Module 4 Practice Questions

Question 1

Which of the following agents may improve hot flashes due to menopause? (Check ALL that apply)
Estrogen
Acupuncture
venlafaxine (Effexor)
Placebo
soy products

Answer 1

All of them

Question 2

What is the best determinant of whether a midlife patient has reached menopause?

Answer 2

the date of her last menstrual period

Question 3

Which of the following is TRUE about estrogen + progestin hormone therapy for menopause and cancer? (only ONE answer is correct)
it reduces the risk of colorectal cancer.
length of hormone use does not affect cancer risk in menopause
it triples the risk of endometrial cancer
it doubles the risk of breast cancer

Answer 3

estrogen + progestin reduces the risk of colorectal cancer.

Question 4

T/F: Smokers can use estrogen therapy for menopause.

Answer 4

True

Note: As long as smoking is the only cardiovascular risk factor, adding estrogen doesn’t increase CVD enough beyond smoking + age alone to make estrogen contraindicated. Note that this is only true for menopausal doses of estrogen, which are about 1/10 to 1/7 as strong as those used for contraception. So smokers over 35 can use menopause-dosing of hormone therapy safely.

Question 5

T/F: Clinicians do not need to consider osteoporosis risk factors until a patient reaches menopause.

Answer 5

False

Note: Prevention of osteoporosis starts at menarche. Our adolescents who do not maintain enough body mass to have periods are also not developing enough bone mass. Dietary calcium intake is important for teens and childbearing adults to ensure adequate bone mass is achieved to carry through old age. Weight-bearing exercise is good for patients of all ages.

Question 6

Which therapy is MOST effective for hot flashes in menopause?

Answer 6

Estrogen

Question 7

What is true about sexuality and menopause?
Dyspareunia can often be resolved with vaginal estrogen.
Most people experience a drop in sexual interest due to menopause
Vaginal dryness is a common concern EARLY in the menopause transition

Answer 7

Dyspareunia can often be resolved with vaginal estrogen.

Question 8

What is the best way to diagnose menopause?

Answer 8

Date of LMP

Question 9

What is the most common symptom of menopause for which women seek care?

Answer 9

Hot flashes

Question 10

T/F: A perimenopausal woman who begins exercising for the first time can expect a reduction in her hot flash severity and frequency.

Answer 10

False

Question 11

What intervention is MOST effective in reducing hot flash severity?

Answer 11

smoking cessation

Question 12

When can menopause be diagnosed and pregnancy no longer be considered possible?

Answer 12

When it has been 12 months since the last menstrual period

Question 13

What is the average age of menopause?

Answer 13

51/52 y/o

Question 14

How does smoking effect menopause?

Answer 14

It makes it occur an average of 2 years earlier and increases symptoms. Smoking decrease or cessation can improve symptoms

Question 15

Why are perimenopausal people more likely to have a multiple gestation pregnancy?

Answer 15

During perimenopause, there are few follicles left and they are less responsive to FSH. When they do respond to FSH, they do so vigorously and are more likely to release multiple eggs in the same window.

Question 16

When does menopause begin?

Answer 16

Typically begins 7 years before the end of the menstrual cycle.

Question 17

What is the hallmark of perimenopausal activity?

Answer 17

RAPIDLY SHIFTING HPO axis

aka-hormone fluctuations

Question 18

What is perimenopause?

Answer 18

The years before cessation of menses when the patient when women notice physiologic changes and the year after the end of menses

Question 19

When do women report their hot flashes “leveling off”?

Answer 19

2-4 years after the final period, but can last up to 7 years or longer

Question 20

What are the three common signs of perimenopause?

Answer 20

-Menstrual changes, then ceasing
-Vasomotor symptoms (hot flashes)
-Vaginal dryness

Additional: sleep disturbances, poor cognition, mood changes, dyspareunia (painful sex due to vaginal dryness)

Question 21

How is urinary incontinence associated with menopause?

Answer 21

It isn’t, this is a myth

Question 22

What lifestyle changes can help with hotflashes?

Answer 22

-regular exercise (starting a program isn’t enough for a sedentary woman, it works best for active patients)
-smoking cessation
-Mediterranean diet (high fat and sugar diet worsens symptoms)
-wearing layers and breathable fibers
-using cold packs and fans
-removing food triggers (may be alcohol or caffeine)

Question 23

What lifestyle changes can help with vulvar symptoms?

Answer 23

-exercise
-lubricants and long-acting moisturizers (use lube for sex)
-coconut or olive oil can be used but may reduce effectiveness of latex condoms

Question 24

What is the MOST effective therapy for vasomotor symptoms of menopause?

