Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

The Mature Woman

22–1. Menopause may be identified by which of the following?

a. The point in time 1 year after cessation of menses

b. The time when menstruation permanently stops due to loss of ovarian function

c. The state associated with physical symptoms and with metabolic and structural changes related to declining estrogen levels

d. All of the above

22–2. Regarding the large observational Nurses’ Health Study from 1985, all EXCEPT which of the following are correct?

a. It identified a significant reduction in heart disease among postmenopausal hormone users.

b. It suggested at least a doubling of cerebrovascular disease among postmenopausal hormone users.

c. Its findings likely were confounded by timing of the initiation of the postmenopausal hormone therapy.

d. It likely was biased by including participants who were not representative of the U.S. postmenopausal population.

22–3. Which of the following is correct regarding the Heart and Estrogen/Progestin Replacement Study (HERS) and HERS II?

a. They included healthy women without preexisting heart disease.

b. They showed that estrogen was a useful medication for secondary prevention of cardiac disease progression.

c. They showed (at 1 year) an increase in myocardial infarctions in women who received conjugated equine estrogen and continuous medroxyprogesterone acetate.

d. They showed (at 4 years) a sustained increased risk of myocardial infarction in women receiving combined hormone therapy.

22–4. Results from the Women’s Health Initiative (WHI) suggest which of following regarding coronary heart disease risk?

a. It is decreased among older users (70–79 years).

b. It is increased among younger users (50–59 years).

c. It is universally increased among postmenopausal users of combined estrogen and progestin hormone replacement.

d. It is likely decreased among women who initiate combined hormone therapy within 10 years of the menopause.

22–5. Results from the WHI suggest which of following regarding stroke risk?

a. It is decreased among older users (70–79 years).

b. It is decreased among younger users (50–59 years).

c. It is universally increased among postmenopausal users of combined estrogen and progestin hormone replacement.

d. It is likely decreased among women who initiate combined hormone therapy within 10 years of the menopause.

22–6. A summary of postmenopausal systemic hormone replacement risks and benefits indicates an increased risk of all EXCEPT which of the following?

a. Stroke

b. Breast cancer

c. Colorectal cancer

d. Venous thromboembolism

22–7. Estrogen replacement therapy is contraindicated in women with all EXCEPT which of the following?

a. Vasomotor symptoms

b. Active liver disease

c. Known or suspected breast carcinoma

d. Abnormal genital bleeding of unknown etiology

22–8. Which of the following is true of estrogen as treatment for hot flashes and sleep disturbances?

a. It reduces hot flash frequency by 18 events per week (75 percent reduction compared with placebo).

b. It is available in oral, parenteral, topical, and transdermal formulations.

c. It should generally be prescribed at the lowest effective dose.

d. All of the above

22–9. Which of the following is true of progestin-only hormone replacement therapy?

a. It may attenuate estrogen’s beneficial effects on lipids and blood flow.

b. It provides protection against estrogen-induced endometrial hyperplasia and cancer.

c. Its use may be limited by its adverse effects of weight gain and irregular vaginal bleeding.

d. All of the above

22–10. Currently recommended alternatives to hormones for treatment of vasomotor symptoms include all EXCEPT which of the following?

a. Bellergal

b. Clonidine

c. Gabapentin

d. Selective serotonin-reuptake inhibitors

22–11. Which of the following is true of dong quai?

a. It is rich in α-linolenic acid and touted to reduce inflammation, heart disease, and cancer.

b. It contains addictive barbiturates and is not recommended for long-term use.

c. It has been shown to significantly reduce vasomotor symptoms compared with placebo in double-blinded controlled trials.

d. It is potentially photosensitizing and contains numerous coumarin-like derivatives that may cause excessive bleeding.

22–12. Decreasing central sympathetic tone by means such as paced respiration has which of the following effects?

a. Increases intensity of hot flashes

b. Increases symptoms of depression and anxiety

c. May decrease frequency of common vasomotor symptoms

d. Results in no significant reduction in hot-flash frequency compared with biofeedback and muscle relaxation techniques

22–13. Your patient is a 57-year-old G3P3 nonsmoking white woman who reached menopause at age 52. She has no family history of osteoporosis, no history of prolonged corticosteroid use, and no hyperparathyroidism or malabsorption syndrome. An evaluation for severe back pain reveals the anterior wedge fracture seen in this image. Bone mineral density screening was performed and gives a T-score of -1.7. Which of the following is the most effective and appropriate intervention?


