LATEST NAMS MENOPAUSE CERTIFICATION EXAM QUESTIONS WITH VERIFIED CORRECT ANSWERS

LATEST NAMS MENOPAUSE CERTIFICATION EXAM QUESTIONS WITH VERIFIED CORRECT ANSWERS “Climacteric phase - CORRECT ANSWER The period of endrocrinologic, somatic, and transitory psychologic changes that occur around the time of menopause." "Perimenopause Menopause Transition, Early List the STRAW Stage What defines the phase? - CORRECT ANSWER 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? - CORRECT ANSWER STRAW Stage: (Stage -1) 60 or more consecutive days of amenorrhea" "Location of GU estrogen receptors (4) - CORRECT ANSWER Vagina, vulva, urethra, trigone of the bladder" "List the effects of estrogen on tissue (4+2) - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER Thinning of the epithelial layers and vagina narrowing leads the urethra to move closer to the introitus." "Stress urinary incontinence - CORRECT ANSWER Vaginal estrogen and urinary incontinence: what type does it help with?" "Treatment for FPHL - CORRECT ANSWER Minoxidil, spironolactone, finasteride, estrogen therapy" "Late reporoductive years -3b and -3a. What happens with menstrual cycles, FSH, AMH, AFC, inhibin? - CORRECT ANSWER -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? - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER Antral Follicle Count 12 follicles detectable with ultrasound is considered normal" "What is the significance of antral follicle count? - CORRECT ANSWER 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." "Aldosterone secretion from the zona glomerulosa in the adrenal gland is regulated by 3 main factors: - CORRECT ANSWER Angiotensin II (RAAS), Potassium Concentration, ACTH secreted by the anterior pituitary." "What part of the pituitary gland secretes adrenocorticotropic hormone? - CORRECT ANSWER Anterior pituitary. The posterior only secretes vasopressin and oxytosin." "Cortisol and HRT - CORRECT ANSWER Most serum cortisol circulates bound to cortisol binding globulin. Oral estrogen increases the cortisol binding globulin, which increases total cortisol concentration. Oral tamoxifen acts similarly. Transdermal does not increase it, so it has a minimal effect on serum cortisol concentration." "Do cortisol levels associate with VMS severity? - CORRECT ANSWER No, cortisol levels have NOT been associated with more severe VMS." "Local DHEA has been proven to help with what? Is routine use recommended? - CORRECT ANSWER Vaginal pain and dyspareunia. Although, routine DHEA use in postmenopausal women is not recommended." "Hair loss. Difference between FPHL and telogen effluvium? - CORRECT ANSWER FPHL is gradual loss felt to be due to the altered estrogen:androgen ratio. Telogen effluvium is a sudden shedding felt to be due to a disruption of the hair cycle often following several months after a life stressor, chronic illness, beta blockers or anticoagulants-usually more patchy hair loss." "Describe the FPHL pattern. - CORRECT ANSWER Thinning at the crown of the head and widening of the hair part." "Treating FPHL - CORRECT ANSWER MINOXIDIL (only FDA approved option) Spironolactone/Finasteride (NOT FDA approved) Ketoconazole shampoo / Antidandruff shampoo" "What is differentiated VIN and what is its association? - CORRECT ANSWER Differentiated VIN is associated with vulvar cancers and may require wide local excision due to the high risk of invasive carcinoma." "What is the most common type of vulvar cancer? - CORRECT ANSWER Squamous cell carcinoma (SCC)" "Vulvar disorder commonly misdiagnosed as eczema or dermatitis? What treatment will likely fail? What other conditions should you evaluate for? - CORRECT ANSWER Paget's disease Will not improve on steroids Screen for co-existing breast, GI or GU cancer. They are present 20-30% of the time." "Normal PVR. Abnormal PVR. - CORRECT ANSWER 100mL 200mL Between 100-200mL consider repeat testing on alternative day." "effect of HRT on cognition - CORRECT ANSWER small or no overall effect on cognition" "What HRT can increase your risk for dementia based on the WHIMS study in 65+ year old healthy women? - CORRECT ANSWER EPT replacement was shown to double the risk of developing dementia. There was no significant increased risk in ET alone. This is why HRT is not recommended after 65 for primary prevention of dementia." "3 reasons supporting the idea that HRT in early menopause may decrease a woman's chance of developing alzheimer's disease? - CORRECT ANSWER 1. Observational studies imply it 2. Clinical trial of transdermal estradiol during the early postmenopause stage is associated with reductions in AD pathology. 3. 18 year cumulative follow up data from WHI found that women randomized to ET had significantly lower risk of dying from AD or dementia compared with women randomized to receive placebo." "Migraine headache and pregnancy - CORRECT ANSWER typically migraines improve-estrogen levels stabilize" "Migraine without aura after menopause - CORRECT ANSWER usually decrease with natural menopause" "menstrual migraine after menopause - CORRECT ANSWER should resolve completely" "When to consider preventative medication for migraines - CORRECT ANSWER 2 times per week or severe and effecting QOL" "What is the most commonly sexually transmitted infection in the US? - CORRECT ANSWER HPV" "What percentage of bone loss do women have from the menopause transition? - CORRECT ANSWER 10-12% on average, about 1 t score" "What T-score defines osteopenia? - CORRECT ANSWER -1.5 to -2.5" "What T-score defines osteoporosis? - CORRECT