WBR0199

Author	PageAuthor::Vendhan Ramanujam
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Community Medical Health Center, MainCategory::Primary Care Office
Sub Category	SubCategory::Endocrine, SubCategory::Obstetrics & Gynecology
Prompt	[[Prompt::A 52 year old female is complaining of headache, hot flashes, vaginal dryness and irritability. Her symptoms started about a year ago and have been gradually worsening. Her last menstrual period was before 12 months. She currently smokes two packs of cigarettes daily and drinks a glass of wine occasionally. She takes hydrochlorothiazide for her hypertension. Her cardiorespiratory examination is unremarkable. Her physical examination reveals scares pubic hairs with a vaginal dryness and atrophy. She is advised vaginal estrogen replacement and short term combined hormonal replacement therapy for her menopausal symptoms and to prevent osteoporosis. She asks about receiving a transdermal estrogen therapy rather than the oral estrogen therapy. By not using oral estrogen, which of the following complications may be avoided?]]
Answer A	AnswerA::Endometrial cancer
Answer A Explanation	[[AnswerAExp::Incorrect-The most common and serious complication of estrogen replacement is endometrial cancer associated with endometrial hyperplasia and the risk is not affected by the change in the route of estrogen administration.]]
Answer B	AnswerB::Hypertension
Answer B Explanation	[[AnswerBExp::Incorrect-Estrogen through any route stimulates hepatic synthesis of renin substrate, resulting in elevated levels of angiotensin I and aldosterone. The hypertension that results is usually reversible if the drug is discontinued.]]
Answer C	AnswerC::Hypertriglyceridemia
Answer C Explanation	AnswerCExp::'''Correct'''-Transdermal estrogen avoids the first pass hepatic metabolism and thus attenuating the increase in triglycerides.
Answer D	AnswerD::Stroke
Answer D Explanation	AnswerDExp::'''Incorrect'''-Estrogen use through any route increases the risk of thromboembolitic events like deep vein thrombosis and stroke.
Answer E	AnswerE::Breast cancer
Answer E Explanation	AnswerEExp::'''Incorrect'''-Estrogen also increases the risk of developing breast cancer.
Right Answer	RightAnswer::C
Explanation	[[Explanation::Transdermal estrogen avoids the first pass hepatic metabolism and thus attenuating the increase in triglycerides. But this route of administration does not affect the risk of other complications. Educational objective: Estrogen replacement therapy is advised for a short term period in post menopausal women, to treat the symptoms of menopause and to prevent osteoporosis. A transdermal patch will avoid hypertriglyceridemia by bypassing the liver, where estrogen will usually promote the increased synthesis and hyper secretion of triglycerides into the circulation. Otherwise, estrogen through both the transdermal and oral routes will carry equal risks of developing endometrial cancer, breast cancer, hypertension and thromboembolic events. Educational Objective: References: ]]
Approved	Approved::Yes
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