Identify data provided in your chosen case and any additional data needed.

Chief Complaint:
Vaginal dryness and dyspareunia.

Menopausal Status:
Postmenopausal

History:
Positive HPV test 2 years ago, negative cytology

Gynecological History:
Hysterectomy (2009), ovaries and cervix retained, no hormone replacement therapy

Medical History:
Osteopenia, hypothyroidism, dyslipidemia, and uterine fibroids

Family History:
Mother passed away from breast cancer, and father died from leukemia and a CVA.

Medications:
Rosuvastatin, levothyroxine, Vitamin D3

Social History:
Lives alone, plays pickleball 3x/week, healthy diet, one glass of wine nightly, no smoking

Objective findings.

Identify findings provided in your chosen case and any additional data needed.

Vital Signs:

–          BP: 130/78

–          Pulse: 78

–          RR: 18

–          Temp: 98.1°F

–          Weight: 152 lbs

–          Height: 67”

–          BMI: 23.8

General Appearance:
Awake, alert, oriented ×3. Well developed, well nourished, and pleasant.

Integumentary:
Warm, dry, and intact. No lesions, rashes, or bruises.

Abdomen:
Soft, non-tender, non-distended (NTND), bowel sounds present in all quadrants. Surgical scar noted

External Genitalia:
Grey, sparse hair distribution. Atrophic changes observed.

Speculum Exam:
No discharge, no lesions, multiparous cervix visible.

Bimanual Exam:
Uterus surgically absent. No adnexal masses palpated bilaterally. Non-tender.

Breast Exam:
Left breast with walnut-sized mass palpated at 9 o’clock position. Non-tender. Right breast normal. No nipple discharge noted.

Additional Objective Data Needed:

–          Diagnostic imaging for the left breast mass (mammogram and breast ultrasound)

–          Pap smear with HPV testing (due to prior HPV-positive result and retained cervix)

–          Wet mount microscopy and vaginal pH testing (to evaluate for atrophic vaginitis)

–          TSH and free T4 levels (to assess thyroid function)

–          Bone mineral density test (to monitor osteopenia)

Describe the rationale for each test or intervention with supporting references.

Mammogram and Breast Ultrasound:
A palpable left breast mass in a woman over age 50 necessitates immediate imaging. Mammography helps detect malignancy, and ultrasound differentiates solid from cystic lesions (Malherbe et al., 2022). Given her family history of breast cancer (mother), early detection is essential.

Pap Smear with HPV Co-Testing: Although Lucy had a hysterectomy, her cervix was retained. Due to her positive HPV result two years ago, current guidelines recommend repeat co-testing every five years for women aged 30-65 if prior cytology was negative (Perkins et al., 2021). Continued surveillance is necessary.

Wet Mount and Vaginal pH Testing: To evaluate for atrophic vaginitis, especially given vaginal dryness and dyspareunia. Postmenopausal atrophic changes typically show elevated vaginal pH (>5) and absence of lactobacilli (UpToDate, 2024).

TSH and Free T4:
To monitor thyroid function and assess the adequacy of levothyroxine dosage. Hypothyroidism may also exacerbate fatigue and genitourinary symptoms (Eghtedari & Correa, 2023).

Bone Mineral Density Test (DEXA Scan):
Necessary to assess the severity of osteopenia and the risk for osteoporosis. Postmenopausal women, especially those with prior diagnosis of osteopenia, should have periodic bone density testing (Varacallo et al., 2023).

Describe the rationales for your choice of each diagnosis with supporting references.

1. Atrophic Vaginitis (N95.2):

Lucy presents with classic symptoms of vaginal dryness and dyspareunia, which are hallmark signs of atrophic vaginitis, also known as GSM. The condition results from estrogen deficiency leading to thinning of vaginal epithelium and reduced lubrication. Physical exam findings of atrophic changes and sparse pubic hair further support this diagnosis (Flores & Hall, 2021).

2. Breast Mass – Rule out Breast Cancer (N63.2):
The presence of a walnut-sized palpable mass in the left breast, coupled with Lucy’s family history of breast cancer (mother at age 62), raises concern for malignancy. Although benign causes are possible, breast cancer must be ruled out in postmenopausal women, especially with risk factors (Daly & Puckett, 2022). Diagnostic imaging and possible biopsy are warranted.

3. Hypothyroidism (E03.9):
Lucy is currently on levothyroxine, but thyroid function should be reassessed periodically, especially in postmenopausal women with symptoms such as fatigue, dry skin, or menstrual irregularities before menopause. Improperly managed hypothyroidism may mimic or exacerbate menopausal symptoms, including vaginal dryness and mood disturbances (Daly & Puckett, 2022).

Describe rationales and supporting references for each.

