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Perimenopausal vasomotor symptoms — DFSRH MCQ

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EasyMenopausePerimenopausal vasomotor symptomsDFSRH

A 49-year-old woman requests systemic hormone replacement therapy for troublesome hot flushes and night sweats. Her previously regular menstrual cycles have become infrequent, with her last spontaneous menstrual period 3 months ago. She has an intact uterus, a BMI of 33 kg/m² and no personal or family history of venous thromboembolism. Examination is unremarkable, her blood pressure is controlled, and there is no abnormal vaginal bleeding or other contraindication to HRT. She accepts that treatment may produce a monthly withdrawal bleed. Which is the most appropriate initial HRT regimen?

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Correct answer: D — Transdermal oestrogen with cyclical progestogen

Transdermal oestrogen with cyclical progestogen is the most appropriate initial regimen. She is perimenopausal because she continues to menstruate and her last spontaneous period was only 3 months ago. Starting continuous combined HRT at this stage commonly produces irregular bleeding; cyclical progestogen provides endometrial protection while generating a predictable withdrawal bleed. Progestogen is required because she has an intact uterus: unopposed systemic oestrogen increases the risk of endometrial hyperplasia and cancer. Her BMI of 33 kg/m² is also clinically decisive. NICE recommends considering transdermal rather than oral HRT when VTE risk is increased, including at BMI above 30 kg/m². Transdermal HRT is not associated with the increased VTE risk seen with oral HRT. A uses the appropriate cyclical regimen but the less suitable oral route. B provides endometrial protection and an appropriate oestrogen route, but continuous progestogen is better reserved until she is postmenopausal. C omits necessary endometrial protection. E combines both near-misses: an oral route despite increased VTE risk and a continuous regimen despite ongoing ovarian activity.

Reference: Treatment for symptoms of the menopause (Updated May 2026) — https://www.rcog.org.uk/for-the-public/browse-our-patient-information/treatment-for-symptoms-of-the-menopause/ Menopause: identification and management — Recommendations (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng23/chapter/Recommendations