NAMS Menopause Certification Exam
2026/2027
Actual Real Exam Test Bank
2 Currently Testing Versions
100 Questions per Version | 200 Questions Total
Aligned with The Menopause Society (formerly NAMS)
Certification Examination Guidelines and Candidate Handbook
Current 2026/2027 Guidelines and Evidence-Based Practice
Domain 1: Physiology and Pathophysiology (~19%)
Domain 2: Menopausal Symptoms and Clinical Manifestations (~20%)
Domain 3: Health Disorders and Comorbidities (~21%)
Domain 4: Therapeutic Interventions and Hormone Therapy (~16%)
Domain 5: Preventive Care and Long-Term Health Management (~19%)
Integrated: Case Studies and Clinical Scenarios
Cognitive Levels: 25% Recall | 50% Application | 25% Analysis
, NAMS Menopause Certification Exam 2026/2027 200 Questions | Version A & B
VERSION A
Section A1: Physiology and Pathophysiology of the Menopause Transition
(Domain 1 ~19%) - Q1-19
Q1: According to the STRAW+10 staging system, what characterizes the early menopause transition
(Stage -2)?
A. Sixty or more consecutive days of amenorrhea
B. A persistent difference of 7 days or more in the length of consecutive cycles
C. Elevated FSH levels on two occasions at least 4 weeks apart
D. Twelve months of amenorrhea with no pathological cause
Correct Answer: B
Rationale: The STRAW+10 staging system defines the early menopause transition (Stage -2) by a persistent difference of
7 days or more in the length of consecutive cycles. Option A describes Stage -1 (late menopause transition), which
requires 60 or more consecutive days of amenorrhea. Option C describes the diagnostic criteria for premature ovarian
insufficiency (POI), not a specific STRAW+10 stage. Option D defines the final menstrual period (FMP), which marks
the transition to postmenopause after 12 months of amenorrhea.
Q2: A 48-year-old woman presents with a cycle that has become irregular, with intervals varying from
21 to 45 days over the past 6 months. Her most recent cycle was 38 days, and the one before was 24
days. According to the STRAW+10 staging system, which stage best describes her status?
A. Stage -2 (Early Menopause Transition)
B. Stage -1 (Late Menopause Transition)
C. Stage +1 (Early Postmenopause)
D. Stage -3 (Late Reproductive Years)
Correct Answer: A
Rationale: This woman demonstrates a persistent difference of 7 or more days in consecutive cycle lengths (38 vs. 24
days, a 14-day difference), which is the hallmark of Stage -2 (early menopause transition) in the STRAW+10 system. She
has not yet experienced 60 or more consecutive days of amenorrhea, which would place her in Stage -1 (late menopause
transition). She is still menstruating, so she is not in the postmenopausal stages. The late reproductive years (Stage -3) are
characterized by regular cycles with subtle changes, not the marked variability seen here.
Q3: What is the approximate average age of natural menopause in the United States?
A. 45 years
B. 48 years
C. 51 years
D. 55 years
Correct Answer: C
Rationale: The average age of natural menopause in the United States is approximately 51 years. This is a foundational
fact in menopause medicine. Early menopause is defined as the last menstrual period (LMP) before age 45, and late
menopause is defined as LMP after age 54. A woman experiencing menopause at age 40 or younger meets criteria for
premature ovarian insufficiency (POI), not natural menopause.
2
, NAMS Menopause Certification Exam 2026/2027 200 Questions | Version A & B
Q4: A 37-year-old woman presents with 4 months of amenorrhea. FSH is measured at 42 mIU/mL on
the first occasion and 48 mIU/mL on a repeat test 5 weeks later. TSH and prolactin are normal. What
is the most appropriate diagnosis?
