OB-GYN-L Messages for December, 1997: Re: GYN: HRT for this patient?

Re: GYN: HRT for this patient?

From: anil

anil@versaform.com

Thu Dec 4 16:08:21 1997

Date: Thu, 4 Dec 1997 15:18:49 -0600 Reply-to: ob-gyn-l@obgyn.net From: "Bryan S. Jick, M.D., F.A.C.O.G." <drbryan@earthlink.net> To: Multiple recipients of list <ob-gyn-l@talk.obgyn.net> Subject: Re: GYN: HRT for this patient?

Hi Yvonne:

My 2c worth: I wouldn't put this lady on HRT. She's bound to end up with progression/recurrence in her rt. arm, and you of course will be involved in the subsequent malpractice suit. What if she falls off her bike and the rt. arm suddenly exacerbates?

I would go with Fosamax, and progestins to minimize hot flushes. Perhaps reloxifene when available might be useful. Also, isn't there some rib surgery done occasionally for true thoracic outlet syndrome? Should she have a contrast CT?

Interesteing case

At 01:31 PM 12/4/97 -0600, you wrote: > 54 yo G0 P0 W female with 1 year hx of menopausal symptoms
>of hot flushes. Pt. is referred by her family nurse practitioner
>for consideration of hormone replacement therapy. Hx is significant
>for possible subclavian vein occlusion. Pt. would like to take
>HRT. Story is as follows:
> In January, 1995, patient woke up in the morning with her
>right whole arm swollen; including some thickness in the
>clavi-pectoral region. Thinking it would resolve on its own, she
>did not seek care until one week later. She tried diuretics and
>elevation with some relief. A surgeon was consulted and his note is
>as follows:
> "The pertinent physical findings demonstrated a right arm
>2-3 cm larger than the left. The right wrist is 1 cm larger. The
>venous pattern of increased spiders and some purple blotches are
>noted only on the right upper arm.
> I believe this is most consistent with the diagnosis of
>right thoracic outlet or subclavian vein occlusion. The exact
>etiolgoy is unclear. It could be that lymphatic occlusion is
>causative, but the quick onset sounds venous to me.
> The thoracic outflow tests for extinction of arterial flow
>are normal."
>
>According to the nurse practitoner, because of her dalay in seeking
>care, she was not treated with anticoagulants. Since then, she has
>become symptomatically menopausal with hot flushes. She is a
>physically very active woman who desires to "continue hiking and
>bicycling into her 80's." She has no family history of heart
>disease. She gets calcium from dairy products and supplements with
>1500 mg calcium daily.
>
>She is 5'9 1/4" tall, weighs 157 pounds and is normotensive. Upper
>extremities are without any asymmetry or evidence of edema at this
>time. Uterus is intact. A bone density scan one year ago showed
>mild osteopenia of the femoral neck and a normal lumbar spine. Her
>lipid panel, mammogram and Pap smear are normal.
>
>Patient is well read and has heard that a previous blood clot may
>not necessarily be a contraindication to HRT. She would like to
>take HRT for all of its benefits.
>
>I would appreciate any help in how to approach the question of
>appropriateness of HRT for this patient in light of her history of
>possible subclavian vein thrombosis. Are there any tests I should
>do now?
>
>Thanking you all in advance,
>
>Yvonne Fried, M.D.
>FACOG
>Ashland, Oregon USA
>

Sincerely,

-- Bryan S. Jick, M.D., F.A.C.O.G. Board-Certified Ob/Gyn drbryan@earthlink.net

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