Menopause Certification Exam: Questions and Answers with Rationales, Exercises of Nursing

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NAMs MENOPAUSE CERTIFICATION EXAM

ACTUAL EXAM 250 QUESTIONS AND CORRECT

ANSWERS WITH RATIONALES (VERIFIED

ANSWERS) |ALREADY GRADED A+

The period of endrocrinologic, somatic, and transitory psychologic changes that occur around the time of menopause. - CORRECT ANSWER>>Climacteric phase LMP before age 45 - CORRECT ANSWER>>Early menopause LMP after age 54 - CORRECT ANSWER>>Late menopause Menopause that occurs before age 40 - CORRECT ANSWER>>Primary ovarian insufficiency Persistent difference of 7 days or more in the length of consecutive cycles. - CORRECT ANSWER>>Early menopause transition (stage - 2) 60 or more consecutive days of amenorrhea - CORRECT ANSWER>>Late menopause transition (stage - 1) 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. - CORRECT ANSWER>>Luteal out of phase event (LOOP) 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) - CORRECT ANSWER>>Obese women and estradiol levels during menopause These ethnic groups have lower estradiol levels then white, black and hispanic women. - CORRECT ANSWER>>Chinese and Japanese women late menopause stage: 5-8 years after FMP. Somatic aging predominates. Increased genitourinary symptoms. - CORRECT ANSWER>>stage + early post menopause: 2 years after FMP. FSH rises, estradiol decreases. VMS predominate. - CORRECT ANSWER>>Stages +1a, +1b, +1c Endocrine labs after menopause - CORRECT ANSWER>>Elevated FSH, LH These hormones work during reproductive years to not deplete follicle pool too quickly. - CORRECT ANSWER>>AMH, inhibin B Menstrual cycle variable, persistent >7 day difference between difference in length of consecutive cycles.

• CORRECT ANSWER>>Phases during menopause transition and PMS symptoms

many pitfalls, variable depending on the day of the cycle you draw the lab, normal or low FSH is not helpful. - CORRECT ANSWER>>How to respond if a patient requests FSH lab? AMH - CORRECT ANSWER>>The potentially superior marker of menopause, a lab. Adrenal androgens: precursor hromones produced by the adrenal gland that are enzymatically converted to active androgens or estrogens in peripheral tissues. - CORRECT ANSWER>>DHEA (dehydroepiandrosterone) Vagina, vulva, urethra, trigone of the bladder - CORRECT ANSWER>>Location of estrogen receptors maintain blood flow, the collagen, and HA within the epithelial surfaces. Supports microbiome which supports acidity of vagina and protects tissue from pathogens. - CORRECT ANSWER>>Effects of estrogen on tissue Thinning, loss of elasticity, loss or absence or rugae. - CORRECT ANSWER>>Vaginal changes with menopause vagina narrows, urethra moves closer to the introitus. - CORRECT ANSWER>>Vagina and urethra in menopause Vaginal estrogen and urinary incontinence: what type does it help with? - CORRECT ANSWER>>Stress urinary incontinence Minoxidil, spironolactone, finasteride, estrogen therapy - CORRECT ANSWER>>Treatment for FPHL

• 3b: menstrual cycles normal, FSH normal, AMH low, AFC low, inhibin low.
• 3a: subtle menstrual changes, variable FSH, AMH low, AFC low, inhibin low. - CORRECT ANSWER>>Late reporoductive years - 3b and - 3a. What happens with menstrual cycles, FSH, AMH, AFC, inhibin? Cycle day #3. Elevated estradiol can suppress FSH giving a falsely normal FSH level. - CORRECT ANSWER>>When it is appropriate to check an FSH during the cycle if you check it? and why? 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. - CORRECT ANSWER>>AMH produced by... used to test... Is it a screening tool for fertility?

When does it peak? 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. - CORRECT ANSWER>>AFC 25 or higher - CORRECT ANSWER>>Late menopause transition (-1) FSH level on random draw Higher - CORRECT ANSWER>>Black women have higher or lower FSH levels? lower - CORRECT ANSWER>>Chinese and Japanese women have higher or lower estradiol levels compared to white, black and hispanic women? SHBG decreases Testosterone/SHBG ratio increases by 80%. - CORRECT ANSWER>>Menopause transition-changes in SHBG and testosterone? ratio? The free androgen index - CORRECT ANSWER>>Testosterone/SHGB ratio is called what? +1b (generally last 2 years) - CORRECT ANSWER>>What stage are VMS more likely? Estrone-via aromatization. - CORRECT ANSWER>>What hormone is generally higher in obese women? testosterone and androstenedione - CORRECT ANSWER>>The postmenopausal ovary continues to produce what two hormones? testosterone. 40-50% lower than in women w/ intact ovaries. - CORRECT ANSWER>>Surgical menopause causes women to have lower levels of what hormone? inhibin and AMH decrease therefore, follicle growth is not restrained, this allows for the growth of the remaining, diminished follicle pool. - CORRECT ANSWER>>Driving piece of menopause is ovarian follicles depleting. What does this do to the inhibin B and AMH? Luteal-more PMS symptoms, more frequent menstrual periods. - CORRECT ANSWER>>In the menopause transition, women spend more time in what phase? 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. - CORRECT ANSWER>>HPO axis theory and the menopause transition progesterone - CORRECT ANSWER>>In the first year after the FMP, there is no production of what hormone? zona reticularis - CORRECT ANSWER>>What region of the adrenal gland secretes the androgens?

