What is the best course of treatment for a 44-year-old female taking oral contraceptives (birth control pills) with symptoms of hot flashes and mood disorder, elevated Follicle-Stimulating Hormone (FSH) levels of 7.9 and Luteinizing Hormone (LH) levels of 3.8, and irregular menstrual cycles?

Assessment and Management

This Patient is NOT in Menopause

This 44-year-old woman is experiencing vasomotor symptoms (hot flashes) and mood changes as side effects of her oral contraceptive pills, not menopause. Her FSH of 7.9 and LH of 3.8 are normal premenopausal values—menopause requires FSH >25-30 IU/L with amenorrhea for 12 months 1. The oral contraceptive pills themselves are the likely culprit for both her vasomotor symptoms and mood disorder 2.

Immediate Management Steps

1. Discontinue or Switch Oral Contraceptives

• Stop the current oral contraceptive pill immediately, as hormonal contraception is known to precipitate or perpetuate depression and mood problems, particularly with older pills containing ethinylestradiol 2.
• Switch to non-hormonal contraception (barrier methods such as condoms, cervical diaphragm, or copper IUD) 1.
• If hormonal contraception is strongly preferred, consider newer pills containing physiological forms of estrogen, which may be better tolerated with weaker links to mood problems 2.

2. Treat Vasomotor Symptoms with Nonhormonal Therapy

For her hot flashes, initiate gabapentin 900 mg/day at bedtime as first-line therapy 3, 4, 5. This choice is optimal because:

• Gabapentin reduces hot flash severity by 46% compared to 15% with placebo 3, 5
• It has equivalent efficacy to estrogen 5
• It has no known drug interactions 4, 5
• It can help with sleep disturbance from hot flashes 3
• Side effects (somnolence, dizziness, fatigue) typically improve after the first week and largely resolve by week 4 3

Alternative first-line option: Venlafaxine 37.5 mg daily, increasing to 75 mg after 1 week 3, 4, 5:

• Reduces hot flash scores by 37-61% 3, 4
• Rapid onset within 1 week 5
• Also treats mood symptoms 4
• Preferred by 68% of patients over gabapentin despite similar efficacy 3

3. Address Mood Disorder

Since the mood disorder is likely related to the oral contraceptive 2:

• Reassess mood symptoms 4-6 weeks after discontinuing the pill
• If mood symptoms persist after stopping hormonal contraception, consider that venlafaxine treats both hot flashes and mood symptoms simultaneously 4
• SSRIs/SNRIs require lower doses for hot flash management than for depression treatment 4

Treatment Algorithm

Step 1: Stop oral contraceptive pills immediately and switch to non-hormonal contraception 1, 2

Step 2: Start gabapentin 900 mg at bedtime OR venlafaxine 37.5-75 mg daily 3, 4, 5

Step 3: Review efficacy at 2-4 weeks for venlafaxine or 4-6 weeks for gabapentin 3. If no response by 4 weeks, treatment is unlikely to be effective and switch to alternative 5

Step 4: If first agent is ineffective or not tolerated, switch to the alternative nonhormonal agent 3

Step 5: Reassess mood symptoms 4-6 weeks after stopping oral contraceptives 2

Critical Pitfalls to Avoid

• Do not prescribe hormone replacement therapy—she is not menopausal and already experiencing adverse effects from exogenous hormones 1, 2
• Do not use paroxetine if she later needs tamoxifen for any reason, as it inhibits CYP2D6 3, 4, 5
• Do not assume menopause based on symptoms alone in a woman on oral contraceptives—the pills suppress FSH/LH and cause amenorrhea 1
• Do not continue oral contraceptives while treating symptoms—this addresses the effect rather than the cause 2

Adjunctive Nonpharmacologic Measures

• Environmental adjustments: dress in layers, maintain cool room temperatures, wear natural fibers, use cold packs intermittently 3
• Weight loss ≥10% of body weight may eliminate hot flash symptoms 3
• Smoking cessation improves frequency and severity of hot flashes 3
• Cognitive behavioral therapy may reduce perceived burden of hot flashes 3
• Acupuncture is safe and effective, with some studies showing equivalence or superiority to venlafaxine or gabapentin 3, 4