A 55-year-old woman attends her GP seeking advice over her menopausal symptoms, which started just under a year ago. She gets regular hot flushes, which make her work in retail very difficult, as well as irritability at home, which has started interfering with her relationship. She says she still has the occasional period once every 4 months. She is otherwise fit and well with no past medical or surgical history. She would like treatment to help her symptoms and does not want any intrauterine devices or systems.

Which treatment would be most appropriate for this patient?

Options:
explanation: This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen.
name: Cyclical oestrogen-only hormone replacement replacement therapy
label: e
answer: no
explanation: This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen.
name: Continuous oestrogen-only hormone replacement therapy
label: d
answer: no
explanation: This patient has symptoms in keeping with the menopause that are affecting her quality of life and so is appropriately seeking treatment. Selective serotonin reuptake inhibitors (SSRIs) are not advised as first-line treatments by National Institute for Health and Care Excellence, with HRT providing added benefits such as on bone mineral density. SSRIs may be considered in situations where HRT is contraindicated, such as breast cancer. There are no such contraindications in this case.
name: Selective serotonin reuptake inhibitor
label: c
answer: no
explanation: This patient has symptoms in keeping with menopause and is of average menopausal age. She is still having periods every 4 months and therefore hormone replacement therapy (HRT) should be given cyclically. She has no risk factors that would contraindicate oral HRT (such as malignancy or venous thromboembolism) and her symptoms are impacting her quality of life significantly. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen and is not keen on an intrauterine system. Therefore a combination HRT is the most appropriate.
name: Cyclical combined hormone replacement therapy
label: a
answer: yes
explanation: This patient is still having periods every 4 months and therefore HRT should be given cyclically. Continuous HRT would be the first-line treatment if her periods had ceased for over a year. She has no risk factors that would contraindicate HRT and her symptoms are impacting her quality of life significantly. She still has a uterus and therefore needs progesterone protection to reduce the risk of endometrial cancer from unopposed oestrogen. She is not keen on an intrauterine system; therefore, combination HRT is the most appropriate.
name: Continuous combined hormone replacement therapy
label: b
answer: no

Correct answer: a


Learning point: Cyclical combined hormone replacement therapy is recommended for menopausal women with irregular periods to alleviate symptoms and protect the endometrium.