OBSTETRICS AND GYNECOLOGY

EVALS 10

MENOPAUSE

1.

Which of the following is a possible cause of Premature Ovarian Failure?

A. Genetic
B. Substance abuse

C.
D.

Sleep deprivation
Sexual promiscuity

Rationale: Other than gene mutations that cause premature ovarian failure, no specific genes have been discovered to date that account for this
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genetic influence. However, several genes are likely involved in aging, including genes coding telomerase activity. (Comprehensive Gynecology, 6
edition)

2. Which statement best describes the Menopause?
A. Athletes enter the Menopause at an early age.
B. There is seldom a precise timing of this event.
C. Smoking is associated with Menopause onset taking place 2 years later.
D. People living in Western countries enter the Menopause at an earlier age.

Rationale:

Menopause is defined by the last menstrual period.

Because cessation of menses is variable and many of the symptoms thought to be related to menopause may occur prior to cessation of
menses, there is seldom a precise timing of this event.

The age of menopause in Western countries (between 51 and 52 years) is thought to correlate with general health status; socioeconomic
status is associated with an earlier age of menopause.

Higher parity, on the other hand, has been found to be associated with a later menopause.

Smoking has consistently been found to be associated with menopause onset taking place 1 to 2 years earlier.

Although body mass has been thought to be related to age of menopause (greater body mass index [BMI] with later menopause), the data
have not been consistent.
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However, physical or athletic activity has not been found to influence the age of menopause. (Comprehensive Gynecology, 6 ed)

3. The primary determinate of age of the Menopause is:
A. Stress
C. Cultural differences
B. Genetic
D. Socioeconomic status

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Rationale: Age of menopause, which is a genetically programmed event, is subject to some variability. (Comprehensive Gynecology, 6 edition)

4. Changes which occur in the ovary during the perimenopause include:
A. Increased risk of malignant change
C. Decreased probability of polycystic ovaries
B. Overall diameter increases to 6 cms
D. Oocyte depletion, followed by hypoestrogenism

Rationale: The menopausal transition (perimenopause) is divided into early and late phases according to menstrual acyclicity.
These changes signify a varying period of time (years) during which rapid oocyte depletion occurs, followed by hypoestrogenism. The ovary
changes markedly from birth to the onset of menopause.

5. A 48 y/o Filipina has entered the menopause when she becomes amenorrheic for ___ months.
A. 10
C. 12
B. 16
D. 20

DEFINITION OF MENOPAUSE
the time when there has been no menstrual period for 12 consecutive months
no other biological or physiological cause can be identified
the end of fertility
the end of the childbearing years
results in the decline of estrogen

6. Clinical treatment of women in the perimenopause should also address:
A. Weight gain and obesity
C. Accompanying vasomotor changes
B. Varying sexual preferences
D. Decreased frequency of easy fatigability

CONSEQUENCES OF MENOPAUSE
EARLY
LATE
Vasomotor function
Bone loss
Genital atrophy
Cardiovascular
Collagen and other tissues
Lipid metabolism
Central nervous system
Central nervous system

VASOMOTOR FUNCTION
Hot Flash and Hot Flush

The hallmark feature of declining estrogen status in the brain

"Vasomotor episode"
Hot Flash

An acute sensation of heat

Hot Flush

Heat dissipation = increase in peripheral temperature

Decrease in skin resistance = diaphoresis

Reduction in core body temperature

7.

Which hormonal change occurs with established menopause?

A. Increased serum prolactin
B. Marked reduction in estrogens

C.
D.

Decreased human chorionic gonadotropin levels

Marked increased adrenocorticotrophic hormone levels

Refer to number 5.

8. The hallmark of declining estrogen status in the brain:
A. Hot flush
C. Mood swings
B. Memory loss
D. Sleep disruption

Refer to number 6.

9. Which of the following is NOT a characteristic of the menopausal vasomotor episode?
A. Decrease in skin resistance
C. Increase in peripheral temperature
B. Increase in cardiac arrhythmias
D. Reduction in core body temperature

Refer to number 6.

10. Which statement is TRUE regarding the effect of estrogen during the menopause?
A. Estrogen therapy improves skin thickness substantially.
B. Estrogen has no effect on vaginal dryness and dyspareunia.
C. Reductions in collagen support have been implicated in urethral prolapse.
D. Vaginal estrogens increase the episodes of recurrent urinary tract infections.

Rationale: Estrogen has a positive effect on collagen, which is an important component of bone and skin and serves as a major support tissue for
the structures of the pelvis and urinary system. Although the literature is not entirely consistent, estrogen therapy generally improves collagen
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content after menopause and improves skin thickness substantially after about 2 years of treatment. (Comprehensive Gynecology, 6 ed)

11. Which of the following is an effect of estrogen treatment on the vagina?
A. Increase in pH
C. Thinner and paler mucosa
B. Increase in blood flow
D. Increase in superficial cells on cytology

Rationale: With estrogen treatment, vaginal cytology changes have been documented, transforming from a cellular pattern of predominantly
parabasal cells to one with an increased number of superficial cells. Along with this change, the vaginal pH decreases, vaginal blood flow
increases, and the electropotential difference across the vaginal mucosa increases to that found in premenopausal women. (Comprehensive
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Gynecology, 6 ed) SOOOO DAPAT B and D are correct!

