Reproductive Health — MCQs
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A 40-year-old woman with well-controlled hypertension on amlodipine presents requesting contraception. She has a BMI of 28 kg/m², smokes 12 cigarettes daily, and is in a stable relationship. Her blood pressure today is 138/86 mmHg. She prefers a method that does not require daily compliance. On examination, cardiovascular and abdominal examinations are unremarkable. What is the most appropriate contraceptive method to recommend?
A 52-year-old woman who has been taking sequential combined HRT for 11 months reports that her withdrawal bleeds have become very heavy over the past 3 cycles, lasting 7-8 days with passage of clots. She started HRT for vasomotor symptoms and her last spontaneous period was 14 months ago. Pelvic examination is normal and she has no intermenstrual bleeding or postcoital bleeding. What is the most appropriate next step?
A 47-year-old woman with regular menstrual cycles presents with troublesome vasomotor symptoms affecting her work and sleep. She requests HRT. Her mother had breast cancer diagnosed at age 72. She has a BMI of 28 kg/m², blood pressure 132/84 mmHg, and no other medical history. How should her family history of breast cancer influence prescribing HRT?
A 39-year-old nulliparous woman requests contraception. She had a pulmonary embolism 5 years ago during long-haul air travel and completed 6 months of anticoagulation. Thrombophilia screening at the time was negative. She is not currently on any anticoagulation. Her BMI is 25 kg/m² and blood pressure is 122/78 mmHg. What is the classification of combined hormonal contraception for this woman according to UK Medical Eligibility Criteria?
A 56-year-old woman with primary ovarian insufficiency diagnosed at age 35 has been taking HRT continuously. She is currently on transdermal oestradiol 100 mcg patches and micronised progesterone 100 mg daily. She asks when she can stop HRT. What is the most appropriate advice regarding duration of HRT in this context?
A 28-year-old woman with well-controlled focal epilepsy on lamotrigine 200 mg daily presents requesting contraception. She is in a stable relationship and does not wish to conceive for at least 3 years. She has no other medical conditions and has a BMI of 23 kg/m². Which contraceptive method requires the most careful consideration due to potential drug interactions?
A 54-year-old woman who has been taking continuous combined HRT (transdermal oestradiol 50 mcg and micronised progesterone 100 mg) for 14 months presents with a single episode of vaginal bleeding lasting 2 days. Her last menstrual period was 3 years ago. She has no abdominal pain or other symptoms. What is the most appropriate initial management?
What is the recommended window for starting progestogen-only contraception postpartum in a non-breastfeeding woman to ensure immediate contraceptive protection without requiring additional precautions?
A 44-year-old woman with menorrhagia has been using a 52 mg levonorgestrel IUS for 18 months with good symptom control. She now presents with a 4-week history of persistent intermenstrual bleeding. Examination reveals the IUS threads are visible and the cervix appears normal. A high vaginal swab shows no evidence of infection. What is the most appropriate next step in management?
A 50-year-old woman presents requesting HRT for moderate vasomotor symptoms. Her last menstrual period was 8 months ago. She has a BMI of 24 kg/m², blood pressure 118/76 mmHg, and no significant medical history. She still has her uterus and both ovaries. What is the most appropriate initial HRT regimen?
Reproductive Health UK Medical PG Practice Questions and MCQs
Question 41: A 40-year-old woman with well-controlled hypertension on amlodipine presents requesting contraception. She has a BMI of 28 kg/m², smokes 12 cigarettes daily, and is in a stable relationship. Her blood pressure today is 138/86 mmHg. She prefers a method that does not require daily compliance. On examination, cardiovascular and abdominal examinations are unremarkable. What is the most appropriate contraceptive method to recommend?
