Online Continuing Education Program
Case Study

STTI Online Case Studies



Meet the Author
Title Perimenopausal/Menopausal Woman
Case Study LC0003
Author Karen Moore Schaefer, RN, DNSc
Contact Hours 1.25
Target Audience: Advance practice nurses and nurses working in primary care settings such as women's health centers, clinics and primary care offices.
Purpose/Goal: The goal of this case study is to improve understanding of the management of women moving through perimenopause into menopause.
   
Objectives Physical Exam Findings
Instructions Laboratory/Test Data
Introduction Course of Care
Medical/Nursing History References
Family/Social History TEST QUESTIONS

Sigma  Theta Tau International is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation.

Learner Objectives: Upon completion of this case study, the learner will be able to:
  1. Recommend interventions to reduce the symptoms of menopause.
  2. Explain the hormonal basis of the physical symptoms of menopause.
  3. Evaluate the consequences of estrogen/progesterone replacement therapy during perimenopause.
  4. Integrate the client's unique history into decisions about menopause management.
  5. Offer nonpharmacological approaches to managing menopausal symptoms.

Meet the Author

Karen Moore Schaefer, RN, DNSc
Dr. Schaefer is an assistant professor at Temple University, College of Allied Health Professions, Department of Nursing. She developed courses in Women's Health and Feminist Methods while teaching at Allentown College of St. Francis de Sales. She has continued to conduct research in women with an emphasis on women with chronic illness. Her current research is on women with fibromyalgia (FM) experiencing pregnancy and the experience of FM in African American women. Her interest in menopause comes out of her teaching in women's health and guiding several students conducting research on women experiencing menopause.

Instructions

Introduction to the case:
The client is a Caucasian 42-year-old married woman who presents to the office with a change in the character and frequency of her menstrual periods. She notes that her periods are irregular and occur more often, and bleeding is reduced, making it hard for her to insert tampons. She is concerned that she might be experiencing perimenopause and is somewhat fearful of the expected experience (Quinn, 1988).

Medical/Nursing History:
The client has had regular 28-day-cycle periods since menarche commenced at age 13. She experienced significant discomfort with each period, which was manifested as weight gain, severe abdominal cramps that would last for the entire 5-day cycle, low back pain, moodiness, nausea, and vomiting on the first day of the cycle. Her mother gave her whiskey and tea that put her to sleep, relieving some of the cramping discomforts. She currently takes vitamin E and Motrin for several days before the expected period. Recently, this has become very difficult because of the irregularity of her current cycles. She is gravida (pregnancies) II, para (children born) 0, abortion II.

Her medical history is significant for wisdom tooth extraction and cervical cancer at the age of 32 (not tested for receptor site sensitivity) with conization and final diagnosis of cancer insitu treated by close surveillance, removal of cysts from her breasts, and removal of multiple lypomas.

Family or Social History:
She married at the age of 38 and is the mother of two stepsons and a stepdaughter. The two boys are in college; the daughter is completing her last year of high school. She has enjoyed becoming an instant mother. She works as an administrator in a community-based preventative health care program requiring the writing of grant proposals twice a year to maintain the programs and the staff. She has been physically active for the last 20 years doing low impact aerobics, walking, swimming, and playing tennis.

Her family history is significant for diabetes (mother and father), cancer (aunts and uncles), and hypertension (mother and father). Her mother experienced menopause at age 42 after the birth of her last child. The client remembers her mother having severe hot flashes requiring that she frequently change her clothes, about a 30-pound weight gain, and dramatic mood changes that created problems within the family structure. (Jones, 1994; Kittell, Mansfield, & Voda, 1998; Lock, 1998).

The client's mother has osteoporosis and has recently been diagnosed with early Alzheimer's disease. Her mother has lost about 4 inches of height due to the osteoporosis. She has also experienced fractures of the arm, wrist, ankle, and tibia on separate occasions. The client's older sister is currently caring for her mother.

Physical Examination Findings:
The client is 5' 5 1/2 " tall and weighs 110 pounds. Her body mass index (BMI) is 17.5. She has very little body fat. Her BP is 112/60, P = 62, R = 14, and Temp. = 97.2. Her physical exam was unremarkable for abnormalities except for an ingrown toenail on the left large toe and scars from the removal of the lypomas and the cysts from her breasts. All lab work has been within normal limits, except for total cholesterol. Calculate your BMI.

Laboratory/Test Data:
Her HDL/LDL ratio is high; total cholesterol is 226. She indicates that her mother always had high cholesterol. A pre-visit FSH (follicle stimulating hormone) and LSH (leutinizing stimulating hormone) were performed. The results indicate a slightly elevated FSH at 39 mU/ml. LSH was normal.

