CCE-CBD-038.1

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What key information would you gather in your history to assess Susan’s symptoms?

• Prompt: What aspects of her symptoms, menstrual history, and lifestyle are important?
• Prompt: What other conditions might mimic menopausal symptoms?

Q2. What are the differential diagnoses for Susan’s symptoms?

• Prompt: What investigations, if any, would you consider?
• Prompt: How would you rule out thyroid dysfunction or mood disorders?

Q3. How would you counsel Susan about menopause and its management options?

• Prompt: How would you explain menopause and symptom progression?
• Prompt: What lifestyle and non-hormonal treatment options would you discuss?

Q4. Susan is considering hormone therapy but is worried about risks. How would you counsel her?

• Prompt: What are the indications, benefits, and risks of menopausal hormone therapy (MHT)?
• Prompt: How would you personalise your recommendations based on Susan’s history?

Q5. What preventive health considerations are relevant for Susan at this stage of life?

• Prompt: How would you discuss cardiovascular health and cancer screening?
• Prompt: What is the role of bone health assessment in menopause?

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THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Q1: What key information would you gather in your history to assess Susan’s symptoms?

A comprehensive history is crucial in evaluating Susan’s menopausal symptoms, excluding differential diagnoses, and identifying associated health risks.

Menstrual and Reproductive History

• Date of last menstrual period (LMP) – menopause is defined as 12 months of amenorrhoea.
• Menstrual pattern changes – irregularity, frequency, and postmenopausal bleeding.
• History of hormonal therapy, contraception, or gynaecological conditions.

Menopausal Symptom Assessment

• Vasomotor symptoms – frequency and severity of hot flushes, night sweats.
• Sleep disturbances – difficulty falling or staying asleep, early morning waking.
• Mood changes – irritability, anxiety, depression, memory issues.
• Genitourinary symptoms – vaginal dryness, dyspareunia, urinary urgency, recurrent UTIs.
• Sexual function concerns – changes in libido, discomfort with intercourse.

Medical and Family History

• Cardiovascular disease risk factors – hypertension, diabetes, smoking, dyslipidaemia.
• Bone health – history of osteoporosis, fragility fractures, parental history of hip fracture.
• Thyroid dysfunction – symptoms of hyperthyroidism or hypothyroidism.
• Psychosocial factors – work stress, personal life changes, mental health history.
• Family history of cancers – particularly breast, ovarian, or endometrial cancer.

Lifestyle and Medication Review

• Dietary intake – calcium and vitamin D levels.
• Exercise patterns – weight-bearing activities, strength training.
• Substance use – alcohol consumption, smoking.
• Current medications – including complementary and alternative medicines.

Red Flags

• Postmenopausal bleeding – potential malignancy, endometrial hyperplasia.
• Severe depression or cognitive impairment – risk of underlying mental health conditions.

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Q2: What are the differential diagnoses for Susan’s symptoms?

Primary Diagnosis: Menopause

• Symptoms consistent with oestrogen decline (vasomotor symptoms, mood changes, sleep disturbances).
• History of menstrual irregularity progressing to amenorrhoea.

Common Differential Diagnoses

• Thyroid Dysfunction (Hypothyroidism/Hyperthyroidism)
  • Overlaps with menopause – fatigue, mood swings, weight changes.
  • Investigations: TSH, free T4.
• Depression/Anxiety Disorders
  • Menopausal mood changes vs. major depressive disorder.
  • Symptoms of anhedonia, persistent low mood, suicidal ideation.
• Sleep Disorders (Insomnia, Obstructive Sleep Apnoea)
  • Poor sleep quality can exacerbate mood and cognitive changes.
  • Assess snoring, daytime somnolence, restless sleep.
• Iron Deficiency Anaemia
  • Presents with fatigue, dizziness, and palpitations.
  • Check full blood count, ferritin.
• Medication Side Effects
  • Beta-blockers, SSRIs, and antihypertensives may mimic menopausal symptoms.

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Q3: How would you counsel Susan about menopause and its management options?

Education on Menopause

• Definition: Permanent cessation of menstruation due to ovarian oestrogen depletion.
• Duration: Symptoms last 4–8 years but vary individually.
• Health implications: Increased risks of osteoporosis, cardiovascular disease.

Lifestyle Modifications

• Diet: Ensure adequate calcium and vitamin D intake.
• Exercise: Weight-bearing activities to reduce osteoporosis risk.
• Sleep hygiene: Regular sleep patterns, avoiding stimulants before bedtime.
• Stress reduction: Yoga, mindfulness, cognitive behavioural therapy (CBT).

Non-Hormonal Treatment Options

• SSRIs/SNRIs: Can alleviate vasomotor symptoms.
• Clonidine/Gabapentin: Alternative for hot flushes.
• Lubricants/Vaginal Oestrogen: For genitourinary symptoms.

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Q4: Susan is considering hormone therapy but is worried about risks. How would you counsel her?

Menopausal Hormone Therapy (MHT) Overview

• Indications: Moderate-severe vasomotor symptoms, osteoporosis prevention.
• Types:
  • Oestrogen-only (if hysterectomy).
  • Combined oestrogen-progestogen (if uterus intact).

Risk-Benefit Discussion

• Benefits:
  • Reduces vasomotor symptoms.
  • Prevents bone loss and osteoporosis-related fractures.
  • May improve mood and sleep.
• Risks:
  • Slight increased risk of breast cancer with long-term use (>5 years).
  • Venous thromboembolism risk (oral formulations).
  • Endometrial cancer risk if unopposed oestrogen in women with a uterus.
• Alternative Options:
  • Non-hormonal therapies for vasomotor symptoms.
  • Vaginal oestrogen for local genitourinary symptoms.

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Q5: What preventive health considerations are relevant for Susan at this stage of life?

Bone Health

• Bone Mineral Density (BMD) testing if risk factors present.
• Calcium and Vitamin D supplementation.
• Weight-bearing exercise for osteoporosis prevention.

Cardiovascular Health

• Monitor blood pressure, cholesterol, and diabetes risk.
• Encourage smoking cessation and regular exercise.

Cancer Screening

• Breast cancer: Mammogram every 2 years (50–74 years).
• Bowel cancer: FOBT every 2 years (50–74 years).
• Cervical cancer: HPV testing every 5 years.

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SUMMARY OF A COMPETENT ANSWER

• Thorough history-taking covering menopausal symptoms, lifestyle, and risk factors.
• Consideration of differential diagnoses, including thyroid dysfunction and mental health conditions.
• Detailed explanation of menopause, symptom management, and lifestyle changes.
• Balanced discussion of hormone therapy risks and benefits, tailored to patient concerns.
• Preventive health measures addressing osteoporosis, cardiovascular disease, and cancer screening.

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PITFALLS

• Failing to inquire about red flag symptoms, such as postmenopausal bleeding.
• Overlooking psychosocial impacts of menopause, such as mood disorders.
• Not considering differential diagnoses such as hyperthyroidism or sleep disorders.
• Providing overly complex explanations of hormone therapy without checking understanding.
• Ignoring lifestyle interventions in menopause management.

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REFERENCES

• RACGP Guidelines on Menopause Management: RACGP Menopause Management
• Jean Hailes for Women’s Health: Menopause Management
• Australian Menopause Society: AMS Guidelines
• Therapeutic Guidelines: Menopause

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

☐ 1.1 Communication is appropriate to the person and the sociocultural context.
☐ 1.2 Engages the patient to gather information about their symptoms, concerns, and expectations.

2. Clinical Information Gathering and Interpretation

☐ 2.1 Takes a targeted history.
☐ 2.2 Considers differential diagnoses.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD