Reproductive Endocrinology Practice Questions

Q: What is the effect of elevated androgens on hair follicles in Polycystic Ovary Syndrome (PCOS)?

Conversion of vellus hair to terminal hair.. In Polycystic Ovary Syndrome (PCOS), hyperandrogenism is a hallmark feature. The effect of androgens on hair follicles is site-specific and mediated primarily by the conversion of Testosterone to **Dihydrotestosterone (DHT)** via the enzyme **5α-reductase** within the hair follicle. ### **Explanation of the Correct Answer (B)** In androgen-sensitive areas (face, chest, lower abdomen), elevated levels of androgens act on **vellus hairs**—which are fine, short, and non-pigmented—and stimulate their transformation into **terminal hairs**, which are coarse, long, and darkly pigmented. This process is known as **hirsutism**. ### **Analysis of Incorrect Options** * **Option A:** This describes the process of **alopecia** (specifically androgenetic alopecia). While PCOS patients can experience thinning of scalp hair, the classic effect on body hair follicles in hirsutism is the opposite. * **Options C & D:** These are incorrect because the conversion of a vellus follicle to a terminal follicle is generally **irreversible**. While medical treatment (like OCPs or Spironolactone) can slow the growth and thin the diameter of new hair, it cannot revert a terminal follicle back into a vellus one. This is why physical modalities like laser or electrolysis are required to remove existing terminal hair. ### **NEET-PG High-Yield Pearls** * **Ferriman-Gallwey Score:** The clinical tool used to quantify hirsutism. A score of **≥8** is typically considered significant in the Indian population. * **Site Specificity:** Androgens increase hair growth on the body (hirsutism) but can cause hair loss on the scalp (androgenetic alopecia). * **Key Enzyme:** 5α-reductase is the target for drugs like Finasteride, though it is not first-line in PCOS. * **First-line Medical Management:** Combined Oral Contraceptive Pills (OCPs) are the primary treatment to suppress ovarian androgen production.

Q: Which of the following is NOT a sonographic criterion for diagnosing Polycystic Ovarian Disease (PCOD)?

Presence of more than 20 cysts in the ovary. The diagnosis of Polycystic Ovarian Syndrome (PCOS) is primarily based on the **Revised Rotterdam Criteria (2003)**. To meet the sonographic criteria, only one ovary needs to satisfy the requirements. ### Why Option B is the Correct Answer The original Rotterdam criteria defined PCO morphology as the presence of **12 or more follicles** (measuring 2–9 mm) in either ovary. While newer guidelines (ESHRE 2018) have increased this threshold to **≥20 follicles** when using high-frequency endovaginal transducers (≥8 MHz), the standard textbook definition and the one most commonly tested in NEET-PG still revolve around the classic Rotterdam threshold of **≥12 follicles**. Therefore, "more than 20" is not the standard diagnostic cutoff in traditional criteria. ### Analysis of Other Options * **Option A:** An **ovarian volume >10 mL** (calculated using the formula $0.5 \times \text{length} \times \text{width} \times \text{thickness}$) in either ovary is a core diagnostic criterion. * **Option C:** The follicles must be small, typically **2–9 mm** in diameter, representing arrested follicular development. * **Option D:** The criteria are met if the morphology is present in **either one or both** ovaries. ### NEET-PG High-Yield Pearls * **Rotterdam Criteria (2/3 required):** 1. Oligo/Anovulation, 2. Clinical/Biochemical Hyperandrogenism, 3. Polycystic ovaries on USG. * **"String of Pearls" Appearance:** Classic description where follicles are arranged peripherally around a dense, echogenic stroma. * **Exclusion:** If a dominant follicle (>10 mm) or corpus luteum is present, the scan should be repeated during the next cycle for accuracy. * **LH:FSH Ratio:** Often >2:1 or 3:1 (though no longer a primary diagnostic criterion).

Q: Which side effect of clomiphene necessitates its immediate discontinuation?

