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Essay 295 - HRT

Essay 295 - HRT Posted by PAUL A.
A 53 year old woman has been referred to the gynaecology clinic because she requests hormone replacement therapy (HRT) for debilitating hot flushes. (a) Describe the assessment you would undertake in the clinic [7 marks]. (b) She is suitable for HRT. Discuss the potential benefits and risks of HRT and your advice on the appropriate duration of treatment [13 marks].
Posted by Johnson  O.
A/
I would take full menstrual history, age at menarche, menstrual cycle, intermenstrual or irregular vaginal bleeding. If she is not menstruating, age at menopause. I would ask about personal and family history of venous thromboembolism, most especially, first and second degree relative. Personal and family history of breast cancer. Life stlye like smoking, sedentary or active life stlye. Result of her last cervical smear test. Previous surgery like hysterectomy.
Examination would include her height, weight and BMI. I would check her blood pressure. Abdominal examination for any palpable abdominal or pelvic mass.
If there is personal or family history of Venous thromboembolism, I would request for thrombophilia screening before commencing HRT treatment.
B/
HRT would reduce the vasomotor symptoms like hot flushes and night sweating. It would improve vagina lubrication thereby reduce the risk of vagina dryness and dyspareunia. It reduces the risk of osteopenia and osteoporosis..
May improve cognitive function, reduce the risk of colorectal cancer and reduce the risk of Alziemer disease.
There is increase risk of venous thromboembolism, stroke, coronary heart disease, deep vein thrombosis and pulmonary embolism. The risk is highest in the first 3months of use and gradually reduces by one year.
Risk of breast cancer increase with the use for more than 5years. Therefore, I would recommend the use for about 1 to 2 years and it should be less than 5years.
Estrogen only HRT increase risk of endometrial cancer in women with uterus.
I would provide written information leaflet to enable her make well informed decision. Clear documentation of discussion and advise given. Yearly breast examination, most especially if she has personal or family history of breast cancer. Regular monitoring of blood pressure by her GP. To report any unexpected vagina bleeding. I would also advise her to reduce smoking, caffiene and do regular exercise.
Posted by Shaimaa M.

A.
Initial assessment should include full history taking asking more detailed question about her presenting complaint time it started, any precipitating factors, association with night sweats. Full menstrual history including Last menstrual period not assuming she achieved menopause, frequency, regularity, heaviness and duration of her periods. Method of contraception used, sexually active or not. Date of last cervical smear and any abnormality. Associated menopausal symptoms of Urogenital symptoms e.g. (urinary symptoms, dyspareunia, symptoms of vaginal dryness as itching or burning and decreased libido. Past history of confirmed DVT or pulmonary embolism. Cardiovascular risk factors e.g. smoking, hypertension, diabetes. Ask about symptoms of thyroid disease (weight changes, palpitation, appetite changes). History of breast cancer and date of last mammogram if appropriate. History of migraines should be ascertained. History for risk factors of osteoporosis e.g. hyperthyroidism, hyperparathyroidism, mal-absorption syndrome. Current medications e.g calcium, steroids or tamoxifen for breast cancer. Previous surgeries e.g. hysterectomy or oophrectomy as this might affect the type of HRT (oestrogen only or combined Oestrogen progesterone HRT). Family history of breast, colon, ovarian cancer, DVT, Osteoporosis.
General examination looking for signs of hyperthyroidism (e.g. tachycardia, sweating) as it might be associated with hot flushes, vaginal examination may show vaginal dryness however is not conclusive.
Request investigations for thyroid function tests (Free T4, TSH) as abnormalities of thyroid may be confused for menopausal symptoms. Bone mineral density if significant risk factors for osteoporosis.
B.
If she is suitable for HRT, Benefits of HRT are decreased vasomotor symptoms which manifest as hot flushes; Oestrogen is effective in treatment of hotflushes however it takes 4 weeks to manifest and the maximum therapeutic response after 3 months. It should be continued for 1 year otherwise symptoms are more likely to recur. HRT decrease urogenital symptoms and improve sexuality. Vaginal oestrogen is associated with improved vaginal dryness and associated symptoms of itching and dysparuenia however urinary symptoms of frequency, urgency, nocturia and incontinence do not improve. Sexual drive might not improved by oestrogen alone by need additional testosterone. HRT decrease the risk of osteoprotic fractures. Evidence does suggest lifelong HRT is required for an effective prevention of osteoporosis and it is also cheaper than other suggested therapies for osteoporosis like biphosphonates. HRT also decrease the risk of colorectal cancer by 1/3 however HRT is not licensed now for prevention of colonic cancer. HRT should be continued for 1 year or symptoms will recur and often used for fewer than 5 years.
HRT are associated with certain risks, increased breast cancer which is similar to late natural menopause which is 2.3% per year that why risk is dependant on duration of HRT type of HRT (more with combined Oestrogen progesterone) but the effect is not sustained once HRT is stopped. Unopposed oestrogen increases the risk of endometrial cancer, risk remains increased for 5 or more years even after stopping HRT however addition of progesterone does not eliminate the risk completely especially if used more than 5 years. Venous thromboembolism risk is more than doubled but absolute risk remains small. The number of additional VTE events in healthy women on HRT for more than 5 years is 4:1000 between 50-59 years of age. RISK of VTE is more likely to be in the first year of using HRT however transdermal HRT has lower risk of VTE compared to oral. HRT may also increase the risk of gall bladder disease however obesity and age may be contributing factors.
Posted by Sophia Y.
(a) Describe the assessment you would undertake in the clinic [7 marks].

I will ask her about symptoms of menopause she is getting other than hot flushes eg night sweats, vaginal dryness, urinary frequency & recurrent UTI & irritability. I will also ask her how these menopausal symptoms have affected her quality of life.
I will take a detailed menstrual history: when her last menstrual period was, whether it was regular or not, any undiagnosed abnormal vaginal bleed - intermenstrual or postcoital bleed. I will also ask what contraception she is on & whether she still has an uterus or not. I will then ask about significant medical history eg liver disease & predisposing factors that can increase risk of HRT. These include previous history of breast cancer, venous thromboembolism (VTE) - DVT or PE, thrombophilia (eg Factor V leiden mutation or anti-thrombin III deficiency), MI or stroke and osteoporosis. I will also ask her any family history of VTE, thrombophilia, osteoporosis or breast cancer. I will ask about smoking & alcohol intake & what drugs she is on (prescribed & not prescribed eg st john\'s wort) which may interfere with the actions of HRT.

On examination i will check her BMI & blood pressure. I will check her serum FSH/LH & estradiol. High FSH (more than 30) & LH with low estradiol which will confirm that she is menopausal. I will also do a thrombophilia screen if there is strong family history of VTE.

(b) She is suitable for HRT. Discuss the potential benefits and risks of HRT and your advice on the appropriate duration of treatment [13 marks].

HRT is proven to be effective of relieving symptoms of menopause eg hot flushes, night sweats, irritability & vaginal dryness. In addition it can reduce the risk of osteoporosis & colorectal cancer.
HRT, however can increase the risk of venous thromboembolism. The risk is higher if there is personal or family history of VTE & thromphilia. It can also increase the risk of breast cancer. In women who have an intact uterus, estrogen only HRT can increase risk of endometrial hyperplasia & thus endometrial cancer. HRT can also worsen lipid profile and therefore increase risk of coronary heart disease & stroke. In addition it increases the risk of developing Alzeimers disease.

I will give her written leaflet on risks & benefits of HRT.

I will advise her not to take it more than 5 years or stop it earlier if she develops any complications or if she wants. We should start her on lowest effective dose & review her yearly. After after 5 years, if she declines to stop it, she should be counselled against the risks & balance it with the benefits to produce an informed choice.
Posted by SANCHU R.
Sanchu
Her other menopausal symptoms like vaginal dryness, mood swings should be asked for since only hotflushes can be managed with other non-hormonal drugs if HRT is contraindicated. Her menstrual history should be obtained. If she is still menstruating, she will be suitable for sequential HRT. If she is in amenorrhea, she would be suitable for the continuous combined HRT. Her medical history should be obtained in detail. H/O Thromboembolic disorders like a DVT, PE, Ischemic heart Disease, TIA or Stroke would contraindicate estrogen. H/O Diabetes and Hypertension would also contraindicate HRT. H/O Breast cancer should be asked for since HRT should be started after discussion with the oncologist.
Family H/o thrombophilia like Factor V Leiden mutation would indicate her thrombophilia screening before prescribing HRT.Drug History to find interacting drugs like anti-epileptics should be obtained. Surgical history of Hysterectomy would indicate estogen replacement without progesterone.
Family H/O Breast cancer should be asked for and her predisposition to breast cancer should be determined. H/O smoking should be asked for since it adds to the risk of thromboembolism.

b) The benefits of HRT would be to relieve menopausal symptoms namely hot flushes, vaginal dryness and mood swings. It is beneficial to prevent and treat osteoporosis but the benefit lasts only as long as it is used.
Although the WHI study showed that it has adverse cardiovascular effects and combined estrogen + progesterone increases the risk of breast cancer , it was done on women 10 years older than the average onset of menopause. Now, it is proven not to have adverse cardiovascular effects in the younger age group when started at the start of menopause. With regard to breastcancer, it does not increase the incidence of breast cancer if used in the younger age group and if used short term i.e. for a maximum of 5 years. It does increase the risk of venous thromboembolism three-fold and the risk can be minimised if transdermal preparation is used.
Posted by H H.
I would ask her of frequency and severity of her hot flushes and effect on her quality of life.Would enquire of other menopausal symptoms like night sweats and palpitation.Will ask of her sexual life and if noticed changes like decrease in libido and vaginal dryness.History of nocturia and urgency.Any change in temper . Personal or family history of cardiovascular disease or hypertension.Personal or family history of venous thromboembolism may indicate thrombophilia. Personal or family history of breast or endometrial cancer.Family history of osteoporosis.Will ask of social history including smoking ,alcohol intake and fluid and beverage intake.Ask of her last pap smear and if was ok.
In examination will detect body mass index and measure blood pressure.



Benfits of HRT will include alleviation of her menopausal symptoms.These are the short benfits and are felt by the patient within one to two weeks of start of treatment.There will be dissapearance of hot flushes,palpitation and night sweats, improvement of her sexual life and lubrication of vagina,in addition to better sleep at night due to absence of night sweats and nocturia.There is improvement in her skin texture and quality of hair and patient feel younger.
If patient contiue with HRT for more than 5 years benfits like reduction in osteoporosis,decrease in teeth loss and macular degeneration, and reduction in colorectal cancer will occur. There is controverse regarding regarding reduction in Alzhymer disease.
Risks include cardiovascular effect,increasing the risk of coronary artery disease.It was thought to be protective but randomized controlled trials showed the reverse (This is for the combined HRT and not estrogesn only HRT ).There is also increase in the risk of cerebro vascular strokes.There is 2 to 3 fold increase in the risk of venous thrombosis.
There is increased risk of gall bladder disease and and side effects of estrogen and progesterone like headache, weight gain, acne, and bloatedness , and vaginal bleeding which may not be welcomed by the patient.
With prolonged use for more than 5 years there is increased risk of breast cancer. In a woman over 50, the risk of cancer breast is 32 per 1000 women over 15years. Use of combined HRT for 5 years increase risk to 38/1000 and use for 10 years increase risk to 51/1000 women.Risk of endometrial cancer only increase with use of unopposed estrogen only HRT stimulation .
For this woman, given the fact that short term benfits are beneficial, so being suitable for HRT ,I would advice her to take HRT to cover her debilitating hot flushes assuring her that these are temporary and are likely to disappear by themselves. I would tell her of the risks and benfits if she take them for long time and would let her decide and her wishes respected.I would give her written information to help her decide.
Posted by SUNDAY A.
a) i would ask regarding her LMP, periods and any abnormal bleeding. Others symptoms such as vaginal dryness, mood swings, headaches, visual disturbance etc should be noted. Relevant past medical history including history of high blood pressure, diabetes,thyroid disease, previous DVT, breast cancer, any Gyneacological cancer ( or family History of such), smears history should be noted. Relevant surgical history such as previous hysterectomy, oophorectomy should be noted as well. Drug history should be requested and any alergies noted. Thereafter i would proceed to a general examination noting the blood pressure, pulse rate, a cardiovascular examination should also be carried out but abdominopelvic examination in the absence of any other complain may not be indicated.

b). The benefits of HRT would include protection against Osteoporosis, cardiovascular disease-particular in the younger age group(under 55yrs), protection against Alzheimer\'s disease and dementia . The risk of breast cancer- particularly if HRT is used for more than 5 years should be discuused. Risk of deep vein thrombosis and cardiovascular disease if used for more than 5 years should also be discussed.
I would advice her not to use HRT for more than 5 years if possible and to stop as soon as the symptoms are better or well controlled. I would advice on lifestyle changes such as exercise, healthy diets that could help with her symptoms alongside her HRT.
Posted by Nur Sakina K.
NSK

Fr A:
I’d enquire her menstrual history assessing age at menarche, last menstrual period(LMP), regularity and frequency cycle. I’m aiming to assess whether she is peri- or postmenopausal.
Symptoms of hot flushes are assessed; the severity, duration symptoms, timing and her current method or treatment to relieve it is asked. I’d ask presence and severity of other associated menopausal symptoms; vaginal dryness, mood swings, insomnia.
Her medical history specifically a hx of coronary artery disease (CAD)- MI or angina, personal hx venous thromboembolic disease (VTED) –DVT/PE or thrombophilia disease is important. A family hx of 1st or 2nd degree relatives with VTED and inherited thrombophilia disease assessed. Presence of these, increases her risk of VTED on HRT. Hence, a thrombophilia screen is crucial prior to starting HRT if not done previously.
Previous hx of endometrial, breast, ovarian cancer and whether disease is still active is asked. Active breast cancer would be a contraindication for HRT. Personal or family history of osteoporosis is elicited. I’d also like to ask if she is a smoker, as this increases her risk of VTED.
Examination involves taking her blood pressure to exclude hypertension, pulse and temperature. I’d also measure her weight and height to calculate her BMI.
Investigations depend on history. In presence of a personal or family hx of VTED, I’d get a thrombophilia screen for inherited thrombophilia such as factor V leiden deficiency, prot s or c deficiency, AT 3 deficiency. To assess menopausal status if unclear from hx, I’d get a serum FSH, LH and estradiol level. FSH > 30iu/l suggests menopause.