DHEA, DHEAS, Androstenedione. - CORRECT ANSWER>>what are considered the 'adrenal androgens'? Angiotensin II, potassium concentration, adrenocorticotropic hormone secreted by the anterior pituitary.

• CORRECT ANSWER>>Aldosterone secretion from the zona reticularis in the adrenal gland is regulated by 3 main factors. Anterior pituitary. The posterior only secretes vasopressin and oxytosin. - CORRECT ANSWER>>What part of the pituitary gland secretes adrenocorticotropic hormone? 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. - CORRECT ANSWER>>Cortisol and HRT No, cortisol levels have NOT been associated with more severe VMS. - CORRECT ANSWER>>Do cortisol levels associate with VMS severity? vaginal pain and dyspareunia - CORRECT ANSWER>>Local DHEA has been proven to help with what? Menstrual disturbance-oligomenorrhea or amenorrhea for at least 4 months. AND elevated FSH over 25 on two occasions at least 4 weeks apart. - CORRECT ANSWER>>How to DX POI? prolactin FSH estradiol TSH pregnancy test - CORRECT ANSWER>>Anyone <40years old who misses 3+ consecutive cycles gets these labs 100 microgram estradiol patch 1.25 mg CEE 2mg oral estradiol If intact uterus-progesterone for 12 days of the month. Physiologic is better than continuous hormonal contractption, but if menorrhagia-IUD plus estrogen patch, or if really not wanting to risk pregnancy, continuous HRT can be used. - CORRECT ANSWER>>treatment of POI

FPHL is gradual, telogen effluvium is sudden and usually precipitated by a life stressor, chronic illness, beta blockers or anticoagulants-usually more patchy hair loss. - CORRECT ANSWER>>Hair loss. Difference between FPHL and telogen effluvium? thinning at the crown of the head and widening of the hair part - CORRECT ANSWER>>FPHL pattern MINOXIDIL spironolactone finasteride - CORRECT ANSWER>>Treating FPHL Japanese - CORRECT ANSWER>>What ethnicity has the least likely chance of having bad hot flashes? black more frequent, longer duration. - CORRECT ANSWER>>What ethnicity is the most likely to have bad hot flashes? 10 years, early menopause transition women have them the longest. - CORRECT ANSWER>>Median length of hot flashes lower ovarian estradiol thermoregulation zone is narrowed neurokinins-regulate GnRH secretion. KNDy new meds serotonin cortisol and HPI axis dysregulation endothelial dysfunction. - CORRECT ANSWER>>Theories about etiology of hot flashes (6) low grade is not precancerous high grade is precancerous-GYN ONC differentiated-wide local excision-high risk of invasive carcinoma. - CORRECT ANSWER>>VIN low grade-what to do high grade-what to do differentiated VIN-what to do squamous cell carcinoma - CORRECT ANSWER>>most common type of vulvar cancer 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. - CORRECT ANSWER>>Vulvar disorder commonly misdiagnosed as eczema or dermatitis? <100mL - CORRECT ANSWER>>Normal PVR will NOT help with stress incontinence. - CORRECT ANSWER>>systemic and vaginal estrogen will not help with this type of urinary incontinence? the vaginal rings