A. Early menopause
B. Premature ovarian insufficiency (POI)
C. Perimenopause
D. Pregnancy-related amenorrhea
Correct Answer: B
Rationale: POI is diagnosed in women under age 40 with amenorrhea for at least 4 months and elevated FSH in the
menopausal range on two occasions at least 4 weeks apart. This patient meets all criteria: age 37, 4 months of amenorrhea,
and two elevated FSH values spaced more than 4 weeks apart. Early menopause refers to LMP before age 45, not before
age 40. Perimenopause typically occurs in a woman's 40s and does not require sustained FSH elevation to this degree.
Pregnancy has been ruled out by the sustained elevated FSH.
Q5: Which hormones are primarily secreted by the zona reticularis of the adrenal cortex?
A. Estradiol and progesterone
B. FSH and LH
C. DHEA, DHEAS, and androstenedione
D. Inhibin B and AMH
Correct Answer: C
Rationale: The zona reticularis of the adrenal cortex secretes the adrenal androgens DHEA, DHEAS, and
androstenedione. These are important precursors for peripheral estrogen production, particularly in postmenopausal
women where ovarian estrogen production has ceased. Estradiol and progesterone are primarily produced by the ovaries.
FSH and LH are produced by the anterior pituitary gland. Inhibin B and AMH are produced by ovarian follicles during the
reproductive years.
Q6: A 52-year-old obese woman (BMI 34) who is 3 years postmenopausal presents with vaginal
bleeding. Compared to a lean postmenopausal woman of the same age, how would her estradiol levels
and associated endometrial cancer risk be characterized?
A. Lower estradiol levels and lower endometrial cancer risk due to decreased ovarian function
B. Higher estradiol levels and increased endometrial cancer risk due to peripheral aromatization of androgens
in adipose tissue
C. Similar estradiol levels and similar endometrial cancer risk regardless of body weight
D. Higher estradiol levels but decreased endometrial cancer risk due to increased SHBG production
Correct Answer: B
Rationale: Obese women have lower premenopausal estradiol levels but higher postmenopausal estradiol levels compared
to lean women. This occurs because adipose tissue contains the aromatase enzyme, which converts adrenal androgens
(DHEA, androstenedione) into estradiol through peripheral aromatization. The resulting higher postmenopausal estradiol
exposure increases the risk of endometrial hyperplasia and endometrial cancer, as the endometrium remains stimulated by
unopposed estrogen in the absence of progesterone. SHBG levels are typically lower in obesity, not higher.
Q7: What is a Luteal Out-of-Phase (LOOP) event, and what hormonal mechanism explains it?
A. A decline in progesterone during the luteal phase causing premenstrual symptoms
B. Elevated FSH during the luteal phase that recruits a second follicle, causing a follicular phase-like rise in
estradiol
C. An anovulatory cycle resulting in persistently low estradiol levels throughout the cycle
3
, NAMS Menopause Certification Exam 2026/2027 200 Questions | Version A & B
D. A sudden drop in inhibin B that triggers a compensatory rise in FSH at mid-cycle
Correct Answer: B
Rationale: A LOOP event explains why some perimenopausal women have elevated estrogen levels despite approaching
menopause. During the early menopause transition, elevated FSH can recruit a second follicle during the luteal phase,
causing a follicular phase-like rise in estradiol. This is a key concept in understanding why perimenopausal women may
experience symptoms of estrogen excess (breast tenderness, heavy menstrual bleeding) even as they approach menopause.
Options A and C describe common but different perimenopausal phenomena. Option D is not a recognized mechanism in
the menopause transition literature.
Q8: Which endocrine lab findings are characteristic after menopause has been established?
A. Elevated estrogen and normal FSH
B. Elevated FSH and LH with decreased estradiol
C. Normal FSH and LH with elevated progesterone
D. Decreased FSH and LH with elevated estradiol
Correct Answer: B
Rationale: After menopause, the loss of ovarian follicles results in decreased estradiol and inhibin production. The
reduction in negative feedback from estrogen and inhibin leads to elevated FSH and LH levels. FSH rises more
dramatically than LH because it is additionally released from the inhibin-mediated suppression that existed during
reproductive years. This pattern of elevated gonadotropins with decreased estradiol is the hallmark endocrine profile of
the postmenopausal state.