- A. Progesterone-only pill
- B. Combined transdermal patch
- C. Depot medroxyprogesterone acetate injection
- D. Combined oral contraceptive pill
- E. Copper intrauterine device (Correct Answer)
Explanation: ***Copper intrauterine device*** - This method is a **long-acting reversible contraceptive (LARC)**, directly addressing the patient's preference for a method that does not require **daily compliance**. - As a **non-hormonal** option, it is ideal for women with **cardiovascular risk factors** such as hypertension and smoking, as it avoids the risks associated with estrogen. *Progesterone-only pill* - While generally safe for patients with **hypertension** and **smoking history**, this method requires **daily adherence**. - It does not meet the patient's specific request for a contraceptive method that does not require **daily compliance**. *Combined transdermal patch* - This method contains **estrogen**, which is generally contraindicated in women over **35 years old** who **smoke** due to increased **cardiovascular risks**. - The combination of age (40), smoking (12 cigarettes daily), and hypertension significantly elevates the risk of **thrombotic events** like VTE, stroke, and MI. *Depot medroxyprogesterone acetate injection* - Although it's a long-acting method, it can cause **delayed return to fertility** after discontinuation, which may be a consideration for some women. - Long-term use of DMPA is associated with a potential decrease in **bone mineral density**, though it usually recovers after cessation. *Combined oral contraceptive pill* - This option contains **estrogen** and is **contraindicated** in women over **35 years old** who **smoke**, particularly with **hypertension**. - The elevated risk of **venous thromboembolism**, myocardial infarction, and **ischemic stroke** makes this an unsafe choice for this patient.
Question 42: A 52-year-old woman who has been taking sequential combined HRT for 11 months reports that her withdrawal bleeds have become very heavy over the past 3 cycles, lasting 7-8 days with passage of clots. She started HRT for vasomotor symptoms and her last spontaneous period was 14 months ago. Pelvic examination is normal and she has no intermenstrual bleeding or postcoital bleeding. What is the most appropriate next step?
- A. Switch to continuous combined HRT as she is >12 months post-menopause
- B. Reassure that heavy withdrawal bleeds are normal with sequential HRT and continue current regimen
- C. Arrange transvaginal ultrasound and consider endometrial sampling before changing HRT (Correct Answer)
- D. Add tranexamic acid during withdrawal bleeds to reduce heaviness
- E. Increase the duration of progestogen phase to 21 days per cycle
Explanation: ***Arrange transvaginal ultrasound and consider endometrial sampling before changing HRT*** - The patient's report of **progressively heavy withdrawal bleeds** lasting longer with clots, after 11 months on sequential HRT, constitutes an **abnormal bleeding pattern** requiring prompt investigation. - This change necessitates ruling out **endometrial pathology** such as **hyperplasia** or **carcinoma**, which is best achieved through a **transvaginal ultrasound** to assess endometrial thickness and potentially **endometrial sampling** to obtain tissue for histological evaluation. *Switch to continuous combined HRT as she is >12 months post-menopause* - While she is technically post-menopausal (last spontaneous period 14 months ago), switching to continuous combined HRT without investigating the **new-onset heavy bleeding** could mask an underlying serious pathology. - Any **unexplained or new-onset abnormal uterine bleeding (AUB)** in a post-menopausal woman, even one on HRT, warrants a thorough **diagnostic workup** before making changes to the treatment regimen. *Reassure that heavy withdrawal bleeds are normal with sequential HRT and continue current regimen* - While sequential HRT causes withdrawal bleeds, they should be **predictable and generally stable**; heavy bleeding with clots that has become worse over recent cycles is not considered normal and requires investigation. - Reassurance without investigation risks missing significant **endometrial pathology**, which is a crucial consideration in a 52-year-old woman presenting with abnormal bleeding. *Add tranexamic acid during withdrawal bleeds to reduce heaviness* - **Tranexamic acid** is a symptomatic treatment for heavy menstrual bleeding; however, it does not address the underlying cause of the **abnormal bleeding pattern** observed in this patient. - Providing symptomatic relief without a **diagnostic workup** would be inappropriate, as it could delay the diagnosis of a serious underlying condition such as **endometrial cancer**. *Increase the duration of progestogen phase to 21 days per cycle* - Increasing the **progestogen phase duration** is sometimes considered to provide better endometrial protection or manage unscheduled bleeding, but it is not the initial diagnostic step for **new-onset heavy withdrawal bleeding**. - The priority is to **diagnose the cause** of the abnormal bleeding through appropriate investigations before making empirical adjustments to the HRT regimen.
Question 43: A 47-year-old woman with regular menstrual cycles presents with troublesome vasomotor symptoms affecting her work and sleep. She requests HRT. Her mother had breast cancer diagnosed at age 72. She has a BMI of 28 kg/m², blood pressure 132/84 mmHg, and no other medical history. How should her family history of breast cancer influence prescribing HRT?
- A. HRT can be prescribed but duration should be limited to maximum 2 years
- B. Genetic testing for BRCA mutations is mandatory before prescribing HRT
- C. HRT is absolutely contraindicated due to family history
- D. HRT can be prescribed but should be oestrogen-only to reduce breast cancer risk
- E. Family history increases baseline risk but HRT can be prescribed with informed consent after discussion of risks and benefits (Correct Answer)
Explanation: ***Family history increases baseline risk but HRT can be prescribed with informed consent after discussion of risks and benefits***- A single first-degree relative diagnosed with **breast cancer after age 70** indicates a moderate increase in baseline risk, but this is **not an absolute contraindication** to Hormone Replacement Therapy (HRT).- Prescribing decisions should be individualized, focusing on **informed consent** and balancing **vasomotor symptom relief** against the duration-dependent increase in breast cancer risk associated with combined HRT.*HRT can be prescribed but duration should be limited to maximum 2 years*- There is no evidence-based **arbitrary time limit** for HRT; duration should be determined by the persistence of symptoms and regular **risk-benefit reassessment**.- While risk increases with duration, setting a strict 2-year cutoff may lead to under-treatment of **vasomotor symptoms** and return of morbidity.*Genetic testing for BRCA mutations is mandatory before prescribing HRT*- **Genetic testing** is only indicated if the family history suggests a **hereditary syndrome**, such as multiple relatives affected, bilateral disease, or diagnosis at an **age <50**.- A single relative diagnosed at age 72 does not meet the clinical criteria for **BRCA mutation** screening or mandatory pre-HRT testing.*HRT is absolutely contraindicated due to family history*- Family history is a risk factor, not an **absolute contraindication**; a personal history of breast cancer would be a contraindication.- According to **NICE guidelines**, women with a family history can still access HRT if the impact on **quality of life** outweighs the risks after thorough counseling.*HRT can be prescribed but should be oestrogen-only to reduce breast cancer risk*- **Oestrogen-only HRT** is only appropriate for women who have had a **hysterectomy**; this patient has regular menstrual cycles and requires the addition of a **progestogen** for endometrial protection.- Using oestrogen-only therapy in a woman with an **intact uterus** significantly increases the risk of **endometrial hyperplasia** and carcinoma.
Question 44: A 39-year-old nulliparous woman requests contraception. She had a pulmonary embolism 5 years ago during long-haul air travel and completed 6 months of anticoagulation. Thrombophilia screening at the time was negative. She is not currently on any anticoagulation. Her BMI is 25 kg/m² and blood pressure is 122/78 mmHg. What is the classification of combined hormonal contraception for this woman according to UK Medical Eligibility Criteria?
- A. UKMEC 1 - no restriction on use
- B. Cannot be classified without repeat thrombophilia screening
- C. UKMEC 2 - benefits generally outweigh risks
- D. UKMEC 3 - risks usually outweigh benefits
- E. UKMEC 4 - unacceptable health risk (Correct Answer)
Explanation: ***UKMEC 4 - unacceptable health risk*** - A personal history of **venous thromboembolism (VTE)**, specifically a **pulmonary embolism**, regardless of being provoked or having negative thrombophilia screening, is classified as **UKMEC 4** for combined hormonal contraception (CHC). - The **oestrogen** component in CHC significantly increases the risk of recurrent thrombosis, making its use an unacceptable health risk for this woman. *UKMEC 1 - no restriction on use* - This category is for individuals with no medical conditions that pose a risk with the contraceptive method. - A history of **pulmonary embolism** is a severe contraindication for oestrogen-containing contraception, directly contradicting UKMEC 1 classification. *Cannot be classified without repeat thrombophilia screening* - The UKMEC classification for combined hormonal contraception in individuals with a history of VTE is primarily based on the **clinical event** itself. - A negative **thrombophilia screen**, either prior or repeated, does not alter the **UKMEC 4** classification due to the inherent risk associated with a past VTE event and oestrogen. *UKMEC 2 - benefits generally outweigh risks* - This category applies to conditions where the advantages of using the method generally outweigh the theoretical or proven risks. - While other contraceptive methods, such as **progestogen-only pills**, might be UKMEC 2 for this patient, combined hormonal contraception carries a much higher, unacceptable risk for those with a history of VTE. *UKMEC 3 - risks usually outweigh benefits* - This classification is for conditions where the theoretical or proven risks usually outweigh the advantages of using the method. - A personal history of **pulmonary embolism** elevates the risk for combined hormonal contraception to the highest category of **UKMEC 4**, indicating an unacceptable health risk, rather than just risks usually outweighing benefits.