ANSWER -2.5" "What Z-score defines osteoporosis? When is Z-score used? - CORRECT ANSWER Z-score 2.0 and a history of a fragility fracture, used in premenopausal women." "What races are at highest risk of osteoporosis? - CORRECT ANSWER White and hispanic populations" "What amount of women require long term care after hip fracture? What amount of women have long term loss of mobility after hip fracture? - CORRECT ANSWER 1 in 4 women (25%) require long term care 1 in 2 woemn (50%) have long term loss of mobility" "Asians have ____BMD than white people? - CORRECT ANSWER lower" "Black women have ____BMD than white people? - CORRECT ANSWER higher" "Over 3 servings of alcohol daily increases the risk for fracture by how much? - CORRECT ANSWER 38% for osteoporotic fracture and 68% for hip fracture" "What 4 ethnic specific versions of FRAX are there? - CORRECT ANSWER white, asiain, black, hispanic" "Dairy free diet amount of calicum. How much do they need to supplement? - CORRECT ANSWER dairy free diet-300mg calcium daily. Needs 800-1200mg" "Tibolone is used to treat ___? Where is it approved? Why wasn't it submitted for approval in the US and Canada? - CORRECT ANSWER Osteoporosis Approved in Mexico with decreased risk of vertebral and nonvertebral fractures noted. Increased risk of stroke" "Nontraditional Symptoms of Menopause (4) - CORRECT ANSWER Cognitive concerns Joint pain Dry eyes Change in weight distribution" "D3 FSH is helpful, when? - CORRECT ANSWER Only if elevated 10" "D3 E2 normal value? And what does it do in perimenopause? - CORRECT ANSWER 80pg/mL is considered a normal E2 level; in perimenopause it increases" "Describe the phases of the STRAW (Stage: -1) Late transition - CORRECT ANSWER The number of remaining oocytes drop below a critical level with sporadic follicular development resulting in sporadic ovulation. Lower progesterone levels are noted. Follicular development eventually stops which results in estradiol deficiency." "List the ethnic prevalence of POI in order from greatest to least for patients that are white, black, hispanic, Japanese, & Chinese. - CORRECT ANSWER Black/Hispanic 1.4%, White 1%, Chinese 0.5%, and Japanese 0.1%." "Alternative/Investigative therapy for VMS (9): - CORRECT ANSWER Gabapentin, Clonidine, Oxybutynin, Neurokinin B antagonists, lifestyle modifications, dietary management, CBT, hypnosis, weight loss" "Initiate HT at what age? - CORRECT ANSWER Before the age of 60 or within 10 years of menopause onset for the treatment of VMS." "DHEA is only FDA approved for what concern? What dose? - CORRECT ANSWER 0.5%/6.5mg vaginal suppository for severe dyspareunia 2/2 VVA" "Ospemifene -Drug Class and Dose -Indication -MC AE -Favorable effects on? - CORRECT ANSWER -SERM (ERAA) -FDA approved for moderate to severe dyspareunia associated with VVA at 60mg orally. -Improves vaginal maturation index, pH, and symptoms of VVA. -MC AE is increased VMS and potential risk of VTE. -Favorable effects on bone!" "Describe the difference in lichen sclerosus and lichen planus. - CORRECT ANSWER The main difference between the two conditions is that LP has a propensity to involve the mucous membranes including the mouth and vagina which are rarely affected in LS." "How does lichen sclerosus and lichen planus appear? - CORRECT ANSWER As white plaques and papules or as erosive-appearing ulcerations, sometimes with fissuring." "How do you diagnose LS or LP? And what is the treatment recommended? - CORRECT ANSWER Diagnosed by biopsy and treatment is with high-potency topical steroids." "Vulvar Masses: Condyloma acuminatum are caused by what? How is it treated? - CORRECT ANSWER Condyloma acuminatum is caused by HPV infection. Treated with topical agents such as trichloroacetic acid, podophyllin, or imiquimod. If extensive, consider laser or excision with GYN ONC." "What are less common masses of the vulva? (5) - CORRECT ANSWER Hidradenomas, lipomas, fibromas, syringomas, and schwannomas." "What are the changes in the female that cause increased risk of postmenopausal UTI? - CORRECT ANSWER Increase in vaginal pH and changes in the microbiome." "What are additional risk factors, external to the postmenopausal changes, that increase a woman's risk of UTI? (4) - CORRECT ANSWER DM, incontinence, prolapse, increased PVR" "Why might you consider vaginal estrogen, after antibiotics for UTI in postmenopausal women? - CORRECT ANSWER Vaginal estrogen restore pH, increases lactobacilli, and may improve immune response." "True or False? The WHI observational study revealed no increased risk of endometrial cancer, breast cancer, or CVD with vaginal ET use. - CORRECT ANSWER TRUE. No increased risk noted for vaginal ET use." "Estradiol ring is FDA approved for the treatment of, what? - CORRECT ANSWER Urinary Urgency" "CE and estradiol are approved for the treatment of VVA and dyspareunia. What are the approved doses? - CORRECT ANSWER CE VVA: 0.5-2g/day (21d on / 7d off) dyspareunia: 0.5g/twice weekly or 0.5g/day (21d on / 7d off) 17β-estradiol cream VVA 2-4g/day for 1-2wks; then 1g 3x/wk" "In women with HT contraindications, which treatment is generally preferred, and why? - CORRECT ANSWER Estradiol vaginal tablets or low-dose estradiol vaginal rings are generally preferred to the use of creams because of their fixed-dosing and lack of significant systemic absorption." "Due to the theoretical risk of endometrial hyperplasia from local absorption of low-dose vaginal ET, in which patients would you consider addition of progestogen? - CORRECT ANSWER Obese