A 52-year-old postmenopausal woman has vasomotor symptoms severely affecting quality of life and requests menopausal hormone therapy (MHT). She has an intact uterus and no personal history of breast cancer or thromboembolism. Her 10-year FRAX score for major osteoporotic fracture is 18%. Which MHT regimen is most appropriate?

• A Combined continuous oestrogen-progestogen therapy (oral or transdermal oestrogen + oral or LNG-IUS progestogen) ✓
• B Oestrogen-only therapy (oral conjugated equine oestrogen 0.625 mg daily)
• C Tibolone alone (synthetic steroid with oestrogenic, progestogenic, and androgenic activity)
• D Selective oestrogen receptor modulator (raloxifene) alone for vasomotor and bone protection

Explanation

Women with an intact uterus must receive combined oestrogen-progestogen MHT — oestrogen alone causes endometrial hyperplasia and carcinoma risk (relative risk ~2–4× per year of use without progestogen). Combined continuous regimens (no cyclical bleeding) are preferred in postmenopausal women. Transdermal oestrogen + oral progestogen or LNG-IUS is preferred over oral combined therapy to minimise first-pass hepatic effects (lower VTE risk with transdermal route). Tibolone has oestrogenic/progestogenic/androgenic properties and does not require separate progestogen but carries breast cancer risk similar to combined MHT. Raloxifene (a SERM) actually worsens vasomotor symptoms and is used for osteoporosis, not symptom relief — it is contraindicated for vasomotor symptoms.

Reference: Shaw's Textbook of Gynaecology, 17th ed.

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Written and medically reviewed by the StethoPrep medical team.