Menopause and HRT — KFP-style written assessment

KFP 1 (10 marks)

A 50-year-old teacher presents with 18 months of irregular cycles, night sweats waking her four times a night, and low mood. BMI 33 kg/m²; blood pressure 128/82; mother had breast cancer at 71; no personal VTE or malignancy. She wants 'something that works' but fears HRT because 'the WHI proved it dangerous'. ^{[15] [1]}

1. State the clinical diagnosis and justify it without laboratory testing. (2) ^[3]
2. Quantify for her what WHI's re-analysis means for a woman her age starting combined HRT. (4) ^[1]
3. Outline the regimen you would offer and the two evidence-based reasons for each element. (4) ^{[3] [7] [10]}

Model answers

1. Perimenopause: newly started vasomotor symptoms plus change in menstrual cycle in a woman aged 45 or over — identified clinically without laboratory tests; FSH is unhelpful here (and invalid on any hormonal contraception she might later use). ^[3]
2. The integrated WHI overview found global-index absolute risk per 10,000 women annually on CEE+MPA ranged from 12 excess cases at ages 50–59 to 38 at 70–79 — about 0.1% per year at her age; CHD HR was 1.18 with CI crossing 1, and neither regimen changed all-cause mortality. For symptom management in women under 60 or within 10 years of menopause the benefit-risk ratio is favourable. Her mother's late-onset breast cancer is not a contraindication but belongs in the risk discussion, using absolute numbers (Cochrane: combined HT took breast cancer from 19 to between 20 and 30 per 1000 after 5.6 years). ^{[1] [17] [18]}
3. Transdermal oestradiol plus micronised progesterone, lowest effective dose, sequential regimen while cycles persist then continuous combined later. Reasons: transdermal rather than oral is advised at increased VTE risk including BMI over 30 — meta-analyses show oral HT raises VTE (combined OR 2.35) while non-oral does not (OR 0.97); micronised progesterone carries the best breast-safety profile among progestogens (E3N estrogen-progesterone RR 1.00 vs 1.69 for other progestagens) and adds no measurable VTE risk to transdermal oestrogen (RR 0.93). ^{[3] [7] [10]}