Q9: A clinician is evaluating a 45-year-old woman with irregular menstrual cycles and wants to assess
FSH levels. On which day of the cycle should FSH be measured to obtain the most reliable result, and
why?
A. Day 14, because this is when LH surge occurs and FSH is most representative of ovulatory function
B. Day 21, because progesterone peaks at this time and FSH correlates with luteal function
C. Day 3, because elevated estradiol later in the cycle can suppress FSH, giving a falsely normal level
D. Day 1, because FSH is at its lowest point at menses and provides a clear baseline
Correct Answer: C
Rationale: FSH should ideally be measured on cycle day 3 because elevated estradiol levels later in the cycle can suppress
FSH, potentially giving a falsely normal result. During the early follicular phase (day 2-5), estradiol is at its lowest and
FSH is not suppressed, providing the most accurate assessment of ovarian reserve and menopausal status. Measuring FSH
on day 14 coincides with the LH surge and is not appropriate for assessing menopausal status. Day 21 is used for
progesterone assessment to confirm ovulation. Day 1 FSH may be transiently elevated due to the declining corpus luteum
and is less standardized.
Q10: What is the role of anti-Mullerian hormone (AMH) and inhibin B during the reproductive years?
A. They stimulate follicular development and ovulation
B. They work to prevent too-rapid depletion of the follicle pool
C. They are the primary hormones responsible for the production of adrenal androgens
D. They regulate the thermoneutral zone in the hypothalamus
Correct Answer: B
Rationale: AMH and inhibin B are hormones produced by ovarian follicles during the reproductive years that serve as
negative feedback regulators of folliculogenesis, preventing too-rapid depletion of the follicle pool. AMH is produced by
small growing follicles and inhibits the recruitment of primordial follicles into the growing pool. Inhibin B is produced by
preantral and small antral follicles and selectively inhibits FSH secretion. Both decline in the late reproductive years,
4
2026/2027
Actual Real Exam Test Bank
2 Currently Testing Versions
100 Questions per Version | 200 Questions Total
Aligned with The Menopause Society (formerly NAMS)
Certification Examination Guidelines and Candidate Handbook
Current 2026/2027 Guidelines and Evidence-Based Practice
Domain 1: Physiology and Pathophysiology (~19%)
Domain 2: Menopausal Symptoms and Clinical Manifestations (~20%)
Domain 3: Health Disorders and Comorbidities (~21%)
Domain 4: Therapeutic Interventions and Hormone Therapy (~16%)
Domain 5: Preventive Care and Long-Term Health Management (~19%)
Integrated: Case Studies and Clinical Scenarios
Cognitive Levels: 25% Recall | 50% Application | 25% Analysis
, NAMS Menopause Certification Exam 2026/2027 200 Questions | Version A & B
VERSION A
Section A1: Physiology and Pathophysiology of the Menopause Transition
(Domain 1 ~19%) - Q1-19
Q1: According to the STRAW+10 staging system, what characterizes the early menopause transition
(Stage -2)?
A. Sixty or more consecutive days of amenorrhea
B. A persistent difference of 7 days or more in the length of consecutive cycles
C. Elevated FSH levels on two occasions at least 4 weeks apart
D. Twelve months of amenorrhea with no pathological cause
Correct Answer: B
Rationale: The STRAW+10 staging system defines the early menopause transition (Stage -2) by a persistent difference of
7 days or more in the length of consecutive cycles. Option A describes Stage -1 (late menopause transition), which
requires 60 or more consecutive days of amenorrhea. Option C describes the diagnostic criteria for premature ovarian
insufficiency (POI), not a specific STRAW+10 stage. Option D defines the final menstrual period (FMP), which marks
the transition to postmenopause after 12 months of amenorrhea.
