NAMS CERTIFICATION QUESTIONS AND ANSWERS
What are the recommendations for transitioning from OCP to MHT? - Answers -
Individualization is required.
May continue contraception until typical age of menopause (51-52 y) or when 90% of
women reach menopause (55 y).
Can transition from hormone contraception to HT if still symptomatic.
Hot flashes may reappear transiently because birth control has higher hormone
concentrations than HT.
Characterized by hypergonadotropic hypogonadism that can be transient.
Affects 1% of women aged younger than 40 years. - Answers - Primary Ovarian
Insufficiency
Etiology of POI, premature menopause, and early menopause - Answers - Most cases
are idiopathic; however, other etiologies include genetic, autoimmune, iatrogenic,
infectious, and metabolic.
How is ovarian reserve measured? - Answers - Follicle-stimulating hormone (FSH) in
conjunction with estradiol (days 2-5 of menstrual cycle, not taking hormones)
Most common for measuring ovarian reserve.
FSH >10 IU/L + estradiol < 60 pg/mL.
FSH <10 IU/L + estradiol >100 pg/mL.
Also AMH, and AFC but not recommended screening tool
What characterizes early menopause transition? - Answers - Persistent cycle irregularity
by ≥7 d.
Decline in inhibin B and AMH because of reduction in follicles (low AFC).
Diminished ovarian reserve. Lower AMH and inhibin B promotes growth of remaining
follicular pool, accelerating follicular atresia.
Early follicular FSH is variable.
Luteal out-of-phase (LOOP) events occur in about one in four cycles.
May or may not have mild vasomotor symptoms (VMS).
May have pronounced premenstrual syndrome.
What characterizes late menopause transition? - Answers - Amenorrhea > 60 d.
Menstrual cycles have variable cycle length.
Variable estradiol levels with increased prevalence of anovulation.
FSH levels are ≥25 IU/L because of few remaining oocytes.
Negligible AMH and AFC.
LOOP cycles occur in a third of women; VMS and other signs of menopause likely.
What are Luteal out-of-phase events? - Answers - Symptoms from elevated estradiol:
Mastalgia
,Migraine
Menorrhagia
Growth of fibroids
Endometrial hyperplasia
Increased risk of reproductive cancers (especially with longer MT).
Pregnancy can occur, with increased incidence of twins.
Obesity is associated with elevated estradiol concentrations because of aromatization of
androgen to estrogen.
Where are adrenal androgens produced, and what are they? - Answers - Adrenal cortex
produces:
Cortisol (glucocorticoid).
Aldosterone (mineralocorticoid).
Androgens, sex steroids: dehydroepiandrosterone (DHEA), dehydroepiandrosterone
sulfate (DHEAS), androstenedione, testosterone.
Adrenal medulla produces and secretes catecholamines: epinephrine, norepinephrine,
and some dopamine.
Adrenal androgens are enzymatically converted to estrogens in the peripheral tissues.
Although cortisol increases with age, androgens decrease.
How does the HPA axis impact adrenal androgen production during MT? - Answers -
85% of those in the late perimenopause and early menopause experience:
Marked rise in DHEA and androstenediol.
Moderate rise in DHEAS, testosterone, and androstenedione.
Adrenal androgen levels return to premenopause level within 1 to 2 years after FMP.
Marked rise in cortisol is associated with rise in FSH in late perimenopause.
Changes in cortisol patterns associated with mood, sleep, and vasomotor symptoms
(VMS).
What are risk factors for vasomotor symptoms? - Answers - Obesity (or weight gain).
Smoking (tobacco or nicotine).
Low socioeconomic position.
Low education attainment.
High-fat or high-sugar diets.
Race or ethnicity.
Oophorectomy.
Medical comorbidities (thyroid disease, diabetes mellitus [DM], obstructive sleep apnea
[OSA], chronic pain conditions).
High anxiety levels.
, What are other possible reasons for VMS not related to menopause? - Answers -
Thyroid dysfunction, infections, malignancy, pheochromocytoma, and carcinoid
syndrome.
Warning signs that trigger evaluation:
New-onset VMS in late menopause.
Younger women (premenopause or menopause transition) with persistent VMS
accompanied by nausea, vomiting, diarrhea, weight loss, fever, cough, wheezing,
palpitations, tachycardia, flushing, or persistent headache.
What are GSM signs of hypoestrogenism? - Answers - Thinning loss of pubic hair
Thinning or fusion of labia
Clitoral hood retraction or fusion
Posterior fissuring
Introital retraction
Pallor or erythema, petechiae
Loss of rugae
Loss of hymenal remnants
Leukorrhea
pH>5
Loss of vaginal and cervical secretions
Prominence of urethral meatus/caruncle
What are symptoms associated with GSM? - Answers - Vulvovaginal dryness
Vulvovaginal itching, burning, or irritation
Vaginal discharge
Dysuria
Nocturia
Urinary frequency or urgency
Recurrent urinary tract infection
Decreased lubrication/arousal with sexual activity
Pain with introital insertion during sexual activity
Dyspareunia
Decreased or delayed orgasm
Postcoital bleeding
What is the Ddx for GSM? - Answers - Lichen sclerosus, planus, or simplex.
Desquamative inflammatory vaginitis.
Contact dermatitis.
Vulvovaginal candidiasis and vaginitis.
Cicatricial pemphigoid.
Idiopathic overactive bladder.
Detrusor overactivity.
Vulvodynia/Vestibulodynia.
Psychological disorders.
Malignancy and treatments (ie, surgery, chemotherapy, radiation therapy).
