Cases/Gynaecology and Breast

Hot Flushes Asking Whether HRT Is Safe — Free SCA Practice Case

Woman struggling with hot flushes asking whether HRT is safe

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Angela Whitmore

Age

49 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation.

Reason for Encounter

"I've been getting hot flushes and I'm not myself — forgetful, irritable, not sleeping. I think it's the menopause, and I want to talk about HRT, but I'm worried about whether it's safe."

Medical Records

●PMH: Nil significant.
●Medications: None.
●Allergies: NKDA.
●Recent contact: No significant recent consultations.

Patient Script

For the friend playing the patient role

Character Overview: You are Angela, a 49-year-old operations manager in finance. You are articulate and used to being on top of things, so the recent changes have unsettled you. You have worked out for yourself that it is probably the menopause and you have come specifically to ask whether HRT is safe for you — you have heard mixed and frightening things over the years. You are thoughtful and will want to read up before deciding.

Opening Sentence: "Hi Doctor. Over the last six months or so I've been getting hot flushes, my sleep's all over the place, I'm irritable, and — this is the bit that worries me most — I've become really forgetful and I can't multitask like I used to, which is a problem in my job. I'm fairly sure it's the menopause. What I really want to know is: is HRT safe for me?"

History if Asked (Data Gathering Phase)

●Vasomotor symptoms: "Hot flushes several times a day, and I wake at night drenched sometimes. It's exhausting."
●Cognitive and mood symptoms: "I'm forgetful — I left my laptop at home before a big meeting recently, which is so unlike me. I can't juggle tasks like I used to, and I'm snappy and irritable. My husband's noticed the irritability."
●Periods: "They've become irregular over the last six months — sometimes every couple of months, and lighter. I did wonder if I was pregnant and did tests, all negative."
●Other symptoms: "Some vaginal dryness, which makes things uncomfortable with my husband sometimes."
●Why she's worried about HRT: "I've heard over the years that HRT causes breast cancer and clots. I don't know what to believe, so I want to understand the actual risks."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Angela has correctly worked out that this is likely the menopause/perimenopause. She wonders whether she needs a blood test to confirm it, as a friend had one. "I'm pretty sure it's the menopause. A friend had a blood test to confirm hers — do I need one?"
●Concerns: Her main concern is the safety of HRT — specifically breast cancer and clots, which she has heard frightening things about — and the impact of her symptoms on her demanding job and her relationship. "The thing that worries me is whether HRT is dangerous — the cancer and clot stories. And honestly, the brain fog is threatening my performance at work."
●Expectations: She wants an honest, balanced account of HRT's risks and benefits so she can decide, and she is likely to want to read more before committing. "I want the real risks and benefits, not scare stories, so I can make up my own mind. I'll probably want to go away and read about it."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Periods/contraception: "Irregular for six months, lighter. My husband had a vasectomy, so we don't use contraception. Last period was about two weeks ago."
●Medications: "Nothing regular. No hormones."
●Smoking/alcohol: "I don't smoke and I don't really drink."
●Migraine: "I do get migraines occasionally — with a bit of visual disturbance beforehand sometimes."
●Family history: "No breast cancer or blood clots in the family that I know of."

Social History and Lifestyle Impact

Angela is an operations manager in a hedge fund. She is married with three children.

●Work: "It's a fast-paced job that needs sharp multitasking — exactly what I feel I've lost. I'm worried it's affecting my performance."
●Home: "Married, three kids. My husband's noticed I'm more irritable. The vaginal dryness has affected our relationship a bit too."
●Lifestyle: "Non-smoker, barely drink, reasonably active."
●Mood: "I feel less like myself — frustrated and a bit low about it, but I'm coping."

If Asked — HRT Safety-Screen and Red Flags

The patient answers these only when directly asked.

●If asked about personal or family history of breast cancer: "No, none."
●If asked about new breast lumps: "No lumps that I've found."
●If asked about abnormal vaginal bleeding (e.g. bleeding between periods, after sex, or heavy): "No, nothing abnormal — just the lighter, less frequent periods."
●If asked about personal or family history of blood clots (DVT/PE): "No, no clots in me or the family."
●If asked about recent heart attack or stroke: "No, nothing like that."
●If asked about migraine (and aura): "Yes, occasional migraines, sometimes with visual aura beforehand." (Relevant to route of HRT and to combined contraception, though HRT is not contraindicated by migraine.)
●If asked about red-flag symptoms (unexplained weight loss, appetite loss, lumps): "No, nothing like that."