FEMRING IS THE HIGHEST - CORRECT ANSWER>>Which topical vaginal estrogen has the highest dose? BV - CORRECT ANSWER>>Most common cause of vulvovaginitis? desquamative inflammatory vaginitis. treat different with clindamycin or hydrocortisone+ET - CORRECT ANSWER>>post menopause burning and diffuse yellow/brown discharge and dyspareunia that does not respond to local ET? circulating androgens - CORRECT ANSWER>>What hormones are associated with sexual desire in women? circulating androgen levels - CORRECT ANSWER>>Women who have had a BSO experience an abrupt and persistent decline in what hormone? female sexual interest/arousal disorder - CORRECT ANSWER>>HSDD and FSAD were combined into a single dysrunction called flibanserin and bremelanotide - CORRECT ANSWER>>HSDD treatments L-arginine, topical alprostadil, wellbutrin, oxytosin. phosphodiesterase inhibitors-lacking in efficacy Eros therapy device $300- vaccum-like the penis pump - CORRECT ANSWER>>FGAD treatments (genital arousal disorder) directed masturbation is most researched behavioral treatment. - CORRECT ANSWER>>FOD (orgasmic disorder) treatments Rarely. They often shrink after menopause. - CORRECT ANSWER>>Does systemic ET cause fibroids to resume growth? Difficulty concentrating and remembering are common. - CORRECT ANSWER>>What is true about cognition and menopause? memory for verbal information can be compromised immediately after surgical menopause, especially if it is before the typical age of mesopause. - CORRECT ANSWER>>What is true about cognition and surgical menopause Mediterranean diet with olive oil and tai chi exercise helps with global cognition Mediterranean diet with olive oil and isoflavone supplements helps with memory. - CORRECT ANSWER>>Meta analysis of RCTs have shown small benefit of what diet/exercise for global cognition and memory? small or no overall effect on cognition - CORRECT ANSWER>>effect of HRT on cognition 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 - CORRECT ANSWER>>What HRT can increase your risk for dementia based on the WHIMS study in 65+ year old healthy women?

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. - CORRECT ANSWER>>3 reasons supporting the idea that HRT in early menopause may decrease a woman's chance of developing alzheimer's disease? typically migraines improve-estrogen levels stabilize - CORRECT ANSWER>>Migraine headache and pregnancy usually decrease with natural menopause - CORRECT ANSWER>>Migraine without aura after menopause should resolve completely - CORRECT ANSWER>>menstrual migraine after menopause

2 times per week or severe and effecting QOL - CORRECT ANSWER>>When to consider preventative medication for migraines patients with cardiovascular disease, as are NSAIDs - CORRECT ANSWER>>Triptans are contraindicated in what? NSAID or triptan 2 days before expected to get your period, and take for 5-7 days. - CORRECT ANSWER>>Menstrual migraine treatment migraine with aura-advise to not use combined hormone contraception caution in women with migraine without aura - CORRECT ANSWER>>cdc and who guidelines for migraine treatment it can take several months. - CORRECT ANSWER>>How long can it take for arthralgia from vitamin d deficiency or hypothyroidism to fully resolve? osteoarthritis - CORRECT ANSWER>>what is th emost common form of arthritis? hippocampus and prefrontal cortex - CORRECT ANSWER>>what areas of th ebrain have th emost estrogen receptors? hashimoto thyroiditis - CORRECT ANSWER>>what is the most common thyroid disorder in women? recheck 6-8 weeks later. anticipate that the dose of levothyroxine may need to be increased.

oral estrogens increase thyroid binding globulin which in turn reduces the levels of free T4. - CORRECT ANSWER>>if a patient on levothyroxine is started on estrogen, when do you recheck and what can you anticipate happening? when the TSH level is higher than 10. - CORRECT ANSWER>>when is treatment of subclinical hypothyroidism recommended? cold nodules - CORRECT ANSWER>>are hot or cold thyroid nodules typically most likely to be malignant? increases risk of gallstones with oral HRT, lower risk with transdermal. - CORRECT ANSWER>>how does HRT impact gallbladder disease? 1992, so women who have received blood products or organ transplants prior to 1992 may have acquired heptatitis c - CORRECT ANSWER>>when did they start screening blood for hep c? 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 - CORRECT ANSWER>>why do we screen for hep C? 1945 to 1965 - CORRECT ANSWER>>all adults born from what year to what year should recieve one time hep c testing? routine screening for all adults is not recommended, however baby boomers are at the highest risk. infection rates are 5x other birth cohorts. - CORRECT ANSWER>>routine screening of all adults for hepatitis c. is it reocmmended? 16 and 18 - CORRECT ANSWER>>what hpv is high risk? 80%-HPV is very common, but it is the high risk ones to worry about - CORRECT ANSWER>>by age 50 what percentage of US women will have acquired a genital HPV infection? HPV - CORRECT ANSWER>>what is the most commonly sexually transmitted infection in the US? 10 - 12% on average, about 1 t score - CORRECT ANSWER>>What percentage of bone loss do women have from the menopause transition?

• 1.5 to - 2.5 - CORRECT ANSWER>>What t score defines osteopenia less than - 2.5 - CORRECT ANSWER>>what t score defines osteoporosis z score less than 2.0 and a history of a fragility fracture - CORRECT ANSWER>>what z score defines osteoporosis before menopause? white and hispanic populations - CORRECT ANSWER>>Who is at highest risk of osteoporosis? 1 in 4 women (25%) require long term care

