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NAMs Menopause Certification Exam
Climacteric phase - ANSWER - The period of endrocrinologic, somatic, and transitory psychologic changes that occur around the time of menopause. Early menopause - ANSWER - LMP before age 45 Late menopause - ANSWER - LMP after age 54 Primary ovarian insufficiency - ANSWER - Menopause that occurs before age 40 Early menopause transition (stage - 2) - ANSWER - Persistent difference of 7 days or more in the length of consecutive cycles. Late menopause transition (stage - 1) - ANSWER - 60 or more consecutive days of amenorrhea Luteal out of phase event (LOOP) - 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. Obese women and estradiol levels during menopause - ANSWER - Obese women are more likely to have anovulatory cycles with high estradiol levels. They are also more likely to have lower premenopause yet higher postmenopause estradiol levels compared with women of normal weight. (why they are at higher risk of endometrial cancer) Chinese and Japanese women - ANSWER - These ethnic groups have lower estradiol levels then white, black and hispanic women. stage +2 - ANSWER - late menopause stage: 5-8 years after FMP. Somatic aging predominates. Increased genitourinary symptoms. Stages +1a, +1b, +1c - ANSWER - early post menopause: 2 years after FMP. FSH rises, estradiol decreases. VMS predominate. Elevated FSH, LH - ANSWER - Endocrine labs after menopause AMH, inhibin B - ANSWER - These hormones work during reproductive years to not deplete follicle pool too quickly.
Vaginal changes with menopause - ANSWER - Thinning, loss of elasticity, loss or absence or rugae. Vagina and urethra in menopause - ANSWER - vagina narrows, urethra moves closer to the introitus. Stress urinary incontinence - ANSWER - Vaginal estrogen and urinary incontinence: what type does it help with? Treatment for FPHL - ANSWER - Minoxidil, spironolactone, finasteride, estrogen therapy Late reporoductive years - 3b and - 3a. What happens with menstrual cycles, FSH, AMH, AFC, inhibin? - 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? - 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? - 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. AFC - ANSWER - Antral follicle count Number of follicles that are detectable with ultrasound. They are sensitive to FSH and considered to represent the availability poo of follicles.
Surgical menopause causes women to have lower levels of what hormone? - 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? - ANSWER - inhibin and AMH decrease therefore, follicle growth is not restrained, this allows for the growth of the remaining, diminished follicle pool. In the menopause transition, women spend more time in what phase? - ANSWER - Luteal-more PMS symptoms, more frequent menstrual periods. HPO axis theory and the menopause transition - 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?
What region of the adrenal gland secretes the androgens? - ANSWER - zona reticularis what are considered the 'adrenal androgens'? - ANSWER - DHEA, DHEAS, Androstenedione. Aldosterone secretion from the zona reticularis in the adrenal gland is regulated by 3 main factors. - ANSWER - Angiotensin II, potassium concentration, adrenocorticotropic hormone secreted by the anterior pituitary. What part of the pituitary gland secretes adrenocorticotropic hormone?
- ANSWER - Anterior pituitary. The posterior only secretes vasopressin and oxytosin. Cortisol and HRT - 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.