Visual symptoms. **Explanation:** **Clomiphene Citrate (CC)** is a Selective Estrogen Receptor Modulator (SERM) and the first-line drug for ovulation induction in PCOS. **Why Visual Symptoms are the Correct Answer:** Visual symptoms (blurring of vision, scotomas, or flashes) occur in approximately 1.5% of patients. These are thought to be due to the drug’s anti-estrogenic effect on the pituitary gland or direct effects on the retina/optic nerve. Unlike other side effects, visual disturbances are a **mandatory indication for immediate discontinuation** of the drug and a referral to an ophthalmologist, as continued use may lead to permanent visual impairment. **Analysis of Incorrect Options:** * **A. Hot Flashes:** This is the **most common** side effect (approx. 10%) due to the anti-estrogenic effect on the hypothalamus. While uncomfortable, it is transient and does not require stopping the drug. * **B. Multiple Pregnancy:** CC increases the risk of twins (approx. 7–10%) and triplets (0.5%). This is a known risk/complication of therapy, not a reason to abort the current cycle once it has occurred. * **C. Teratogenic Effects:** Clomiphene is cleared from the body before the period of organogenesis begins. Large-scale studies have shown no significant increase in congenital anomalies compared to the general population. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** It blocks estrogen receptors in the hypothalamus, inhibiting negative feedback. This increases GnRH pulse frequency, leading to increased FSH and LH. * **Dose:** Usually started at 50 mg/day for 5 days (Day 2 to Day 6 or Day 3 to Day 7 of the cycle). * **Ovarian Hyperstimulation Syndrome (OHSS):** Rare with Clomiphene compared to Gonadotropins. * **Anti-estrogenic effect:** It may cause thinning of the endometrium and thickening of cervical mucus, which can sometimes lead to a "conception-ovulation gap."

Q: Which type of abnormality in sexual development has the best prognosis?

Congenital adrenal hyperplasia. **Explanation:** **Congenital Adrenal Hyperplasia (CAH)**, specifically the 21-hydroxylase deficiency variant, has the best prognosis among Disorders of Sexual Development (DSD) because it is a **purely hormonal/enzymatic defect** rather than a structural or chromosomal one. These patients are genetically female (46,XX) with normal internal female reproductive organs (uterus, fallopian tubes, and ovaries). With early diagnosis, glucocorticoid/mineralocorticoid replacement, and corrective surgery for virilized external genitalia, they can achieve **normal puberty, regular menstruation, and successful pregnancy (fertility is preserved).** **Why other options are incorrect:** * **Mixed Gonadal Dysgenesis (45,X/46,XY):** These patients have a high risk of developing gonadoblastoma (up to 25%) and usually require gonadectomy. They have streak gonads and impaired fertility. * **Androgen Insensitivity Syndrome (46,XY):** While these patients have a female phenotype, they lack a uterus and ovaries (due to AMH production) and have undescended testes. They are **permanently infertile** and require gonadectomy due to malignancy risk. * **True Hermaphroditism (Ovotesticular DSD):** This involves the presence of both ovarian and testicular tissue. Management is complex, and achieving normal fertility is rare and highly dependent on the functionality of the existing gonadal tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of ambiguous genitalia** in a newborn: CAH (21-hydroxylase deficiency). * **Gold standard for diagnosis of CAH:** Elevated 17-hydroxyprogesterone (17-OHP) levels. * **Malignancy Risk:** Highest in DSDs containing a Y-chromosome and dysgenetic gonads (e.g., Mixed Gonadal Dysgenesis). * **Fertility:** CAH is the only condition among the options where natural conception and childbirth are routinely possible.

Q: What is the most common cause of hirsutism?

