MENOPAUSE QUIZ 1 Dr Mona Shroff www.obgyntoday.info
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Round 1 History / Famous Personalities Round 2 Physiology of
menopause Round 3 Pharmacology Round 4 Osteoporosis Round 5 Cancer
Round 6 VISUAL ROUND Round 7 Cardiovascular & Genitourinary
issues Round 8 Mental health & Public Health issues 2 Dr Mona
Shroff www.obgyntoday.info
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HISTORY / FAMOUS PERSONALITIES R O U 1 N D 3 Dr Mona Shroff
www.obgyntoday.info
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TEAM A 1.BORN ON JUNE 14 1864 IN GERMANY. 2.HIS FIRST NAME WAS
ALOIS. 3.NEUROPATHOLOGIST & PSYCHIATRIST WHO ALONG WITH FRANS
NISSL EXTENSIVELY STUDIED THE NORMAL AND PATHOLOGICAL ANATOMY OF
CEREBRAL CORTEX. 4 Dr Mona Shroff www.obgyntoday.info
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ALOIS ALZHEIMER 5 Dr Mona Shroff www.obgyntoday.info
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TEAM B 1.American endocrinologist born on 12 jan 1900.
2.Extensively studied pathophysiology of parathyroid & gave
distinction b/w osteoporosis & disorders of calcium metabolism.
3.Pioneer of replacement therapy for menopause & birth control
by hormone therapy & has multiple syndromes named after him. 6
Dr Mona Shroff www.obgyntoday.info
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FULLER ALBRIGHT 7 Dr Mona Shroff www.obgyntoday.info
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TEAM C 1.Born in lausanne, switzerland in 1933, passed away on
15 may 2007. 2.Instrumental in the creation of the european
foundation for osteoporosis in 1987, which became the international
osteoporosis foundation in 1998. 3.Pioneering work led to the
discovery of a new class of therapeutic agents, the bisphosphonates
8 Dr Mona Shroff www.obgyntoday.info
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PROFESSOR HERBERT FLEISCH 9 Dr Mona Shroff
www.obgyntoday.info
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TEAM D Major areas of research interest. Polycystic Ovary
Disorder (PCOS), long-term effects of treatment with growth hormone
of growth hormone-deficient persons,research ethics besides
longstanding interests in the hormone changes occurring with aging
in both men and women. Associate Dean for Ethics, David Geffen
School of Medicine at UCLA Proposed the estrogen window hypothesis
for carcinogenesis of breast carcinoma. 10 Dr Mona Shroff
www.obgyntoday.info
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PROF. S.G. KORENMAN 11 Dr Mona Shroff www.obgyntoday.info
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TEAM E Dr Mona Shroff www.obgyntoday.info 12 In 1929-1930 he
succeeded in isolating oestrone, a feat independently accomplished
at about the same time by Butenandt in Germany.Butenandt
AmericanAmerican biochemist. He received the Nobel Prize in
Physiology or Medicine in 1943biochemist Nobel Prize in Physiology
or Medicine Worked with biologist Edgar Allen to study the ovarian
systems of rats and mice. He later isolated two other related
products, oestriol and oestradiol-17
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EDWARD DOISY Dr Mona Shroff www.obgyntoday.info 13
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ROUND 2 PHYSIOLOGY 14 Dr Mona Shroff www.obgyntoday.info
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TEAM A What causes A menopausal woman to have 1. Hirsutism? 2.
Decreased libido? What is free testosterone index ? What does it
indicate 15 Dr Mona Shroff www.obgyntoday.info
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Hirsutism - altered androgen : estrogen ratio Reduced libido
decreased testosterone Ratio of total testosterone to SHBG. If
FSH rise(> 10 times) more compared to LH rise (3 times) due
to shorter half life of LH. Menstrual irregularity 18 Dr Mona
Shroff www.obgyntoday.info
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TEAM C What leads to shortening of menstrual cycle in
perimenopause & thereafter irregular cycles near menopause ?
What is the critical threshold of follicles below which menopause
occurs regardless of age 19 Dr Mona Shroff www.obgyntoday.info
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Shortening in early perimenopause due to rising FSH faster
follicular maturation shortened follicular phase.Later more
anovulatory cycles-irregular,delayed. 1000 follicles 20 Dr Mona
Shroff www.obgyntoday.info
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TEAM D How do you explain the rise in fsh levels in
perimenopausal transition inspite of normal to slightly raised
estradiol levels? What is the average postmenopausal estrogen
production rate? 21 Dr Mona Shroff www.obgyntoday.info
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Reduced inhibin secretion from follicles feedback on FSH
levels. 45-60 microgm/24 hrs 22 Dr Mona Shroff
www.obgyntoday.info
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TEAM E Mention 2 other causes of hot flushes. Name 3 drugs
useful in treatment of hot flushes besides HRT. Dr Mona Shroff
www.obgyntoday.info 23
TEAM F What does the term continuation of ovarian function
postmenopausally refer to? What is the avg weight & volume of a
postmenopausal ovary? Dr Mona Shroff www.obgyntoday.info 25
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As the ovary fails, it continues to produce testosterone and
perhaps in increased amountsfor a variable number of years. This is
the so called continuation of ovarian function postmenopausally.
i.e. progressive androgenisation Wt. < 10 gms Vol. < 8 cucc.
