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MRCOG PART 2 SBAs and EMQs

MRCOG Part 2, MRCOG 2

Course PAID
notes	336
EMQ	1502
SBA	2115

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ESSAY 180 - HRT

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		Posted by Sarwat F. Wed Jan 25, 2006 03:32 am
Initial assessment will include history, examination and investigations. history will include past medical and surgical history, medication history and family history. it is important to ask for any history of thromboembolism or thrombophilias, history of fractures. History of thromboembolism is important because screening for thrombophilias will be required before starting HRT in woman with multiple risk factors for thromboembolism. Personal history of breast cancer or genital tract malignancy. family history of any breast cancer, genital tract malignancy, fractures, heart disease, alzheimers disease is asked. all these factors are important as HRT is associated with increased risk of breast cancer with a relative risk of 1.35. genital tract malignancy is important as estrogen in HRT is associated with increased risk of endometrial cancer. Personal history of heart disease is important because although observational studies indicated that HRT is beneficial with history of cardiovascular disease, further studies showed that it is not beneficial and estrogen replacement may result in increased acute coronary events. History of fractures places a woman at high risk of bone disease and some treatment to prevent boneloss will be necessary in long term. Examination is done including height, weight, breast examination, abdominal examination, pelvic examination and pelvic ultrasound is done. Height and weight is checked to calculate body mass index, which is again important as high body mass index, is associated with increased risk for thromboembolism. Breast examination and abdominal examination is important to exclude any obvious pathology and pelvic ultrasound to exclude any fibroids. this examination will also provide a baseline assesssment so that if the woman develops any problem further on she is not assumed to be present before evaluation. Investigations will include serum LH, FSH and estradiol levels. it has been a policy of some clinicians to exclude thyroid disease at this stage as flushing and sweats can be present with thyroid disease although literature does not support routine assessment of thyroid function. Baseline bone scan can also be ordered at this stage to determine bone mineral density although it is unlikely if the woman is not having any bone pain or other symptoms. Counselling of this woman will include explaining pathophysiology of menopause in simple language and offering various options of available treatments. She will be explained about short term and long-term problems of menopause. Short-term problems include flushes, sweating, vaginal dryness and urinary problems including incontinence, freuency and urgency. longterm problems include osteoporosis, heart disease, alzheimers disease. Management will start with general measures like life style modification, calcuim and vitamin D intake, and regular exercise. She will be explained that there are hormonal as well as non-hormonal modes of treatment. Hormonal options include estrogen and progesterone combined HRT, tibilone and SERMs. Benefits of combined HRT include relief from hot flushes, night sweats, vaginal drynes and protection from longterm problems of bone and alzheimers disease. tibilone has lower doses of HRT and risk of estrogen related side effects is even lower. Risk of estrogen related HRT include breast cancer with a relative risk of 1.35, endometrial cancer in unopposed HRT, thromboembolic disease with 3 folds risk and systemic side effects of fluid retention, breast tenderness, nausea headache. it is also mentioned that SERMs are not beneficial for vasomotor symptoms. She will also be explained about various routes of HRT including oral, implants, patches, gel and vaginal rings and creams. the benefit of nonoral therapy is that it is associated with less unwanted effects. Woman may ask about monthly bleeding so she will be explained about nonbleed preparations as well. it is important to give her written information and to arrange a review appointment so that blood results can be reviewed and she is also able to make an informed choice.