Polycystic ovary disease. **Explanation:** **1. Why Polycystic Ovary Syndrome (PCOS) is Correct:** PCOS is the most common cause of hirsutism, accounting for approximately **70–80% of all cases**. The underlying pathophysiology involves a state of functional ovarian hyperandrogenism. Elevated levels of Luteinizing Hormone (LH) stimulate the ovarian theca cells to produce excess androgens (androstenedione and testosterone). These androgens are converted to dihydrotestosterone (DHT) in the hair follicles, leading to the transformation of fine vellus hair into coarse terminal hair in androgen-sensitive areas. **2. Analysis of Incorrect Options:** * **Arrhenoblastoma (Sertoli-Leydig Cell Tumor):** While this is a potent source of androgens, it is a rare ovarian tumor. It typically presents with **virilization** (clitoromegaly, voice deepening) and a rapid onset of symptoms, rather than simple hirsutism. * **Cushing Syndrome:** This results from chronic glucocorticoid excess. While it can cause hirsutism due to adrenal androgen co-secretion, it is much less common than PCOS and is usually accompanied by systemic features like moon facies, truncal obesity, and striae. * **Congenital Adrenal Hyperplasia (CAH):** Specifically the Non-Classic (Late-onset) form, CAH is a significant cause of hirsutism but is statistically less frequent than PCOS. It is caused by a partial deficiency of the 21-hydroxylase enzyme. **3. Clinical Pearls for NEET-PG:** * **Ferriman-Gallwey Score:** Used to clinically quantify hirsutism (Score ≥8 is significant in the Indian population). * **Idiopathic Hirsutism:** The second most common cause; characterized by hirsutism with normal menses and normal androgen levels. * **First-line Treatment:** Combined Oral Contraceptive Pills (OCPs) are the mainstay for PCOS-related hirsutism. * **Rapid Onset:** Always suspect an androgen-secreting tumor if hirsutism is sudden in onset and associated with virilization.

Q: Ovulation is presumed to have occurred if the progesterone level is __________ on day 21?

3 ng/mL. **Explanation:** The assessment of serum progesterone levels during the mid-luteal phase (Day 21 of a 28-day cycle) is a gold-standard biochemical marker to confirm that ovulation has occurred. **Why 3 ng/mL is correct:** After ovulation, the collapsed follicle transforms into the **corpus luteum**, which secretes progesterone. A serum progesterone level of **>3 ng/mL** is the widely accepted threshold to provide presumptive evidence of ovulation. While levels >10 ng/mL are often considered optimal for supporting a pregnancy, any value above 3 ng/mL indicates that luteinization has taken place. **Analysis of Incorrect Options:** * **0.3 ng/mL:** This is a typical level found during the **follicular phase** (pre-ovulatory). It indicates that the corpus luteum has not yet formed. * **30 ng/mL:** While possible in a healthy pregnancy or a very robust luteal phase, this is significantly higher than the minimum diagnostic threshold required to simply "presume" ovulation. * **300 ng/mL:** This is a pathologically high or physiological impossibility for a standard Day 21 check; such levels are not seen in normal menstrual cycles. **NEET-PG High-Yield Pearls:** * **Timing:** Progesterone should be measured 7 days before the expected menses. In a 28-day cycle, this is **Day 21**. * **Peak Secretion:** Progesterone levels peak approximately 7–8 days after the LH surge. * **Anovulation:** A level **<3 ng/mL** on Day 21 suggests anovulation, requiring further workup (e.g., PCOS, thyroid dysfunction, or hyperprolactinemia). * **Other signs of ovulation:** Spinnbarkeit (thin, stretchy cervical mucus), Mittelschmerz (mid-cycle pain), and a 0.5°F rise in Basal Body Temperature (BBT).

Q: A 30-year-old female presents with complaints of lethargy, anorexia, weight loss, and secondary amenorrhea. She has a history of postpartum hemorrhage and failed lactation. Which of the following is the most probable diagnosis?