Course of Care:
The client was counseled and asked to return in three months after repeat FSH and LSH levels are drawn. Counseling included:

Because of the amount of information that was given to her, she was given several pamphlets and Web sites that would provide her with similar information. She was warned that the sites often do not have all the options available for menopausal women and was encouraged to bring questions to her appointments. Possible client education materials include: Menopause: What to Expect; Your Guide to Menopause

References

Antonijevic, I. A., Stalla, G. K., & Steiger, A. (2000). Modulation of the sleep electroencephalogram by estrogen replacement in postmenopausal women. American Journal of Obstetrics & Gynecology, 182 (2), 277-282.

Arnott, M. S. (winter, 2000). Hormone replacement therapy: Is it an option for breast cancer survivors? Living Beyond Breast Cancer, 7-10.

Body Mass Index Table. National Heart, Lung and Blood Institute [Online]. Available: www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm

Burnette, M. M., Meilahn, E., Wing, R., & Kuller, L. (1998). Smoking cessation, weight gain, and changes in cardiovascular risk factors during menopause: The healthy women study. American Journal of Public Health, 88(1), 93-96.

Calculate Your Body Mass Index. Obesity Education Initiative. National Heart, Lung and Blood Institute [Online]. Available: www.nhlbisupport.com/bmi/bmicalc.htm

Connelly, M. T., Ferrari, N., Hagen, N., & Inui, T. S. (1999). Patient-identified needs for hormone replacement therapy counseling: A qualitative study. Annals of Internal Medicine, 131(4), 265-268.

Crandall, S. G. (1997). Menopause made easier. RN, 60(7), 46-51.

DeMasters, J. (2000). HRT & menopause. AWHONN Lifelines, 4(2), 26-35

Early menopause: When the change of life comes too early: Hormone tests [Online]. Available: www.earlymenopause.com/tests.htm

Fox-Young, S., Sheehan, M., O'Connor, V., Cragg, C., & Del Mar, C. (1999). Women's knowledge about the physical and emotional changes associated with menopause. Women & Health, 29(2), 37-51.

Gaster, B., & Holroyd, J. (2000). St. John's Wort for depression: A systematic review. Archives of Internal Medicine, 160(2), 152-156; 245-246.

Greendale, G., Lee, N. P., & Arriola, E. R. (1999). The menopause. The Lancet, 353(152), 571-580.

Hulley, S., Grady, D., Bush, T., Furberg, C., Herrington, D., Riggs, B., & Vitting, B. (1998). Randomized trial estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women: Heart and estrogen/progestin replacement study (HERS) research group. Journal of the American Medical Association, 19(7), 605-613.

Ingram, D., Sanders, K., Kolybaba, M., & Lopez, D. (1997). Case-control study of phyto-oestrogens and breast cancer. Lancet, 350, 990-994.

Is This Menopause? [On-Line]. Available: www.oxford.net/~tishy/33signs.html.

Izzo, A.A., & Ernst, E. (2001). Interactions between herbal medicines and prescribed drugs: a systematic review. Drugs 61 (15), 2163-2175. Retrieved May 20, 2002 from http://www.ncbi.nlm.nih.gov:80/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11772128&dopt=Abstract.

Jones, J. (1994). Embodied meaning: Menopause and the change of life. Social Work in Health Care, 19(3/4), 43-65.

Kittell, L. A., Mansfield, P. K. , & Voda, A. M. (1998). Keeping up appearances: The basic social process of the menopausal transition. Qualitative Health Research, 8(5), 618-633.

Li, S., Holm, K., Gulnanick, M., Lanuza, D. & Penckofer, S. (1999). The relationship between physical activity and perimenopause. Health Care of Women International, 20 (2), 163-178.

Lindsay, S. H., & Claywell, L. G. (1999). Considering soy: Its estrogenic effects may protect women. Advancing Evidence-Based Practice: Women's Health. Supplement to JOGNN, 28(6), 21-24.

Lock, M. (1998). Menopause: Lessons from anthropology. Psychosomatic Medicine, 60(4), 410-419.

McNagny, S. E. (1999). Prescribing hormone replacement therapy for menopausal symptoms. Annals of Internal Medicine, 131(8), 605-616.

Menopause: What to Expect, National Institutes of Health [On-Line]. Available: www.nih.gov/health/chip/nia/menop/men3.htm.

Moore, A. A., & Noonan, M. D. (1999). A nurse's guide to hormone replacement therapy. Advancing Evidence-Based Practice: Women's Health. Supplement to JOGNN, 28(6), 13-20.

National Cholesterol Education Program, Heart National Institute, Blood Cholesterol Levels--What You Should Do [On-Line]. Available: www.lifeclinic.com/focus/cholesterol/about_it.asp

Quinn, A. A. (1988). Integrating a changing me: A grounded theory of the process of menopause for perimenopausal women. Journal of Nurse-Midwifery, 36(1), 25-29 [On-line]. Available: www.stti.iupui.edu/cgi-bin/websql/rnr/search/hts/fullview.hts?sid=10099.

