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Perimenopause with vasomotor symptoms — MSRA MCQ

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Hardall topics relevant for this examPerimenopause with vasomotor symptomsMSRA

A 49-year-old woman requests treatment for distressing vasomotor symptoms, sleep disruption and reduced concentration. Her last menstrual period was 7 months ago. She has an intact uterus and is sexually active with a male partner; avoiding pregnancy remains important. Her BMI is 34 kg/m². She has well-controlled type 2 diabetes without microvascular or macrovascular disease. Blood pressure is 126/76 mmHg. She has no personal or strong family history of venous thromboembolism, no migraine with aura, no unexplained vaginal bleeding, and no history of breast, endometrial or ovarian cancer. She wishes to use systemic HRT after counselling. Which is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: B — Arrange insertion of a levonorgestrel intrauterine system and start low-dose transdermal oestradiol

Explanation lettering: B = shown as A · C = shown as B · E = shown as C · A = shown as E

She has clinically diagnosed perimenopausal symptoms: in people aged 45 years or over, laboratory testing is not required to establish menopause or perimenopause. As she has a uterus, systemic oestrogen requires endometrial protection with a progestogen. Her BMI above 30 kg/m² increases VTE risk, so transdermal rather than oral HRT is preferred. A levonorgestrel intrauterine system (IUS) can provide the progestogen component of HRT and highly effective contraception, which remains necessary because HRT itself is not contraceptive and she is only 7 months from her last period. A is less appropriate because oral HRT carries greater VTE risk than transdermal HRT in this higher-risk patient. B leaves the endometrium unopposed. D provides contraception, but a progestogen-only pill is not a licensed or established substitute for the progestogen component needed to protect the endometrium during systemic oestrogen therapy. E is incorrect: obesity and uncomplicated type 2 diabetes require individual risk assessment, not automatic exclusion from HRT.

Reference: Menopause: identification and management (NG23), recommendations (Updated 2024) — https://www.nice.org.uk/guidance/ng23/chapter/Recommendations Common questions about oestrogen tablets, patches, gel and spray (Reviewed 5 January 2023) — https://www.nhs.uk/medicines/hormone-replacement-therapy-hrt/oestrogen-tablets-patches-gel-and-spray/common-questions-about-oestrogen-tablets-patches-gel-and-spray/ Who can get an IUS (intrauterine system) or hormonal coil? (Reviewed 22 February 2024) — https://www.nhs.uk/contraception/methods-of-contraception/ius-hormonal-coil/who-can-get-it/