2024 NAMS MENOPAUSE
CERTIFICATION EXAM QUESTIONS
WITH ANSWERS
Climacteric phase
The period of endrocrinologic, somatic, and transitory psychologic changes that occur around
the time of menopause.
Early menopause
LMP before age 45
Late menopause
LMP after age 54
Primary ovarian insufficiency
Menopause that occurs before age 40
Early menopause transition (stage -2)
Persistent difference of 7 days or more in the length of consecutive cycles.
Late menopause transition (stage -1)
60 or more consecutive days of amenorrhea
Luteal out of phase event (LOOP)
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.
Obese women and estradiol levels during menopause
Obese women are more likely to have anovulatory cycles with high estradiol levels. They are
also more likely to have lower premenopause yet higher postmenopause estradiol levels
compared with women of normal weight. (why they are at higher risk of endometrial cancer)
Chinese and Japanese women
These ethnic groups have lower estradiol levels then white, black and hispanic women.
stage +2
late menopause stage: 5-8 years after FMP. Somatic aging predominates. Increased
genitourinary symptoms.
Stages +1a, +1b, +1c
early post menopause: 2 years after FMP. FSH rises, estradiol decreases. VMS predominate.
Elevated FSH, LH
Endocrine labs after menopause
AMH, inhibin B
These hormones work during reproductive years to not deplete follicle pool too quickly.
Phases during menopause transition and PMS symptoms
Menstrual cycle variable, persistent >7 day difference between difference in length of
consecutive cycles.
How to respond if a patient requests FSH lab?
,many pitfalls, variable depending on the day of the cycle you draw the lab, normal or low FSH is
not helpful.
The potentially superior marker of menopause, a lab.
AMH
DHEA (dehydroepiandrosterone)
Adrenal androgens: precursor hromones produced by the adrenal gland that are enzymatically
converted to active androgens or estrogens in peripheral tissues.
Location of estrogen receptors
Vagina, vulva, urethra, trigone of the bladder
Effects of estrogen on tissue
maintain blood flow, the collagen, and HA within the epithelial surfaces. Supports microbiome
which supports acidity of vagina and protects tissue from pathogens.
Vaginal changes with menopause
Thinning, loss of elasticity, loss or absence or rugae.
Vagina and urethra in menopause
vagina narrows, urethra moves closer to the introitus.
Stress urinary incontinence
Vaginal estrogen and urinary incontinence: what type does it help with?
Treatment for FPHL
Minoxidil, spironolactone, finasteride, estrogen therapy
Late reporoductive years -3b and -3a. What happens with menstrual cycles, FSH, AMH, AFC,
inhibin?
-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?
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?
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.
AFC
, Antral follicle count
Number of follicles that are detectable with ultrasound.
They are sensitive to FSH and considered to represent the availability pool of follicles.
Late menopause transition (-1) FSH level on random draw
25 or higher
Black women have higher or lower FSH levels?
Higher
Chinese and Japanese women have higher or lower estradiol levels compared to white, black
and hispanic women?
lower
Menopause transition-changes in SHBG and testosterone? ratio?
SHBG decreases
Testosterone/SHBG ratio increases by 80%.
Testosterone/SHGB ratio is called what?
The free androgen index
What stage are VMS more likely?
+1b (generally last 2 years)
What hormone is generally higher in obese women?
Estrone-via aromatization.
The postmenopausal ovary continues to produce what two hormones?
testosterone and androstenedione
Surgical menopause causes women to have lower levels of what hormone?
testosterone. 40-50% lower than in women w/ intact ovaries.
Driving piece of menopause is ovarian follicles depleting. What does this do to the inhibin B
and AMH?
inhibin and AMH decrease
therefore, follicle growth is not restrained, this allows for the growth of the remaining,
diminished follicle pool.
In the menopause transition, women spend more time in what phase?
Luteal-more PMS symptoms, more frequent menstrual periods.
HPO axis theory and the menopause transition
It is felt that the HPO axis may become less sensitive to estrogen, so even with good follicle
growth and estradiol secretion, LH surges can fail which can lead to more cycle irregularity.
In the first year after the FMP, there is no production of what hormone?
progesterone
What region of the adrenal gland secretes the androgens?
zona reticularis
what are considered the 'adrenal androgens'?
DHEA, DHEAS, Androstenedione.
Aldosterone secretion from the zona reticularis in the adrenal gland is regulated by 3 main
factors.
Angiotensin II, potassium concentration, adrenocorticotropic hormone secreted by the anterior
pituitary.