Dr Mona Shroff www.obgyntoday.info 26
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PHARMACOLOGY R O U 3 N D 27 Dr Mona Shroff
www.obgyntoday.info
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TEAM A When can a woman who is on OCPills for contraception,be
shifted to HRT if necessary? 28 Dr Mona Shroff
www.obgyntoday.info
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When FSH on D6-D7 of pill free week is high.(>20) If in mid
fifties can change directly. 29 Dr Mona Shroff
www.obgyntoday.info
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TEAM B NAME 4 SERMS.WHICH OF THE SERMS COMES NEAREST TO THE
IDEAL SERM. 30 Dr Mona Shroff www.obgyntoday.info
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- Clomiphene Tamoxifen Toremifene Droloxifene Iodoxifene
Raloxifene Ormeloxifene-NEAREST TO IDEAL 31 Dr Mona Shroff
www.obgyntoday.info
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TEAM C The U.S. Food and Drug Administration is now requiring
that a new, highlighted (boxed) warning be placed on all estrogen
products for use by postmenopausal women. The warning highlights
the increased risk for which diseases? 32 Dr Mona Shroff
www.obgyntoday.info
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stroke blood clots invasive breast cancer heart disease and
heart attacks Dr Mona Shroff www.obgyntoday.info 33
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TEAM D Why is the max duration for which teriparatide can be
used for Rx of late postmenopausal osteoporosis? Why? 34 Dr Mona
Shroff www.obgyntoday.info
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In male and female rats, teriparatide caused an increased
incidence of osteosarcoma that was dependent on dose and treatment
duration. (In rats, osteosarcoma was seen at doses 3 to 60 times
the human exposure following a 20 g dose) Long-term use (>2
years) is not recommended Transient orthostatic hypotension
(infrequent) 35 Dr Mona Shroff www.obgyntoday.info
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TEAM E What are the implications of progesterone challenge test
in menopausal women? Dr Mona Shroff www.obgyntoday.info 36
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If NEGATINE : No estrogen primed endometrium hence reassuring
If POSITIVE : May have proliferative, Hyperplastic or Neoplastic
endometrium Dr Mona Shroff www.obgyntoday.info 37
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TEAM F What is a tissue selective estrogen complex? Dr Mona
Shroff www.obgyntoday.info 38
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A TSEC is the partnering of a SERM and other estrogens to
achieve clinical results based on their blended tissue selective
activity profiles. One option for a TSEC is the pairing of a
SERM(Bazedoxifene) with CEE. Dr Mona Shroff www.obgyntoday.info
39
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OSTEOPOROSIS R O U 4 N D 40 Dr Mona Shroff
www.obgyntoday.info
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TEAM A WHAT ARE THE CRITERIA FOR A MENOPAUSAL WOMAN TO UNDERGO
BMD TESTING? Dr Mona Shroff www.obgyntoday.info 41
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All women aged 65 years or older, regardless of other risk
factors for osteoporosis. Postmenopausal women younger than 65
years with 1 or more risk factors for osteoporosis (other than
being white, postmenopausal, and female). All postmenopausal women
who have had a fragility fracture. 42 Dr Mona Shroff
www.obgyntoday.info
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TEAM B On BMD testing when will a woman be diagnosed as having
osteopenia & osteoporosis ? Dr Mona Shroff www.obgyntoday.info
43
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Normal BMD : T-score is 1.0 or above (no lower than 1.0 SD
below the BMD norm for young normal women). Osteopenia : T-scores
between 1.0 and 2.5 SDs (between 1.0 and 2.5 SDs below that of
young normal women). Osteoporosis : T-score is 2.5 or lower (at
least 2.5 SDs lower than the norm for young normal women) 44 Dr
Mona Shroff www.obgyntoday.info
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TEAM C What are the criteria for starting pharmacotherapy for
treatment of postmenopausal bone loss? Dr Mona Shroff
www.obgyntoday.info 45
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T-scores below 2.0 by central DXA with no risk factors,
T-scores below 1.5 by central DXA with 1 or more risk factors,
Prior fragility fractures. Some authorities,including the World
Health Organization, designate an intervention threshold T-score of
2.5 SDs.(if no risk factors). 46 Dr Mona Shroff
www.obgyntoday.info
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TEAM D Name 2 drugs each,recommen ded for primary prevention
& secondary prevention of postmenopausal osteoporosis. Dr Mona
Shroff www.obgyntoday.info 47
TEAM E Give one example each of cortical bone & trabecular
bone. Which are the most comman sites for compression vertebral
fractures in menopause? Dr Mona Shroff www.obgyntoday.info 49
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Cortical : all perepheral bones Trabecular :
spine,pelvis,proximal femur D 12, L1-2-3 Dr Mona Shroff
www.obgyntoday.info 50
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TEAM F Mention 2 ways by which estrogen prevents osteoporosis?