patients. Generally, progestogens are not indicated." "PALM-COEIN - CORRECT ANSWER P: Polyp A: Adenomyosis L: Leiomyoma M: Malignancy/hyperplasia C: Coagulopathy O: ovulatory dysfunction E: Endometrial I: Iatrogenic N: Not yet classified" "Female Sexual Dysfunction is separated into what (3) categories in DSMV? - CORRECT ANSWER Desire/Arousal: FSIAD Pain: Genito-Pelvic Pain/Penetration Disorder Orgasm: Female Orgasmic Disorder" "Treatments for FSD - CORRECT ANSWER Psychotherapy Pharmacotherapy (low-dose vaginal estrogen) Vibrator Therapy PFPT Flibanserin Bremelanotide Testosterone** (Off-label)" "Hormone Effects on Vaginal Tissue - CORRECT ANSWER Enhances skin sensation. Also increases vaginal lubrication and elasticity." "What is the Global Concensus Position Statement on Testosterone for HSDD - CORRECT ANSWER Testosterone significantly increases sexual function (frequency, desire, arousal, orgasm, and responsiveness) and self image. No adverse effects with physiological testosterone use." "Name the pelvic floor muscles - CORRECT ANSWER Levator ani muscle groups: -superficial: transverse perineal, bulbospongiosus, ischiocavernosus -deep: pubococcygeus, iliococcygeus, obturator internus, coccygeus" "List important risk factors for OA. - CORRECT ANSWER Obesity, female, congenital joint abnormality or deformity, joint injuries, occupational factors associated with joint overuse, and family history (approximately 50% of disease risk is genetic)" "Most studies suggest estrogen ____ clinical response to antidepressants like SSRIs and SNRIs. - CORRECT ANSWER Augments." "In the Thyroid Studies Collaboration, subclinical hypothyroidism was associated with a 2-fold increase in what? At what level? - CORRECT ANSWER CHD events and mortality, but only if the TSH level was elevated above 10mIU/L" "In the Study of Osteoporotic Fractures, women aged 65y with suppressed TSH levels 0.1mIU/L were associated with what? - CORRECT ANSWER 3-fold increase in hip fracture and a 4-fold increase in vertebral fractures" "Describe the affects estrogen has on the thyroid gland and hormones. - CORRECT ANSWER Oral estrogens increase thyroid binding globulin and total T4. Estrogen does not affect free T4, but can limit the conversion to free T3 which in turn reduces the levels of free T4. Estrogen can also increase thyroglobulin production leading to goiter, or deficiency of estrogen can lead to decreased thyroid function." "What's the most common CURABLE STI in sexually active women? Treatment options. - CORRECT ANSWER Vaginal trichomoniasis; treated with metronidazole or tinidazole single dose, orally" "What are the BMD Testing Recommendations? - CORRECT ANSWER USPSTF: -All women 65yoa -Women 65yoa if FRAX score for 10y risk is 8.4% -Perimenopausal women at high risk for fracture" "When is drug therapy needed for osteoporosis? - CORRECT ANSWER History of vertebral, hip, fragility, or other low-trauma fracture. T-score -2.5 10y FRAX 20% or hip fracture risk 3%" "What ages is the FRAX risk assessment appropriate for? - CORRECT ANSWER Postmenopausal women aged 40-90y" "What is the appropriate dose of Vit D and Calcium for PRIMARY PREVENTION OF FRACTURE? - CORRECT ANSWER Vit D 400IU and Calcium 1000mg" "After 5yrs of bisphosphonate therapy in high-risk women, what additional treatment(s) should you consider and why? - CORRECT ANSWER Denosumab (RANK ligand inhibitor) for the additional gains in BMD. Similarly, switching from bisphosphonate to teraparatide (PTH receptor agonist) results in additional gains in spine BMD and hip." "What is the single most important preventable risk factor for CVD in women? - CORRECT ANSWER Smoking. A woman who smokes is 2-6x more likely to have a heart attack than a woman who does not smoke." "Does the AHA or NAMS recommend HT for the primary or secondary prevention of CVD? - CORRECT ANSWER NO." "According to AHA, what are the four initial drug classes for management of HTN, in adults who do not have a compelling need for a specific BP-lowering medication? - CORRECT ANSWER Thiazide diuretics, CCB, ARBs, ACE-i" "What is the dose recommendations for high-intensity statin therapy for atorvastatin and rosuvastatin? - CORRECT ANSWER Atorvastatin (40)-80mg Rosuvastatin (20)-40mg" "Metabolic syndrome is also associated with what (3) conditions? - CORRECT ANSWER Steatohepatitis, CKD, and PCOS" "LADA (latent autoimmune diabetes of adulthood) can be diagnosed by measuring what two antibodies? - CORRECT ANSWER Anti-glutamic acid decarboxylase antibody and zinc transporter-8" "In the WHI, women receiving HT had a ____ % reduction in the development of ____. This was also seen in a USPSTF systematic review. - CORRECT ANSWER 14-19% reduction in the development of DM in postmenopausal women treated with HT." "Is it recommended to use HT to reduce risk of MetS or DM? - CORRECT ANSWER No, it is not recommended." "What diabetic medications reduce CVD risk in persons with known CVD? - CORRECT ANSWER empaglifozin (Jardiance) & canagliflozin (Invokana) liraglutide (Victoza) & semaglutide (Ozempic)" "FDA defines food as: - CORRECT ANSWER food or drink for man or animal; chewing gum; articles used for components of such item" "FDA defines drug as: - CORRECT ANSWER articles recognized in teh US pharmacopeia, homeopathic pharmacopeia, or national formulary; articles intended for use in the diagnosis, cure, and mitigation, treatment, and prevention of disease in man or animal; articles (OTHER THAN FOOD) intended to affect the structure/function of the body of man or animal" "DSHEA - CORRECT ANSWER Dietary Supplement Health & Education Act" "DSHEA and FDA, who is responsible for substantiating claims? - CORRECT ANSWER DSHEA does not prevent the FDA from determining a dietary supplement is a drug, but it does restrict the power of the FDA to regulate the quality of dietary supplements and limits intervention when a potential safety issue arises. The manufacturer is responsible for substantiating claims about their product with adequate evidence to show they are not false or misleading." "In the US, what is a good QC indicator in manufacturing regarding dietary supplements? - CORRECT ANSWER USP and NSF (national sanitation foundation)" "Which dietary supplement & vitamin are not recommended by the USPSTF based on their increased cardiovascular and cancer risks? - CORRECT ANSWER beta-carotene and Vit E" "Mediterranean diet is associated with reduced risk for what cancer? - CORRECT ANSWER Breast and colorectal" "Greater fruit and vegetable intake has been associated with decrease risk or outcomes in which cancers (4)? - CORRECT ANSWER Pancreatic Breast Colon Bladder" "List the populations at risk for Thiamin (B1) deficiency (6) - CORRECT ANSWER Alcohol abuse/misuse Elderly Malnutrition Bariatric Surgery Critical Illness Heart Failure" "List the food sources of B3 (niacin). - CORRECT ANSWER Meat, fish, poultry, enriched and whole-grain breads, fortified cereals" "What can niacin (B3) be used to treat? - CORRECT ANSWER All major lipid parameters, reducing LDL and triglycerides while increasing HDL. Women have a greater reduction than men in meta-analysis review." "What are the AE associated with niacin (B3)? - CORRECT ANSWER flushing (ASA), itching, and GI distress" "Co-enzyme Q10 is a common supplement for statin-induced myalgias, but can also be adjunctive therapy in what disease processes? - CORRECT ANSWER CHF, HTN, DM, Obesity, Migraine" "Melatonin has inconsistent results on which disease processes? - CORRECT ANSWER Circadian rhythm sleep disorders Insomnia (onset/maintenance) Nocturnal blood pressure Benzodiazepine withdrawal" "CEE and estradiol are used in the ____ of osteoporosis. What is NOT? - CORRECT ANSWER PREVENTION; CE, synthetic conjugated estrogens" JW, a 53-year-old post-menopausal female, presents to the pharmacy with a new prescription for 17β- estradiol topical gel (EstroGel) for vasomotor symptom relief. Which of the following is the appropriate administration of 17β- estradiol topical gel (EstroGel)? A. Apply 1 pump depression once daily to one arm from wrist to shoulder B. Apply 1 pump depression once daily to one upper arm and shoulder area C. Apply 1 packet once daily to one upper thigh D. Apply 1 pouch once daily to each thigh and calf - CORRECT ANSWER A." "JW, a 53-year-old post-menopausal female, presents to the pharmacy with a new prescription for 17β- estradiol topical gel (EstroGel) for vasomotor symptom relief. Which statement should be included in the counseling for 17β- estradiol topical gel (EstroGel)? A. Apply gel after applying lotion, powder, or oil B. Washing hands after application is not necessary C. Allow gel to dry before dressing D. Massage or rub in gel after application - CORRECT ANSWER C." "CG is a 55-year-old post-menopausal woman seeking treatment for vasomotor symptoms. She has an intact uterus and a history of breast cancer. Which of the following patient data is an absolute contraindication to hormone replacement therapy? A. Former smoker B. Current treatment for type 2 diabetes C. History of breast cancer D. Family history of CHD - CORRECT ANSWER C." "CG is a 55-year-old post-menopausal woman seeking treatment for vasomotor symptoms. She has an intact uterus and a history of breast cancer. Which treatment is most appropriate for this patient? A. Micronized 17β- estradiol (Estrace) B. Venlafaxine (Effexor) C. Ospemifene (Osphena) D. Raloxifene (Evista) - CORRECT ANSWER B." "HC, a 52-year-old female, has been prescribed a continuous combined oral estrogen and progestogen product for vasomotor symptom relief related to menopause. She has read about the potential risks associated with HRT and would like to discuss these before filling the prescription. Which of the following strategies will help reduce the incidence of breast cancer? A. Limit duration of use to 5 years B. Use bioidentical HRT instead C. Use transdermal estrogen instead D. Use phytoestrogens instead - CORRECT ANSWER A." "HC, a 52-year-old female, has been prescribed a continuous combined oral estrogen and progestogen product for vasomotor symptom relief related to menopause. She has read about the potential risks associated with HRT and would like to discuss these before filling the prescription. Which of the following strategies will help reduce the incidence of VTE? A. Use transdermal estrogen instead B. Use black cohosh instead C. Use a product with medroxyprogesterone acetate - CORRECT ANSWER B." "HC, a 52-year-old female, has been prescribed a continuous combined oral estrogen and progestogen product for vasomotor symptom relief related to menopause. She has read about the potential risks associated with HRT and would like to discuss these before filling the prescription. Which of the following are vaginal tablets and are not taken ORALLY and are administered vaginally? (Select ALL THAT APPLY) A. Imvexxy B. Duavee C. Vagifem D. Activella - CORRECT ANSWER A." "Chief complaint: Pain with sexual intercourse History of present illness: OR is a 46-year-old female presenting to the office today for an annual