Download Case 1: PMS, Contraception, Pregnancy and Lactation

1. What condition is MT’s most likely diagnosis?
A. Endometriosis
B. Perimenopause
C. Menopause
D. Premenstrual syndrome
2. Which of the following drug therapy regimens would be most appropriate for MT at this
time?
A. Premarin 0.3mg daily + Provera 1.5mg days 1-12
B. Premarin 0.3mg daily
C. Cyclessa daily
D. Estrace vaginal cream – ½ applicatorful nightly
3. MT could adopt healthy lifestyle measures to limit her vasomotor symptoms. Measures with
the best evidence for effectiveness are:
A. Add a regimen of soy.
B. Decrease exercise that causes sweating
C. Limit consumption of hot foods and alcohol.
D. Wear lightweight clothes. Avoid layers.
4. MT is well controlled on her therapy for a few years. MT, now 52 yo, discontinues her drug
therapy for several months and returns to the gynecologist for an evaluation as the hot flashes
have returned but she is not having any menstrual periods. If MT has experienced
menopause, which serum level will increase?
A. FSH
B. progesterone during the luteal phase
C. 17-estradiol
D. testosterone
5. It is determined that MT has experienced menopause. The most effective treatment to
alleviate MT’s vasomotor symptoms is:
A. Hormone replacement therapy
B. Clonidine
C. Oral contraceptive
D. Testosterone
6. The most appropriate starting regimen to treat MT’s symptoms with minimal side effects is:
A. Premarin 0.3mg daily
B. Premarin 0.3mg daily + Provera 1.5mg days 1-12
C. Prempro 0.625/2.5 daily
D. Ortho Tri-Cyclen Lo daily days 1-21
7. According to the WHI, what factor in MT’s personal or family medical history is a significant
risk factor for adverse events when MT takes an HT regimen?
A. Father’s colon cancer
B. MT’s GERD
C. MT’s age
D. Mother’s stroke
8. MT is prescribed a regimen that includes 0.3mg of conjugated equine estrogen po daily.
After 6 months, she is still having vasomotor symptoms. What is the most effective option to
improve control of her vasomotor symptoms?
A. Decrease the daily estrogen dose to ½ tablet of 0.3mg CEE
B. Increase the daily estrogen dose to 0.45mg CEE
C. Change to an equivalent transdermal estrogen regimen
D. Change to a selective estrogen receptor modulator
9. For patients with a family history of thromboembolic disease, which of the following
regimens to relieve vasomotor symptoms has evidence to suggest that the risk of clotting
problems would be less than the other products?
A. Cenestin 0.3mg
B. Premarin 0.45mg
C. Femring 0.05mg/24hrs
D. Alora 0.025mg/24hrs
10. MT asks her doctor to switch her to a transdermal estrogen product. Which of the following
estrogen products is the most appropriate and equivalent to her regimen in #6?
A. Climara 0.025mg/24hrs
B. Vivelle-Dot 0.0375mg/day
C. Femring 0.05mg/day
D. Evamist 2-3sprays/day
11. MT’s doctor decided to prescribe Evamist to treat her vasomotor symptoms. Which of the
following counseling points is correct when talking to MT about her new prescription?
A. Application site reactions are common with this product and include redness and itching
at the site of administration.
B. You should avoid washing the site for at least 2 hours after application because it could
decrease absorption.
C. MT should avoid allowing children and pets to touch the site of application on the
forearm.
D. Evamist is associated with fewer risks when compared to HRT given by other routes.
12. MT comes to your pharmacy counter with a bottle of red clover and says that she is tired of
taking all of these prescription medications and is going to try an herbal supplement that her
friend said worked well for hot flashes. Which of the following statements about red clover is
correct.
A. She should consider taking it because studies have shown that it does significantly
reduce the severity of hot flashes.
B. She should continue her current therapy because red clover has not been proven
effective or safe for use in hot flashes.
C. Red clover contains coumarins, which may interact with warfarin and decrease its
effectiveness at thinning the blood.
D. Using red clover supplements for coumarins and isoflavones is more effective than
using food sources.
13. MT estimates her daily calcium intake at one glass of skim milk and one carton of low fat
yogurt daily. Which form and dose of calcium supplement is most likely the best choice for
MT?
A. Puritan’s Pride Calcium carbonate 1200mg Plus Vitamin D 1000mg, one tablet daily
B. Caltrate 600 + D, calcium carbonate and vitamin D3 800 IU, one tablet daily
C. Citracal Maximum, 315 mg calcium citrate + vitamin D 250IU, two tablets daily
D. Viactiv 500mg calcium carbonate + 500IU vitamin D, one tablet twice daily
14. For MT, the recommended daily dose of vitamin D according to the IOM is _____ because
_________.
A. 800mg ergocalciferol/day, MT’s vitamin D levels are normal
B. 600mg cholecalciferol/day, MT’s vitamin D levels are normal
C. 600mg ergocalciferol/day, MT’s vitamin D levels are low
D. 1000mg cholecalciferol/day, MT’s vitamin D levels are low
15. If MT decided to discontinue HRT therapy after several years, which of the following
statements is true according to NAMS guidelines?