Responses to Management (The Negotiation Phase)

●If the Doctor diagnoses perimenopause without a blood test: "So I don't need a blood test to confirm it? My friend had one." (The tested point is explaining that menopause is a clinical diagnosis in women over 45 with typical symptoms, and blood tests are unreliable due to fluctuating hormones.)
●If the Doctor explains the risks and benefits of HRT: "So what are the actual risks? I keep hearing about breast cancer and clots." (The tested point is a balanced, accurate account of HRT benefits and risks — including that risk varies by type and route.)
●If the Doctor mentions checking things before prescribing: "What do you need to check before I could start it?"
●If the Doctor offers non-hormonal options: "What if I decide I don't want HRT — is there anything else?"
●If the Doctor mentions herbal remedies: "What about natural remedies like black cohosh — do they work?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Diagnosing Perimenopause/Menopause (NICE NG23)

●In women over 45 with typical symptoms, menopause/perimenopause is a clinical diagnosis — no blood test is required. FSH testing is unreliable because hormone levels fluctuate, and is reserved for specific situations (e.g. women under 45, or diagnostic uncertainty).
●Perimenopausal symptoms extend well beyond hot flushes: irregular periods, night sweats, sleep disturbance, low mood, irritability, poor concentration and memory ("brain fog"), joint aches, and urogenital symptoms (vaginal dryness).

HRT Benefits

●HRT is the most effective treatment for vasomotor symptoms and also improves mood, sleep, energy, concentration, and urogenital symptoms, and helps maintain bone health and reduce fracture risk.

HRT Risks — Balanced and Type/Route-Dependent

●Breast cancer: a small, largely type-dependent increase associated with combined (oestrogen + progestogen) HRT, which reduces after stopping; oestrogen-only HRT carries little or no increase.
●Venous thromboembolism: a small increase with oral HRT; transdermal HRT (patch/gel) is not associated with the increased VTE risk and is preferred where VTE risk is a concern.
●Stroke: a very small increased risk with oral HRT.
●For most symptomatic women around the time of menopause, the benefits outweigh the risks. Framing risk accurately — and by type and route — is essential.

Choosing the Right HRT

●Women with a uterus need combined HRT (oestrogen with a progestogen) to protect the endometrium; unopposed oestrogen is only for women without a uterus.
●The transdermal route avoids the VTE risk and is often preferred (e.g. in those with migraine, higher BMI, or VTE-risk factors). Regimen (cyclical vs continuous) depends on menopausal stage.

Contraindications and Pre-Prescribing Checks

●Assess for contraindications/cautions: current/past breast cancer, oestrogen-dependent cancer, undiagnosed abnormal vaginal bleeding, active/recent VTE or arterial thromboembolic disease, and active liver disease.
●Migraine (including with aura) is a caution, not a contraindication to HRT (unlike combined hormonal contraception). Check blood pressure before starting.

Non-Hormonal and Local Options

●For women who cannot or prefer not to take systemic HRT: vaginal moisturisers/lubricants and low-dose vaginal oestrogen for urogenital symptoms; menopause-specific cognitive behavioural therapy (CBT) for vasomotor symptoms, sleep, and mood.

Herbal Remedies

●Some remedies (e.g. isoflavones, black cohosh) may help hot flushes, but preparations are poorly regulated, with variable content and uncertain safety and interactions — advise caution and honesty about the limited evidence.

Contraception in Perimenopause

●Perimenopausal women can still conceive; HRT is not a contraceptive. Contraception is generally advised until the appropriate age/duration criteria are met (not required here, as her partner has had a vasectomy).

Common Candidate Mistakes in This Case

●Ordering blood tests to "confirm" menopause: unnecessary and unreliable in a woman over 45 with typical symptoms.
●Mishandling the risk discussion: either amplifying the breast-cancer/clot fears or claiming HRT is risk-free, rather than giving a balanced, route-specific account.
●Prescribing unopposed oestrogen in a woman with a uterus: omitting endometrial protection.
●Treating migraine as an absolute contraindication: wrongly withholding HRT (migraine is a caution, and the transdermal route is preferred).
●Pressuring a decision: not respecting her wish to read and reflect, or failing to offer non-hormonal alternatives and follow-up.

Free MRCGP SCA practice case for GP registrars covering Hot Flushes Asking Whether HRT Is Safe — Gynaecology and Breast. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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