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Stem
A 50-year-old para 2 woman presents to her general practitioner with four months of irregular, sometimes heavy menstrual bleeding, daily hot flushes and night sweats that wake her several times a night, vaginal dryness with dyspareunia, low mood, and fatigue. Her last cervical screening was normal six months ago and a mammogram two months ago was normal. She has never smoked, drinks alcohol only occasionally, and has a body mass index of 27. Her blood pressure is 134/82 mmHg. She had a provoked deep vein thrombosis in her left calf at age 38 while taking a combined oral contraceptive pill, which was treated with anticoagulation for six months and has not recurred. She has no other medical history and takes no regular medication. She is not on any hormonal contraception; her partner has had a vasectomy. There is no family history of breast or ovarian cancer.
Examination: abdomen soft and non-tender; speculum examination shows a normal cervix and mild vaginal pallor with loss of rugae; bimanual examination reveals a normal-sized, mobile, non-tender uterus and no adnexal masses.
Questions
a) What is the clinical diagnosis, and which one feature in the history most influences your choice of HRT route? (2 marks)
b) Outline the focused investigations you would arrange before starting treatment. (3 marks)
c) Outline the management, specifying the oestrogen, the progestogen, and the route, with a rationale for each choice. (4 marks)
d) What safety-net advice and follow-up would you give? (1 mark)
Model answers
a) The perimenopause / menopausal transition with symptomatic oestrogen fluctuation — irregular (sometimes heavy) cycles plus vasomotor, genitourinary and mood symptoms in an age-appropriate woman. The single feature that most influences the route of HRT is her personal history of provoked deep vein thrombosis — this is a contraindication to oral oestrogen and mandates a transdermal route (after haematology input). The diagnosis of the transition is clinical; FSH measurement is not required in a woman over 45 with typical symptoms and would be unreliable in the perimenopause when it fluctuates with each cycle.
b) (i) Pregnancy test (beta-hCG) — even with a vasectomised partner, exclude pregnancy before any abnormal bleeding is attributed to the transition. (ii) Full blood count — to quantify the impact of the heavy bleeding (iron-deficiency anaemia). (iii) Transvaginal ultrasound and endometrial biopsy (Pipelle) — any heavy or irregular bleeding in a woman over 45 warrants exclusion of endometrial pathology; an endometrial thickness over 4 to 5 mm on transvaginal ultrasound is the threshold for biopsy, with hysteroscopy and targeted biopsy if sampling is inadequate or bleeding recurs. (iv) Baseline metabolic screen — fasting lipids and glucose, given the BMI and blood pressure. (v) A baseline DEXA is not routinely required here (no POI, no early menopause, no glucocorticoids) but FRAX can be used to estimate her 10-year fracture risk. (vi) A coagulation screen and haematology review to characterise her VTE risk before any systemic oestrogen.
c) (1) Lifestyle — weight-bearing and aerobic exercise, healthy diet rich in calcium and vitamin D, sleep hygiene, layered clothing and a fan, caffeine and alcohol moderation. (ii) Transdermal oestradiol (e.g. a 50 mcg/24-h patch, or 0.5 to 1 mg gel daily) — chosen because oral oestrogen is contraindicated by her VTE history; the transdermal route bypasses the first-pass hepatic effect and does not lower antithrombin III or activate coagulation. (iii) Cyclical micronised progesterone 200 mg nocte for 12 days each month (or the levonorgestrel intrauterine system 52 mg if she prefers) — she has an intact uterus, so a progestogen is mandatory to prevent endometrial hyperplasia and cancer; micronised progesterone is preferred for its neutral breast and vascular profile; a cyclical (sequential) regimen is used because she is perimenopausal (within 1 to 2 years of her last period) and would otherwise have irregular bleeding on continuous combined therapy. (iv) Low-dose vaginal oestradiol (cream or 10 mcg tablet, twice weekly) for the genitourinary syndrome — can be added regardless of systemic therapy and continued long-term. (v) Iron supplementation if she is anaemic; tranexamic acid 1 g four times daily plus an NSAID (mefenamic acid 500 mg three times daily) on heavy days if the irregular bleeding persists after the cycle settles. (vi) Haematology input to characterise her VTE risk and endorse the transdermal route before starting.
d) Safety-net and follow-up: review at 3 months for symptom control and side-effects, then annually for blood pressure, weight, breast awareness and ongoing need; urgent review for any unscheduled or postmenopausal bleeding (transvaginal ultrasound and biopsy — do not attribute to HRT), calf pain or swelling, chest pain, breathlessness, sudden severe headache, or visual change. The aim is the lowest effective dose for the shortest necessary time, but duration is individualised — there is no mandatory stop-date. She should use a separate contraceptive until she is 2 years past her last period (although her partner's vasectomy effectively covers this).