Q2: A 48-year-old woman presents with a cycle that has become irregular, with intervals varying from
21 to 45 days over the past 6 months. Her most recent cycle was 38 days, and the one before was 24
days. According to the STRAW+10 staging system, which stage best describes her status?
A. Stage -2 (Early Menopause Transition)
B. Stage -1 (Late Menopause Transition)
C. Stage +1 (Early Postmenopause)
D. Stage -3 (Late Reproductive Years)
Correct Answer: A
Rationale: This woman demonstrates a persistent difference of 7 or more days in consecutive cycle lengths (38 vs. 24
days, a 14-day difference), which is the hallmark of Stage -2 (early menopause transition) in the STRAW+10 system. She
has not yet experienced 60 or more consecutive days of amenorrhea, which would place her in Stage -1 (late menopause
transition). She is still menstruating, so she is not in the postmenopausal stages. The late reproductive years (Stage -3) are
characterized by regular cycles with subtle changes, not the marked variability seen here.
Q3: What is the approximate average age of natural menopause in the United States?
A. 45 years
B. 48 years
C. 51 years
D. 55 years
Correct Answer: C
Rationale: The average age of natural menopause in the United States is approximately 51 years. This is a foundational
fact in menopause medicine. Early menopause is defined as the last menstrual period (LMP) before age 45, and late
menopause is defined as LMP after age 54. A woman experiencing menopause at age 40 or younger meets criteria for
premature ovarian insufficiency (POI), not natural menopause.
2
, NAMS Menopause Certification Exam 2026/2027 200 Questions | Version A & B
Q4: A 37-year-old woman presents with 4 months of amenorrhea. FSH is measured at 42 mIU/mL on
the first occasion and 48 mIU/mL on a repeat test 5 weeks later. TSH and prolactin are normal. What
is the most appropriate diagnosis?
A. Early menopause
B. Premature ovarian insufficiency (POI)
C. Perimenopause
D. Pregnancy-related amenorrhea
Correct Answer: B
Rationale: POI is diagnosed in women under age 40 with amenorrhea for at least 4 months and elevated FSH in the
menopausal range on two occasions at least 4 weeks apart. This patient meets all criteria: age 37, 4 months of amenorrhea,
and two elevated FSH values spaced more than 4 weeks apart. Early menopause refers to LMP before age 45, not before
age 40. Perimenopause typically occurs in a woman's 40s and does not require sustained FSH elevation to this degree.
Pregnancy has been ruled out by the sustained elevated FSH.
Q5: Which hormones are primarily secreted by the zona reticularis of the adrenal cortex?
A. Estradiol and progesterone
B. FSH and LH
C. DHEA, DHEAS, and androstenedione
D. Inhibin B and AMH
Correct Answer: C
Rationale: The zona reticularis of the adrenal cortex secretes the adrenal androgens DHEA, DHEAS, and
androstenedione. These are important precursors for peripheral estrogen production, particularly in postmenopausal
women where ovarian estrogen production has ceased. Estradiol and progesterone are primarily produced by the ovaries.
FSH and LH are produced by the anterior pituitary gland. Inhibin B and AMH are produced by ovarian follicles during the
reproductive years.
Q6: A 52-year-old obese woman (BMI 34) who is 3 years postmenopausal presents with vaginal
bleeding. Compared to a lean postmenopausal woman of the same age, how would her estradiol levels
and associated endometrial cancer risk be characterized?
A. Lower estradiol levels and lower endometrial cancer risk due to decreased ovarian function
B. Higher estradiol levels and increased endometrial cancer risk due to peripheral aromatization of androgens
in adipose tissue
C. Similar estradiol levels and similar endometrial cancer risk regardless of body weight
D. Higher estradiol levels but decreased endometrial cancer risk due to increased SHBG production
Correct Answer: B
Rationale: Obese women have lower premenopausal estradiol levels but higher postmenopausal estradiol levels compared
to lean women. This occurs because adipose tissue contains the aromatase enzyme, which converts adrenal androgens
(DHEA, androstenedione) into estradiol through peripheral aromatization. The resulting higher postmenopausal estradiol
exposure increases the risk of endometrial hyperplasia and endometrial cancer, as the endometrium remains stimulated by
unopposed estrogen in the absence of progesterone. SHBG levels are typically lower in obesity, not higher.