1 in 2 woemn (50%) have long term loss of mobility - CORRECT ANSWER>>What amount of women require long term care after hip fracture? What amount of women have long term loss of mobility after hip fracture? lower - CORRECT ANSWER>>Asians have ____BMD than white people? higher - CORRECT ANSWER>>Black women have ____BMD than white people? 38% for osteoporotic fracture and 68% for hip fracture - CORRECT ANSWER>>Over 3 servings of alcohol daily and risk for fracture? white, asiain, black, hispanic - CORRECT ANSWER>>What 4 ethnic specific versions of FRAX are there? dairy free diet-300mg calcium daily. Needs 800-1200mg - CORRECT ANSWER>>Dairy free diet amount of calicum. How much do they need to supplement? approved in mexico decreased risk of vertebral and nonvertebral fracture increased risk of stroke - CORRECT ANSWER>>Tibolone and osteoporosis where is it approved? why wasn't it submitted for approval in the US and canada? 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. - CORRECT ANSWER>>Why was estrogen not approved for osteoporosis? osteosarcoma - CORRECT ANSWER>>Black box warning for PTH receptor agonists? hypercalcemia - CORRECT ANSWER>>caution using PTH receptor agonists in what condition? someone incredibly high risk for vertebral fracture - CORRECT ANSWER>>when would you use PTH receptor agonists? vertebral fractures - CORRECT ANSWER>>raloxifene helps with what kind of fractures? increased risk of death from stroke in high risk patients, estrogen like risk of VTE, worsens hot flashes - CORRECT ANSWER>>raloxifene risk factors 1 in 1000 after 2-3 years. - CORRECT ANSWER>>atypical femur risk in women on bisphosphonate? small increase in spine BMD. daily SQ injections or nasal. - CORRECT ANSWER>>Salmon calcitonin and osteoporosis? Decreased fibroblast activity disrupted elastin decreased GAG production Disrupted melanocyte regulation

Decreased blood flow and cellular oxygenation effects on keratinocytes Disruption of cellular growth factors and repair enzymes accelerated lipoatrophy Fat pad modification Bone resorptuon - CORRECT ANSWER>>Implications of estrogen drop on skin during menopause Involuntary loss of urine that occurs with an activity such as coughing or sneezing that increases intraabdominal pressure. Leakage is in drops, usually 2/2 to poor urethral support, urethral sphincter weakness, dysfunction of pelvic floor - CORRECT ANSWER>>Definition of stress incontinence Involuntary loss of urine preceded by sensation of urgency to urinate. Generally associated with losses of larger volumes of urine that soak through pads and clothing. Leakage results from detrusor (bladder) overactivity/uninhabited contractions of detrusser - CORRECT ANSWER>>Definition of urgency incontinence includes stress and urgency - CORRECT ANSWER>>Definition of mixed incontinence 100 or less, whereas >200 is abnormal, between 100-200 advised to repeat on different day - CORRECT ANSWER>>A postvoid residuals (w/in 15 minutes of emptying) of what volume is considered normal pyridium challenge - CORRECT ANSWER>>how to test for incontinence Term used to describe idiopathic urinary urgency (w or w/o incontinennce) with urinary frequency (>8voids w/in 24h) adn sometimes nocturia (awakening to urinate more than 2x/night - CORRECT ANSWER>>OAB Hypoactive sexual desire disorder Female genital arousal disorder Persistent genital arousal disorder Female orgasm disorder Femal orgasmic illness syndrome - CORRECT ANSWER>>ISSWSH Sexual Disorders in Menopause Levator ani superficial (transverse perineal, bulbospongiosus, ischiocavernosus) Deep (pubococcygeus, iliococcygeus, obturator internus, coccygeus( muscles - CORRECT ANSWER>>Pelvic floor muscles P: Polyp A: Adenomyosis L: Leiomyoma M: Malignancy/hyperplasia C: Coagulopathy O: ovulatory dysfunction E: Endometrial I: Iatrogenic N: Not yet classified - CORRECT ANSWER>>PALM COEIN causes of AUB

When <4mm - CORRECT ANSWER>>When is EMB not needed? Cocs decrease 7 to 4 days; IUD NSAID - reduce prostaglandin synthesiss which may have a role in aberrant neovasculariation - CORRECT ANSWER>>Management of AUB Mefenamic acid 500 mg TID for 5 days or Ibuprofen 600 mg Q6h or 800mg Q8 h for first 3 days - CORRECT ANSWER>>Dosing of NSAIDS for AUB 1300 mg TID for 5 days of menstrual cycle ; causes GI upset - CORRECT ANSWER>>Dosing of tranexamic acid for AUB Addback therapy can be used to protect against VMS and bone mineral density losss - CORRECT ANSWER>>GnRH therapy for fibroids Tranexamic acid and mefenamic acid mirena GnRH Selective progesterone receptor modulators Uterine artery embolization - CORRECT ANSWER>>Nonsurgical treatment of fibroids 5cm in diameter - CORRECT ANSWER>>Hysteroscopic myomectomy is most suitable for fibroids smaller than Pruritic, purple, polygonal planar papules and plaques (6 P's) - CORRECT ANSWER>>Lichen Planus inflammatory condition - autoimmune - antibodies against extracellular matrix. Affects males and females equally - but female genital and perineal region is most commonly affected. - CORRECT ANSWER>>Lichen sclerosis et atrophicus Leukoplakia with thick, leathery vulvar skin associated with chronic irritation and scratching., hyperplasia of the vulvar squamous epithelium - CORRECT ANSWER>>Lichen Simplex Chronicus only when it is symptomatic, these respond to topical corticosteroids. When it has a burning sensation, patients should be prescribed an antifungal - CORRECT ANSWER>>lichen planus treatment topical steroid (clobetasol) - CORRECT ANSWER>>lichen sclerosis tx Corticosteroid: Triamcinolone 0.1% (Alway start off with low potency then move if it gets worst) - CORRECT ANSWER>>Lichen Simplex Chronicus Treatment Remove potential aggravators such as sleep deprivation, alcohol, exercise, caffeine, smoking Sleep hygiene, exercise, warm baths, leg vibration, massage, acupuncture, passive strestching - CORRECT ANSWER>>Non-pharmo Tx for restless legs and periodic imb movements Parmipexole and ropinirole - CORRECT ANSWER>>PHarmo tx for RLS

Systemic symptoms (fever, weight loss, rash) Systemic illness malignancy, immunosupression Neurologic symptoms and/or signs in consciousness Sudden/abrupt onset new onset or progressive New/different from previoux headache hx - CORRECT ANSWER>>Red flags for headache triptans, NSAIDs - CORRECT ANSWER>>Abortive therapy for migraine Beta Blockers (propranolol) , Antiepileptic Drugs (divalproex), Tricyclic Antidepressants (amitriptyline) - CORRECT ANSWER>>Preventative therapy for migraines CAn be used to mitigate falling estrogen levels, no product FDA approved; can add lowdose estrogen supplement during w/d phase of ocp, use continuous HT; if progesterogen causes, switch to micronized - CORRECT ANSWER>>Hormone therapy for headache 2/2 to menopause 2/2 to arthritis 2/2 to other rheumatologic condition - CORRECT ANSWER>>What to consider when evaluating women with arthralgia drug induced (statines, fibrates) endocrine (vit D deficiency, thyroid, cushings) Menopause plymyalgia rheumatica - CORRECT ANSWER>>Causes of myalgia metagolic (pagets disease) neoplasia (multiple myeloma, metastatic infections fracture - CORRECT ANSWER>>Causes of bone pain

• 2 to +1a; - CORRECT ANSWER>>Perimenopause STRAW staging
  • CORRECT ANSWER>>STRAW staging system Loss of ovarian follicular activity prior to the age of 40 - CORRECT ANSWER>>POI 3% - CORRECT ANSWER>>Prevalence of POI in US True
• higher risk for abdominal adiposity, dm, dyslipidemia - CORRECT ANSWER>>T/F Premature menopause is a risk factor for CAD

1. Iatrogenic/Indused (surgery, chemotherapy, cystectomy, hysterectomy, radiation)
2. spontaneous (genetic disorders, x-chromosome disorder (monosomy, trisomy); specific mutations: POF1, POF2, FMR genes
3. autoimmune causes: polyendocrine syndromes, other endocrinopathies, non-endocrine auto-immune conditions

4. idiopathic - CORRECT ANSWER>>Etiology of premature menopause H&P Labs:

• TSH
• Prolactin
• Pregnancy test
• Elevated FSH (>25 IU/L on 2 checks/4-6 weeks apart)
• AMH
• E2 can fluctuate greatly
• Low AFC - CORRECT ANSWER>>Diagnosis of POI Genetic testing Autoimmune workup
• TSH, thyroperoxidase antibody, 21-OH antibodies, fasting glucose, HbA1C
• Ovarian antibodies lack sensitivity and specificity - CORRECT ANSWER>>Assessment of etiology of POI Transdermal 17 (100 mcg/d patch or gel) Oral 17B estradiol 2mg/day vaginal ring: 17B .1mg/day Oral CEE: .9-`1.25mcg/day - CORRECT ANSWER>>Estrogen therapy in premature menopause Can consider, adjust therapy to achieve goal range of 80-120 pg/ml - CORRECT ANSWER>>Should you check estradiol levels for prematures No studied General principle, use higher doses; micronized 200-400 mg/d (cont/cyclically) or IUD - CORRECT ANSWER>>Use of progestogen in premature menopause May be more socially acceptable; lower cost Better bone outcomes and lower blood pressure with replacement estradiol (limited evidence) - CORRECT ANSWER>>COCs vs estrogen in younger women Comes from zone retic and ovaries - CORRECT ANSWER>>Production of androgens yes - CORRECT ANSWER>>Consider testosterone replacement in POI and surgically postmenopausal women true - CORRECT ANSWER>>T/F Fat and lean mass increase prior to menopausal transition about 2 years after FMP - CORRECT ANSWER>>Rate of fat gain doubles and lean mass declines during menopausal transition; when do things stabilize? 2 - 4 fold increase in fat mass (6%, 1.6kg over 3.5 years .5% loss of lean muscle - CORRECT ANSWER>>Weight gain during menopausal transition Premenopaust weight increase,MT - stead increase, post meno no change - CORRECT ANSWER>>Changes in weight gain during peri/meno

yes likely driven by decreased active energy expenditure - CORRECT ANSWER>>Should calorie intake decrease in post menopause IN women w/o DM, HRT (oral or transdermal E+/-P) improves lean body mass, reduces abdominal adiposity, improves insulin resistance, improves lipids, decreases BP - CORRECT ANSWER>>HRT on cardiovascular risk factors Initiate weight loss medication as adjunct to lifestyle:

• if BMI (27-29.9 in presence of comorbid)
• If BMI >30 and failure of lifestyle - CORRECT ANSWER>>When to add anti-obesity medication ~8% GI lipase inhibitor poop in your pants - CORRECT ANSWER>>Weight loss w/ orlistat 8 - 12% C/I: glaucoma, hyperthyroid, MAOI SE: insomnia, dry mouth, paresthesias, metabolic acidocis, anxiety, tachy - CORRECT ANSWER>>Weight loss with phentermine/topiramate ER ~5-6.4% Dopamine and norepinephrine reuptake inhibitor and u-opioid receptor antagonist C/I: htn, seizures, eating disorder, opioid use, SE: nausea, headache - CORRECT ANSWER>>Weight loss with Naltrexone SR/Bupropion SR (Contrave) GLP-1 receptor agonist Dose up to 3mg daily in .6mg steps Weight loss ~7-10% C/I: pancreatitis, fam hx of medullary thyroid, multiple endocrine neoplasia S/E: nausea, diarrhea, vomiting constipation - CORRECT ANSWER>>Weight loss with liraglutide ~14-16% GLP-1 receptor agonist Dose up yo 2.4mg daily in slow weekly dose titration C/I: pancreatitis, fam hx of medullary thyroid, multiple endocrine neoplasia S/E: nausea, diarrhea, vomiting constipation - CORRECT ANSWER>>Weight loss with semaglutide GLP-1s help the pancreas release more insulin, delay stomach emptying, and reduce appetite. - CORRECT ANSWER>>How do GLP-1 receptor agonists work? Short term, FDA approved for shortterm use (<12 weeks); common practice to prescribe for longer; retrospective data suggests; better weight loss iwth longer use >6m; no increase in AE cardiovascular; no addiction potential I do not believe any of theis - CORRECT ANSWER>>Weight loss with pentermine monotherapy Roux-en-y bypass Sleeve gastrectomy

Biliopancreatic diversion iwth duodenal switch - CORRECT ANSWER>>Surgical management of obesity BMI > BMI >35 w/ 1 comorbid BMI 30-35 w/ T2DM, poor glycemic control despite lifestyle - CORRECT ANSWER>>Who is eligible for bariatric surgery? Disorders that reduce or slow hair growth without irreparably damaging the hair follicle

• primarily affect the hair shaft - CORRECT ANSWER>>Non-scarring alopecia replacement of hair follicles with scar tissue - CORRECT ANSWER>>scarring alopecia Androgenetic alopecia Telogen Effluvium Alopecia Areata - CORRECT ANSWER>>examples of non-scarring alopecia Send to derm - CORRECT ANSWER>>How to treat scarring alopecia Female pattern thinning Genetic predisposition Hromonal factors A slow minaturization over time
• follicular miniturization - finer hair
• shorter growth cycle - shorter hair
• longer latent period - delay before new hair starts NOT AN ABRUPT SHED - CORRECT ANSWER>>Androgenetic alopecia 50+% of women Can begin in teens Usually NOT androgen excess What did you first notice (ponytail smaller, part wider, see scalp - CORRECT ANSWER>>Female pattern thinng: Who when what TSH, CBC, ferritin ?PCOS? - CORRECT ANSWER>>What labs to obtain in fmale pattern thinning minoxidil 5% once daily - CORRECT ANSWER>>Topical treatment for female pattern thinning Younger women
• OCP w/ drospirenon
• spironolactone 100-200 mg daily Minoxidil 2.5mg daily Finasteride 5mg daily Dutasteride .5mg daily - CORRECT ANSWER>>Systemic treatment for female pattern hair thinning Premature shedding of hair in the resting phase - CORRECT ANSWER>>Telogen effluvium

Thyroid Rapid weight loss Significant illness Anesthesia Malnutrition Pregnancy Heparin, β-blockers, IFN, lithium, retinoids, OCP discontinuation, antidepressants, anticonvulsants, ACE inhibitors, colchicine, NSAIDs - CORRECT ANSWER>>causes of telogen effluvium testosterone levels decrease but not as significantly as estrogen levels therefore leading to a hypoestrogenemic and relative hyerandrogenic state that may lead to patterned hair loss - CORRECT ANSWER>>Testosterone estrogen level trend in menopause and impact on hair Vasoactive hormone Increase blood flow, increases transductive lubrication Supplies glyogen to superficial and intermediate layers maintaining acidic pH Supports collagen content of the vagina, maintains thickenss and elasticity of the vaginal walls Supports epithelium , connective tissue, and smooth muscle of the vulva agina, uretrha and bladder trigone - CORRECT ANSWER>>The role of estrogen on urogenital health long term aid to vaginal dryness attaches to mucin and epithelial cells on vaginal wall Carries up to 60x its weight in water HOlds water in place requires maintenance 2-3x week - CORRECT ANSWER>>non-pharmacologic vaginal moisturizer Can: Type I and II Carcinosarcoma Cannot: Leiomyosarcoma Stromal sarcoma - CORRECT ANSWER>>What uterine cancer can you use topical estrogen? Which to not? Can: HGSOC Germ cell Granulosa cell Cannot: Endometrioid - CORRECT ANSWER>>Which ovarian cancer can you use topical estrogen? Which can you not?

All - CORRECT ANSWER>>Which types of cervical cancer can ou use topical estrogen daily for 2 weeks then 2x weekly - CORRECT ANSWER>>Dosing of vaginal estrogen Type:

• provoking factord
• sense of urgency
• Frequency
• Ability to defer Severity and Impact on QoL
• Leak frequency
• Pad use
• Impact on ADL Complexity & Safety
• Bladder emptying
• Blood, stones
• Pain
• Comorbidities - CORRECT ANSWER>>Evaluation of incontinence Stress incontinence Overactive bladder Oveflow incontinence - CORRECT ANSWER>>Main types of incontinence Every 5 years starting at age 35 - CORRECT ANSWER>>Screening for thyroid disease Hypothyroidism caused by hashimoto thyroiditis - CORRECT ANSWER>>Most common thyroid disease .4 mIU/L to 4.5 mIU/L; if TSH level is elevated, free T4 and antithyroperoxidase antibodies should be measured - CORRECT ANSWER>>Normal range of serum TSH 1.6ug per KG Over 50 start w/ 25ug to 50 with progression every 2-3 weeks until euthyroid is reached Wtih CHD start lower titrate every 6-8 weeks Monitor TSH every 4-6 weeks after any change - CORRECT ANSWER>>Levo dosing TSH levels should e monitored 6-8 weeks later; anticipate that dose of Levo may need to e increased; oral (not transdermal) estrogens increase thyroid binding globuling which reduces FT4 - CORRECT ANSWER>>If patient is treated with thyroid medication starts oral ET; what do yo u need to do and why? abnormally high secretion of thyroid hormones Low TSH (persistently less than .1mIU/L in all persons aged 65 and older - CORRECT ANSWER>>hyperthyroidism/ grave's disease 3 fold increase in hip fractures for pt iwth excess endogenous thyroid hormone production (i.e. TSH <.1mIU/L) - CORRECT ANSWER>>Bone effects of TSH

Rarely associated with thyroid cancer - CORRECT ANSWER>>hot thyroid nodule Sleep complaint that occurs at least 3 times per week for at least 3 months and is associated with distress or impaired daytime personal functioningS - CORRECT ANSWER>>Definition of insomnia SCOFF - CORRECT ANSWER>>Screening tool for eating disorder DAST10 - CORRECT ANSWER>>Screening tool for drug abuse HARK - CORRECT ANSWER>>Screening tool for intimate partner violence PHQ - CORRECT ANSWER>>Screening tool for depression GAD- 7 - CORRECT ANSWER>>Screening tool for anxiety An average annual loss of about 2% begining 1-3 years before menopause and lasting 5-10 years. Acrosss the menopause transition women lose up toe 10-12% of bone loss (one Tscore) After this, women lose about .5% per year - CORRECT ANSWER>>Rate of bone loss at menopause 30% - CORRECT ANSWER>>By the time a woman is 80, how much bone loss has she lost?