1. Atrophic Vaginitis (Genitourinary Syndrome of Menopause):

–          Treatment:

Over-the-counter vaginal moisturizers and lubricants (such as Replens) for symptom relief.

Vaginal estrogen therapy (such as estradiol 0.01% cream, 2-4 g intravaginally twice weekly).

–          Rationale:
First-line therapy for moderate symptoms includes non-hormonal lubricants. For persistent symptoms, low-dose vaginal estrogen restores vaginal epithelium and reduces dyspareunia. Local estrogen minimizes systemic absorption, making it safer for postmenopausal women (Bleibel & Nguyen, 2020).

2. Breast Mass (Rule out Breast Cancer):

–          Treatment/Intervention:

Diagnostic bilateral mammogram and targeted breast ultrasound.

Referral to a breast specialist for further evaluation (e.g., biopsy if imaging is suspicious).

–          Rationale:

A new palpable breast mass in a woman over 50 with a family history of breast cancer warrants immediate diagnostic imaging. Early identification of malignancy improves prognosis. On the other hand, referral ensures appropriate oncologic or surgical management if necessary (Daly & Puckett, 2022)

3. Hypothyroidism:

–          Treatment/Intervention:

Continue levothyroxine 75 mcg daily.

Order TSH and free T4 to evaluate current thyroid function and adjust the dose if needed.

–          Rationale:

TSH monitoring is recommended every 6-12 months or sooner if symptoms suggest under- or over-treatment. Maintaining euthyroid state is critical to prevent symptoms like fatigue, cognitive decline, and metabolic disturbance in postmenopausal women (Daly & Puckett, 2022).

Social Determinants of Heath (SDoH) for your chosen case.

Several social determinants of health may influence Lucy’s care outcomes.

First, social isolation is a notable concern—she recently relocated after the death of her husband and now lives alone. This transition may affect her mental health, adherence to follow-up care, and her ability to recognize or act upon new symptoms.

Second, although Lucy maintains a healthy lifestyle and engages in regular physical activity (pickleball 3x/week), her emotional support network may be limited, which is particularly important as she manages postmenopausal symptoms and a new breast mass finding.

In addition, access to healthcare could pose a challenge in a new geographic location, especially if she has not yet established care with specialists such as an endocrinologist or gynecologist.

Her economic status is not disclosed, but financial limitations could impact her ability to afford prescription treatments, specialist referrals, or hormone therapy.

Lastly, her health literacy may influence her understanding of HPV surveillance, breast cancer screening, and menopause management, which emphasizes the need for clear, supportive patient education.

Describe rationales and supporting references for each.

1. Referral to Breast Specialist (Surgical Oncology):
Lucy should be referred to a breast specialist or surgical oncologist for further evaluation of the palpable left breast mass. This referral is necessary for diagnostic confirmation (e.g., biopsy) and timely intervention if malignancy is confirmed. Given her family history of breast cancer, expedited evaluation is essential for prognosis and care planning (Daly & Puckett, 2022).

2. Referral to Gynecologist or Women’s Health NP:
Given her positive HPV history, retained cervix, and current menopausal symptoms, a gynecologic provider can manage continued cervical surveillance and address treatment options for the genitourinary syndrome of menopause. Vaginal estrogen therapy requires ongoing monitoring, and a specialist can tailor care based on risk factors and preferences (Bleibel & Nguyen, 2020).

3. Referral to Endocrinologist:
An endocrinologist can co-manage Lucy’s hypothyroidism and osteopenia. Adjusting levothyroxine dosing based on current labs and implementing bone health strategies (e.g., calcium, vitamin D, and bisphosphonates if needed) will help prevent progression to osteoporosis (Hong & Kang, 2023).

Patient Education Needs

HPV Surveillance: Lucy needs education on the importance of regular cervical screening due to her HPV-positive status and retained cervix. Clarify that even after a hysterectomy, screening is still needed when the cervix is present (Eun & Perkins, 2020).

Genitourinary Syndrome of Menopause: Provide education on lifestyle modifications, including the use of vaginal lubricants and moisturizers. Discuss the safety and benefits of localized estrogen therapy, particularly in symptom relief and quality of life (Eun & Perkins, 2020).

Breast Health: Reinforce the importance of follow-up imaging and the potential need for biopsy. Provide support for decision-making and address emotional concerns related to family cancer history.

Medication Adherence and Follow-Up: Emphasize the need for consistent use of thyroid medication and routine monitoring. Ensure the patient understands dosage timing, dietary interactions (e.g., calcium), and when to seek reevaluation.

Emotional and Grief Support: Encourage Lucy to consider grief counseling or support groups to address the emotional toll of her recent loss. Emotional wellness is closely linked to physical health and treatment adherence (Cacciatore et al., 2021).