NAMS MENOPAUSE CERTIFICATION EXAM
QUESTIONS AND ANSWERS
The period of endrocrinologic, somatic, and transitory psychologic changes that occur
around the time of menopause. - Answers - climacteric phase
Perimenopause Menopause Transition, Early
List the STRAW Stage
What defines the phase? - Answers - STRAW Stage: (Stage -2)
Persistent difference of 7 days or more in the length of consecutive cycles.
Perimenopause Menopause Transition, Late
List the STRAW Stage
What defines the phase? - Answers - STRAW Stage: (Stage -1)
60 or more consecutive days of amenorrhea
Luteal out of phase event (LOOP) - Answers - Explains why some perimenopausal
women have elevated estrogen level sometimes...In the early menopause transition,
elevated FSH levels are adequate to recruit a second follicle which results in a follicular
phase-like rise in estradiol secretion superimposed on the mid-to-late luteal phase of the
ongoing ovulatory cycle.
Describe the E2 level during the life of a patient with obesity. - Answers - They are also
more likely to have lower premenopause/perimenopausal estradiol levels compared to
patients with average BMIs. However, the level is the highest in postmenopausal
patients with obesity.
In comparison to other ethnicities, Chinese and Japanese women have ___ E2 levels? -
Answers - These ethnic groups have lower estradiol levels than white, black and
hispanic women.
STRAW Stage +2, describe the timeline as well as the predominant symptoms. -
Answers - Postmenopause, Late. (Remaining Lifespan) 5-8 years after FMP. Somatic
aging predominates. Increased genitourinary symptoms.
Stages +1a, +1b, +1c, describe the timeline as well as the supportive criteria and the
symptoms. - Answers - Postmenopause, Early. 2 years after FMP.
+1a/b (2yrs) FSH variable where as the AMH and InhB are low. The AFC are very low.
VMS predominate.
1c (3-6yrs) FSH levels stabilize. The other measures continue as previous.
Elevated FSH, LH - Answers - Endocrine labs after menopause
,AMH, Inhibin B - Answers - These hormones work during reproductive years to not
deplete follicle pool too quickly.
Describe the phases during the early menopause transition and what happens with
PMS symptoms - Answers - Menstrual cycle shortens. Due to unrestrained FSH,
follicular phase compresses. More premenstrual symptoms due to the longer luteal
phase. Cycle irregularity and skipped cycles because of ovulatory failure and increased
atresia.
How to respond if a patient requests FSH lab? - Answers - many pitfalls, variable
depending on the day of the cycle you draw the lab, normal or low FSH is not helpful.
What lab is potentially the superior marker of time to menopause? - Answers - AMH
DHEA (dehydroepiandrosterone) - Answers - Adrenal androgens: precursor hromones
produced by the adrenal gland that are enzymatically converted to active androgens or
estrogens in peripheral tissues.
Location of GU estrogen receptors (4) - Answers - Vagina, vulva, urethra, trigone of the
bladder
List the effects of estrogen on tissue (4+2) - Answers - 1 ) maintains blood flow to
tissue, maintains the collagen within the epithelium, and maintains the hyaluronic acid
and mucopolysaccharides within the moistened epithelial surface, maintains pH (4.5) 2)
supports microbiome and protects tissue from pathogens
List the vaginal changes with menopause you might note on clinical/microscopic exam. -
Answers - Thinning of the epithelial layer, loss of elasticity with narrowing of the canal
and poor distention, noted on pelvic exam with loss or absence or rugae. Due to the
decrease in glycogen content, the lactobacilli are decreased resulting in higher pH.
List the vulvar and urethral changes in menopause. - Answers - Thinning of the
epithelial layers and vagina narrowing leads the urethra to move closer to the introitus.
Stress urinary incontinence - Answers - Vaginal estrogen and urinary incontinence:
what type does it help with?
