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BusySpR MRCOG PART II
MRCOG Part 2, MRCOG II

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MRCOG 2 Past Questions Tutorial: GROUP 3: Sat 16/11 from 10:00 - Statistics. Sun 17/11 from 10:00 - Oncology 1. Group 2: Sat 16/11 from 19:00 - Contraception & STI. See DISCUSSIONS below for details.

 

 

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Forum >> ESSAY 257 - HRT
ESSAY 257 - HRT Posted by PAUL A.
Sat Jan 26, 2008 02:28 am
A 50 year old woman has a total abdominal hysterectomy and bilateral salpingo-oophrectomy for a stage Ia endometrial adenocarcinoma. She attends the gynaecology clinic 6 weeks later complaining of severe hot flushes and requests HRT. (a) Outline your clinical assessment [6 marks]. (b) What will you tell her about the benefits of HRT? [4 marks] (c) What will you tell her about the risks of HRT? [7 marks] (d) Evaluate the hormonal treatment options for this woman [3 marks].
Posted by S M.
Sat Jan 26, 2008 04:07 am
I will take a detailed history of her symptoms and enquire if she is having any other symptoms of menopause such as vaginal dryness and mood disturbances. I will ensure that she has not had any vaginal bleed after the hysterectomy and feels well in herself. I will explore her attitude and motivation towards HRT use. I will use my hospital protocol to assess her for the risks of HRT. I will enquire about history of thrombophilia and whether or not she has had a Deep Vein Thrombosis or Pulmunary embolism. I will ask her whether she suffers from any severe liver disease or heart disease. I will ask her if she has ever has ever has breast cancer or stroke. I will also equire about family history of cancer esp breast cancer and clots. Finally I will examine her to make sure that there is no clinical evedence of residual disease.

I will tell her that HRT will sort out her hot flushes. It will also make the vagina more moist thus increasing sexual satisfaction.
It might also elevate her mood and prevent fluctuations in mood.
HRT also plays a role in prevention of osteoporosis. I will also tell her that some early report claim that HRT taken for a few years soon after menopause prevents dementia and also coronary heart disease. HRT has also been said to have a protective effect for colonic cancer.

I will reassure her that HRT taken for a short duration soon after menopause does not carry any major risks. Most of the risks of HRT are more prominent in older women (more than 59 yrs of age) taking HRT. HRT increses the risk of breast cancer by a small fraction. It also incerases the risk of clots. The risk of stroke and cardiovascular disease is present in older women who have been taking HRT for a long duration. Some studies report a risk of dementia, in older women taking HRT. HRT, i will tell her, also increases the risk of coronary vascular disease and stroke in older women. HRT also raises the risk of endometrial cancer but as she has had a hysterectomy which treats her ailment, she need not worry. However she should report any abnormal PV bleeding. I will give her written information to reinforce the verbal discussion.

The hormonal options available for this lady are low dose estrogen tablets. She can even use estrogen patches or implants if she is not interested in tablets. Tibolone, a synthetic steroid works well to reduce hot flushes and also increases libido.
Posted by Sahathevan S.
Sat Jan 26, 2008 05:08 am
(a) Outline your clinical assessment .
A detailed history should be elicited in particular to assess risk of cardiovascular disease, osteoporosis and breast cancer. Nature and severity of other menopausal symptoms such as night sweats , dryness in vagina and urinary incointinence should be asked. Family or personal history of breast cancer is important to assess the risk. Also personal or family history of cardiovascular disease or symptoms suggestive of cardiovascular disease (chest pain, SOB on exertion) should be asked. Personal or family History of VTE is vital to investigate thrombophilia. History of any vaginal bleeding should be inquired to asses any residual disease.On clinical examination BP should be recorded and BMI need to be calculated.If the women have Family history of VTE in first or second degree relatives she should be investigated with thrombophilia screen before offering HRT. There are no other investigations needed if she is asymptomatic.

(b) What will you tell her about the benefits of HRT?
I will tell her the main benefit of HRT is relieving her menopausal symptoms such as hot flushes, night sweats, vaginal dryness which expected to relive within 4 weeks and she will have maximum response in 3 months. HRT associated with Psychological well-being this may secondary to reliving of menopausal symptoms.HRT likely to reduce the death from osteoporosis but it has to be taken life long to achieve this benefit. Studies have shown Oestrogen replacement may delay or prevent the onset of Alzheimersdisease.Localvaginalsymptoms (vulvovaginal atrophy) can be relieved by topical oestrogen. Also short term use of combined HRT is associated with decrease the risk of colorectal carcinoma. Risk of Macular degeneration, Cataract and tooth loss are low in women on HRT.

(c) What will you tell her about the risks of HRT?
I will explain that the overall risk of complications in women taking HRT remains small. However 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 .Also risk of thrombo-embolic disease particularly increased( by 2-3fold) in the first year of use. This risk is increased. risk of breast cancer which his is associated with long-term use of HRT (more than 5 years).HRT increase risk of breast cancer at the age of 50 .The risk will be 2,6,12 extra cases per 1000 in 5,10,15 years respectively. The background risk is 45 per1000. The risk of breast cancer in women who have discontinued HRT for 5 years is similar to that in never users. Gall bladder disease is also a recognized risk for HRT. Some particular side effects recognized for oestrogen HRT which are headache, nausea, breast tenderness and leg cramps.I will provide written information.

(d) Evaluate the hormonal treatment options for this woman.
Traditionally ERT ( Oestrogen replacement therapy) has not been advocated in first 2 years following surgery for endometrial cancer because of the concern of activating any residual disease. However there is no evidence to support this. this is being currently investigated by prospective RCT. Therefore benefit of HRT may outweigh the theoretical risk. In these women there is controversy over using oestrogen only or oestrogen and progesterone or progesterone preparation.
Route of administration of above chosen HRT can be oral, patches, implants, vaginal ring, gel and nasal spray. However oral preparation s are commonly used.
Noethisterone (5 mg daily) is an options of progesterone has been shown to be effective in reducing hot flushes and sweat but it has less effect on other menopausalsymptoms. Mrdroxyprogesterone acetate and megestrol acetate 40 mg daily are also effective and these may be useful if she has relative contraindication for HRT.Tibolone which is effective at relieving hot flushes and sweats and will prevent osteophorosis.




Posted by S M.
Sat Jan 26, 2008 06:17 am
A 50 year old woman has a total abdominal hysterectomy and bilateral salpingo-oophrectomy for a stage Ia endometrial adenocarcinoma. She attends the gynaecology clinic 6 weeks later complaining of severe hot flushes and requests HRT. (a) Outline your clinical assessment [6 marks]. (b) What will you tell her about the benefits of HRT? [4 marks] (c) What will you tell her about the risks of HRT? [7 marks] (d) Evaluate the hormonal treatment options for this woman [3 marks].

a) I will take a history of any other symptoms such as night sweats, palpitations, depression, vaginal dryness loss of libido or urinary symptoms since these symptoms will also need to be treated if they affect her quality of life. A history of breast cancer is important because there is an inceased risk of recurrence with HRT. I would enquire about venous thrombosis in the past, since there is an increased risk with HRT. Risk factors for venous thrombosis are also important such as a raised body mass index, smoking and immobility. The presence of these factors also increases the risk of venous thrombosis with HRT.

b) The main benefit is to treat the vasomotor symptoms such as night sweats and hot flushes. It reduces urogenital symptoms such as vaginal dryness. HRT will also reduce the risk of ovarian cancer. In the longterm it prevents the development of osteoporosis. I would provide information leaflets to support the consultation.


c) I would tell her that there is an increased risk of developing breast cancer. The HRT may also increase benign breast disease. There may be significant mastalgia and morbidity from ultrasound guided breast biopsy. HRT increases the risk of venous thrombosis, pumonary embolism and death. There is also increased risk of liver disease and raised triglycerides. I would provide information leaflets to support the consultation.

d) An estrogen only HRT may be given to this woman since she she does not have a uterus. This can be given in the oral form which is effective for hot flushes, night sweats and preventing osteoporosis but associated with sideeffects. The estrogen can be given in the form of patches which is also effective but has less sideffects. An alternative to estrogen is norethisterone. This is only effective for hot flushes and night sweats. It does not prevent osteoporosis.
Posted by Srivas  P.
Sat Jan 26, 2008 01:30 pm
(a) This woman who has been treated for Stage 1 Endometrial carcinoma can be given HRT after taking relevant medical and family history and in consultation with her oncologists. Risk of recurrence of endometrial carcinoma with HRT is low after early stage 1/11 cancer.

I will like to know if she has other complaints like vaginal dryness, dysparunia, any urinary frequency, higher risk for osteoporosis which may require longer use of HRT. She should be assessed for risk for osteoporosis-small body frame, excessive smoking, chronic alcoholism, and long term use of drugs like Heparin, DMPA, corticosteroids and diuretics like furosemide?all these may contribute to osteoporosis.

She should be assessed for risk factors for VTE as HRT by itself also increases the risk 3 fold. This includes history of diabetes mellitus, hypertension, whether she is now mobile after surgery, any varicose veins, obesity, previous history of VTE and family history of VTE in 1st and 2nd degree relatives. Presence of multiple risk factors for VTE will contraindicate HRT for her. Clinical examination should include BMI, B.P. Previous H/O VTE or H/O VTE in 1st/2nd degree should initiate doing Thrombophilia screening tests. In thrombophilia positive patients decision to give HRT is based on severity of menopausal symptoms, type of thrombophilic defect, combination of thrombophilia defects, her risk versus benefit analysis and opinion of hematology specialist.

Finally, family history, suggesting Lynch syndrome should be taken, wherein her risk of getting colorectal cancers are increased and she is likely to benefit with HRT use.

(b) HRT will improve her symptoms like hot flashes within 3-4 weeks, vaginal dryness in 4 mths but may not have much improvement on urinary incontinence. She may have psychological benefit due to symptom control.

HRT will improve her BMD and reduce risk of vertebral and hip fractures later in life but needs to take it life long for continued benefit. Stoppage of HRT takes away the benefit soon after stopping HRT.

It is likely to improve her skin texture, prevents tooth loss, macular degeneration and cataract. HRT offer some protection against colonic cancer---6 fewer cases per 10000 woman/year according to WHI study. Prevents onset of Alzheimer?s disease but may have no effect on established disease.

(c) HRT should not be given for primary prevention of heart disease as it has been shown to increase risks of CHD and stroke, especially in the first year of use and the increased risk disappears after HRT is discontinued. According to WHI study, the increase in risk may be 7 extra cases of CHD/10000 woman over 1 year use and 8 extra cases of Stroke /10000 women over one year, above her baseline risk.

The risk of breast cancer in this woman at age 50 is 45 per 1000 over 20 years and 32 per 1000 over 15 years. Her risk of breast cancer is increased 2, 6 and 12 extra breast cancers per 1000 women, when HRT is used over 5, 10 and 15 years respectively. However her risk of breast cancer after discontinuation of HRT for 5 years, become equal to never users.

HRT also increases her risk of embolism. Baseline risk of VTE is 5/100000 woman per year in pre menopausal woman and is doubled to 10/100000 woman in this post hysterectomised woman without HRT. Her risks will get tripled to 30/100000 woman when she takes HRT. The risk is increased in first year of use and in those with family history of VTE. She is also at increased risk of gall bladder disease.

I will also tell her about systemic effects of hormones ?head ache, fluid retention, breast tenderness, nausea, leg cramps. This can be managed by reducing dose where possible or changing route of delivery.

d) Estrogen alone as ERT is an option in this woman who has had hysterectomy and does not need additional protectiion of progesterone to prevent endometrial cancer. This also minimizes progestrogenic side effects. Also risk of breast cancers seem to be increased more with progesterone component of HRT-hence ERT alone is best for her.

Tibolone is a synthetic steroid that has estrogenic, androgenic and progestagenic properties and significantly reduces hot flushes and sweating and increases BMD in postmenopausal women and is an option for her.

