CCFP priority topic 65 of 105
Menopause on the CCFP exam
8 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 22, 2026.
What the exam tests
Key features
The CFPC’s 8 key features for Menopause. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 8
Ask about symptoms
In every woman near the age of menopause, ask about the symptoms of the transition.
CFPC skill Clinical reasoning, patient-centred approachPhase History, hypothesis generationSources Society of Obstetricians and Gynaecologists of Canada
On the exam
A 49-year-old woman wants a sleeping pill. Her cycles are getting longer, and her partner sees no pauses in her breathing. Expect a short menu (pick several from a list).
Pick the questions that matter most.
Common mistakes
Treating it as plain insomnia with questions on naps, sleep habits or late exercise. Or chasing sleep apnea when her partner saw no pauses. Ask about night sweats first.
Approach
- Ask about hot flashes and night sweats: how often, and how they affect sleep, work and quality of life.
- Ask about her cycles: length, how regular, how heavy.
- Ask about mood, worry, memory and focus. Short depression and anxiety questionnaires help.
- Ask about vaginal dryness, pain with sex, sex drive, leaking urine and bladder infections.
- Midlife waking several times a night: ask about night sweats before you treat it as insomnia.
- Rule out a primary sleep problem, such as sleep apnea, when the history points to one.
Key feature 2 of 8
Diagnose without tests
When the story fits the transition, name it from the history alone, with no lab work.
CFPC skill Clinical reasoningPhase DiagnosisSources Society of Obstetricians and Gynaecologists of Canada, Choosing Wisely Canada
On the exam
A woman of 49 with longer cycles and night sweats. Expect one best answer for the next step.
Pick the next step.
Common mistakes
Ordering follicle-stimulating hormone (FSH) or estradiol to confirm it. Levels do not track symptoms, and a misleading result can deny her treatment that works.
Approach
- Stage the transition by her cycles. Cycle length that varies by 7 days or more marks early perimenopause.
- Skipped cycles, with 60 days or more without a period, mark late perimenopause.
- Menopause is 12 months in a row with no period, usually between 45 and 55. You confirm it looking back.
- Do not routinely order FSH, estradiol, progesterone or luteinizing hormone (LH) to make the diagnosis.
- After a hysterectomy, go by symptoms. Test only when needed.
- Periods that stop before 40 are premature ovarian insufficiency, not the usual transition.
Key feature 3 of 8
When it is not just menopause
When features do not fit menopause, look for serious disease before you name it.
CFPC skill SelectivityPhase Hypothesis generation, historySources Society of Obstetricians and Gynaecologists of Canada
On the exam
A woman of 52 with hot flashes, weight loss and blood in her stool. Expect a short menu (pick several from a list).
Pick what to ask and test first.
Common mistakes
Calling it all menopause because she has hot flashes. Weight loss, rectal bleeding and bleeding after menopause are not part of the transition.
Approach
- Weight loss, blood in the stool or other unexplained findings are not menopause. Work them up first.
- Any bleeding after menopause needs a pelvic ultrasound, and an endometrial biopsy (a sample of the womb lining) as needed.
- With abnormal bleeding during the transition, consider a pelvic ultrasound.
- Pick tests from the history. A typical story with no red flags needs none.
Key feature 4 of 8
A normal FSH
A lab result that does not fit should not talk you out of a typical history.
CFPC skill Clinical reasoningPhase DiagnosisSources Choosing Wisely Canada, Society of Obstetricians and Gynaecologists of Canada
On the exam
A woman's FSH came back in the premenopausal range, and her cycles are 6 to 10 weeks apart. Expect one best answer.
Pick what to do with the result.
Common mistakes
Reading the normal FSH as a negative test, or repeating it to settle the question. Either way, her night sweats go untreated.
Approach
- Hormone levels do not track symptoms. A normal FSH does not rule out the transition.
- Go with the history: changing cycles and hot flashes at the usual age.
- Do not chase the result with repeat levels or other hormone tests. Treat the symptoms she has.
- Do not use levels to choose or adjust hormone therapy either. Adjust to symptoms, at the lowest dose that works.