Question 45: A 56-year-old woman with primary ovarian insufficiency diagnosed at age 35 has been taking HRT continuously. She is currently on transdermal oestradiol 100 mcg patches and micronised progesterone 100 mg daily. She asks when she can stop HRT. What is the most appropriate advice regarding duration of HRT in this context?
- A. Stop immediately as she has passed the average age of natural menopause
- B. Continue at least until age 51-52 (average age of natural menopause) and then review (Correct Answer)
- C. Continue lifelong due to early menopause
- D. Continue until age 60 and then reassess
- E. Reduce dose by 50% now and stop completely at age 60
Explanation: ***Continue at least until age 51-52 (average age of natural menopause) and then review***- Women with **Primary Ovarian Insufficiency (POI)** should be advised to take **HRT** until the average age of natural menopause to replace physiological hormone levels.- This duration is crucial for the **prevention of osteoporosis**, **cardiovascular protection**, and maintaining cognitive function, as benefits significantly outweigh risks in this demographic.*Stop immediately as she has passed the average age of natural menopause*- The patient is currently **56 years old**, meaning she has already reached the average age of natural menopause; however, stopping should be a shared decision based on a **risk-benefit review** rather than an immediate mandate.- Abruptly stopping without review can lead to a return of **vasomotor symptoms** and a rapid decline in **bone mineral density**.*Continue lifelong due to early menopause*- While some women choose to continue HRT longer, **lifelong therapy** is not a universal requirement and must be balanced against individual risks like **breast cancer** or thromboembolism as the patient ages.- Current guidelines recommend a **reassessment** at the age of natural menopause rather than committing to lifelong treatment from the outset.*Continue until age 60 and then reassess*- Age 60 is a common milestone for reassessing HRT in standard menopause, but it is not the standard clinical benchmark for defining the **minimum duration** for POI patients.- Clinical practice focuses on the **age of natural menopause (51-52)** as the primary target for physiological replacement before moving to symptom-based management.*Reduce dose by 50% now and stop completely at age 60*- There is no clinical evidence supporting a mandatory **tapering protocol** specifically at age 56 for women who experienced POI.- Dose reduction should be based on **symptom control** and patient preference rather than an arbitrary age-based percentage cut.
Question 46: A 28-year-old woman with well-controlled focal epilepsy on lamotrigine 200 mg daily presents requesting contraception. She is in a stable relationship and does not wish to conceive for at least 3 years. She has no other medical conditions and has a BMI of 23 kg/m². Which contraceptive method requires the most careful consideration due to potential drug interactions?
- A. Copper intrauterine device
- B. Desogestrel progestogen-only pill
- C. Levonorgestrel intrauterine system
- D. Etonogestrel subdermal implant
- E. Combined oral contraceptive pill (Correct Answer)
Explanation: ***Combined oral contraceptive pill*** - Use of **ethinylestradiol** induces the **glucuronidation** of **lamotrigine**, which can significantly decrease lamotrigine serum concentrations by up to 50%, risking a loss of **seizure control**. - This interaction is **bidirectional** and complex; during the **pill-free interval**, lamotrigine levels can rise rapidly, potentially leading to **toxicity** (e.g., ataxia, diplopia). *Copper intrauterine device* - This is a **non-hormonal** method and does not interact with any **anti-epileptic drugs**, including lamotrigine. - It is classified as **UKMEC 1** for patients with epilepsy, making it a safe and highly effective long-term option. *Desogestrel progestogen-only pill* - Unlike estrogen, **progestogens** do not significantly induce the metabolism of **lamotrigine**, so they do not lower the seizure threshold. - As lamotrigine is not a **liver enzyme inducer**, it does not decrease the efficacy of the **progestogen-only pill**. *Levonorgestrel intrauterine system* - The **LNG-IUS** acts primarily locally and does not have a clinically significant interaction with **lamotrigine** metabolism. - It is a preferred **Long-Acting Reversible Contraceptive (LARC)** for women on lamotrigine due to its high efficacy and safety profile (**UKMEC 1**). *Etonogestrel subdermal implant* - The **subdermal implant** efficacy is not affected by **lamotrigine** because lamotrigine does not induce **cytochrome P450 enzymes**. - There is no evidence that the etonogestrel implant significantly reduces **lamotrigine plasma levels**, unlike estrogen-containing methods.