What is the simplest way to assess adequacy of estrogen therapy? Dr
Mona Shroff www.obgyntoday.info 51
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Maintains balance b/w osteoblastic & osteoclastic
activity(decrease osteoclastic activity) Increases Vit D receptors
in osteoblasts modulates Vit D activity. Aseess vaginal wall pH,if
< 4.5 ; E therapy adequate Dr Mona Shroff www.obgyntoday.info
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CANCERS R O U 5 N D 53 Dr Mona Shroff www.obgyntoday.info
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TEAM A Arrange the following HRT regimens in increasing order
of association with risk of endometrial cancer? 1. Estrogen only 2.
Sequential E-P 3. Continuous combined 54 Dr Mona Shroff
www.obgyntoday.info
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1. Continuous combined 2. Sequential E-P 3. Estrogen only 55 Dr
Mona Shroff www.obgyntoday.info
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TEAM B Arrange the following HRT regimens in increasing order
of association with risk of Breast cancer? 1. Estrogen only 2.
Sequential E-P 3. Continuous combined 56 Dr Mona Shroff
www.obgyntoday.info
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1. Estrogen only 2. Sequential E-P 3. Continuous combined(>4
yrs) Dr Mona Shroff www.obgyntoday.info 57
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TEAM C When would endometrial evaluation be called for in a
woman on HRT? Dr Mona Shroff www.obgyntoday.info 58
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Endometrial evaluation is called for when : (any menopausal
woman not taking HRT develops uterine bleeding after more than 1
year of amenorrhea. ) any postmenopausal woman on HRT for 6 months
or more with persistent uterine bleeding. and any previously
amenorrheic woman on HRT who begins bleeding without apparent
cause. 59 Dr Mona Shroff www.obgyntoday.info
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TEAM D Name one cancer with probabale increased risk with HRT,(
other than Ca breast & endometrium ) and one with probable
decreased risk with HRT. 60 Dr Mona Shroff www.obgyntoday.info
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Probable increased risk : Ca ovary Probable decreased risk : Ca
colon Dr Mona Shroff www.obgyntoday.info 61
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TEAM E When do you do mammography on a patient aged 53 yrs on
combined HRT? What is the effect of raloxiphene on breast? Dr Mona
Shroff www.obgyntoday.info 62
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After stopping HRT for 2 wks since HRT causes increase in
breast density. Raloxiphene--No change in breast density. Dr Mona
Shroff www.obgyntoday.info 63
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TEAM F What is the lowest dose of progesterone that is
endometrium protective Sequential ? Continuous combined ? Dr Mona
Shroff www.obgyntoday.info 64
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Not well established but from current literature Sequential MPA
: 5-10 mg/d for 12-14 d Combined MPA : 1.5 -2.5 mg/d Dr Mona Shroff
www.obgyntoday.info 65
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VISUAL ROUND R O U 6 N D 66 Dr Mona Shroff
www.obgyntoday.info
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TEAM A Dr Mona Shroff www.obgyntoday.info 67
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How much progesterone does it release daily? What is the
difference between LNG IUS & transdermal progesterone on
endometrial hyperplasia? Dr Mona Shroff www.obgyntoday.info 68
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20 micgm LNG /d Transdermal progesterone does not protect
against endometrial hyperplasia. Dr Mona Shroff www.obgyntoday.info
69
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TEAM B Dr Mona Shroff www.obgyntoday.info 70
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The soy compounds are called genistein, daidzein, and glycitein
Mention the effects of phytoestrogens on Uterus Breast bones What
is EQUOL? Dr Mona Shroff www.obgyntoday.info 71
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No effect on uterus & bone,protective on breast. Daidzein,
an isoflavone phytoestrogen found in soy, is metabolized to equol
and O- desmethylangolensin (O-DMA) by intestinal
bacteria.Approximately 30%-50% of the human population produce
equol-weak estrogen with modest effects on endpoints regulated by
estrogen receptor alpha. Dr Mona Shroff www.obgyntoday.info 72
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TEAM C Dr Mona Shroff www.obgyntoday.info 73
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How much estradiol does estring release? How much estradiol
does femring release? What is the difference between their use? Dr
Mona Shroff www.obgyntoday.info 74
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Estring : 7.5 mic gm/d Femring : 50-100 mic gm /d Femring needs
