Sample Synoptic Self-Assessment · PGCert tier

Menopause & Andropause Synoptic Self-Assessment

A 20-item postgraduate-tier synoptic on the women’s and men’s midlife endocrine pathway — pitched deliberately above MRCGP-AKT difficulty. Anchored to NICE NG23 (2024 update); BMS 2024; the joint BMS-RCOG-BSGE-BGCS-FSRH-GIRFT-RCGP 2024 unscheduled bleeding pathway; NICE TA1143 fezolinetant; NICE NG215; FSRH UKMEC; BSSM 2022 testosterone guideline; ISSAM 2024; TRAVERSE 2023. Five items are flagged ★ Professor / Superspecialist tier.

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~30 minutes · 20 items · 5 Professor-level · CPD certificate · Independent & non-promotional

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01 · About this synoptic

Four-quadrant blueprint

Q1–Q5 · Diagnosis

Clinical Dx ≥ 45 without FSH · POI workup · BSSM 2022 testosterone threshold · STRAW+10 · andropause + new AF on TRAVERSE backdrop.

Q6–Q10 · HRT regimens

Transdermal vs oral · LNG-IUS for HRT · migraine with aura · timing hypothesis · breast-cancer risk quantification.

Q11–Q15 · Bleeding pathway & non-hormonal

BMS-RCOG 2024 pathway · low-risk early bleeding · risk-factor escalation · fezolinetant TA1143 · GSM in breast-cancer survivor · complex bleeding with major risk factor.

Q16–Q20 · Andropause & special pops

Secondary hypogonadism + fertility · perimenopausal contraception + HRT · TRT monitoring · testosterone for women HSDD · pre-conception in T2DM-CKD.

How it works. Select your answer for each item. Selection is recorded but not marked. When all twenty are answered, click Mark my answers. The results panel reveals the correct answer for each item plus a 60–120-word rationale focused on why the correct answer is correct, with one hyperlinked guideline reference per item. The certificate at the foot auto-populates with your name, date, score, quadrant breakdown, and personal reflection.

Progress 0 / 20 answered

Q1 · Clinical diagnosis without FSH Diagnosis

A 47-year-old woman has 8 months of hot flashes, night sweats, sleep disturbance and irregular periods (last 6 weeks ago). BMI 27. No medications. Per NICE NG23 (2024 update), what is the most appropriate next step?

ADiagnose perimenopause clinically and counsel on therapeutic options without testing FSH BTest FSH on two occasions 4–6 weeks apart before diagnosis CReassure and review in 6 months DRefer to gynaecology EInitiate antidepressant first-line

Q2 · POI workup Diagnosis

A 34-year-old woman with 5 months of secondary amenorrhoea, vasomotor symptoms and dyspareunia. Two FSH 4 weeks apart: 36 and 41 IU/L. AMH undetectable. Pregnancy test negative. Per ESHRE 2024 / Davis Lancet 2024, the next set of investigations before HRT initiation includes:

APelvic ultrasound only BKaryotype, fragile X premutation, autoimmune screen (TPO, adrenal antibodies), DEXA, lipid profile + ApoB CRepeat FSH at 12 weeks DMRI pelvis ERefer to oncology

Q3 · BSSM 2022 testosterone threshold Diagnosis

A 58-year-old man with 18 months of low libido, ED, low mood. Two morning samples: total T 7.4 and 7.8 nmol/L; LH 6 and 7 IU/L (normal); FSH 5; PSA 1.2; Hb 148, Hct 0.42. BMI 28. Family complete. What is the most appropriate management?

ARepeat in 12 months BContinue sildenafil; do not treat testosterone CInitiate transdermal testosterone gel 50 mg daily; review symptoms, Hb / Hct, PSA at 3 months DRefer to urology before treatment EStart clomiphene

Q4 · STRAW+10 staging Diagnosis

A 49-year-old woman has cycles of 21–55 days length variation over the last 12 months and a 75-day amenorrhoea interval. Vasomotor symptoms started 6 months ago. What is her STRAW+10 stage?