Answer 24

Hormones/Estrogen (with or without progestogens)

Question 25

What pharmacological and non-pharm interventions can help with menopause symptoms?

Answer 25

Placebo, CBT, hypnosis, mindfulness, acupuncture, yoga, soy (phytoestrogens), valerian root(for sleep), estrogen

Question 26

Which therapy has been shown to reduce the number and severity of hot flashes?
-Acupuncture
-Clinical hypnosis
-Cognitive behavioral therapy

Answer 26

Clinical hypnosis

Question 27

T/F: Soy products are universally beneficial for hot flashes

Answer 27

False

Question 28

What is TRUE about menopause hormone therapy and smoking?
-Smokers who have no other CVD risk factors can use HT
-HT is contraindicated in smokers
-Smokers can use ET but not progestins

Answer 28

Smokers who have no other CVD risk factors can use HT

Question 29

Appropriate regimens for non-smoking perimenopausal patients with an intact uterus who desire contraception and vasomotor symptom relief CAN be prescribed which?
-Nuva Ring, used continuously
-Liletta IUD and oral estradiol tablets
-Copper IUD and an estradiol patch

Answer 29

-Nuva Ring, used continuously
-Liletta IUD and oral estradiol tablets

Question 30

Women in their 50s who choose to use hormone therapy can expect LOWER risks of which problem(s)?
-all cancers combined
-death
-hip fx
-all of the above

Answer 30

-all of the above

Question 31

What makes a patient ineligible for estrogen?

Answer 31

-Breast CA: cannot have systemic estrogen
-High risk for CVD: cannot have estrogen (aka at risk for stroke)

Question 32

Why is it ok for smokers to use hormone therapy for menopause symptoms?

Answer 32

There is a MUCH lower dose of estrogen in HT. Unless the patient has other risk factors for CVD, she can have HT, but cannot be on contraceptive therapy

Question 33

What type of patients should be given progestin when being treated with ET? Why?

Answer 33

Patients with a uterus. They will build overgrowth of the endometrium (endometrial hypoplasia), which can cause endometrial cancer.

Question 34

Why don’t we need progestinal agents for local estrogen?

Answer 34

Because they cause lower levels of estrogen that does not build up the endometrial lining.

Question 35

What is the WHI and what was it assessing? What did it find?

Answer 35

Women’s Health Initiative. A randomized controlled trial on midlife women and menopausal. Testing estrogen only vs placebo for those without a uterus and estrogen+progestin vs. placebo for those with a uterus.

Some risks depend on the timing of therapy and starting sooner is better

Question 36

What are the WHI main findings for Estrogen therapy alone?

Answer 36

-Slight decrease risk for breast CA and colon CA & net decrease in ALL CAs.
-Lower risk of CHD for 50’s
-Slight increase risk for PE
-decrease hip fx
-Lower risk for all-cause mortality even after hormones stopped

Question 37

What are the WHI main findings for Estrogen+Progestin therapy?

Answer 37

-Reduced risk for colon CA and net decrease in all CAs
-slight increase for invasive breast CA
-Slight increase risk in stroke, CHD, & PE for 50s
-Decrease hip fx
-Lower all cause mortality

Question 38

What should you do for a patient that has moderate to sever vasomotor symptoms but cannot take estrogen for whom lifestyle changes is not enough?

Answer 38

-Consider SNRIs, Gabapentine (sedating), SSRIs
-Brisdelle (low dose paroxetine) can be used for hot flashes
-Micronized progesterone alone can reduce vasomotor symptoms and improve sleep

Question 39

B. is a 62-year-old who was menopausal at age 50. B. had a difficult time with hot flashes for the first year or two after menopause but has not had a problem with them for about 10 years now. B.’s MAIN concerns NOW are vaginal dryness, daily vaginal discomfort, and external vaginal and vulvar pain with intercourse. B. recently had a DEXA scan and her T-score was -2.6. B.’s medical history is significant for tension headaches, GERD, and hemorrhoids. Surgical history includes a tonsillectomy at age 14, a hysterectomy (uterus removed but not ovaries) at age 44 for the treatment of heavy bleeding, and a breast mass biopsy (benign) last year.

When B. asks about over-the-counter treatments for her vulvovaginal concerns, the clinician’s best advice is:

A mild vinegar and water vaginal rinse will increase her comfort.

A vaginal moisturizer may work better than a vaginal lubricant in promoting overall vaginal health.

Apply a thin layer of petroleum jelly to the vulva and vaginal introitus twice weekly.

Avoid using vitamin E oil because it is damaging to vaginal tissue.

Answer 39

A vaginal moisturizer may work better than a vaginal lubricant in promoting overall vaginal health.