- Letting a level override the history can deny her treatment that works.
Key feature 5 of 8
When hormones are out
If hormones are unsafe for a patient, or she does not want them, offer other treatments that help.
CFPC skill Clinical reasoning, patient-centred approachPhase TreatmentSources Society of Obstetricians and Gynaecologists of Canada
On the exam
A woman whose night sweats wake her declines hormones. Expect a short menu (pick several from a list).
Pick the options to offer.
Common mistakes
Pushing hormones after she said no, or offering vaginal estrogen for night sweats. A sleeping pill treats the waking, not the night sweats.
Approach
- Respect her choice. Non-hormonal prescriptions are an option when hormones are unsafe or unwanted.
- Options: an SSRI or SNRI (two types of antidepressant), gabapentin or oxybutynin. None works as well as estrogen.
- Fezolinetant, a newer non-hormonal drug, is approved in Canada for hot flashes.
- Most other options are used off label in Canada.
- Cognitive behavioural therapy (CBT) and clinical hypnosis can help.
- Vaginal estrogen treats dryness and painful sex, not night sweats.
| Medicine | Status in Canada | Know this |
|---|---|---|
| SSRI or SNRI, gabapentin, oxybutynin | Used off label | Options when hormones are unsafe or unwanted. |
| Fezolinetant | Approved for hot flashes | First of a new class. Not a hormone. |
| Clonidine | Approved for hot flashes | Not recommended: weak evidence, side effects. |
Key feature 6 of 8
Natural products
Ask women in the transition about herbal and natural remedies, then explain benefits, harms and interactions.
CFPC skill Clinical reasoning, selectivityPhase History, treatmentSources Society of Obstetricians and Gynaecologists of Canada
On the exam
A woman wants something natural for her hot flashes. Expect a short menu (pick several from a list).
Pick what to ask and what to advise.
Common mistakes
Endorsing an herbal product because she wants something natural, without giving the evidence. Or never asking, and missing a product that interacts with her medicines.
Approach
- Ask directly about herbal products and supplements.
- Many natural health products have little proof that they help.
- Soy and other plant estrogens have mixed results. So does acupuncture.
- For poor sleep, try other treatments before cannabis products.
- Among therapies outside medicine, CBT and clinical hypnosis have the best evidence.
- For poor sleep, melatonin is a low-cost natural option to try.
- Check each product against her other medicines for interactions.
| Option | Evidence |
|---|---|
| Soy and other plant estrogens | Mixed results |
| Most other natural health products | Little proof that they help |
| Cannabis | Try other options first for sleep |
| Melatonin | Worth a try for poor sleep |
Key feature 7 of 8
Prevention at midlife
Use the visit to talk about prevention, such as bone health and breast screening.
CFPC skill Clinical reasoningPhase TreatmentSources Choosing Wisely Canada, Society of Obstetricians and Gynaecologists of Canada
On the exam
A woman's periods stopped at 50, and she asks for a bone scan. Expect one best answer.
Pick the right bone-health plan.
Common mistakes
A screening bone density scan at 50 with no risk factors, or a routine vitamin D level. Neither is advised for a low-risk woman.
Approach
- Assess fracture risk first: past fractures, family history, calcium and vitamin D intake, activity and falls.
- No screening bone density scan (DXA) for low-risk women under 65.
- From 65, start with the Canadian FRAX fracture-risk tool. Order a bone density test only if medication is being considered.
- No routine vitamin D level in low-risk adults. Test with kidney disease, cirrhosis (liver scarring), malabsorption, parathyroid disease, or on anticonvulsants or glucocorticoids.
- Advise a calcium-rich diet, 1,200 to 1,500 mg a day, and 1,000 to 2,000 IU of vitamin D a day, plus weight-bearing exercise.
- Raise breast screening at this visit too.
- Check blood pressure, lipids and A1c (average blood sugar).
Key feature 8 of 8
Who can take hormones
Take the history that shows whether hormone therapy is safe and worthwhile for this patient.
CFPC skill Clinical reasoning, selectivityPhase HistorySources Health Canada, Society of Obstetricians and Gynaecologists of Canada
On the exam
A woman of 52 with bad hot flashes asks about hormones. Expect a short menu (pick several from a list).
