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Topic: In The Middle of A Provider Fight - Tamoxifen & Pristiq/Effexor

Forum: Hormonal Therapy - Before, During, and After —

Risks and benefits, side effects, and costs of anti-estrogen medications. Note: Please remember that there are good experiences and bad with ALL treatments and this is a safe place to share YOUR experience, not to be influenced or influence others.

Posted on: Oct 16, 2018 11:52AM - edited Oct 16, 2018 11:52AM by Spoonie77

Spoonie77 wrote:

Hi all - Hope someone can help me a bit. I'm a "little" desperate....

I was supposed to start my Tamoxifen 2 weeks ago, yet for the past 3 weeks I have been caught between an ongoing war between my MO and my mental health provider. Uggggh.

My MO wants me on Tamoxifen. As I'm on Cymbalta, I need to switch to a different anti-depressant, Effexor. I'm totally fine with this, though a bit apprensive at the switch to a different SSRI med, I want to be sure I'm taking steps to keep the cancer from coming back, that means Tamox for now.

My Mental Health Provider is not on board, she doesn't give me one ounce of explanation for why not.

(Side note - I just moved, have only seen this lady once, did not like her then as she did not care/empathaize at all with my struggles with Breast Cancer & other chronic conditions at all, very cold, do not like her even more after her handling of this medical issue. And now, the clinic won't let me switch to new provider! UGGH!)

I'll spare ya all of the details, but broad strokes are she (MHP) will not autorize Effexor, only Pristiq. I contacted my MO. Asked them to talk with my MHP. They did. They want me on Effexor, not Pristiq.

Yet, my MHP won't budge and I can't take my Tamox until this is solved. I feel hopeless in that if my MO can't make headway, how the hell am I as a patient supposed to sway her?

I can't find any research on Tamoxifen and Pristiq. There is a ton that says Effexor is the recommended SSRI for IDC.

Can someone help me find the evidence I need to take to my MHP since my MO apparently cannot show her that Pristiq is not the drug I need at the moment? Or am I and my MO totally incorrect, and Pristiq is fine with Tamoxifen? I tried searching the board but am not having much luck.

Help.

Thanks in advance!


"Spoonie" who entered BC World @ 41. DXd w/MS & Thyroid Cancer @42. Treatment: LX/SLNB/RADs. Plan A: 5mg Tamox = 0 QOL. Plan B: OS/AI = Rare allergy to OS meds. Plan C: Only option left,  Diet & Exercise. PS: Not a dr, just a Googler. Dx 7/20/2018, IDC, Left, 3cm, Stage IIA, Grade 2, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 8/30/2018, DCIS, Left, 1cm, Stage 0, Grade 2 Surgery 8/30/2018 Lumpectomy: Left; Lymph node removal: Left, Sentinel Radiation Therapy 10/1/2018 Whole-breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 3/30/2019 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 7/2/2019 Zoladex (goserelin)
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Oct 16, 2018 02:36PM gb2115 wrote:

I just looked up the drug interactions. Pristiq appears to have no interactions with tamoxifen (I looked it up in 2 different databases). I also found several websites that said Pristiq is ok. I don't know why your MHP is against the Effexor, but not sure why your MO is against the Pristiq.

If you want to check interactions, just google Drug interaction checker, and bunch of different sites pop up. You can plug in your meds and see it right there. You can also go onto the Walgreens website to "chat" with a pharmacist. I've done that before and they are helpful.

Maybe double check with your pharmacist and take that information to your MO? Or ask the MHP why you can't take Effexor.

Hope it works out quickly! I think the big issue with the interactions is that the tamoxifen might not work as well over time, so for the long haul you wouldn't want to be doing that. But I'm surprised your MO isn't letting you start it anyway just to get it going while you taper or switch your meds. I don't think it's a scary interaction, you just wouldn't want to be on them together for a long time.

Dx IDC in October 2016, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Mammaprint low risk luminal A, Lumpectomy + radiation + tamoxifen. Age 38 at diagnosis.
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Oct 16, 2018 05:21PM - edited Oct 16, 2018 05:24PM by Spoonie77

Thanks for the reply GB. I appreciate it.

The problem was that my MHP wouldn't talk to me or to my MO about why she insisted on Pristiq.


..sigh..


My MO wasn't intimately familiar with Pristiq and had said that most patients had switched to Effexor, so that's why she suggested it, being that's been the standard of care previously. She's fine with Pristiq if it wasn't a CYP450 2D6 inhibitor, which Cymbalta and most other SSRI's are.

