Men's and women's health ACCP Questions & Answers Flashcards
1
Q
- M.T. is a 72-year-old white man (height 69 inches,
weight 68 kg) with a history of hypertension who
admits smoking one pack of cigarettes per day
and having a poor diet. He states that he walks on
his treadmill 30 minutes a day. His bone mineral
density (BMD) T-score is –2.1 at the hip and –2.2
at the spine. His fracture history includes a fall at
age 68 with an ankle fracture. His Fracture Risk
Assessment Tool (FRAX) score (10-year major
fracture probability) is 14%, and his probability of
hip fracture is 6.7%. Which best describes M.T.’s
condition?
A. He has low bone mass (osteopenia) of the hip
and spine.
B. He has osteoporosis of the spine and low bone
mass (osteopenia) of the hip.
C. He has osteoporosis of the hip and spine.
D. He has normal BMD of the hip and spine.
A
- Answer: A
The patient’s T-score at the hip and spine are between -1
and -2.5 SD, which is considered low bone mass (Answer
A is correct). Normal BMD is defined as a T-score
within 1 SD of the young adult mean, which the patient
does not have (Answer D is incorrect). Osteoporosis is
defined as having BMD with a T-score of at least -2.5
SD, which the patient does not have in either the hip or
the spine (Answers B and C are incorrect).
2
Q
- Which treatment is best for M.T.?
A. Take calcium 1200 mg orally daily, vitamin D
800 international units orally daily, and alendronate
70 mg orally weekly.
B. Take calcium 1200 mg orally daily and vitamin
D 600 international units orally daily, and
begin weight-bearing exercise.
C. Take calcium 1200 mg orally daily, vitamin D
600 international units orally daily, and raloxifene
60 mg orally daily.
D. Take calcium 1200 mg orally daily, vitamin
D 400 international units orally daily, and
risedronate 35 mg orally weekly, and begin
weight-bearing exercise.
A
- Answer: A
Even though the patient is currently thought to have
osteopenia, his 10-year probability of a major osteoporosis-
related fracture is 14%, and his 10-year
probability of a hip fracture is 6.7% according to the
FRAX score, which indicates a need for drug therapy
(Answer A is correct). Bisphosphonates such as
alendronate and risendronate are considered first-line
drugs because they inhibit normal and abnormal bone
resorption and reduce vertebral and non-vertebral fractures
by 30%–50%. Raloxifene is indicated for preventing
osteoporosis in postmenopausal women. It works
as a selective estrogen receptor modulator and is best
for preventing vertebral fractures, not hip fractures
(Answer C is incorrect). Calcium and vitamin D are
both recommended for this patient as well. Because of
the patient’s age and poor diet, the recommended dosage
of vitamin D is 800 international units orally per
day (Answer A is correct; Answer D is incorrect); 600
international units orally per day is recommended for
those younger than 70 years (Answer B is incorrect).
Answer B is also incorrect because the patient requires
pharmacotherapy and not just calcium and vitamin D.
He walks 30 minutes/day, which satisfies the recommendation
of weight-bearing activity (Answers B and
D are incorrect).
Drug therapy begins with the following:
(a) A hip or vertebral fracture
(b) BMD T-score below -2.5 at the femoral neck or
spine, excluding secondary causes
(c) BMD T-score between -1.0 and -2.5 at the femoral
neck or spine and a 10-year probability of hip
fracture 3% or greater or 10-year probability of
major osteoporosis-related fracture 20% or greater
according to the FRAX system.
3
Q
- A 29-year-old woman (height 65 inches, weight
63 kg) has a history of two deep venous thromboses
(DVTs) but is otherwise healthy; she is seeking
to become pregnant. She currently takes warfarin 3 mg orally daily. Which regimen is the best recommendation
for this patient?
A. Continue current warfarin dose to prevent
clots during pregnancy.
B. Continue warfarin therapy but increase the
dose to prevent clots during pregnancy.
C. Discontinue warfarin; start enoxaparin 60 mg
subcutaneously every 12 hours until pregnant
and continue through pregnancy.
D. Discontinue warfarin; start heparin 5000 units
subcutaneously every 8 hours daily until 12
weeks pregnant, and then reinitiate warfarin.
A
- Answer: C
Warfarin is contraindicated in pregnancy and a known
teratogen (Answers A, B, and D are incorrect). Warfarin
should not be used at any time during pregnancy unless
the benefit outweighs the risk in very rare and special
cases. If a woman needs anticoagulation and is planning
to conceive or is pregnant, she should find an alternative
anticoagulant such as a low-molecular-weight
heparin (e.g., enoxaparin) or heparin (although with
heparin, there may be a risk of osteoporosis with
extended duration of use (Answer D is incorrect). A
low-molecular-weight heparin would be the agent of
choice (Answer C is correct).