Treatment for FPHL - Answers - Minoxidil, spironolactone, finasteride, estrogen therapy
Late reporoductive years -3b and -3a. What happens with menstrual cycles, FSH, AMH,
AFC, inhibin? - Answers - -3b: menstrual cycles normal, FSH normal, AMH low, AFC
low, inhibin low.
-3a: subtle menstrual changes, variable FSH, AMH low, AFC low, inhibin low.
, When it is appropriate to check an FSH during the cycle if you check it? and why? -
Answers - Cycle day #3. Elevated estradiol can suppress FSH giving a falsely normal
FSH level.
AMH
produced by...
used to test...
Is it a screening tool for fertility?
When does it peak? - Answers - produced by granulosa cells
used to test damage to ovarian follicle reserve. If AMH is low, the woman has a low
ovarian reserve.
not recommended as a screening tool to predict fertility.
Peaks at around 25 years old. So before age 25, this test is not helpful.
It is influenced by exogenous hormones. Lower in hormonal contraception users, but
increases after d/cing.
What does AFC stand for? What is considered a normal value? - Answers - Antral
Follicle Count
> 12 follicles detectable with ultrasound is considered normal
What is the significance of antral follicle count? - Answers - The ability of the ovaries to
respond. It can represent the number of follicles detectable with ultrasound. It is
sensitive to FSH, and represents the available pool of follicles.
What is the FSH level on a random draw in Late menopause transition (STRAW Stage:
-1)? - Answers - 25 IU/L or higher
Black women have higher or lower FSH levels? - Answers - Higher
Chinese and Japanese women have higher or lower estradiol levels compared to white,
black and hispanic women? - Answers - Lower
What happens to SHBG during menopause? How does that effect the free androgen
index? - Answers - SHBG decreases.
Testosterone/SHBG ratio increases by 80%.
Testosterone:SHGB ratio is called what? - Answers - The free androgen index
What stage are VMS more likely? - Answers - +1b (generally last 2 years)
What hormone is generally higher in obese women? - Answers - Estrone-via
aromatization.
QUESTIONS AND ANSWERS
The period of endrocrinologic, somatic, and transitory psychologic changes that occur
around the time of menopause. - Answers - climacteric phase
Perimenopause Menopause Transition, Early
List the STRAW Stage
What defines the phase? - Answers - STRAW Stage: (Stage -2)
Persistent difference of 7 days or more in the length of consecutive cycles.
Perimenopause Menopause Transition, Late
List the STRAW Stage
What defines the phase? - Answers - STRAW Stage: (Stage -1)
60 or more consecutive days of amenorrhea
Luteal out of phase event (LOOP) - Answers - Explains why some perimenopausal
women have elevated estrogen level sometimes...In the early menopause transition,
elevated FSH levels are adequate to recruit a second follicle which results in a follicular
phase-like rise in estradiol secretion superimposed on the mid-to-late luteal phase of the
ongoing ovulatory cycle.
Describe the E2 level during the life of a patient with obesity. - Answers - They are also
more likely to have lower premenopause/perimenopausal estradiol levels compared to
patients with average BMIs. However, the level is the highest in postmenopausal
patients with obesity.
In comparison to other ethnicities, Chinese and Japanese women have ___ E2 levels? -
Answers - These ethnic groups have lower estradiol levels than white, black and
hispanic women.
STRAW Stage +2, describe the timeline as well as the predominant symptoms. -
Answers - Postmenopause, Late. (Remaining Lifespan) 5-8 years after FMP. Somatic
aging predominates. Increased genitourinary symptoms.
Stages +1a, +1b, +1c, describe the timeline as well as the supportive criteria and the
symptoms. - Answers - Postmenopause, Early. 2 years after FMP.
+1a/b (2yrs) FSH variable where as the AMH and InhB are low. The AFC are very low.
VMS predominate.
1c (3-6yrs) FSH levels stabilize. The other measures continue as previous.