follow-up complaining of pain with sexual intercourse. She recently started taking Estroven Maximum Strength® but has noted little benefit. She denies other menopausal symptoms. Past medical history: Gestational DM with first pregnancy Surgical history: Hysterectomy (2016) secondary to fibroids, ovaries remain Social history: (-) for tobacco, EtOH, and illicit drugs Family history: (-) for breast and cervical cancer Current nonprescription medications: Centrum multivitamin one tablet daily, ibuprofen 200 mg one tablet as needed Current complementary and alternative medications: Estroven Maximum Strength® one caplet daily Which of the following is the most appropriate course of action for this patient? A. Oral estrogen only B. Combination oral estrogen and progestogen C. - CORRECT ANSWER C." "Chief complaint: Pain with sexual intercourse History of present illness: OR is a 46-year-old female presenting to the office today for an annual follow-up complaining of pain with sexual intercourse. She recently started taking Estroven Maximum Strength® but has noted little benefit. She denies other menopausal symptoms. Past medical history: Gestational DM with first pregnancy Surgical history: Hysterectomy (2016) secondary to fibroids, ovaries remain Social history: (-) for tobacco, EtOH, and illicit drugs Family history: (-) for breast and cervical cancer Current nonprescription medications: Centrum multivitamin one tablet daily, ibuprofen 200 mg one tablet as needed Current complementary and alternative medications: Estroven Maximum Strength® one caplet daily Which statement should be included in the counseling for estradiol hemihydrate vaginal tablet (Vagifem)? A. If the tablet is expelled, it may be rinsed - CORRECT ANSWER C." "Chief complaint: Pain with sexual intercourse History of present illness: OR is a 46-year-old female presenting to the office today for an annual follow-up complaining of pain with sexual intercourse. She recently started taking Estroven Maximum Strength® but has noted little benefit. She denies other menopausal symptoms. Past medical history: Gestational DM with first pregnancy Surgical history: Hysterectomy (2016) secondary to fibroids, ovaries remain Social history: (-) for tobacco, EtOH, and illicit drugs Family history: (-) for breast and cervical cancer Current nonprescription medications: Centrum multivitamin one tablet daily, ibuprofen 200 mg one tablet as needed Current complementary and alternative medications: Estroven Maximum Strength® one caplet daily Which of the following would be the best advice regarding the use of Estroven Maximum Strength®? A. Continue Estroven Maximum Strength® as it is both s - CORRECT ANSWER D." "The most effective treatment to alleviate postmenopausal vasomotor symptoms (hot flashes and night sweats) is: A. Estrogen therapy. B. Selective estrogen-receptor modulators (SERMs). C. Testosterone therapy. D. Clonidine. - CORRECT ANSWER A." "Which of the following CYP450 isoenzymes metabolizes both estrogen and medroxyprogesterone? A. 3A4 B. 1A2 C. 2D6 D. All of the above - CORRECT ANSWER A." "Continued vasomotor symptoms in a 52-year-old postmenopausal individual with a history of hysterectomy receiving 0.3 mg of oral conjugated equine estrogens can best be managed by: A. Changing to a SERM B. Changing to gabapentin C. Increasing the daily estrogen dose D. Decreasing the daily estrogen dose - CORRECT ANSWER C." "A 54-year-old postmenopausal individual is complaining of vaginal dryness, itching, and pain with intercourse. They have not had any other problems associated with menopause and have an intact uterus. Which of the following recommendations is the best treatment option that balances risks and benefits for the management of this patient's symptoms? A. Oral conjugated estrogen + medroxyprogesterone acetate B. Transdermal estradiol + micronized oral progesterone C. Intravaginal estrogen cream + oral progestogen D. Intravaginal estrogen cream - CORRECT ANSWER D." "Conjugated equine estrogen therapy alone has demonstrated to significantly increase the risk of: A. Coronary heart disease B. Stroke C. Colorectal cancer D. Breast cancer - CORRECT ANSWER B." "Which of the following agents would be the best option to treat moderate hot flashes in a 55-year-old patient with history of breast cancer? A. Ospemifene B. Estrogen C. Paroxetine D. Progestogen - CORRECT ANSWER C." "What is the first-line therapy for a 58-year-old postmenopausal patient suffering from mild genitourinary syndrome of menopause? A. Intravaginal moisturizer and lubricants B. Intravaginal estrogen cream C. Paroxetine D. Clonidine - CORRECT ANSWER A." "A 52-year-old individual had a hysterectomy 6 months ago and is seeking treatment for vasomotor symptoms. There is no significant family history. Based on the findings from the Women's Health Initiative (WHI) extended-post intervention study, what would be the most appropriate information to provide the patient regarding menopause hormone therapy (MHT): A. Do not initiate hormone therapy now because individuals younger than 60 years have increased risk of coronary heart disease and stroke and have the least favorable benefit-risk profile with MHT B. Initiate hormone therapy now because individuals younger than 60 years have not shown an increased risk of coronary heart disease and have most favorable benefit-risk profile with MHT C. Initiate MHT later because individuals older than 60 years will be within the "window of opportunity" to reduce risk of breast cancer D. Initiate hormone