SERMS like raloxifene can also be given but it carries same risk of VTE as ERT and is ineffective for hot flushes and worsens it.

Natural sources of estrogen like Phytoestrogens have been shown to have benefit for hot flushes but potential risk of breast cancer has not been investigated and can be given in specialized units.
Posted by Idris O.
Sat Jan 26, 2008 02:47 pm
a)I would ask her about the presence of other menopausal symptoms like vaginal dryness, sleep disturbances, irritability and night sweats. The severity of symptoms and the effect on her quality of life. I would ask about personal history of breast cancer or the use of tamoxifen . I would ask about other high risk features like history of cardiac disease or previous history of VTE.Any family history of breast, ovarian,stomach, or colon cancer. Also any family history of osteoporosis or VTE. I would assess her BMI.
b)I would inform her menopausal symptoms are transient and self limiting and usually last 1-2years.
The benefit of HRT include the relief of vasomotor symptoms of hot flushes, dryness of vagina and night sweats.There is also improvement in skin colour and hair texture. It also improves mood, libido and urinary symptoms. Long term use prevents osteoporosis colon cancer, possibly Alzheimer?s disease, ,periodontal disease, macular degeneration and tooth loss.I would offer her information leaflet on HRT.
c)There is an increased risk of VTE in the first year of use. It increases the risk of coronary heart disease or stroke in the first year of use especially in women with heart disease or hypertension.It also increases the risk of breast cancer if used greater than 5years. The risk reverts back to background risk after discontinuing its use.There is an increased risk of ovarian cancer. There is also an increased risk of endometrial cancer especially with long term use. The effect of short term HRT use on recurrence of endometrial cancer is uncertain and HRT is best avoided.The advice of a gynaecological oncology would also be sought before starting her on this treatment and surveillance would be required in case of suggestive symptoms of recurrence. There is also increased risk of gall bladder disease. I would provide her with information leaflets.
d)Progestogens given alone are not shown to be of much benefit, but combined progestogen and oestrogen HRT relief vasomotorl symptoms. It is not known whether added progestogen would protect against the recurrence of endometrial adenocarcinoma. Alternatives include tibolone,or selective oestrogen receptor modulators like raloxifene if there is a personal history or strong family history of breast carcinoma,but do not relief menopausal symptoms. Phyto-oestrogens found in red clover and soya have oestrogenic activities and relief menopausal symptoms but have potential implications for recurrence of endometrial carcinoma.
Healthy lifestyle habits, such as weight bearing exercise, stopping smoking,reducing alcohol, high fibre diet are of benefit.
Posted by hoping ..
Sat Jan 26, 2008 04:30 pm
I will assess her post operative recovery and address her symptoms of hot flushes.I will enquire if she has any other symptoms and effect on quality of life. Any past history of VTE or in first degree relative should be checked. I will asses her mobility and smoking status.Any cardiac event in past especially in last year should also be asked about. Past history of stroke in herself or in first degree relatives of and breast cancer should be obtained. I f there is any history of liver problems , it should be checked.
I will advise her that HRT is effective in reducing severity and frequency of hot flushes. It also reduces symptoms of vaginal discomfort and dyspareunia due to lack of estrogen in vaginal mucosa. It can relieve urinary symptoms of pain and urgency secondary to lack of estrogen. It delays onset of Alzhiemers disease. It has protective effect against cataract and tooth decay. It also protects against hot flushes but only if taken for many years.It protects against colorectal cancer.
HRT increases risk of venous thromboembolism by 3 fold. It increases risk of cardiac event in first year of commencing especially in women who have had previous episode. It increases risk of stroke. It leads to increased risk of breast cancer when taken for long, it causes 6 additional cases for every 1000 if taken for five years.If breast cancer is diagnosed in women on HRT it is likely to present at higher stage.HRT also increases risk of gallbladder cancer.
As she had hysterectomy, estrogen only HRT would be appropriate than combined HRT. This will reduce risks attributed to progesterone component especially VTE, breast cancer. Patches are preferable to oral route as have lower risk of VTE. Oestrogen implant can also be offered and testosterone implant if there are issues of reduced libido. Local estrogen in form of vaginal ring, cream or pessaries is suitable for local symptoms , it is less effective in treating hot flushes.
Posted by Anna A.
Sat Jan 26, 2008 07:05 pm
a. Obtain thorough history is very important steps as an initial assessment before starting hormone replacement therapy (HRT). History of personal or family of venous thrombo-embolism (VTE) should be asked. If there is a such history, arrangement should be made to screen thrombofillia. Personal or family history of breast cancer and the staging of breast cancer are important factor to determine as HRT is not a good option in managing her hot flushes. Drug history, like complication with contraceptive pills in a form of allergic or cholestasis will make HRT is contraindicated in this patient. Quality of life should be assessed to determine how bad the patient is affected with her hot flushes. Family history of osteoporosis and personal history of smoking and consume alcohol make the patient vulnerable to suffer osteoporosis. Multiple history of medical illness especially cardiovascular diseases should be obtained. Body mass index and blood pressure should be measured.
b. She should understand that HRT is an effective treatment for menopausal symptoms. In long term treatment, HRT will improve bone density, thus it can prevent osteoporosis. HRT is proven to reduce the risk of colorectal cancer. HRT may prevent or reduce the development of Alzheimer?s disease but it has no effect on established disease. She should be informed that HRT can reduce the risk of macular degeneration, tooth loss and cataract. HRT can also improve urogenital atropy.
c. She should know that HRT is associated with increased risk to develop breast cancer. At the age of 50, the risk to develop breast cancer is 38 in 1000 after 5 years of using combined HRT and 51 in 1000 after 10 years (background risk is 32 in 1000 over 15 years). But the risk of breast cancer is similar to never user after 5 years of stopping HRT. The risk of cardiovascular diseases and stroke is increased especially in the first and second years of HRT. HRT double the risk of VTE, therefore personal history of VTE is contraindicated. Sequential HRT and unopposed estrogen therapy is associated with increased risk of endometrial cancer. The risk of ovarian cancer with HRT is controversial. Side effect of HRT like breast tenderness, nausea and vomiting should be explain to the patient as well. Information leaflet and further follow up should be provided.
d. HRT is not associated with increased risk of recurrent in endometrial cancer. Progestogen only replacement therapy is a viable option for this patient but sometime it may worsen the menopausal symptom. If this happen continues combined HRT is another option. Oestrogen only replacement in the form of implant or patches may be prescribed as this can reduce the risk of VTE. Oestrogen cream is effective in treating local urogenital symptom but it does not reduce menopausal symptom.
Posted by Reiaz M.
Sun Jan 27, 2008 01:38 am
a) Two issues need to be adressed in this patient. Firstly she is a post operative patient and secondly she is experiencing manifestations of the climacteric.
On the history other symptoms of the climacteric are sought. These include insomnia, irritability, mood swings and palpitations, Any vaginal bleeding or discharge from the incision site should be determined.
A past history of cardiac events or thromboembolic disease should be determined. It is also important to enquire about a family history of breast cancer and thromboembolic events. Current use of cigarettes is sought.
On examination her BMI is calculated. The incision is inspected and the vaginal vault is also examined.
Patients with a positive family history of thromboemboism should have a thrombophilia scrren done. A mammogram is also requested.

b) She is told that HRT is likely to alleviate her hot flushes, with an improvement usually noted within 4 weeks and maximal effect achieved at 3 months.
HRT decreases her risk of osteoporosis. Patients on HRt have an initial increase in bone mineral density in the first 12-18 months of use. Her risk of vertebral fractures is decreased.
HRT use is also associated with a decrese in the risk of colorectal cancer and it may play a role in the delay/prevention of Alzheimers disease.
Patients on HRt report an improvement in psychological well being. HRt may also decrese the risk of tooth loss and macular degeneration. HRt may also help prevent urogenital atrophy.

c) Most women who use HRT will have no adverse outcome secondary to treatment.
Endometrial cancer is an estrogen dependent tumour. Although there is a theoretical risk of tumour reaactivation, this risk is very low with stage 1A disease.
HRT increses her risk of breast cancer. The actual number of excess women who will develop breast cancer as a result of treatment is low with an excess of 12/1000 women after 15 years of HRT use.
This patient is at increased risk of thromboembolism as a result of her pelvic malignancy and post operative state. HRT increases the risk of venous thromboembolism 2 fold. There is also an increased risk of pulmonary embolism.
Patients on HRT also have an increased risk of stroke and myocardial infarction.

d) This patient can be started on an estrogen only preparation since she has had a hysterectomy. The transdermal route is associated with a decreased risk mof venousthromboembolism and may be preferred in this patient.
A combined estrogen/progestagen preparartion may also be used in an attempt to decrese the risk of disease reactivation, but this may be associated with progestagenic side effects.
Tibolone is another option which may be used in this patient.
Posted by M M A.
Sun Jan 27, 2008 09:59 pm
(a)
Appropriate history is taken about personal and familial history of venous thromboembolism and thrombophilia.
We inquire also about history of breast and ovarian cancer and try to look for any factors that is contraindicated for the use of HRT.
We do risk assessment for VTE and ask about sign and symptoms of post-operative complications like fever, vaginal spotting and pain. Also we ask about urinary tract symptoms.
History of liver disease and coronary heart disease is also relevant.
We do general examination of the patient including BMI and blood pressure measurement, also look for the presence of varicose veins, we do breast examination after taking her permission . Abdominal scar also examined and if she has vaginal spotting, pelvic ( speculum ) examination is done gently to detect granulation tissue formation.

(b)HRT is significantly improve vasomotor symptoms, also it protect against osteoporosis and reduce osteoporosis related hip fractures., although it is not used primarily for this indication.
It has long term effect also by decreasing urogenital atrophy and reduce incidence of colorectal cancer.
In addition it reduce macular degeneration and improve cognitive function, hair and skin.

(c )
HRT is associated with increase risk of venous thromboembolism by 8-foldss especially with systemic preparation that undergo first pass hepatic metabolism as they affect liver production of clotting factors; therefore, transdermal preparation will carry less risk of VTE.
There is also increase risk of oestrogen dependant malignancy like breast and ovarian cancer.
Risk of breast cancer increase with increase duration of use especially if used more than 5 years but it return back to normal life time risk after stopping the treatment.
Progesterone can be used alone in this lady which can be regarded as one of the line therapy of treating endometrial cancer, it can improve vasomotor symptoms but it is needed in high doses which carries also risk of breast cancer.
HRT also increase risk of coronary heart disease and stroke.

