NAMS Menopause Certification Exam - Comprehensive Review 2026/2027
NAMS Menopause Certification Exam
Comprehensive Review Examination 2026/2027
200 Questions | Detailed Rationales
1. A 48-year-old perimenopausal woman with a history of depression controlled with sertraline 100 mg daily reports
worsening mood symptoms. Her FSH is 18 mIU/mL. Which of the following is the most appropriate management
approach?
A. A. Discontinue sertraline and start HT
B. B. Optimize antidepressant therapy and consider HT as adjunctive treatment if mood symptoms are linked
to perimenopause [CORRECT]
C. C. Double the sertraline dose
D. D. Refer for electroconvulsive therapy
Correct Answer: B
Rationale: Correct because management of mood disturbances in perimenopausal women with pre-existing depression
requires optimizing current antidepressant therapy. HT may be considered as adjunctive treatment for
perimenopause-related mood symptoms.
2. A 47-year-old woman in the menopausal transition is concerned about her risk of osteoporosis. She has a BMI of 19, a
sedentary lifestyle, and a maternal history of hip fracture. Which of the following has the strongest evidence for primary
prevention of osteoporosis in this patient?
A. A. High-dose calcium supplementation alone
B. B. Weight-bearing exercise, adequate nutrition, and lifestyle modification [CORRECT]
C. C. Prophylactic bisphosphonate therapy
D. D. Hormone therapy initiation in the menopausal transition
Correct Answer: B
Rationale: Correct because lifestyle interventions including weight-bearing exercise, adequate calcium and vitamin D
intake, smoking cessation, and fall prevention have the strongest evidence for primary prevention of osteoporosis and
should be first-line for all women.
3. A 45-year-old woman presents with hair loss, acne, and irregular periods. Laboratory testing shows elevated testosterone
and DHEA-S levels. Which of the following is the most likely diagnosis?
A. A. Premature ovarian insufficiency
B. B. Polycystic ovary syndrome [CORRECT]
C. C. Menopausal transition
D. D. Androgen-secreting tumor
Correct Answer: B
Rationale: Correct because the combination of hyperandrogenism (hair loss, acne, elevated testosterone),
oligomenorrhea, and elevated DHEA-S is classic for PCOS. POI would present with elevated FSH and low estrogen, not
elevated androgens.
4. A 55-year-old woman with a T-score of -2.0 and a wrist fracture from a fall asks about her fracture risk. Which of the
following best explains the significance of a wrist fracture in a postmenopausal woman?
A. A. Wrist fractures are not related to osteoporosis
B. B. A wrist fracture is a sentinel fragility fracture that significantly increases future fracture risk
[CORRECT]
C. C. Wrist fractures only occur in women with normal bone density
NAMS Menopause Certification Exam - Comprehensive Review | Page 1
, NAMS Menopause Certification Exam - Comprehensive Review 2026/2027
D. D. A wrist fracture indicates high-impact trauma
Correct Answer: B
Rationale: Correct because a wrist (Colles) fracture from a fall from standing height or less is a fragility fracture that
predicts increased risk of vertebral and hip fractures. It should prompt bone density testing and fracture risk assessment.
5. Which of the following best describes the effect of menopause on insulin resistance?
A. A. Insulin sensitivity improves after menopause
B. B. Menopause is associated with increased insulin resistance independent of age and body composition
[CORRECT]
C. C. Insulin resistance only changes if the woman gains weight
D. D. Progesterone is the primary hormone affecting insulin sensitivity
Correct Answer: B
Rationale: Correct because the decline in estrogen after menopause is independently associated with increased insulin
resistance, contributing to higher rates of type 2 diabetes and metabolic syndrome in postmenopausal women.
6. A 40-year-old woman presents with secondary amenorrhea, hot flashes, and night sweats for 6 months. She reports a
family history of autoimmune disease. FSH is 55 mIU/mL on two occasions. TSH, prolactin, and pregnancy test are
negative. Which of the following autoimmune conditions is most commonly associated with POI?
A. A. Rheumatoid arthritis
B. B. Thyroid autoimmunity (Hashimoto thyroiditis) [CORRECT]
C. C. Systemic lupus erythematosus
D. D. Type 1 diabetes
Correct Answer: B
Rationale: Correct because thyroid autoimmunity is the most common autoimmune condition associated with POI.