I just got off the phone with my MO's office.

Apparently, my MO's office and the MHP finally talked. Pristiq is a newer version of Effexor I guess. (even though when I look it up on a few websites like (https://www.verywellhealth.com/antidepressants-tha... where it shows Pristiq as having "slight interactions" with Tamox and as far as I can find there are no studies showing the effectiveness of Tamos w/Pristiq https://www.health.harvard.edu/newsletter_article/antidepressants-and-tamoxifen)

So my MO is fine with it as long as it doesn't inhibit the Tamoxifen. (I'm going to ask my MHP this directly at my appt next week)

However, I'm still concerned because Pristiq is not supposed to be used for patient's with High Bloood Pressure and with those on some of the meds I am currently on. (That's why I was so concerned GB - I had already done the interaction internet thing and it said big red flags with my other drugs, besides the Tamox question, and that's when the "war" started - Effexor doesn't have these contraindications.)

Anyway, at least I know that as far as the Tamox goes, it looks like I can take either. I just have to talk with my MHP next week before I start the Pristiq about those other red flags. I'm still not comfortable with having her supervise my meds. My trust in her is broken. This whole process just was a nightmare. Just because her and her staff wouldn't communicate with me or my team.

As far as starting the Tamoxifen, like you mentioned GB, I can't. It takes at least 2 weeks for the Cymbalta to decrease in my system enough to actually allow the Tamoxifen to activate. And I can't wean off of it, without something to replace it, because the side effects for me in the past have been HORRENDOUS. If that wasn't the case, even if I took it now, according to my MO and others on my team, it would be like take nothing. I'd just pee it out as it wouldn't be able to convert into its active form. And it's wayyyyy to expensive to do that.

Wish me good luck next Tues! I hope my MHP will get on board with the Effexor or ease my concerns enough to start the Pristiq next week.


"Spoonie" who entered BC World @ 41. DXd w/MS & Thyroid Cancer @42. Treatment: LX/SLNB/RADs. Plan A: 5mg Tamox = 0 QOL. Plan B: OS/AI = Rare allergy to OS meds. Plan C: Only option left,  Diet & Exercise. PS: Not a dr, just a Googler. Dx 7/20/2018, IDC, Left, 3cm, Stage IIA, Grade 2, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 8/30/2018, DCIS, Left, 1cm, Stage 0, Grade 2 Surgery 8/30/2018 Lumpectomy: Left; Lymph node removal: Left, Sentinel Radiation Therapy 10/1/2018 Whole-breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 3/30/2019 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 7/2/2019 Zoladex (goserelin)
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Oct 16, 2018 05:33PM Cowgirl13 wrote:

Spoonie, run from this mental health provider. Is she a psychiatrist or PhD or what? Very serious to try to over ride your onc. I'm curious about her credentials.

Be the kind of woman that when your feet hit the floor each morning the Devil says: 'Oh crap! She's up! Dx 5/28/2009, IDC, Left, 2cm, Stage IIA, Grade 3, 0/4 nodes, ER+/PR+, HER2+ Surgery 6/17/2009 Chemotherapy 8/2/2009 Carboplatin (Paraplatin), Taxotere (docetaxel) Radiation Therapy 12/21/2009 Hormonal Therapy 2/22/2010 Arimidex (anastrozole)
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Oct 16, 2018 05:40PM ksusan wrote:

If she's prescribing, not a PhD. I agree: It's a bad fit and she's not communicating well.

Mutant uprising quashed. Dx 1/2015, IDC, Right, Stage IIA, 1/1 nodes, ER+/PR+, HER2- Dx 1/2015, DCIS, Left, Stage 0, Grade 3, 0/2 nodes Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery Lymph node removal: Sentinel; Mastectomy: Left, Right Radiation Therapy Whole-breast Chemotherapy Cytoxan (cyclophosphamide), Taxotere (docetaxel)
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Oct 16, 2018 05:58PM Spoonie77 wrote:

What both of you stated, is how I feel, and what was my gut instinct after my first appt with her, but having moved to a new state I needed care in Aug, and thought in the meantime she'd do. Then "this" all happened and when I requested last week to transfer my care to another MHP I found out that unfortunately, I have to have this MHPs (certified psychiatrist MD) approval to switch. She won't approve it. I'm depressed about the whole situation. :(


