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MRCOG PART 2 SBAs and EMQs

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notes337
EMQ1500
SBA2111
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SAQ HRT

SAQ HRT Posted by koukab A.

1) I will do assessment by history and examination.I will ask for age of menopause as it will affect HRT regimen.If she is menopausal for less than one year,I will give her sequential regimen and if she is menopausal for more than a year I will offer her continuous combined regimen.I will ask about her symptoms ie type of symptoms,duration and severity of symptoms as I will tailor the HRT regimen according to her symptoms.I will ask for personal or family history of VTE and history of any known thrombophilia as HRT may be contraindicated in case of VTE.Thrombophilia screening is not indicated routinely but may be needed if there is family history of VTE with some thrombophilia.I will ask for history of breast cancer for patient and her family as HRT with breast cancer is having conflicting data according to WHI study and need more caution.I will ask for history of ovarian or endometrial cancer as HRT is contraindicated with history of granulosa cell tumours or sarcoma of endometrium. I will ask for history of stroke or MI as HRT increases the risk of coronary heart disease according to WHI study.I will ask for life style habits like smoking and alcohol as avoidance of these may improve some symptoms.I will ask for diet and exercise habits as diet rich in calcium and weight bearing exercise will reduce risk of osteoporosis.I will ask for use of over the counter medications like soy,black cohosh as these may have interactions with HRT.I will check her baseline BP and BMI as obesity is risk factor for VTE.I will do abdominal examination for palpable masses.I will do pelvic examination only if needed like in case of some mass.                 2) To reduce progestogenic side effects I can reduce dose of progesterone to half.I can reduce duration of progestogen intake in sequential regimen to 7 to 10 days.Reducing the dose and duration may result in breakthrough bleeding or hyperplasia so I will keep low threshold for ultrasound and endometrial sampling.I can change type of progestogen like progesterone and dydrogesterone have fewer side effects due to receptor specificity.Drospirenone has anti mineralocorticoid and antiendrogenic properties and can be given to reduce side effects.I can change route of administration of progestogens like transdermal preparation or vaginal passeries or gel may be given with less side effect profile.I can advice LNG IUS as progestogen component of HRT.It is licensed for this purpose for 4years in UK.I can provide her with alternatives like tibolone.