Screening for thyroid antibodies and TSH is recommended in all women diagnosed with POI.
7. Which selective estrogen receptor modulator is approved for the treatment of dyspareunia associated with vulvovaginal
atrophy in postmenopausal women?
A. A. Tamoxifen
B. B. Raloxifene
C. C. Ospemifene [CORRECT]
D. D. Bazedoxifene
Correct Answer: C
Rationale: Correct because ospemifene is the only SERM specifically approved by the FDA for the treatment of
moderate-to-severe dyspareunia due to vulvovaginal atrophy in postmenopausal women.
8. Which of the following is the primary mechanism by which estrogen deprivation contributes to osteoporosis in
postmenopausal women?
A. A. Decreased intestinal calcium absorption
B. B. Increased osteoclast activity and bone resorption [CORRECT]
C. C. Reduced vitamin D synthesis in the skin
D. D. Impaired osteoblast differentiation
Correct Answer: B
Rationale: Correct because estrogen normally inhibits osteoclast-mediated bone resorption through the RANKL/OPG
pathway. Loss of estrogen removes this inhibitory effect, leading to increased bone turnover and net bone loss.
9. A 53-year-old woman being started on hormone therapy asks about potential side effects. Which of the following is a
common side effect of progestin in combined HT?
A. A. Increased bone density beyond the effect of estrogen alone
B. B. Progestin-related side effects including bloating, breast tenderness, and mood changes [CORRECT]
C. C. Reduced efficacy of vasomotor symptom relief
NAMS Menopause Certification Exam - Comprehensive Review | Page 2
, NAMS Menopause Certification Exam - Comprehensive Review 2026/2027
D. D. Decreased risk of breast tenderness
Correct Answer: B
Rationale: Correct because progestins commonly cause side effects including bloating, breast tenderness, mood changes,
and irregular bleeding. These side effects are a leading reason women discontinue combined HT.
10. A 48-year-old woman presents for her annual examination and reports that her mother was diagnosed with breast
cancer at age 65. She is concerned about starting hormone therapy for her moderate vasomotor symptoms. Which of the
following is the most accurate counseling regarding HT and breast cancer risk?
A. A. A family history of breast cancer is an absolute contraindication to HT
B. B. HT increases breast cancer risk primarily with combined estrogen-progestin and prolonged use; the
absolute risk increase is modest [CORRECT]
C. C. Estrogen-only HT carries a higher breast cancer risk than combined therapy
D. D. The breast cancer risk from HT is irreversible even after discontinuation
Correct Answer: B
Rationale: Correct because the WHI and observational studies show that breast cancer risk increases primarily with
combined estrogen-progestin therapy, especially beyond 5 years. A family history of breast cancer is not an absolute
contraindication but requires careful shared decision-making.
11. A 52-year-old woman presents for a follow-up visit after starting transdermal estrogen with cyclic micronized
progesterone 3 months ago. She reports resolution of hot flashes but has continued progestin-related side effects including
bloating and irritability. Which of the following is the most appropriate adjustment?
A. A. Discontinue all HT
B. B. Consider a levonorgestrel-releasing IUD for endometrial protection instead of oral progesterone
[CORRECT]
C. C. Increase the progesterone dose
D. D. Switch to a different brand of progesterone
Correct Answer: B
Rationale: Correct because the LNG-IUD provides effective endometrial protection with minimal systemic progestin
exposure, potentially reducing progestin-related side effects while maintaining the benefits of estrogen therapy.
12. A 53-year-old woman on continuous combined HT reports a single episode of light spotting after 8 months of
amenorrhea. Which of the following is the most appropriate management?
A. A. Immediate endometrial biopsy
B. B. Evaluate with transvaginal ultrasound and consider endometrial sampling based on endometrial
thickness [CORRECT]
C. C. Discontinue HT immediately
D. D. Reassure that spotting is always benign on continuous HT
Correct Answer: B
Rationale: Correct because any unscheduled bleeding on continuous combined HT after amenorrhea warrants
evaluation. Transvaginal ultrasound assessment of endometrial thickness can guide the need for endometrial sampling.