(d)
HRT reduce vasomotor symptom by 80-90%, although it can be associated with increase risk of oestrogen dependant malignancy, it can be used in this lady with stage 1 , operated endometrial carcinoma as it is not an absolute contraindication.
However, we should consider alternative therapies to HRT by being safer to her, they reduce vasomotor symptoms by 40-60%.s

Posted by Hala T.
Mon Jan 28, 2008 04:58 am
a) A detailed history should be taken exploring the specific symptoms she is suffering from, their nature and severity and their effects on her life. Detailed family history of breast cancer, ischaemic heart disease. Personal history of cardiovascular disease or symptoms suggestive C.V.D as chest pain, shortness of breath on exertion should be enquired.
Personal or family history of venous thromboembolism should be enquired. Social history of employment , smoking, physical activity ,drug history should be obtained.
Examination should include blood pressure measurements for hyprtension, weight and BMI.
Routine breast examination is not necessary and should only performed if clinically indicated. Routine thrombophilia screen is not indicated , but worthwhile if she had family history of VTE in first or second degree relatives. No additional investigation is required in this woman.
b) I would tell her that menopausal symptoms are transient and for this purpose , only short-term use of HRT is required ( 1-2 years and < 5 years).
The main benefit will be symptom control and improved quality of her life. The menopausal symptoms to improve are hot flushes, night sweat, vaginal dryness and improvement in skin and hair.
Hot flushes relieved within 4 weeks , maximum response achieved by 3 months. Oestrogen therapy associated with improvement in psychological well-being , may be secondary to the relief of vasomotor symptoms.
I would make her understand that the potential benefits like prevention of osteoporosis, colo-rectal cancer , possibly Alzheimer?s disease , macular degeneration, tooth loss may only be achieved with long-term use and would not apply with short-term use to control menopausal symptoms .
c) I would tell her that HRT is associated with an increased risk of coronary artery disease and stroke especially in the first year of use. So, if the woman has had a previous cardiovascular event or is at high risk , then HRT would not be recommended .
The risk of thromboembolic disease is particularly increased in the first year of use and if she has a history of VTE or at high risk , HRT is not recommended.
The risk of breast cancer associated with long-term use of HRT ( > 5 years ) and the benefits of use over 1-2 years outweigh the risks.
Other risks including gall bladder disease ,and drug side effects like fluid retention, nausea , headache , leg cramps , dyspepsia and mood swings , depression and acne.
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.
She should be informed that only short-term use of HRT is required for vasomotor symptoms , and hence the risk-benefit profile is different from that with long-term use.
d) Conjugated equine oestrogen is an option , but it provided no overall protection against
myocardial infarction or coronary death during a 7-year period of use. Oral estrogen has the advantages that is easy to administer, easy to stop and has short half-life . It is cheap and well researched. I would discuss the options of transdermal( patches), percutaneous (gel)route that associated with reduced risk of VTE . It has advantages that is easy to administer , easy to stop . It avoids the first-pass effect and gastrointestinal problems .
The effects of transdermal oestrogens are similar to those of oral oestrogens.
The option of prescribing progestogens such as norethisterone or megestrol is also effective for hot flushes, but some less effective than systemic Oestrogen. SERMs are unsuitable as they do not relieve menopausal symptoms.
I would provide written information . Concordance with therapy can be improved by involvement of the woman in decision-making , discussion of the woman?s preferences and which regimen she wishes to use and the arrangement for follow-up visits to deal with adverse effects.
Posted by Hala T.
Mon Jan 28, 2008 05:02 am
a) A detailed history should be taken exploring the specific symptoms she is suffering from, their nature and severity and their effects on her life. Detailed family history of breast cancer, ischaemic heart disease should be obtained. Personal history of cardiovascular disease or symptoms suggestive C.V.D as chest pain, shortness of breath on exertion should be enquired.
Personal or family history of venous thromboembolism should be enquired. Social history of employment , smoking, physical activity ,drug history should be obtained.
Examination should include blood pressure measurements for hyprtension, weight and BMI.
Routine breast examination is not necessary and should only performed if clinically indicated. Routine thrombophilia screen is not indicated , but worthwhile if she had family history of VTE in first or second degree relatives. No additional investigation is required in this woman.
b) I would tell her that menopausal symptoms are transient and for this purpose , only short-term use of HRT is required ( 1-2 years and < 5 years).
The main benefit will be symptom control and improved quality of her life. The menopausal symptoms to improve are hot flushes, night sweat, vaginal dryness and improvement in skin and hair.
Hot flushes relieved within 4 weeks , maximum response achieved by 3 months. Oestrogen therapy associated with improvement in psychological well-being , may be secondary to the relief of vasomotor symptoms.
I would make her understand that the potential benefits like prevention of osteoporosis, colo-rectal cancer , possibly Alzheimer?s disease , macular degeneration, tooth loss may only be achieved with long-term use and would not apply with short-term use to control menopausal symptoms .
c) I would tell her that HRT is associated with an increased risk of coronary artery disease and stroke especially in the first year of use. So, if the woman has had a previous cardiovascular event or is at high risk , then HRT would not be recommended .
The risk of thromboembolic disease is particularly increased in the first year of use and if she has a history of VTE or at high risk , HRT is not recommended.
The risk of breast cancer associated with long-term use of HRT ( > 5 years ) and the benefits of use over 1-2 years outweigh the risks.
Other risks including gall bladder disease ,and drug side effects like fluid retention, nausea , headache , leg cramps , dyspepsia and mood swings , depression and acne.
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.
She should be informed that only short-term use of HRT is required for vasomotor symptoms , and hence the risk-benefit profile is different from that with long-term use.
d) Conjugated equine oestrogen is an option , but it provided no overall protection against
myocardial infarction or coronary death during a 7-year period of use. Oral estrogen has the advantages that is easy to administer, easy to stop and has short half-life . It is cheap and well researched. I would discuss the options of transdermal( patches), percutaneous (gel)route that associated with reduced risk of VTE . It has advantages that is easy to administer , easy to stop . It avoids the first-pass effect and gastrointestinal problems .
The effects of transdermal oestrogens are similar to those of oral oestrogens.
The option of prescribing progestogens such as norethisterone or megestrol is also effective for hot flushes, but some less effective than systemic Oestrogen. SERMs are unsuitable as they do not relieve menopausal symptoms.
I would provide written information . Concordance with therapy can be improved by involvement of the woman in decision-making , discussion of the woman?s preferences and which regimen she wishes to use and the arrangement for follow-up visits to deal with adverse effects.



Posted by Farina A.
Mon Jan 28, 2008 05:26 pm
Before commencing HRT, I would like to ask about the impact of the symptoms on her routine life, her smoking hobbits and about any personal or family (first or second degree relative) history of thromboembolic disease, breast cancer, hyperlipidemia, cardiovascular disease (stroke) or if she knows any thing about her thrombophilia status. Hypertension and diabetes mellitus are not contraindications for HRT but if present may require higher doses of antihypertensive and hypoglycemic drugs to control the disease. Her BMI is important to note along with presence of gross varicose veins and breast lumps. History of premenstrual syndrome may be important as it may reappear with HRT.

Severe hot flushes along with sexual and urinary complain (dysparunia and incontinence) are likely to be improved with HRT. I would also like to tell her that long term use of HRT reduces the risk of osteoporosis and vertebral and femoral neck fractures. HRT can delay the onset of Depression, Alziemer?s disease, cataract and tooth decay. It also improves the sense of well being.

About the risk of HRT, I would like to tell her that the risk of DVT is increase 2 to 3 fold. Risk of breast cancer is increase with HRT (51 per 1000 with estrogen + progesterone and 35 per 1000 with estrogen alone). Patients with established cardiovascular disease can have increased risk of deterioration of the disease and are advised against HRT. Women on HRT under going major surgery are believed to be at high risk of thromboembolism, so may need thromboprophylaxis. HRT increases the risk of gall bladder disease. HRT may increase the risk of malignant melanoma as it has estrogen receptors.

Estrogen only preparation can effectively reduce the symptoms of hot flushes without any progestational side effect of fluid retention and breast tenderness. As this patient has undergone hysterectomy there is no more additional risk of endometrial carcinoma. Continuous combined estrogens and progesterones may result in progestational side effect. Sequential estrogens and progesterones can also produce progestational side effects. Estrogen patches has less thrombogenic effects with effective relief of hot flushes. Estrogen implants are also effective in relieving hot flushes.
Posted by Lekshmi B.
Mon Jan 28, 2008 10:53 pm
A) A detailed history will be taken to look for risk factors for thromboembolism.This includes past history of venous thromboembolism (VTE),family history of thrombosis and history of thrombophilia and if present the type of inherited defect .History of smoking will also be asked for. I will also ask for any history of ischaemic heart disease and gall bladder disease which if present will increase the risk associated with HRT.Past history of Carcinoma breast if present will also be against offering HRT. I will assess her body mass index and look for any varicose veins which serve as additional risk factors for VTE.Any history of bleeding PER vaginum suggestive of recurrence of malignancy will be noted.

B) I will tell her that HRT will help to reduce her vasomotor symptoms like hot flushes .The effects will begin in 1 month with peak benefit in 3 months time. It will also improve symptoms like night sweats thereby improving sleep with the resultant improvement in quality of life. Prolonged use of HRT for more than a year will also improve genito urinary functions leading to better sexual life.HRT will also help to delay onset of Alzheimer?s disease and reduce risk of colorectal carcinoma. It also reduces incidence of cataract, macular degeneration and tooth loss. Life long treatment also offers protection against osteoporosis.

C) HRT increases risk of coronary heart disease especially if there is a previous history of ischaemic heart disease. There is also an increased risk of stroke and 2-3 times increased risk of VTE.The risk of gall bladder disease is also increased. An increased risk of Carcinoma breast is seen with 2 extra cases reported per 1000 women when used for 5 years and 6 and 12 extra cases per 1000 for 10 and 15 years of HRT use.5 years after stopping HRT the risk reduces to a level similar to that of a nonuser. The risk of Carcinoma ovary is also increased. Systemic side effects related to hormones like, fluid retention, breast tenderness, headache, nausea and leg cramps can also develop. There is no evidence to prove that HRT is associated with an increase in weight gain.
D) There is no evidence to suggest an increased risk of cancer recurrence in women treated for early stage Ca Endometrium if put on HRT.Since hysterectomy has been done she can be offered Oestrogen only HRT.Oral conjugated synthetic oestrogens or estradiol tablets can be given.Transdermal Oestrogen patches are preferred in women with risk factors for VTE who opt for it. This route of treatment reduces risk of VTE.Oestrogen containing vaginal rings and local gels are other options. Continuous combined Oestrogen and progesterone therapy may also be tried in women who opt for it.
Posted by K P.
Mon Jan 28, 2008 11:59 pm
I would ask her how often she gets the hot flushes and when she is getting it. I would also ask if there are any exacerbating and relieving factors. I would ask if she has tried anything for it and how it is affecting the quality of her life and activities of daily living. I would also explore if she had any other symptoms related to oestrogen deficiency like night sweats, urogenital symptoms - vaginal dryness, loss of libido and mood disturbances - depression. I would also ascertain if she had recovered from her surgery, asking if she has any pain, or bleeding, urinary or bowel disturbances.I would ask if she developed any complications between the surgery and her current visit that warranted a visit to her GP. I would explore and past medical and family history of venous thromboembolism, arterial disease, liver diease,ischaemic heart disease, breast cancer and ovarian cancer as these are risk factors which my contraindicate use of HRT in this woman. I would then examine her, ensuring that her wound is well healed and there are no evidence of abdominal or adnexal masses.I would look for evidence of gross varicose veins. I would measure her blood pressure and calculate her BMI.

There are short term and long term benefits of HRT. Short term benefits are the improvement of this ladies vasomotor symptoms. HRT can also significantly improve any urogential symptoms if present. Topical oestrogen is especially effective with local vaginal dryness. She will have considerable improvement in her mood. Long term benefits include the reduction of osteoporosis however incidence of hip and vetebral fractures are only reduced with lifelong HRT and not a short course of HRT. There is evidence that HRT can reduced the incidence of colorectal carcinoma and Alzeihmer\'s disease. HRT improves the lipid profile with an increase in HDL and a decrease in LDL cholesterol. However there is also and increase in triglyceride levels.

With regards to risks of HRT, this ladies main concern would be the recurrence of her endometrial carcinoma. Current evidence suggests that there is no increase in the recurrence of endometrial carcinoma in HRT users. Other risks include a 2 - 3 fold increase in venous thromboembolism and stoke. There is an increase in breast cancer which is dependant on duration of use and the Million Women\'s Study had also recently demonstrated an increase in ovarian cancer in HRT users, again with prolonged usage. The Women\'s Health Initiative also demonstrated an increase in ischaemic heart disease in these women although this was more associated with combined oestrogen and progesterone rather than oestrogen only preparations.