12. Which of the following drugs does NOT prevent osteoporosis?
A. estrogen
C. alendronate
B. raloxifene
D. progesterone

SERMs/SELECTIVE ESTROGEN RECEPTOR MODULATORS

Raloxifene, Droloxifene, Tamoxifen

Act as low dose estrogen on the skeleton

Decrease bone resorption and vertebral fractures

BIPHOSPHONATES

Etidronate, Alendronate, Risedronate, Ibandronate,Zolendronate

Significant effect on the prevention and treatment of osteoporosis

Reduce both spine and hip fractures

Should not be used for more than 10 years and not with another anti-resorptive agent

13. Which of the following conditions is benefitted by estrogen after the menopause?
A. poliomyelitis
C. costochondritis
B. osteoarthritis
D. atherosclerosis

Rationale: Osteoarthritis is a source of significant distress. There is a powerful effect of estrogen in inhibiting damage to chondrocytes. In WHI,
estrogen alone (but not combination hormone therapy) significantly decreased osteoarthritis.

14. Which of the following statements is TRUE regarding endometrial disease and estrogen use?
A. Prolonged use of the oral contraceptive pill causes endometrial cancer.
B. Endometrial disease occurs with unopposed estrogen therapy in women who have a uterus.
C. Combination hormonal therapy does not eliminate the excess risk for endometrial disease attributed to estrogen.
D. The risk for endometrial cancer in women taking estrogen and progestogen is higher to that of women in the general population.

ESTROGENS

Should be used at the lowest possible dose that can control hot flushes

Administered via vaginal route for vulvovaginal or urinary symptoms

May be administered continuously (daily), for 21 to 25 days each month

PROGESTOGENS

Should be added to the regimen (plus estrogen) if the woman still has a uterus.
o Giving too much estrogen unopposed by progesterone increases the risk for endometrial cancer

Withdrawal bleeding occurs, when administered sequentially (10-14 days each month)

15. Which statement is correct with regards to hormone regimens for the menopause?
A. Synthetic estrogens, given orally, are less potent than natural estradiol.
B. Estrogen should be used at the highest dose that can control hot flushes.
C. When progestogens are given sequentially, withdrawal bleeding doesnt occur.
D. In menopausal women with urinary complaints, vaginal therapy is most appropriate.

Refer to number 14.

16. Tibolone, a SERM-like compound, has the following effects, EXCEPT:
A. prevents osteoporosis
C. improves sexual function
B. suppresses hot flushes
D. causes Alzheimers disease

Rationale: Tibolone has also been shown to be an effective treatment for osteoporosis. Tibolone has SERM-like properties, but it is not specifically
a SERM because it has mixed estrogenic, antiestrogenic, androgenic, and progestogenic properties. The drug does not seem to cause uterine
or breast cell proliferation and also is beneficial for vasomotor symptoms. It prevents osteoporosis and has been shown to be beneficial in
treatment of osteoporosis as well at a dose of 2.5 mg daily.

17. The most accurate method of measuring bone density is:
A. DEXA
C. skeletal survey
B. serum calcium
D. vitamin D assay

Rationale: Bone mass can be detected by a variety of radiographic methods. Dual-energy x-ray absorptiometry (DEXA) scans have become the
standard of care for detection of osteopenia and osteoporosis. By convention, the T score is used to reflect the number of standard deviations
of bone loss from the peak bone mass of a young adult. Osteopenia is defined by a T score of 1 to 2.5 standard deviations; osteoporosis is
defined as greater than 2.5 standard deviations.

18. Which of the following will NOT reduce postmenopausal bone loss?
A. estrogen
C. melatonin
B. calcitonin
D. risedronate

Rationale: Melatonin controls the daily night-day cycle, thereby allowing the entrainment of the circadian rhythms of several biological functions.
The hormone can be used as a sleep aid and in the treatment of sleep disorders. It is not part of treatment for postmenopausal bone loss.

19. One of the initial endocrinologic changes signaling the onset of menopause is:
A. increased FSH
C. decreased blood sugar
B. increased AMH
D. increased ovarian inhibin-B

Rationale: The initial endocrinologic change signaling the onset of menopause is decreased AMH and ovarian inhibin-B production
accompanied by an increase in FSH.

20. How is hormonal therapy (HT) linked to breast cancer?
A. Estrogen causes new cancers.
B. Progestogen mitigates growth.
C. Dose and duration of therapy are non-contributory.
D. HT causes the growth of undetectable preexisting small tumors.

Rationale: It is generally thought that HT is linked to breast cancer through a promotional effect; that is, by causing the growth of undetectable
preexisting small tumors. There is no evidence that estrogen actually causes new cancers. Thus, dose and duration of therapy is important,
and particularly the use of a progestogen, which may potentiate growth. The normal time needed for the average breast cancer to be clinically
detectable from a microscopic stage is approximately 10 years. Thus, the promotional effect of HT on breast cancer in susceptible women takes
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several years for clinical detection. (Comprehensive Gynecology, 6 edition)

GOOD LUCK and GOD BLESS! J

By: ROBERT C. REA