4
Q
- J.K. is a 51-year-old postmenopausal woman with
severe hot flashes that have not resolved with
venlafaxine 75 mg orally daily. She is otherwise
healthy, with no history of cancer and no surgical
procedures. She is given conjugated estrogen
0.625 mg orally daily. Which treatment is best for
J.K.?
A. No other drug is needed; estrogen alone is sufficient
for hot flashes.
B. No other drug is needed; estrogen should be
discontinued, and she should continue on
venlafaxine.
C. Venlafaxine should be continued and
Medroxyprogesterone acetate should be added
to decrease the risk of stroke.
D. Venlafaxine should be discontinued and
Medroxyprogesterone acetate should be added
to decrease the risk of endometrial cancer.
A
- Answer: D
Medroxyprogesterone acetate is added to conjugated
estrogens to decrease the risk of endometrial cancer;
venlafaxine is not relieving her hot flashes, therefore it
should be discontinued (Answer D is correct). The addition
of medroxyprogesterone acetate does not decrease
the risk of stroke (Answer C is incorrect). Estrogen
alone is insufficient because the patient has an intact
uterus, as indicated by her medical history (no surgical
procedures) (Answer A is incorrect). Venlafaxine is not
relieving her hot flashes; therefore, it should be discontinued
(Answer B is incorrect).
5
Q
- C.S. is a 49-year-old postmenopausal woman experiencing
severe hot flashes, vaginal dryness, and
pain during sexual intercourse. C.S. has a history of
irregular heavy uterine bleeding, which resulted in
a total hysterectomy 5 months ago. Her hot flashes
are affecting her quality of life. Which treatment is
best to recommend for C.S.?
A. Estradiol vaginal cream 0.1 mg/g.
B. Conjugated estrogen and medroxyprogesterone
acetate 0.625 mg/2.5 mg tablets.
C. Conjugated estrogen 0.3-mg tablets.
D. Ospemifene 60-mg tablets.
A
- Answer: C
The patient is experiencing systemic symptoms such as
hot flashes, and she has localized genitourinary atrophy,
which probably results in pain during sexual intercourse.
Estradiol vaginal cream and ospemifene are
indicated for genitourinary atrophy, not for vasomotor
symptoms (Answers A and D are incorrect). The best
treatment would be an oral or transdermal systemic
agent (Answer C is correct). The patient has had a hysterectomy;
therefore, a progestogen in combination
with estrogen is unnecessary (Answer B is incorrect).
6
Q
- S.F. is a 20-year-old woman initiated on ethinyl
estradiol 30 mcg/drospirenone 3 mg oral tablets
5 months ago for contraception. She was recently
prescribed lamotrigine for bipolar disorder. Which
best describes the drug interaction that may occur
with ethinyl estradiol/drospirenone and lamotrigine
in this patient?
A. The effectiveness of ethinyl estradiol and
drospirenone may be decreased.
B. The effectiveness of lamotrigine may be
increased.
C. The effectiveness of lamotrigine may be
decreased.
D. The effectiveness of ethinyl estradiol and
drospirenone may be increased.
A
- Answer: C
The efficacy of lamotrigine may be decreased (Answer
C is correct; Answer B is incorrect). Estrogen and drospirenone
are not affected by lamotrigine (Answers A
and D are incorrect). (See Answer 6 table.)
7
Q
- A study compares the incidence of herpes simplex
genital infections in patients receiving suppressive
therapy with acyclovir versus valacyclovir. After
1 year of follow-up, 25% in the acyclovir group and
20% in the valacyclovir group experience a recurrent
infection (p<0.05). Which best represents how
many patients (in 1 year) would need to be treated
with valacyclovir over acyclovir to prevent one
recurrent infection?
A. 5.
B. 20.
C. 25.
D. There is insufficient information to calculate
this number.
A
- Answer: B
The number of patients needed to treat with valacyclovir
over acyclovir to prevent one recurrent HSV genital
infection (1 year of follow-up of study participants
receiving suppressive therapy [acyclovir or valacyclovir],
with 25% and 20%, respectively, experiencing a
recurrent infection) is 20 = 1/(0.25−0.20) (Answer B
is correct; all other answers are incorrect). The only
information needed is the absolute risk in both groups
(which is provided).
8
Q
- K.M. is a 28-year-old woman (height 68 inches,
weight 98 kg) with a history of migraine with aura
who is seeking contraception. Her blood pressure
today is 135/82 mm Hg; she denies smoking and
alcohol use and states that she would like to have
children in a year or so. Which is the best contraceptive
agent for K.M.?
