Menopause
NAMS Menopause Certification Exam
2025
Climacteric phase - -the period of endocrinology, somatic, and transitory psychologic
changes that occur around the time of menopause.
Early menopause - -lmp before age 45
Late menopause - -lmp after age 54
Primary ovarian insufficiency - -menopause that occurs before age 40
Early menopause transition (stage -2) - -persistent difference of 7 days or more in the
length of consecutive cycles.
Late menopause transition (stage -1) - -60 or more consecutive days of amenorrhea
Luteal out of phase event (loop) - -explains why some perimenopausal women have
elevated estrogen level sometimes...in the early menopause transition, elevated fsh
levels are adequate to recruit a second follicle which results in a follicular phase-like rise
in estradiol secretion superimposed on the mid-to-late luteal phase of the ongoing
ovulatory cycle.
Obese women and estradiol levels during menopause - -obese women are more likely
to have anovulatory cycles with high estradiol levels. They are also more likely to have
lower premenopause yet higher postmenopause estradiol levels compared with women
of normal weight. (why they are at higher risk of endometrial cancer)
Chinese and japanese women - -these ethnic groups have lower estradiol levels then
white, black and hispanic women.
Stage +2 - -late menopause stage: 5-8 years after fmp. Somatic aging predominates.
Increased genitourinary symptoms.
Stages +1a, +1b, +1c - -early post menopause: 2 years after fmp. Fsh rises, estradiol
decreases. Vms predominate.
Elevated fsh, lh - -endocrine labs after menopause
Amh, inhibin b - -these hormones work during reproductive years to not deplete follicle
pool too quickly.
Menopause
,Menopause
Phases during menopause transition and pms symptoms - -menstrual cycle variable,
persistent >7 day difference between difference in length of consecutive cycles.
How to respond if a patient requests fsh lab? - -many pitfalls, variable depending on the
day of the cycle you draw the lab, normal or low fsh is not helpful.
The potentially superior marker of menopause, a lab. - -amh
Dhea (dehydroepiandrosterone) - -adrenal androgens: precursor hormones produced
by the adrenal gland that are enzymatically converted to active androgens or estrogens
in peripheral tissues.
Location of estrogen receptors - -vagina, vulva, urethra, trigone of the bladder
Effects of estrogen on tissue - -maintain blood flow, the collagen, and ha within the
epithelial surfaces. Supports microbiome, which supports acidity of vagina and protects
tissue from pathogens.
Vaginal changes with menopause - -thinning, loss of elasticity, loss or absence or
rugae.
Vagina and urethra in menopause - -vagina narrows, urethra moves closer to the
introitus.
Stress urinary incontinence - -vaginal estrogen and urinary incontinence: what type
does it help with?
Treatment for fphl - -minoxidil, spironolactone, finasteride, estrogen therapy
Late reporoductive years -3b and -3a. What happens with menstrual cycles, fsh, amh,
afc, inhibin? - --3b: menstrual cycles normal, fsh normal, amh low, afc low, inhibin low.
-3a: subtle menstrual changes, variable fsh, amh low, afc low, inhibin low.
When it is appropriate to check an fsh during the cycle if you check it? And why? - -
cycle day #3. Elevated estradiol can suppress fsh giving a falsely normal fsh level.
Amh
Produced by...
Used to test...
Is it a screening tool for fertility?
When does it peak? - -produced by granulosa cells
Used to test damage to ovarian follicle reserve. If amh is low, the woman has a low
ovarian reserve.
Menopause
, Menopause
Not recommended as a screening tool to predict fertility.
Peaks at around 25 years old. So before age 25, this test is not helpful.
It is influenced by exogenous hormones. Lower in hormonal contraception users, but
increases after d/cing.
Afc - -antral follicle count
Number of follicles that are detectable with ultrasound.
They are sensitive to fsh and considered to represent the availability pool of follicles.
Late menopause transition (-1) fsh level on random draw - -25 or higher
Black women have higher or lower fsh levels? - -higher
Chinese and japanese women have higher or lower estradiol levels compared to white,
black and hispanic women? - -lower
Menopause transition-changes in shbg and testosterone? Ratio? - -shbg decreases
Testosterone/shbg ratio increases by 80%.
Testosterone/shgb ratio is called what? - -the free androgen index
What stage are vms more likely? - -+1b (generally last 2 years)
What hormone is generally higher in obese women? - -estrone-via aromatization.
The postmenopausal ovary continues to produce what two hormones? - -testosterone
and androstenedione
Surgical menopause causes women to have lower levels of what hormone? - -
testosterone. 40-50% lower than in women w/ intact ovaries.
Driving piece of menopause is ovarian follicles depleting. What does this do to the
inhibin b and amh? - -inhibin and amh decrease
Therefore, follicle growth is not restrained, this allows for the growth of the remaining,
diminished follicle pool.
In the menopause transition, women spend more time in what phase? - -luteal-more
pms symptoms, more frequent menstrual periods.
Hpo axis theory and the menopause transition - -it is felt that the hpo axis may become
less sensitive to estrogen, so even with good follicle growth and estradiol secretion, lh
surges can fail which can lead to more cycle irregularity.