Fr B:
Benefits include improvement of hot flushes and other vasomotor symptoms present. This should be the primary indication for starting HRT. HRT also prevents or delays onset of Alzheimer’s disease. However in existing Alzheimer’s disease, it does not delay its progression. It also provides bone protection against osteoporosis by reducing bone loss and increasing bone mass. The benefit is maximal 24 months after treatment. However, it does not reduce the incidence of hip fracture at 80 years old. It can reduce risk of vertebral fractures and tooth loss. It also protects against colorectal cancer and ocular degenerations (macular degeneration, cataracts). Urogenital atrophy is also helped with topical HRT in woman complaining of vaginal dryness. In stress incontinence, HRT has no benefit in treating this.

Risks include an increased (2-3x) risk of VTED-DVT/PE. This risk is compounded by the presence of pre-existing thrombophilia disease. In woman with high risk thrombophilia disease (anti-thrombin 3 deficiencies, multiple defects) or a previous hx VTED, HRT should be avoided. There is also and increased incidence of CAD with HRT use. In woman with existing CAD, the risk of recurrent disease is highest in the 1st year of use. In woman with no known CAD, continuous combined HRT increases the risk of CAD, stroke and PE. Thus, it should not be used as a primary or secondary prevention of CAD. There is also an increased risk of endometrial (with sequential or unopposed oestrogen HRT), breast and ovarian cancer. These risks are related to duration of use. Risk increases with prolonged use. Once HRT is stopped for 5 years, the woman’s risk of breast cancer declines to non-users (45/1000 woman over 20 years). However it’s use in women with premature ovarian failure does not increase the risk of breast cancer. There is also an increased risk of developing gallbladder disease on HRT.

For her symptoms relief, I’d recommend HRT for 2-3 years. Symptom improvements are usually seen in 4 weeks and are maximal at 3 months of tx. If she wishes to continue it after this period, I’d reassess her suitability and indication for continuing HRT. At most, I’d prescribe it for 5 years. After this period, the risk outweighs its benefit.

Thanks paul.
Posted by Mohamed A.
a)
I will start by asking about the onset and severity of hot flushes and its effect on her quality of life. I’ll ask about any other associated symptoms like vaginal dryness, dysparunia, decreased libido, urinary symptoms. Also I would like to enquire about LMP, parity, last smear history, the need for contraception, also previous contraceptive use and if any complications with COCPs and menopausal for how long. I will ask about family or personal history of breast cancer. Family or personal history of cardiovascular diseases and thromboembolic diseases. I will also ask about family history of osteoporosis.

I will check her weight, blood pressure and BMI. I may ask for a thrombophilia screen in women with a history of VTE or VTE in 1st or 2nd degree relatives.


b)
Potential benefits of HRT includes relief of vasomotor symptoms within 4 weeks and maximum response in 3 months, estrogen is associated with improvement in psychological well being. HRT prevents bone loss with some gain in density in first 18-24 months but should be taken life-long to be protective against osteoporosis. Estrogen may delay or prevent Alzheimer’s disease. Topical estrogen may relief vaginal symptoms. Estrogen and progesterone may decrease the risk of colorectal cancer. Also HRT may protect the woman from macular degeneration, cataract and tooth loss.



Risks of HRT include cardiovascular diseases, the WHI trial showed that continuous HRT is associated with increased risk of coronary heart disease, stroke and pulmonary embolism. Women with established coronary artery disease are associated with increased risk of coronary artery events in the first year.
HRT increases the risk of breast cancer, which is related to the duration of estrogen exposure. Risk in women who discontinued HRT for > 5years is similar to non-users.
Also women who develop breast cancer while on HRT tends to have bigger and more advanced tumors .
Sequential combined HRT but NOT continuous combined HRT is associated with an increased risk of endometrial carcinoma. HRT users are more likely to develop ovarian cancer which again is related to the duration of use. HRT is associated with a 2-3 fold increased risk of VTE, HRT should be avoided if multiple risk factors are present.
HRT is associated with systemic side effects like headache, fluid retention, breast discomfort, mood swings and depression. HRT may cause abnormal genital bleeding which may warrant investigations. Increased risk of gall bladder disease and may cause enlargement of uterine fibroids or reactivation of endometriosis.

I will advise the woman that HRT is beneficial in contrlling severe menopausal symptoms where the benefit of short term use outweighs the risks. I will advise her that she may use HRT for a maximum of 5 years duration, however,woman with a strong family history of osteoporosis who might need a life-long HRT or women who wants to continue HRT for a longer period(>5 years) must be properly counseled and assessed and provide written information regarding the risks of HRT use.
Posted by Ajith S.

A
I would ask details history regarding her severity of menopausal symptoms and what medications and therapies she tried so far. Menstrual history, past Gynaecology history- including surgeries, Breast or other hormone dependent cancers, pap smear, DVT , Cholystasis during pregnancy and past history of Fractures and any cardiovascular disease like MI, Strokes etch. I would inquire regarding Family Hx of DVT, Breast cancers, Osteoporosis, Stroke, Hyperlipidimias .
I will Inquire regarding her Mammogram and BMD scan .In Clinic I will check her BMI,BP PR, features of Hyperthyroidism, Breast lumps, LN enlargement , abdomen and Vaginal examination for any evidence of Atrophic changes and check of ovarian cyst. I would like to do some blood investigations – FBE, LFT, EUC, TFT, Fasting Lipids and Glucose levels, Mammogram and BMD scan if not already done. If there is past history or First degree relatives have History DVT I would like to do Thrombophillias screen.
B
I explain to her that HRT has following advantages Type of HRT and mode of taking HART depends on pt history and preferences –however is she has uterus need to take both forms of hormones. I explains to her there are are other alternative medications like SSRI, Clonidine for Symptoms relief but not effective as HRT.
It is good and best drug to control Menopausal symptoms like Hot Flushes, Night swatting, dry Vaginal Symptoms .HRT help to prevent Osteoporosis and Cancer of colon.
I will explain to her that following risks she has to take if she wishes to have HRT.HRT- either Estrogens or Estrogens and Progestogen can courses Deep Vein Thrombosis main risk is initially few months but risk is getting less with the time.HRT can causes Breast Cancer If uses longer than 5 Years. Also women who develop breast cancer while on HRT tends to have bigger and more advanced tumours So better to use HRT or short term-less than 5 years . If she Stops HRT within Five years Breast cancer risk will equal to person who did not use HRT. Though the actual risk is small but definitive risk is there. I advice her that necessity of self breast examination and annual breast check by GP.
There is evidence to say HRT associated with cardiovascular diseases especially people who have cardiovascular diseases.
There is weak evidence that HRT may helpful to prevent cognitive function impairment.
I will e give her written information’s and contact details of relevant organisations Ex Menopausal society details to her to educate herself.
If she like to trail of HRT will advice her that It will take 3-4 weeks to work well and try to stay in lowest possible dose.
Posted by Shalini  M.
Sh
a)It is essential to begin by taking a detailed menstrual history-LMP,frequency,duration of bleeding as hot flushes could be a symptom of menopause or climacteric period.History of urogenital symptoms like vaginal dryness,dyspareunia,bleeding suggestive of vaginal atrophy due to estrogen deficiency and urethral syndrome(dysuria,frequency,urgency)should be taken.it is essential to rule out any absolute contraindications to HRT like coronary artery disease,stroke,venous thrombolism in the patient.Also any past history of breast or endometrial cancer should be enquired into as it alters the treatment and increases risk of Hrt in such cases.Any family history of venous thrombolism should be asked and screening for thrombophilias is essential to rule them before prescription.Any history of fibroids or endometriosis in the patient should be enquied into as it can cause resurgence of symptoms.It is important to take her weigt n height to calculate the BMI as BMI>30 increases risk of venous thrombolism.Also the BP should be checked and her cervical cytology should be reviewed.mamography should be done to detect any asymptomatic breast lesions before prescription and it should be repeated eveer 3yearly.DEXA scan should be done to detect any osteoporosis.
b)HRT reduces vasomotor symptoms like hot flushes,anxiety,irritability,insomnia,as also memory loss,poor concentration,tiredness.Also urogenital symptoms of vaginal atrophy and urethral symptoms improve.Her libido and sexuality will improve.Also the risk of osteoporosis and vertebral fractures reduces as also the risk of colorectal cancer and development of Alzheimer\'s disease.Side effects are due to progestogen-mood swings,fluid retention(bloatedness,weight gain) and increased risk of breast cancer after 4 years of use.Increased risk of venous thrombolism is there with HRT which is immediately after starting the use.Also premenstrual stype symptoms occur.
There is no fixed duration of treatment and it has to be individualised after weighing the risks and benefits in each case.HRT should be prescribed for the shortest duration at the minimum dose for symptom relief only and should be graduallly tapered in a step-wise fashion over 6 months to prevent immediate symptom recurrence.Thus it should be prescribed in this case till she is relieved from her symptoms and then tapered slowly.
Posted by robina K.
(A) At 53 years i will presume that she is postmenopausal.History about the severity of hot flushes affecting her quality of life should be obtained.Other symptoms like vaginal dryness,decreased libido,night sweats and insomnia should be obtained.Presence or absence of uterus is also important as this will effect the type and duration of HRT.Detailed history is asked to rule out absolute and relative contra indications to HRT.Active breast cancer, active genital tract cancers, active venous thromboembolism and active liver disease are absolute contra indications.Previous breast cancer,previous thromboembolism and hypertention are relative contra indications.I will also inquire about last smear and result.

I will check her B.P , BMI and will perform breast examination for any lump.An abdominal examination is performed for any masses and a bimanual pelvic examination to confirm any mass suspected on abdominal examination.A cervical smear is taken if due.A mamography is advised if breast lumps are found or if the breast examination is inconclusive.Thrombophilia screen is offered if personal or family history of DVT.A lipid profile is also advised.