		Posted by adnan S. Wed Jan 25, 2006 03:43 am
Symptoms like infrequent periods hot flushes & vaginal dryness usuallycommence before the onset of menopause.A detailed history is taken regarding her menstrual status ,these infrequent periods are they associated with scanty bleeding ,interval between the periods as they prolong near menopause but does not predict time of menopause ..Regarding severity of hot flushes are they affecting quality of life,typically they sarts on the face ,neck ,head or chest.Flushes atre associated with insomnia which aggravates coexisting amanesia..Psycological symptoms like depressed mood,anxiety ,irritability lack of concentration ,loss of memory also enquired. .Vaginal dryness.causing dysparunia ,any associated urinary symptos like dysurea ,stress incontinence repeated urinary tract infections.Cardiovascular risk assessment is done by enqurieng past h/o IHD,Angina,CVA,hypertention & smoking,venous thrombo embolism.,family h/o IHD,VTE .Personal & family h/o breast caner should be enquird.O/E check her weight & height [BMI] ,Blood pressure for hypertention is done .Routine breast & pelvic examination are not requird unless clinically indicated .Cervical smear is taken if she is due...In majority of cases diagnosis of menopause is done by history alone ,serum FSH levels.fluctuates markedly & are of limited value for diagnosis.FSH levels rise >20 IU/Ldespite continued menstruation in the peri-menopausal period but LH level remain in the normal range. I will explain her about benefits and risks of HRT ,which depends on the type of HRT (Estrogen only,Estrogen+Progesterone:Sequential or combined HRT) duration of use and to some extant the route of administration.The choice of HRT will depend on her needs,with intact uterus continues combined HRT is preferd as it is not associated with increased endometrial cancer risk compared to sequential combined HRT(progesterone for 10 days per cycle) is associated with risk of endometrial hyperplasia &carcinoma. I will explain to her that menopausal symptoms are transient and needs only short term use of HRT is required. (1-2yrs definitely <5yrs).The main benefit will be symptom control .The menopausal symptoms expected to improve are hot flushes ,night sweats with in 4 wks maximum response achieved by 3 months.If vaginal dryness is the main complaint topical Estrogens (pessary/tablets) may be adequate.I will explain to her other potential benefits like prevention of osteoporosis ,colorectal carcinoma ,Alzheimers disease ,macular degeneration,&tooth loss would occur only with long term use .I will also explain to her HRT does not protect against & is associated with increase in the risk of coronary artery disease & stroke in the first year of use ,so if the women had a previous event or at high risk of CVA ,HRT shuld not be recommended.There is increased risk of venous thromboembolism in the first year of use ,hence if she has a h/o VTE or at high risk of VTE ,HRT is not recommended,she should be consider alternative treatments.The risk of breast cancer is associated with long term use >5yrs,the risk is 45 per 1000 over 20 yrs increases to 2,6&12 extra cases after 5,10 &15yrs of use of HRT and the benefit of use over 1-2 yrs out weigh the risks.Other risks like endometrial carcinoma( long term use of sequential HRT only) gall blader disease,drug side effects like estrogen related fluid retention ,breast tenderness ,nausea headache ,leg cramps ,usually resolve with increasing duration of use,if progesterone related mood swing depression acne reduce the dose where possible,and abnormal vaginal bleeding require investigations.Over all risk of these side effects in women taking HRT remains small.Alternatives to HRT like progestyerons like norethisterone megestrol,SSRIs like paroxetine,are effective for hot flushes.SERMs donot relive menopausal symptoms hence not suitable.Adequate written information is provide so that she can make informed choice.
		Posted by Sreekala S. Wed Jan 25, 2006 05:11 am
A detailed history should be taken including her symptoms, menstrual history- intermenstrual bleeding, post coital bleeding, cervix smear history and obstetric history. Her medical history including osteoporosis, hypertension, DM, Ischaemic heart disease, cerebrovascular disease, peripheral arterial disease,hyperlipidemia, personal and family history of breast cancer, endometrial cancer , risk factors for DVT/VTE and drug history should be noted. Examination should include recording BP, height, weight, breast examination, speculum and bimanual examination. A pipelle sampling should be offered in view of her infrequent periods and TVS considered if endometrial polyp/hyperplasia is suspected. Serum FSH levels has to be checked. A value greater than 30iu/l suggests menopausal range. DEXA scan can be considered if osteoporosis is suspected. Mammography is not routinely done unless the woman is at high risk for breast cancer. The woman can be offered HRT if she wishes. There is no need to wait for 12 months of amenorrhoea before commencing the HRT. She should be counselled about the risks and benefits of the various preparations and should be made to take an informed decision.The different routes of administration are oral, vaginal, transdermal, subcutaneous and intranasal. Continuous combined estrogen and progestogen preparations are not recommended in this woman as there is a risk of irregular bleeding