NAMS Certification Exam 2024 questions and answers, Exams of Advanced Education

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NAMS Certification Exam 2024 questions and answers Early Menopause FMP before age 45 Late Menopause FMP after age 54 Bilateral oophorectomy prior to age 45 increases risks for: - All cause mortality - Coronary heart disease - CVD - Menopause symptoms - Worsening mood symptoms - Higher incidence of Parkinson Disease - Associated with cognitive impairment Early Menopause Transition (-2) 7 or more days persistent difference in cycle length from previous normal cycle - Results of increased follicular aging and depletion - Inhibin B decreases - FSH increases (Variable) LOOP Cycles Explains elevation of Estradiol in perimenopause - Rising FSH levels recruit 2nd follicle during luteal phase which leads to overproduction of Estradiol - This causes menstrual changes in future cycles Decreased AMH in Early Menopause Transition More frequent anovulatory cycles Decreased Inhibin B in Early Menopause Transition - Skipped menstrual cycles - Mastalgia - Migraine - Menorrhagia (with LOOP cycles) - Endometrial Hyperplasia Late Menopause Transition (-1) 60 or more days of amenorrhea for women aged 45 years or older - Women 40-44 years with recurrent episodes of amenorrhea of 60 day for longer within a year improves prediction of entry into late menopause transition Late Menopause Transition (-1) Duration 1-3 years Late Menopause Transition (-1) Symptoms VMS likely STRAW Stage where FSH > 25 Late Menopause Transition (-1) Elevated FSH symptoms in Late Menopause Transition - VMS - Sleep disturbance - Changes in weight distribution - Increased variability in cycle length Decreased Inhibin B in Late Menopause Transition - Mood changes - Cognitive complaints - Changes in sexual functioning - Increased prevalence of anovulation Decreased AMH in Late Menopause Transition - GSM - Bone loss - CVD issues - Interval of amenorrhea > 60 days POI Menopause before age 40 POI diagnosis - Oligomenorrhea or amenorrhea x 4 months - FSH > 25 on two occasions at least 4 weeks apart - BMI 27-29.9 with co-morbidity - BMI >30 When can you consider surgery for weight loss? - BMI >35 with co-morbidity - BMI >40 Menopause and Sleep - Repeated middle-of-night interruption is common in menopause - VMS leads to increased sleep complaints and puts patient at higher risk of depression HT and sleep - HT may be prescribed as first line therapy for hot-flash related sleep disturbance Increased risks of Hysterectomy and/or BSO - Higher prevalence of VMS - Early onset dementia in women < 50 years of age HT and Dementia - Initiating HT age older than 65 increases risk of dementia - The negative effects of HT on dementia in older postmenopausal women do not apply to younger postmenopausal - HT should not be recommended for cognition Menopause and Dementia "Brain Fog" or difficulty concentrating are common in menopause First line treatment for Insomnia CBT; recommend sleep diary for 1-2 weeks Menopause and Arthralgia - Chronic MSK joint pain affects 50% of population, more common in women age 45-55 - Important to rule out underlying disease Arthralgia vs Arthritis Arthralgia - no harm to joints; just pain Arthritis - pathologic abnormality of joint Fibromyalgia Chronic condition with widespread aching and pain in the muscles and fibrous soft tissue - Associated with fatigue, sleep disturbance, anxiety/depression Mild Hot Flash Sensation of heat without sweating Moderate Hot Flash Sensation of heat with sweating, able to continue activity Severe Hot Flash Sensation of heat with sweating, causing cessation of activity VMS is associated with increase risk of? CVD and osteoporosis Does VMS worsen in premenopause or post menopause? VMS prevalence increases in peri/postmenopause Risk factors for VMS - Higher adiposity in early menopause transition - Smoking - Diet high in fat and sugar - Low socioeconomic class Who experiences VMS most? Black women, and for longer duration Contraindication for HT - Unexplained vaginal bleeding - Liver disease or gallbladder disease - Breast cancer - Prior CVD, MI - Prior VTE, stroke - Personal history of inherited high risk of thromboembolic disease Benefits of HT - Prevents osteoporosis - Reduces new onset diabetes risk - Reduces coronary heart disease when started < 60 or within 10 years of menopause - May improve depression/anxiety - May improve sexual function and genitourinary health Paroxetine Only non-hormone medication FDA approved for VMS Gabapentin for VMS - May improve VMS - Adverse effects include tremors and weight gain Clonidine for VMS Adverse effects include HTN the abruptly stopped, hypotension with consistent use, HA, dry mouth Oxybutynin for VMS - FDA approved for overactive bladder - May reduce VMS after 1 week but side effects include dry mouth SSRI for VMS - Citalopram and Escitalopram SNRI for VMS Desvenlafaxine and Venlafaxine Models of sexual response Biopsychosocial model which is an integrative model of sexual function that evolves over time reflecting a women's fluctuations in health status, mental health, interpersonal concerns, and sociocultural beliefs/values 17-b-estradiol vaginal ring Estring (VVA and urinary urgency) Estradiol acetate vaginal ring Femring - Approved for both VVA and VMS due to high dose of estradiol causing systemic levels of estrogen - Need Progesterone if intact uterus Estrace Vaginal Cream (17-beta-estradiol cream) - Indicated for VVA and dyspareunia - CBT - Only FDA approved medication is Flibanserin - Only approved for premenopausal women; increases risk of hypotension and syncope when combined with alcohol Testosterone and HSDD Not FDA approved Studies show it may have positive effect Female sexual arousal disorder (FSAD) inability to maintain adequate lubrication/swelling response for > 6 months FSAD treatment - CBT, mindfulness/meditation - Eros Therapy Device, masturbation - Consider L-arginine - Wellbutrin Ospemifene Administered orally on a daily basis for dyspareunia/vaginismus Anovulatory Bleeding Presents as noncyclic menstrual blood flow ranging from spotting to heavy Indication for EMB If EMS greater than 4 mm in postmenopausal women Pure Menstrual Migraine Migraine attacks occur only premenstrually Menstrually related migraine Migraine occurs both premenstrually and at other times of cycle Triptans are contraindicated in? Ischemic heart disease or some vascular disorders (due to constriction of dilated intracranial arteries) When to consider preventive therapy for Migraines? >2 attacks per week on average Preventive Therapy for migraines - Amitryptiline - Beta-blcokers (avoid with asthma) - Topiramate and Divalproex) Headaches and HT - Increase risk of stroke in women who take COC who have migraine with aura - No contraindication has not been identified for this with migraine who need HT doses for treatment of symptoms of menopause and/or their HA Hypothyroidism Elevated TSH with low FT4 Treat with Synthroid HT and Hypothyroidism If patient taking Synthroid initiates/stops Oral HT: - TSH 6-8 weeks after initiation of Oral HT - Expect FT4 to decrease cold thyroid nodule These are more often cancer than hot nodules when looking at I-123 scan These need to be worked up Monitor TSH when on Synthroid - TSH every 4-6 weeks until TSH in normal range - Once TSH is normal, assess every 6-12 months Osteopenia T score between -1 and -2.5 Osteoporosis T score -2.5 or lower Osteoporosis risk factors Alcohol use (>3 drinks/day) Corticosteroid use Calcium low Estrogen low Smoking Sedentary lifestyle Parental history of osteoporosis/hip fracture Personal history of fracture FRAX Score - 10 year osteoporosis risk assessment - Valid age 40-90 - Order DEXA if major osteoporotic fracture > 9.3% HT and Osteoporosis ET prevents bone loss in postmenopausal women Not indicated for treatment of osteoporosis since it has not shown to reduce fracture risk in women with known osteoporosis Bisphosphonates (e.g., Alendronate, Risedronate, Zoledronic Acid) Used for post-menopausal osteoporosis treatment Side effects: Esophagitis, GI distress, muscle pain, visual disturbances Rare Adverse Event: Osteonecrosis of jaw Bisphosphonates and BMD testing - Repeat BMD after 5 years of treatment to determine if therapy can be discontinued - Monitor renal function Osteopenia Treatment Adequate intake of calcium (800-1,200 daily) Adequate intake of Vitamin D (800-1,000 IU/d Weight-bearing and resistance exercise Fall prevention Smoking cessation Moderating alcohol intake (< 2 drinks/day for women) Raloxifene Indicated for younger postmenopausal women at risk for vertebral fracture (not hip fracture) Do not prescribe if VMS symptoms and high VTE risk May decrease breast cancer risk