(B) Regarding benefits of HRT I will tell her that it relieves vasomotor symptoms like hot flushes, night sweats and insomnia, has beneficial effect on genital tract like HRT may prevent prolapse relieves vaginal dryness thus improving libido, however personal,social and psychological causes for decreased libido should be explored.HRT also decreases the incidence of urogenital tract infections like endometritis and trigonitis.With HRT there is a general feeling of well being.
Long term use of HRT prevents osteoporosis ,improves hair and skin quality, delay tooth and visual loss by decreasing macular degeneration.HRT also decreases incidence of Alzeihmer disease and colorectal cancer.
Explaining the risks of HRT I will give her information about the risk of developing breast cancer.Breast cancer risk at 50 years is 31 per 1000, use of HRT for 5 years is associated with an increase risk of 38 per 1000 and after 10 years use risk is increased to 51 per 1000.
With HRT there is 2-3 fold increase in risk of venous thromboembolism.There is increased risk of stroke specially in the first year of use.Increased risk of coronary heart disease specially in first year if there is previous history of coronary artery disease.There is also increased risk of endometrial carcinoma if combine sequential or unopposed HRT is used.There could be drug side effects like weight gain, breast tenderness, acne, depression and bloatedness. I will tell her that all these side effects are rare and i will provide her with written information.
I will provide her the information about the types of HRT and routes of administration.If her uterus is intact she can choose among the combine HRT and if she has no uterus she can have estrogen only HRT. HRT can be administered orally as combine tablets taken continously to avoid any unwanted bleeding.Other routes are transdermal daily estradiol patch or gels progestogens can be used orally or in the form of mirena.Other routes could be vaginal rings,creams or sub dermal implants.I will inform her that for vasomotor symptoms she should take HRT for 1-2 years and should have yearly B.P. BMI and mammography checkup done and if there are symptoms of VTE LIKE unilateral leg swelling, breathlesness or chest pain she should stop HRT immediately and contact her doctor.I will also discuss the alternatives of HRT like life style modification exercise,avoiding cofee, tea hot environment.Eating food rich in phytoestrogens like cereals, soyo and red clover leaf.Other alternatives to HRT should be discussed like SSRI paroxetine, SNRI venlafaxine and transdermal clonidine.Complementory therapies like reflexology and accupunture, herbs and homeopathic substances should be discussed ,though there efficacy is not evidence based.These include black cohosh, st johnes wort, ginseng and agnus castus.Finally iwill provide her with written information.
Posted by robina K.
A little addition to part A .When HRT is discontinued after 5 years of use the risk of breast cancer falls to the background risk. Thanks
Posted by robina K.
SORRY the addition is for part B THANKS
Posted by Ron C.
RnRn
A.
I’ll explore exact nature of any additional symptoms other than hot flushes, severity of her symptoms, impact on quality of life and whether compromises everyday social and/or working life. I’ll find out what she has tried so far, whether she smokes, takes alcohol and caffeinated drinks. I’ll ask when her final menstrual period was (truly >12 months amenorrhea ?), post-menopausal or post-coital bleed, a brief cycle & smear history including any past hormonal contraception. Her previous obstetric history and gynae history, in particular surgery (uterus present ?). a personal or family history of medical problems, in particular DVT, stroke, cardiovascular disease, breast cancer or endometrial cancer. On examination I’ll assess blood pressure and pulse, weight & height for BMI. Legs for varicose veins, breasts for any lumps. I’ll only arrange bloods for thrombopathy screen in a positive personal or family history for DVT/PE. I’ll arrange bloods for lipid-profile and – if not certain- for FSH to confirm peri-menopause.

B.
Duration for younger women till average age of menopause; 51-52. In this situation till 54-55, as mostly symptoms resolve in 2 years. After this re-assessment and/or a trial of stopping is indicated. Main advantage is improvement of vasomotor symptoms, with often improved mood/irritability as well. Some may feel more energetic and sleep better. Aging of skin, teeth and eyes are slowed down. Calcium loss from bones seen in menopause is halted, which may reduce risk for fractures. This protective effect only lasts while on HRT and calcium loss will occur after all once HRT stopped. Beneficial effect on cognitive function/reduce risk Alzheimer are not proven. Unopposed estrogen increases risk of endometrial cancer in women with a uterus and progesterone needs to be added, though even sequential combined HRT still has increased risk. All other risks are lower for estrogen-only HRT. Breast cancer risk is related to duration, with 2, 5 & 12 extra cases per 1000 after 5, 10 & 15 years use. Risk normalizes within 5 years after stopping. Risk for DVT increased (relative risk 1.4) mainly in first year of use, transdermal HRT may reduce this risk. Risk of stroke and cardiovascular disease/ myocard infarction are increased, but these data are based on a population that was many years post-menopausal with higher average age. More recent suggests even a possible protective effect in younger women who only recently turned menopausal, though further research needs to confirm this.
Posted by Dr Saritha M.
a)
I will enquire the severity of hotflushes and its effect on sleep like insomnia, associated urogenital symptoms ike dysuria, dyspareunia, vaginal dryness. Her menstrual history regarding last cyles regularity,excess blood loss, spontanesous cessation. duration since her last cycle. Personal history of smoking, Previous history of thromboembolism,cardiovascular problems, history breast malignacy is enquired. Family history of thromboembolism and breast cancer is enquired.
On examination, BP measurement, BMI is checked. Rotine gyneacological examination is not done but if symptoms indicative then it is carried out. But it is taken taken as a screening opportunity for bresat examination, pelvic examination, cervical cytology.
B)
Potential benefits of HRT are improvement in vasomotorsymptoms by 4weeks and maximum response for by 3 months. even pschologica symptom improvement is seen. Improvemrnt in the osteoprosis increase in done density or delays resorption if taken for 2 years. but to be taken for life long but risk are more on long term.it delays or prevent Alzheimres disease , long term protection of coorectal carcinoma with both estrogen and progesterone but if detected in the advanced stage.significant improvement in the urogenita symptoms if given topically, not effective in stress incontinence.it also decrease the macuar degeneration
Risks inculde breast cancer it is more if used moer than 5 years. on discontinuation it drops to never users risk. it also increase endometrial hyperplasia and carcinoma, any history of bleeding to investigated with biopsy, increase risk of coronary heart disease even in without prior history of risk factor hence not used for CAD prvention. Increased risk of thrmboemboism in the first year of use and hence not given with previoshistory or presence of 3 /4 risk factors. systemic side effects of estrogen and progestrone to be explained.
provide written information leaflets and advise ragarding follow up and report any sign of thrombolism are present.
Posted by A A.
PART A
I will enquire about severity of her symptoms and its effect on quality of life.Any other symptom like vaginal dryness and night sweating.I will ask about date of LMP,cycle length,regularity and amount of bleeding or whether she is postmenopausal.I will ask about presence of uterus or if she had hysterectomy( whether indication was estrogen based).I will ask about her past history of MI/CVA,angina,hypertension and smoking.Family history of cardiovascular disease.I will enquire about personal and family history of venous thromboembolism.I will ask about her personal and family history of breast cancer,ovarian cancer and endometrial cancer. Present/ past history of contraception and any complication associated with COCP.I will ask about her family history of osteoporosis.In Examination I will check her BP and BMI.If women is asymptomatic there is no need of any other investigation.However if women has personel and family history of VTE I will do her thrombophilia screening.
PART B
I will explain to her that potential benefits and risks/side effects depend upon type of HRT (Estrogen + progesterone, either sequential or continuous combined HRT), duration of use and to some extent route of administration. I will explain that postmenopausal symptoms are usually transient and therefore treatment requires only for one to two years, but definitely < 5 years.
Main benefits of HRT is symptom control like improvement in hot flushes, night sweats and vaginal dryness. It also improves the psychological well being and quality of life. There is improvement in skin and hair. Additional benefits include reduction in risk of osteoporosis, Alzheimers disease, colorectal cancer, cataract, macular degeneration and tooth loss. But all of these effects occur only after long term use and would not apply for short term use of HRT for symptom control. Regarding its risk HRT is not protective against and is associated with increased risk of cornary heart disease and stroke, specially in first year of use. So in the presence of cardiovascular risk factor HRT will not be recommended and other alternatives should be used. I will explain that HRT also increases the risk of VTE about 2 to 3 fold particularly in first year of its use.There is also increased risk of breast cancer with long term use (background risk is 32 per 1000 women over 15 years use). With estrogen + progestiron HRT use of 5 and 10 years, risk of breast cancer increases to 38 and 51 per 1000 women respectively. Discontinuation of HRT for 5 years will result in the reduction of risk equal to never users. So short term use of HRT benefits outweigh the risk. I will explain there is also increased risk of ovarian cancer which increases with increased duration of use. There is also increased risk of endometrial carcinoma, but it is only associated with Estrogens and sequential HRT. There is also drug side effect like fluid retention, headache, breast tenderness and mood swings. HRT can also cause vaginal bleeding and gall bladder disease requiring investigation. But I will reassure the woman that overall these risks remain small. In the absence of above risk factors HRT can be used for 1 to 2 years for symptom control and definitively <5years.other options can be used like clonidine, SSRI(Paroxetine/Fluoxetine) or SNRI, Progesterones like megesterol, for vasomotor symptoms control but are less effective than HRT. For vaginal dryness local treatment like lubricants and topical estrogen creams can be used, advise on life style changes like regular and sustained exercises should be done and cafeinated drinks should be avoided.
I will provide written information about the benefits and risk of HRT.

Posted by Leen K.
LEEN
A 53 year old woman has been referred to the gynaecology clinic because she requests hormone replacement therapy (HRT) for debilitating hot flushes. (a) Describe the assessment you would undertake in the clinic [7 marks]. (b) She is suitable for HRT. Discuss the potential benefits and risks of HRT and your advice on the appropriate duration of treatment [13 marks].

(a) My assessment would include taking a detailed history to assess her suitability for HRT, in particular loooking for any relative or absolute contraindications to HRT. I would ask her about her last menstrual period. I would also ask her about the presence of any unexplained vaginal bleeding she might have - HRT should not be given until the bleeding is investigated, as it might mask symptoms of genital tract cancers. I would want to find out about her previous contraception, especially any problems she had with oestrogen based contraception - eg. migraine, thromboembolism (TE). A gynaecological history should also include previous surgery (such as hysterectomy and/or oophorectomy)
I would also want to ask about her past medical history, in particular history of previous stroke, TE, breast cancer(whether it is oestrogen or progesterone receptor positive), arterial disease, cardiac disease, thrombophilia; all of which are either relative or absolute contraindications to HRT usage. A strong family history of stroke, TE or breast cancer might prompt investigations such as thrombophilia screening or even genetic testing (eg. BRCA1 & 2 gene mutation, hereditary non-polyposis colon cancer gene mutation)
Examination should include assessment of her body mass index, as extreme obesity is an contraindication. Blood pressure should also be measured to exclude hypertension.

(b) HRT will most likely improve her vasomotor symptom(s) and therefore improve her quality of life. It will also protect her against osteoporosis whilst she is on it, although she will need lifelong HRT to prevent her from getting osteoporosis. HRT is also associated with a decreased risk of colon cancer and Alzheimer\'s disease. It has also been shown to improve lipid profiles, more so in transdermal oestrogen route.
However, despite the improved lipid profiles, HRT does not protect against cardiac disease, and should not be used as cardio-protection. There is also an increased risk of stroke and venous TE, especially in the first year of use. HRT is also associated with an increased risk of breast cancer and endometrial cancer among its users. The risk of venous TE and breast cancer drops back to general population risks levels 5 years after stopping HRT.
HRT is recommended for 2-3 years for relief of vasomotor symptoms. It should be tailed off gradually, rather than stopped suddenly, to reduce the risk of vasomotor symptoms recurring suddenly.
Posted by Shilpa G.
h/o onset ofmenopause duration of hotflushes and their progression, other symptoms like mood disturbances, loss of libido, vaginal dryness, urinary incontinence, venous thromboembolism, previous h/o stroke , cerebrovascular accident , h/o thrombophilia, o/e BMI , blood pressure ,
b. the benefits of HRT are the releif of her hot flushes and other vasomotor symptoms, urgency , urge incontinence, prevents osteoporosis for the duration of HRT , once HRT is stopped , benefit declines. HRT with testosterone improves libido. the adverse effects are increased risk of breast cancer during the course of HRT but risk returns to that of women who have never had HRT soon after it is discontinued. the risk is related to duration of therapy and not the dose. COC preparation increases the risk of breast cancer than estrogen alone , increase false positive and false negative mammogram tests because of increase in the mammographic density by progesterone . increase in risk of stroke and myocardial infarction .HRT does not appear to be effective for alzhemer\'s disease . Estrogen only therapy is associated with increased risk of endometrial carcinoma whereas combined HRT does not have increased risk
Posted by Manoj M.

M
(a) A history of other vasomotor symptoms like night sweats, with severity of symptoms and affect on quality of life.
A history of other menopausal symptoms like vaginal dryness.
A personal and family history of cardiovascular diseases to ascertain risk factors like ischaemic heart disease and history of smoking.
A history of thrombosis, personal and family to ascertain risk factors.
Risk factors of breast cancer both personal and family history.
Past history of hysterectomy to ascertain need of progesterone arm of HRT.
A drug history to exclude any interaction with HRT.
I will ask about her last smear and results prior to HRT.
I will check her BP and BMI prior to commence her on HRT.