A. Levonorgestrel intrauterine system.
B. Oral norethindrone tablet.
C. Transdermal ethinyl estradiol/etonogestrel
patch.
D. Oral ethinyl estradiol/desogestrel tablet.
A
- Answer: B
The patient has a history of migraine with aura, which
precludes any estrogen product (oral ethinyl estradiol/
desogestrel oral tablet and transdermal contraceptive
patch). Her blood pressure is slightly elevated but not
greater than 160/100 mm Hg, which would not be a contraindication
for estrogen use; however, her migraine
with aura rules out the use of estrogen products
(Answers C and D are incorrect). She also has obesity
at 215 lb (98 kg) and weighs more than 90 kg, so the
patch is not recommended (again, Answer C is incorrect).
The levonorgestrel IUS (Mirena, Kyleena, Skyla,
Liletta) may be an option, but the patient is interested
in conceiving in a year or so, which makes the IUS not
cost-effective because they last 3–6 years. (Answer A
is incorrect). Norethindrone oral tablet is a progestogen-
only pill and the best choice (Answer B is correct).
9
Q
- L.L. is a 38-year-old woman who has been trying
to conceive for the past 7 months. Her husband’s
medical examination is normal; L.L. is not ovulating
every month. She has not tried any medications
previously to induce ovulation. Which medication
is best to initiate in L.L. to induce ovulation?
A. Human chorionic gonadotropin (hCG).
B. Nafarelin/gonadotropin-releasing hormone
(GnRH) agonist.
C. Human menopausal gonadotropin (hMG).
D. Clomiphene.
A
- Answer: D
Clomiphene citrate is the first-line choice to stimulate
ovulation (Answer D is correct). Another first-line
option could be an aromatase inhibitor such as letrozole;
however, this was not an answer choice. Menopur
(hMG), Synarel (GnRH agonist), and Ovidrel (hCG)
are not first-line agents and are usually used after clomiphene
citrate or aromatase inhibitors have failed or
when the patient is undergoing assisted reproductive
therapies (Answers A, B, and C are incorrect).
10
Q
- T.G. is a 22-year-old woman who comes to a community
pharmacy and asks about emergency contraception
(EC). She states that she was out of town
for the weekend and was swimming when her contraceptive
vaginal ring slipped out. She has been
without the ring for 3 days because she did not have
a new one with her for replacement. She states she
had unprotected intercourse 4 nights ago. She is
worried about becoming pregnant. Which is the
best recommendation for T.G.?
A. Recommend that she see her physician for a
levonorgestrel 1.5 mg prescription.
B. Recommend EC; it may still be effective
because she is within the 120-hour time
window.
C. Do not recommend EC; it may be ineffective
because she is beyond the 72-hour time window.
D. Do not recommend EC; instead, recommend
that she insert a new contraceptive vaginal ring.
A
- Answer: B
Clinical studies suggest that levonorgestrel emergency
contraception is still effective for up to 120 hours after
unprotected intercourse though package labeling only
states 72 hours, and the patient does not need a prescription
(Answer B is correct; Answer A is incorrect).
She stated that her vaginal ring slipped out of place.
If the vaginal ring had been out of place longer than 3 hours and unprotected intercourse had occurred,
EC should have been recommended (Answers C and
D are incorrect). When inserting a new vaginal ring,
she should also be instructed to use a BUM for at least
7 days (again, Answer D is incorrect).
11
Q
- K.S. is a 45-year-old man who has difficulty maintaining
an erection during intercourse. His medical
history includes diabetes mellitus and hyperlipidemia.
His drugs include aspirin, metformin, and
pravastatin. Blood pressure is 130/81 mm Hg,
hemoglobin A1C 6.2, total cholesterol 195 mg/dL,
low-density lipoprotein cholesterol (LDL) 106 mg/
dL, high-density lipoprotein cholesterol (HDL) 54
mg/dL, triglycerides 145 mg/dL, total testosterone
concentration 970 ng/dL (reference range 270–
1070 ng/dL), and free testosterone concentration
22 ng/dL (reference range 9–30 ng/ dL). Which
drug is best to initiate for his erectile dysfunction?
A
- Answer: A
The patient’s laboratory values are within normal limits,
indicating that his disease states are not necessarily the
cause of his erectile dysfunction. A phosphodiesterase
inhibitor such as vardenafil may be initiated (Answer
A is correct). Testosterone replacement would not be
effective because the patient has normal testosterone
concentrations (Answer B is incorrect). Yohimbine
would not be considered first-line therapy because
its efficacy is controversial (Answer C is incorrect).
