Diary/2021년 2021. 8. 23. 15:54



Hormone Therapy and Other Treatments for Symptoms of Menopause

The results of large clinical trials have led physicians and patients to question the safety of hormone therapy for menopause. In the past, physicians prescribed hormone therapy to improve overall health and prevent cardiac disease, as well as for symptoms



Combined estrogen/progestogen therapy, but not estrogen alone, increases the risk of breast cancer when used for more than three to five years.


Therefore, in women with a uterus, it is recommended that physicians prescribe combination therapy only to treat menopausal symptoms such as vasomotor symptoms (hot flashes) and vaginal atrophy, using the smallest effective dosage for the shortest possible duration.


Although estrogen is the most effective treatment for hot flashes, nonhormonal alternatives such as low-dose paroxetine, venlafaxine, and gabapentin are effective alternatives. 


Women with a uterus who are using estrogen should also take a progestogen to reduce the risk of endometrial cancer. 


Women who cannot tolerate adverse effects of progestogens may benefit from a combined formulation of estrogen and the selective estrogen receptor modulator bazedoxifene.


black cohosh, botanical products, omega-3 fatty acid supplements - not helping


One systematic review suggests modest improvement in hot flashes and vaginal dryness with soy products, and small studies suggest that clinical hypnosis significantly reduces hot flashes.


Patients with genitourinary syndrome of menopause may benefit from vaginal estrogen, nonhormonal vaginal moisturizers, or ospemifene (the only nonhormonal treatment approved by the U.S. Food and Drug Administration for dyspareunia due to menopausal atrophy). 


There is no evidence that using low-dose vaginal estrogen increases the risk of breast cancer recurrence.


Risks and Benefits of Hormone Therapy

combined oral regimen consisting of conjugated equine estrogen and medroxyprogesterone with placebo, and found that the combined regimen increased the risk of coronary artery disease, breast cancer, stroke, and venous thromboembolism (VTE). The study also found a decreased risk of colorectal cancer, hip fractures, and total fractures with combined hormone therapy.


women without a uterus  = those taking estrogen alone -> had no significant change in risk of coronary heart disease or breast cancer.

but increase in strokes and VTE (similar to the trial of combined estrogen and progestogen)


Estrogen - Stroke, VTE


combined hormone therapy had a significantly increased risk of breast cancer and VTE, and a reduction in hip fractures. In contrast, women taking estrogen alone had a significantly reduced risk of breast cancer.


timing hypothesis : starting hormone therapy early in menopause (compared with starting it 10 years or more after the onset of menopause) may be cardioprotective because of estrogen's apparent ability to slow the progression of atherosclerosis in younger women.


Vasomotor Symptoms : common in women with a higher body mass index, with lower income and education, who smoke cigarettes, or who are black


Estrogen is the most effective therapy for hot flashes

there is no evidence that lowering the ambient temperature; using fans; exercising; or avoiding triggers, such as alcohol and spicy foods, improves hot flashes

 transdermal estrogen, which avoids the first-pass liver effect, may have a lower risk of VTE compared with oral estrogen


 the dosage may be increased after evaluating for effectiveness during the first eight weeks of therapy, with reassessment annually or as needed.


Progestogens can cause fatigue, dysphoria, and fluid retention. 


Patients with a uterus who cannot tolerate these adverse effects may benefit from Duavee, a combination of 0.45-mg conjugated equine estrogen and the selective estrogen receptor modulator bazedoxifene, which is approved by the FDA for treating hot flashes and preventing osteoporosis. Bazedoxifene does not stimulate the endometrium.  Duavee is contraindicated in women who have a history of breast cancer or VTE. 


The levonorgestrel-releasing intrauterine system (Mirena) is an off-label option for providing local progestogen to the endometrium for patients who cannot tolerate systemic therapy.


Low-dose paroxetine (Brisdelle) is the only nonhormonal medication approved by the FDA to treat hot flashes,  Patients taking tamoxifen should not use paroxetine because of inhibition of the hepatic enzyme cytochrome P450 2D6, which decreases the effectiveness of tamoxifen.  Desvenlafaxine (Khedezla) and venlafaxine do not inhibit CYP2D6 and are appropriate alternatives.


Other nonhormonal options include gabapentin (Neurontin) and pregabalin (Lyrica). These medications can cause dizziness and other adverse effects, and should be titrated from a lower dosage.



Deciding When to Discontinue Hormone Therapy

after three to five years. Clinicians should inform patients that some women will have a difficult time stopping hormone therapy. 


Transitioning from Contraception to Hormone Therapy


Genitourinary Syndrome of Menopause


This condition affects up to one-half of women during menopause. In 2014, a consensus conference endorsed the new term genitourinary syndrome of menopause to replace the terms vulvovaginal atrophy and atrophic vaginitis, partly because the older terminology does not encompass the extent of genital tract symptoms many women experience.


Thinning of the vulvar mucosa may cause vulvar burning, irritation, or constriction of the introitus, resulting in entry dyspareunia.


vaginal estrogen, nonhormonal vaginal moisturizers, and the newer oral systemic estrogen agonist-antagonist ospemifene (Osphena). It is reasonable to try nonhormonal therapy as a first-line option to alleviate vulvovaginal symptoms caused by genitourinary syndrome of menopause.