(b)Most menopausal symptoms are transient.
Benefits of HRT are symptom control especially her vasomotor symptoms with debilitating hotflushes.
It may also help her with other menopausal symptoms e.g. sleeplessness, vaginal dryness.
Long term benefits of using more than 5 years include protection against osteoporosis, delays onset of Alzeheimers disease, tooth loss, macular degeneration and colorectal cancer.
Short term risk include increased ischaemic cardiovascular and stroke risk in the first year of use especially with underlying cardiovascular disease.
Increases risk of venous thrombosis in the first year of use.
Long term risks include breats cancer risk when used 5-15 or more years (baseline risk of breast cancer 32/1000 with combined estrogen progesterone HRT use, increases to 38 and 51/1000 with 10 and 15yrs use). When discontinued for 5 years goes to background risk.
OTher risks involved include endometrial cancer risk in non hysterectomised woman and abnormal vaginal bleeding requiring investigations.
There is also increased risk of gall bladder disease.
The overall risk of taking HRT is small and this depends upon risk/benefit assessment.
I will advice regarding need for thrombophilia screen priro to HRT if personal or famility history of thrombosis or thrombophilias.
I will advice the duration of HRT depends on the needs of the patient for symptom control especially her vasomotor symptoms and she can use it as long as she wants understanding the risks involved.
She will need yearly review or earlier if her risk factors changes.
She has safer alternative for osteoporosis prevention like bisphophonates.
Advice on breast self assessment and educate on symptoms of thrombosis and to seek medical attention if any symptoms.
Posted by ELIZA SHIREEN E.
A)
Hormone replacement therapy is effective treatment for menopausal symptoms such as hot flushes.Assessment should be done for its suitability.A detailed history particularly other menopausal symptoms such as hot flushes, vaginal dryness,dyspareunia,night sweats ,their severity and effect on quality of life.Her LMP, cycle length,amount of bleeding, whether she is postmenopausal will be asked.Presence of uterus or history of hysterectomy will also be asked.Her personal and family history of cardiovascular disease,MI,stroke,or symptoms suggestive of cardiovascular disease such as chest pain or shortness of breath, thromboembolism,breast cancer should be asked.Family history of osteoporosis should be enquired.Personal history of endometrial cancer,ovarian cancer is to be taken.Drug and contraceptive history especially any complications from the use of COCP will be needed.
Clinical examination includes BP and BMI should be cheked.
If she has no history or symptoms of VTE or CVD ,she does not require any investigations.Thrombophilia screening should be done in presence of family history of VTE.
B)
Woman should be explained about benefits ,risks ,type and duration of HRT.The main benefit will be symptom control –hot flushes, vaginal drynessand feeling of general wellbeing.There are potential silent benefits such as prevention of osteoporosis colorectal carcinoma,alzheimers disease,macular degeneration but these may only be achieved with long term use and would not apply with short term use to control menopausal symptoms.Other benefits include improvement of skin and hair quality,decrease risk of tooth loss and visual loss.
HRT does not protect against and is associated with an increased risk of coronary artery disease and stroke especially in the first year of use. Risk of thromboembolic disease is particularly increased in the first year of use.The risk of breast cancer is associated with long term use of HRT (more than 5years use).In a 50 year old woman use of combine HRT for 5 and 10 years increases risk of breast cancer to 38 and 51 per 1000 respectively.The risk in women who have discontinued HRT for 5 years is dreased to similar to that in never users.Risk of endometrial carcinoma is associated with long term use of sequential HRT only. Other risks include gall blader disease,drug side effects, abnormal vaginal bleeding require investigations.The overall risk of complications in women taking HRT remains small.
The potential risks and benefits need to be balanced with the severity of symptoms and their effect on woman’s life.For menopausal symptoms recommended duration of therapy is one or two years and not more than 5 years.
Alternatives to HRT should be discussed and written information about risks,benefits and duration should be provided.
Posted by PAUL A.
A/
I would take full menstrual history, age at menarche, menstrual cycle, intermenstrual or irregular vaginal bleeding. If she is not menstruating, age at menopause (1) . I would ask about personal and family history of venous thromboembolism (1) , most especially, first and second degree relative. Personal and family history of breast cancer. Life stlye like smoking, sedentary or active life stlye. Result of her last cervical smear test. Previous surgery like hysterectomy (1) ? cardiovascular disease, osteoporosis .
Examination would include her height, weight and BMI. I would check her blood pressure. Abdominal examination for any palpable abdominal or pelvic mass (1) .
If there is personal or family history of Venous thromboembolism, I would request for thrombophilia screening before commencing HRT treatment (1) .
B/
HRT would reduce the vasomotor symptoms like hot flushes and night sweating (1) . It would improve vagina lubrication thereby reduce the risk of vagina dryness and dyspareunia. It reduces the risk of osteopenia and osteoporosis while on treatment ..
May improve cognitive function, reduce the risk of colorectal cancer and reduce the risk of Alziemer disease (1) .
There is increase risk of venous thromboembolism, stroke, coronary heart disease, deep vein thrombosis and pulmonary embolism this is a list . The risk is highest in the first 3months of use and gradually reduces by one year.
Risk of breast cancer increase by how much? with the use for more than 5years. Therefore, I would recommend the use for about 1 to 2 years and it should be less than 5years (1) .
Estrogen only HRT increase risk of endometrial cancer in women with uterus is risk not increased with oestrogen + progestogen HRT? .
Cardiovascular disease, ovarian cancer, drug side-effects
I would provide written information leaflet to enable her make well informed decision. Clear documentation of discussion and advise given. Yearly breast examination, most especially if she has personal or family history of breast cancer. Regular monitoring of blood pressure by her GP. To report any unexpected vagina bleeding. I would also advise her to reduce smoking, caffiene and do regular exercise. YOU NEED A MORE DETAILED DISCUSSION OF RISKS – SEE NOTES ON HRT
Posted by PAUL A.
A.
Initial assessment should include full history taking asking more detailed question about her presenting complaint time it started, any precipitating factors what would you expect to be a precipitating factor? , association with night sweats. Full menstrual history including Last menstrual period (1) not assuming she achieved menopause, frequency, regularity, heaviness and duration of her periods. Method of contraception used, sexually active or not. Date of last cervical smear and any abnormality. Associated menopausal symptoms (1) of Urogenital symptoms e.g. (urinary symptoms, dyspareunia, symptoms of vaginal dryness as itching is this a menopausal symptom? or burning and decreased libido ? menopausal symptom . Past history of confirmed DVT or pulmonary embolism. Cardiovascular risk (1) factors e.g. smoking, hypertension, diabetes. Ask about symptoms of thyroid disease (weight changes, palpitation, appetite changes) why? . History of breast cancer and date of last mammogram if appropriate why if? . History of migraines should be ascertained WHY? Is HRT contraindicated? . History for risk factors of osteoporosis e.g. hyperthyroidism, hyperparathyroidism, mal-absorption syndrome. Current medications e.g calcium, steroids or tamoxifen for breast cancer. Previous surgeries e.g. hysterectomy (1) or oophrectomy as this might affect the type of HRT (oestrogen only or combined Oestrogen progesterone HRT). Family history of breast, colon, ovarian cancer, DVT, Osteoporosis.
General examination looking for signs of hyperthyroidism you have ignored basic things like BP and BMI and have dedicated a large proportion of time and space to hyperthyroidism!!! (e.g. tachycardia, sweating) as it might be associated with hot flushes, vaginal examination may show vaginal dryness however is not conclusive.
Request investigations for thyroid function tests (Free T4, TSH) as abnormalities of thyroid may be confused for menopausal symptoms Are you suggesting that women who present with menopausal symptoms should have TFTs before HRT is prescribed? (-1) . Bone mineral density if significant risk factors for osteoporosis.
B.
If she is suitable for HRT, Benefits of HRT are decreased vasomotor symptoms (1) which manifest as hot flushes; Oestrogen is effective in treatment of hotflushes however it takes 4 weeks to manifest and the maximum therapeutic response after 3 months. It should be continued for 1 year otherwise symptoms are more likely to recur ? evidence . HRT decrease urogenital symptoms and improve sexuality ? evidence?? How do you measure ‘sexuality’ and what is the evidence that this is improved by HRT? . Vaginal oestrogen is associated with improved vaginal dryness and associated symptoms of itching this is not a menopausal symptom and dysparuenia however urinary symptoms of frequency, urgency, nocturia and incontinence do not improve symptoms of urogenital atrophy including urinary frequency and urgency may improve . Sexual drive might not improved by oestrogen alone by need additional testosterone. HRT decrease the risk of osteoprotic fractures. Evidence does suggest lifelong HRT is required for an effective prevention of osteoporosis and it is also cheaper than other suggested therapies for osteoporosis like biphosphonates IF YOU READ THIS IN A BOOK, THROW IT AWAY AND NEVER OPEN IT AGAIN. The risks of life-long HRT use far outweigh any potential benefits including osteo-protection (-1) . HRT also decrease the risk of colorectal cancer by 1/3 however HRT is not licensed now for prevention of colonic cancer. HRT should be continued for 1 year or symptoms will recur and often used for fewer than 5 years will symptoms not recur if it is used for 3 or 5 years? .
HRT are associated with certain risks, increased breast cancer which is similar to late natural menopause which is 2.3% per year that why risk is dependant on duration of HRT type of HRT (more with combined Oestrogen progesterone) but the effect is not sustained once HRT is stopped ? meaning?? Is 2.3% the absolute risk or the increase in risk? Is this per year of taking HRT? . Unopposed oestrogen increases the risk of endometrial cancer, risk remains increased for 5 or more years even after stopping HRT however addition of progesterone does not eliminate the risk completely especially if used more than 5 years by how much is the risk increased? . Venous thromboembolism risk is more than doubled (1) but absolute risk remains small. The number of additional VTE events in healthy women on HRT for more than 5 years is 4:1000 between 50-59 years of age. RISK of VTE is more likely to be in the first year of using HRT however transdermal HRT has lower risk of VTE compared to oral. HRT may also increase the risk of gall bladder disease however obesity and age may be contributing factors.

Suggest you read notes on HRT and RCOG document here:

http://www.rcog.org.uk/womens-health/clinical-guidance/menopause-and-hormone-replacement-study-group-statement
Posted by PAUL A.
(a) Describe the assessment you would undertake in the clinic [7 marks].

I will ask her about symptoms of menopause (1) she is getting other than hot flushes eg night sweats, vaginal dryness, urinary frequency & recurrent UTI & irritability. I will also ask her how these menopausal symptoms have affected her quality of life (1) .
I will take a detailed menstrual history: when her last menstrual period was, whether it was regular or not ? meaning – how is LMP regular? , any undiagnosed abnormal vaginal bleed - intermenstrual or postcoital bleed. I will also ask what contraception she is on & whether she still has an uterus (1) or not. I will then ask about significant medical history eg liver disease & predisposing factors that can increase risk of HRT. These include previous history of breast cancer, venous thromboembolism (VTE) - DVT or PE (1) , thrombophilia (eg Factor V leiden mutation or anti-thrombin III deficiency), MI or stroke and osteoporosis. I will also ask her any family history of VTE, thrombophilia, osteoporosis or breast cancer (1) . I will ask about smoking & alcohol intake & what drugs she is on (prescribed & not prescribed eg st john\'s wort) which may interfere with the actions of HRT.

On examination i will check her BMI & blood pressure (1) . I will check her serum FSH/LH & estradiol. High FSH (more than 30) & LH with low estradiol which will confirm that she is menopausal not necessary and should not be done (-1) . I will also do a thrombophilia screen if there is strong family history of VTE (1) .

(b) She is suitable for HRT. Discuss the potential benefits and risks of HRT and your advice on the appropriate duration of treatment [13 marks].

HRT is proven to be effective of relieving symptoms of menopause eg hot flushes, night sweats, irritability & vaginal dryness (1) . In addition it can reduce the risk of osteoporosis during treatment & colorectal cancer.
HRT, however can increase the risk of venous thromboembolism by how much? . The risk is higher if there is personal or family history of VTE & thromphilia. It can also increase the risk of breast cancer by how much? . In women who have an intact uterus, estrogen only HRT can increase risk of endometrial hyperplasia & thus endometrial cancer does oestrogen + progestogen HRT not increase risk? . HRT can also worsen lipid profile and therefore increase risk of coronary heart disease & stroke. In addition it increases the risk of developing Alzeimers disease DOES IT??? ALL AVAILABLE EVIDENCE POINTS TO A POTENTIAL REDUCTION IN RISK (-1) .

I will give her written leaflet on risks & benefits of HRT.

I will advise her not to take it more than 5 years (1) or stop it earlier if she develops any complications or if she wants. We should start her on lowest effective dose & review her yearly. After after 5 years, if she declines to stop it, she should be counselled against the risks & balance it with the benefits to produce an informed choice.