• 2 to +2 (comparison to a young white woman - CORRECT ANSWER>>Normal T score range for BMD is the number of standard deviations above or below the average BMD for the average person of the same age, gender, and ethnicity, the normal is also - 2 to +2 - CORRECT ANSWER>>What is a z-score? T score < - 2.5 - CORRECT ANSWER>>Definition of osteoporosis T score between - 1 and - 2.5 - CORRECT ANSWER>>Definition of osteopenia Women who have a low BMD (z-score < - 2) and have a history of fragility fracture - CORRECT ANSWER>>Definition of osteoporosis in premenopausal women Used to predict the 10 year risk of fracture o Elements include
• Age - 40 - 90
• Gender
• BMI
• Previous fracture
• Previous hip fracture
• Current smoking
• Glucocorticoid use (3 months at more than 5mg / day)
• Rheumatoid arthritis
• Secondary osteoporosis
• EtOH - more than 3 drinks a day
• Bone mineral density - CORRECT ANSWER>>FRAX score

Age, thinness, genetics, smoking, hx of fracture, diseases and drugs (AI, steroids), excessive etoh, infertility - CORRECT ANSWER>>Risk factors for low bone mineral density screening tool for osteoporosis tells 10 year probability of hip fx or major osteoporotic fracture (hip, proximal humerus, distal radium, symptomatic spine fracture) - CORRECT ANSWER>>FRAX score is ____ All women aged 65 and older, younger postmenopausal women wiht one other important risk factor of low BMD (personal family hx of fracture, low body weight) - CORRECT ANSWER>>DEXA screening recommendations 800 - 1200 mg; excessive intake (>2000) should be avoided ecause this is associated with renal stones - CORRECT ANSWER>>REcommended daily intake of calcium

20 ng/ml - CORRECT ANSWER>>Normal vitamin D correct - CORRECT ANSWER>>Systemic estrogen is approved for osteoporosis prevention Stupid, but true - CORRECT ANSWER>>Systemic estrogen is NOT approved for osteoporosis treatment correct - CORRECT ANSWER>>The benefits fo estrogen abate within a few months after stopping therapy SERMS (selective estrogen receptor modulators, have weak estrogen agonist properties in bone whil functioning as antiestrogen in female reproductive tissues - CORRECT ANSWER>>What are estrogen

agonists/antagonists Selective Estrogen Receptor Modulator (SERM) Induces small increases in BMD 60 mg daily for 3 years reduced vertebral fractures by 30% Risk of VTE in elderly women Reduced risk of invasive breast cancer - CORRECT ANSWER>>Raloxifene (Evista) younger postmenopausal women with osteoporosis at risk for vertebral but not hip fracture w/o significant vasomotor symptoms - CORRECT ANSWER>>Raloxifene is an appealing treatment options for: Selective Estrogen Receptor Modulator (SERM) vertebral fracture risk reduced by 42% over 3 years no effect on nonvertebral risk, no effect on reast cancer irsk proven Combo of bazedoxifene 20 mg and .45 mg CEE daily improves VMS and prevents bone loss in young postmenopausal women - CORRECT ANSWER>>Bazedoxifene Fosamax: inhibit bone resorption used in osteoporosis. AE: dysphagia, esophageal ulcer. Nursing: take 1st thing in the morning w/o food, 8oz of water, remain upright for 30mins after taking, if dose missed- skip - CORRECT ANSWER>>Bisphosphonates Classification: Bone resorption inhibitor. Bisphosphonate

Therapeutic Effects: TX and prevention of post-menopausal and cortico-steroid-induced osteoporosis, Adverse Reactions & side effects: Altered taste, photosensitivity, rash, musculoskeletal pain, fluid overload, esophagitis. Common upset stomach & heartburn, GI effects Nursing Implications & teaching:Take first thing in the AM, before eating anything; then pt MUST remain upright for at least 30 mins! Take only with plain water. Monitor for GI side effects. Use sunscreen to prevent photosensitivity reactions. - CORRECT ANSWER>>Fosamax (alendronate) Biphosphate. Taken daily, weekly, or monthly. - CORRECT ANSWER>>Risedronate (Actonel) Biphosphate. IV annually. - CORRECT ANSWER>>Zoledronic acid (Reclast, Zometa) Results in additional gains - CORRECT ANSWER>>After 5 years fo treatment in women with high risk of osteoporosiss, consider switching to denosumab Monoclonal antibody for postmenopausal women Subcutaneous injection every 6 months - CORRECT ANSWER>>Denosumab (Prolia) Reduces bone loss in osteoporosis potent inhibitor of bone resorption - CORRECT ANSWER>>salmon calcitonin annual genital chlamy and gonn - CORRECT ANSWER>>STI screening in < 2021 guidelines: ceftriaxone 500 mg IM x or ceftriaxone 1g IM x1 if > 150kg If chlamydia not ruled out; doxy 100 BID 7 days - CORRECT ANSWER>>treatment for gonorrhea 3 months - CORRECT ANSWER>>when to repeat testing for Chlamydia? History of endometrial cancer Personal history of breast cancer History of thromboembolic disorders Acute or chronic liver disease Coronary artery disease Elevated triglyc Undiagnosed vaginal bleeding - CORRECT ANSWER>>Contraindications to HRT