What are the recommendations for transitioning from OCP to MHT? - Answers -
Individualization is required.
May continue contraception until typical age of menopause (51-52 y) or when 90% of
women reach menopause (55 y).
Can transition from hormone contraception to HT if still symptomatic.
Hot flashes may reappear transiently because birth control has higher hormone
concentrations than HT.
Characterized by hypergonadotropic hypogonadism that can be transient.
Affects 1% of women aged younger than 40 years. - Answers - Primary Ovarian
Insufficiency
Etiology of POI, premature menopause, and early menopause - Answers - Most cases
are idiopathic; however, other etiologies include genetic, autoimmune, iatrogenic,
infectious, and metabolic.
How is ovarian reserve measured? - Answers - Follicle-stimulating hormone (FSH) in
conjunction with estradiol (days 2-5 of menstrual cycle, not taking hormones)
Most common for measuring ovarian reserve.
FSH >10 IU/L + estradiol < 60 pg/mL.
FSH <10 IU/L + estradiol >100 pg/mL.
Also AMH, and AFC but not recommended screening tool
What characterizes early menopause transition? - Answers - Persistent cycle irregularity
by ≥7 d.
Decline in inhibin B and AMH because of reduction in follicles (low AFC).
Diminished ovarian reserve. Lower AMH and inhibin B promotes growth of remaining
follicular pool, accelerating follicular atresia.
Early follicular FSH is variable.
Luteal out-of-phase (LOOP) events occur in about one in four cycles.
May or may not have mild vasomotor symptoms (VMS).
May have pronounced premenstrual syndrome.
What characterizes late menopause transition? - Answers - Amenorrhea > 60 d.
Menstrual cycles have variable cycle length.
Variable estradiol levels with increased prevalence of anovulation.
FSH levels are ≥25 IU/L because of few remaining oocytes.
Negligible AMH and AFC.
LOOP cycles occur in a third of women; VMS and other signs of menopause likely.
What are Luteal out-of-phase events? - Answers - Symptoms from elevated estradiol:
Mastalgia
,Migraine
Menorrhagia
Growth of fibroids
Endometrial hyperplasia
Increased risk of reproductive cancers (especially with longer MT).
Pregnancy can occur, with increased incidence of twins.
Obesity is associated with elevated estradiol concentrations because of aromatization of
androgen to estrogen.
Where are adrenal androgens produced, and what are they? - Answers - Adrenal cortex
produces:
Cortisol (glucocorticoid).
Aldosterone (mineralocorticoid).
Androgens, sex steroids: dehydroepiandrosterone (DHEA), dehydroepiandrosterone
sulfate (DHEAS), androstenedione, testosterone.
Adrenal medulla produces and secretes catecholamines: epinephrine, norepinephrine,
and some dopamine.
Adrenal androgens are enzymatically converted to estrogens in the peripheral tissues.
Although cortisol increases with age, androgens decrease.
How does the HPA axis impact adrenal androgen production during MT? - Answers -
85% of those in the late perimenopause and early menopause experience:
Marked rise in DHEA and androstenediol.
Moderate rise in DHEAS, testosterone, and androstenedione.
Adrenal androgen levels return to premenopause level within 1 to 2 years after FMP.
Marked rise in cortisol is associated with rise in FSH in late perimenopause.
Changes in cortisol patterns associated with mood, sleep, and vasomotor symptoms
(VMS).
What are risk factors for vasomotor symptoms? - Answers - Obesity (or weight gain).
Smoking (tobacco or nicotine).
Low socioeconomic position.
Low education attainment.
High-fat or high-sugar diets.
Race or ethnicity.
Oophorectomy.
Medical comorbidities (thyroid disease, diabetes mellitus [DM], obstructive sleep apnea
[OSA], chronic pain conditions).
High anxiety levels.
, What are other possible reasons for VMS not related to menopause? - Answers -
Thyroid dysfunction, infections, malignancy, pheochromocytoma, and carcinoid
syndrome.
Warning signs that trigger evaluation:
New-onset VMS in late menopause.
Younger women (premenopause or menopause transition) with persistent VMS
accompanied by nausea, vomiting, diarrhea, weight loss, fever, cough, wheezing,
palpitations, tachycardia, flushing, or persistent headache.
What are GSM signs of hypoestrogenism? - Answers - Thinning loss of pubic hair
Thinning or fusion of labia
Clitoral hood retraction or fusion
Posterior fissuring
Introital retraction
Pallor or erythema, petechiae
Loss of rugae
Loss of hymenal remnants
Leukorrhea
pH>5
Loss of vaginal and cervical secretions
Prominence of urethral meatus/caruncle
What are symptoms associated with GSM? - Answers - Vulvovaginal dryness
Vulvovaginal itching, burning, or irritation
Vaginal discharge
Dysuria
Nocturia
Urinary frequency or urgency
Recurrent urinary tract infection
Decreased lubrication/arousal with sexual activity
Pain with introital insertion during sexual activity
Dyspareunia
Decreased or delayed orgasm
Postcoital bleeding
What is the Ddx for GSM? - Answers - Lichen sclerosus, planus, or simplex.
Desquamative inflammatory vaginitis.
Contact dermatitis.
Vulvovaginal candidiasis and vaginitis.
Cicatricial pemphigoid.
Idiopathic overactive bladder.
Detrusor overactivity.
Vulvodynia/Vestibulodynia.
Psychological disorders.
Malignancy and treatments (ie, surgery, chemotherapy, radiation therapy).