SUGGEST YOU READ NOTES ON HRT
Posted by PAUL A.
Sanchu
Her other menopausal symptoms (1) like vaginal dryness, mood swings should be asked for since only hotflushes can be managed with other non-hormonal drugs if HRT is contraindicated. Her menstrual history should be obtained. If she is still menstruating, she will be suitable for sequential HRT. If she is in amenorrhea, she would be suitable for the continuous combined HRT not necessarily – will have to be at least 12 months from LMP . Her medical history should be obtained in detail. H/O Thromboembolic disorders like a DVT, PE, Ischemic heart Disease, TIA or Stroke (1) would contraindicate estrogen. H/O Diabetes and Hypertension would also contraindicate HRT. H/O Breast cancer (1) should be asked for since HRT should be started after discussion with the oncologist.
Family H/o thrombophilia like Factor V Leiden mutation would indicate her thrombophilia screening before prescribing HRT (1) .Drug History to find interacting drugs like anti-epileptics how do these affect therapy? You are not prescribing COCP should be obtained. Surgical history of Hysterectomy (1) would indicate estogen replacement without progesterone.
Family H/O Breast cancer should be asked for and her predisposition to breast cancer should be determined. H/O smoking should be asked for since it adds to the risk of thromboembolism. would you examine her?

b) The benefits of HRT would be to relieve menopausal symptoms (1) namely hot flushes, vaginal dryness and mood swings. It is beneficial to prevent and treat osteoporosis does it treat osteoporosis? but the benefit lasts only as long as it is used. are there any other potential benefits?
Although the WHI study showed that it has adverse cardiovascular effects and combined estrogen + progesterone increases the risk of breast cancer , it was done on women 10 years older than the average onset of menopause. Now, it is proven not to have adverse cardiovascular effects in the younger age group when started at the start of menopause. With regard to breastcancer, it does not increase the incidence of breast cancer if used in the younger age group and if used short term i.e. for a maximum of 5 years (1) so what if used for more than 5 years? . It does increase the risk of venous thromboembolism three-fold (1) and the risk can be minimised if transdermal preparation is used. what about risk of endometrial cancer, ovarian cancer, drug side-effects?

See notes on HRT and RCOG document here

http://www.rcog.org.uk/womens-health/clinical-guidance/menopause-and-hormone-replacement-study-group-statement
Posted by PAUL A.
I would ask her of frequency and severity of her hot flushes and effect on her quality of life (1) .Would enquire of other menopausal symptoms (1) like night sweats and palpitation.Will ask of her sexual life and if noticed changes like decrease in libido and vaginal dryness.History of nocturia and urgency.Any change in temper . Personal or family history of cardiovascular disease or hypertension.Personal or family history of venous thromboembolism (1) may indicate thrombophilia. Personal or family history of breast or endometrial cancer (1) .Family history of osteoporosis.Will ask of social history including smoking ,alcohol intake and fluid and beverage intake.Ask of her last pap smear and if was ok.
In examination will detect body mass index and measure blood pressure (1) .



Benfits of HRT will include alleviation of her menopausal symptoms (1) .These are the short term benfits and are felt by the patient within one to two weeks of start of treatment.There will be dissapearance of hot flushes,palpitation and night sweats, improvement of her sexual life ? evidence?? and lubrication of vagina,in addition to better sleep at night due to absence of night sweats and nocturia.There is improvement in her skin texture and quality of hair and patient feel younger such claims are used to sell HRT in magazines but should not be made by doctors .
If patient contiue with HRT for more than 5 years benfits like reduction in osteoporosis,decrease in teeth loss and macular degeneration, and reduction in colorectal cancer will occur (1) osteoporisis – need to be life-long to prevent fractures. There is controverse regarding regarding reduction in Alzhymer disease.
Risks include cardiovascular effect,increasing the risk of coronary artery disease.It was thought to be protective but randomized controlled trials showed the reverse (This is for the combined HRT and not estrogesn only HRT ).There is also increase in the risk of cerebro vascular strokes (1) .There is 2 to 3 fold increase in the risk of venous thrombosis (1) .
There is increased risk of gall bladder disease and and side effects of estrogen and progesterone like headache, weight gain, acne, and bloatedness , and vaginal bleeding which may not be welcomed by the patient (1) .
With prolonged use for more than 5 years there is increased risk of breast cancer. In a woman over 50, the risk of cancer breast is 32 per 1000 women over 15years. Use of combined HRT for 5 years increase risk to 38/1000 and use for 10 years increase risk to 51/1000 women (1) .Risk of endometrial cancer only increase with use of unopposed estrogen only HRT stimulation not true – also increased with sequential combined HRT .
For this woman, given the fact that short term benfits are beneficial language , so being suitable for HRT ,I would advice her to take HRT to cover her debilitating hot flushes assuring her that these are temporary and are likely to disappear by themselves how long is short-term? . I would tell her of the risks and benfits if she take them for long time and would let her decide and her wishes respected.I would give her written information to help her decide.
Posted by Lanka  A.
A 53 year old woman has been referred to the gynaecology clinic because she requests hormone replacement therapy (HRT) for debilitating hot flushes. (a) Describe the assessment you would undertake in the clinic [7 marks]. (b) She is suitable for HRT. Discuss the potential benefits and risks of HRT and your advice on the appropriate duration of treatment [13 marks].
a)
I would obtain a clinical history to determine the duration of her menopause, and any episodes of post menopausal bleeding as well as any investigations such as endometrial biopsies . if she is still menstruating, frequency, duration and severity of bleeding and associated dysmenorrheoa.
I would inquire about her parity, mode of delivery of her children and current method of contraception.
past medical history of cardiovascular events such as strokes, ischemic heart disease, thrombophilia, thromboembolic episodes such as DVT and pulmonary embolism.
I would note any history of breast cancer or any other estrogen dependent cancers such as endometrila cancer
other medical diseases such as diabetes, hypertension , hypercholesterleamia, liver disease, osteoporosis, any fractures and their severity as well as current management details.
I would inquire about any first degree relatives suffering from above mentioned conditions.
I would note her smoking status

b)
I woud explain that HRT is would be given to replace hormones that are not produced by ovaries and given for minimal duration for the shortest duration
HRT would be helpful in reducing the distressing hotfluses, night sweats. it is beneficial in reducing the risk of hip fractures at early stage by preventing osteoporosis. HRT has shown to reduce colorectal cancers. HRT will not increase the risk of breat cancer in the first 5yrs and it will increase after that.
additinally HRT will releive symtoms such as vaginal dryness, irritable bladder symptoms
other risks associated with HRT are, it increases the risk of thromboembolism, coronory heart disease, stroke
HRT does not increase the life expectancy and there is no difference in the death rate between users and non users
HRT does not act like a contraceptive therfore if she is premenopausal contraceptive use simultanouesly is necessary
I would advice her on minimal dose of HRT preferably transdermal for not more than 5yrs to reduce the risk of thromboembolism and other vascular and liver diseases
Posted by PAUL A.
a) You consistently produce one of the shortest answers – it should be apparent that you need more detail to earn marks

i would ask regarding her LMP (1) , periods and any abnormal bleeding. Others symptoms such as vaginal dryness, mood swings, headaches, visual disturbance is visual disturbance a menopausal symptom? etc writing this is a waste of time should be noted. Relevant past medical history including history of high blood pressure, diabetes,thyroid disease, previous DVT, breast cancer, any Gyneacological cancer ( or family History of such), smears history should be noted you will not get marks for writing a list. I will enquire about personal or family history of breast cancer because HRT is associated with an increased risk. Then deal with cardiovascular disease, DVT… . Relevant surgical history such as previous hysterectomy (1) , oophorectomy should be noted as well. Drug history should be requested and any alergies noted you will not get marks for such statements unless there is a specific drug of relevance . Thereafter i would proceed to a general examination noting the blood pressure ? BMI , pulse rate, a cardiovascular examination should also be carried out but abdominopelvic examination in the absence of any other complain may not be indicated.

b). The benefits of HRT would include protection against Osteoporosis you certainly do not start with this – she presented with menopausal symptoms. HRT has to be used life-long to provide osteo-protection , cardiovascular disease THIS CAN NO LONGER BE REGARDED AS A BENEFIT EVEN IN YOUNGER WOMEN -particular in the younger age group(under 55yrs), protection against Alzheimer\'s disease and dementia you have not mentioned menopausal symptoms!!! . The risk of breast cancer- particularly if HRT is used for more than 5 years should be discuused so why have you not discussed it? How high is the risk? . Risk of deep vein thrombosis and cardiovascular disease you said this was a benefit if used for more than 5 years should also be discussed YOU SHOULD DISCUSS IT – WHAT IS THE RISK OF DVT?? ENDOMETRIAL / OVARIAN CANCER; DRUG SIDE-EFFECTS .
I would advice her not to use HRT for more than 5 years if possible and to stop as soon as the symptoms are better or well controlled are you suggesting that she takes HRT for 3 months and her symptoms improve then she stops? What will happen to her symptoms then?? . I would advice on lifestyle changes such as exercise, healthy diets that could help with her symptoms alongside her HRT. SUGGEST YOU READ NOTES ON HRT
Posted by PAUL A.
NSK

Fr A:
I’d enquire her menstrual history assessing age at menarche, last menstrual period(LMP), regularity and frequency cycle. I’m aiming to assess whether she is peri- or postmenopausal (1) .
Symptoms of hot flushes are assessed; the severity (1) effect on quality of life, duration symptoms, timing and her current method or treatment to relieve it is asked. I’d ask presence and severity of other associated menopausal symptoms (1) ; vaginal dryness, mood swings, insomnia.
Her medical history specifically a hx of coronary artery disease (CAD)- MI or angina (1) , personal hx venous thromboembolic disease (VTED) –DVT/PE or thrombophilia disease is important. A family hx of 1st or 2nd degree relatives with VTED and inherited thrombophilia disease assessed (1) . Presence of these, increases her risk of VTED on HRT. Hence, a thrombophilia screen (1) is crucial prior to starting HRT if not done previously.
Previous hx of endometrial, breast, ovarian cancer and whether disease is still active is asked. Active breast cancer would be a contraindication for HRT. Personal or family history of osteoporosis is elicited. I’d also like to ask if she is a smoker, as this increases her risk of VTED.
Examination involves taking her blood pressure to exclude hypertension, pulse and temperature. I’d also measure her weight and height to calculate her BMI (1) .
Investigations depend on history. In presence of a personal or family hx of VTED, I’d get a thrombophilia screen mentioned already for inherited thrombophilia such as factor V leiden deficiency, prot s or c deficiency, AT 3 deficiency. To assess menopausal status if unclear from hx, I’d get a serum FSH, LH and estradiol level. FSH > 30iu/l suggests menopause in a 53 year old woman with menopausal symptoms? Why should this be unclear? (-1) .

Fr B:
Benefits include improvement of hot flushes (1) and other vasomotor symptoms present. This should be the primary indication for starting HRT. HRT also prevents or delays onset of Alzheimer’s disease. However in existing Alzheimer’s disease, it does not delay its progression. It also provides bone protection against osteoporosis by reducing bone loss and increasing bone mass. The benefit is maximal 24 months after treatment. However, it does not reduce the incidence of hip fracture at 80 years old (1) . It can reduce risk of vertebral fractures and tooth loss. It also protects against colorectal cancer and ocular degenerations (macular degeneration, cataracts). Urogenital atrophy is also helped (1) with topical HRT in woman complaining of vaginal dryness. In stress incontinence, HRT has no benefit in treating this.

Risks include an increased (2-3x) risk of VTED-DVT/PE (1) . This risk is compounded by the presence of pre-existing thrombophilia disease. In woman with high risk thrombophilia disease (anti-thrombin 3 deficiencies, multiple defects) or a previous hx VTED, HRT should be avoided. There is also and increased incidence of CAD with HRT use. In woman with existing CAD, the risk of recurrent disease is highest in the 1st year of use (1) . In woman with no known CAD, continuous combined HRT increases the risk of CAD, stroke and PE. Thus, it should not be used as a primary or secondary prevention of CAD. There is also an increased risk of endometrial (with sequential or unopposed oestrogen HRT) (1) , breast and ovarian cancer. These risks are related to duration of use. Risk increases with prolonged use. Once HRT is stopped for 5 years, the woman’s risk of breast cancer declines to non-users (1) by how much is the risk increased? (45/1000 woman over 20 years). However it’s use in women with premature ovarian failure does not increase the risk of breast cancer ? relevance to the question . There is also an increased risk of developing gallbladder disease on HRT.
Posted by PAUL A.
a)
I will start by asking about the onset and severity of hot flushes and its effect on her quality of life (1) . I’ll ask about any other associated symptoms (1) like vaginal dryness, dysparunia, decreased libido, urinary symptoms. Also I would like to enquire about LMP, parity, last smear history, the need for contraception, also previous contraceptive use and if any complications with COCPs and menopausal for how long (1) . I will ask about family or personal history of breast cancer. Family or personal history of cardiovascular diseases and thromboembolic diseases. I will also ask about family history of osteoporosis (1) .

