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NAMS Menopause Certification Exam
Study Set Questions With Solutions
which 3 common drugs? Hyperthyroidism, hyperparathyroidism, hypercalciuria, certain drugs (eg: tamoxifen, steroids, PPIs), calcium/vitamin D deficiency, RA, celiac disease, malabsorptive diseases such as Crohn disease, and ulcerative colitis Median age of menopause in US women 52.54 y POI Intermittent ovarian function & insufficient estrogen levels occurring at age <40 y which STRAW stage?
menarche / early reproductive
which STRAW stage?
peak reproductive
which STRAW stage?
late reproductive
which STRAW stage?
perimenopause -2 to -1 & +1a which STRAW stage?
FMP & 12 months after final menstrual period FMP = 0 12 months after = +1a which STRAW stage?
VMS most likely +1a (most likely) -1 (likely)
aka perimenopause/menopause transition
menopause transition: -2 and -1, prior to FMP
perimenopause: -2 to +1a, includes 12 mo of amenorrhea following FMP which STRAW stage?
initial drop in AMH/AFC/inhibin, cycles still regular, FSH normal -3b
aka late reproductive which STRAW stage?
cycles shorter, first increase in FSH -3a
aka late reproductive levels spike with ovulation, marker of ovarian reserve inhibin B Produced by granulosa cells of activated follicles, most reflective of true ovarian reserve; provides the best single prediction of time to menopause AMH what day of cycle to draw FSH to predict ovarian response/reserve? day 3
normal day 3 FSH? FSH value for menopause? < 10 > # of ultrasound detected follicles 2-10 mm in size AFC (antral follicle count) normal AFC > Luteal-Out-Of-Phase (LOOP) event
- FSH elevation recruits follicles for the subsequent cycle before the current cycle is over
- Excess estradiol production as new follicles start growing
- Increase chance of TWINS
- Very short follicular phase
- More time spent in luteal phase (more PMS/PMDD sx) symptoms of LOOP event —Mastalgia —Worsening migraine —Growing fibroids —Risk of endometrial hyperplasia
- longer time in luteal phase (worsening PMDD in peri) premenopausal vs postmenopausal estradiol levels in obesity
normal adrenal function found no evidence of improvement in sexual symptoms, serum lipids, serum glucose, weight, or bone mineral density) dx of POI? amenorrhea >4 mo in age < FSH >25 on 2 occasions 4 etiologies of POI
most common? (1) Genetic (turner, fragile X) (2) Autoimmune (adrenal Ab/Addison's) (3) Cancer (chemo, radiation, surgical oophrectomy) (4) Idiopathic --> most common most common genetic cause of POI? Turner syndrome/X chromosome abnormalities treatment for Turner syndrome with delayed puberty? Started estrogen replacement at age 12, add progestin at age of menarche
transdermal estradiol 0.1 mg recommended diagnostic w/u for POI FHx Estradiol, FSH, LH Karyotype Anti-21hydroxylase antibodies --> Addison disease
Fragile X screen TSH/T4/TPO Glucose, metabolic profile, complete blood count estrogen options for POI 100 μg transdermal estradiol patch 1.25 mg conjugated equine estrogens (CEE) 2 mg of estradiol PO progestin therapy for POI If uterus is present, cyclical progestins should be added ≥12 d/mo estrogen maintains what pH in the vagina? acidic, 3.8 - 4. high BMI associated with (increase/decrease) in severity of VMS in menopause transition increase % skin collagen loss in 1st 5 yrs after menopause 30%
(2% per yr decline over next 20 yrs) 2 most common causes of hair loss in menopause transition Female pattern hair loss (FPHL; thinning on crown) and telogen effluvium (sudden onset of hair shedding, stress-induced) tx of FPHL
stimulation
Fezolinetant = NKB antagonist stellate ganglion block --> tx for what? VMS only 2 FDA-approved non-hormonal tx for VMS low dose paroxetine (7.5 mg) fezolinetant Off-label non-hormonal tx for VMS SSRIs SNRIs Gabapentin Clonidine Oxybutynin which vaginal lesions should be biopsied? white, pigmented, or thickened lesions other populations who get GSM (ie: other prolonged low estrogen states) prolonged lactation hypothalamic amenorrhea POI Chemo/radiation GnRH agonists Aromatase inhibitors
Non-hormonal GSM treatment
when to use? vaginal lubricants/moisturizers, topical lido
mild/mod GSM, use 1st line (test answer) hormonal options for GSM
when to use? vaginal ET vaginal DHEA systemic ET (with VMS)
mod to severe GSM, use 2nd line, not studied in breast CA/avoid if able (test answer) oral option for GSM ospemifene
antagonist at breast, however, don't use in breast CA (not studied) ospemifene: MOA Risks Contraindications Benefits
Estring, 8 pg/mL
others: 3-4 pg/mL (below normal postmeno ranges) Progesterone needed with local GSM therapies? Generally no -- estradiol never above 10
consider if pt has other RFs for endometrial CA which vaginal lesion?