Question 47: A 54-year-old woman who has been taking continuous combined HRT (transdermal oestradiol 50 mcg and micronised progesterone 100 mg) for 14 months presents with a single episode of vaginal bleeding lasting 2 days. Her last menstrual period was 3 years ago. She has no abdominal pain or other symptoms. What is the most appropriate initial management?
- A. Reassure and continue current HRT regimen with review in 3 months
- B. Switch to sequential combined HRT to regulate bleeding
- C. Refer for urgent transvaginal ultrasound and consider endometrial sampling (Correct Answer)
- D. Stop HRT immediately and review in 6 weeks
- E. Increase progesterone dose to 200 mg daily
Explanation: ***Refer for urgent transvaginal ultrasound and consider endometrial sampling***- Any unscheduled vaginal bleeding occurring after the initial **6 months** of **continuous combined HRT** must be investigated as **postmenopausal bleeding (PMB)** due to the risk of endometrial pathology.- An **urgent transvaginal ultrasound** is the first-line investigation to assess **endometrial thickness**, and **endometrial sampling** may be needed to exclude **endometrial hyperplasia** or **malignancy**.*Reassure and continue current HRT regimen with review in 3 months*- Bleeding is only considered normal or expected during the initial **3 to 6-month settling-in period** of starting HRT.- Delaying investigation for a patient on HRT for **14 months** with unscheduled bleeding carries a risk of missing a significant diagnosis such as **endometrial cancer**.*Switch to sequential combined HRT to regulate bleeding*- Sequential HRT is typically used in **perimenopausal** women, whereas this patient is **3 years post-menopause**.- Changing the HRT regimen would mask symptoms and delay the necessary investigation of the **endometrial lining** for any underlying pathology.*Stop HRT immediately and review in 6 weeks*- Stopping HRT does not provide a diagnosis and neglects the critical need to visualize the **uterus** and **endometrium**.- Clinical guidelines prioritize **timely investigation** (often a 2-week wait referral) rather than observing if the bleeding resolves spontaneously.*Increase progesterone dose to 200 mg daily*- While insufficient progesterone can sometimes cause breakthrough bleeding, **endometrial pathology** must be ruled out first in a patient with unscheduled bleeding on long-term HRT.- Increasing the progesterone dose without a prior **transvaginal ultrasound** or biopsy would be inappropriate management for potential **postmenopausal bleeding**.
Question 48: What is the recommended window for starting progestogen-only contraception postpartum in a non-breastfeeding woman to ensure immediate contraceptive protection without requiring additional precautions?
- A. Within 24 hours of delivery
- B. Within 48 hours of delivery
- C. On day 21 postpartum (Correct Answer)
- D. On day 28 postpartum
- E. Within 6 weeks postpartum
Explanation: ***On day 21 postpartum*** - Starting **progestogen-only contraception** up to and including **day 21** after delivery provides immediate contraceptive protection because ovulation is unlikely to occur before this time. - This window applies to both breastfeeding and non-breastfeeding women, serving as the standard threshold for requiring **additional precautions** (such as condoms) if started later. *Within 24 hours of delivery* - While **progestogen-only methods** can be safely started immediately after birth, they are not strictly required this early as the risk of **conception** is negligible before day 21. - Starting at this time is safe but is not the specific "limit" for ensuring **immediate protection** without additional backup methods. *Within 48 hours of delivery* - Similar to the 24-hour mark, starting within **48 hours** is medically safe (UKMEC 1 or 2) but does not represent the end of the window for **immediate coverage**. - It is often recommended for convenience before discharge, but the **21-day rule** remains the physiological cutoff for immediate efficacy. *On day 28 postpartum* - If progestogen-only contraception is started after **day 21**, immediate protection is no longer guaranteed, and **barrier methods** are required for a short period. - For **progestogen-only pills (POP)**, additional precautions are needed for **2 days**, whereas for the **injectable**, they are needed for **7 days** if started at this stage. *Within 6 weeks postpartum* - The **6-week** mark is relevant for **combined hormonal contraception (CHC)** to reduce the risk of **venous thromboembolism (VTE)**, but it is not the threshold for progestogen-only methods. - Waiting until **6 weeks** would leave the patient at risk of pregnancy if they have already resumed sexual activity after **day 21 postpartum**.