Note: according to WGH, vaginal moisturizers, unlike vaginal lubricants, replenish and maintain fluids in vaginal epithelial cells, can give long-lasting relief, and can help support a normal vaginal pH. Lubricants are best used at the time of sex for more comfortable intercourse.

Question 40

B. is a 62-year-old who was menopausal at age 50. B. had a difficult time with hot flashes for the first year or two after menopause but has not had a problem with them for about 10 years now. B.’s MAIN concerns NOW are vaginal dryness, daily vaginal discomfort, and external vaginal and vulvar pain with intercourse. B. recently had a DEXA scan and her T-score was -2.6. B.’s medical history is significant for tension headaches, GERD, and hemorrhoids. Surgical history includes a tonsillectomy at age 14, a hysterectomy (uterus removed but not ovaries) at age 44 for the treatment of heavy bleeding, and a breast mass biopsy (benign) last year.

The clinician considers prescribing a progestogen for B. Which statement reflects an appropriate prescribing decision WITH an appropriate rationale?

The clinician decides NOT to prescribe a progestogen because her medical history makes progestogen medically contraindicated.

The clinician decides NOT to prescribe a progestogen because: 1) she doesn’t have a uterus, and 2) she’s having only local symptoms, which do not require a systemic dose of estrogen.

The clinician decides to prescribe a progestogen because unopposed estrogen is dangerous for B.

Answer 40

The clinician decides NOT to prescribe a progestogen because: 1) she doesn’t have a uterus, and 2) she’s having only local symptoms, which do not require a systemic dose of estrogen.

Note: the usual reason to prescribe a progestogen for hormone therapy is for endometrial protection for women taking systemic-dosed estrogen. This woman is having only vaginal dryness and doesn’t need systemic estrogen. Plus, her uterus is absent—so even if she were bothered by hot flashes, she still wouldn’t need a progestogen.

Question 41

B. is a 62-year-old who was menopausal at age 50. B. had a difficult time with hot flashes for the first year or two after menopause but has not had a problem with them for about 10 years now. B.’s MAIN concerns NOW are vaginal dryness, daily vaginal discomfort, and external vaginal and vulvar pain with intercourse. B. recently had a DEXA scan and her T-score was -2.6. B.’s medical history is significant for tension headaches, GERD, and hemorrhoids. Surgical history includes a tonsillectomy at age 14, a hysterectomy (uterus removed but not ovaries) at age 44 for the treatment of heavy bleeding, and a breast mass biopsy (benign) last year.

Expected and normal physical exam findings for B. are:

Wet prep: lower pH of vaginal secretions.

Speculum exam: decreased vaginal rugae.

Wet prep: increased lactobacilli.

Answer 41

Speculum exam: decreased vaginal rugae.

Note: as a result of decreased estrogen levels, menopausal women usually have decreased vaginal rugae making vaginal tissue smooth (see WGH under “Presentation and Variation of the Menopause Experience”.) This also can contribute to discomfort with intercourse because the smooth, unrugated vaginal tissue has difficulty stretching to accommodate vaginal penetration.

Question 42

B. is a 62-year-old who was menopausal at age 50. B. had a difficult time with hot flashes for the first year or two after menopause but has not had a problem with them for about 10 years now. B.’s MAIN concerns NOW are vaginal dryness, daily vaginal discomfort, and external vaginal and vulvar pain with intercourse. B. recently had a DEXA scan and her T-score was -2.6. B.’s medical history is significant for tension headaches, GERD, and hemorrhoids. Surgical history includes a tonsillectomy at age 14, a hysterectomy (uterus removed but not ovaries) at age 44 for the treatment of heavy bleeding, and a breast mass biopsy (benign) last year.

B. tells the clinician that her friend takes an oral form of hormone therapy (HT) and she would like to start that now. An appropriate response is:

Answer 42

A product with a different ROUTE would be better tailored to the symptoms she is most concerned about.

Note: although an oral HT formulation could help with her symptoms, clinicians should first look to a vaginal preparation that would target this woman’s particular symptoms of vaginal discomfort. This has the benefit of avoiding exposing her to the risks of systemic HT when her only concerns are vaginal. See WGH for a listing of vaginal preparations. See also the 2017 NAMS position statement on HT: local ET is preferred when treating solely vaginal symptoms.

