Knowledge Items
Core principles of menopause treatment selection.
Item 1 · Knowledge
Shared decision making
What is the best first step when choosing a treatment for menopausal symptoms?
Answer: B
- B is correct. Treatment should be individualized to the patient's symptoms, history, and goals, with shared decision-making and periodic reevaluation of benefits and risks.1
- A is incorrect. Clinician habit does not account for the patient's contraindications or priorities.1
- C is incorrect. Shared decision-making requires the clinician to explain options, benefits, and risks.1
- D is incorrect. Bothersome symptoms warrant treatment. Severity is not a threshold for starting care.1
Item 2 · Knowledge
Most effective treatment for vasomotor symptoms
For a patient with no contraindications and bothersome hot flashes and night sweats, which treatment is most effective?
Answer: C
- C is correct. Hormone therapy remains the most effective treatment for vasomotor symptoms.1,2
- A and B are incorrect. Both are recommended nonhormonal options (Level I), but neither is more effective than hormone therapy.2
- D is incorrect. The Menopause Society does not recommend herbal supplements for vasomotor symptoms (Levels I to II).2
Item 3 · Knowledge
Genitourinary syndrome of menopause
A patient has genitourinary syndrome of menopause (GSM) symptoms not relieved by vaginal lubricants and moisturizers. She has no hot flashes. Which treatment is recommended?
Answer: A
- A is correct. For bothersome GSM symptoms not relieved by over-the-counter therapies, in women without other indications for systemic hormone therapy, low-dose vaginal estrogen is recommended.1
- B is incorrect. Oral estradiol is systemic therapy. Without vasomotor symptoms or another systemic indication, it adds systemic exposure without added benefit for GSM.1
- C is incorrect. Pellets deliver systemic hormone, not local treatment.
- D is incorrect. Paroxetine treats vasomotor symptoms, not GSM.2
Competency Items
Apply prescribing requirements for fezolinetant (Veozah) and elinzanetant (Lynkuet) to patient cases.
Item 4 · Competency
A 52-year-old has 9 to 12 moderate to severe hot flashes a day. She had an unprovoked deep vein thrombosis (DVT), so systemic hormone therapy is not an option. Her medications are levothyroxine and atorvastatin, and she takes no CYP1A2 inhibitors. Her estimated glomerular filtration rate (eGFR) is 88 mL/min/1.73 m², she has no cirrhosis, and her baseline liver tests are normal. She starts fezolinetant 45 mg daily. Which follow-up plan meets the prescribing requirements?
Answer: D
- D is correct. The boxed warning requires baseline hepatic tests, then tests monthly for the first 3 months and at 6 and 9 months.4,5
- A is incorrect. Baseline plus one test at 3 months is the elinzanetant schedule, not the fezolinetant schedule.6
- B and C are incorrect. Both fall short of the required schedule.4
Teaching points
- A history of DVT rules out estrogen therapy.3
- Do not start fezolinetant if ALT or AST is 2 or more times the upper limit of normal (ULN), or if total bilirubin is 2 or more times ULN.4
- Stop it if transaminases rise above 5 times ULN, or above 3 times ULN with total bilirubin above 2 times ULN.4
- Tell patients to stop the drug and seek care for fatigue, nausea, vomiting, itching, jaundice, pale stools, dark urine, or abdominal pain.4
Item 5 · Competency
A 55-year-old has moderate to severe hot flashes and night sweats that disrupt her sleep. She prefers a nonhormonal treatment. She takes diltiazem for hypertension. Her baseline liver tests and renal function are normal. Which elinzanetant regimen follows the prescribing requirements?
Answer: B
- B is correct. Diltiazem is a moderate CYP3A4 inhibitor.7 Elinzanetant is metabolized mainly by CYP3A4,8 and the label reduces the dose to 60 mg once daily at bedtime with moderate CYP3A4 inhibitors.6
- A is incorrect. 120 mg is the standard dose without a moderate CYP3A4 inhibitor.6
- C is incorrect. The dose is wrong, and the label calls for bedtime dosing.6
- D is incorrect. The label calls for a dose reduction, not avoidance. Strong CYP3A4 inhibitors and CYP3A4 inducers are the drugs to avoid.6
Teaching points
- Nervous system effects (somnolence, fatigue, dizziness) occurred in 11.9% of patients on elinzanetant and 3.5% on placebo. Advise patients to avoid driving until these effects resolve.6
- Check liver tests at baseline and 3 months after starting.6
- Return to 120 mg if the inhibitor is stopped.6
Item 6 · Competency
A 57-year-old has 10 to 12 moderate to severe hot flashes a day that disrupt her work and sleep. She had an ischemic stroke 2 years ago and has an intact uterus. She is 4 months into a planned 12-month course of itraconazole for chronic pulmonary histoplasmosis. Her other medications are low-dose aspirin, rosuvastatin, lisinopril, and cimetidine for reflux. Her eGFR is 82 mL/min/1.73 m², she has no liver disease, and her baseline liver tests are normal. Which option follows the prescribing requirements for each therapy?