Q7: What is a Luteal Out-of-Phase (LOOP) event, and what hormonal mechanism explains it?
A. A decline in progesterone during the luteal phase causing premenstrual symptoms
B. Elevated FSH during the luteal phase that recruits a second follicle, causing a follicular phase-like rise in
estradiol
C. An anovulatory cycle resulting in persistently low estradiol levels throughout the cycle
3
, NAMS Menopause Certification Exam 2026/2027 200 Questions | Version A & B
D. A sudden drop in inhibin B that triggers a compensatory rise in FSH at mid-cycle
Correct Answer: B
Rationale: A LOOP event explains why some perimenopausal women have elevated estrogen levels despite approaching
menopause. During the early menopause transition, elevated FSH can recruit a second follicle during the luteal phase,
causing a follicular phase-like rise in estradiol. This is a key concept in understanding why perimenopausal women may
experience symptoms of estrogen excess (breast tenderness, heavy menstrual bleeding) even as they approach menopause.
Options A and C describe common but different perimenopausal phenomena. Option D is not a recognized mechanism in
the menopause transition literature.
Q8: Which endocrine lab findings are characteristic after menopause has been established?
A. Elevated estrogen and normal FSH
B. Elevated FSH and LH with decreased estradiol
C. Normal FSH and LH with elevated progesterone
D. Decreased FSH and LH with elevated estradiol
Correct Answer: B
Rationale: After menopause, the loss of ovarian follicles results in decreased estradiol and inhibin production. The
reduction in negative feedback from estrogen and inhibin leads to elevated FSH and LH levels. FSH rises more
dramatically than LH because it is additionally released from the inhibin-mediated suppression that existed during
reproductive years. This pattern of elevated gonadotropins with decreased estradiol is the hallmark endocrine profile of
the postmenopausal state.
Q9: A clinician is evaluating a 45-year-old woman with irregular menstrual cycles and wants to assess
FSH levels. On which day of the cycle should FSH be measured to obtain the most reliable result, and
why?
A. Day 14, because this is when LH surge occurs and FSH is most representative of ovulatory function
B. Day 21, because progesterone peaks at this time and FSH correlates with luteal function
C. Day 3, because elevated estradiol later in the cycle can suppress FSH, giving a falsely normal level
D. Day 1, because FSH is at its lowest point at menses and provides a clear baseline
Correct Answer: C
Rationale: FSH should ideally be measured on cycle day 3 because elevated estradiol levels later in the cycle can suppress
FSH, potentially giving a falsely normal result. During the early follicular phase (day 2-5), estradiol is at its lowest and
FSH is not suppressed, providing the most accurate assessment of ovarian reserve and menopausal status. Measuring FSH
on day 14 coincides with the LH surge and is not appropriate for assessing menopausal status. Day 21 is used for
progesterone assessment to confirm ovulation. Day 1 FSH may be transiently elevated due to the declining corpus luteum
and is less standardized.
Q10: What is the role of anti-Mullerian hormone (AMH) and inhibin B during the reproductive years?
A. They stimulate follicular development and ovulation
B. They work to prevent too-rapid depletion of the follicle pool
C. They are the primary hormones responsible for the production of adrenal androgens
D. They regulate the thermoneutral zone in the hypothalamus
Correct Answer: B
Rationale: AMH and inhibin B are hormones produced by ovarian follicles during the reproductive years that serve as
negative feedback regulators of folliculogenesis, preventing too-rapid depletion of the follicle pool. AMH is produced by
small growing follicles and inhibits the recruitment of primordial follicles into the growing pool. Inhibin B is produced by
preantral and small antral follicles and selectively inhibits FSH secretion. Both decline in the late reproductive years,
4