Menopause
NAMS Menopause Certification Exam
2025
Climacteric phase - -the period of endocrinology, somatic, and transitory psychologic
changes that occur around the time of menopause.
Early menopause - -lmp before age 45
Late menopause - -lmp after age 54
Primary ovarian insufficiency - -menopause that occurs before age 40
Early menopause transition (stage -2) - -persistent difference of 7 days or more in the
length of consecutive cycles.
Late menopause transition (stage -1) - -60 or more consecutive days of amenorrhea
Luteal out of phase event (loop) - -explains why some perimenopausal women have
elevated estrogen level sometimes...in the early menopause transition, elevated fsh
levels are adequate to recruit a second follicle which results in a follicular phase-like rise
in estradiol secretion superimposed on the mid-to-late luteal phase of the ongoing
ovulatory cycle.
Obese women and estradiol levels during menopause - -obese women are more likely
to have anovulatory cycles with high estradiol levels. They are also more likely to have
lower premenopause yet higher postmenopause estradiol levels compared with women
of normal weight. (why they are at higher risk of endometrial cancer)
Chinese and japanese women - -these ethnic groups have lower estradiol levels then
white, black and hispanic women.
Stage +2 - -late menopause stage: 5-8 years after fmp. Somatic aging predominates.
Increased genitourinary symptoms.
Stages +1a, +1b, +1c - -early post menopause: 2 years after fmp. Fsh rises, estradiol
decreases. Vms predominate.
Elevated fsh, lh - -endocrine labs after menopause
Amh, inhibin b - -these hormones work during reproductive years to not deplete follicle
pool too quickly.
Menopause
,Menopause
Phases during menopause transition and pms symptoms - -menstrual cycle variable,
persistent >7 day difference between difference in length of consecutive cycles.
How to respond if a patient requests fsh lab? - -many pitfalls, variable depending on the
day of the cycle you draw the lab, normal or low fsh is not helpful.
The potentially superior marker of menopause, a lab. - -amh
Dhea (dehydroepiandrosterone) - -adrenal androgens: precursor hormones produced
by the adrenal gland that are enzymatically converted to active androgens or estrogens
in peripheral tissues.
Location of estrogen receptors - -vagina, vulva, urethra, trigone of the bladder
Effects of estrogen on tissue - -maintain blood flow, the collagen, and ha within the
epithelial surfaces. Supports microbiome, which supports acidity of vagina and protects
tissue from pathogens.
Vaginal changes with menopause - -thinning, loss of elasticity, loss or absence or
rugae.
Vagina and urethra in menopause - -vagina narrows, urethra moves closer to the
introitus.
Stress urinary incontinence - -vaginal estrogen and urinary incontinence: what type
does it help with?
Treatment for fphl - -minoxidil, spironolactone, finasteride, estrogen therapy
Late reporoductive years -3b and -3a. What happens with menstrual cycles, fsh, amh,
afc, inhibin? - --3b: menstrual cycles normal, fsh normal, amh low, afc low, inhibin low.
-3a: subtle menstrual changes, variable fsh, amh low, afc low, inhibin low.
When it is appropriate to check an fsh during the cycle if you check it? And why? - -
cycle day #3. Elevated estradiol can suppress fsh giving a falsely normal fsh level.
Amh
Produced by...
Used to test...
Is it a screening tool for fertility?
When does it peak? - -produced by granulosa cells
Used to test damage to ovarian follicle reserve. If amh is low, the woman has a low
ovarian reserve.
Menopause
, Menopause
Not recommended as a screening tool to predict fertility.
Peaks at around 25 years old. So before age 25, this test is not helpful.
It is influenced by exogenous hormones. Lower in hormonal contraception users, but
increases after d/cing.
Afc - -antral follicle count
Number of follicles that are detectable with ultrasound.
They are sensitive to fsh and considered to represent the availability pool of follicles.
Late menopause transition (-1) fsh level on random draw - -25 or higher
Black women have higher or lower fsh levels? - -higher
Chinese and japanese women have higher or lower estradiol levels compared to white,
black and hispanic women? - -lower
Menopause transition-changes in shbg and testosterone? Ratio? - -shbg decreases
Testosterone/shbg ratio increases by 80%.
Testosterone/shgb ratio is called what? - -the free androgen index
What stage are vms more likely? - -+1b (generally last 2 years)
What hormone is generally higher in obese women? - -estrone-via aromatization.
The postmenopausal ovary continues to produce what two hormones? - -testosterone
and androstenedione
Surgical menopause causes women to have lower levels of what hormone? - -
testosterone. 40-50% lower than in women w/ intact ovaries.
Driving piece of menopause is ovarian follicles depleting. What does this do to the
inhibin b and amh? - -inhibin and amh decrease
Therefore, follicle growth is not restrained, this allows for the growth of the remaining,
diminished follicle pool.
In the menopause transition, women spend more time in what phase? - -luteal-more
pms symptoms, more frequent menstrual periods.
Hpo axis theory and the menopause transition - -it is felt that the hpo axis may become
less sensitive to estrogen, so even with good follicle growth and estradiol secretion, lh
surges can fail which can lead to more cycle irregularity.
Menopause
