Discussing HRT — menopausal symptoms
PLAB 2 & PRES 3 · women's health · medium · 8 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Mrs Elaine Foster, 52, has been having troublesome menopausal symptoms for the past year. Her periods have become irregular — her last period was four months ago. She still has her uterus. Her blood pressure is 126/78 mmHg, she does not smoke, and she has no personal history of breast cancer, blood clots, stroke or migraine with aura. Please discuss hormone replacement therapy (HRT) with her: its benefits, risks and alternatives, and agree a plan.
What examiners look for
An HRT consultation is a risk-communication test wearing a prescribing costume. The candidate who wins it is not the one who "gets her on HRT" — it is the one whose numbers she can repeat to her sister at the kitchen table. Absolute risk is the only honest currency here. "A few extra cases of breast cancer per 1,000 women over several years, on top of about 23 per 1,000 who would be diagnosed anyway" informs; "it slightly increases the risk" and "it doubles the risk" both mislead, in opposite directions. The uterus changes everything in this station. Combined HRT for a woman with a uterus, oestrogen-only without one — and the progestogen is womb protection, not an optional sidekick. Stating the pairing as a safety feature pre-empts the commonest misunderstanding. Route matters and patients find it reassuring: patches and gels avoid the clot risk that tablets carry. Offering a choice of how to take HRT — patch, gel, tablet, hormonal coil — returns control to a woman who arrived feeling railroaded by headlines and sisters. Contraception is the forgotten mark. At 52 with a period four months ago she can still conceive, HRT does not prevent it, and the startled reaction in this station tells you how rarely anyone mentions it. The hormonal coil covering both roles is the elegant solution to offer. The sister is in the room even though she is not in the room. Answering "my sister says it causes cancer" with data plus respect — and giving her written figures to take home — treats the person who will actually re-litigate your consultation tonight. Bleeding rules are the safety net: irregular bleeding in the settling-in months is expected; persistent unscheduled bleeding, or bleeding after a settled pattern, needs review. Patients cannot report what they were never told to watch for. Never set an arbitrary expiry date. "Five years and you must stop" is outdated and costs marks; the modern answer is individualised duration with a three-month check and annual review, continuing while benefits outweigh risks for her.
Guideline references
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