MSCP exam practice questions, with answers and rationales

Answer: B. Late menopause transition (−1)

Amenorrhea of 60 days or more places her in the late menopause transition (−1). Bleeding criteria are the principal STRAW+10 criteria and hormones are only supportive; FSH is often above 25 IU/L in −1 but fluctuates, so a value of 18 IU/L does not move her back to −2, which is defined by variable cycle lengths without a 60-day gap. The teaching that a single FSH often cannot stage a woman argues against staging by FSH, not for delaying a stage that her bleeding pattern already defines.

Reference: STRAW+10 workshop (Harlow et al., 2012)

Answer: C. Hypothalamic amenorrhea

In secondary amenorrhea, a high FSH points to the ovary and a low or normal FSH points elsewhere; a low FSH with a low estradiol, once pregnancy, prolactin, and thyroid causes are excluded, indicates hypothalamic amenorrhea. POI would show an FSH above 25 IU/L; a low estradiol alone does not establish ovarian failure. PCOS also comes with a low or normal FSH and can occur at a normal BMI, but estrogen is typically preserved, which does not fit an estradiol of 15 pg/mL.

Reference: Endocrine Society guideline on functional hypothalamic amenorrhea (2017); The Menopause Society, Menopause Practice: A Clinician's Guide, 6th ed. (2019)

Answer: C. Transdermal estradiol with a progestogen, in consultation with hematology

Withholding estrogen entirely from a 30-year-old commits her to decades of hypoestrogenism with substantial bone and cardiovascular consequences, so the risk calculus differs from that of a 60-year-old. Transdermal estradiol, which largely avoids first-pass hepatic effects on clotting factors, with an appropriate progestogen and hematology input, is the reasonable path. Halving an oral dose does not remove the first-pass effect.

Answer: A. Measure plasma free metanephrines

New VMS in late postmenopause, especially with headache or other systemic symptoms, should not be assumed to be menopausal; episodic sweating, headache, and palpitations point first to pheochromocytoma, screened for with plasma free (or urinary fractionated) metanephrines. Fezolinetant is a reasonable nonhormonal VMS drug but would treat the symptom before a dangerous cause is excluded. About 10% of women have VMS for more than 20 years, but that describes long-standing symptoms, not new onset 17 years after the final period.

Reference: Menopause Practice: A Clinician's Guide, 6th ed. (The Menopause Society); Endocrine Society 2014 pheochromocytoma and paraganglioma guideline

Answer: A. Systemic estrogen therapy is associated with new-onset or worsened urinary urgency, frequency, and incontinence

This is a common and counterintuitive point. Low-dose vaginal estrogen improves genitourinary symptoms, but systemic estrogen therapy — with or without a progestogen — is associated with new onset or exacerbation of urgency, frequency, and incontinence. Clinicians who assume all estrogen helps all urinary symptoms miss this. Infection should be excluded, but the temporal link to starting systemic therapy points to the therapy itself. Adding local vaginal estrogen is often effective when genitourinary symptoms persist or emerge on systemic treatment.

Reference: The Menopause Society 2020 GSM Position Statement

Answer: B. Endometrial sampling, since recurrent bleeding needs histology despite the earlier thin stripe

A thin endometrium can be reassuring after a single episode in a low-risk woman, but the negative predictive value does not carry forward to recurrent or persistent bleeding. Recurrence mandates histologic evaluation — office biopsy, and hysteroscopy with directed sampling if the biopsy is nondiagnostic or bleeding continues. Certain cancers, notably type II endometrial cancers such as serous carcinoma, can arise on an atrophic, thin endometrium, which is precisely why repeat imaging is not sufficient here. Under ACOG's 2026 update, most women with postmenopausal bleeding would have had sampling at the first episode.

Reference: ACOG Committee Opinion 734 (2018), updated by ACOG Clinical Practice Update (Obstet Gynecol 2026; 148(1):e87–e91)

Answer: A. Start drug therapy, such as a bisphosphonate

Osteopenia qualifies for drug treatment when FRAX 10-year major osteoporotic fracture risk is at least 20% or hip-fracture risk is at least 3%; either threshold is enough, and her hip risk of 3.4% meets it. Withholding therapy because the major-fracture figure is under 20% overlooks the separate hip threshold. Repeating DXA would be reasonable below both thresholds, but here it only delays treatment she already qualifies for.