HRT is the only hormonal prepartion that has been shown to be effective in the treatment of vasomotor symptoms. However it is associated with significant risks as outlined above. The above should be explained to the patient and her choice has to be priority. The current recommendations are the a short course of HRT of 2- 3 years to treat symptoms.Although other hormonal preparations such has selelective oestrogen receptor modulators have a better risk profile studies have shown that they are not effective in treating vasomotor symptoms.
Posted by PAUL A.
Tue Jan 29, 2008 03:07 am

I will take a detailed history of her symptoms and enquire if she is having any other symptoms of menopause such as vaginal dryness (1) effect on quality of life and mood disturbances. I will ensure that she has not had any vaginal bleed after the hysterectomy and feels well in herself. I will explore her attitude and motivation towards HRT use. I will use my hospital protocol to assess her for the risks of HRT. I will enquire about history of thrombophilia and whether or not she has had a Deep Vein Thrombosis or Pulmunary embolism (1) . I will ask her whether she suffers from any severe liver disease or heart disease. I will ask her if she has ever has ever has breast cancer (1) or stroke. I will also equire about family history of cancer esp breast cancer and clots. Finally I will examine her to make sure that there is no clinical evedence of residual disease. BP, BMI

I will tell her that HRT will sort out (1) improve her hot flushes. It will also make the vagina more moist thus increasing sexual satisfaction this is largely psychological and there is no evidence that HRT increases sexual satisfaction .
It might also elevate her mood and prevent fluctuations in mood.
HRT also plays a role in prevention of osteoporosis only with life-long use . I will also tell her that some early report claim that HRT taken for a few years soon after menopause prevents dementia is this just a ?claim? or is there any scientific evidence? and also coronary heart disease. HRT has also been said to have a protective effect for colonic cancer.

I will reassure her that HRT taken for a short duration soon after menopause does not carry any major risks. Most of the risks of HRT are more prominent in older women (more than 59 yrs of age) taking HRT. HRT increses the risk of breast cancer by a small fraction what is ?small?? 10%?? . It also incerases the risk of clots by how much? . The risk of stroke and cardiovascular disease is present in older women the question is about a 50 year old ? why tell her about older women? who have been taking HRT for a long duration. Some studies report a risk of dementia how is this consistent with your statement above about a protective effect?? , in older women taking HRT. HRT, i will tell her, also increases the risk of coronary vascular disease and stroke in older women if the examiner wanted information about older women, they would have asked you about an older woman . HRT also raises the risk of endometrial cancer but as she has had a hysterectomy which treats her ailment, she need not worry why mention it? . However she should report any abnormal PV bleeding. I will give her written information (1) to reinforce the verbal discussion.

Why should you have a 50 year old in clinic and then tell her about older women???
The hormonal options available for this lady are low dose estrogen tablets. She can even use estrogen patches or implants if she is not interested in tablets. Tibolone, a synthetic steroid works well to reduce hot flushes and also increases libido are there any issues with using oestrogens in a woman with a recently treated oestrogen-sensitive tumour? Why not use oestrogens + progestogens or just progestogens? .
Posted by PAUL A.
Tue Jan 29, 2008 03:35 am
(a) Outline your clinical assessment .
A detailed history should be elicited in particular to assess risk of cardiovascular disease, osteoporosis and breast cancer. Nature and severity of other menopausal symptoms such as night sweats , dryness in vagina (1) effect on quality of life and urinary incointinence is incontinence a menopausal symptom? should be asked. Family or personal history of breast cancer is important to assess the risk (1) . Also personal or family history of cardiovascular disease or symptoms suggestive of cardiovascular disease (chest pain, SOB on exertion) should be asked (1) . Personal or family History of VTE (1) is vital to investigate thrombophilia. History of any vaginal bleeding should be inquired to asses any residual disease.On clinical examination BP should be recorded and BMI (1) need to be calculated.If the women have Family history of VTE in first or second degree relatives she should be investigated with thrombophilia screen before offering HRT. There are no other investigations needed if she is asymptomatic.

(b) What will you tell her about the benefits of HRT?
I will tell her the main benefit of HRT is relieving her menopausal symptoms such as hot flushes, night sweats, vaginal dryness (1) which expected to relive within 4 weeks and she will have maximum response in 3 months. HRT associated with Psychological well-being this may secondary to reliving of menopausal symptoms.HRT likely to reduce the death from osteoporosis reduces incidence of fractures but it has to be taken life long to achieve this benefit. Studies have shown Oestrogen replacement may delay or prevent the onset of Alzheimersdisease.Localvaginalsymptoms (vulvovaginal atrophy) can be relieved by topical oestrogen. Also short term use of combined HRT is associated with decrease the risk of colorectal carcinoma (1) . Risk of Macular degeneration, Cataract and tooth loss are low are they lower than in non-users? in women on HRT.

(c) What will you tell her about the risks of HRT?
I will explain that the overall risk of complications in women taking HRT remains small. However 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) .Also risk of thrombo-embolic disease particularly increased( by 2-3fold) in the first year of use (1) . This risk is increased. risk of breast cancer which his is associated with long-term use of HRT (more than 5 years).HRT increase risk of breast cancer at the age of 50 .The risk will be 2,6,12 extra cases per 1000 in 5,10,15 years respectively (1) . The background risk is 45 per1000. The risk of breast cancer in women who have discontinued HRT for 5 years is similar to that in never users (1) . Gall bladder disease is also a recognized risk for HRT. Some particular side effects recognized for oestrogen HRT which are headache, nausea, breast tenderness and leg cramps (1) .I will provide written information (1) .

(d) Evaluate the hormonal treatment options for this woman.
Traditionally ERT ( Oestrogen replacement therapy) has not been advocated in first 2 years following surgery for endometrial cancer because of the concern of activating any residual disease. However there is no evidence to support this. this is being currently investigated by prospective RCT. Therefore benefit of HRT may outweigh the theoretical risk (1) in the short term. In these women there is controversy over using oestrogen only or oestrogen and progesterone or progesterone preparation what is the value? EVALUATE .
Route of administration of above chosen HRT can be oral, patches, implants, vaginal ring, gel and nasal spray. However oral preparation s are commonly used.
Noethisterone (5 mg daily) is an options of progesterone has been shown to be effective in reducing hot flushes and sweat (1) but it has less effect on other menopausalsymptoms. Mrdroxyprogesterone acetate and megestrol acetate 40 mg daily are also effective and these may be useful if she has relative contraindication for HRT.Tibolone which is effective at relieving hot flushes and sweats and will prevent osteophorosis.

V GOOD ANSWER
Posted by PAUL A.
Tue Jan 29, 2008 03:59 am
a) I will take a history of any other symptoms such as night sweats, palpitations, depression depression is not a menopausal disease , vaginal dryness loss of libido or urinary symptoms since these symptoms will also need to be treated if they affect her quality of life (1) . A history of breast cancer is important because there is an inceased risk of recurrence with HRT (1) . I would enquire about venous thrombosis in the past, since there is an increased risk with HRT. Risk factors for venous thrombosis are also important such as a raised body mass index, smoking and immobility. The presence of these factors also increases the risk of venous thrombosis with HRT (1) you must separate history from examination to earn full marks. What about risk factors for arterial disease? .

b) The main benefit is to treat the vasomotor symptoms such as night sweats and hot flushes (1) . It reduces urogenital symptoms such as vaginal dryness (1) . HRT will also reduce the risk of ovarian cancer NO ? risk is increased ? see NOTES > KEY PAPERS (-1) . In the longterm it prevents the development of osteoporosis. I would provide information leaflets to support the consultation.


c) I would tell her that there is an increased risk of developing breast cancer WHAT IS THE RISK? You are expected to quote figures . The HRT may also increase benign breast disease. There may be significant mastalgia and morbidity from ultrasound guided breast biopsy. HRT increases the risk of venous thrombosis, pumonary embolism what is the risk? and death. There is also increased risk of liver disease and raised triglycerides. I would provide information leaflets (1) to support the consultation.

d) An estrogen only HRT may be given to this woman since she she does not have a uterus. This can be given in the oral form which is effective for hot flushes, night sweats and preventing osteoporosis is oestrogen recommended for osteoporosis prophylaxis? but associated with sideeffects. The estrogen can be given in the form of patches which is also effective but has less sideffects. An alternative to estrogen is norethisterone (1) . This is only effective for hot flushes and night sweats. It does not prevent osteoporosis.

You are expected to provide a more detailed answer quoting specific risks (percentages?)
Posted by PAUL A.
Tue Jan 29, 2008 04:23 am
(a) This woman who has been treated for Stage 1 Endometrial carcinoma can be given HRT after taking relevant medical and family history and in consultation with her oncologists. Risk of recurrence of endometrial carcinoma with HRT is low after early stage 1/11 cancer this is totally unnecessary ? you are wasting YOUR TIME & SPACE. You must recognise that the examiner does not have extra marks to give you .

I will like to know if she has other complaints like vaginal dryness, dysparunia, any urinary frequency, higher risk for osteoporosis which may require longer use of HRT HRT is NOT recommended for osteoporosis prophylaxis . She should be assessed for risk for osteoporosis-small body frame, excessive smoking, chronic alcoholism, and long term use of drugs like Heparin, DMPA, corticosteroids and diuretics like furosemide?all these may contribute to osteoporosis This is not necessary as osteoporosis is not an issue .

She should be assessed for risk factors for VTE as HRT by itself also increases the risk 3 fold (1) . This includes history of diabetes mellitus, hypertension, whether she is now mobile after surgery, any varicose veins, obesity, previous history of VTE and family history of VTE in 1st and 2nd degree relatives. Presence of multiple risk factors for VTE will contraindicate HRT for her. Clinical examination should include BMI, B.P (1) . Previous H/O VTE or H/O VTE in 1st/2nd degree should initiate doing Thrombophilia screening tests. In thrombophilia positive patients decision to give you were asked about clinical assessment, NOT treatment HRT is based on severity of menopausal symptoms, type of thrombophilic defect, combination of thrombophilia defects, her risk versus benefit analysis and opinion of hematology specialist.

Finally, family history, suggesting Lynch syndrome should be taken, wherein her risk of getting colorectal cancers are increased and she is likely to benefit with HRT use.

(b) HRT will improve her symptoms like hot flashes within 3-4 weeks, vaginal dryness (1) in 4 mths but may not have much improvement on urinary incontinence. She may have psychological benefit due to symptom control.

HRT will improve her BMD and reduce risk of vertebral and hip fractures later in life but needs to take it life long for continued benefit. Stoppage of HRT takes away the benefit soon after stopping HRT.

It is likely to improve her skin texture, prevents tooth loss, macular degeneration and cataract. HRT offer some protection against colonic cancer---6 fewer cases per 10000 woman/year according to WHI study. Prevents onset of Alzheimer?s disease but may have no effect on established disease (1) .

(c) HRT should not be given for primary prevention of heart disease as it has been shown to increase risks of CHD and stroke, especially in the first year of use (1) and the increased risk disappears after HRT is discontinued. According to WHI study, the increase in risk may be 7 extra cases of CHD/10000 woman over 1 year use and 8 extra cases of Stroke /10000 women over one year, above her baseline risk.

The risk of breast cancer in this woman at age 50 is 45 per 1000 over 20 years and 32 per 1000 over 15 years. Her risk of breast cancer is increased 2, 6 and 12 extra breast cancers per 1000 women, when HRT is used over 5, 10 and 15 years respectively (1) . However her risk of breast cancer after discontinuation of HRT for 5 years, become equal to never users (1) .

HRT also increases her risk of embolism. Baseline risk of VTE is 5/100000 woman per year in pre menopausal woman and is doubled to 10/100000 woman in this post hysterectomised woman without HRT. Her risks will get tripled to 30/100000 woman when she takes HRT (1) . The risk is increased in first year of use and in those with family history of VTE. She is also at increased risk of gall bladder disease.

I will also tell her about systemic effects of hormones ?head ache, fluid retention, breast tenderness, nausea, leg cramps (1) . This can be managed by reducing dose where possible or changing route of delivery.

d) Estrogen alone as ERT is an option in this woman who has had hysterectomy and does not need additional protectiion of progesterone to prevent endometrial cancer. This also minimizes progestrogenic side effects. Also risk of breast cancers seem to be increased more with progesterone component of HRT-hence ERT alone is best for her (1) what about concerns Re: endometrial cancer? .

Tibolone is a synthetic steroid is it a hormone? that has estrogenic, androgenic and progestagenic properties and significantly reduces hot flushes and sweating and increases BMD in postmenopausal women and is an option for her.