ALate reproductive (−3a) BEarly menopause transition (−2) CEarly postmenopause (+1a) DLate menopause transition (−1) ELate postmenopause (+2)

Q5 · ★ Professor-level Andropause + new-onset AF on TRAVERSE backdrop Diagnosis

A 64-year-old man started transdermal testosterone gel 8 months ago for confirmed testosterone deficiency — symptoms improved. He attends with new-onset palpitations and intermittent fluttering for 3 weeks. ECG confirms atrial fibrillation, rate 86. eGFR 72. He has hypertension (BP 138/84) and previous TIA on aspirin. What is the most appropriate management?

AContinue TRT; routine cardiology referral BStop TRT permanently and discharge CContinue TRT; add aspirin 75 mg DSwitch transdermal to IM testosterone undecanoate EPause TRT; manage AF per NICE NG196 (rate control, anticoagulation per CHA₂DS₂-VASc); cardiology review; reassess TRT after rhythm management

Q6 · HRT regimen for BMI 33 postmenopausal woman HRT regimens

A 50-year-old woman, BMI 33, has moderate-severe vasomotor symptoms. Last menstrual period 13 months ago. BP 130/80. No personal or family VTE or breast-cancer history. What is the most appropriate first-line HRT regimen?

ATransdermal oestradiol 50 microgram patch twice weekly + micronised progesterone 100 mg orally daily BOral oestradiol 1 mg + oral norethisterone 1 mg daily COral CEE 0.625 mg + medroxyprogesterone 5 mg sequential DTibolone 2.5 mg daily EVaginal oestradiol tablet alone

Q7 · Mirena LNG-IUS for HRT HRT regimens

A 51-year-old woman has the Mirena 52 mg LNG-IUS in situ for 4 years for heavy menstrual bleeding. She now requests HRT for severe vasomotor symptoms. BMI 24. Which approach is most appropriate?

ARemove LNG-IUS; start oral combined HRT BContinue current LNG-IUS for endometrial protection (off-licence but BMS-endorsed); add transdermal oestradiol; replace LNG-IUS at 5 years for HRT indication CAdd oral progesterone alongside LNG-IUS DSwitch LNG-IUS to copper IUD EDecline HRT; offer SSRI

Q8 · Migraine with aura + perimenopause HRT regimens

A 49-year-old woman with 30-year history of migraine with aura has disabling night sweats, 2-hourly nocturnal awakenings and low mood for 9 months. Last period 4 months ago. BMI 27. BP 124/78. No VTE or breast-cancer history. Per BMS 2022, what is the most appropriate first-line HRT regimen?

ADecline HRT; offer SSRI for vasomotor symptoms BOral oestradiol + oral micronised progesterone sequential CTransdermal oestradiol 50 microgram patch twice weekly + micronised progesterone 200 mg orally for 12 days per cycle DTibolone 2.5 mg daily ECombined oral contraceptive

Q9 · Timing hypothesis HRT regimens

A 53-year-old woman, 8 months post-menopause, asks about HRT for moderate vasomotor symptoms plus “is HRT good for my heart?”. No CVD; no breast-cancer history. What is the most accurate counselling per the timing hypothesis?

AHRT is proven cardioprotective at any age BHRT increases CV mortality at all ages CHRT reduces all-cause mortality at the population level DHRT initiated within 10 years of menopause or before age 60 has a neutral-to-favourable cardiovascular profile per ELITE / KEEPS / WHI re-analysis; symptom relief is the indication, not primary CV prevention EHRT is contraindicated above age 50

Q10 · ★ Professor-level Quantified breast cancer risk counselling HRT regimens

A 51-year-old woman wishes to start combined continuous HRT for vasomotor symptoms. BMI 26, no family history of premenopausal breast cancer, alcohol 6 units/week. She asks “how much extra breast cancer risk?” Per the NICE NG23 / BMS 2024 decision aid for women starting combined continuous HRT under age 55 for < 5 years, the most accurate quantitative counselling is:

