yearly mammograms. She has a history of HTN. She complains of hot flushing, night sweats, and genitourinary symptoms. She had felt well until 1 month ago and she presented to her gynecologist for her annual gyn examination and to discuss her symptoms. She has a history of ASCUS about 5 years ago on her pap, other than that, Pap smears have been normal. Home medications are Norvasc 10mg qd and HCTZ 25mg qd. Her BP today is 150/90. She has regular monthly menstrual cycles. Her LMP was 1 month ago.
This patient appears to be active in her health maintenance, her blood pressure is elevated during this visit. She does have a History of HTN, and she is currently on Norvasc 10mg every day and HCTZ 25mg QD, Blood pressure elevation may be related to her fear of a cancer diagnosis, stress, but it is not a reason to change her current medication regime immediately. My follow up questions will be
- what does her gynecologist recommend?
- is complaint with her prescribed medication?
- Did she take her medication prior to her visit?
- What are her blood pressure readings at home?
Reviewing this question can give me a better understanding on measures and steps to take in treating this patient. It also appears this patient may be entering the early phases of menopause. Natural menopause typically begins at about age 51 to 52 years, with 95% of women entering menopause between the ages of 45 and 55 years. (Rosenthal & Burchum, 2018) If so, it would be the very early stages of menopause, as she continues to have regular menstrual cycles. At this stage, prescribing of hormone replacement would not be indicated. If her symptoms were more severe, she could be considered for the start of SSRIs or SNRIs. Escitalopram is the recommended SSRI for treating moderate to severe hot flashes. It does have a risk of sexual dysfunction that would need to be monitored. It would not influence her hypertension. The SNRI that is recommended is venlafaxine. I would recommend the escitalopram first because of the risk of dose-dependent diastolic hypertension since she is currently being treated for hypertension. The North American Menopause Society developed a tool that can be used for women with menopausal symptoms who are ages 45 years and older. (Manson et al., 2015) Unfortunately, since she is not having moderate to severe hot flashes, it would be appropriate to monitor the symptoms and prescribe nothing to treat the current state. Her blood pressure is elevated and should be addressed. If she is entering menopause, she will be at a higher risk of developing more cardiovascular disease. Hypertension in older women is not being treated aggressively enough because of a large proportion, especially those most at risk for stroke and heart disease by age does not have enough blood pressure control. (Wassertheil-Smoller et al., 2000)
My initial education would start with her dietary regimen and weight controlled. If she is entering menopause, she will be at a higher risk of developing more cardiovascular disease. Hypertension in older women is not being treated aggressively enough because of a large proportion, especially those most at risk for stroke and heart disease by age does not have enough blood pressure control. (Wassertheil-Smoller et al., 2000) Due to her history of hypertension and currently being on medications, I would continue with her current medication and do a 24-hour ambulatory monitoring to validate her blood pressure reading. If I must change her medication, due to the readings being elevated after 24 hours monitoring, I will change the Norvasc to Metoprolol. Although CCBs are appropriate to treat her hypertension, it is not working as well as would be desired. Metoprolol, a beta-blocker, blocks cardiac beta-1 receptors; it reduces heart rate, the force of contraction, and the conduction velocity through the AV node (Rosenthal & Burchum, 2018) Because of this it is essential to teach the patient to monitor for bradycardia and orthostatic hypotension.
Rosenthal, L., & Burchum, J. (2018). Lehnes Pharmacotherapeutics for Nurse Practitioners and Physicians Assistants. Elsevier Health Sciences.
Manson, J. E., Ames, J. M., Shapiro, M., Gass, M. L., Shifren, J. L., Stuenkel, C. A., & Schnatz, P. F. (2015). Algorithm and mobile app for menopausal symptom management and hormonal/non-hormonal therapy decision making: a clinical decision-support tool from The North American Menopause Society. Menopause, 22(3), 247-253.
Wassertheil-Smoller, S., Anderson, G., Psaty, B. M., Black, H. R., Manson, J., Wong, N., & Lasser, N. (2000). Hypertension and its treatment in postmenopausal women: baseline data from the Womenâ€™s Health Initiative. Hypertension, 36(5), 780-789.