SERMS like raloxifene do they relieve menopausal symptoms? (-1) can also be given but it carries same risk of VTE as ERT and is ineffective for hot flushes and worsens it so what is the point in offering them to a woman COMPLAINING OF MENOPAUSAL SYMPTOMS? .

Natural sources of estrogen like Phytoestrogens have been shown to have benefit for hot flushes but potential risk of breast cancer has not been investigated and can be given in specialized units.

You consistently fail to focus on the question asked. Unless you answer the question asked, and nothing else, you will not earn a pass mark
Posted by PAUL A.
Tue Jan 29, 2008 08:11 pm
a)I would ask her about the presence of other menopausal symptoms like vaginal dryness, sleep disturbances, irritability and night sweats. The severity of symptoms and the effect on her quality of life (1) . I would ask about personal history of breast cancer (1) or the use of tamoxifen . I would ask about other high risk features like history of cardiac disease or previous history of VTE (1) .Any family history of breast, ovarian,stomach, or colon cancer. Also any family history of osteoporosis or VTE. I would assess her BMI ? BP .
b)I would inform her menopausal symptoms are transient and self limiting and usually last 1-2years.
The benefit of HRT include the relief of vasomotor symptoms of hot flushes, dryness of vagina is this a vasomotor symptom? and night sweats (1) .There is also improvement in skin colour ?? to which colour?? and hair texture. It also improves mood, libido and urinary symptoms. Long term (1) use prevents osteoporosis colon cancer, possibly Alzheimer?s disease, ,periodontal disease, macular degeneration and tooth loss (1) .I would offer her information leaflet on HRT.
c)There is an increased risk of VTE in the first year of use by how much? . It increases the risk of coronary heart disease or stroke in the first year of use especially in women with heart disease or hypertension (1) .It also increases the risk of breast cancer if used greater than 5years by how much? . The risk reverts back to background risk after discontinuing its use immediately?? .There is an increased risk of ovarian cancer she just had a TAH + BSO . There is also an increased risk of endometrial cancer she has just had her uterus and ovaries removed especially with long term use. The effect of short term HRT use on recurrence of endometrial cancer is uncertain and HRT is best avoided.The advice of a gynaecological oncology would also be sought before starting her on this treatment and surveillance would be required in case of suggestive symptoms of recurrence. There is also increased risk of gall bladder disease. I would provide her with information leaflets (1) .
d) Progestogens given alone are not shown to be of much benefit are progestogens not beneficial in the treatment of hot flushes? , but combined progestogen and oestrogen HRT relief vasomotorl symptoms. It is not known whether added progestogen would protect against the recurrence of endometrial adenocarcinoma. Alternatives include tibolone,or selective oestrogen receptor modulators like raloxifene if there is a personal history or strong family history of breast carcinoma,but do not relief menopausal symptoms her complaint is hot flushes, so what is the point of SERMs?? . Phyto-oestrogens found in red clover and soya have oestrogenic activities and relief menopausal symptoms but have potential implications for recurrence of endometrial carcinoma.
Healthy lifestyle habits, such as weight bearing exercise, stopping smoking,reducing alcohol, high fibre diet are of benefit you were asked about HORMONAL options .
Posted by PAUL A.
Tue Jan 29, 2008 08:21 pm
I will assess her post operative recovery and address her symptoms of hot flushes.I will enquire if she has any other symptoms and effect on quality of life (1) . Any past history of VTE or in first degree relative should be checked (1) . I will asses her mobility and smoking status.Any cardiac event in past especially in last year should also be asked about. Past history of stroke (1) in herself or in first degree relatives of and breast cancer (1) should be obtained. I f there is any history of liver problems , it should be checked.
I will advise her that HRT is effective in reducing severity and frequency of hot flushes (1) . It also reduces symptoms of vaginal discomfort and dyspareunia due to lack of estrogen in vaginal mucosa. It can relieve urinary symptoms of pain and urgency secondary to lack of estrogen (1) . It delays onset of Alzhiemers disease. It has protective effect against cataract and tooth decay. It also protects against hot flushes but only if taken for many years ??? .It protects against colorectal cancer.
HRT increases risk of venous thromboembolism by 3 fold (1) . It increases risk of cardiac event in first year of commencing especially in women who have had previous episode (1) . It increases risk of stroke. It leads to increased risk of breast cancer when taken for long, it causes 6 additional cases for every 1000 if taken for five years (1) .If breast cancer is diagnosed in women on HRT it is likely to present at higher stage.HRT also increases risk of gallbladder cancer does it??? .
As she had hysterectomy, estrogen only HRT would be appropriate than combined HRT. This will reduce risks attributed to progesterone component especially VTE is this due to progestogens??? , breast cancer. Patches are preferable to oral route as have lower risk of VTE. Oestrogen implant can also be offered and testosterone implant if there are issues of reduced libido. Local estrogen in form of vaginal ring, cream or pessaries is suitable for local symptoms , it is less effective in treating hot flushes do you have any concerns about giving this woman oestrogens given that she has just been treated for an oestrogen-sensitive malignancy? Do progestogens not treat hot flushes? .
Posted by PAUL A.
Tue Jan 29, 2008 08:41 pm
a. Obtain thorough history is very important steps as an initial assessment before starting hormone replacement therapy (HRT). History of personal or family of venous thrombo-embolism (VTE) should be asked (1) . If there is a such history, arrangement should be made to screen thrombofillia. Personal or family history of breast cancer (1) and the staging of breast cancer are important factor to determine as HRT is not a good option in managing her hot flushes. Drug history, like complication with contraceptive pills in a form of allergic or cholestasis will make HRT is contraindicated in this patient. Quality of life should be assessed to determine how bad the patient is affected with her hot flushes (1) . Family history of osteoporosis and personal history of smoking and consume alcohol make the patient vulnerable to suffer osteoporosis. Multiple history of medical illness especially cardiovascular diseases (1) should be obtained. Body mass index and blood pressure should be measured (1) .
b. She should understand that HRT is an effective treatment for menopausal symptoms (1) . In long term treatment, HRT will improve bone density, thus it can prevent osteoporosis. HRT is proven to reduce the risk of colorectal cancer (1) . HRT may prevent or reduce the development of Alzheimer?s disease but it has no effect on established disease. She should be informed that HRT can reduce the risk of macular degeneration, tooth loss and cataract (1) . HRT can also improve urogenital atropy.
c. She should know that HRT is associated with increased risk to develop breast cancer. At the age of 50, the risk to develop breast cancer is 38 in 1000 after 5 years of using combined HRT and 51 in 1000 after 10 years (background risk is 32 in 1000 over 15 years) (1) . But the risk of breast cancer is similar to never user after 5 years of stopping HRT (1) . The risk of cardiovascular diseases and stroke is increased especially in the first and second years of HRT (1) . HRT double the risk of VTE (1) , therefore personal history of VTE is contraindicated. Sequential HRT and unopposed estrogen therapy is associated with increased risk of endometrial cancer she does not have a uterus . The risk of ovarian cancer with HRT is controversial she does not have any ovaries . Side effect of HRT like breast tenderness, nausea and vomiting should be explain to the patient as well (1) . Information leaflet (1) and further follow up should be provided.
d. HRT is not associated with increased risk of recurrent in endometrial cancer. Progestogen only replacement therapy (1) is a viable option for this patient but sometime it may worsen the menopausal symptom why? . If this happen continues combined HRT (1) what is the value? is another option. Oestrogen only replacement does the recent endometrial cancer concern you? in the form of implant or patches may be prescribed as this can reduce the risk of VTE. Oestrogen cream is effective in treating local urogenital symptom but it does not reduce menopausal symptom.

V Good answer
Posted by PAUL A.
Tue Jan 29, 2008 08:50 pm
a) Two issues need to be adressed in this patient. Firstly she is a post operative patient and secondly she is experiencing manifestations of the climacteric.
On the history other symptoms of the climacteric are sought. These include insomnia, irritability, mood swings (1) and palpitations are palpitations a menopausal symptom? , Any vaginal bleeding or discharge from the incision site should be determined.
A past history of cardiac events or thromboembolic disease should be determined (1) . It is also important to enquire about a family history of breast (1) ? personal Hx? cancer and thromboembolic events. Current use of cigarettes is sought.
On examination her BMI is calculated ? BP . The incision is inspected and the vaginal vault is also examined.
Patients with a positive family history of thromboemboism should have a thrombophilia scrren done. A mammogram is also requested.

b) She is told that HRT is likely to alleviate her hot flushes (1) , with an improvement usually noted within 4 weeks and maximal effect achieved at 3 months.
HRT decreases her risk of osteoporosis. Patients on HRt have an initial increase in bone mineral density in the first 12-18 months of use. Her risk of vertebral fractures is decreased this requires long-term / life-long use and must be made clear .
HRT use is also associated with a decrese in the risk of colorectal cancer and it may play a role in the delay/prevention of Alzheimers disease.
Patients on HRt report an improvement in psychological well being. HRt may also decrese the risk of tooth loss and macular degeneration (1) . HRt may also help prevent urogenital atrophy.

c) Most women who use HRT will have no adverse outcome secondary to treatment.
Endometrial cancer is an estrogen dependent tumour. Although there is a theoretical risk of tumour reaactivation, this risk is very low with stage 1A disease.
HRT increses her risk of breast cancer. The actual number of excess women who will develop breast cancer as a result of treatment is low with an excess of 12/1000 women after 15 years of HRT use (1) .
This patient is at increased risk of thromboembolism as a result of her pelvic malignancy and post operative state. HRT increases the risk of venous thromboembolism 2 fold (1) . There is also an increased risk of pulmonary embolism.
Patients on HRT also have an increased risk of stroke and myocardial infarction particularly in the first year of use in women with a previous event. .

d) This patient can be started on an estrogen only preparation do you have any concerns about endometrial cancer recurrence? since she has had a hysterectomy. The transdermal route is associated with a decreased risk mof venousthromboembolism and may be preferred in this patient.
A combined estrogen/progestagen preparartion may also be used in an attempt to decrese the risk of disease reactivation, but this may be associated with progestagenic side effects (1) .
Tibolone is another option which may be used in this patient. what about a progestogen only?
Posted by PAUL A.
Tue Jan 29, 2008 09:08 pm
(a)
Appropriate history is taken about personal and familial history of venous thromboembolism (1) and thrombophilia.
We inquire also about history of breast (1) and ovarian cancer and try to look for any factors that is contraindicated for the use of HRT how does the examiner know that you know what these factors are? .
We do risk assessment for VTE see your first sentence and ask about sign and symptoms of post-operative complications like fever, vaginal spotting and pain. Also we ask about urinary tract symptoms.
History of liver disease and coronary heart disease (1) is also relevant.
We do general examination of the patient including BMI and blood pressure measurement (1) , also look for the presence of varicose veins, we do breast examination not necessary after taking her permission . Abdominal scar also examined and if she has vaginal spotting, pelvic ( speculum ) examination is done gently to detect granulation tissue formation.

(b)HRT is significantly improve vasomotor symptoms (1) , also it protect against osteoporosis and reduce osteoporosis related hip fractures you must make it clear this requires long-term use ., although it is not used primarily for this indication.
It has long term effect also by decreasing urogenital atrophy and reduce incidence of colorectal cancer.
In addition it reduce macular degeneration and improve cognitive function, hair and skin (1) .

(c )
HRT is associated with increase risk of venous thromboembolism by 8-foldss 2-3 fold especially with systemic preparation that undergo first pass hepatic metabolism as they affect liver production of clotting factors; therefore, transdermal preparation will carry less risk of VTE.
There is also increase risk of oestrogen dependant malignancy like breast and ovarian cancer.
Risk of breast cancer increase with increase duration of use especially if used more than 5 years but it return back to normal life time risk after stopping the treatment what is the risk? Does it return to background immediately after stopping? .
Progesterone can be used alone in this lady which can be regarded as one of the line therapy of treating endometrial cancer, it can improve vasomotor symptoms you were asked about risks but it is needed in high doses which carries also risk of breast cancer.
HRT also increase risk of coronary heart disease and stroke in the first year of use in women with a previous event .