I will check her weight, blood pressure and BMI (1) . I may ask for a thrombophilia screen (1) in women with a history of VTE or VTE in 1st or 2nd degree relatives.


b)
Potential benefits of HRT includes relief of vasomotor symptoms (1) within 4 weeks and maximum response in 3 months, estrogen is associated with improvement in psychological well being. HRT prevents bone loss with some gain in density in first 18-24 months but should be taken life-long to be protective against osteoporosis (1) . Estrogen may delay or prevent Alzheimer’s disease. Topical estrogen may relief vaginal symptoms. Estrogen and progesterone may decrease the risk of colorectal cancer. Also HRT may protect the woman from macular degeneration, cataract and tooth loss (1) .



Risks of HRT include cardiovascular diseases, the WHI trial showed that continuous HRT is associated with increased risk of coronary heart disease, stroke and pulmonary embolism. Women with established coronary artery disease are associated with increased risk of coronary artery events in the first year (1) .
HRT increases the risk of breast cancer, which is related to the duration of estrogen exposure. Risk in women who discontinued HRT for > 5years is similar to non-users.
Also women who develop breast cancer while on HRT tends to have bigger and more advanced tumors (1) what is the increase in risk?.
Sequential combined HRT but NOT continuous combined HRT is associated with an increased risk of endometrial carcinoma (1) . HRT users are more likely to develop ovarian cancer which again is related to the duration of use (1) . HRT is associated with a 2-3 fold increased risk of VTE (1) , HRT should be avoided if multiple risk factors are present.
HRT is associated with systemic side effects like headache, fluid retention, breast discomfort, mood swings and depression. HRT may cause abnormal genital bleeding which may warrant investigations (1) . Increased risk of gall bladder disease and may cause enlargement of uterine fibroids or reactivation of endometriosis.

I will advise the woman that HRT is beneficial in contrlling severe menopausal symptoms where the benefit of short term use outweighs the risks. I will advise her that she may use HRT for a maximum of 5 years duration (1) , however,woman with a strong family history of osteoporosis who might need a life-long HRT HRT is not recommended for ostroporosis prophylaxis or women who wants to continue HRT for a longer period(>5 years) must be properly counseled and assessed and provide written information regarding the risks of HRT use. GOOD ANSWER
Posted by PAUL A.
A
I would ask details history regarding her severity of menopausal symptoms and what medications and therapies she tried so far. Menstrual history, past Gynaecology history- including surgeries, Breast or other hormone dependent cancers, pap smear, DVT , Cholystasis during pregnancy and past history of Fractures and any cardiovascular disease like MI, Strokes etch this is a list – it is not a sentence. You should not have menstrual history, past gynae Hx, breast cancer … in one sentence. . I would inquire regarding Family Hx of DVT, Breast cancers, Osteoporosis, Stroke, Hyperlipidimias this is another list – see good answer above .
I will Inquire regarding her Mammogram and BMD scan .In Clinic I will check her BMI,BP PR , features of Hyperthyroidism, Breast lumps, LN what do these mean? enlargement , abdomen and Vaginal examination for any evidence of Atrophic changes and check of ovarian cyst. I would like to do some blood investigations – FBE, LFT, EUC, TFT, Fasting Lipids and Glucose levels, Mammogram and BMD scan if not already done why are these necessary? None of these tests are required . If there is past history or First degree relatives have History DVT I would like to do Thrombophillias screen (1) .
B
I explain to her that HRT has following advantages Type of HRT and mode of taking HART depends on pt history and preferences –however is she has uterus need to take both forms of hormones. I explains to her there are are other alternative medications like SSRI, Clonidine for Symptoms relief but not effective as HRT not asked about this .
It is good and best drug to control Menopausal symptoms like Hot Flushes (1) , Night swatting, dry Vaginal Symptoms .HRT help to prevent Osteoporosis needs life-long use and Cancer of colon.
I will explain to her that following risks she has to take if she wishes to have HRT.HRT- either Estrogens or Estrogens and Progestogen can courses Deep Vein Thrombosis main risk is initially few months but risk is getting less with the time by how much is the risk increased? .HRT can causes Breast Cancer If uses longer than 5 Years by how much is the risk increased? . Also women who develop breast cancer while on HRT tends to have bigger and more advanced tumours So better to use HRT or short term-less than 5 years (1) . If she Stops HRT within Five years Breast cancer risk will equal to person who did not use HRT (1) . Though the actual risk is small but definitive risk is there. I advice her that necessity of self breast examination and annual breast check by GP.
There is evidence to say HRT associated with cardiovascular diseases especially people who have cardiovascular diseases (1) .
There is weak evidence that HRT may helpful to prevent cognitive function impairment.
I will e give her written information’s and contact details of relevant organisations Ex Menopausal society details to her to educate herself.
If she like to trail of HRT will advice her that It will take 3-4 weeks to work well and try to stay in lowest possible dose. see GOOD answer above
Posted by Shaimaa M.
Dear Mr Paul

The book I was reading to gather this answer was Oxford handbook of Obstetrics and Gynaecology, last edition

Most of the information in my answer is listed there

1- Hyperthyroidism symptoms may mimic menopausal symptoms, I am not saying they should regularly have TFT done but if suspected then yes? what do you think?

2- You commented \"The risks of life-long HRT use far outweigh any potential benefits including osteo-protection\"
My answer stated that for osteoprotection it should be used life-long.

3- When we are likely to stop HRT if it is only Vasomotor symptoms?

Thank you for your support and help.
Posted by PAUL A.
Dear Mr Paul

The book I was reading to gather this answer was Oxford handbook of Obstetrics and Gynaecology, last edition THIS IS NOT A TEXTBOOK FOR GYNAECOLOGISTS AND YOU SHOULD NOT USE IT TO PREPARE FOR YOUR EXAM

Most of the information in my answer is listed there

1- Hyperthyroidism symptoms may mimic menopausal symptoms, I am not saying they should regularly have TFT done but if suspected then yes? what do you think?
this should not appear in your answer
2- You commented \"The risks of life-long HRT use far outweigh any potential benefits including osteo-protection\"
My answer stated that for osteoprotection it should be used life-long. Precisely and I stated that the risks outweigh the benefits THEREFORE IT SHOULD NOT BE USED

3- When we are likely to stop HRT if it is only Vasomotor symptoms?

Thank you for your support and help.
Posted by PAUL A.
Sh
a)It is essential to begin by taking a detailed menstrual history-LMP (1) ,frequency,duration of bleeding as hot flushes could be a symptom of menopause or climacteric period.History of urogenital symptoms like vaginal dryness,dyspareunia,bleeding suggestive of vaginal atrophy due to estrogen deficiency and urethral syndrome(dysuria,frequency,urgency)should be taken (1) .it is essential to rule out any absolute contraindications to HRT like coronary artery disease,stroke,venous thrombolism in the patient (1) .Also any past history of breast or endometrial cancer (1) should be enquired into as it alters the treatment and increases risk of Hrt in such cases.Any family history of venous thrombolism should be asked and screening for thrombophilias (1) is essential to rule them before prescription.Any history of fibroids or endometriosis in the patient should be enquied into as it can cause resurgence of symptoms.It is important to take her weigt n height to calculate the BMI (1) as BMI>30 increases risk of venous thrombolism.Also the BP should be checked and her cervical cytology should be reviewed.mamography should be done to detect any asymptomatic breast lesions before prescription and it should be repeated eveer 3yearly. DEXA scan should be done to detect any osteoporosis why? This is not recommended before starting HRT.
b)HRT reduces vasomotor symptoms like hot flushes (1) , anxiety psychiatric disorder, not a menopausal symptom ,irritability,insomnia,as also memory loss,poor concentration,tiredness.Also urogenital symptoms of vaginal atrophy and urethral symptoms improve.Her libido and sexuality Define sexuality! How do you measure it? will improve.Also the risk of osteoporosis and vertebral fractures reduces in a 53 year old? Treatment needs to be life-long as also the risk of colorectal cancer and development of Alzheimer\'s disease (1) possibly .Side effects are due to progestogen- so does the oestrogen not have side-effects?? mood swings,fluid retention(bloatedness,weight gain) and increased risk of breast cancer after 4 years of use where did you get 4 years from? Is the risk of breast cancer due to progestogen? By how much is the risk increased? .Increased risk of venous thrombolism by how much is the risk increased? is there with HRT which is immediately after starting the use.Also premenstrual stype symptoms occur.
There is no fixed duration of treatment and it has to be individualised after weighing the risks and benefits in each case.HRT should be prescribed for the shortest duration at the minimum dose for symptom relief only and should be graduallly tapered in a step-wise fashion over 6 months to prevent immediate symptom recurrence.Thus it should be prescribed in this case till she is relieved from her symptoms and then tapered slowly so will you prescribe it then when she is symptom free after say 3 months, reduce dose and stop it???

See NOTES ON HRT and RCOG document here

http://www.rcog.org.uk/womens-health/clinical-guidance/menopause-and-hormone-replacement-study-group-statement

.
Posted by PAUL A.
(A) At 53 years i will presume that she is postmenopausal Why? The average age at menopause is 51 years (-1) .History about the severity of hot flushes affecting her quality of life (1) should be obtained.Other symptoms (1) like vaginal dryness,decreased libido,night sweats and insomnia should be obtained.Presence or absence of uterus (1) is also important as this will effect the type and duration of HRT.Detailed history is asked to rule out absolute and relative contra indications to HRT.Active breast cancer, what about past history of breast cancer? active genital tract cancers, active venous thromboembolism and active liver disease are absolute contra indications.Previous breast cancer,previous thromboembolism and hypertention are relative contra indications not clear where you got this distinction from – if a woman had breast cancer 2 years ago, is that ‘active’? Would you prescribe HRT for her? .I will also inquire about last smear and result.

I will check her B.P , BMI (1) and will perform breast examination for any lump how often do you undertake breast examinations and how good are you at detecting lumps?? (-1) .An abdominal examination is performed for any masses and a bimanual pelvic examination to confirm any mass suspected on abdominal examination. A cervical smear is taken if due the woman should respond to her invitation as normal .A mamography is advised if breast lumps are found or if the breast examination is inconclusive.Thrombophilia screen is offered if personal or family history of DVT (1) .A lipid profile is also advised not necessary .

(B) Regarding benefits of HRT I will tell her that it relieves vasomotor symptoms like hot flushes (1) , night sweats and insomnia, has beneficial effect on genital tract like HRT may prevent prolapse ? evidence relieves vaginal dryness thus improving libido, however personal,social and psychological causes for decreased libido should be explored.HRT also decreases the incidence of urogenital tract infections like endometritis have you encountered a post-menopausal woman with spontaneous endometritis??? and trigonitis.With HRT there is a general feeling of well being.
Long term use of HRT prevents osteoporosis life-long therapy needed ,improves hair and skin quality, delay tooth and visual loss by decreasing macular degeneration.HRT also possibly decreases incidence of Alzeihmer disease and colorectal cancer (1) .
Explaining the risks of HRT I will give her information about the risk of developing breast cancer.Breast cancer risk at 50 years is 31 per 1000, use of HRT for 5 years is associated with an increase risk of 38 per 1000 and after 10 years use risk is increased to 51 per 1000 (1) .
With HRT there is 2-3 fold increase in risk of venous thromboembolism (1) .There is increased risk of stroke specially in the first year of use.Increased risk of coronary heart disease specially in first year if there is previous history of coronary artery disease (1) .There is also increased risk of endometrial carcinoma if combine sequential or unopposed HRT is used (1) .There could be drug side effects like weight gain, breast tenderness, acne, depression and bloatedness (1) . I will tell her that all these side effects are rare and i will provide her with written information.
I will provide her the information about the types of HRT and routes of administration.If her uterus is intact she can choose among the combine HRT and if she has no uterus she can have estrogen only HRT. HRT can be administered orally as combine tablets taken continously to avoid any unwanted bleeding.Other routes are transdermal daily estradiol patch or gels progestogens can be used orally or in the form of mirena.Other routes could be vaginal rings,creams or sub dermal implants.I will inform her that for vasomotor symptoms she should take HRT for 1-2 years (1) and should have yearly B.P. BMI and mammography checkup done and if there are symptoms of VTE LIKE unilateral leg swelling, breathlesness or chest pain she should stop HRT immediately and contact her doctor. I will also discuss the alternatives of HRT like life style modification exercise,avoiding cofee, tea hot environment.Eating food rich in phytoestrogens like cereals, soyo and red clover leaf.Other alternatives to HRT should be discussed like SSRI paroxetine, SNRI venlafaxine and transdermal clonidine.Complementory therapies like reflexology and accupunture, herbs and homeopathic substances should be discussed ,though there efficacy is not evidence based.These include black cohosh, st johnes wort, ginseng and agnus castus YOU WERE NOT ASKED ABOUT ANY OF THIS. This is valuable time that should be spent on the next question .Finally iwill provide her with written information.
Posted by PAUL A.
RnRn
A.
I’ll explore exact nature of any additional symptoms like what? other than hot flushes, severity of her symptoms, impact on quality of life (1) and whether compromises everyday social and/or working life. I’ll find out what she has tried so far, whether she smokes, takes alcohol and caffeinated drinks. I’ll ask when her final menstrual period was (1) (truly >12 months amenorrhea ?), post-menopausal or post-coital bleed, a brief cycle & smear history including any past hormonal contraception. Her previous obstetric history and gynae history, in particular surgery (uterus (1) present ?). a personal or family history of medical problems, in particular DVT, stroke, cardiovascular disease, breast cancer or endometrial cancer (1) more discussion needed, not a list . On examination I’ll assess blood pressure and pulse, weight & height for BMI (1) . Legs for varicose veins, breasts for any lumps you have no training in breast examination and should not undertake them . I’ll only arrange bloods for thrombopathy screen in a positive personal or family history for DVT/PE (1) . I’ll arrange bloods for lipid-profile not necessary (-1) and – if not certain why should you be uncertain??? - for FSH to confirm peri-menopause this is not a useful test .