13. A 62-year-old woman has been using a vaginal estradiol ring for 3 years for GSM. She had a TIA 6 months ago and is
on aspirin. Her neurologist recommends stopping the vaginal ring. Which of the following is the most appropriate
alternative?
A. A. Oral estrogen therapy
B. B. Vaginal moisturizers, lubricants, and ospemifene (after neurology clearance) [CORRECT]
C. C. Testosterone cream
D. D. Systemic progesterone
Correct Answer: B
Rationale: Correct because when vaginal estrogen must be discontinued, ospemifene provides a non-estrogen systemic
option for dyspareunia due to GSM. Vaginal moisturizers and lubricators serve as supportive non-hormonal measures.
NAMS Menopause Certification Exam - Comprehensive Review | Page 3
, NAMS Menopause Certification Exam - Comprehensive Review 2026/2027
14. A 55-year-old woman with well-controlled hypertension on lisinopril wants to start HT for moderate vasomotor
symptoms. Which of the following is the most accurate recommendation?
A. A. HT is contraindicated in all women with hypertension
B. B. HT can be considered with well-controlled hypertension, preferably using transdermal estrogen
[CORRECT]
C. C. Only estrogen-only HT is safe in hypertensive women
D. D. HT will worsen hypertension regardless of route
Correct Answer: B
Rationale: Correct because well-controlled hypertension is not an absolute contraindication to HT. Transdermal estrogen
is preferred as oral estrogen may increase blood pressure through hepatic effects on renin substrate production.
15. A 49-year-old woman presents with a 1-week history of severe right-sided headache, jaw pain with chewing, and scalp
tenderness. She is in the early menopausal transition. ESR is 68 mm/hr. Which of the following is the most critical next
step?
A. A. Start HT for vasomotor symptoms
B. B. Initiate high-dose corticosteroids immediately and obtain temporal artery biopsy [CORRECT]
C. C. Prescribe a muscle relaxant
D. D. Order brain MRI
Correct Answer: B
Rationale: Correct because the clinical presentation of new-onset headache, jaw claudication, and scalp tenderness with
elevated ESR is highly suggestive of giant cell arteritis, a medical emergency requiring immediate corticosteroid therapy
to prevent vision loss.
16. A 48-year-old woman being evaluated for irregular vaginal bleeding has a transvaginal ultrasound showing an
endometrial thickness of 4 mm. Her FSH is 22 mIU/mL. Which of the following is the most appropriate interpretation?
A. A. The endometrial thickness is abnormal and requires biopsy
B. B. An endometrial thickness of 4 mm in a perimenopausal woman is within normal limits [CORRECT]
C. C. Immediate hysterectomy is indicated
D. D. This finding is diagnostic of endometrial cancer
Correct Answer: B
Rationale: Correct because in premenopausal and perimenopausal women, endometrial thickness varies with the
menstrual cycle and there is no single cutoff that reliably excludes pathology. A thickness of 4 mm is not concerning in
this context.
17. A 53-year-old transgender man who has been on testosterone therapy for 3 years presents with vasomotor symptoms
after bilateral oophorectomy. Which of the following is the most appropriate management approach?
A. A. Discontinue testosterone and start estrogen
B. B. Continue testosterone and consider adding a low-dose estrogen if symptoms are severe [CORRECT]
C. C. Increase the testosterone dose
D. D. Prescribe gabapentin only, as estrogen is contraindicated
Correct Answer: B
Rationale: Correct because transgender men who undergo oophorectomy may experience vasomotor symptoms due to
loss of ovarian estrogen. Management requires individualized care considering gender-affirming goals, and options
include continuing testosterone with possible low-dose estrogen if symptoms are severe.
18. A 42-year-old woman with POI has been on HT for 2 years. She now reports that her hot flashes have resolved. She
asks if she can stop HT. Which of the following is most accurate?