(d)
HRT reduce vasomotor symptom by 80-90%, although it can be associated with increase risk of oestrogen dependant malignancy, it can be used in this lady with stage 1 , operated endometrial carcinoma as it is not an absolute contraindication.
However, we should consider alternative therapies to HRT by being safer to her, they reduce vasomotor symptoms by 40-60%. You were asked about hormonal options ? HRT is not a specific hormone. / progestogens, oestrogen only, combined oestrogen + progestogen s
Posted by PAUL A.
Tue Jan 29, 2008 09:42 pm
a) A detailed history should be taken exploring the specific symptoms she is suffering from, their nature and severity and their effects on her life (1) quality of life . Detailed family history of breast cancer, ischaemic heart disease should be obtained (1) . Personal history of cardiovascular disease (1) or symptoms suggestive C.V.D as chest pain, shortness of breath on exertion should be enquired.
Personal or family history of venous thromboembolism (1) should be enquired. Social history of employment , smoking, physical activity ,drug history should be obtained.
Examination should include blood pressure measurements for hyprtension, weight and BMI (1) .
Routine breast examination is not necessary and should only performed if clinically indicated. Routine thrombophilia screen is not indicated , but worthwhile if she had family history of VTE in first or second degree relatives. No additional investigation is required in this woman not necessary .
b) I would tell her that menopausal symptoms are transient and for this purpose , only short-term use of HRT is required ( 1-2 years and < 5 years).
The main benefit will be symptom control and improved quality of her life. The menopausal symptoms to improve are hot flushes (1) , night sweat, vaginal dryness and improvement in skin and hair (1) .
Hot flushes relieved within 4 weeks , maximum response achieved by 3 months. Oestrogen therapy associated with improvement in psychological well-being , may be secondary to the relief of vasomotor symptoms.
I would make her understand that the potential benefits like prevention of osteoporosis, colo-rectal cancer , possibly Alzheimer?s disease , macular degeneration, tooth loss (1) may only be achieved with long-term use (1) and would not apply with short-term use to control menopausal symptoms .
c) I would tell her that HRT is associated with an increased risk of coronary artery disease and stroke especially in the first year of use (1) . So, if the woman has had a previous cardiovascular event or is at high risk , then HRT would not be recommended .
The risk of thromboembolic disease is particularly increased by how much? in the first year of use and if she has a history of VTE or at high risk , HRT is not recommended.
The risk of breast cancer associated with long-term use of HRT ( > 5 years ) what is the risk? and the benefits of use over 1-2 years outweigh the risks.
Other risks including gall bladder disease ,and drug side effects like fluid retention, nausea , headache , leg cramps , dyspepsia and mood swings , depression and acne (1) .
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.
She should be informed that only short-term use of HRT is required for vasomotor symptoms , and hence the risk-benefit profile is different from that with long-term use. ? written information
d) Conjugated equine oestrogen is an option , but it provided no overall protection against
myocardial infarction or coronary death during a 7-year period of use
the woman has menopausal symptoms, not heart disease . Oral estrogen has the advantages that is easy to administer, easy to stop and has short half-life . It is cheap and well researched. I would discuss the options of transdermal( patches), percutaneous (gel)route that associated with reduced risk of VTE . It has advantages that is easy to administer , easy to stop . It avoids the first-pass effect and gastrointestinal problems .
The effects of transdermal oestrogens are similar to those of oral oestrogens.
The option of prescribing progestogens such as norethisterone or megestrol is also effective for hot flushes (1) , but some less effective than systemic Oestrogen. SERMs are these hormones? are unsuitable as they do not relieve menopausal symptoms.
I would provide written information . Concordance with therapy can be improved by involvement of the woman in decision-making , discussion of the woman?s preferences and which regimen she wishes to use and the arrangement for follow-up visits to deal with adverse effects you were asked a factual question ? evaluate hormonal options ? it does not require you to give the woman information or follow her up .
Posted by Dr seema jain J.
Wed Jan 30, 2008 01:59 pm
a) My clinical assessement of her would include detailed history taking and examination. I would enquire whether she has diabetes and/or hypertension. Any history of previous VTE or history of any thrombophilic disorder is of importance. History of breast cancer and any treatment taken for it should be noted. Family history of any thrombophilic disorder is important. Medical history pertaining to any drug intake (steroids, anticoagulants etc.) need to be enquired into. Any other symptoms like dryness of vagina, dyspareunia, change in sexual desire should be asked. On examination it is important to check her Blood pressure and her BMI.Presence of varicose veins should be noted. Breast examination and gynec examination should be done.
b) I will tell that HRT has a positive impact on symptoms like hot flushes and night sweats. It also is helpful in prevention of osteoporosis by increasing the bone density. Mood swings and sexual desire can be improved by HRT. HRT can have a beneficial effect on primary prevention of cardiovascular disease if started within 5 years of menopause and if continued till 5 years in women with no history of cardiovascular disease.. Decrease in the incidence of colorectal cancer has been noted. Urinary symptoms like urgency and urge incontinence can improve with HRT. HRT can improve balance while walking and prevent fractures. Some studies have shown a decrease in cataract & macular degeneration in HRT users. HRT may delay or prevent the development of Alziemer?s disease.
c) Themain concern with HRT include breast cancer and VTE. Women on HRT have increased chance of having breast cancer which is equivalent to increase in 2/1000, 6/1000 and 12/1000 at the end of 5, 10 & 15 years respectively. This risk becomes zero after stopping HRT for 5 years. The risk is more with estrogen + progesterone in comparison to only estrogen therapy. There is a 2-4 fold increase in the development of VTE (1\\10000 to 3/10000) especially the ones who are on oral HRT. The risk profile of Tibolone is similar to estrogen/progesterone whereas Raloxifene is associated with decreased risk of breast cancer though it can worsen the hot flushes. Breast cancers occurring in women taking HRT appear to have a better prognosis than non users. In women who have cardiovascular disease,HRT can increase the risk of stroke and myocardial infarction.

d) Since this lady is hysterectomised and is suffering from hot flushes and night sweats, unopposed estrogen can be used though in women with endometrial cancer to use unopposed or combined HRT is a debatable issue. The other option for her is to use tibolone 2.5 mg daily. If she has any decrease in sexual desire, testosterone patch or DHEAS can be helpful. If she has any vaginal or urinary symptoms, vaginal creams or tablets over and above systemic therapy may be required. Transdermal entrogen in the form of patches or sprays can be used. The other hormonal options for hot flushes are megestrol and morethisterone but the dose that is required is high and so side effects are encountered. Herbal preparations like isoflavones may be helpful though the effect has not been proven in large studies.
Posted by Azza Shawky E.
Wed Jan 30, 2008 02:03 pm
Outline your clinical assessment 6 m
Detailed history should be taken to assess the risk of cardiovuscular disease,VTE,and breast cancer. Iwill ask her about nature and severty of other menopausal symptoms as dryness of vagina ,night sweat and depressed mood.Personal history should be enquired about previous history of cardiovuscular disease as cornary artery disease(C.A.D) and symptom of SOB, chest pain as HRT isincrease the risk of(C.A.D). personal and family history of breast cancer is imortant. Iwill ask her about vaginal bleeding to exclude residual of cancer. Past history of medical disease should be taken as D.M Hypertenstion and obesty as consider risk factor of VTE.personal and family history ofVTE frist and second degree relative should be taken before commencing HRT and HRT is avoided in multiple pre exiting risk factor ofVTE. Thrompophylia secreening should be consider in woman with VTE frist and second degree relative.Clinical examinaton should done checking of her
Posted by Azza Shawky E.
Wed Jan 30, 2008 08:26 pm
a)evaluate your clinical assessment6m
Detailed history should should taken from this patient to assess the risk of VTE, cardiovuscular disease,breast cancer (ca). Iwill aske her about the nature and severity of menopausal symptom as night sweat ,dryness of vagina and mood depression.personal and family history should be enquired as previous history of breast ca and coronary artery disease (CAD) as HRT has increase the risk of CAD.past medical history of hypertention ,DM and obesity is important as risk factors for VTE .personal and family history of frist and second degree relative of VTE should be obtained before commencing HRTasHRT is avoided with multiple pre exiting risk factor of VTE.clinical examination should be done by checking blood pressure and calculate BMI Ishould ask her about history of bleeding to exclude residual disease. screning of thrombophyllia should be done before start HRT in woman with previous or family history of frist and second degree relative of VTE. universal screening of woman for thrombophyllic defect prior to commencing HRT.woman should give leaflet and written information
b)what you tell her about the benift of HRT4M
Iwill inform her about benift ofHRT as it relieve hot flushes and night sweat withen 4 weeks maximal effect achieving by 3 month.
HRT prevent loss of bone denisty with some gain in denisty in frist 18-24 month and reduce the incidence of vertebral fractures. Their is some evidence that estrogen replacement in HRT may delay or prevent the onset of alzhiemer diesase.short term use of estrogen and progestogen associated with decrease the risk of colorectal cancer .topical estrogen in HRT is effective in relieving vaginal symptom .HRT also improving the quality of life .however estrogen therapy decrease risk of macular degeneration,catarct and tooth loss.
c) what you tell about the risk of HRT7M
HRT associated with increase risk ofcoronary artery disease CAD
event in woman with established CAD but in woman without CAD continous combind HRT increase the risk ofCAD the relative risk of it 1.23 stroke relative risk 1.41 pulmonary embolism relative risk is2.13 . HRTincrease the incidence of breast cancer. the risk of breast ca at age 50 years 45/1000 over 20 ys and 32/1000 over 15 ys. the risk of breast ca in woman who discontinue HRTfor 5 ys similar to that never use . current use of HRT increase mortality of breast ca as it stimulate growth of breast ca. Iwill inform her about unopposed estrogen therapy associated with increase risk of endometrial hyperplasia and endometrial ca also sequential and comindHRT associated with endometrial ca. Their is evidence that current use of HRT Iincrease risk of overian ca the relative risk of overian ca 1.22 and the die from overian ca the relative risk 1.23 so the current use of HRT, incidence of overian ca increase with increase duration of use but did not differ significally with type of preparation,consituent or mode of adminstration. Iwill inform her about VTE increase with age and is double in postmenopausal woman and HRT increase the risk of VTE 2-3 fold. transedermal estrogen containing HRTis safe than oral preparation with VTE as it avoid frist pass mechanism by liver. .Iwill tell her HRT estogen related can cause fluid retention headache,leg cramps and dyspepsia and HRT progestogen related can cause depression ,mood swing and breast tenderness.no evidence that HRT increase weight gain. HRT associated with increase gallbladder disease.
d)evaluate hormonal replacement therapy option in this woman 3m
estrogen replacement therapy ERT reduce hot flushes and night sweat and improve urogenetal symptoms and depressed mood and increase bone denisty, however estrogen increase risk of endometrial hyperplasia and endometrial ca but this risk is not here as she undergo hysterectomy. estrogen can give as oral rout,patches,implant,vaginal cream or nasal spray. the dose ofconjugated equine estrogen 0.3-0.625mg, estrogen patches 25-50ug or estrogen implant 50 mg every 6 month. progestogen reduce hot flushes and night sweat but has no effect on bone denisty, as oral norethisterone 5mg dailyor medroxypregesterone acetat or megestrol 40mg. Tibolone signefically improve vaso motor symptoms libdo andvaginal lubricant. phytoestrone improve frequency and severity of vasomotor symptom with no harmeful effect. Clonidine also reduce vasomotor symptom with no unwanted side effect..all woman commencing HRT should counsel about its risk and benifit and should aware about symptom and sign of VTE and should beable to acess medical help rapidly if they suspect that they have thrombus.
Posted by maha G.
Thu Jan 31, 2008 03:06 pm
[a}I would ask about other menopausal symptoms as vaginal dryness,night sweats and changes in libido and the implication of it on quality of her life
I would ask about past history of any contraceptives use especially combined oral contraception and any associated side effects.
Family or personal history of venous thromboembolism[VTE} should be elicited,thrombophillia screen warrented only if there is positive family history of VTE in first or 2nd degree relative.
I would assess her risk for osteoporosis ,check her body mass index,bone densitometry,history of any endocrine disorder as Cushing?s syndrome ,history of special habits as smoking and any family history of osteoporosis.
I would enquiry about any personal or family history of cardiovascular disorder and any symptoms suggestive of cardiovascular disorder as chest pain or S.O.B. also I would check her blood pressure.
Ask about any family history of breast cancer
{b}Iwould explain to her that menopausal symptoms especially hot flushes are transient,the recommended duration of treatment is 1 to 2 years,HRT will improve her menopausal symptoms in 4 weeks and maximum effect after 3 months treatment.
HRT will reduce osteoporosis and increase bone gain in 18 to 24 months of treatment however rixk of hip fracture not reduced with estrogen replacement for 10 years and need life long treatment.
HRT will reduce risk of colorectal cancer with short term treatment however diagnosed cases of colorectal cancer with HRT would be advanced.
HRT may be prevent or delay devolpment of Alzhiemer? s disease however it dosenot prevent progression or improve cogentive function of established disease.
Additional benfits of HRT are improvement of quality of hair and skin,reduce risk of teeth loss,macular degeneration.
{c}I would explain to her that risk is small and short term treatment will reduce riskand may be benfit outweigh risk.
HRT has no protective cardiovascular effect and may lead to increase risk especially in 1st year.
The risk of VTE will increase with HRT to 2to 3 fold.
The risk of breast cancer with HRT will increase if used more than 5 years,the risk is dependent on duration of use,the background risk at age of 50 is 32 per 1000 over 15 years will increase to 38 per 1000and 51 per 1000 after 5 and 10 years use of combined HRT however risk with estrogen only HRT after 10 years use is 37 per 1000, furthermore the mortality of breast cancer will increase with HRT.
The adverse effects due to use of estrogen such as increase gall bladder disease ,headache,naeusia,leg crampsand breast tenderness.The progestogenic side effects as water retention,bloating,mood swings and breast tenderness.
{d}The HRT options for her are either estrogen only HRT ,combined HRT or progestogen only HRT.Alternatives as Tibolone will reduce hot flushes and osteoporosis,SERMS are not suitable for her{increae hot flushes } .
Traditionally Estrogen only HRT are used for hysterectomized ladies ,however there is theoretical risk of activation of any residual ,anyway the benfit outweigh the risk.
Combined HRT are associated with more risk of breast caner than estrogen only,continous HRT are inappropriate.The patches are associated with less VTE and may be less systemic side effects.
Progestogen only HRT as megestrol or medroxyprogesterone can be used whenever there is contraindication for estrogen use ,it will be associated with progestogenic side effects.