Question 43

J. is a 52-year-old woman who comes to the office for a problem visit because she hasn’t had a period recently. She is having 8 -10 hot flashes during the day and wakes 3-4 times each night with sweats that require changing the sheets. She does not sleep at night even though she has to get up at 5 am to go to work. She is not interested in having sex with her husband. She feels as though she is forgetful, and just wants to cry because she does not know what is wrong with her. J.’s mother had osteoporosis and had a stroke at age 82. J.’s sister had endometrial cancer, and J.’s maternal grandmother had dementia. J.’s medical history is significant for fibrocystic breast changes. She is a smoker. She has never had surgery.J.’s mother had told her that she should only have menopausal symptoms for the first few months after her periods stop or something is wrong. The clinician responds, understanding that:

The timing and severity of symptomatic perimenopause varies from woman to woman.

These symptoms LIKELY represent depression or pituitary dysfunction.

J. should first try hormone therapy to find out if it would relieve her symptoms.

Monitoring J.’s hormone levels will be helpful in managing her symptoms.

Answer 43

The timing and severity of symptomatic perimenopause varies from woman to woman.

Note: it is not possible to predict how long a woman will have symptoms or how severe the symptoms will be in the perimenopause. There is a wide range of normal. See WGH about the presentation and variation of the menopause experience.

Question 44

To make a menopause diagnosis, the clinician MUST:

Answer 44

ask the date of J.’s last period.

Note: individuals are in menopause when they have not had a period for 12 months thus the clinician must know the date of the patient’s LMP. See WGH “Diagnosing Menopause” and the NAMS webpage “Confirming Menopause”.

Question 45

J. is a 52-year-old woman who comes to the office for a problem visit because she hasn’t had a period recently. She is having 8 -10 hot flashes during the day and wakes 3-4 times each night with sweats that require changing the sheets. She does not sleep at night even though she has to get up at 5 am to go to work. She is not interested in having sex with her husband. She feels as though she is forgetful, and just wants to cry because she does not know what is wrong with her. J.’s mother had osteoporosis and had a stroke at age 82. J.’s sister had endometrial cancer, and J.’s maternal grandmother had dementia. J.’s medical history is significant for fibrocystic breast changes. She is a smoker. She has never had surgery.

Regarding J.’s family, medical, and surgical histories, which is true as J. considers hormone therapy (HT)?

J. should use HT to decrease her risk for developing dementia.

J. could reduce her risk for osteoporosis by using estrogen.

J.’s sister’s endometrial cancer makes HT medically contraindicated for J.

J.’s fibrocystic breast changes make HT medically contraindicated.

Answer 45

J. could reduce her risk for osteoporosis by using estrogen.
Note: family history of endometrial cancer is not a medical contraindication for patients to use HT. See the list of contraindications to HT in WGH.

Question 46

J. is a 52-year-old woman who comes to the office for a problem visit because she hasn’t had a period recently. She is having 8 -10 hot flashes during the day and wakes 3-4 times each night with sweats that require changing the sheets. She does not sleep at night even though she has to get up at 5 am to go to work. She is not interested in having sex with her husband. She feels as though she is forgetful, and just wants to cry because she does not know what is wrong with her. J.’s mother had osteoporosis and had a stroke at age 82. J.’s sister had endometrial cancer, and J.’s maternal grandmother had dementia. J.’s medical history is significant for fibrocystic breast changes. She is a smoker. She has never had surgery.

If J. wants to proceed with pharmacologic therapy for vasomotor symptom relief, the clinician could appropriately write which prescription?

Conjugated equine estrogen (Premarin) orally once daily.

Ethinyl estradiol + norethindrone acetate (Femhrt) orally once daily.

Norethindrone acetate (Aygestin) orally once daily.

Estradiol hemihydrate (Vagifem) once daily per vagina for two weeks then twice weekly.

Answer 46

Ethinyl estradiol + norethindrone acetate (Femhrt) orally once daily.

Question 47

J. is a 52-year-old woman who comes to the office for a problem visit because she hasn’t had a period recently. She is having 8 -10 hot flashes during the day and wakes 3-4 times each night with sweats that require changing the sheets. She does not sleep at night even though she has to get up at 5 am to go to work. She is not interested in having sex with her husband. She feels as though she is forgetful, and just wants to cry because she does not know what is wrong with her. J.’s mother had osteoporosis and had a stroke at age 82. J.’s sister had endometrial cancer, and J.’s maternal grandmother had dementia. J.’s medical history is significant for fibrocystic breast changes. She is a smoker. She has never had surgery.

J. declines “regular hormone therapy” due to concern about breast cancer risk that was read about in the newspaper. Considering alternatives, which is true?

Answer 47

Fluoxetine 20 mg (Prozac) orally daily could help decrease hot flashes but could exacerbate other symptoms she reports.

Note: SSRIs have been shown to help decrease vasomotor symptoms but they also can have the negative effect of decreased libido. This woman already has decreased libido. See the table of nonhormonal pharmacological options for vasomotor symptoms in WGH.

