NUR 656 Module 6 SOAP Note Example

SOAP Note: Vasomotor Symptoms at 52 and a Shared Decision About Hormone Therapy

[Student Name]

Southern New Hampshire University

NUR 656: Primary Care of Women

Module Six SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: Vasomotor Symptoms at 52 and a Shared Decision About Hormone Therapy

Hot flashes and night sweats affect most women during the menopause transition, and for many they are severe enough to disrupt sleep, work and mood for years. Hormone therapy is the most effective treatment, yet many women and clinicians avoid it because of how the Women's Health Initiative was reported in 2002. Linda is a 52-year-old whose symptoms have worn her down. This SOAP note documents her evaluation and a decision about treatment. It argues that placing the trial's findings in context, assessing individual risk and comparing hormonal and nonhormonal options honestly allows a woman to make a choice she understands.

Subjective

Chief concern: "I haven't slept through the night in a year."

History of present illness: Linda's last menstrual period was fourteen months ago. She has eight to ten hot flashes a day, each lasting a few minutes, and night sweats that wake her about four times a night, sometimes requiring a change of clothes. She is tired and irritable at work and has trouble concentrating. She has tried layered clothing, a bedroom fan and avoiding alcohol, with little effect. She has mild vaginal dryness with intercourse. She has avoided hormone therapy because a friend told her it causes breast cancer and heart attacks.

Past history: no history of breast cancer, endometrial cancer, blood clots, stroke, heart disease or liver disease. No migraine with aura. Uterus intact. Nonsmoker. Family history: mother had a hip fracture at 76; no breast or ovarian cancer in first-degree relatives. Medications: none. Screening mammogram eight months ago was normal. Depression screening negative, although she reports low mood related to sleep loss.

Objective

Blood pressure 122/78, body mass index 26. Examination normal, including breast examination. Pelvic examination shows mild vaginal atrophy. Laboratory results from her annual visit three months ago: total cholesterol 208 mg/dL, HDL 58 mg/dL, LDL 128 mg/dL, fasting glucose 94 mg/dL. Her calculated ten-year atherosclerotic cardiovascular disease risk is 3.1%, which is low. Follicle-stimulating hormone testing is not needed, since fourteen months without periods at her age establishes menopause.

Assessment

1. Bothersome menopausal hot flashes and night sweats, frequent enough to disrupt her sleep and work.

2. Genitourinary syndrome of menopause, mild.

3. Eligibility for hormone therapy. The Women's Health Initiative randomized healthy postmenopausal women aged 50 to 79 to estrogen plus progestin or placebo, and the combined therapy arm was stopped early after an average of 5.2 years because of increased breast cancer risk, along with increases in coronary events, stroke and blood clots, balanced against fewer hip fractures and colorectal cancers (Writing Group for the Women's Health Initiative Investigators, 2002). The average participant, however, was 63 and more than a decade past menopause. The North American Menopause Society (2022) position statement concluded that when a woman is under 60, or fewer than ten years past her final period, and has no contraindication, the benefit-risk ratio is favorable for treatment of bothersome vasomotor symptoms, and that risks differ by age, time since menopause, type and route of hormone and duration. It noted that transdermal estrogen may carry lower risk of blood clots than oral estrogen. Linda is 52, fourteen months past menopause, with low cardiovascular risk and no contraindications, placing her in the group for whom benefits generally outweigh risks.

Options Discussed

Hormone therapy: an estradiol patch paired with nightly micronized progesterone, which protects the uterine lining, since her uterus is intact, is the most effective treatment for vasomotor symptoms and also helps vaginal dryness and bone density. She heard that taking estrogen and progestogen together nudges breast cancer risk upward slightly, more so the longer it is used, that her absolute risk of blood clot or stroke at her age with transdermal estrogen is low and that the decision can be revisited each year.

Nonhormonal options: Lederman et al. (2023) tested fezolinetant, a neurokinin 3 receptor antagonist, in the SKYLIGHT 1 trial and reported fewer and milder hot flashes with the drug than with placebo, with liver enzyme monitoring recommended during use. Certain antidepressants and gabapentin also reduce hot flashes to a lesser degree. Cognitive behavioral therapy can reduce how bothersome symptoms feel. Linda asked for her risk in plain numbers, and these were shown on a simple chart. She chose hormone therapy, saying the chance of sleeping again mattered most to her.

Differential and Other Contributors

Before attributing her symptoms entirely to menopause, other causes of flushing, sweats and fatigue were considered. Hyperthyroidism can cause heat intolerance and poor sleep, but her recent thyroid-stimulating hormone was normal. Medications and alcohol can trigger flushing, and she takes no medications and rarely drinks. Night sweats with weight loss or fever would raise concern for infection or lymphoma, and she has neither. Depression and anxiety can disturb sleep and concentration and can coexist with menopause; her screen was negative, but her low mood from sleep loss will be reassessed at follow-up, since treating the hot flashes may resolve it or reveal an independent mood disorder that needs its own care. Sleep apnea can also cause fragmented sleep and daytime fatigue, and her partner reports no snoring or pauses in breathing, so testing was not pursued now.

Plan

Estradiol 0.05 mg per day transdermal patch, changed twice weekly, with oral micronized progesterone 100 mg nightly. She knows some spotting is expected early on, but any bleeding that continues past the six-month mark, or that is ever heavy, should be checked. Vaginal moisturizers were recommended; low-dose vaginal estrogen can be added if dryness persists. Continue annual mammography. Follow-up in three months to assess symptom response and side effects and to adjust the dose, then yearly to reconsider the need for therapy, the dose and her risk profile. Bone health will be addressed at her next preventive visit, given her mother's hip fracture. She was advised to seek care immediately for leg swelling or pain, chest pain, sudden shortness of breath or new neurologic symptoms.

Conclusion

Linda's fear of hormone therapy came from headlines about a trial of older women. Explaining what the Women's Health Initiative found and whom it studied, applying the position statement's criteria to her own risk and presenting hormonal and nonhormonal options honestly allowed her to make an informed choice that fit her priorities.

References

Lederman, S., Ottery, F. D., Cano, A., Santoro, N., Shapiro, M., Stute, P., Thurston, R. C., English, M., Franklin, C., Lee, M., & Neal-Perry, G. (2023). Fezolinetant for treatment of moderate-to-severe vasomotor symptoms associated with menopause (SKYLIGHT 1): A phase 3 randomised controlled study. The Lancet, 401(10382), 1091-1102. https://doi.org/10.1016/S0140-6736(23)00085-5

North American Menopause Society. (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767-794. https://doi.org/10.1097/GME.0000000000002028

Writing Group for the Women's Health Initiative Investigators. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the Women's Health Initiative randomized controlled trial. JAMA, 288(3), 321-333. https://doi.org/10.1001/jama.288.3.321