Welcome to your Menopause

A. Continuous estrogens and progestogens (oral) hormone replacement therapy (HRT)
B. HRT not recommended
C. Levonorgestrel IUS (Mirena)
D. Norgestimate
E. Estrogens plus progestogens plus testosterone (oral)
F. Testosterone only (oral) HRT
G. Estrogens only (oral) HRT
H. Estrogen transdermal patch and vaginal progesterone cream HRT
I. Estrogen transdermal patch only HRT
J. Estrogen cream or pessaries vaginally HRT
K. Estrogen cream for vaginal application and oral progestogens HRT
L. Sequential Estrogens and progestogens (oral) HRT
Choose the single most appropriate hormonal drug therapy from the list of options above. Each option may be used once, more than once, or not at all.

1. A 50-year-old woman presents with one episode of postmenopausal bleeding which lasted for 2 days but has now stopped. Clinical examination reveals atrophic vagina and cervix. A transvaginal scan shows an endometrial thickness of 3mm. She gives a history of breast cancer in her first cousin who is 69 years old.
2. A 50-year-old woman presents with distressing symptoms of hot flushes and night sweats. Her periods have been very irregular for about a year and she has not had any periods for the last 4 months. Her follicle-stimulating hormone (FSH) level is 45 IU/mL. She wishes to have regular menstrual periods every month and does not have any issues in tablets or injections
3. A 50-year-old woman presents to her general practitioner with severe menopausal symptoms (hot flushes and night sweats). She had a vaginal hysterectomy for genital organ prolapse 2 years ago. However, she is a known epileptic who is taking 600 mg carbamazepine twice a day.
A. Refer to the haematologist
B. Don’t prescribe her HRT
C. Estrogen alone HRT oral
D. Estrogen alone HRT transdermal
E. Progesterone alone HRT
Choose the most appropriate advice for each scenario, and each option can be used once or more than once.

4. 48 year old Caucasian woman has presented to her GP with severe postmenopausal symptoms. She gives a history for VTE and also was found to have thrombophilia when she had VTE. She considers taking HRT to relieve her from the distressing symptoms. The best management option is
5. 50 year old post women, who has undergone vaginal hysterectomy 2 years back for a utero-vaginal prolapse. During the surgery, she had intraoperative bleeding from the uterine pedicle and the vision of the field was very narrow because her very high (>35kg/m2)BMI but the bleeding was successfully identified and managed. Her post-op period was uneventful. She has now presented with menopausal symptoms that is affecting her quality of life. She wishes to use HRT. The best management option is
A. Tibolone
B. Ethinyl estradiol
C. Tibolone
D. Estrogen creams
E. Raloxifene
F. Lubricants
G. Paroxetine
H. Progesterone for12- 14 days
I. Levonorgestrel-releasing intrauterine system
J. Exercise and stopping smoking
K. Estrogen only HRT (17 βEstradiol)
L. Cyclical oestrogens and progestogen
M. Bisphosphonates
N. Clonidine
O. Continuous combined oestrogen and progestogen therapy
Choose the single most appropriate answer from the above list of options. Each option may be used once, more than once, or not at all.

6. 56-year-old postmenopausal woman who is a chronic smoker attends the clinic for advice. She is worried about osteoporosis and requests HRT. What is the most appropriate advice?
7. 40-year-old woman with oestrogen-receptor positive breast cancer treated with wide local excision followed by radiotherapy and is on Tamoxifen attends gynaecology clinic for advice regarding HRT. She is suffering from severe vasomotor symptoms
8. 55-year-old lady is complaining of dyspareunia and severe nocturia. She has been treated previously for recurrent urinary infections. On examination the vulva and vagina appear dry. She has been prescribed systemic HRT which she is continuing now but is not helping her vaginal symptoms. What is the most appropriate choice?
9. 59 year old post-menopausal women attends her GP clinic with symptoms of loss of libido. She is very worried about and is not willing to take HRT. What is the most appropriate treatment u would advise her?