vulva, itchy, white lichen sclerosis which vaginal lesion?
vagina, burning, red lichen planus tx for both lichen sclerosis & lichen planus high-potency topical steroids, ointments preferred to creams
(ex: Clobetasol ointment 0.05%, betamethasone ointment 0.05%) 4 Vulvovaginal neoplasias (1) vulval intraepithelial neoplasia (VIN) (2) squamous cell carcinoma
(3) basal cell carcinoma (4) Paget disease undifferentiated VIN (uVIN) HPV-related? lichen sclerosis/planus related? common/uncommon? avg age? yes no most common age < differentiated VIN (dVIN) HPV-related? lichen sclerosis/planus related? common/uncommon? avg age? no yes uncommon/rare age > when do bartholin cysts require a biopsy? when they occur in postmenopausal women women with recurrent UTIs should be evaluated for?
2 FDA-approved options for HSDD (now FSIAD) flibanserin (Addyi) bremelanotide (Vylessi) global consensus position on testosterone use for HSDD/FSIAD? use it!! greatly improves sexual function and QOL
no severe AEs with physiologic use what to Rx for testosterone for HSDD/FSIAD? FDA-approved male testosterone formulations, use 1/10th the dose transverse perineal, bulbospongiosus, ischiocavernosus superficial pelvic floor muscles pubococcygeus, iliococcygeus, obturator internus, coccygeus deep pelvic floor muscles meds for pelvic floor dysfunction diazepam, baclofen, cyclobenzaprine, or methocarbamol
oral or topical compounded
refractory: botox injection main treatment for pelvic floor dysfunction pelvic floor PT, vaginal dilators PALM COEIN causes of AUB
P: Polyp A: Adenomyosis L: Leiomyoma/fibroids M: Malignancy (uterus or cervix) C: Coagulopathy O: ovulatory dysfunction E: Endometrial I: Iatrogenic N: Not yet classified most common cause of AUB anovulatory (ie: ovulatory dysfunction)
anovulation = no corpus lutem = no progesterone = unopposed estrogen = irregular/heavy/prolonged bleeding workup for AUB CBC, TSH, UPT, coag labs (if indicated) Pap Endo Bx (if age >45) TVUS
Sometimes: MRI, hysteroscopy, D&C does negative endo bx rule out CA?
what lifestyle interventions may help protect against dementia? —Maintaining an extensive social network —Staying active mentally —Engaging in regular physical exercise —Increasing dietary intake of omega-3 fatty acids and certain vitamins from natural foods —Following a Mediterranean diet —Abstaining from tobacco use —Consuming alcohol in moderation populations of women with highest rate of sleep disturbance late perimenopause (45%) surgical postmenopause (47%) does HT help insomnia? is HT FDA-approved for insomina? YES -- improved sleep quality demonstrated across multiple studies no do migraines increase or decrease in perimenopause? why? INCREASE -- abrupt decreases in estradiol is a well-established migraine trigger tx for menstrual migraines continuous progestin-only BC, continuous HT, cyclic triptans % of women with arthralgia due to menopause 50% tx for menopause-induced arthralgia
HT
association between childhood abuse and VMS? increase severity/duration of VMS in survivors of childhood abuse prevalence of lifetime intimate partner violence 1 in 4 women midlife women with joint pain: top 3 ddx? osteoarthritis autoimmune (RA) menopause does HT affect RA incidence or severity? no -- no effect the risk of depression increases by ____ fold in perimenopause
ethnic group at highest risk of depression? 2
Hispanic thyroid disease screening recommendations by: American Thyroid Association American College of Physicians USPSTF