Reproduced, with permission, from Lindsay R, Cosman F: Osteoporosis. In Fauci AS, Braunwald E, Kasper DL, et al (eds): Harrison’s Principles of Internal Medicine, 17th ed. New York, McGraw-Hill, 2008, Figure 348-2.

a. Limit physical activity

b. Initiate physical therapy and analgesia

c. Initiate oral calcium, 1000 mg daily

d. Initiate an oral bisphosphonate therapy for bone fracture prevention and treatment

22–14. Which of the following is the first Food and Drug Administration (FDA)-approved medication for osteoporosis treatment that works by stimulating bone formation rather than slowing bone resorption?

a. Calcitonin

b. Bisphosphonates

c. Human parathyroid hormone

d. Selective estrogen-receptor modulators

22–15. Which of the following is true of raloxifene?

a. It is a potent bisphosphonate.

b. It increases breast cancer risks.

c. It increases thromboembolism risks.

d. It significantly decreases nonvertebral fracture risks.

22–16. Which of these oral bisphosphonates offers a dosing schedule (once monthly) that is more convenient for patients but still tolerated as well as daily dosing, thereby improving compliance?

a. Alendronate

b. Zoledronate

c. Risedronate

d. Teriparatide

22–17. Doctors of the patient from whom this image is taken hope to increase bone density, turnover, and size by increasing osteoblast numbers. Which of the following is true of the medication to be prescribed?


Reproduced, with permission, from Bradshaw KD: Menopausal transition. In Schorge JO, Schaffer JI, Halvorson LM, et al (eds): Williams Gynecology, 1st ed. New York, McGraw-Hill, 2008, Figure 21-10D.

a. It is given once weekly orally.

b. It may be delivered by nasal spray.

c. It is not recommended for patients at increased risk of skeletal malignancy.

d. It may cause upper gastrointestinal inflammation, ulceration, and bleeding.

22–18. Vitamin D deficiency leads to which of the following?

a. Decreased bone turnover

b. Improved calcium absorption

c. Decreased rate of bone loss

d. Secondary hyperparathyroidism

22–19. The image presents a schematic of the daily whole-body turnover of calcium. All EXCEPT which of the following interventions are expected to be beneficial to bone health and calcium absorption?


Reproduced, with permission, from Friedman PA: Agents affecting mineral ion homeostasis and bone turnover. In Brunton LL, Chabner BA, Knollmann BC (eds): Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 12th ed. New York, McGraw-Hill, 2011, Figure 44-2.

a. Increasing caffeine intake

b. Increasing calcium intake to > 1200 mg daily

c. Improving absorption by increasing daily vitamin Dto > 400–600 IU/d

d. Decreasing renal excretion by decreasing sodium excretion (i.e., low-sodium diet)

22–20. Vaginal products for estrogen replacement in post-menopausal women have which of the following effects?

a. Decrease vaginal mucosal sensorimotor responses

b. Increase vaginal mucosal fluid secretions and elasticity

c. Have lower patient-acceptance rates compared with systemic therapies

d. Have comparable systemic estradiol concentrations compared with systemic therapies

22–21. Which of the following statements are correct when agents are compared with daily or twice-weekly application of vaginal conjugated estrogen cream (Premarin)?

a. 17β-Estradiol tablet suppositories offer equivalent relief of atrophic vaginitis symptoms.

b. Continuous low-dose estradiol-releasing intravaginal rings are more acceptable to patients.

c. Continuous low-dose estradiol-releasing intravaginal rings are prescribed as a single unit and worn for 90 days.

d. All of the above

22–22. Prolonged treatment of decreased libido using androgens in postmenopausal women could contribute to all EXCEPT which of the following?

a. Acne and hirsutism

b. Clitoral hypertrophy

c. Worsening lipid profile

d. Decreased bone mineral density

22–23. All EXCEPT which of the following are among the top four causes of mortality in older women?

a. Cancer

b. Heart disease

c. Diabetes mellitus

d. Cerebrovascular disease

22–24. The incidence and prevalence of dementia increase as patients grow older. This would argue for routine dementia screening practices and identification/treatment of any reversible causes of dementia. Which of the following is a potentially reversible cause of dementia?

a. Hypothyroidism

b. Thiamine deficiency

c. Vitamin B12 deficiency

d. All of the above

22–25. Which of the following may be a reason to suggest estrogen therapy for a postmenopausal patient with mild urinary incontinence?

a. Periurethral vascularity is diminished by hypoestrogenism.

b. Estrogen receptors are found throughout the lower urinary tract.

c. Hypoestrogenism is associated with deleterious changes in collagen.

d. All of the above

Chapter 22 ANSWER KEY