treatment of POI - ANSWER - 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. Hair loss. Difference between FPHL and telogen effluvium? - ANSWER - 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. FPHL pattern - ANSWER - thinning at the crown of the head and widening of the hair part Treating FPHL - ANSWER - MINOXIDIL spironolactone finasteride
What ethnicity has the least likely chance of having bad hot flashes? - ANSWER - Japanese What ethnicity is the most likely to have bad hot flashes? - ANSWER - black more frequent, longer duration. Median length of hot flashes - ANSWER - 10 years, early menopause transition women have them the longest. Theories about etiology of hot flashes (6) - ANSWER - lower ovarian estradiol thermoregulation zone is narrowed neurokinins-regulate GnRH secretion. KNDy new meds serotonin cortisol and HPI axis dysregulation endothelial dysfunction. VIN low grade-what to do high grade-what to do differentiated VIN-what to do - ANSWER - low grade is not precancerous
Most common cause of vulvovaginitis? - ANSWER - BV post menopause burning and diffuse yellow/brown discharge and dyspareunia that does not respond to local ET? - ANSWER - desquamative inflammatory vaginitis. treat different with clindamycin or hydrocortisone+ET What hormones are associated with sexual desire in women? - ANSWER
- circulating androgens Women who have had a BSO experience an abrupt and persistent decline in what hormone? - ANSWER - circulating androgen levels HSDD and FSAD were combined into a single dysrunction called - ANSWER - female sexual interest/arousal disorder HSDD treatments - ANSWER - flibanserin and bremelanotide FGAD treatments (genital arousal disorder) - 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 - ANSWER - directed masturbation is most researched behavioral treatment. Does systemic ET cause fibroids to resume growth? - ANSWER - Rarely. They often shrink after menopause. What is true about cognition and menopause? - ANSWER - Difficulty concentrating and remembering are common. What is true about cognition and surgical menopause - ANSWER - memory for verbal information can be compromised immediately after surgical menopause, especially if it is before the typical age of mesopause. Meta analysis of RCTs have shown small benefit of what diet/exercise for global cognition and memory? - ANSWER - Mediterranean diet with olive oil and tai chi exercise helps with global cognition Mediterranean diet with olive oil and isoflavone supplements helps with memory. effect of HRT on cognition - ANSWER - small or no overall effect on cognition
menstrual migraine after menopause - ANSWER - should resolve completely When to consider preventative medication for migraines - ANSWER - > times per week or severe and effecting QOL Triptans are contraindicated in what? - ANSWER - patients with cardiovascular disease, as are NSAIDs Menstrual migraine treatment - ANSWER - NSAID or triptan 2 days before expected to get your period, and take for 5-7 days. cdc and who guidelines for migraine treatment - ANSWER - migraine with aura-advise to not use combined hormone contraception caution in women with migraine without aura How long can it take for arthralgia from vitamin d deficiency or hypothyroidism to fully resolve? - ANSWER - it can take several months. what is th emost common form of arthritis? - ANSWER - osteoarthritis
what areas of th ebrain have th emost estrogen receptors? - ANSWER - hippocampus and prefrontal cortex what is the most common thyroid disorder in women? - ANSWER - hashimoto thyroiditis if a patient on levothyroxine is started on estrogen, when do you recheck and what can you anticipate happening? - ANSWER - 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. when is treatment of subclinical hypothyroidism recommended? - ANSWER - when the TSH level is higher than 10. are hot or cold thyroid nodules typically most likely to be malignant? - ANSWER - cold nodules how does HRT impact gallbladder disease? - ANSWER - increases risk of gallstones with oral HRT, lower risk with transdermal.
what is the most commonly sexually transmitted infection in the US? - ANSWER - HPV What percentage of bone loss do women have from the menopause transition? - ANSWER - 10 - 12% on average, about 1 t score What t score defines osteopenia - ANSWER --1.5 to - 2. what t score defines osteoporosis - ANSWER - less than - 2. what z score defines osteoporosis before menopause? - ANSWER - z score less than 2.0 and a history of a fragility fracture Who is at highest risk of osteoporosis? - 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? - 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? - ANSWER - lower
Black women have ____BMD than white people? - ANSWER - higher Over 3 servings of alcohol daily and risk for fracture? - ANSWER - 38% for osteoporotic fracture and 68% for hip fracture What 4 ethnic specific versions of FRAX are there? - ANSWER - white, asiain, black, hispanic Dairy free diet amount of calicum. How much do they need to supplement? - ANSWER - dairy free diet-300mg calcium daily. Needs 800-1200mg Tibolone and osteoporosis where is it approved? why wasn't it submitted for approval in the US and canada? - ANSWER - approved in mexico decreased risk of vertebral and nonvertebral fracture increased risk of stroke Why was estrogen not approved for osteoporosis? - ANSWER - decreased risk of vertebral and hip fracture in low fracture risk