"Spoonie" who entered BC World @ 41. DXd w/MS & Thyroid Cancer @42. Treatment: LX/SLNB/RADs. Plan A: 5mg Tamox = 0 QOL. Plan B: OS/AI = Rare allergy to OS meds. Plan C: Only option left,  Diet & Exercise. PS: Not a dr, just a Googler. Dx 7/20/2018, IDC, Left, 3cm, Stage IIA, Grade 2, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 8/30/2018, DCIS, Left, 1cm, Stage 0, Grade 2 Surgery 8/30/2018 Lumpectomy: Left; Lymph node removal: Left, Sentinel Radiation Therapy 10/1/2018 Whole-breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 3/30/2019 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 7/2/2019 Zoladex (goserelin)
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Oct 16, 2018 08:31PM - edited Oct 16, 2018 08:35PM by Lula73

Spoonie77- yes pristiq is the newer version of Effexor in a sense. Here's the main differences:

Effexor is metabolized through the CYP450 2D6 pathway but does not appear to affect tamoxifen absorption and activity. As Effexor is metabolized in this pathway it is broken down to its active and inactive metabolites. The major active metabolite of venlafaxine is desvenlafaxine. It’s mainly this metabolite that causes the reuptake inhibition of serotonin and norepinephrine in the brain which fights the depression.

Pristiq is the major active metabolite (of venlafaxine) called desvenlafaxine. So basically your body does not have to break Pristiq down/metabolize it to use it. This also means it is not metabolized thru the CYP450 2D6 pathway. Therefore no potential interaction with tamoxifen due to its metabolism.

Additionally, Pristiq does not have a complicated dose titration process like Effexor does. You get right off the ground running with Pristiq. Since you are switching from one med to another, you want this to be as seamless as possible with the activity of serotonin and norepinephrine in the brain remaining as constant as possible. That's what Pristiq gives you that Effexor does not. Additionally, medication compliance should be greater with Pristiq because of the ease of dosing.

When you look into the 2 meds from a pharmacological/pharmacokinetic standpoint Pristiq is the better way to go. To me, your MO is showing his unwillingness to take 5 minutes to do a quick google search and read a quick journal article that explains all this. Your psych doc likely expects any other doc who is changing patients' anti-depressant meds to be up to date on them and if not (which is the case here), allow the doc that's trained in mental healthcare to call the shots on the mental health meds taking into account the meds needed for cancer. Remember that if your serotonin and norepinephrine activity drops and depression takes over it can be an imminent threat to your health/life/will to live while bc (while still serious) is not. Your psych doc knows this and takes it very seriously. She is a keeper because she fights for you.

-Lula Dx 1/2017, DCIS/IDC, Right, 1cm, Stage IA, Grade 1, 0/2 nodes, ER+/PR+, HER2- Surgery 2/14/2017 Lymph node removal: Sentinel; Mastectomy: Left, Right; Prophylactic ovary removal; Reconstruction (left): DIEP flap; Reconstruction (right): DIEP flap Hormonal Therapy 3/3/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 11/1/2017 Prophylactic ovary removal Hormonal Therapy 1/3/2018 Femara (letrozole)
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Oct 16, 2018 11:05PM - edited Oct 16, 2018 11:11PM by Spoonie77

I don't know about her being a keeper.....although I do understand your point of view Lula.

I'd be willing to agree with you if that MHP had been willing to talk to me or to my team about the drug at all. She wasn't. I tried. They tried. She refused to explain to anyone, what you so elegantly and infomatively shared with me (which I DEEPLY appreciate! makes so much sense that way).

I WISH my MHO had taken the time to do what you just did. She didn't. She referred me, through her staff, to see a Pharmacist to look at my case. I tried to schedule an appt with him, however it was not covered by my insurance, nor could I get in to see him within 3 weeks. I told her staff this and they were very apologetic and said they would talk to the MHP and ask her to speak with him. They (her staff) said in the meantime to start the Effexor, as she wrote a Rx for it.

That seemed strange to me....write a RX and wait to talk to the Pharmacist after the fact.

Anyway, I didn't pick it up, didn't take it. Good thing. Her staff called me back 2 days later, saying stop taking Effexor, start Pristiq. No explanation given to me other than this Pharmacist suggested it.

See? This is just another reason all my alarm bells went ringing. It just didn't feel right, nor have I had this happen in my 20 some years of being in the system. It was all just "off".