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Learning/Medicine 2021. 8. 20. 15:36



Nongenital Herpes Simplex Virus

Nongenital herpes simplex virus type 1 is a common infection usually transmitted during childhood via nonsexual contact. Most of these infections involve the oral mucosa or lips (herpes labialis). The diagnosis of an infection with herpes simplex virus typ




Nongenital herpes simplex virus type 1 is a common infection usually transmitted during childhood via nonsexual contact. 


 Most of these infections involve the oral mucosa or lips (herpes labialis). The diagnosis of an infection with herpes simplex virus type 1 is usually made by the appearance of the lesions (grouped vesicles or ulcers on an erythematous base) and patient history. However, if uncertain, the diagnosis of herpes labialis can be made by viral culture, polymerase chain reaction, serology, direct fluorescent antibody testing, or Tzanck test. The differential diagnosis of nongenital herpes simplex virus infection includes aphthous ulcers, acute paronychia, varicellazoster virus infection, herpangina, herpes gestationis (pemphigoid gestationis), pemphigus vulgaris, and Behçet syndrome. Oral acyclovir suspension is an effective treatment for children with primary herpetic gingivostomatitis. Oral acyclovir, valacyclovir, and famciclovir are effective in treating acute recurrence of herpes labialis (cold sores). Recurrences of herpes labialis may be diminished with daily oral acyclovir or valacyclovir. Topical acyclovir, penciclovir, and docosanol are optional treatments for recurrent herpes labialis, but they are less effective than oral treatment.



HSV invades and replicates in neurons, as well as in epidermal and dermal cells. The virus travels from the skin during contact to the sensory dorsal root ganglion, where latency is established. Oral HSV-1 infections reactivate from the trigeminal sensory ganglia, affecting the facial, oral, labial, oropharyngeal, and ocular mucosa.


Recurrent infections may be precipitated by various stimuli, such as stress, fever, sun exposure, extremes in temperature, ultraviolet radiation, immunosuppression, or trauma. The virus remains dormant for a variable amount of time.


Oral HSV-1 usually recurs one to six times per year. The duration of symptoms is shorter and the symptoms are less severe during a recurrence.


Clinical Presentation
In primary oral HSV1, symptoms may include a prodrome of fever, followed by mouth lesions with submandibular and cervical lymphadenopathy. The lesions usually heal within 10 to 14 days. 


In recurrent herpes labialis, symptoms of tingling, pain, paresthesias, itching, and burning precede the lesions in 60 percent of persons. The lesions then appear as clusters of vesicles on the lip or vermilion border. The vesicles may have an erythematous base. The lesions subsequently ulcerate and form a crust. Healing begins within three to four days, and reepithelization may take seven to eight days.


Herpetic keratitis is an HSV infection of the eye. Common symptoms are eye pain, light sensitivity, and discharge with gritty sensation in the eye. Slit lamp need. 


Herpetic whitlow is a vesicular lesion found on the hands or digits.  It occurs in children who suck their thumbs or medical and dental workers exposed to HSV-1 while not wearing gloves. Herpes gladiatorum is often seen in athletes who wrestle. Herpetic sycosis is a follicular infection with HSV that causes vesiculopapular lesions in the beard area. It is often caused by autoinoculation from shaving. 


HSV infection is one of the most common causes of erythema multiforme.




by the appearance of the lesions and the patient's history. if the pattern of the lesions is not specific to HSV, its diagnosis can be made by viral culture, PCR, serology, direct fluorescent antibody testing, or Tzanck test. Viral culture should be obtained from vesicles when possible. The swab should be sent in special viral transport media directly to the laboratory (or placed on ice if transport will be delayed).




Oral acyclovir suspension (Zovirax; 15 mg per kg five times per day for seven days) can be used to treat herpetic gingivostomatitis in young children. Children should be treated symptomatically with oral analgesics and cold, soothing foods such as ice pops and ice cream.




The patients took oral valacyclovir (2 g twice for one day) and applied clobetasol 0.05% gel (twice per day for three days) at onset of symptoms. - good result 



Topical treatment for herpes labialis is less effective than oral treatment. 

Treatment with docosanol cream, when applied five times per day and within 12 hours of episode onset, is safe and somewhat effective. OTC



Oral acyclovir is effective in suppressing herpes labialis in immunocompetent adults with frequent recurrences. 

oral acyclovir (400 mg twice per day)

oral valacyclovir (500 mg per day)

patients receiving treatment for cancer, acyclovir was found to be effective in the prevention of HSV infections.  In another study, daily valacyclovir (500 mg per day) and acyclovir (400 mg twice per day) were equally effective in the prevention of recurrent HSV eye disease.


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Learning/Medicine 2021. 8. 19. 21:57



Adhesive capsulitis is a common cause of shoulder pain and limited movement. The objectives of this review were to assess the efficacy and safety of corticosteroid injections for adhesive capsulitis and to evaluate the optimum dose and anatomical site of injections. PubMed and CENTRAL databases were searched for randomised trials and a total of ten trials were included. Results revealed that corticosteroid injection is superior to placebo and physiotherapy in the short-term (up to 12 weeks). There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. Dosages of intra-articular triamcinolone 20 mg and 40 mg showed identical outcomes, while subacromial and glenohumeral corticosteroid injections had similar efficacy. The use of corticosteroid injections is also generally safe, with infrequent and minor side effects. Physicians may consider corticosteroid injection to treat adhesive capsulitis, especially in the early stages when pain is the predominant presentation.



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