Sheehan's syndrome. ### Explanation **Correct Answer: A. Sheehan's syndrome** **Why it is correct:** Sheehan’s syndrome is **postpartum hypopituitarism** caused by ischemic necrosis of the anterior pituitary gland. During pregnancy, the pituitary gland enlarges (hypertrophies), making it highly susceptible to ischemia if severe hypotension occurs due to **postpartum hemorrhage (PPH)**. The clinical presentation follows a pattern of progressive pituitary hormone deficiency: * **Prolactin deficiency:** Leads to **failure of lactation** (often the earliest sign). * **Gonadotropin (FSH/LH) deficiency:** Leads to **secondary amenorrhea** and loss of pubic/axillary hair. * **ACTH and TSH deficiency:** Causes lethargy, anorexia, weight loss, and hypotension. **Why the other options are incorrect:** * **B. Empty sella syndrome:** This involves a herniation of the subarachnoid space into the sella turcica, flattening the pituitary. While it can cause hypopituitarism, it is not classically associated with a specific history of PPH. * **C. Kallmann syndrome:** A genetic condition characterized by **hypogonadotropic hypogonadism and anosmia** (loss of smell). It presents as primary amenorrhea, not secondary amenorrhea following childbirth. * **D. Asherman syndrome:** This involves intrauterine adhesions (synechiae) usually following over-zealous D&C. While it causes secondary amenorrhea, it **does not affect systemic hormones**; therefore, lactation, thyroid, and adrenal functions remain normal. **High-Yield Clinical Pearls for NEET-PG:** * **Earliest Sign:** Failure of lactation (due to prolactin deficiency). * **Most Common Initial Symptom:** Secondary amenorrhea. * **Investigation of Choice:** MRI of the pituitary (shows an empty sella in late stages). * **Management:** Lifelong hormone replacement therapy (Cortisol and Thyroid hormones must be replaced before Growth Hormone or Estrogen).

Question 1

A 10-year-old girl presents with primary amenorrhea, absent breast development, and a malformed uterus. What is the most likely diagnosis?

Accepted Answer

Turner's syndrome

Answer

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome

Answer

Swyer syndrome

Answer

Mixed gonadal dysgenesis

Question 2

What is the effect of elevated androgens on hair follicles in Polycystic Ovary Syndrome (PCOS)?

Accepted Answer

Conversion of vellus hair to terminal hair.

Answer

Conversion of terminal hair to vellus hair.

Answer

Reversible conversion of vellus hair to terminal hair.

Answer

Reversible conversion of terminal hair to vellus hair.

Question 3

A woman presents with amenorrhea. She has negative bleeding after a progesterone challenge test but bleeds following a combined estrogen-progesterone challenge test. What is the most likely underlying cause?

Accepted Answer

Pituitary tumor

Answer

Anovulation

Answer

Asherman syndrome

Answer

Pregnancy

Question 4

Which of the following is NOT a sonographic criterion for diagnosing Polycystic Ovarian Disease (PCOD)?

Accepted Answer

Presence of more than 20 cysts in the ovary

Answer

Enlarged ovaries with a volume greater than 10 mL

Answer

Cyst size ranging from 2 to 9 mm

Answer

Cysts identified in either one or both ovaries

Question 5

Which side effect of clomiphene necessitates its immediate discontinuation?

Accepted Answer

Visual symptoms

Answer

Hot flashes

Answer

Multiple pregnancy

Answer

Teratogenic effects

Question 6

Which type of abnormality in sexual development has the best prognosis?

Accepted Answer

Congenital adrenal hyperplasia

Answer

Mixed gonadal dysgenesis

Answer

Androgen insensitivity syndrome

Answer

True hermaphroditism

Question 7

What is the most common cause of hirsutism?

Accepted Answer

Polycystic ovary disease

Answer

Arrhenoblastoma

Answer

Cushing syndrome

Answer

Congenital adrenal hyperplasia

Question 8

Ovulation is presumed to have occurred if the progesterone level is __________ on day 21?

Accepted Answer

3 ng/mL

Answer

0.3 ng/mL

Answer

30 ng/mL

Answer

300 ng/mL

Question 9

All of the following are true regarding the use of GnRH analogues in the treatment of endometriosis, EXCEPT?

Accepted Answer

The risk of osteoporosis decreases with prolonged use because estrogen-mediated osteoblastic activity continues.

Answer

Continuous administration leads to downregulation of pituitary gonadotropins.

Answer

Add-back therapy typically includes estrogens.

Answer

Discontinuation of therapy can result in recurrence.

Question 10

A 30-year-old female presents with complaints of lethargy, anorexia, weight loss, and secondary amenorrhea. She has a history of postpartum hemorrhage and failed lactation. Which of the following is the most probable diagnosis?

Accepted Answer

Sheehan's syndrome

Answer

Empty sella syndrome

Answer

Kallmann syndrome

Answer

Asherman syndrome

Reproductive Endocrinology — MCQs

Reproductive Endocrinology — MCQs

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