Download Case 1: PMS, Contraception, Pregnancy and Lactation

1. Which of the following drug therapy regimens would be most appropriate for MT at this
time?
A. Estrace vaginal cream – ½ applicatorful nightly
B. Premarin 0.3mg daily + Provera 1.5mg days 1-12
C. Premarin 0.3mg daily
D. Cyclessa daily
2. 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. Limit consumption of hot foods and alcohol.
C. Wear lightweight clothes. Avoid layers.
D. Decrease exercise that causes sweating
3. 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. It is determined that MT has
experienced menopause. The most effective treatment to alleviate MT’s vasomotor
symptoms is:
A. Clonidine
B. Oral contraceptive
C. Testosterone
D. Hormone replacement therapy
4. 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. Premarin 0.625mg daily
D. Ortho Tri-Cyclen Lo daily days 1-21
5. 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
6. 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. Change to an equivalent transdermal estrogen regimen
C. Change to a selective estrogen receptor modulator
D. Increase the daily estrogen dose to 0.45mg CEE
7. 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. Enjuvia 0.3mg
B. Premarin 0.45mg
C. Alora 0.025mg/24hrs
D. Femring 0.05mg/24hrs
8. 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. Vivelle-Dot 0.0375mg/day
B. Climara 0.025mg/24hrs
C. Femring 0.05mg/day
D. Evamist 2-3sprays/day
9. 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
10. 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 based on individual factors
11. 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.
12. 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
13. 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. Osteopenia, osteopenia
C. Osteoporosis, osteopenia
D. Osteoporosis, osteoporosis
14. 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, dietary calcium, weight bearing exercise, BMI
C. age, gender, alcohol use, and parental hip fracture
D. gender, glucocorticoid use, serum calcium, weight bearing exercise
15. 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. Recommend Actonel 35mg once a week
C. Recommend Prolia 60 mg q 6 mo
D. Suggest an increase in the dose of estrogen to 0.625mg
16. MT is determined to be a candidate for osteoporosis drug therapy and she is started on
Actonel 35mg weekly. Which of the following would be an appropriate counseling point?
A. Take medication on a full stomach.
B. Take medication with a minimum of 12 oz of water.
C. MT should not take this medication at the same time as other medications.
D. Osteonecrosis is a common side effect; MT should watch for jaw pain.
17. She cannot tolerate the therapy. To prevent further bone-related problems, what would be the
most logical next choice therapy to try?
A. Alendronate 5mg daily
B. Prolia 60mg q 6 months
C. Zolendronic acid injection 5mg yearly
D. Forteo 20mcg subcutaneously daily
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.
Hint: First, think about what type of incontinence she is experiencing.
18. Which of the following medications would be best choice to treat MT’s symptoms of urge
and nocturia?
A. Oxybutynin
B. Duloxetine
C. Estrogen
D. Phenylephrine
19. All of the following are expected adverse effects of treating MT’s urgency and nocturia
except:
A. constipation
B. dry mouth
C. blurred vision
D. increased heart rate
20. MT wants to know if there is anything non-pharmacologic she can try doing to decrease her
symptoms without having to take medication. What should you recommend?
A. She can increase the amount of aerobic exercise she performs to strengthen pelvic floor
muscles.
B. She should try to drink as little water as possible to decrease frequency of symptoms.
C. There are no non-pharmacologic treatments that may be effective in this patient. She
needs medication to treat her symptoms.
D. Kegel exercises and dietary changes should improve her symptoms but she may need to
use medication also for a more effective treatment.