therapy later because individual - CORRECT ANSWER B." "Long-term MHT can be routinely prescribed for which of the following conditions? A. Dementia unresponsive to other therapies B. Coronary heart disease C. Diabetes D. None of the above - CORRECT ANSWER D." "Which of the following intravaginal estrogens is also approved for treatment of vasomotor symptoms? A. Estring (estradiol vaginal ring) B. Femring (estradiol vaginal ring) C. Vagifem (estradiol vaginal tablet) D. Imvexxy (estradiol vaginal insert) - CORRECT ANSWER B." "A 47-year-old postmenopausal individual with an intact uterus reports experiencing bothersome vasomotor symptoms. There is a history of gallbladder disease. Which of the following is the best treatment option for management of symptoms? A. Transdermal estrogen B. Transdermal estrogen with micronized progesterone C. Oral conjugated equine estrogen D. Oral conjugated equine estrogen with micronized progesterone - CORRECT ANSWER B." "Which of the following is most effective for the treatment of severe hot flashes in a 54-year-old healthy menopausal individual? A. Estrogen and progestogen therapy B. Black cohosh C. Bazedoxifene D. Paroxetine - CORRECT ANSWER A." "MJ is a healthy 53-year-old female. She reports her last menses was 9 months ago. MJ is likely experiencing? A. Menopause B. Perimenopause C. Postmenopause D. Early onset menopause - CORRECT ANSWER B." "A 51-year-old individual is experiencing severe vasomotor symptoms. The past medical history is significant for hysterectomy. Which of the following is the best treatment options to alleviate vasomotor symptoms? A. Black cohosh B. Systemic estrogen therapy C. Compounded bioidentical hormone therapy D. Transdermal estrogen with progestogen therapy - CORRECT ANSWER B." "A 54-year-old female with a history of deep vein thrombosis, dyslipidemia, and depression is seeking treatment for bothersome vasomotor symptoms. Which of the following is the best treatment options to alleviate vasomotor symptoms? A. Black cohosh B. Medroxyprogesterone C. Duavee (conjugated estrogen with bazedoxifene) D. Paroxetine - CORRECT ANSWER D." "Luteal out of phase event (LOOP) - CORRECT ANSWER 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. - CORRECT ANSWER 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? - CORRECT ANSWER 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. - CORRECT ANSWER 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. - CORRECT ANSWER 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 - CORRECT ANSWER Endocrine labs after menopause" "AMH, Inhibin B - CORRECT ANSWER 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 - CORRECT ANSWER 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? - CORRECT ANSWER 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? - CORRECT ANSWER AMH" "DHEA (dehydroepiandrosterone) - CORRECT ANSWER Adrenal androgens: precursor hromones produced by the adrenal gland that are enzymatically converted to active androgens or estrogens in peripheral tissues." "What is the FSH level on a random draw in Late menopause transition (STRAW Stage: -1)? - CORRECT ANSWER 25 IU/L or higher" "Black women have higher or lower FSH levels? - CORRECT ANSWER Higher" "Chinese and Japanese women have higher or lower estradiol levels compared to white, black and hispanic women? - CORRECT ANSWER Lower" "What happens to SHBG during menopause? How does that effect the free androgen index? - CORRECT ANSWER SHBG decreases. Testosterone/SHBG ratio increases by 80%." "Testosterone:SHGB ratio is called what? - CORRECT ANSWER The free androgen index" "What stage are VMS more likely? - CORRECT ANSWER +1b (generally last 2 years)" "What hormone is generally higher in obese women? - CORRECT ANSWER Estrone-via aromatization." "The postmenopausal ovary continues to produce what two hormones? - CORRECT ANSWER testosterone and androstenedione" "Surgical menopause causes women to have lower levels of what hormone? - CORRECT ANSWER 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? What does that do to FSH? - CORRECT ANSWER Inhibin B and AMH decrease. Decreased InhB leads to unrestrained FSH. This allows for the growth of the remaining, diminished follicle pool (shortened follicular phase). Increased atresia. Occasional LOOP cycles." "In the menopause transition, women spend more time in what phase? - CORRECT ANSWER Luteal-more PMS symptoms, more frequent menstrual periods." "HPO axis theory and the menopause transition - CORRECT ANSWER 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? - CORRECT ANSWER progesterone" "What region of the adrenal gland secretes the androgens? - CORRECT ANSWER zona reticularis" "What are considered the 'adrenal androgens'? - CORRECT ANSWER Precursor hormones produced by the adrenal gland, which are enzymatically converted to active androgens/estrogens in peripheral tissue. Dehydroepiandrosterone DHEA Dehydroepiandrosterone-sulfate DHEAS Androstenedione Testosterone" "Diagnostic criteria, POI includes: - CORRECT ANSWER Menstrual disturbance-oligomenorrhea or amenorrhea for at least 4 months. AND Elevated FSH over 25 on two occasions at least 4 weeks apart., with low estradiol." "Anyone 40years old who misses 3+ consecutive cycles gets these labs: - CORRECT ANSWER prolactin FSH estradiol TSH pregnancy test *also consider karyotype, FMR1 gene mutation, adrenal Ab (ACTH), glucose, calcium, phosphorus, pelvic US, and BMD" "What are the medications and doses used in the treatment of POI? What is the duration of therapy? - CORRECT ANSWER 