Fluoxetine is inappropriate because the patient does not
have premature ejaculation (Answer D is incorrect).
12
Q
- T.M., a 33-year-old man, has a history of intravenous
drug abuse and lives in and out of homeless
shelters. He is taken to the emergency department
by ambulance after experiencing paralysis on the
right side of his body. The people at the shelter
thought he might be having a stroke. In the emergency
department, screening was positive for the
Venereal Disease Research Laboratory test (syphilis
test) with 10 white blood cells/mm3. T.M. has
no known significant medical history (except for
treatment of a sexually transmitted disease [STD]),
but he is allergic to penicillin (anaphylactic reaction).
Assuming serologic testing confirms a diagnosis
of syphilis, which therapy is best for T.M.?
A. Levofloxacin 750 mg intravenously for one
dose.
B. Penicillin G 4 million units every 4 hours
intravenously for 14 days after penicillin
desensitization.
C. Benzathine penicillin G 2.4 million units
intramuscularly every week for 3 weeks after
penicillin desensitization.
D. Azithromycin 500 mg intravenously or orally
daily for 6 weeks.
A
- Answer: B
Penicillin G 4 million units every 4 hours intravenously
for 14 days after penicillin desensitization is the correct
therapy for a patient with neurosyphilis who is allergic
to penicillin (Answer B is correct). Levofloxacin would
not cover syphilis (Answer A is incorrect). Three doses
of benzathine penicillin G are indicated for late latent
syphilis, not neurosyphilis (Answer C is incorrect).
Furthermore, although azithromycin is an alternative
for patients who are penicillin allergic in other situations,
patients with neurosyphilis should be desensitized
and given penicillin (Answer D is incorrect).
13
Q
- A prospective double-blind study compared the
effects of three different antivirals—acyclovir,
famciclovir, and valacyclovir—in 360 patients
with first-episode genital herpes. Which statistical
test is best to compare the mean duration of time
until the lesions healed?
A. Analysis of variance (ANOVA).
B. Chi-square test.
C. Mann-Whitney U test.
D. Student t-test.
A
- Answer: A
Data are continuous and probably normally distributed
(given the large population of 360 patients in
the study); therefore, a parametric test is indicated.
Because ANOVA is a parametric test used to compare
more than two groups, it would be appropriate (Answer
A is correct). The Student t-test is a parametric test for
comparing only two groups (Answer D is incorrect). A
chi-square test is used to assess nominal data between
two groups (Answer B is incorrect). The Mann-Whitney
U test is a nonparametric analog to the Student t-test
(Answer C is incorrect).
14
Q
Patient Case
Questions 1 and 2 pertain to the following case:
E.L. is a 50-year-old woman with hot flashes and vaginal irritation. She has tried exercise, diet, and antidepressants
to help relieve her hot flashes but has been unsuccessful. She is otherwise healthy with no history of cancer and
no surgical procedures. She states that her hot flashes are interfering with her daily activities and wants to try HT.
1. When counseling E.L. on the use of HT and explaining the WHI trial, which has been proven to be statistically
significant with conjugated estrogen and medroxyprogesterone acetate?
A. Increased risk of VTE
B. Decreased risk of stroke
C. Decreased risk of MI
D. Increased risk of fractures
A
- Answer: A
DVT is increased with conjugated estrogens and
medroxyprogesterone acetate (Prempro) (Answer A
is correct). Myocardial infarction and strokes are also
increased (Answers B and C are incorrect). Fractures
are decreased (Answer D is incorrect).
15
Q
E.L. is a 50-year-old woman with hot flashes and vaginal irritation. She has tried exercise, diet, and antidepressants
to help relieve her hot flashes but has been unsuccessful. She is otherwise healthy with no history of cancer and
no surgical procedures. She states that her hot flashes are interfering with her daily activities and wants to try HT.
- Which treatment is best to recommend to E.L.?
A. Estrogen patch 0.025 mg (17β-estradiol); change patch twice weekly.
B. Prasterone 6.5 mg vaginal inserts; insert vaginally once daily.
C. Conjugated estrogen 0.3 mg/medroxyprogesterone acetate 1.5 mg; take 1 tablet daily.
D. Ospemifene 60 mg; take 1 tablet daily.
A
- Answer: C
The patient has an intact uterus; therefore, she needs
both an estrogen and a progestogen. Conjugated estrogens
and medroxyprogesterone acetate (Prempro) is the
only product listed that includes a progestogen (Answer
C is correct). The patient has hot flashes in addition to
vaginal dryness; therefore, a systemic product is recommended
(Answer B is incorrect). A vaginal insert or
cream would be appropriate for GSM symptoms but not
for hot flashes, and ospemifene is indicated for vaginal
atrophy. The patch would be appropriate if a progestogen
were added to the regimen (Answers A and D are
incorrect).