A. A. She should stop HT immediately since symptoms have resolved
B. B. She should continue HT at least until the average age of natural menopause for bone and cardiovascular
protection [CORRECT]
C. C. She only needs HT for symptom control
NAMS Menopause Certification Exam - Comprehensive Review | Page 4
NAMS Menopause Certification Exam
Comprehensive Review Examination 2026/2027
200 Questions | Detailed Rationales
1. A 48-year-old perimenopausal woman with a history of depression controlled with sertraline 100 mg daily reports
worsening mood symptoms. Her FSH is 18 mIU/mL. Which of the following is the most appropriate management
approach?
A. A. Discontinue sertraline and start HT
B. B. Optimize antidepressant therapy and consider HT as adjunctive treatment if mood symptoms are linked
to perimenopause [CORRECT]
C. C. Double the sertraline dose
D. D. Refer for electroconvulsive therapy
Correct Answer: B
Rationale: Correct because management of mood disturbances in perimenopausal women with pre-existing depression
requires optimizing current antidepressant therapy. HT may be considered as adjunctive treatment for
perimenopause-related mood symptoms.
2. A 47-year-old woman in the menopausal transition is concerned about her risk of osteoporosis. She has a BMI of 19, a
sedentary lifestyle, and a maternal history of hip fracture. Which of the following has the strongest evidence for primary
prevention of osteoporosis in this patient?
A. A. High-dose calcium supplementation alone
B. B. Weight-bearing exercise, adequate nutrition, and lifestyle modification [CORRECT]
C. C. Prophylactic bisphosphonate therapy
D. D. Hormone therapy initiation in the menopausal transition
Correct Answer: B
Rationale: Correct because lifestyle interventions including weight-bearing exercise, adequate calcium and vitamin D
intake, smoking cessation, and fall prevention have the strongest evidence for primary prevention of osteoporosis and
should be first-line for all women.
3. A 45-year-old woman presents with hair loss, acne, and irregular periods. Laboratory testing shows elevated testosterone
and DHEA-S levels. Which of the following is the most likely diagnosis?
A. A. Premature ovarian insufficiency
B. B. Polycystic ovary syndrome [CORRECT]
C. C. Menopausal transition
D. D. Androgen-secreting tumor
Correct Answer: B
Rationale: Correct because the combination of hyperandrogenism (hair loss, acne, elevated testosterone),
oligomenorrhea, and elevated DHEA-S is classic for PCOS. POI would present with elevated FSH and low estrogen, not
elevated androgens.
4. A 55-year-old woman with a T-score of -2.0 and a wrist fracture from a fall asks about her fracture risk. Which of the
following best explains the significance of a wrist fracture in a postmenopausal woman?
A. A. Wrist fractures are not related to osteoporosis
B. B. A wrist fracture is a sentinel fragility fracture that significantly increases future fracture risk
[CORRECT]
C. C. Wrist fractures only occur in women with normal bone density
NAMS Menopause Certification Exam - Comprehensive Review | Page 1
, NAMS Menopause Certification Exam - Comprehensive Review 2026/2027
D. D. A wrist fracture indicates high-impact trauma
Correct Answer: B
Rationale: Correct because a wrist (Colles) fracture from a fall from standing height or less is a fragility fracture that
predicts increased risk of vertebral and hip fractures. It should prompt bone density testing and fracture risk assessment.
5. Which of the following best describes the effect of menopause on insulin resistance?
A. A. Insulin sensitivity improves after menopause
B. B. Menopause is associated with increased insulin resistance independent of age and body composition
[CORRECT]
C. C. Insulin resistance only changes if the woman gains weight
D. D. Progesterone is the primary hormone affecting insulin sensitivity
Correct Answer: B
Rationale: Correct because the decline in estrogen after menopause is independently associated with increased insulin
resistance, contributing to higher rates of type 2 diabetes and metabolic syndrome in postmenopausal women.
6. A 40-year-old woman presents with secondary amenorrhea, hot flashes, and night sweats for 6 months. She reports a
family history of autoimmune disease. FSH is 55 mIU/mL on two occasions. TSH, prolactin, and pregnancy test are
negative. Which of the following autoimmune conditions is most commonly associated with POI?
A. A. Rheumatoid arthritis
B. B. Thyroid autoimmunity (Hashimoto thyroiditis) [CORRECT]
C. C. Systemic lupus erythematosus
D. D. Type 1 diabetes
Correct Answer: B
Rationale: Correct because thyroid autoimmunity is the most common autoimmune condition associated with POI.