due to spontaneous ovarian activity as she is a perimenopausal woman. The options available are monthly cyclic or 3 monthly cyclic regimens. Progestogens can be given either for 10-14 days every 4 weeks, for 14 days every 13 weeks or every day continuously. The first leads to monthly bleeds, the second option leads to 3 monthly bleeds and the last aims at achieving amenorrhoea. A combined estrogen with progestogen preparations are preferable over estogen alone therapy as there is an increased risk of endometrial malignancy with unopposed estrogen. But, the 47th study group on menopause and HRT suggests that the risk of increased breast cancer with addition of progestogens should be balanced against the risks of endometrial malignancy if progestogens are excluded. Low dose Vaginal estrogens are effective for vaginal dryness and do not increase the risk of endometrial cancer. Transdermal preparations avoid passage through the gut and avoid the first pass metabolism. Estrogen Implants have the advantage that once inserted under local anaesthesia, are effective for many months. Progestogens can be delivered as an intra uterine system and can be effective for contraception as well especially when she has infrequent periods . There is an increased risk of VTE, breast cancer, endometrial cancer, stroke and early excess risk of MI with the use of Estrogens and Progestogens. Tibolone(2.5mg) is an effective alternative for vasomotor symptoms which also helps to prevent osteoporosis. But, it increases the risk of breast cancer, though lesser risk than combined estrogens and progestogens. Clonidene 50-75mg BD can be used but, was shown to have a limited effect.Progestogens- NET 5mg/day or Megestrol acetate 40m/day and antidepressants(Venlaflaxine, paroxetine, Fluoxetine) can be used as alternatives for vasomotor symptoms especially if estrogen is contraindicated. There is no evidence to support the benefit of herbal medicines and food supplements in controlling hot flushes but could be offered after discussion if HRT is contraindicated. The woman should be advised to be followed up after 3 months to determine the suitability of HRTand to answer any queries. Thereafter 6monthly or annual follow ups can be arranged. BP recording in each visit, pelvic and breast examination should be considered if indicated during the follow up visits.The woman should be advised about the importance of self examination of breasts and be aware of the signs and symptoms of DVT/VTE and seek immediate medical help if VTE is suspected. She should report immediately if there is an abnormal vaginal bleeding. Questions should be anwered, further appointments arranged if she desires. Information Leaflets should be provided and addresses of support groups given. She should be made to take an informed decision and discussion documented in the notes
		Posted by ASFASDF A. Wed Jan 25, 2006 12:03 pm
My initial assessment would involve assessing the risk of HRT to the lady. ? ie previous hx of breast cancer ? referral to oncology for further advice would be warranted. Hx of arterial disease, smoking, blood pressure, diabetes, previous MI or stroke ? HRT should not be given in women with previous cardiac disease. Hx of VTE, family Hx of VTE. A hx of VTE would preclude HRT(ie thrombophilia screen may be negative but the lady is still at high risk). A family hx warrants a thrombophilia screen and being +ve, especially if a high risk thrombophilia such as antithrombin III deficiency would preclude HRT. Hx of endometrial cancer ? again oncology review would be required before giving HRT. Hx of weightloss/osteoporosis ? may lead to benefit with decreased risk of #vertibrae if taken for life. Hx of problems with vaginal dryness ? is it an issue during intercourse. Examination- BP, BMI required, breast examination is not a requirement. We know she is perimenopausal from the hx: Investigations ? routine thrombophila screen not indicated, but worthwhile if family hx ? (ie) APC resistance, protein C,protein S levels, factor V leiden deficiency, antithrombin III deficiency, If she had no uterus, she would not require progestogenic component to her HRT. Counselling: I would explain that HRT has risks, but is good at controlling symptoms of hot flushes and vaginal dryness. But alternatives exist (ie) lubricating gel for vaginal dryness or topical vaginal oestrogen cream. There is evidence that hot flushes can be controlled by progestagens and SSRI?s. Excluding ?feeling well?, the risks of HRT outweigh the benefits but the risks remain low. In terms of DVT, the risk is tripled but in absence of risk factors remains low. The risk of heart attack increases by 1.2, of a stroke by 1.4 and of a PE 2fold, again with out riskfactors, the absolute risk remains low. Osteoporosis related #?s can only be prevented if taken HRT lifelong. Breast cancer risk is 32 per 1000 at age of 50 over 15 years. HRT taken for 5 , 10 or 15 years will increase this by 2,6, or 12 cases per 1000. In essence, a few years of HRT makes very little difference to the breast cancer ? and HRT need only be taken for a while for symptom relief She would require sequential HRT, as continuous combined HRT would make her bleed irregularly (assuming she had a uterus). Sequential HRT increases the risk of endometrial cancer. I would explain the routes of administration, ie gels, patches, pills, implants; give her written information and arrange follow up.