Pick the history that decides it.
Common mistakes
Refusing hormones because her sister had breast cancer: that is a risk to weigh, not a contraindication. Or prescribing without asking about clots, stroke or bleeding.
Approach
- Ask about each contraindication: unexplained vaginal bleeding, breast cancer, endometrial cancer, heart disease, clots, stroke, clotting disorders, liver disease, pregnancy.
- Ask her age and the date of her last period. Starting is safe under 60, or within 10 years of menopause, if nothing rules it out.
- Weigh her symptoms, other illnesses, family history, goals and wishes.
- With a uterus, add a progestogen (a progesterone-type hormone) to protect its lining. After a hysterectomy, estrogen alone is enough.
- If her ovaries stopped working before 45, consider hormones until the usual age of menopause.
- There is no set stop date. Review the need regularly.
| Finding | On the Canadian estrogen label |
|---|---|
| Unexplained vaginal bleeding | Ruled out |
| Breast cancer, now or in the past | Ruled out |
| Endometrial cancer, or endometrial hyperplasia (a thickened womb lining) | Ruled out |
| Past clot, stroke, heart attack or clotting disorder | Ruled out |
| Breast cancer in a sister or mother | Not on the list: weigh it |
Flashcards
Answer it first, then check.
KF 1A 49-year-old wakes four times a night and wants a sleeping pill. What do you ask?
About night sweats, hot flashes and changes in her cycle. Night sweats can be what wakes her. Source: Society of Obstetricians and Gynaecologists of Canada
KF 2Does a 49-year-old with longer cycles and hot flashes need an FSH test?
No. The history makes the diagnosis. Hormone levels do not track her symptoms. Source: Choosing Wisely Canada
KF 3Hot flashes at 52, plus weight loss and blood in the stool. What comes first?
Find the cause of the weight loss and bleeding. Do not call it menopause until you have.
KF 4Her FSH is in the premenopausal range, but the story is typical. What now?
Make the diagnosis anyway and treat her symptoms. One hormone level does not overrule the history. Source: Choosing Wisely Canada
KF 5A woman declines hormones for hot flashes. Name three prescription options.
Any three of: an SSRI, an SNRI, gabapentin, oxybutynin or fezolinetant. None works as well as estrogen. Source: Society of Obstetricians and Gynaecologists of Canada
KF 6A woman wants soy for her hot flashes. What does the evidence say?
The results are mixed. Many natural health products have little proof that they help. Source: Society of Obstetricians and Gynaecologists of Canada
KF 7A healthy 50-year-old with no risk factors asks for a bone scan. Your answer?
Not now. Screening scans are not advised under 65 in low-risk women. Assess fracture risk instead. Source: Choosing Wisely Canada
KF 8Name four contraindications to estrogen therapy for menopause symptoms.
Any four of: unexplained vaginal bleeding, breast cancer, heart disease, past clot, stroke, active liver disease. Source: Health Canada
FAQ
Is an FSH level ever useful?
Not for diagnosing the usual transition. Choosing Wisely Canada advises against routine hormone levels, which do not track symptoms. After a hysterectomy, go by symptoms first. The SOGC allows testing only when it is needed, never routinely.
Which guideline should I know for the exam?
The CFPC names none. The main Canadian source is the Society of Obstetricians and Gynaecologists of Canada (SOGC) menopause guideline series (No. 422, 2021–2022). Know who can start hormones safely, the contraindications, and the non-hormonal options.
Can she take hormones if her sister had breast cancer?
A relative's breast cancer is not on the contraindication list of a Canadian estrogen product label. Her own breast cancer is. Weigh family history with her other risks and wishes, then decide together.
Is fezolinetant a hormone?
No. It is a newer non-hormonal drug, the first of its class approved in Canada for hot flashes. It is an option when hormones are unsafe or unwanted.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 22, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- SOGC guidelines and JOGCSociety of Obstetricians and Gynaecologists of Canada
- Choosing Wisely recommendationsChoosing Wisely Canada
- Drug Product DatabaseHealth Canada