16
Q
R.K. is a 71-year-old woman (height 63 inches, weight 64 kg) with a history of rheumatoid arthritis who smokes
½ pack/day. She is lactose intolerant and has minimal intake of dairy products. She takes calcium 1200 mg orally
per day in divided doses and vitamin D 600 international units/day orally. Her calculated CrCl is 60–70 mL/minute.
Her BMD T-score is -2.6 at the hip and -2.1 at the spine. Her FRAX score indicates she has a 10-year probability of
a major osteoporotic fracture of 22% and a 10-year probability of a hip fracture of 11%.
3. Which statement best describes the correct diagnosis for R.K.?
A. She has normal BMD of the spine.
B. She has low bone mass (osteopenia) of the hip.
C. She has osteoporosis of the hip.
D. She has severe osteoporosis of the spine.
A
- Answer: C
The definitions of bone mineral density and T-scores
are as follows:
Normal = BMD within 1 standard deviation (SD) of the
young adult mean, Low bone mass (osteopenia) = BMD
between -1 SD and -2.5 SD,
Osteoporosis = BMD at least -2.5 SD,
Severe osteoporosis = BMD less than -2.5 and history
of a fracture. The patient has a T-score of -2.6 at the
hip, which is indicative of osteoporosis (Answer C is
correct; Answers A and B are incorrect). The patient
does not have severe osteoporosis of the spine because
her T-score at the spine is -2.1 and not less than -2.5
(Answer D is incorrect).
17
Q
R.K. is a 71-year-old woman (height 63 inches, weight 64 kg) with a history of rheumatoid arthritis who smokes
½ pack/day. She is lactose intolerant and has minimal intake of dairy products. She takes calcium 1200 mg orally
per day in divided doses and vitamin D 600 international units/day orally. Her calculated CrCl is 60–70 mL/minute.
Her BMD T-score is -2.6 at the hip and -2.1 at the spine. Her FRAX score indicates she has a 10-year probability of
a major osteoporotic fracture of 22% and a 10-year probability of a hip fracture of 11%.
- Which is the best therapy for R.K.?
A. No further treatment is needed; continue calcium 1200 mg/vitamin D 600 international units/day orally.
B. Give abaloparatide 80 mcg subcutaneously daily, and continue calcium 1200 mg/vitamin D 600 international
units/day orally.
C. Give romosozumab 210 mg subcutaneously every month, continue calcium 1200 mg/day orally, and
increase vitamin D to 800 international units/day orally.
D. Give risedronate 35 mg orally every week; continue calcium 1200 mg orally per day, and increase vitamin
D to 800 international units/day orally.
A
- Answer: D
Drug therapy is indicated for the following: A hip or
vertebral fracture; a BMD T-score below -2.5 at the
femoral neck or spine, excluding secondary causes; or
a BMD T-score between -1.0 and -2.5 at the femoral
neck or spine and a 10-year probability of hip fracture
3% or greater or a 10-year probability of major osteoporosis-
related fracture of 20% or greater based on the
FRAX system. The patient needs therapy because her T-score is less than -2.5 at the hip, and her 10-year probability
of hip fracture is at least 3% or her 10-year probability
of major osteoporosis-related fracture at least
20% based on the FRAX system (Answer D is correct;
Answer A is incorrect). Bisphosphonates such as alendronate
and risedronate are considered first-line drugs
because they inhibit normal and abnormal bone resorption
and reduce vertebral and non-vertebral fractures
by 30%–50%. For risendronate, the treatment dosage is
35 mg orally weekly, further indicating that Answer D
is correct. In addition, the patient’s CrCl is 60–70 mL/
minute, which allows use of a bisphosphonate. Use of
a bisphosphonate is contraindicated at a CrCl less than
30–35 mL/minute. Abaloparatide (Tymlos) is reserved
for treating women at a high risk of fracture, including
those with a very low BMD (T-score less than -3.0) and
a previous vertebral fracture (Answer B is incorrect).
The patient should receive vitamin D 800 international
units daily because she is older than 70 years and takes
calcium 1200 mg daily in divided doses (again, Answer
D is correct; Answers A and B are incorrect). In addition,
the patient is likely not receiving calcium from her
diet due to her lactose intolerance and minimal intake
of dairy products. Romosozumab is not indicated as
first-line treatment and is indicated for those at high risk
of fracture, those with a previous fracture, or those for
whom other osteoporosis therapies have failed (Answer
C is incorrect).