A~ 3 fewer cases per 1,000 women over 5 years B~ 50 extra cases per 1,000 women over 5 years CHRT halves breast cancer risk DThe risk is unknown E~ 8–10 extra cases per 1,000 women over 5 years (versus background ~ 23/1,000)

Q11 · BMS-RCOG 2024 pathway — low-risk early bleeding Bleeding & non-hormonal

A 56-year-old woman attends with 3 weeks of light vaginal spotting. Started continuous combined HRT (transdermal oestradiol 50 mcg patch + micronised progesterone 100 mg daily) 5 months ago for vasomotor symptoms. BMI 28. No personal or family endometrial / breast / colorectal cancer. No diabetes / PCOS. Cervical screen up to date. Examination unremarkable. Per the BMS-RCOG 2024 pathway, what is the most appropriate next step?

AOptimise HRT (e.g. increase progestogen to 200 mg, or switch to sequential) and reassess at 6 months BUSCP referral CUrgent transvaginal ultrasound within 6 weeks now DStop HRT entirely EEndometrial biopsy in primary care

Q12 · BMS-RCOG 2024 pathway — risk-factor escalation Bleeding & non-hormonal

A 62-year-old woman has 7 days of moderate vaginal bleeding. Started continuous combined HRT 14 months ago. BMI 31. No diabetes / PCOS. No family endometrial or colorectal cancer. Per BMS-RCOG 2024 pathway, what is the next step?

AOptimise HRT and reassess in 6 months BRefer for urgent transvaginal ultrasound within 6 weeks CRefer urgently under USCP 2-week pathway DStop HRT entirely EReassure

Q13 · Fezolinetant in breast-cancer survivor Bleeding & non-hormonal

A 54-year-old woman on tamoxifen for ER-positive breast cancer has 16 hot flashes/day, 4 nocturnal episodes, sleep collapse, PHQ-9 12. Oncologist has confirmed in writing that systemic HRT is not appropriate. BMI 25, ALT 22, eGFR 80. Per NICE TA1143, the most appropriate first-line non-hormonal pharmacological option is:

AParoxetine 20 mg daily BClonidine 50 microgram twice daily CFezolinetant 45 mg orally once daily, with baseline and 3-monthly LFTs DTibolone 2.5 mg daily EBlack cohosh 40 mg daily

Q14 · GSM in breast-cancer survivor Bleeding & non-hormonal

A 60-year-old woman, 3 years post-completion of treatment for ER-positive early breast cancer (aromatase inhibitor completed 6 months ago), has severe vaginal dryness, dyspareunia, and recurrent UTIs. Tried Replens / Hyalofemme moisturisers consistently for 6 months, limited improvement. Per NICE NG215 / BMS 2024, the next step is:

AContinue moisturisers and lubricants only BInitiate systemic transdermal HRT CInitiate fezolinetant 45 mg daily DDiscuss with oncology; if agreement, prescribe vaginal oestradiol 10 microgram tablet (Vagifem) twice weekly ERefer for vaginal laser therapy

Q15 · ★ Professor-level Complex bleeding with major risk factor Bleeding & non-hormonal

A 59-year-old woman attends with 5 weeks of progressively heavier vaginal bleeding (now requiring pad day/night). On transdermal oestradiol 75 mcg patch for 7 years + LNG-IUS in situ throughout (last replaced 7 years ago). BMI 42. T2DM 8 years on metformin and dapagliflozin. Cervical screen up to date. No Lynch / Cowden but father had colorectal cancer aged 71. Hb 102 g/L (down from 132). Examination unremarkable. Per BMS-RCOG 2024 pathway, the appropriate triage and pathway is:

AOptimise HRT and reassess in 6 months BUrgent transvaginal ultrasound within 6 weeks via direct access CStop oestradiol patch and reassess at 4 weeks DEndometrial biopsy in primary care ERefer immediately under USCP 2-week pathway — major risk factors present (BMI ≥ 40 AND expired LNG-IUS > 5 y); concurrent IDA management; replace LNG-IUS at gynae visit

Q16 · Secondary hypogonadism + fertility preservation Andropause & special pops

A 32-year-old man has 18 months of low libido, fatigue, ED. He is trying to conceive (2 years, no pregnancy). BMI 24. Two morning samples: total testosterone 6.8 and 7.1; LH 2.4 and 2.6 (low); FSH 3.0 (low); prolactin normal. Pituitary MRI normal. Semen analysis: low-normal motility and count. What is the most appropriate management?