100 microgram estradiol patch, 1.25 mg CEE, 2mg oral estradiol Cyclical progestins, if intact uterus, 12 d/month DOT is until the natural age for menopauseQ" "What is the recommended length of duration for progesterone in POI treatment if the uterus is intact? - CORRECT ANSWER 12 days of the month" "What is the alternative treatment approach for menorrhagia in POI? - CORRECT ANSWER IUD plus estrogen patch" "When is continuous HRT considered in the treatment of POI? - CORRECT ANSWER When not wanting to risk pregnancy" "What ethnicity has the least likely chance of having bad hot flashes? - CORRECT ANSWER Japanese" "What ethnicity is the most likely to have early and severe hot flashes? - CORRECT ANSWER Black more frequent, longer duration." "Median length of hot flashes - CORRECT ANSWER 10 years, early menopause transition women have them the longest." "THEORIES about etiology of hot flashes (6) - CORRECT ANSWER 1) lower ovarian estradiol 2) hypothalamic thermoregulatory dysfunction 3) narrowed thermoregulation zone 4) neurokinins-regulate GnRH secretion 5) hypertrophy of KNDy neurons 6) serotonin 7) cortisol and HPI axis dysregulation 8) endothelial dysfunction" "What is VIN? What does it include? How is it classified? - CORRECT ANSWER Vulvar intraepithelial neoplasia. Vulvovaginal neoplasias cause pain and/or itching. They can include VIN, squamous cell carcinomas, basal cell carcinomas, and Paget disease. Classified as low grade, high grade, and differentiated type." "What is low-grade VIN and what is its significance? - CORRECT ANSWER Low-grade VIN is consistent with HPV effect and is not precancerous." "What is high-grade VIN and how should it be managed? - CORRECT ANSWER High-grade VIN is precancerous and requires consultation with a GYN ONC." "Systemic and vaginal estrogen will not help with this type of urinary incontinence? - CORRECT ANSWER Will NOT help with stress incontinence" "Which topical vaginal estrogen has the highest dose? - CORRECT ANSWER the vaginal rings FEMRING IS THE HIGHEST" "Most common cause of vulvovaginitis? - CORRECT ANSWER BV" "What postmenopausal condition is associated with burning and diffuse yellow/brown discharge and dyspareunia? Hint: it does not respond to local ET. How do you treat it? - CORRECT ANSWER Desquamative inflammatory vaginitis (DIV). Treat with clindamycin or hydrocortisone + ET." "What hormones are associated with sexual desire in women? - CORRECT ANSWER circulating androgens" "Women who have had a BSO experience an abrupt and persistent decline in what hormone? - CORRECT ANSWER circulating androgen levels" "In DSMV, HSDD and FAD were combined into a single dysfunction called? - CORRECT ANSWER Female Sexual Interest/Arousal Disorder" "HSDD treatments - CORRECT ANSWER flibanserin and bremelanotide" "FGAD treatments (genital arousal disorder) - CORRECT ANSWER L-arginine, topical alprostadil, wellbutrin, oxytosin. phosphodiesterase inhibitors-lacking in efficacy Eros therapy device $300- vaccum-like the penis pump" "FOD (orgasmic disorder) treatments - CORRECT ANSWER directed masturbation is most researched behavioral treatment." "What is true about cognition and surgical menopause - CORRECT ANSWER Memory for verbal information can be compromised immediately after surgical menopause, especially if it is before the typical age of menopause." "Meta analysis of RCTs have shown small benefit of what diet/exercise for global cognition and memory? - CORRECT ANSWER Mediterranean diet with olive oil as well as isoflavone supplements helps with memory; MD and Tai Chi exercise helps with global cognition." "Triptans are contraindicated in what? - CORRECT ANSWER Patients with cardiovascular disease, as are NSAIDs" "Menstrual migraine treatment - CORRECT ANSWER NSAID or triptan 2 days before expected to get your period, and take for 5-7 days." "What are the birth control recommendations by the CDC and WHO regarding patients with migraines? - CORRECT ANSWER Patients with migraine with aura, advised to not use combined hormone contraception. Caution is advised in women with migraine without aura." "How long can it take for arthralgia from vitamin d deficiency or hypothyroidism to fully resolve? - CORRECT ANSWER Several months" "What is the most common form of arthritis? - CORRECT ANSWER Osteoarthritis" "What areas of the brain have the most estrogen receptors? - CORRECT ANSWER hippocampus and prefrontal cortex" "What is the most common thyroid disorder in women? - CORRECT ANSWER Hashimoto thyroiditis" "If a patient on levothyroxine is started on estrogen, when do you recheck and what can you anticipate happening? - CORRECT ANSWER Recheck 6-8 weeks later; anticipate that the dose of levothyroxine may need to be increased." "When is treatment of subclinical hypothyroidism recommended? - CORRECT ANSWER TSH level is higher than 10" "Are hot or cold thyroid nodules typically most likely to be malignant? - CORRECT ANSWER Cold nodules" "How does HRT impact gallbladder disease? - CORRECT ANSWER Increases risk of gallstones and reduces gallbladder motility with oral HRT, lower risk with transdermal." "When did they start screening blood for Hep C? - CORRECT ANSWER 1992, so women who have received blood products or organ transplants prior to 1992 may have acquired Hepatitis C" "Why do we screen for Hep C? - CORRECT ANSWER Most infections become chronic and most are asymptomatic until liver damage is detected years later. Our treatments are improving so if we catch this earlier in people, outcomes will be better." "Initially