Study guide
13.4 Menopause & Menopausal Hormone Therapy
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
13.4 Menopause & Menopausal Hormone Therapy
Key Takeaways Explain This Topic AI
Menopause management, risks and benefits of therapy is a separately enumerated blueprint subsection.
Systemic hormone therapy is most appropriate for symptomatic women under 60 or within ten years of menopause without contraindications.
A progestin must accompany systemic estrogen in a woman with a uterus to prevent endometrial hyperplasia and carcinoma.
Hormone therapy is contraindicated in estrogen-dependent cancer, unexplained vaginal bleeding, active thromboembolism and active liver disease.
Low-dose vaginal estrogen treats genitourinary syndrome of menopause with minimal systemic absorption and does not require a progestin.
Last updated: August 2026
Women's health in internal medicine encompasses the management of the menopausal transition, evidence-based menopausal hormone therapy (MHT), systematic evaluation of abnormal uterine bleeding, workup of postmenopausal bleeding, and guideline-directed screening for cervical, endometrial, and ovarian malignancies. Mastery of these clinical topics is heavily tested on the ABIM examination.
- 1. Menopause & Perimenopause
- Clinical Definitions & Diagnostic Principles
Menopause: A permanent cessation of menses diagnosed retrospectively after 12 consecutive months of amenorrhea resulting from the loss of ovarian follicular activity, in the absence of other physiological (lactation, pregnancy) or pathological (thyroid dysfunction, hyperprolactinemia) causes. The average age of natural menopause in the United States is 51.4 years (normal range: 45 to 55 years).
Premature Ovarian Insufficiency (POI): Loss of normal ovarian function before age 40 , characterized by amenorrhea, elevated serum FSH (>25-40 IU/L on 2 occasions >1 month apart), and hypoestrogenism. POI mandates systemic hormone replacement therapy until at least the median age of natural menopause (~51 years) to preserve bone mineral density and reduce cardiovascular mortality.
Perimenopause (Menopausal Transition): The symptomatic period preceding menopause characterized by menstrual irregularity (>7 days difference in cycle length between consecutive cycles in early transition; >=60 days of amenorrhea in late transition), vasomotor symptoms, insomnia, and mood changes.
ABIM Diagnostic Pearl — Laboratory Testing in Menopause:
In a woman aged >45 years presenting with classic irregular menses and vasomotor symptoms, routine measurement of serum FSH, LH, estradiol, or anti-Müllerian hormone (AMH) is NOT recommended or required for diagnosis.
Because ovarian follicular development fluctuates dramatically during perimenopause, single hormone measurements are erratic, misleading, and do not change management.
Laboratory testing (TSH, prolactin, hCG, FSH) is indicated only in women <45 years presenting with secondary amenorrhea to rule out POI, prolactinoma, thyroid disease, or pregnancy.
Symptom Complexes
Vasomotor Symptoms (VMS):
Hot flashes and night sweats affect up to 80% of menopausal women, lasting an average of 7 to 9 years.
Pathophysiology: Estrogen withdrawal alters hypothalamic thermoregulation. Loss of estrogen negative feedback leads to hypertrophy and hyperactivity of Kisspeptin-Neurokinin B-Dynorphin (KNDy) neurons in the infundibular nucleus of the hypothalamus, which excessively stimulate the median preoptic thermoregulatory center, triggering inappropriate peripheral vasodilation and diaphoresis.
Genitourinary Syndrome of Menopause (GSM / Vulvovaginal Atrophy):
Affects >50% of postmenopausal women and is progressive without treatment.
Pathophysiology: Estrogen receptors in the vulva, vagina, urethra, and bladder trigone become depleted. Hypoestrogenism causes loss of vaginal rugae, thinning of the vaginal stratified squamous epithelium, loss of cellular glycogen, depletion of protective Lactobacillus species, elevation of vaginal pH (>5.0), and loss of connective tissue elasticity.
Presentation: Vaginal dryness, burning, dyspareunia, vulvar pruritus, urinary urgency, frequency, dysuria, and recurrent urinary tract infections.
- 2. Menopausal Hormone Therapy (MHT)
- Indications & The "Window of Opportunity" Timing Hypothesis
Approved Indications:
Moderate-to-severe vasomotor symptoms (hot flashes, night sweats)
Prevention of postmenopausal osteoporosis and fragility fractures in symptomatic women at elevated fracture risk
Moderate-to-severe symptoms of vulvovaginal atrophy / GSM
The Timing Hypothesis (NAMS / The Menopause Society & WHI Data):
In healthy symptomatic women who are <60 years of age OR within 10 years of menopause onset , the benefits of systemic MHT generally outweigh the risks (favorable cardiovascular profile, reduced all-cause mortality, and decreased fracture incidence).