AClomiphene 25 mg alternate days, with andrology / fertility input BTransdermal testosterone gel 50 mg daily CIM testosterone undecanoate 1000 mg every 12 weeks DReassure and re-test at 12 months ESurgical sperm retrieval

Q17 · Perimenopausal contraception + HRT Andropause & special pops

A 49-year-old woman on desogestrel POP for 4 years; periods stopped 8 months ago. Now severe vasomotor symptoms, requesting HRT. BMI 24. No VTE / breast-cancer / migraine history. What is the appropriate management?

AStop POP; start sequential HRT only BContinue POP for contraception; add transdermal oestradiol — desogestrel POP does not provide adequate HRT-equivalent endometrial protection, so add micronised progesterone 100 mg daily or fit a 52 mg LNG-IUS CContinue POP; add transdermal oestradiol patch 50 mcg without additional progestogen DStop POP; start combined oral contraceptive EStop POP; start tibolone

Q18 · TRT monitoring — erythrocytosis threshold Andropause & special pops

A 62-year-old man on transdermal testosterone gel for 6 months for confirmed testosterone deficiency. Symptoms improved. Bloods: total testosterone 19 nmol/L, Hb 175 g/L, Hct 0.55, PSA 1.4 (baseline 1.1). What is the appropriate action?

AContinue current dose BContinue TRT; add aspirin CPause TRT; venesection if Hct remains > 0.54; reassess for OSA / smoking; restart at lower dose with closer monitoring DStop TRT permanently and discharge ERefer urology for PSA (rise of 0.3)

Q19 · Testosterone for women — HSDD Andropause & special pops

A 52-year-old postmenopausal woman on transdermal oestradiol + micronised progesterone for 9 months. Vasomotor symptoms resolved. Persistent low desire and reduced sexual responsiveness despite stable relationship. Total testosterone 0.4 nmol/L (low for female reference). Per BMS 2022, the most appropriate next step is:

AIncrease oestradiol dose BAdd tibolone CRefer for psychosexual counselling without trial DTrial testosterone supplementation off-licence (AndroFeme cream, or Testogel sachets at one-tenth male dose), aim total testosterone mid-female range; reassess at 3 months ENo intervention; reassure

Q20 · ★ Professor-level Pre-conception planning in T2DM-CKD Andropause & special pops

A 38-year-old NHS administrator with 6-year T2DM (HbA1c 71) on metformin, dapagliflozin, semaglutide, gliclazide, ramipril, indapamide, atorvastatin, ezetimibe, with eGFR 38 (down from 52), UACR 78, K⁺ 4.9, BMI 32, BP 138/86. Laser-treated proliferative retinopathy 2 y ago. Hopes to conceive within 12 months. Which combination of medication changes is required pre-conception?

ANo changes; continue all therapy through conception BStop only the SGLT2 inhibitor CContinue all therapy; add folic acid only DStop all therapy and reassess at conception EStop dapagliflozin, semaglutide, atorvastatin, ezetimibe, ramipril, indapamide, gliclazide; switch to insulin (multiple-daily injection or pump); reduce metformin to 500 mg BD (eGFR 38); start folic acid 5 mg; defer pregnancy until HbA1c < 48 if achievable safely; joint nephro-obstetric-diabetes referral

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Menopause & Andropause Synoptic Self-Assessment — 20 single-best-answer items at PGCert tier

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Authored by Prof Rajesh Varma · MD Acumen Ltd · mdacumen.com
Curriculum-aligned with NICE NG23 (2024 update); BMS 2024; BMS-RCOG-BSGE-BGCS-FSRH-GIRFT-RCGP 2024 unscheduled bleeding pathway; NICE TA1143; NICE NG215; BSSM 2022 testosterone guideline; ISSAM 2024; TRAVERSE 2023.

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