Elevated FSH, LH - Answers - Endocrine labs after menopause
,AMH, Inhibin B - Answers - These hormones work during reproductive years to not
deplete follicle pool too quickly.
Describe the phases during the early menopause transition and what happens with
PMS symptoms - Answers - Menstrual cycle shortens. Due to unrestrained FSH,
follicular phase compresses. More premenstrual symptoms due to the longer luteal
phase. Cycle irregularity and skipped cycles because of ovulatory failure and increased
atresia.
How to respond if a patient requests FSH lab? - Answers - many pitfalls, variable
depending on the day of the cycle you draw the lab, normal or low FSH is not helpful.
What lab is potentially the superior marker of time to menopause? - Answers - AMH
DHEA (dehydroepiandrosterone) - Answers - Adrenal androgens: precursor hromones
produced by the adrenal gland that are enzymatically converted to active androgens or
estrogens in peripheral tissues.
Location of GU estrogen receptors (4) - Answers - Vagina, vulva, urethra, trigone of the
bladder
List the effects of estrogen on tissue (4+2) - Answers - 1 ) maintains blood flow to
tissue, maintains the collagen within the epithelium, and maintains the hyaluronic acid
and mucopolysaccharides within the moistened epithelial surface, maintains pH (4.5) 2)
supports microbiome and protects tissue from pathogens
List the vaginal changes with menopause you might note on clinical/microscopic exam. -
Answers - Thinning of the epithelial layer, loss of elasticity with narrowing of the canal
and poor distention, noted on pelvic exam with loss or absence or rugae. Due to the
decrease in glycogen content, the lactobacilli are decreased resulting in higher pH.
List the vulvar and urethral changes in menopause. - Answers - Thinning of the
epithelial layers and vagina narrowing leads the urethra to move closer to the introitus.
Stress urinary incontinence - Answers - Vaginal estrogen and urinary incontinence:
what type does it help with?
Treatment for FPHL - Answers - Minoxidil, spironolactone, finasteride, estrogen therapy
Late reporoductive years -3b and -3a. What happens with menstrual cycles, FSH, AMH,
AFC, inhibin? - Answers - -3b: menstrual cycles normal, FSH normal, AMH low, AFC
low, inhibin low.
-3a: subtle menstrual changes, variable FSH, AMH low, AFC low, inhibin low.
, When it is appropriate to check an FSH during the cycle if you check it? and why? -
Answers - Cycle day #3. Elevated estradiol can suppress FSH giving a falsely normal
FSH level.
AMH
produced by...
used to test...
Is it a screening tool for fertility?
When does it peak? - Answers - produced by granulosa cells
used to test damage to ovarian follicle reserve. If AMH is low, the woman has a low
ovarian reserve.
not recommended as a screening tool to predict fertility.
Peaks at around 25 years old. So before age 25, this test is not helpful.
It is influenced by exogenous hormones. Lower in hormonal contraception users, but
increases after d/cing.
What does AFC stand for? What is considered a normal value? - Answers - Antral
Follicle Count
> 12 follicles detectable with ultrasound is considered normal
What is the significance of antral follicle count? - Answers - The ability of the ovaries to
respond. It can represent the number of follicles detectable with ultrasound. It is
sensitive to FSH, and represents the available pool of follicles.
What is the FSH level on a random draw in Late menopause transition (STRAW Stage:
-1)? - Answers - 25 IU/L or higher
Black women have higher or lower FSH levels? - Answers - Higher
Chinese and Japanese women have higher or lower estradiol levels compared to white,
black and hispanic women? - Answers - Lower
What happens to SHBG during menopause? How does that effect the free androgen
index? - Answers - SHBG decreases.
Testosterone/SHBG ratio increases by 80%.
Testosterone:SHGB ratio is called what? - Answers - The free androgen index
What stage are VMS more likely? - Answers - +1b (generally last 2 years)
What hormone is generally higher in obese women? - Answers - Estrone-via
aromatization.