Initiating systemic MHT in women >60 years of age or >10 to 20 years post-menopause carries an unfavorable risk profile with increased risks of coronary heart disease, stroke, venous thromboembolism, and dementia.
Critical Rule: Systemic MHT should NEVER be initiated for the primary or secondary prevention of cardiovascular disease or dementia .
Regimen Selection & Rules of Administration +-----------------------------------------------------------------------------------------+
- | MENOPAUSAL HORMONE THERAPY (MHT) RULES |
- +-----------------------------------------------------------------------------------------+
- | 1. WOMEN WITH AN INTACT UTERUS: |
- | - MUST receive Estrogen PLUS Progestogen (or Bazedoxifene) |
- | - Unopposed systemic estrogen stimulates endometrial proliferation and increases |
- | endometrial adenocarcinoma risk 8- to 10-fold! |
- | - Preferred Progestogen: Micronized Progesterone (100 mg daily continuous or |
- | 200 mg daily cyclic for 12-14 days/month) due to lower VTE/breast cancer risk |
- | - TSEC Alternative: Conjugated Estrogens 0.45 mg + Bazedoxifene 20 mg (SERM) |
- +-----------------------------------------------------------------------------------------+
- | 2. WOMEN WITH PRIOR HYSTERECTOMY: |
- | - Receive Estrogen-Alone Therapy (ET) |
- | - Progestogen is NOT required because there is no uterus / no endometrial cancer risk|
- +-----------------------------------------------------------------------------------------+
- | 3. ROUTE OF ESTROGEN ADMINISTRATION: |
- | - Transdermal Estradiol (patch 0.025-0.1 mg/d, gel, spray): PREFERRED in women with |
- | hypertension, obesity, hypertriglyceridemia, diabetes, smoking, or moderate VTE |
- | risk. Bypasses hepatic first-pass metabolism, does not increase clotting factors |
- | (prothrombin, factor VII) or CRP, and does not elevate triglycerides. |
- | - Oral Estrogens: Increases hepatic coagulation factor synthesis and triglycerides. |
- +-----------------------------------------------------------------------------------------+
- | 4. ISOLATED GENITOURINARY SYNDROME OF MENOPAUSE (GSM): |
- | - First-line: Low-Dose Local Vaginal Estrogen (cream 0.01%, 10 mcg tablet, ring) |
- | - Minimal systemic absorption; does NOT increase VTE or breast cancer risk |
- | - Does NOT require opposing progestin therapy even with an intact uterus! |
- +-----------------------------------------------------------------------------------------+
- Non-Hormonal Pharmacotherapy for Vasomotor Symptoms
For women with absolute contraindications to estrogen (breast cancer, prior VTE, stroke) or who decline hormonal therapy:
Fezolinetant (Veozah, 45 mg PO daily):
First-in-class selective Neurokinin 3 (NK3) receptor antagonist .
Directly blocks neurokinin B binding on hypertrophied hypothalamic KNDy neurons, restoring normal thermoregulatory center signaling without hormone exposure.
Monitoring: Baseline serum hepatic transaminases (ALT, AST) and total bilirubin; repeat at 3, 6, and 9 months. Discontinue if ALT/AST >=3x ULN.
SSRIs & SNRIs:
Venlafaxine ER (37.5-75 mg daily) , Desvenlafaxine (50 mg daily) , Escitalopram (10-20 mg daily) , or Paroxetine (7.5 mg daily) .
CRITICAL BOARD CONTRAINDICATION — Tamoxifen & CYP2D6:
Tamoxifen is a prodrug requiring hepatic CYP2D6 bioactivation into its active anti-estrogenic metabolite, Endoxifen .
Potent CYP2D6 inhibitors—specifically Paroxetine and Fluoxetine —inhibit this conversion, significantly lowering endoxifen levels and increasing breast cancer recurrence .
In breast cancer patients on Tamoxifen, Paroxetine and Fluoxetine are strictly contraindicated . Use Venlafaxine , Desvenlafaxine , or Gabapentin instead.
Gabapentin (300 to 900 mg PO at bedtime):
Modulates voltage-gated calcium channels in hypothalamic thermoregulatory pathways; particularly beneficial for nocturnal hot flashes and comorbid insomnia.
Clonidine (0.05-0.1 mg PO BID or weekly patch):
Central alpha-2 adrenergic agonist; reduces central noradrenergic surge. Limited by side effects (sedation, dry mouth, orthostatic hypotension, rebound hypertension).
- Absolute Contraindications to Systemic MHT
- Active, past, or suspected breast cancer or estrogen-dependent neoplasia (endometrial cancer)
- Unexplained, undiagnosed abnormal uterine bleeding
- Active or prior venous thromboembolism (DVT or PE) or known thrombophilia
- Active or recent arterial thromboembolic disease (myocardial infarction, stroke, TIA)
- Severe active liver disease or acute hepatic impairment
- Porphyria cutanea tarda