A. The likelihood of hot flashes returning is very low.
B. Return of hot flashes can be prevented by tapering the dose of HT.
C. The likelihood of hot flashes returning is about 50:50.
D. If hot flashes return, the patient should reinstitute HT therapy at a higher dose.
16. Current NAMS recommendations suggest that MT can most safely and effectively use HT:
A. for 3-5 years
B. in the form of BHT
C. in the vaginal dosing form
D. indefinitely if she uses the lowest dose available
17. If MT had vaginal symptoms only and was using a low dose vaginal estrogen (Estrace
vaginal cream 0.1mg/g), according to NAMS 2012 guidelines, would it be necessary to add a
progestin to her regimen?
A. Yes, it is necessary to protect her from endometrial hyperplasia.
B. Yes, it is necessary to treat the vaginal dryness and dyspareunia
C. No, use of progesterone locally on the vaginal tissue has adverse effects.
D. No, the lowest dose vaginal preparations do not appear to stimulate the endometrium.
18. After MT is taking HRT for two years with amenorrhea, she starts having bleeding episodes.
The appropriate course of action is to:
A. Tell MT to discontinue HRT and contact her gynecologist immediately
B. Decrease the estrogen content of her HRT to decrease the bleeding
C. Increase the estrogen content of her HRT to decrease the bleeding
D. Increase the progestin content of her HRT to decrease the bleeding
19. At the time of MT’s menopause diagnosis and beginning of HT therapy her T score indicates
that she has _________. Three years later, she suffers a fracture in her forearm. She has a
repeat DEXA scan and is told that she has a T score of -2.1 MT’s t-score is now indicative
of:
A. Osteopenia, osteoporosis
B. Osteoporosis, osteopenia
C. Osteoporosis, osteoporosis
D. Osteopenia, osteopenia
20. According to the FRAX algorithm, which of the following are potential risk factors that
would be included as part of the determination of MT to see if she is a candidate for drug
therapy to improve or maintain her BMD?
A. age, serum calcium, serum vitamin D, gender
B. age, gender, alcohol use, and parental hip fracture
C. age, dietary calcium, weight bearing exercise, BMI
D. gender, glucocorticoid use, serum calcium, weight bearing exercise
21. What medication would be the most appropriate to treat MT’s condition if her 10-year major
hip fracture probability, according to the FRAX, was 5%?
A. No drug therapy would be required
B. Suggest an increase in the dose of estrogen to 0.625mg
C. Recommend Prolia 60 mg q 6 mo
D. Recommend Actonel 35mg once a week
22. MT is determined to be a candidate for osteoporosis drug therapy and she is started on
Actonel 35mg weekly. She cannot tolerate the therapy. To prevent further bone-related
problems, what would be the most logical next choice therapy to try?
A. Zolendronic acid 5mg yearly
B. Alendronate 5mg daily
C. Prolia 60mg q 6 months
D. Forteo 20mcg subcutaneously daily
23. If MT begins taking an oral bisphosphonate for her osteoporosis which of the following
would be an appropriate counseling point?
A. Take medication on a full stomach.
B. MT should not take this medication at the same time as other medications.
C. Take medication with a minimum of 12 oz of water.
D. Osteonecrosis is a common side effect; MT should watch for jaw pain.
MT, now 55, presents for an annual exam. After completing your standard annual screening
questionnaire you notice she indicated ‘bladder problems’. Upon further discussion, she tells you
that she has been wearing pads for accidental leakage of urine for the past year. She needs them
for the occasional “leaking” when she coughs or sneezes, but she sometimes feels a sudden urge
and leaks when she’s just sitting at her desk typing.
24. Which type of incontinence is MT most likely presenting with?
A. Stress incontinence
B. Urge incontinence
C. Mixed incontinence
D. Postmenopausal incontinence
25. Which of the following medications would be most effective to treat MT’s symptoms of urge
and nocturia?
A. Duloxetine
B. Oxybutynin
C. Estrogen
D. Phenylephrine
26. Which item in MT’s history is the most significant risk factor for UUI?
A. Omeprazole therapy
B. Sertraline therapy
C. Moderate use of alcohol
D. Walking on the treadmill
27. All of the following are expected adverse effects of treating MT’s urgency and nocturia
except:
A. constipation
B. dry mouth
C. increased heart rate
D. blurred vision
28. MT wants to know if there is anything she can try doing to decrease her symptoms without
having to take medication. What should you recommend?
A. She can try kegel exercises and dietary changes to improve her symptoms but she may
need to use medication for a more effective treatment.
B. She can increase the amount of aerobic exercise so preforms to strengthen pelvic floor
muscles.
C. She should try to drink as little water as possible to decrease frequency of symptoms.
D. There are no non-pharmacologic treatments that may be effective in this patient. She
needs medication to treat her symptoms.
29. According to the 2012 NAMS guidelines, is estrogen considered an effective therapy for
incontinence?
A. Yes, systemic estrogen may be effective for SUI.
B. No, topical estrogen will worsen UUI.
C. No, HT in any form has been shown to worsen all types of UI.
D. Yes, topical ET may be effective for UUI.