Posted by PAUL A.
Thu Jan 31, 2008 04:25 pm
Before commencing HRT, I would like to ask about the impact of the symptoms on her routine life (1) quality of life , her smoking hobbits and about any personal or family (first or second degree relative) history of thromboembolic disease (1) , breast cancer, hyperlipidemia, cardiovascular disease (stroke) what about myocardial infarction? or if she knows any thing about her thrombophilia status this is a very long sentence addressing several unrelated issues . Hypertension and diabetes mellitus are not contraindications for HRT but if present may require higher doses of antihypertensive and hypoglycemic drugs to control the disease. Her BMI is important to note along with presence of gross varicose veins and breast lumps ? will you do a breast examination? . History of premenstrual syndrome may be important as it may reappear with HRT.

Severe hot flushes (1) along with sexual and urinary complain (dysparunia and incontinence ? evidence that HRT is effective treatment for incontinence ) are likely to be improved with HRT. I would also like to tell her that long term use of HRT reduces the risk of osteoporosis and vertebral and femoral neck fractures. HRT can delay the onset of Depression ? evidence?? Is depression a menopausal disease? , Alziemer?s disease, cataract and tooth decay. It also improves the sense of well being (1) .

About the risk of HRT, I would like to tell her that the risk of DVT is increase 2 to 3 fold (1) . Risk of breast cancer is increase with HRT (51 per 1000 with estrogen + progesterone and 35 per 1000 with estrogen alone) is this the absolute risk or the ?increase?? How will the woman make an informed decision if she is not given the background risk? . Patients with established cardiovascular disease can have increased risk of deterioration of the disease and are advised against HRT (1) . Women on HRT under going major surgery are believed to be at high risk of thromboembolism, so may need thromboprophylaxis. HRT increases the risk of gall bladder disease. HRT may increase the risk of malignant melanoma as it has estrogen receptors ? drug side-effects?? .

Estrogen only preparation can effectively reduce the symptoms of hot flushes without any progestational side effect of fluid retention and breast tenderness (1) . As this patient has undergone hysterectomy there is no more additional risk of endometrial carcinoma is the recurrence risk in stage Ia 0%? . Continuous combined estrogens and progesterones may result in progestational side effect. Sequential estrogens and progesterones can also produce progestational side effects what is the value of the progestogen? . Estrogen patches has less thrombogenic effects with effective relief of hot flushes. Estrogen implants are also effective in relieving hot flushes. what about progestogen-only for hot flushes?
Posted by PAUL A.
Thu Jan 31, 2008 04:42 pm
A) A detailed history will be taken to look for risk factors for thromboembolism.This includes past history of venous thromboembolism (VTE),family history of thrombosis and history of thrombophilia (1) and if present the type of inherited defect .History of smoking will also be asked for. I will also ask for any history of ischaemic heart disease (1) hypertension, stroke and gall bladder disease which if present will increase the risk associated with HRT.Past history of Carcinoma breast (1) if present will also be against offering HRT. I will assess her body mass index ? check BP and look for any varicose veins which serve as additional risk factors for VTE. Any history of bleeding PER vaginum suggestive of recurrence of malignancy will be noted will bleeding at this stage suggest recurrence?? .

B) I will tell her that HRT will help to reduce her vasomotor symptoms like hot flushes (1) .The effects will begin in 1 month with peak benefit in 3 months time. It will also improve symptoms like night sweats thereby improving sleep with the resultant improvement in quality of life . Prolonged use of HRT for more than a year will also improve genito urinary functions (1) leading to better sexual life.HRT will also help to delay onset of Alzheimer?s disease and reduce risk of colorectal carcinoma. It also reduces incidence of cataract, macular degeneration and tooth loss (1) . Life long treatment also offers protection against osteoporosis (1) .

C) HRT increases risk of coronary heart disease especially if there is a previous history of ischaemic heart disease (1) . There is also an increased risk of stroke and 2-3 times increased risk of VTE (1) .The risk of gall bladder disease is also increased. An increased risk of Carcinoma breast is seen with 2 extra cases reported per 1000 women when used for 5 years and 6 and 12 extra cases per 1000 for 10 and 15 years of HRT use (1) .5 years after stopping HRT the risk reduces to a level similar to that of a nonuser (1) . The risk of Carcinoma ovary is also increased she had BSO . Systemic side effects related to hormones like, fluid retention, breast tenderness, headache, nausea and leg cramps can also develop (1) . There is no evidence to prove that HRT is associated with an increase in weight gain.
D) There is no evidence to suggest an increased risk of cancer recurrence in women treated for early stage Ca Endometrium if put on HRT.Since hysterectomy has been done she can be offered Oestrogen only HRT (1) .Oral conjugated synthetic oestrogens or estradiol tablets can be given.Transdermal Oestrogen patches are preferred in women with risk factors for VTE who opt for it. This route of treatment reduces risk of VTE.Oestrogen containing vaginal rings and local gels are other options. Continuous combined Oestrogen and progesterone (1) therapy may also be tried in women who opt for it. what about progestogen-only?

Good answer

Posted by PAUL A.
Thu Jan 31, 2008 05:07 pm
I would ask her how often she gets the hot flushes and when she is getting it. I would also ask if there are any exacerbating and relieving factors. I would ask if she has tried anything for it and how it is affecting the quality of her life and activities of daily living (1) . I would also explore if she had any other symptoms related to oestrogen deficiency like night sweats, urogenital symptoms - vaginal dryness (1) , loss of libido and mood disturbances - depression depression is not a menopausal condition and there is no evidence that the risk of depression is increased in menopausal women . I would also ascertain if she had recovered from her surgery, asking if she has any pain, or bleeding, urinary or bowel disturbances.I would ask if she developed any complications between the surgery and her current visit that warranted a visit to her GP. I would explore and past medical and family history of venous thromboembolism (1) , arterial disease, liver diease,ischaemic heart disease (1) , breast cancer and ovarian cancer (1) as these are risk factors which my contraindicate use of HRT in this woman. I would then examine her, ensuring that her wound is well healed and there are no evidence of abdominal or adnexal masses.I would look for evidence of gross varicose veins. I would measure her blood pressure and calculate her BMI (1) .

There are short term and long term benefits of HRT. Short term benefits are the improvement of this ladies vasomotor symptoms (1) . HRT can also significantly improve any urogential symptoms if present (1) . Topical oestrogen is especially effective with local vaginal dryness. She will have considerable improvement in her mood. Long term benefits include the reduction of osteoporosis however incidence of hip and vetebral fractures are only reduced with lifelong HRT (1) and not a short course of HRT. There is evidence that HRT can reduced the incidence of colorectal carcinoma and Alzeihmer\'s disease (1) macular degeneration, tooth loss ... HRT improves the lipid profile with an increase in HDL and a decrease in LDL cholesterol. However there is also and increase in triglyceride levels.

With regards to risks of HRT, this ladies main concern would be the recurrence of her endometrial carcinoma. Current evidence suggests that there is no increase in the recurrence of endometrial carcinoma in HRT users. Other risks include a 2 - 3 fold increase in venous thromboembolism (1) and stoke (1) . There is an increase in breast cancer which is dependant on duration of use what is the risk? and the Million Women\'s Study had also recently demonstrated an increase in ovarian cancer she had BSO in HRT users, again with prolonged usage. The Women\'s Health Initiative also demonstrated an increase in ischaemic heart disease in these women although this was more associated with combined oestrogen and progesterone rather than oestrogen only preparations see risk of stroke. ? drug side-effects & written information. .