Recker, R. R., Davies, K. M., Dowd, R. M., & Heaney, R. P. (1999). The effect of low-dose continuous estrogen and progesterone therapy with calcium and vitamin D on bone in elderly women. A randomized controlled trial. Annals of Internal Medicine, 130(11), 897-904.

Scheiber, L. B., & Torregrosa, L. (2000). Postmenopausal osteoporosis: When-and how-to measure. Consultant, 40(4), 781-789.

Staropoli, C. A., Flaws, J. A., Bush, T. L., & Moulton, A. W. (1998). Predictors of menopausal hot flashes. Journal of Women's Health, 7(9), 1149-1155.

The Foundation for Better Health Care: [On-Line]. Available: www.fbhc.org/home.html

Third International Symposium on the Role of Soy in Preventing and Treating Chronic Illness, 1999 [On-line]. Available: www.soyfoods.com/3rdSoySymp/

Your Guide To Menopause. Society of Obstetricians and Gynaecologists of Canada [On-Line]. Available: www.sogc.org.

Test Questions

Please select the correct answer for each of the following questions. If you answer 80% or more correctly, you will be given the opportunity to register for continuing education credit. After receipt of the registration information and fee, a continuing education certificate will be mailed to you.

Question 1

The client indicates that she is afraid she will have the same experience her mother had with menopause. She asks what she can do to avoid excessive weight gain. Which of the following is the best explanation for the nurse to give?

You will need to start watching your fat intake to avoid excessive weight gain and continue your exercise program.
Your lifestyle currently includes many preventive interventions; exercise, in particular, will help to prevent the loss of bone structure.
Weight gain is not an expected outcome of menopause. Continue your current lifestyle and you should be fine.
Eat six small meals a day and increase the foods containing calcium and vitamin D in your diet.

Question 2

The client is concerned about becoming moody/emotional as she moves through perimenopause into menopause and is fearful of putting her relatively new marriage in jeopardy. The nurse suggests the following to provide the client with some options to treat the emotional symptoms associated with menopause.

Estrogen replacement will help improve sleep disturbance, which in turn helps to prevent the emotional upheaval from not getting restful sleep.
You can try taking an antidepressant such as amitriptyline, which will improve the serotonin levels and prevent emotional lability.
St. John's Wort is a natural estrogen replacement that women have reported as being helpful with mood swings.
There is no reason to believe that you will have the same experience of moodiness that your mother had.

Question 3

The client discusses that she has kept up her exercise program because it helps to strengthen the bones. Her bone scan at the age of 40 indicated that she had the bone structure of a 30-year-old. She asks the nurse what else she should do to prevent the early onset of osteoporosis. The best response the nurse can give her is:

Take 1000 - 1500 mg of calcium carbonate and continue your exercises. Have a bone density scan done every five years.
Take 1000 - 1500 mg of calcium carbonate with vitamins D and A. Have a bone density scan done every five years and continue your exercise.
Take 1000 - 1500 mg of calcium citrate on a daily basis. Have a bone density scan done every two years and continue your exercise
Eat foods high in calcium such as yogurt, skim milk, and green leafy vegetables. Have a bone density scan done every five years and continue your exercise.

Question 4

The client's laboratory results do not indicate that she is in menopause, but perhaps the early stage of perimenopause. She has learned from other women that they started taking estrogen/progesterone supplements before entering menopause. She asks if this would be appropriate for her. The nurse's best response is:

Estrogen replacement is not appropriate for you. Your lab results do not indicate that you are in menopause.
You are still having your periods so you are not a candidate for hormone replacement therapy.
Intermittent doses of estrogen and progesterone therapy may help control the effects of hormone fluctuation.
Hormone replacement is used only after your periods have stopped for one year.

Question 5

The client is weighing the odds of estrogen replacement. She asks the nurse what the advantages for her would be if she chose to take estrogen. The nurse explains all of the following except:

Estrogen raises the good cholesterol (HDL cholesterol) and can lower the bad cholesterol (LDL cholesterol).
In women without heart disease, estrogen does not reduce a woman's risk for heart disease.
Estrogen relieves menopausal symptoms such as hot flashes, vaginal dryness, incontinence, and mood disturbances.
Several studies have shown that when estrogen is taken there is a decrease in the risk for Alzheimer's disease.

Question 6

The nurse explains to the client that the irregular periods of menopause are due to the:

Atrophy of the ovaries
Pituitary secretion of hormones
Increased levels of testosterone
An increase in progesterone

Question 7

The client questions the use of soy as a possible substitute for estrogen to treat menopausal symptoms. (See oral presentations and poster presentations from the Third International Symposium on the Role of Soy in Preventing and Treating Chronic Illness, 1999) The nurse explains:

The Isoflavones in plant soy have been found to reduce the symptoms of menopause.
The Isoflavones in plant soy do not give the woman the cardiovascular effects that occur from estrogen.
The Isoflavones in plant soy, like estrogen, may increase the risk for breast cancer.
The Isoflavones in plant soy do not protect the woman from osteoporosis.