B.
Duration for younger women till average age of menopause; 51-52. In this situation till 54-55, as mostly symptoms resolve in 2 years ? meaning??? . After this re-assessment and/or a trial of stopping is indicated. Main advantage is improvement of vasomotor symptoms (1) , with often improved mood/irritability as well. Some may feel more energetic and sleep better. Aging of skin, teeth and eyes are slowed down. Calcium loss from bones seen in menopause is halted, which may reduce risk for fractures not unless taken life-long . This protective effect only lasts while on HRT and calcium loss will occur after all once HRT stopped. Beneficial effect on cognitive function/reduce risk Alzheimer are not proven. Unopposed estrogen increases risk of endometrial cancer in women with a uterus and progesterone needs to be added, though even sequential combined HRT still has increased risk (1) . All other risks are lower for estrogen-only HRT. Breast cancer risk is related to duration, with 2, 5 & 12 extra cases per 1000 after 5, 10 & 15 years use (1) . Risk normalizes within 5 years after stopping (1) . Risk for DVT increased (1) (relative risk 1.4) mainly in first year of use, transdermal HRT may reduce this risk. Risk of stroke and cardiovascular disease/ myocard infarction are increased, but these data are based on a population that was many years post-menopausal with higher average age. More recent suggests even a possible protective effect in younger women who only recently turned menopausal, though further research needs to confirm this (1) what about duration of treatment? .
Posted by PAUL A.
a)
I will enquire the severity of hotflushes and its effect on sleep like insomnia, associated urogenital symptoms ike dysuria, dyspareunia, vaginal dryness (1) . Her menstrual history regarding last cyles regularity,excess blood loss, spontanesous cessation. duration since her last cycle (1) . Personal history of smoking, Previous history of thromboembolism,cardiovascular problems, history breast malignacy is enquired. Family history of thromboembolism and breast cancer is enquired (1) .
On examination, BP measurement, BMI is checked (1) . Rotine gyneacological examination is not done but if symptoms indicative then it is carried out. But it is taken taken as a screening opportunity for bresat examination Do you have any training on breast examination? , pelvic examination, cervical cytology NO – woman should respond to her routine invitation (-1) .
B)
Potential benefits of HRT are improvement in vasomotorsymptoms (1) by 4weeks and maximum response for by 3 months. even pschologica symptom improvement is seen. Improvemrnt in the osteoprosis increase in done density or delays resorption if taken for 2 years. but to be taken for life long but risk are more on long term (1) your English is not very clear .it delays or prevent Alzheimres disease , long term protection of coorectal carcinoma with both estrogen and progesterone but if detected in the advanced stage ? meaning?? Poor English .significant improvement in the urogenita symptoms like what? if given topically, not effective in stress incontinence.it also decrease the macuar degeneration
Risks inculde breast cancer it is more if used moer than 5 years by how much is the risk increased? . on discontinuation it drops to never users risk after 1 month of stopping?? . it also increase endometrial hyperplasia and carcinoma, any history of bleeding to investigated with biopsy, increase risk of coronary heart disease even in without prior history of risk factor hence not used for CAD prevention (1) Your English needs to improve . Increased risk of thrmboemboism by how much? in the first year of use and hence not given with previoshistory or presence of 3 /4 risk factors. systemic side effects of estrogen and progestrone to be explained what are these? .
provide written information leaflets and advise ragarding follow up and report any sign of thrombolism are present.

A more detailed answer is required. See good answer above
Posted by PAUL A.
PART A
I will enquire about severity of her symptoms and its effect on quality of life (1) .Any other symptom like vaginal dryness and night sweating.I will ask about date of LMP (1) ,cycle length,regularity and amount of bleeding or whether she is postmenopausal.I will ask about presence of uterus (1) or if she had hysterectomy( whether indication was estrogen based).I will ask about her past history of MI/CVA,angina,hypertension and smoking (1) .Family history of cardiovascular disease.I will enquire about personal and family history of venous thromboembolism.I will ask about her personal and family history of breast cancer,ovarian cancer and endometrial cancer (1) . Present/ past history of contraception and any complication associated with COCP.I will ask about her family history of osteoporosis.In Examination I will check her BP and BMI (1) .If women is asymptomatic there is no need of any other investigation.However if women has personel and family history of VTE I will do her thrombophilia screening (1) .
PART B
I will explain to her that potential benefits and risks/side effects depend upon type of HRT (Estrogen + progesterone, either sequential or continuous combined HRT), duration of use and to some extent route of administration. I will explain that postmenopausal symptoms are usually transient and therefore treatment requires only for one to two years, but definitely < 5 years (1) .
Main benefits of HRT is symptom control like improvement in hot flushes, night sweats and vaginal dryness (1) . It also improves the psychological well being and quality of life. There is improvement in skin and hair. Additional benefits include reduction in risk of osteoporosis needs life-long treatment , Alzheimers disease, colorectal cancer, cataract, macular degeneration and tooth loss (1) . But all of these effects occur only after long term use and would not apply for short term use of HRT for symptom control. Regarding its risk HRT is not protective against and is associated with increased risk of cornary heart disease and stroke, specially in first year of use (1) . So in the presence of cardiovascular risk factor HRT will not be recommended and other alternatives should be used. I will explain that HRT also increases the risk of VTE about 2 to 3 fold (1) particularly in first year of its use.There is also increased risk of breast cancer with long term use (background risk is 32 per 1000 women over 15 years use). With estrogen + progestiron HRT use of 5 and 10 years, risk of breast cancer increases to 38 and 51 per 1000 women respectively (1) . Discontinuation of HRT for 5 years will result in the reduction of risk equal to never users (1) . So short term use of HRT benefits outweigh the risk. I will explain there is also increased risk of ovarian cancer which increases with increased duration of use. There is also increased risk of endometrial carcinoma, but it is only associated with Estrogens and sequential HRT (1) . There is also drug side effect like fluid retention, headache, breast tenderness and mood swings. HRT can also cause vaginal bleeding and gall bladder disease requiring investigation (1) . But I will reassure the woman that overall these risks remain small. In the absence of above risk factors HRT can be used for 1 to 2 years for symptom control and definitively <5years.other options can be used like clonidine, SSRI(Paroxetine/Fluoxetine) or SNRI, Progesterones like megesterol, for vasomotor symptoms control but are less effective than HRT. For vaginal dryness local treatment like lubricants and topical estrogen creams can be used (1) and these can be used for longer , advise on life style changes like regular and sustained exercises should be done and cafeinated drinks should be avoided.
I will provide written information about the benefits and risk of HRT.

EXCELLENT ANSWER – Model answer
Posted by PAUL A.
LEEN
A 53 year old woman has been referred to the gynaecology clinic because she requests hormone replacement therapy (HRT) for debilitating hot flushes. (a) Describe the assessment you would undertake in the clinic [7 marks]. (b) She is suitable for HRT. Discuss the potential benefits and risks of HRT and your advice on the appropriate duration of treatment [13 marks].

(a) My assessment would include taking a detailed history to assess her suitability for HRT, in particular loooking for any relative or absolute contraindications to HRT. I would ask her about her last menstrual period (1) . I would also ask her about the presence of any unexplained vaginal bleeding she might have - HRT should not be given until the bleeding is investigated, as it might mask symptoms of genital tract cancers. I would want to find out about her previous contraception, especially any problems she had with oestrogen based contraception - eg. migraine, thromboembolism (TE). A gynaecological history should also include previous surgery (such as hysterectomy (1) and/or oophorectomy)
I would also want to ask about her past medical history, in particular history of previous stroke, TE, breast cancer(whether it is oestrogen or progesterone receptor positive), arterial disease, cardiac disease, thrombophilia (1) you have written a list ; all of which are either relative or absolute contraindications to HRT usage Which are relative and which are absolute? . A strong family history of stroke, TE or breast cancer might prompt investigations such as thrombophilia screening (1) or even genetic testing (eg. BRCA1 & 2 gene mutation, hereditary non-polyposis colon cancer gene mutation)
Examination should include assessment of her body mass index, as extreme obesity is an contraindication. Blood pressure should also be measured to exclude hypertension (1) .

(b) HRT will most likely improve her vasomotor symptom(s) (1) and therefore improve her quality of life. It will also protect her against osteoporosis whilst she is on it, although she will need lifelong (1) HRT to prevent her from getting osteoporosis. HRT is also associated with a decreased risk of colon cancer and Alzheimer\'s disease (1) . It has also been shown to improve lipid profiles, more so in transdermal oestrogen route.
However, despite the improved lipid profiles, HRT does not protect against cardiac disease, and should not be used as cardio-protection (1) . There is also an increased risk of stroke and venous TE increased by how much? , especially in the first year of use. HRT is also associated with an increased risk of breast cancer by how much? and endometrial cancer among its users. The risk of venous TE and breast cancer drops back to general population risks levels 5 years after stopping HRT why should it take 5 years for VTE risk to reduce? .
HRT is recommended for 2-3 years (1) for relief of vasomotor symptoms. It should be tailed off gradually, rather than stopped suddenly, to reduce the risk of vasomotor symptoms recurring suddenly.
Posted by PAUL A.
You have used a fraction of the time / space provided and you start your answer with an abbreviation h/o onset ofmenopause duration of hotflushes and their progression, other symptoms like mood disturbances, loss of libido, vaginal dryness, urinary incontinence, venous thromboembolism, previous h/o stroke , cerebrovascular accident , h/o thrombophilia this is just a list of items with completely different implications. Vaginal dryness has very different implications from VTE , o/e BMI , blood pressure (1) ,
b. the benefits of HRT are the releif of her hot flushes and other vasomotor symptoms (1) , urgency , urge incontinence, prevents osteoporosis for the duration of HRT , once HRT is stopped , benefit declines. HRT with testosterone improves libido. the adverse effects are increased risk of breast cancer by how much is the risk increased? during the course of HRT but risk returns to that of women who have never had HRT soon after 1 month after?? it is discontinued. the risk is related to duration of therapy and not the dose. COC WHAT IS THIS? preparation increases the risk of breast cancer than estrogen alone , increase false positive and false negative mammogram tests because of increase in the mammographic density by progesterone . increase in risk of stroke and myocardial infarction .HRT does not ??? appear to be effective for alzhemer\'s disease . Estrogen only therapy is associated with increased risk of endometrial carcinoma whereas combined HRT does not have increased risk incorrect

See EXCELLENT answer above as a guide to what is expected
Posted by Maayka ..
maayka

(a) I would take a detailed history to find out what other symptoms she may be experiencing such as vaginal dryness, reduced libido, irritability, insomnia, urinary problems – to be able to assess at a later date improvement of all her symptoms. A relevant medical history specifically checking if there is cardio vascular disease or any abnormal pv bleeding is relevant. The latter to determine if she is postmenopausal or perimenoausal since it may require investigation before prescribing any HRT or alternatives. If she had herself any history of cancers such as breast or endometrial carcinoma or hyperplasia would not make her a good candidate for HRT. A history of VTE especially with a common thromphophilia would be a red flag against the use of HRT because of the already increased risk of VTE in an otherwise normal healthy postmenopausal woman. Her family history of breast cancer or ovarian cancers and VTE will be deteremined. A gynaecological history should rule out any abnormal pv bleeding and check that her recent cervical smear is up to date and normal. A surgical history is necessary to elicit if she had a past hysterectomy as an intact uterus would require combined HRT vs oestrogen only HRT if no uterus in situ. Also her social history, whether smoker or not and her level of physical activity will determine if she has made lifetstyle changes which may aid in the menopausal period.

