A 60-year-old woman trying to discontinue hormone replacement therapy.

DR REYNOLDS: Mrs W is a 60-year-old white woman who is trying to discontinue her estrogen therapy. She lives alone near Boston and teaches middle school. Her 29-year-old son lives in another state. She has managed care insurance. At the age of 40, Mrs W underwent hysterectomy and bilateral salpingo-oophorectomy to treat refractory endometriosis. After several days of severe flushes, sweats, and depression, she began taking conjugated estrogen, 0.625 mg/d. With that therapy she has felt well for the past 2 decades. Over the past few years, she became increasingly concerned about her family history of breast cancer and the health risks of postmenopausal hormone replacement therapy (HRT) after reading about it in the lay press. Mrs W asked her former physician about these risks, and he encouraged her to continue treatment. At times, she discontinued the estrogen on her own, but disabling hot flushes ensued and she restarted treatment each time. Four months ago, Mrs W visited a new primary care physician, Dr K, who encouraged her to taper the HRT. With her dose decreased to 0.3 mg/d, she didn’t feel as well as she did with the higher dose. She then stopped taking the medication according to the planned taper. She has numerous hot flushes daily, sometimes as often as every 30 minutes. The hot flushes wake Mrs W from sleep. She is not depressed, but she has a general sense of not feeling as well as when taking the hormonal therapy. Her past medical history is significant for multiple breast cysts requiring aspiration and an excisional biopsy of a left breast mass many years ago that was benign. She had atrial fibrillation treated with nodal ablation and is now in sinus rhythm. She had superficial phlebitis 1 year ago. She has never had a venous thromboembolic event. Her menarche was at age 10; her only pregnancy was at the age of 32 and was carried to term. Mrs W’s mother had rectal cancer diagnosed at the age of 70. Her maternal grandmother was in her 50s when she died of breast cancer; Mrs W’s younger sister was diagnosed as having breast cancer in her late 30s. Her father died of an abdominal aortic aneurysm. There is no family history of osteoporosis or premature coronary heart disease (CHD). Mrs W does not smoke or drink alcohol. She walks several times a week and has begun strengthening exercises. Her husband died several months ago and she reports “normal grief” and a strong support network. On physical examination, Mrs W looked younger than her age. At 5’3” she weighed 116 lb; her blood pressure was 120/60 mm Hg and her pulse was regular at 60/min. She had a left breast scar at 3-o’clock but otherwise normal breast examination findings. Her pelvic examination showed no cervical cuff and no adnexal masses. The remainder of her physical examination results were normal. Mrs W’s only medication was atenolol, 25 mg/d. Laboratory data showed a total cholesterol level of 179 mg/dL (4.6 mmol/L) and high-density lipoprotein (HDL) level of 91 mg/dL (2.4 mmol/L), measured in August 2000. Bone density testing in June 2001 showed a T score at the femoral neck of −1.68. A mammogram within the last year was unremarkable.