HRT is the only hormonal prepartion that has been shown to be effective in the treatment of vasomotor symptoms. However it is associated with significant risks as outlined above. The above should be explained to the patient and her choice has to be priority if you find the need to refer the examiner to another part of your answer then you are doing something wrong . The current recommendations are the a short course of HRT of 2- 3 years to treat symptoms.Although other hormonal preparations such has selelective oestrogen receptor modulators these drugs are NOT hormones. They are not relevant as they do not treat menopausal symptoms have a better risk profile studies have shown that they are not effective in treating vasomotor symptoms. HRT is not a hormone. You should consider the use of estrogen-only, estrogen + progestogen and progestogen-only preparations
Posted by PAUL A.
Thu Jan 31, 2008 06:42 pm
a) My clinical assessement of her would include detailed history taking and examination. I would enquire whether she has diabetes and/or hypertension. Any history of previous VTE or history of any thrombophilic disorder (1) is of importance. History of breast cancer (1) and any treatment taken for it should be noted. Family history of any thrombophilic disorder is important. Medical history pertaining to any drug intake (steroids, anticoagulants etc. there are no marks for this ) need to be enquired into. Any other symptoms like dryness of vagina, dyspareunia (1) effect of symptoms on quality of life , change in sexual desire should be asked. On examination it is important to check her Blood pressure and her BMI (1) .Presence of varicose veins should be noted. Breast examination ? indication? and gynec examination should be done.
b) I will tell that HRT has a positive impact on symptoms like hot flushes and night sweats (1) . It also is helpful in prevention of osteoporosis any benefits require life-long use by increasing the bone density. Mood swings and sexual desire can be improved by HRT. HRT can have a beneficial effect on primary prevention of cardiovascular disease if started within 5 years of menopause and if continued till 5 years in women with no history of cardiovascular disease ? evidence .. Decrease in the incidence of colorectal cancer has been noted. Urinary symptoms like urgency and urge incontinence can improve with HRT. HRT can improve balance while walking and prevent fractures. Some studies have shown a decrease in cataract & macular degeneration in HRT users. HRT may delay or prevent the development of Alziemer?s disease (1) .
c) Themain concern with HRT include breast cancer and VTE. Women on HRT have increased chance risk of having breast cancer which is equivalent to increase in by 2/1000, 6/1000 and 12/1000 at the end of 5, 10 & 15 years respectively (1) . This risk becomes zero after stopping HRT for 5 years this is not an appropriate way to present this information. Likely to cause confusion . The risk is more with estrogen + progesterone in comparison to only estrogen therapy. There is a 2-4 fold increase in the development of VTE (1) (1\\10000 to 3/10000) especially the ones who are on oral HRT. The risk profile of Tibolone is similar to estrogen/progesterone whereas Raloxifene is this HRT?? Thought you had moved on to VTE is associated with decreased risk of breast cancer though it can worsen the hot flushes. Breast cancers occurring in women taking HRT appear to have a better prognosis than non users. In women who have cardiovascular disease,HRT can increase the risk of stroke and myocardial infarction (1) ? drug side-effects .

d) Since this lady is hysterectomised and is suffering from hot flushes and night sweats, unopposed estrogen can be used though in women with endometrial cancer to use unopposed or combined HRT is a debatable issue (1) . The other option for her is to use tibolone 2.5 mg daily. If she has any decrease in sexual desire, testosterone patch or DHEAS can be helpful. If she has any vaginal or urinary symptoms, vaginal creams or tablets over and above systemic therapy may be required. Transdermal entrogen in the form of patches or sprays can be used. The other hormonal options for hot flushes are megestrol and morethisterone (1) but the dose that is required is high and so side effects are encountered. Herbal preparations like isoflavones may be helpful though the effect has not been proven in large studies what about oestrogen + progestogen? .
Posted by PAUL A.
Thu Jan 31, 2008 08:11 pm
a) evaluate OUTLINE ? do not set your own question your clinical assessment6m
Detailed history should should taken from this patient to assess the risk of VTE, cardiovuscular disease,breast cancer (ca). Iwill aske her about the nature and severity of menopausal symptom as night sweat ,dryness of vagina (1) effects on quality of life and mood depression.personal and family history should be enquired as previous history of breast ca (1) and coronary artery disease (CAD) (1) as HRT has increase the risk of CAD.past medical history of hypertention ,DM and obesity is important as risk factors for VTE .personal and family history of frist and second degree relative of VTE (1) should be obtained before commencing HRTasHRT is avoided with multiple pre exiting risk factor of VTE.clinical examination should be done by checking blood pressure and calculate BMI (1) Ishould ask her about history of bleeding to exclude residual disease is bleeding at this stage suggestive of residual disease in a woman with stage Ia disease? . screning of thrombophyllia should be done before start HRT in woman with previous or family history of frist and second degree relative of VTE. universal screening of woman for thrombophyllic defect prior to commencing HRT ? meaning?? Will you do this? .woman should give leaflet and written information
b)what you tell her about the benift of HRT4M
Iwill inform her about benift ofHRT as it relieve hot flushes and night sweat (1) withen 4 weeks maximal effect achieving by 3 month.
HRT prevent loss of bone denisty with some gain in denisty in frist 18-24 month and reduce the incidence of vertebral fractures requires long-term use . Their is some evidence that estrogen replacement in HRT may delay or prevent the onset of alzhiemer diesase.short term use of estrogen and progestogen associated with decrease the risk of colorectal cancer .topical estrogen in HRT is effective in relieving vaginal symptom which symptom? .HRT also improving the quality of life .however estrogen therapy decrease risk of macular degeneration,catarct and tooth loss (1) .
c) what you tell about the risk of HRT7M
HRT associated with increase risk ofcoronary artery disease CAD
event in woman with established CAD (1) but in woman without CAD continous combind HRT increase the risk ofCAD the relative risk of it 1.23 stroke relative risk 1.41 pulmonary embolism relative risk is2.13 (1) . HRTincrease the incidence of breast cancer. the risk of breast ca at age 50 years 45/1000 over 20 ys and 32/1000 over 15 ys what is the risk in a woman taking HRT?? . the risk of breast ca in woman who discontinue HRTfor 5 ys similar to that never use (1) . current use of HRT increase mortality of breast ca as it stimulate growth of breast ca. Iwill inform her about unopposed estrogen therapy associated with increase risk of endometrial hyperplasia and endometrial ca also sequential and comindHRT associated with endometrial ca she had a TAH . Their is evidence that current use of HRT Iincrease risk of overian ca the relative risk of overian ca 1.22 and the die from overian ca the relative risk 1.23 so the current use of HRT, incidence of overian ca increase with increase duration of use but did not differ significally with type of preparation,consituent or mode of adminstration she had BSO . Iwill inform her about VTE increase with age and is double in postmenopausal woman and HRT increase the risk of VTE 2-3 fold (1) . transedermal estrogen containing HRTis safe than oral preparation with VTE as it avoid frist pass mechanism by liver. .Iwill tell her HRT estogen related can cause fluid retention headache,leg cramps and dyspepsia and HRT progestogen related can cause depression ,mood swing and breast tenderness (1) .no evidence that HRT increase weight gain. HRT associated with increase gallbladder disease.
d)evaluate hormonal replacement therapy option You have written your own question ? Evaluate HORMONAL TREATMENT OPTIONS in this woman 3m
estrogen replacement therapy ERT reduce hot flushes and night sweat (1) and improve urogenetal symptoms and depressed mood and increase bone denisty, however estrogen increase risk of endometrial hyperplasia and endometrial ca but this risk is not here as she undergo hysterectomy. estrogen can give as oral rout,patches,implant,vaginal cream or nasal spray. the dose ofconjugated equine estrogen 0.3-0.625mg, estrogen patches 25-50ug or estrogen implant 50 mg every 6 month. progestogen reduce hot flushes and night sweat (1) but has no effect on bone denisty, as oral norethisterone 5mg dailyor medroxypregesterone acetat or megestrol 40mg. Tibolone ? hormone? signefically improve vaso motor symptoms libdo andvaginal lubricant. phytoestrone improve frequency and severity of vasomotor symptom with no harmeful effect. Clonidine ? hormone?? also reduce vasomotor symptom with no unwanted side effect..all woman commencing HRT should counsel about its risk and benifit and should aware about symptom and sign of VTE and should beable to acess medical help rapidly if they suspect that they have thrombus.
Posted by PAUL A.
Thu Jan 31, 2008 08:31 pm
[a}I would ask about other menopausal symptoms as vaginal dryness,night sweats and changes in libido (1) and the implication of it on quality of her life (1)
I would ask about past history of any contraceptives use especially combined oral contraception and any associated side effects.
Family or personal history of venous thromboembolism[VTE} (1) should be elicited,thrombophillia screen warrented only if there is positive family history of VTE in first or 2nd degree relative.
I would assess her risk for osteoporosis ,check her body mass index, bone densitometry why?? ,history of any endocrine disorder as Cushing?s syndrome ,history of special habits as smoking and any family history of osteoporosis how does this influence your management? HRT is not recommended for primary prevention of osteoporosis .
I would enquiry about any personal or family history of cardiovascular disorder and any symptoms suggestive of cardiovascular disorder as chest pain or S.O.B (1) . also I would check her blood pressure (1) .
Ask about any family history of breast cancer ? personal Hx??
{b}Iwould explain to her that menopausal symptoms especially hot flushes are transient,the recommended duration of treatment is 1 to 2 years,HRT will improve her menopausal symptoms (1) in 4 weeks and maximum effect after 3 months treatment.
HRT will reduce osteoporosis and increase bone gain in 18 to 24 months of treatment however rixk of hip fracture not reduced with estrogen replacement for 10 years and need life long treatment (1) .
HRT will reduce risk of colorectal cancer with short term treatment however diagnosed cases of colorectal cancer with HRT would be advanced.
HRT may be prevent or delay devolpment of Alzhiemer? s disease however it dosenot prevent progression or improve cogentive function of established disease.
Additional benfits of HRT are improvement of quality of hair and skin,reduce risk of teeth loss,macular degeneration (1) .
{c}I would explain to her that risk is small and short term treatment will reduce riskand may be benfit outweigh risk ? meaning?? .
HRT has no protective cardiovascular effect and may lead to increase risk especially in 1st year (1) .
The risk of VTE will increase with HRT to 2to 3 fold (1) .
The risk of breast cancer with HRT will increase if used more than 5 years,the risk is dependent on duration of use,the background risk at age of 50 is 32 per 1000 over 15 years will increase to 38 per 1000and 51 per 1000 after 5 and 10 years use of combined HRT (1) however risk with estrogen only HRT after 10 years use is 37 per 1000, furthermore the mortality of breast cancer will increase with HRT.
The adverse effects due to use of estrogen such as increase gall bladder disease ,headache,naeusia,leg crampsand breast tenderness.The progestogenic side effects as water retention,bloating,mood swings and breast tenderness (1) .
{d}The HRT options for her are either estrogen only HRT ,combined HRT or progestogen only HRT.Alternatives as Tibolone will reduce hot flushes and osteoporosis,SERMS are not suitable for her{increae hot flushes } .
Traditionally Estrogen only HRT are used for hysterectomized ladies ,however there is theoretical risk of activation of any residual ,anyway the benfit outweigh the risk (1) .
Combined HRT are associated with more risk of breast caner than estrogen only, continous HRT are inappropriate why? .The patches are associated with less VTE and may be less systemic side effects.
Progestogen only HRT as megestrol or medroxyprogesterone can be used whenever there is contraindication for estrogen use (1) ,it will be associated with progestogenic side effects.

good answer
Posted by PAUL A.
Mon Feb 4, 2008 11:35 pm
A good candidate should

(a) Clinical assessment
? Assess severity of hot flushes and effects on quality of life (1)
? Identify other menopausal symptoms ? vaginal dryness (1)
? Assess risk factors for cardiovascular disease ? family history, personal history; smoking. Family / personal Hx of VTE (2)
? Assess risk factors for breast cancer ? personal / family history (1)
? Check BP and BMI (1)

(b) With respect to benefits of HRT
? Explain that the main benefit would be relief of hot flushes. Explain other menopausal symptoms that are improved including night sweats, vaginal dryness (2) .
? Explain potential additional benefits ? prevention of osteoporosis, colo-rectal carcinoma, possibly Alzheimer?s disease, macular degeneration, tooth loss. Stress that these may only be achieved with long term use and would not apply with short-term use to control menopausal symptoms (2)

(c) With respect to the risks of HRT
? Explain that in women with early endometrial cancer, there is no evidence that HRT is associated with an increased risk of recurrence (1)
? Explain the risk of breast cancer: associated with long-term use of HRT (>5 years). In a 50 year old woman, (back ground risk 32 per 1000 over 15 years), oestrogen + progestogen HRT for 5 and 10 years increases risk to 38 and 51 per 1000 respectively. The risk of breast cancer in women who have discontinued HRT for 5 years is similar to that in never users. Oestrogen-only HRT also associated with increased risk of breast cancer (2)
? Discuss risk of thrombo-embolic disease ? risk is particularly increased in the first year of use (1)
? Explain risk of coronary artery disease and stroke especially in the first year of use in women with a previous event (1)
? Explain increased risk of gall bladder disease and drug side-effects (1)
? Provide written information (1)

(d) With respect to hormonal treatment options

? Consider the use of oestrogens + progestogens in a woman with an oestrogen-sensitive tumour (1)
? Consider the use of oestrogen-only HRT ? avoids progestogenic side-effects (1)
? Consider the use of progestogens such as megestrol ? effective in treating hot flushes (1)
s Posted by PAUL A.
Mon May 7, 2012 01:39 am

s