Examination should check her BP, pulse, BMI and general including the breast, abdomen and pelvic area to rule out any masses she may have - and need investigating before HRT started.

(b) Benefits of HRT are that it reduces the vasomotor symptoms in about 70% women who are symptomatic, and is sometimes better than the alternatives available. There is also a reduction in urogenital symptoms like urgency and dysuria but minimal effect on stress incontinence. The benefit of reduction of osteoporotic fractures is quite significant and can be aided with bisphosphonates and weight bearing exercises. It improves the patient’s physiological well being and sometimes depending on how significant their symptoms were has a major impact on their quality of life. It aids in reducing the onset of Alzheimer’s disease and reduces the risk of colorectal cancer.

The risks of HRT include an increased incidence of cardiovascular disease, especially within the first year of use, in women without any pre- existing conditions. It increases the incidence of breast cancer and chance of it being increased in size if diagnosed. It also increases the incidence of endometrial disease like hyperplasia and carcinoma and ovarian carcinoma. It has an eight fold increased incidence of VTE in postmenopausal women. It may also increase the incidence of gall bladder disease.


She should decide , after being informed of the benefits and risks, together with any side effects she may experience, how long she may wish to stay on the HRT. She would be strongly advised to use it for the shortest possible duration of between 6 months to 5 years , so as to reduce the risks associated
Posted by PAUL A.
M
(a) A history of other vasomotor symptoms like night sweats, with severity of symptoms and affect on quality of life (1) .
A history of other menopausal symptoms like vaginal dryness (1) .
A personal and family history of cardiovascular diseases to ascertain risk factors like ischaemic heart disease and history of smoking (1) .
A history of thrombosis, personal and family to ascertain risk factors.
Risk factors of breast cancer both personal and family history (1) .
Past history of hysterectomy (1) to ascertain need of progesterone arm of HRT.
A drug history to exclude any interaction with HRT.
I will ask about her last smear and results prior to HRT.
I will check her BP and BMI (1) prior to commence her on HRT.

(b)Most menopausal symptoms are transient.
Benefits of HRT are symptom control especially her vasomotor symptoms (1) with debilitating hotflushes.
It may also help her with other menopausal symptoms e.g. sleeplessness, vaginal dryness.
Long term benefits of using more than 5 years include protection against osteoporosis has to be life-long , delays onset of Alzeheimers disease, tooth loss, macular degeneration and colorectal cancer (1) .
Short term risk include increased ischaemic cardiovascular and stroke risk in the first year of use especially with underlying cardiovascular disease (1) .
Increases risk of venous thrombosis in the first year of use by how much? .
Long term risks include breats cancer risk when used 5-15 or more years (baseline risk of breast cancer 32/1000 with combined estrogen progesterone HRT use, increases to 38 and 51/1000 with 10 and 15yrs use) (1) . When discontinued for 5 years goes to background risk (1) .
OTher risks involved include endometrial cancer risk in non hysterectomised not with continuous combined woman and abnormal vaginal bleeding requiring investigations.
There is also increased risk of gall bladder disease.
The overall risk of taking HRT is small and this depends upon risk/benefit assessment.
I will advice regarding need for thrombophilia screen priro to HRT if personal or famility history of thrombosis or thrombophilias.
I will advice the duration of HRT depends on the needs of the patient for symptom control especially her vasomotor symptoms and she can use it as long as she wants incorrect – you should explain that she should not use it for more than 5 years as risks outweigh benefits understanding the risks involved.
She will need yearly review or earlier if her risk factors changes.
She has safer alternative for osteoporosis prevention like bisphophonates.
Advice on breast self assessment and educate on symptoms of thrombosis and to seek medical attention if any symptoms.
Posted by PAUL A.
A)
Hormone replacement therapy is effective treatment for menopausal symptoms such as hot flushes not answering the question .Assessment should be done for its suitability.A detailed history particularly other menopausal symptoms such as hot flushes, vaginal dryness,dyspareunia,night sweats,their severity and effect on quality of life (1) .Her LMP (1) , cycle length,amount of bleeding, whether she is postmenopausal will be asked.Presence of uterus (1) or history of hysterectomy will also be asked.Her personal and family history of cardiovascular disease (1) ,MI,stroke,or symptoms suggestive of cardiovascular disease such as chest pain or shortness of breath, thromboembolism,breast cancer should be asked.Family history of osteoporosis should be enquired (1) .Personal history of endometrial cancer,ovarian cancer is to be taken.Drug and contraceptive history especially any complications from the use of COCP will be needed.
Clinical examination includes BP and BMI should be cheked (1) .
If she has no history or symptoms of VTE or CVD ,she does not require any investigations.Thrombophilia screening (1) should be done in presence of family history of VTE.
B)
Woman should be explained about benefits ,risks ,type and duration of HRT do not repeat the question .The main benefit will be symptom control (1) –hot flushes, vaginal drynessand feeling of general wellbeing.There are potential silent benefits such as prevention of osteoporosis colorectal carcinoma,alzheimers disease,macular degeneration but these may only be achieved with long term use (1) and would not apply with short term use to control menopausal symptoms.Other benefits include improvement of skin and hair quality,decrease risk of tooth loss and visual loss (1) .
HRT does not protect against and is associated with an increased risk of coronary artery disease and stroke especially in the first year of use (1) . Risk of thromboembolic disease is particularly increased in the first year of use by how much? .The risk of breast cancer is associated with long term use of HRT (more than 5years use).In a 50 year old woman use of combine HRT for 5 and 10 years increases risk of breast cancer to 38 and 51 per 1000 respectively (1) what is the background risk for comparison?.The risk in women who have discontinued HRT for 5 years is dreased to similar to that in never users (1) .Risk of endometrial carcinoma is associated with long term use of sequential HRT only (1) . Other risks include gall blader disease,drug side effects, abnormal vaginal bleeding require investigations (1) .The overall risk of complications in women taking HRT remains small.
The potential risks and benefits need to be balanced with the severity of symptoms and their effect on woman’s life.For menopausal symptoms recommended duration of therapy is one or two years and not more than 5 years (1) .
Alternatives to HRT should be discussed and written information about risks,benefits and duration should be provided. Good answer
Posted by PAUL A.
A 53 year old woman has been referred to the gynaecology clinic because she requests hormone replacement therapy (HRT) for debilitating hot flushes. (a) Describe the assessment you would undertake in the clinic [7 marks]. (b) She is suitable for HRT. Discuss the potential benefits and risks of HRT and your advice on the appropriate duration of treatment [13 marks].
a)
I would obtain a clinical history to determine the duration of her menopause (1) , and any episodes of post menopausal bleeding as well as any investigations such as endometrial biopsies . if she is still menstruating, frequency, duration and severity of bleeding and associated dysmenorrheoa.
I would inquire about her parity, mode of delivery of her children and current method of contraception.
past medical history of cardiovascular events (1) such as strokes, ischemic heart disease, thrombophilia, thromboembolic episodes such as DVT and pulmonary embolism.
I would note any history of breast cancer (1) or any other estrogen dependent cancers such as endometrila cancer
other medical diseases such as diabetes, hypertension , hypercholesterleamia, liver disease, osteoporosis, any fractures and their severity as well as current management details.
I would inquire about any first degree relatives suffering from above mentioned conditions.
I would note her smoking status She presented with menopausal symptoms and you have not asked her anything about her symptoms!! Will you examine her?

b)
I woud explain that HRT is would be given to replace hormones that are not produced by ovaries and given for minimal duration for the shortest duration ? meaning
HRT would be helpful in reducing the distressing hotfluses (1) , night sweats. it is beneficial in reducing the risk of hip fractures at early stage ? meaning by preventing osteoporosis requires life-long use . HRT has shown to reduce colorectal cancers. HRT will not increase the risk of breat cancer in the first 5yrs and it will increase after that by how much? .
additinally HRT will releive symtoms such as vaginal dryness, irritable bladder symptoms
other risks associated with HRT are, it increases the risk of thromboembolism by how much? , coronory heart disease, stroke especially in women with previous events
HRT does not increase the life expectancy and there is no difference in the death rate between users and non users
HRT does not act like a contraceptive therfore if she is premenopausal contraceptive use simultanouesly is necessary
I would advice her on minimal dose of HRT preferably transdermal for not more than 5yrs (1) to reduce the risk of thromboembolism and other vascular and liver diseases

See EXCELLENT ANSWER ABOVE
Posted by PAUL A.
A good answer should include the following
(a)
History
• Effect of hot flushes on quality of life. Other menopausal symptoms – vaginal dryness, dyspareunia, urinary frequency, mood changes (1 mark)
• Presence of uterus (1 mark)
• LMP – assess suitability for continuous combined HRT (1 mark)
• Assess risk factors (2 mark)
1) Personal history of VTE / family history in first / second degree relatives
2) Personal history of breast cancer
3) Personal / family history of cardiovascular disease
4) Personal / family history of osteoporosis

Examination (1 mark)
• BMI
• BP
• Lower limbs for gross varicose veins

Investigations
• Not required but thrombophilia screen may be appropriate in a woman with personal / family Hx of VTE (1 mark)
(b)
Benefits
• Relief of menopausal symptoms like hot flushes. Lowest effective dose should be used for the shortest duration of time (1 mark)
• Treatment should be reassessed at least annually and treatment should be for up to 5 years (1 mark)
• Local treatment may be used for a longer duration to treat urogenital symptoms (1 mark)
Other potential benefits
• Reduces risk of osteoporotic fractures during treatment but effect declines after cessation and not recommended for osteo-protection (1 mark)
• Improved mood, reduced risk of macular degeneration / tooth loss and possibly reduced risk of Alzheimer’s disease (1 mark)

Risks
• Increased risk of VTE: 2-3 fold increase in risk especially in the first year of use (1 mark)
• Breast cancer: increased risk related to duration of use. Oestrogen + progestogen HRT for 5 and 10 years increases risk to 38 and 51 per 1000 respectively (background risk ~32 per 1000). (1 mark)
• The risk of breast cancer in women who have discontinued HRT for 5 years is similar to that in never users. (1 mark)
• Cardiovascular disease: does not confer protection and may be associated with increased risk of stroke / myocardial infarction especially in the first year of use in women with previous events (1 mark)
• Endometrial cancer: in a woman with a uterus, oestrogen-only and sequential oestrogen + progestogen HRT associated with increased risk of endometrial cancer (1 mark)
• Ovarian cancer: recent data indicate that current use of HRT associated with increased risk of ovarian cancer (1 mark)
• Drug side-effects: headache, fluid retention, mood changes. Also associated with increased risk of abnormal vaginal bleeding requiring investigation (1 mark)


Ref: Menopause and Hormone Replacement - study group statement. Consensus views arising from the 47th Study Group: Menopause and Hormone Replacement
http://www.rcog.org.uk/womens-health/clinical-guidance/menopause-and-hormone-replacement-study-group-statement
Posted by Vinutha G.
Hormone replacement therapy for any woman should be started after balancing the risks and benefits to that individual patient .
Iwill ask her about the severity of her hot flushes ,about there impact on her life ,any other associated problems like dyspareunia ,urinary symptoms
I will take a menstrual history regarding her previous periods ,her menopause ,any post menopaual bleeding .
Her medical history with special emphasis on cardiovascular state (angina )needs to be ascertained Her surgical history whether hysterctomised or not and type of hysterectomy needs to be checked
Any past history of t hromboembolism if present the number of episodes ,any history of cancer of the breast (personal or in the family ),any other cancers any liver disease in the oast needs to be taken .
Iwill also check on all the medicines she is taking including any previous HRT .her recent smear history will also need to be looked into if a smoker heavy or otherwise .Her contraceptive needs if any should be ascertained.
Iwill examine her BMI ,BP,breasts examination
any mass in the abdomen.
b)Having found her to be suitable I will counsel her on the risks associated a small increased risk of breast cancer by 5/10000 at the end of 5 years to 7/10000 at the end of ten years ,an increased risk of cardiovascular events myocardial infarction and stroke but more in women with a positive history . Also nform her that associated with an increased risk of thromboembolic events .
An increased risk of endometrial cancer and ovarian canceralso exists .
The benefits associated with the therapy along with the improvement in quality of life due to treatment of hot flushes are a decrease in colorectal cancer .improvement in libido ,and dryness ,cognitive improvement
In the long term it can protect bones from osteoporosis
Iwill advise her on the route of administration oral combined (if uterus present).
i will also tell her about the patches ,combined with the Levonorgestrel device and the side effects (irregular bleeding )associated with it
I will advice her to take it for a minimum period so that she is bevnefited as hot flushes generally last for 2-5 years
Iwill provide her with information leaflets .
I will check her BMI her BP and check
eeeeeeeeee Posted by PAUL A.

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