Question 49: A 44-year-old woman with menorrhagia has been using a 52 mg levonorgestrel IUS for 18 months with good symptom control. She now presents with a 4-week history of persistent intermenstrual bleeding. Examination reveals the IUS threads are visible and the cervix appears normal. A high vaginal swab shows no evidence of infection. What is the most appropriate next step in management?
- A. Remove and replace the levonorgestrel IUS
- B. Reassure and review in 3 months
- C. Perform transvaginal ultrasound scan to check device position and exclude structural pathology (Correct Answer)
- D. Remove the device and commence combined oral contraceptive pill
- E. Add oral tranexamic acid to reduce bleeding
Explanation: ***Perform transvaginal ultrasound scan to check device position and exclude structural pathology*** - In a patient who previously had good symptom control, a new onset of **persistent intermenstrual bleeding** after 18 months warrants investigation to exclude **structural pathology** (e.g., polyps, fibroids, endometrial hyperplasia) or **device displacement**. - **Transvaginal ultrasound (TVUS)** is the most appropriate initial investigation as it can confirm the **IUS position** and effectively screen for any **uterine or endometrial abnormalities**. *Remove and replace the levonorgestrel IUS* - Replacing the device without first identifying the cause of the new bleeding change risks recurrence of symptoms if an underlying **pathological cause** is present, rather than just device malfunction or age. - This step should only be considered if the current IUS is confirmed to be **malpositioned** or when its lifespan primarily expires after 5–8 years. *Reassure and review in 3 months* - While irregular spotting is common in the first **3-6 months** of IUS use, new onset **persistent intermenstrual bleeding** after long-term stability is atypical and requires active investigation. - Delaying evaluation of new onset bleeding in a 44-year-old woman carries the risk of missing significant **structural abnormalities** or endometrial changes that require prompt attention. *Remove the device and commence combined oral contraceptive pill* - The IUS was providing effective control for **menorrhagia**; removing it prematurely without a diagnosis may lead to a recurrence of heavy menstrual bleeding. - The **combined oral contraceptive pill** may manage bleeding, but it does not replace the need to exclude secondary causes via **ultrasound** and could mask important diagnostic clues. *Add oral tranexamic acid to reduce bleeding* - **Tranexamic acid** is primarily used for **heavy menstrual bleeding** rather than **intermenstrual bleeding**, and it does not facilitate a diagnosis for the change in bleeding pattern. - Using it here would only mask symptoms without addressing potential **structural causes** or **IUS malposition**, which could delay appropriate management.
Question 50: A 50-year-old woman presents requesting HRT for moderate vasomotor symptoms. Her last menstrual period was 8 months ago. She has a BMI of 24 kg/m², blood pressure 118/76 mmHg, and no significant medical history. She still has her uterus and both ovaries. What is the most appropriate initial HRT regimen?
- A. Continuous combined oestrogen and progestogen HRT
- B. Oestrogen-only HRT
- C. Sequential combined HRT with 10 days of progestogen per month
- D. Sequential combined HRT with 14 days of progestogen per month (Correct Answer)
- E. Tibolone 2.5 mg daily
Explanation: ***Sequential combined HRT with 14 days of progestogen per month*** - This patient is **perimenopausal** (last period 8 months ago) and has an **intact uterus**, requiring a sequential regimen to prevent irregular bleeding and ensure **endometrial protection**. - A minimum of **12 to 14 days** of progestogen per month is necessary in sequential regimens to adequately reduce the risk of **endometrial hyperplasia**. *Continuous combined oestrogen and progestogen HRT* - This regimen is indicated only for women who are **postmenopausal**, defined as at least **12 months** since their last menstrual period. - Starting this too early in the perimenopausal transition often leads to problematic and unpredictable **breakthrough bleeding**. *Oestrogen-only HRT* - This is strictly reserved for women who have undergone a **hysterectomy** (no uterus). - Using unopposed oestrogen in a woman with a uterus significantly increases the risk of **endometrial carcinoma**. *Sequential combined HRT with 10 days of progestogen per month* - Clinical guidelines recommend a minimum of **12 days** of progestogen exposure to effectively transform the endometrium. - Using only **10 days** provides suboptimal protection against the development of **endometrial hyperplasia**. *Tibolone 2.5 mg daily* - Tibolone is a synthetic steroid with oestrogenic, progestogenic, and androgenic properties indicated for **postmenopausal** women. - Like continuous combined HRT, it should only be started at least **one year after** the last menstrual period to avoid irregular bleeding.
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