Question 48

T/F: Combined hormonal contraceptives can help to control vasomotor symptoms.

Answer 48

True

Question 49

T/F: Hormone therapy like Premarin (conjugated estrogens) prescribed for vasomotor symptoms can also provide contraception.

Answer 49

False

Question 50

T/F: Women over 35 who smoke should not be prescribed hormone therapy for vasomotor symptoms.

Answer 50

False

Question 51

T/F: Combined hormonal contraception is contraindicated for women over 35 who smoke.

Answer 51

True

Question 52

T/F: Perimenopausal/menopausal estrogen therapy to control vasomotor symptoms is contraindicated in women over 35 who smoke

Answer 52

False

Question 53

A.C., age 47, has never had surgery. She is sexually active. Her LMP was last week. She and her male partner have been using condoms irregularly for contraception. She smokes 1/2 a pack of cigarettes a day. She is experiencing disruptive hot flashes about 8-10 times a day and night sweats. Which treatments would be appropriate to provide contraception and treat her vasomotor symptoms?
Depo Provera (DMPA)
FemRing
Combined oral contraceptives
Mirena IUD (an LNG-IUD) and Premarin (conjugated estrogens)
NuvaRing
EstRing
Depo Provera (DMPA) and FemRing
Skyla IUD (an LNG-IUD) and Estring

Answer 53

Mirena IUD (an LNG-IUD) and Premarin (conjugated estrogens)
Depo Provera (DMPA) and FemRing

Note:
-the LNG-IUD will provide contraception and a low dose of progestogen which will protect her endometrium from hyperplasia. The conjugated estrogens will give relief from the vasomotor symptoms.
-DMPA would provide contraception and FemRing would treat her vasomotor symptoms. Both are safe for women over 35 who smoke. The DMPA would also provide protection against the endometrial hyperplasia which the systemic dose of estrogen in FemRing could provoke.
-CHC is contraindicated >35 smoker

Question 54

L.L. is 48 years old and in a long term relationship with a man. She is experiencing vasomotor symptoms that are disrupting her life. What else do you need to know to safely prescribe hormone therapy for her?
How many times has she been pregnant?
Has she had a hysterectomy?
Does she have a family history of DVT?
Is she using contraception?
When was her last menstrual period?

Answer 54

Has she had a hysterectomy?
Is she using contraception?
When was her last menstrual period?

Question 55

S.N. smoked for 20 years, but gave it up 5 years ago. She is now 47 years old and experiencing severe vasomotor symptoms. Lifestyle adjustments have not helped. Her LMP was 14 months ago. Check all statements that are correct.
-Combined oral contraceptives would be an appropriate treatment for her vasomotor symptoms.
-An appropriate treatment for her could be oral conjugated estrogens and progestin.
-It is safe to prescribe estrogen to this person to manage her vasomotor symptoms.
-Mirena IUD (an LNG-IUD) could provide endometrial protection, but will not control her hot flashes.

Answer 55

-An appropriate treatment for her could be oral conjugated estrogens and progestin.
-It is safe to prescribe estrogen to this person to manage her vasomotor symptoms.
-Mirena IUD (an LNG-IUD) could provide endometrial protection, but will not control her hot flashes.

Question 56

Which of these estrogen treatments require the addition of a progestogen to protect a woman’s endometrium from hyperplasia?
Group of answer choices
Vaginal estrogen cream (Estrace)
EstRing
Oral conjugated estrogens like Premarin
FemRing

Answer 56

Oral conjugated estrogens like Premarin
FemRing

Question 57

What is EstRIng?

Answer 57

vaginal ring containing low dose estrogen for treatment of vaginal atrophy

Question 58

What is FemRing?

Answer 58

vaginal ring containing estrogen in dose high enough to treat systemic symptoms of menopause

Question 59

What is Estrace?

Answer 59

vaginal cream for local treatment of vaginal dryness and menopause

Question 60

What are Premarin tablets?

Answer 60

oral estrogen with without progestins for systemic treatment of both vaginal symptoms and vasomotor symptoms of menopause

Question 61

What is NuvaRing?

Answer 61

Vaginal ring containing estrogen and progesterone in doses appropriate for contraception

Question 62

After starting a patient of systematic EPH therapy, when should they return for a follow up?

Answer 62

At 6-8 weeks, start at a low dose and titrate as needed.

Question 63

Your patient is on systemic EPH for menopause but is now complaining of vaginal symptoms in which lubricants and moisturizers are not helping. Can you prescribe anything for her?

Answer 63

Yes, she can be prescribed vaginal estrogen