Answer: C
- C is correct. Famotidine is not listed as a CYP inhibitor.7 Fezolinetant is metabolized mainly by CYP1A2,9 and itraconazole is a CYP3A4 inhibitor.7 Fezolinetant is a Level I recommended nonhormonal treatment.2 In a phase 3 trial, it lowered hot flash frequency and severity compared with placebo by week 4, and the benefit lasted through 52 weeks.11 She needs liver tests monthly for 3 months, then at 6 and 9 months.4,5
- A is incorrect. A history of stroke rules out estrogen therapy regardless of route.3 The Menopause Society names cardiovascular disease as a reason a woman is not a good candidate for hormone therapy.2
- B is incorrect. Itraconazole, a strong CYP3A4 inhibitor,7 raises elinzanetant exposure (AUC) 4.6- to 6.3-fold.8 The label says to avoid strong CYP3A4 inhibitors.6
- D is incorrect. Fezolinetant is contraindicated with CYP1A2 inhibitors of any strength.4 Cimetidine is a weak CYP1A2 inhibitor7 that roughly doubles fezolinetant exposure.4,10
Teaching points
- Itraconazole also carries a risk of liver injury. Coordinate liver monitoring with her infectious disease clinician, since an enzyme rise could come from either drug.
- Monitoring gap: before the boxed warning, only 42% of persistent fezolinetant users had liver testing within 3 months of starting.12
Answer Key
Select an item number to return to the question.
| Item | Topic | Level | Answer |
|---|---|---|---|
| 1 | Shared decision making | Knowledge | B |
| 2 | Most effective treatment for vasomotor symptoms | Knowledge | C |
| 3 | Genitourinary syndrome of menopause | Knowledge | A |
| 4 | Fezolinetant liver monitoring | Competency | D |
| 5 | Elinzanetant with a moderate CYP3A4 inhibitor | Competency | B |
| 6 | Choosing fezolinetant when other options are ruled out | Competency | C |
Check current labeling
This resource is for education and does not replace clinical judgment. Fezolinetant and elinzanetant are new drugs, and their prescribing information changes. Confirm doses, contraindications, and monitoring against the current label before prescribing. Content reviewed September 2026.
References
Sources cited in the rationales above.
- The North American Menopause Society. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794. doi:10.1097/GME.0000000000002028
- The North American Menopause Society. The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause. 2023;30(6):573-590. doi:10.1097/GME.0000000000002200
- Stuenkel CA, Davis SR, Gompel A, et al. Treatment of symptoms of the menopause: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2015;100(11):3975-4011. doi:10.1210/jc.2015-2236
- Veozah (fezolinetant) tablets. Prescribing information. Astellas Pharma US. DailyMed
- US Food and Drug Administration. FDA adds warning about rare occurrence of serious liver injury with use of Veozah (fezolinetant) for hot flashes due to menopause. Drug Safety Communication. December 2024. FDA.gov
- Lynkuet (elinzanetant) capsules. Prescribing information. Bayer HealthCare. DailyMed
- US Food and Drug Administration. Drug development and drug interactions: table of substrates, inhibitors and inducers. FDA.gov
- Lee A. Elinzanetant: first approval. Drugs. 2025;86(1):121-125. doi:10.1007/s40265-025-02244-3
- Iwai M, Nielsen J, Miyagawa M, et al. In vitro evaluation of CYP-mediated metabolism of fezolinetant and pharmacokinetic interaction between fezolinetant and fluvoxamine in healthy postmenopausal smokers and nonsmokers. J Clin Pharmacol. 2025;65(4):508-519. doi:10.1002/jcph.6157
- Choules MP, Otsuka Y, Nielsen JC, Iwai M, Bonate PL. Physiologically based pharmacokinetic (PBPK) model to predict the magnitude of drug-drug interaction between fezolinetant and CYP1A2 inhibitors. J Clin Pharmacol. 2025;65(9):1096-1105. doi:10.1002/jcph.70024
- Lederman S, Ottery FD, Cano A, et al. Fezolinetant for treatment of moderate-to-severe vasomotor symptoms associated with menopause (SKYLIGHT 1): a phase 3 randomised controlled study. Lancet. 2023;401(10382):1091-1102. doi:10.1016/S0140-6736(23)00085-5
- Hsu CD, Carpenter RM, Richardson G, et al. Utilization of fezolinetant for the treatment of moderate-to-severe vasomotor symptoms of menopause in a real-world setting. Menopause. 2026;33(5):529-535. doi:10.1097/GME.0000000000002703
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