Screening for thyroid antibodies and TSH is recommended in all women diagnosed with POI.
7. Which selective estrogen receptor modulator is approved for the treatment of dyspareunia associated with vulvovaginal
atrophy in postmenopausal women?
A. A. Tamoxifen
B. B. Raloxifene
C. C. Ospemifene [CORRECT]
D. D. Bazedoxifene
Correct Answer: C
Rationale: Correct because ospemifene is the only SERM specifically approved by the FDA for the treatment of
moderate-to-severe dyspareunia due to vulvovaginal atrophy in postmenopausal women.
8. Which of the following is the primary mechanism by which estrogen deprivation contributes to osteoporosis in
postmenopausal women?
A. A. Decreased intestinal calcium absorption
B. B. Increased osteoclast activity and bone resorption [CORRECT]
C. C. Reduced vitamin D synthesis in the skin
D. D. Impaired osteoblast differentiation
Correct Answer: B
Rationale: Correct because estrogen normally inhibits osteoclast-mediated bone resorption through the RANKL/OPG
pathway. Loss of estrogen removes this inhibitory effect, leading to increased bone turnover and net bone loss.
9. A 53-year-old woman being started on hormone therapy asks about potential side effects. Which of the following is a
common side effect of progestin in combined HT?
A. A. Increased bone density beyond the effect of estrogen alone
B. B. Progestin-related side effects including bloating, breast tenderness, and mood changes [CORRECT]
C. C. Reduced efficacy of vasomotor symptom relief
NAMS Menopause Certification Exam - Comprehensive Review | Page 2
, NAMS Menopause Certification Exam - Comprehensive Review 2026/2027
D. D. Decreased risk of breast tenderness
Correct Answer: B
Rationale: Correct because progestins commonly cause side effects including bloating, breast tenderness, mood changes,
and irregular bleeding. These side effects are a leading reason women discontinue combined HT.
10. A 48-year-old woman presents for her annual examination and reports that her mother was diagnosed with breast
cancer at age 65. She is concerned about starting hormone therapy for her moderate vasomotor symptoms. Which of the
following is the most accurate counseling regarding HT and breast cancer risk?
A. A. A family history of breast cancer is an absolute contraindication to HT
B. B. HT increases breast cancer risk primarily with combined estrogen-progestin and prolonged use; the
absolute risk increase is modest [CORRECT]
C. C. Estrogen-only HT carries a higher breast cancer risk than combined therapy
D. D. The breast cancer risk from HT is irreversible even after discontinuation
Correct Answer: B
Rationale: Correct because the WHI and observational studies show that breast cancer risk increases primarily with
combined estrogen-progestin therapy, especially beyond 5 years. A family history of breast cancer is not an absolute
contraindication but requires careful shared decision-making.
11. A 52-year-old woman presents for a follow-up visit after starting transdermal estrogen with cyclic micronized
progesterone 3 months ago. She reports resolution of hot flashes but has continued progestin-related side effects including
bloating and irritability. Which of the following is the most appropriate adjustment?
A. A. Discontinue all HT
B. B. Consider a levonorgestrel-releasing IUD for endometrial protection instead of oral progesterone
[CORRECT]
C. C. Increase the progesterone dose
D. D. Switch to a different brand of progesterone
Correct Answer: B
Rationale: Correct because the LNG-IUD provides effective endometrial protection with minimal systemic progestin
exposure, potentially reducing progestin-related side effects while maintaining the benefits of estrogen therapy.
12. A 53-year-old woman on continuous combined HT reports a single episode of light spotting after 8 months of
amenorrhea. Which of the following is the most appropriate management?
A. A. Immediate endometrial biopsy
B. B. Evaluate with transvaginal ultrasound and consider endometrial sampling based on endometrial
thickness [CORRECT]
C. C. Discontinue HT immediately
D. D. Reassure that spotting is always benign on continuous HT
Correct Answer: B
Rationale: Correct because any unscheduled bleeding on continuous combined HT after amenorrhea warrants
evaluation. Transvaginal ultrasound assessment of endometrial thickness can guide the need for endometrial sampling.