Reference: BHOF Clinician's Guide 2022; The Menopause Society 2021 osteoporosis position statement

Answer: B. Higher thyroxine-binding globulin has lowered free T4

Oral estrogen raises thyroxine-binding globulin, which binds more T4 and lowers free T4; on a fixed levothyroxine dose she cannot compensate, so TSH rises and she may need a higher dose. Estrogen is not an absorption binder in the way calcium and iron are. A fall in TBG is the effect of androgens, and it would raise free T4, not lower it.

Reference: ATA 2014 hypothyroidism guideline; The Menopause Society 2022 HT position statement

Answer: B. Coronary artery calcium scoring

Coronary artery calcium scoring is the recommended tiebreaker in intermediate-risk adults where the decision is uncertain. A score of zero indicates low short-term risk and can justify deferring a statin, while a score of 100 or more, or above the 75th percentile for age and sex, supports starting one. Its value is precisely in shared decision-making for the undecided patient. Exercise testing evaluates symptomatic patients for ischemia, and carotid ultrasound is not recommended for this purpose.

Reference: ACC/AHA primary prevention guidance

Answer: B. Transdermal estradiol with micronized progesterone

Transdermal estradiol avoids first-pass hepatic effects on clotting factors and is not associated with excess VTE in observational studies, so it is preferred with obesity; micronized progesterone also appears less thrombogenic than other progestogens. An LNG-IUS spares her a systemic progestogen, but oral estradiol still raises hepatic clotting factors. CEE/bazedoxifene avoids a progestogen but pairs oral estrogen with a SERM, and SERMs themselves raise VTE risk.

Reference: The Menopause Society 2022 hormone therapy position statement

Answer: A. Switch from paroxetine to venlafaxine

Paroxetine inhibits CYP2D6 at any dose, including the 7.5 mg salt, and tamoxifen is a prodrug that needs CYP2D6 for activation. Venlafaxine (extended-release), a weak CYP2D6 inhibitor, is the preferred alternative, and gabapentin is another option. Enzyme inhibition persists throughout the day, so separating the doses does not help.

Reference: The Menopause Society 2023 nonhormone therapy position statement

Answer: B. The cream does not deliver enough progesterone to protect the endometrium

Over-the-counter progesterone creams do not deliver serum concentrations sufficient to protect the endometrium, so a woman using one alongside systemic estrogen is functionally on unopposed estrogen and accruing hyperplasia and carcinoma risk. This is among the most consequential misconceptions in this area, precisely because the patient believes she is protected. Adequate endometrial protection requires an approved progestogen — oral micronized progesterone, a progestin, or the levonorgestrel intrauterine system.

Reference: ACOG Clinical Consensus No. 6 (2023)

Answer: C. Annual low-dose CT beginning now

She has 22 pack-years and quit 11 years ago, so she meets the USPSTF (2021) criteria: age 50 to 80, at least 20 pack-years, and currently smoking or quit within 15 years; screening is annual low-dose CT. The 30 pack-year and age-55 thresholds come from the 2013 USPSTF recommendation, which the 2021 update lowered. Screening stops once she reaches 15 years since quitting (at 55), so waiting until 55 would mean she is never screened.

Reference: USPSTF 2021 (lung cancer screening)

Answer: A. Not yet; a single dose is recommended at 75

CDC/ACIP recommends a single RSV dose for all adults 75 and older and for adults 50 to 74 at increased risk (e.g., chronic heart or lung disease, diabetes, immunocompromise, nursing home residence). Without a risk condition she is not yet in a recommended group. Offering it to all adults 60 and older reflects the original 2023 shared decision-making recommendation, which was narrowed in 2024 (and extended to at-risk adults 50 to 59 in 2025). RSV vaccine is a one-time dose, not a yearly vaccine like influenza.

Reference: CDC/ACIP adult RSV vaccine recommendations (2024–2025)

Answer: B. Routine type-specific HSV serology is not recommended for asymptomatic adults

Routine HSV serologic screening in asymptomatic adults is not recommended: the tests have limited specificity at low index values, a positive result does not indicate site of infection or when it was acquired, and the psychological harm and relationship consequences of a false positive are substantial. HSV-1 seropositivity is extremely common and usually reflects oral acquisition in childhood, so it certainly does not establish genital herpes. Testing is appropriate for symptomatic lesions, ideally by PCR of the lesion.

Reference: CDC Sexually Transmitted Infections Treatment Guidelines; USPSTF: Genital Herpes: Screening