CERTIFICATION EXAM QUESTIONS
WITH ANSWERS
Climacteric phase
The period of endrocrinologic, somatic, and transitory psychologic changes that occur around
the time of menopause.
Early menopause
LMP before age 45
Late menopause
LMP after age 54
Primary ovarian insufficiency
Menopause that occurs before age 40
Early menopause transition (stage -2)
Persistent difference of 7 days or more in the length of consecutive cycles.
Late menopause transition (stage -1)
60 or more consecutive days of amenorrhea
Luteal out of phase event (LOOP)
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.
Obese women and estradiol levels during menopause
Obese women are more likely to have anovulatory cycles with high estradiol levels. They are
also more likely to have lower premenopause yet higher postmenopause estradiol levels
compared with women of normal weight. (why they are at higher risk of endometrial cancer)
Chinese and Japanese women
These ethnic groups have lower estradiol levels then white, black and hispanic women.
stage +2
late menopause stage: 5-8 years after FMP. Somatic aging predominates. Increased
genitourinary symptoms.
Stages +1a, +1b, +1c
early post menopause: 2 years after FMP. FSH rises, estradiol decreases. VMS predominate.
Elevated FSH, LH
Endocrine labs after menopause
AMH, inhibin B
These hormones work during reproductive years to not deplete follicle pool too quickly.
Phases during menopause transition and PMS symptoms
Menstrual cycle variable, persistent >7 day difference between difference in length of
consecutive cycles.
How to respond if a patient requests FSH lab?
,many pitfalls, variable depending on the day of the cycle you draw the lab, normal or low FSH is
not helpful.
The potentially superior marker of menopause, a lab.
AMH
DHEA (dehydroepiandrosterone)
Adrenal androgens: precursor hromones produced by the adrenal gland that are enzymatically
converted to active androgens or estrogens in peripheral tissues.
Location of estrogen receptors
Vagina, vulva, urethra, trigone of the bladder
Effects of estrogen on tissue
maintain blood flow, the collagen, and HA within the epithelial surfaces. Supports microbiome
which supports acidity of vagina and protects tissue from pathogens.
Vaginal changes with menopause
Thinning, loss of elasticity, loss or absence or rugae.
Vagina and urethra in menopause
vagina narrows, urethra moves closer to the introitus.
Stress urinary incontinence
Vaginal estrogen and urinary incontinence: what type does it help with?
Treatment for FPHL
Minoxidil, spironolactone, finasteride, estrogen therapy
Late reporoductive years -3b and -3a. What happens with menstrual cycles, FSH, AMH, AFC,
inhibin?
-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?
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?
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.
AFC
, Antral follicle count
Number of follicles that are detectable with ultrasound.
They are sensitive to FSH and considered to represent the availability pool of follicles.
Late menopause transition (-1) FSH level on random draw
25 or higher
Black women have higher or lower FSH levels?
Higher
Chinese and Japanese women have higher or lower estradiol levels compared to white, black
and hispanic women?
lower
Menopause transition-changes in SHBG and testosterone? ratio?
SHBG decreases
Testosterone/SHBG ratio increases by 80%.
Testosterone/SHGB ratio is called what?
The free androgen index
What stage are VMS more likely?
+1b (generally last 2 years)
What hormone is generally higher in obese women?
Estrone-via aromatization.
The postmenopausal ovary continues to produce what two hormones?
testosterone and androstenedione
Surgical menopause causes women to have lower levels of what hormone?
testosterone. 40-50% lower than in women w/ intact ovaries.
Driving piece of menopause is ovarian follicles depleting. What does this do to the inhibin B
and AMH?
inhibin and AMH decrease
therefore, follicle growth is not restrained, this allows for the growth of the remaining,
diminished follicle pool.
In the menopause transition, women spend more time in what phase?
Luteal-more PMS symptoms, more frequent menstrual periods.
HPO axis theory and the menopause transition
It is felt that the HPO axis may become less sensitive to estrogen, so even with good follicle
growth and estradiol secretion, LH surges can fail which can lead to more cycle irregularity.
In the first year after the FMP, there is no production of what hormone?
progesterone
What region of the adrenal gland secretes the androgens?
zona reticularis
what are considered the 'adrenal androgens'?
DHEA, DHEAS, Androstenedione.
Aldosterone secretion from the zona reticularis in the adrenal gland is regulated by 3 main
factors.
Angiotensin II, potassium concentration, adrenocorticotropic hormone secreted by the anterior
pituitary.