all adults born from what year to what year were recommended to receive one time Hep C testing? Since 2013, what age to what age is recommended to screen for NOT at risk patients? - CORRECT ANSWER 1945 to 1965; USPSTF recommends 18-79yo be tested once in their lifetime, unless higher risks necessitate additional testing" "Routine screening of all adults for Hepatitis C, is it recommended? - CORRECT ANSWER Per USPSTF 2020, recommended screening for all adults 18-79yoa. Consider increased screening in 18yoa if high risk, and more than once screening in adults with continued risk." "What HPV types are high risk (12)? Which two are responsible for most HPV-related cancers? - CORRECT ANSWER 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 16 & 18 are responsible for most HPV-related cancers" "By age 50y, what percentage of US women will have acquired a genital HPV infection? - CORRECT ANSWER 80% HPV is very common, and most clear it on their own" "Why was estrogen not approved for osteoporosis? - CORRECT ANSWER Decreased risk of vertebral and hip fracture in low fracture risk population, but estrogen has not been shown to decrease fracture risk in women with osteoporosis. More prevention than treatment." "Black box warning for PTH receptor agonists? - CORRECT ANSWER Osteosarcoma" "Caution using PTH receptor agonists in what condition? - CORRECT ANSWER Hypercalcemia" "When would you use PTH receptor agonists? - CORRECT ANSWER Patients with high risk for vertebral fracture" "raloxifene helps with what kind of fractures? - CORRECT ANSWER vertebral fractures" "raloxifene risk factors - CORRECT ANSWER increased risk of death from stroke in high risk patients, estrogen like risk of VTE, worsens hot flashes" "atypical femur risk in women on bisphosphonate? - CORRECT ANSWER 1 in 1000 after 2-3 years." "What is the effect of salmon calcitonin on patients with osteoporosis? How is it given? - CORRECT ANSWER Small increase in spine BMD. Daily SQ injections or nasal." "Early Menopause - CORRECT ANSWER FMP before age 45" "Late Menopause - CORRECT ANSWER FMP after age 54" "Natural Menopause - CORRECT ANSWER Permanent cessation of menses because of loss of follicular activity" "Induced Menopause - CORRECT ANSWER Surgical or iatrogenic loss of ovarian function" "Perimenopause - CORRECT ANSWER Stage in the menopause transition characterized by two phases, early and late. In early perimenopause cycles are characterized by irregular menstrual cycles by persistent 7 days of cycle difference in consecutive cycles. In late perimenopause, cycles are absent for an interval of 60 days minimum up to 1yr." "Postmenopause - CORRECT ANSWER The period defined as 12mo of amenorrhea" "Premature menopause - CORRECT ANSWER FMP before age 40" "Primary Ovarian Insufficiency - CORRECT ANSWER New term (no longer POF). FMP before age 40." "Premenopause - CORRECT ANSWER Reproductive stage between menarche and onset of perimenopause" "FSH - CORRECT ANSWER Follicle Stimulating Hormone" "AMH - CORRECT ANSWER AntiMullerian Hormone" "InhB - CORRECT ANSWER Inhibin B" "E2 - CORRECT ANSWER Estradiol" "Classic Symptoms of Menopause (5) - CORRECT ANSWER Change in menstrual cycle Vasomotor symptoms (Night sweats / Hot flashes) Vulvovaginal symptoms (Dyspareunia, Change in pH) Sleep disturbance Psychological symptoms (Depression, Anxiety, Mood)" "What is the cause of earlier mortality in women with surgical menopause 45? - CORRECT ANSWER CVD" "Increased trunk-mass-to-leg-fat-mass ratio has been associated with what changes in vitals, and labs? - CORRECT ANSWER Increased blood pressure, fasting glucose, and abnormal lipoprotein profiles." "Women with increased visceral adipose tissue stores are more likely to suffer from what comorbidities? - CORRECT ANSWER Cardiometabolic conditions, DM, metabolic syndrome, hepatic statosis, and aortic plaques." "Obese, postmenopausal women have a _____ rate of breast cancer than postmenopausal women of normal weights. - CORRECT ANSWER Higher" "Obesity and VMS: Elevated BMI is associated with ____ frequent / _____ VMS during perimenopause. Higher BMI is associated with _____ VMS when women are postmenopausal. - CORRECT ANSWER more / severe fewer" "Obesity and hormone values: Obese premenopausal / perimenopausal women have _____ estradiol levels than non obese patients. Obese postmenopausal women have _____ estradiol levels than non obese patients. - CORRECT ANSWER Lower / High" "What are the effects of androgens on GU health? (2) - CORRECT ANSWER Simulates nerve fibers and maintains healthy epithelium" "Menopause is associated with what body composition changes? - CORRECT ANSWER Menopause is associated with increase in central adiposity as well as visceral fat and decrease of lean body mass." "What are the hormonal changes noted with sleep disurbance? - CORRECT ANSWER Increased cortisol, lower thyrotropin, lower leptin, reduced glucose tolerance" "List the risk factors for VMS (5) - CORRECT ANSWER 1) low socioeconomic status 2) low education level 3) obesity (in perimenopause) 4) smoking/tobacco use 5) surgical hysterectomy/oophrectomy" "VMS are associated with what two adverse health outcomes? - CORRECT ANSWER CVD and poor bone health" "First-line treatment for VMS. - CORRECT ANSWER HT is the first-line. (ET, EPT, ERAAs). -in women with a uterus, EPT or CEE plus bazedoxifene (an ERAA)" "SSRI/SNRI therapy for VMS (5): - CORRECT ANSWER Paroxetine 10-25mg only FDA approved Citalopram 10-20mg Escitalopram 10-20mg Venlafaxine 37.5mg-150mg Desvenlafaxine 100-150mg"