I have been in the medical system since a teenager due to my chronic pain/fatigue/conditions, the ones beside depression/anxiety, so I am very familiar with how things should work and how I feel, as a patient, I should be included in the process of choosing my meds & weighing pros and cons. I don't take kindly to a doctor, of any kind, shoving a med (even if it may be the right one for me in the end) down my throat literally, without allowing me to have access to information about why it may be the best choice for me and a chance to have a discussion about their thoughts and so forth.

I just wanted communication and to feel that my health, both sides (mental and phys) were being weighed equally. Without her (this MHP) taking the time to communicate this to me, I couldn't and don't feel confident in her at all. Nor do I feel she places importance on fighting my cancer.


I hope she can some how regain my trust, as it looks like I am stuck with her. :( I see her on Tuesday to discuss all of this and honestly, I want to ask her to pass my care to someone else. I really don't understand how she can come back from this, she had only seen me once prior to this. I was a brand new patient, not someone that she knew well at all. That's why it's even more unnerving to me that she didn't take the time to communicate with me being new to her care. <eek>


Thanks again Lula for taking the time to write to me and share the info that you did. It was very informative and really, that's all I wanted from my MHP. Care to take on my case?! LOL! :)

"Spoonie" who entered BC World @ 41. DXd w/MS & Thyroid Cancer @42. Treatment: LX/SLNB/RADs. Plan A: 5mg Tamox = 0 QOL. Plan B: OS/AI = Rare allergy to OS meds. Plan C: Only option left,  Diet & Exercise. PS: Not a dr, just a Googler. Dx 7/20/2018, IDC, Left, 3cm, Stage IIA, Grade 2, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 8/30/2018, DCIS, Left, 1cm, Stage 0, Grade 2 Surgery 8/30/2018 Lumpectomy: Left; Lymph node removal: Left, Sentinel Radiation Therapy 10/1/2018 Whole-breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 3/30/2019 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 7/2/2019 Zoladex (goserelin)
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Oct 17, 2018 12:33AM Lula73 wrote:

I’m glad it helped. Unfortunately I don’t have the right letters after my name to be able to take on any case-LOL! I hope you find making the transition to Pristiq a smooth one. I’m guessing you’re pre-menopausal hence the tamoxifen?

-Lula Dx 1/2017, DCIS/IDC, Right, 1cm, Stage IA, Grade 1, 0/2 nodes, ER+/PR+, HER2- Surgery 2/14/2017 Lymph node removal: Sentinel; Mastectomy: Left, Right; Prophylactic ovary removal; Reconstruction (left): DIEP flap; Reconstruction (right): DIEP flap Hormonal Therapy 3/3/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 11/1/2017 Prophylactic ovary removal Hormonal Therapy 1/3/2018 Femara (letrozole)
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Oct 17, 2018 02:54PM gb2115 wrote:

It's really too bad you can't get both doctors on the phone to each other. Would probably clear up a lot very quickly!

Fingers crossed for you! I am currently struggling with anxiety unmedicated because I couldn't take Zoloft with the tamoxifen. I thought about Effexor, but am just kind of winging it day to day. Sometimes I feel like I really need something though, but can't stand the thought of piling on more side effects, and my blood pressure is running higher than it used to. I don't want to add anything to make that worse. It's hard though. Life on Zoloft was much easier....

Dx IDC in October 2016, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Mammaprint low risk luminal A, Lumpectomy + radiation + tamoxifen. Age 38 at diagnosis.
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Oct 17, 2018 09:48PM Spoonie77 wrote:

Lula - yep, pre meno. Thanks for the well wishes on the switch to Pristiq. I hope it won't cause issues. Fingers crossed. I'll start the switch after I see the MHP next week to discuss further issues. I need to know I'm safe with this med and the others I'm on before I start. What's one more week when she made me wait three? <shrug>


Hi GB2115 - Wow, I'm happy for you that you are able to wing it w/o the Zoloft. Fingers crossed you can continue to do that. Will you be on the Tamoxifen 5-10 years? What's your plan for a med or will you just try to keeping winging it as long as you can hold out? I wish I could do that, but I know myself well, and with my other chronic pain/conditions, my depression would have me suicidal in under a couple of months and my anxiety would have me homebound in weeks, so "something" is mandatory. Hopefully Pristiq will lead to less SEs in the long run than the Effexor would've brought. I guess I'll be winging it with you, in a way. I see you were young at your dx too. I was 41 this year when I got the news. I am soooooo over all of this and just want to be done. Here's hoping the weeks speed by. How have you handled the Tamoxifen over the past year or so?