		Posted by Srivas P. Wed Jan 25, 2006 10:08 pm
WHI study and Million Women study have created alarm about risks of heart attacks, strokes, venous thromboembolism and breast cancer in woman on HRT. The present recommendations are that HRT is not to be used for prevention of Coronary heart disease and prevention and treatment of osteoporosis unless there are vasomotor symptoms. Hormone replacement therapy (HRT) is effective for symptomatic relief of menopausal symptoms and its use for this is justified when symptoms adversely affect quality of life and should be considered for the shortest possible duration, and with the lowest effective doses and treatment should be reappraised annually. The absolute risk of VTE with HRT is low. The WHI study indicates no increase of breast cancer risk for women taking HRT for less than 5 years. She should also be informed about decreased risk of colonic cancer and reduced risk of vertebral fractures with HRT use. In women with a uterus, continuous, combined estrogen-progestin replacement therapy is still considered the best option for the relief of moderate to severe menopausal symptoms such as hot flashes, severe mood swings, night sweats and difficulty concentrating. Local estrogen replacement may be given long term to reverse the symptoms of urogenital atrophy, recurrent urinary tract infection which are late manifestation of estrogen deficiency There is no evidence that local vaginal estrogen treatment is associated with significant risks. Her personal history and a family history of presence of VTE in a first- or second-degree relative should be obtained and if positive, a thrombophilia testing should be done. Severity of any previous event should be assessed whether or not it was objectively confirmed then. Contra indications to HRT include recent vascular thrombosis, active liver disease and Breast cancer. In this woman who has irregular vaginal bleeding endometrial aspirate should be done by Pipelle sampling and a concomitant USG showing endometrial thickeness less than 5 mm may help rule out endometrial carcinoma which is a contraindication for HRT. Other risk factors for VTE include obesity, varicose veins, prolonged immobility, paralysis of lower limbs, trauma or surgery to the pelvis or leg, malignancy and myeloproliferative disorders, cardiac failure, inflammatory bowel disease and nephrotic syndrome. HRT should be avoided in women with multiple pre-existing risk factors for VTE. If the woman has family history of breast cancer, mammography may be advised yearly. In women with a previous VTE, with or without an underlying heritable thrombophilia, oral HRT should usually be avoided view of the relatively high risk of recurrent VTE and transdermal estrogen is a better option. If the woman gives family history of VTE without a personal history of VTE and has an underlying thrombophilic trait identified through screening, HRT is not recommended in anti thrombin deficiency or with combinations of defects or with additional risk factors for VTE. Women should be counseled regarding perceived benefits and possible risks of HRT and given consideration of alternative therapies if she has associated marked osteoporosis with prolonged use of corticosteroids, heparin, GnRH agonists etc. She must have bone densitometry and if has osteoporosis she could be offered Tibolone, which improves bone mineral density and takes care of vasomotor symptoms. Tibolone carries less VTE risk compared to HRT and this may be a better option if she is high risk for VTE. Tibolone may be associated with an increased risk of breast cancer, but less than that associated with combined estrogen and progestogen preparations. Though Raloxifene improves osteoporosis, it worsens her vasomotor symptoms and hence is not advocated for this woman. Raloxifene also increases risk of VTE but reduces breast cancer risks. Biphosphonates can be combined with HRT when she has significant osteoporosis along with vasomotor complaints as Biphosphonates do not worsen hot flushes and its effect on the bone density is sustained longer than with HRT. Antidepressants venlafaxine, paroxetine and fluoxetine are options for women with hot flushes who are not candidates for estrogen therapy. These are not contraindicated in women with breast cancer. The additional antidepressant effect of these agents may be beneficial in women who also suffer from mood disorders. There is no convincing evidence to support the use of food supplements like Soya and herbs like Ginseng and other phytoestrogens pending extensive study. She should also be advised life style changes like exercises, avoiding caffeine, smoking weight control and stress management. Concluding HRT definitely has role for short term use, up to 4-5 years, for menopausal symptoms and it should be reviewed again if it is needed long term and fresh risk benefit analysis should be done for continued use.
