A 46-year-old woman presents for her annual examination. Her main complaint is frequent sweating episodes with a sensation of intense heat starting at her upper chest and spreading up to her head. These have been intermittent for the past 6 to 9 months but are gradually worsening. She has three to four flushing/sweating episodes during the day and two to three at night. She occasionally feels her heart race for about a second, but when she checks her pulse it is normal. She reports feeling more tired and has difficulty with sleep due to sweating. She denies major life stressors. She also denies weight loss, weight gain, or change in bowel habit. Her last menstrual cycle was 3 months ago. Physical examination is normal. Which treatment is most appropriate in alleviating this woman's symptoms?

The differential diagnosis for palpitations and sweating is broad, but major consideration should be given to hyperthyroidism, panic attacks, cardiac arrhythmias, malignancy, and vasomotor instability. This patient denies symptoms of malignancy such as weight loss. She does not have symptoms of clinical depression such as decreased concentration, apathy, weight changes, sleep changes, sadness, irritability, or suicidal thoughts. She reports no change in bowel habits or weight, which would indicate a thyroid disorder. The most likely diagnosis for this patient is vasomotor symptoms associated with the menopause transition. The best treatment option would be a combination estrogen and progesterone low-dose oral contraceptive. Her symptoms are more suggestive of hyperthyroidism than hypothyroidism; so levothyroxine would be of no benefit. Estrogen alone would increase the risk of endometrial hyperplasia and cancer. Fluoxetine and gabapentin have been used to treat hot flushes but are much less effective than hormone replacement.