13. A 62-year-old woman has been using a vaginal estradiol ring for 3 years for GSM. She had a TIA 6 months ago and is
on aspirin. Her neurologist recommends stopping the vaginal ring. Which of the following is the most appropriate
alternative?
A. A. Oral estrogen therapy
B. B. Vaginal moisturizers, lubricants, and ospemifene (after neurology clearance) [CORRECT]
C. C. Testosterone cream
D. D. Systemic progesterone
Correct Answer: B
Rationale: Correct because when vaginal estrogen must be discontinued, ospemifene provides a non-estrogen systemic
option for dyspareunia due to GSM. Vaginal moisturizers and lubricators serve as supportive non-hormonal measures.
NAMS Menopause Certification Exam - Comprehensive Review | Page 3
, NAMS Menopause Certification Exam - Comprehensive Review 2026/2027
14. A 55-year-old woman with well-controlled hypertension on lisinopril wants to start HT for moderate vasomotor
symptoms. Which of the following is the most accurate recommendation?
A. A. HT is contraindicated in all women with hypertension
B. B. HT can be considered with well-controlled hypertension, preferably using transdermal estrogen
[CORRECT]
C. C. Only estrogen-only HT is safe in hypertensive women
D. D. HT will worsen hypertension regardless of route
Correct Answer: B
Rationale: Correct because well-controlled hypertension is not an absolute contraindication to HT. Transdermal estrogen
is preferred as oral estrogen may increase blood pressure through hepatic effects on renin substrate production.
15. A 49-year-old woman presents with a 1-week history of severe right-sided headache, jaw pain with chewing, and scalp
tenderness. She is in the early menopausal transition. ESR is 68 mm/hr. Which of the following is the most critical next
step?
A. A. Start HT for vasomotor symptoms
B. B. Initiate high-dose corticosteroids immediately and obtain temporal artery biopsy [CORRECT]
C. C. Prescribe a muscle relaxant
D. D. Order brain MRI
Correct Answer: B
Rationale: Correct because the clinical presentation of new-onset headache, jaw claudication, and scalp tenderness with
elevated ESR is highly suggestive of giant cell arteritis, a medical emergency requiring immediate corticosteroid therapy
to prevent vision loss.
16. A 48-year-old woman being evaluated for irregular vaginal bleeding has a transvaginal ultrasound showing an
endometrial thickness of 4 mm. Her FSH is 22 mIU/mL. Which of the following is the most appropriate interpretation?
A. A. The endometrial thickness is abnormal and requires biopsy
B. B. An endometrial thickness of 4 mm in a perimenopausal woman is within normal limits [CORRECT]
C. C. Immediate hysterectomy is indicated
D. D. This finding is diagnostic of endometrial cancer
Correct Answer: B
Rationale: Correct because in premenopausal and perimenopausal women, endometrial thickness varies with the
menstrual cycle and there is no single cutoff that reliably excludes pathology. A thickness of 4 mm is not concerning in
this context.
17. A 53-year-old transgender man who has been on testosterone therapy for 3 years presents with vasomotor symptoms
after bilateral oophorectomy. Which of the following is the most appropriate management approach?
A. A. Discontinue testosterone and start estrogen
B. B. Continue testosterone and consider adding a low-dose estrogen if symptoms are severe [CORRECT]
C. C. Increase the testosterone dose
D. D. Prescribe gabapentin only, as estrogen is contraindicated
Correct Answer: B
Rationale: Correct because transgender men who undergo oophorectomy may experience vasomotor symptoms due to
loss of ovarian estrogen. Management requires individualized care considering gender-affirming goals, and options
include continuing testosterone with possible low-dose estrogen if symptoms are severe.
18. A 42-year-old woman with POI has been on HT for 2 years. She now reports that her hot flashes have resolved. She
asks if she can stop HT. Which of the following is most accurate?
A. A. She should stop HT immediately since symptoms have resolved
B. B. She should continue HT at least until the average age of natural menopause for bone and cardiovascular
protection [CORRECT]
C. C. She only needs HT for symptom control
NAMS Menopause Certification Exam - Comprehensive Review | Page 4