		Posted by hala M. Thu Jan 26, 2006 12:11 am
The age of menopause in developed countries is 51 and my initial assessment of this lady would be divided into three parts: the check of her menopausal status. checking for the suitability for taking HRT and the appropriate choice of HRT in relation to her assessment. The menopausal status is confirmed by the persistence of FSH levels of 40IU in two tests 6 weeks apart. The initial assessment would be by taking a detailed personal history of thrombosis VTE (risk of recurrence with HRT use), cardiovascular disease CVD and its risk factors (HRT use is not associated with benefit in secondary preventions of CVD, but the presence of CVD risk factors such as hypertension, obesity and smoking make the use of HRT beneficial), strokes, DM, varicose veins and bowel inflammatory disease. I need to note as well the risk factors for osteoporosis such as long term steroid use, poor nutrition, immobility and thyroid disease. It is important to take a family history in relevance to VTE in the 1?st and 2?nd degree (suggests the possibility of thrombophilia), CVD and hormonal dependent cancer with hereditary predisposition such ad breast, ovarian and endometrial cancers. Thrombophilia screening should be offered if the history is positive. During the history taking it is good practice to enquire about the current medication, cervical smear, lifestyle and contraception. As part of the initial assessment I need to perform a general examination including height, weight, BMI, BP, breast and abdomen. Pelvic examination is needed when history suggests so. If the history is positive for any of the above then the investigation for it needs to be performed such as thrombophilia, lipid profile and bone mineral density DMD. Counselling is going to be about the choice of the most suitable form of HRT (according to the findings above), dose, route and the possible associated side effects ( headache, bloating, low mood, acne and skin irritation). I need to tell her about the perceived benefit and possible risks with HRT use. In the absence of any contraindication HRT is an effective choice to relieve her hot flushes (oral or transdermal), but it is necessary to give progesterone for 12-14 days to prevent the endometrial hyperplasia. The other perceived benefits associated with HRT use include osteoporosis prevention, Alzheimer prevention and colorectal cancers. The evidence in CVD prevention is controversial, but it is still beneficial in a young woman with/without risk factors for CVD. I need to tell her that the risks associated with HRT use include the VTE risk increase by 3 in the first 2 years of use and this is possibly due to the unmasking of thrombophilia, therefore she needs to be told about the symptoms and signs of VTE and encouraged to report if she had them. HRT should be avoided if she is at high risk of VTE. The risk of breast cancer increases after 5 years of use by 6% and in case of high risks cases SERM (Raloxifen) is a good alternative. She needs to be encouraged to come for follow up after HRT starting to assess her needs to stay on it and she needs to be advised about the self breast examination.