"Spoonie" who entered BC World @ 41. DXd w/MS & Thyroid Cancer @42. Treatment: LX/SLNB/RADs. Plan A: 5mg Tamox = 0 QOL. Plan B: OS/AI = Rare allergy to OS meds. Plan C: Only option left,  Diet & Exercise. PS: Not a dr, just a Googler. Dx 7/20/2018, IDC, Left, 3cm, Stage IIA, Grade 2, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 8/30/2018, DCIS, Left, 1cm, Stage 0, Grade 2 Surgery 8/30/2018 Lumpectomy: Left; Lymph node removal: Left, Sentinel Radiation Therapy 10/1/2018 Whole-breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 3/30/2019 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 7/2/2019 Zoladex (goserelin)
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Oct 17, 2018 10:05PM - edited Oct 18, 2018 12:06AM by MameMe

I wonder if the meds doc is pushing Pristiq due to a prof. relationship with the manufacturer. Effexor has generic versions now, but I don't think Pristiq does. She sounds awfully rigid and quite invested in seeing Pristiq get prescribed.

Mame

Widespread, low volume mets to eye, lungs, chest wall and bones, dx 4/14/14. "There's gotta be a pony in this s--t somewhere..." Dx 2/2003, IDC, Right, 2cm, Stage IIA, Grade 1, 0/2 nodes, ER+/PR+, HER2- Dx 12/2012, IDC, Left, 1cm, Stage IA, Grade 2, 0/2 nodes, ER+/PR-, HER2- Dx 4/4/2014, IDC, Left, 2cm, Stage IV, metastasized to bone/lungs/other, Grade 2, 0/1 nodes, ER+/PR-, HER2- (IHC) Chemotherapy 4/30/2017 Doxil (doxorubicin) Chemotherapy 2/28/2018 Halaven (eribulin) Targeted Therapy Afinitor (everolimus) Chemotherapy Taxol (paclitaxel) Hormonal Therapy Aromasin (exemestane) Chemotherapy Gemzar (gemcitabine) Hormonal Therapy Faslodex (fulvestrant) Targeted Therapy Ibrance (palbociclib) Chemotherapy Xeloda (capecitabine)
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Oct 18, 2018 01:13AM Spoonie77 wrote:

Thanks Mame, that is what I wondered in the beginning too.

At this point, I'll never be sure and I just have to hope that either I can somehow move forward with her or find a way to convince her to approve my switching to another MHP. This is not the situation I wanted to be in.

Does anyone know of any specific studies or information that document that Pristiq has no interactions with Tamoxifen?

Her (the MHP) office called me today and they stated something odd to me. They said that she had noted in her msg to me that "Effexor has interaction with Tamoxifen, while Pristiq does not.".

I don't believe this is correct.

As far as I'm aware Tamoxifen and Effexor do not have interaction, hence why my Oncology team was suggesting that as the med to switch to.

Anyone have anything they can point me to that backs up either claim by my MHP?

I'm going to try and search "the interwebs" but lately they've not been playing nice with my intent to find info.


"Spoonie" who entered BC World @ 41. DXd w/MS & Thyroid Cancer @42. Treatment: LX/SLNB/RADs. Plan A: 5mg Tamox = 0 QOL. Plan B: OS/AI = Rare allergy to OS meds. Plan C: Only option left,  Diet & Exercise. PS: Not a dr, just a Googler. Dx 7/20/2018, IDC, Left, 3cm, Stage IIA, Grade 2, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 8/30/2018, DCIS, Left, 1cm, Stage 0, Grade 2 Surgery 8/30/2018 Lumpectomy: Left; Lymph node removal: Left, Sentinel Radiation Therapy 10/1/2018 Whole-breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 3/30/2019 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 7/2/2019 Zoladex (goserelin)
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Oct 18, 2018 11:25AM gb2115 wrote:

I have been ok on the tamoxifen. My MO said 5-10 years, but when she found out that I had a primary relative with Stage 4 recurrence 17 years after her dx, my MO changed it to definitely 10 years. I have some side effects, but nothing that isn't manageable (and better than having the cancer come back). I've been on it for about a year and a half.

Dx IDC in October 2016, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Mammaprint low risk luminal A, Lumpectomy + radiation + tamoxifen. Age 38 at diagnosis.
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Oct 18, 2018 12:21PM edwards750 wrote:

I took Tamoxifen for 5 years. Not too bad except for joint pain and hot flashes.

Diane

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