progesterone for endometrial protection. Dr Mona Shroff
www.obgyntoday.info 75
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TEAM D Dr Mona Shroff www.obgyntoday.info 76
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What does the chart represent? In the late reproductive stage
(stage -3),what happens to the E2 level in the early follicular
phase? Dr Mona Shroff www.obgyntoday.info 77
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Stages of reproductive aging. In the late reproductive stage
(stage - 3), E2 level in the early follicular phase is either
normal or elevated An E2 level 80 pg/ml is often considered to be
elevated. Dr Mona Shroff www.obgyntoday.info 78
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TEAM E Dr Mona Shroff www.obgyntoday.info 79
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Which year was it launched? Which day of year is the world
menopause day celebrated? Dr Mona Shroff www.obgyntoday.info
80
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The Indian Menopause Society was launched in 1995. 18 october
Dr Mona Shroff www.obgyntoday.info 81
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CARDIOVASCULAR & GENITOURINARY ISSUES R O U 7 N D 82 Dr
Mona Shroff www.obgyntoday.info
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TEAM A What were the results of the HERS 1&2 trials of HRT
on CVS? 83 Dr Mona Shroff www.obgyntoday.info
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HERS II trial results confirm the initial findings of HERS I
increased risk of coronary events in the early years of treatment
increase in thromboembolic events in the HRT group compared with
placebo mainly seen in the first year of use 84 Dr Mona Shroff
www.obgyntoday.info
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TEAM B What is the effect of Tibolone on CVS? Dr Mona Shroff
www.obgyntoday.info 85
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Tibolone increases cardiac output, blood flow in capillaries,
& has no effect on blood pressure. In vivo models showed
prevention of atherosclerosis (Direct anti-atherogenic effect by
inhibiting leukocyte adhesion molecule action) It decreases
triglycerides & lipoproteins.It has transient lowering effect
on HDL levels but it normalizes with long term use 86 Dr Mona
Shroff www.obgyntoday.info
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TEAM C Name an agent of choice for Rx of overactive bladder in
a menopausal woman.(from currently available preparations) Dr Mona
Shroff www.obgyntoday.info 87
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Tolterodine ER 88 Dr Mona Shroff www.obgyntoday.info
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TEAM D How much postvoid residual volumes indicate urinary
retention in menopausal women? Dr Mona Shroff www.obgyntoday.info
89
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Postvoid residual volumes greater than 200 mL indicate urinary
retention in elderly women. 90 Dr Mona Shroff
www.obgyntoday.info
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TEAM E Name 3 drugs useful for menopausal vaginal atrophy. Dr
Mona Shroff www.obgyntoday.info 91
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Local low dose estradiol Oral E Tibolone Dr Mona Shroff
www.obgyntoday.info 92
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TEAM F Name 2 conditions where transdermal E is preferable
where oral route is contraindicated. Dr Mona Shroff
www.obgyntoday.info 93
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Migraine Liver ds. Crohns ds Dr Mona Shroff www.obgyntoday.info
94
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ROUND 8 MENTAL / PUBLIC HEALTH ISSUES & MISC. 95 Dr Mona
Shroff www.obgyntoday.info
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TEAM A How does HRT act on the nervous system? When & how
long should it be given for benefit. 96 Dr Mona Shroff
www.obgyntoday.info
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Neuroprotection: It reduces the risk of Alzheimers disease by
reducing b amyloid protein & cholinergic dysfunction in brain.
It enhances the proliferation of neuronal cell population within
the hippocampus. It regulates the synaptic neurotransmission &
increases nerve growth factor. Thus it enhances neuroplasticity,
memory, and cognition. It delays the onset of Parkinsons disease by
its action on dopaminergic system in midbrain Start v.early in
menopause & for at least 10 yrs 97 Dr Mona Shroff
www.obgyntoday.info
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TEAM B NAME 3 TESTS YOU WOULD ADVISE FOR A WOMAN WITH PREMATURE
MENOPAUSE ? Dr Mona Shroff www.obgyntoday.info 98
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LABORATORY EVALUATION OF PREMATURE OVARIAN FAILURE FSH (to
establish the diagnosis of premature ovarian failure) Karyotype
(