		Posted by BAHAA-Uddin BOR B. Thu Jan 26, 2006 12:50 am
The initial assessment is always through history,examination and investigations . Detailed history should be taken exploring the specific symptoms she is suffering from, the nature and severity of these current symptoms, her menstrual status.,gynaecological history , had she ever been diagnosed with fibroids or endometriosis.,past medical history of myocardial infarction,angina and hypertension.Detailed family history of breast cancer ,ischaemic hear disease , stroke at young age osteoporosis and history of venous thromboembolism.Social history : employment ,smoking , physical activity.,current relationship ,sexual problems , the frequency of her sexual intercourse ,the current contraception and the smear history. Examination should include blood pressure measurement for hypertension,weight.,body mass index.Routine breast and pelvic examination is not mandatory.,but should be performed if there is any significant past medical history.. Around the time of the menopause ,FSH levels fluctuate markedly and are of limited value as a diagnostic tool .FSH levels > 30 IU/L are considered postmenopausal.,while FSH levels rise >20 IU/L despite continued menstruation in the peri-menopausal period but LH levels remain in normal range.. Thyroid function tests to rule out thyroid problem causing hotflushes .Screening for thrombophilia is inappropriate but should be considered if she had family history of VTE in first or second degree relatives. Pelvic ultrasound scan , Out-patient hysteroscopic examination to rule any endometrial pathology such as submucous fibroid or polyps . I would to explain to her the benefits ,risks ,side effects depend on the type of HRT ., duration of use and route of administration.The choice of HRT will depend on her needs.With intact uterus , she will reqire combined therapy of oestrogen and progestogen., thus reducing the risk of endometrial hyperplasia and carcinoma..The sequential preparation is associated with increased risk.Progestogen can be given daily in continuous combined regimen or sequential every 14 days in 4 weeks or 13 weeks.The main benefit of HRT in her case would be relief of her vasomotor symptoms like hotflushes and night sweats.Vaginal dryness responds well to topical oestrogen therapy. The other potential benefits like prevention of osteoprosis.,colorectal carcinoma,prevention of Alzheimer disease ,macular degeneration,,tooth loss would occur only with long-term use. She should be also told that HRT does not offer any protection against and is associated with increase in risk of coronary artery disease and stroke in the first year of use. It also increases the risk of venous thromboembolism ( 2-3 times.) hence women with history of VTE or strong family history should consider alternative therapy.The risk of breast cancer associated with long-term use of over ( > 5 years )and benefits of use over 1-2 years outweigh the risk. If the extra risk is confirmed ,it would be sensible to reduce the duration of Progestogen from 14 days to 7 days. (Women\'sHealth Initiative RCT ).The shortened course is useful in women with progestogen intolerance. Any abnormal vaginal bleeding or drug side effects may require further investigation. Certainly there are side effects associated with HRT as breast tenderness., fluid retention, nausea, headache., leg cramps., dyspepsia( OESTROGEN related ), and mood swings., depression, acne ( PROGESTOGEN related ). Also,HRT is associated increased risk of gall bladder diseases., fibroid enlargement and reactivation of endometriosis. The overall risk of these disorders with HRT remains small . The oestrogenic and progestogenic side effects can be managed with change in dosage or route of administration . I would discuss the alternatives to HRT like norethisterone , megestrol and SSRIs such as Paroxietine are effective for hotflushes .SERMs do not relieve menopausal symptoms and hence unsuitable . Adequate wrotten information must be provided ,So that the woman can take an informed choice.Discussion of the woman\'s preference s and which regimen she wishes to use anmd arrange for follow-up visits to deal with adverse effects. I would give her information leaflet , address of support group.I would like to encourage her to participate in breast and cervical screening.,offer contraception and further follow-up with GP.
		Posted by Vaani M. Thu Jan 26, 2006 03:36 am
Initial assessment of her reason for request for hormone replacement therapy has to be known. A detailed history of severity of symptoms and how much it is afftecting her daily routine life is to be understood. A detailed personal history of breast cancer, thromboembolism, heart disease and amount of blood flow during menstruation is to be enquired into. A family history of breast cancer, colonic cancers, venous thromboembolism, thrombophilias, heart disease and genital tract cancers as endometrial or ovarian cancers is to be taken in detail. Examination of this woman would include her height, weight ( BMI), blood pressure, systemic examination of breasts, cardiovascular system has to be done. Investigations of this woman would include FSH level to confirm menopausal status, a lipid profile, and mammography if at high risk of breast cancer. Counselling would be about need and various methods of hormone replacement therapies. If symptoms are very mild, she could be given reassurance and explanation of the condition. Emollient gels could be used for the vaginal dryness, and hot flushes would probably be relieved spontaneously if mild. If severe she would require hormones containing oestrogen and progesterone combined depending on her risk status. If she is at risk of thromboembolism with a personal or family history she could take use oestrogen by the transdermal route and progesterone as oral, or in the intrauterine form. Oestrogen cream could be applied vaginally for the dryness. If she is at high risk of breast cancer, she could preferably use lowest effective dose, for shortest possible time preferably local hormones than systemic intake of hormones. If she is thin and with high risk of osteoporosis she could use alternative methods as weight bearing exercises, bisphosphonates, and calcium. Selective oestrogen receptor modulators as raloxifene would aggravate her risk of venous thromboembolism and her already present hot flushes and would not be advisable. Similarly she would not be advised tibolone as she is still menstruating although infrequently. After appropriate counselling, she should be given information leaflets, addresses of support groups and the choice to decide herself about her need and method of hormone replacement to be taken.
		Posted by Zaibunnisa khan K. Thu Jan 26, 2006 08:53 pm
The initial assessment will include history ,examination and relevant investigations. In the history i will ask about the duration of presenting complaint,severity of the symptoms and its effects on her social and sexual life.Her previous menstrual history regularity as irregular menses are commonly associated with anovulation ,obstetrics history include nulliparity , hormonal contraception , or iucd in situ and gynecological history infertility ,fibriod ,endometriosis ,any genital malignancy and breast cancer , medical history regarding diabetes ,hypertension,thyroid disease,liver disorders and thromboembolism (vte ) which are risk factors for endometrial cancer and and also increases the risk of hormone replacement therapy ,surgical history .Drug history of such as steroids,anticoagulant hormonal contraception.Family history of breast or endometrial cancer ,or vte ,her personal history of smoking ,about life style and psychosexual history. .Eximination will consists of measurement of BMI, blood pressure ,breast examination ,per abdomen examination for masses ,tenderness and vaginal examination include per speculum examination pap smear if it is due , to look for signs of atrophic vaginitis and atrophic cervicitis as cause for infrequent periods soreness , dryness and examine status of cervix, healthy looking or any obvious lesion such as cervical erosion( ectropion) ,polyp ,any vaginal discharge and bleeding and its amount . Bimanual vaginal examination for assessment of uterine size ,mobility ,position and adenaxal masses and tenderness and per rectal examination to exclude any masses. Initial investigation will consists of her full blood count to assess her haemoglobin ,random blood sugar ,lipid profile ,and transvaginal ultrasound for assessment of endometrial thickness ,any endometrial pathology hyperplasia ,polyp which my be the cause for irregular periods ovarian pathology and outpatient endometrial biopsy to exclude endometrial hyperplasia and endometrial cancer which are the frequent causes of infrequent periods in this age group . Hysteroscopic directed biopsy In case outpatient hysteroscopy facilities are available. Councelling will consists of explaining her that her symptoms could be due to esterogen deficiency which can be improved by hrt . Short and long term benefits and risks associated with hrt will be explained to her .I will discussed that hrt will relieve her symptoms of hot flushes and improve her vaginal dryness on short term but there is proven long term benefit of preventing osteoporosis reducing verteberal femoral and hip fractures .Risk associated with hrt breast cancer and endometrial cancer and vte and strokes Hrt increases the risk of vte four fold and relative risk of 1.26-1.66 for developing breast cancer .The risk are more with combined esterogen and progesterone hrt . Risks are more in case she has personal or family history of vte in first or second degree relative with obesity and varicose veines ,hormone dependent breast and endometrial cancer She will be councelled that before initing hrt she will be assessed to exclude any risk factor or contraindication for hrt In case of risk factor for vte she may need thrombophilia screening .Risk of vte can be reduced by using topical estrogen for vaginal dryness and progesterone for hotflushes.Risk of endometrial cancer can be reduced by using combine esterogen and progesterone Selective esterogen receptor modulators can be used to reduce the breast cancer but do not relieve hot flushes and expensives. Councelling will also include different types and route of hrt orall , transdermal vaginal and implant.Other options in case hrt is contraindicated such as selective esterogen modulators ,physoesterogen ,clonidine . She will be counceled about change of life style to stop smoking , increase aerobic exercise and balanced diet. Verbal disscussion will be supported by written information about hrt ,its risks and benefits ,different types and routs .