Reproductive Endocrinology Practice Questions

Q: A patient presents with a history of amenorrhea and hirsutism. Ultrasound of the ovary is provided. What is the most likely diagnosis?

Polycystic Ovary Syndrome (PCOS). ***Polycystic Ovary Syndrome (PCOS)*** - **Amenorrhea** and **hirsutism** are classic presenting symptoms of PCOS, part of the **Rotterdam criteria** for diagnosis. - Ultrasound typically shows **multiple peripheral follicles** arranged in a "**string-of-pearls**" pattern around the ovarian cortex. *Endometriosis* - Primarily presents with **cyclical pelvic pain** and **dysmenorrhea**, not amenorrhea or hirsutism. - Ultrasound would show **endometriomas** (chocolate cysts) rather than multiple peripheral follicles. *Adenomyomatosis* - This is a **benign gallbladder condition** characterized by **hyperplasia of the gallbladder wall**, not an ovarian pathology. - Would not cause **amenorrhea** or **hirsutism** as it doesn't affect reproductive hormones. *Choriocarcinoma* - A **malignant gestational trophoblastic neoplasm** that presents with **irregular bleeding** and elevated **β-hCG levels**. - Would not typically cause **hirsutism** or the characteristic ovarian ultrasound findings described.

Q: In a 40-day menstrual cycle, at which day does ovulation typically occur?

26th day. **Explanation:** The key to solving this question lies in understanding the phases of the menstrual cycle. A menstrual cycle consists of two main phases: the **Follicular Phase** (pre-ovulatory) and the **Luteal Phase** (post-ovulatory). 1. **The Concept of the Fixed Luteal Phase:** While the follicular phase varies in length among women, the **luteal phase is constant and lasts 14 days** (ranging from 12–16 days). This is because the lifespan of the *corpus luteum* is biologically predetermined. 2. **Calculation:** To determine the day of ovulation, subtract the fixed luteal phase from the total cycle length. * **Formula:** Day of Ovulation = Total Cycle Length – 14 days * **Calculation:** 40 – 14 = **26th Day**. **Analysis of Incorrect Options:** * **Option A (14th day):** This is only correct for a "textbook" 28-day cycle (28 – 14 = 14). It is a common misconception that ovulation always occurs on day 14. * **Option B (20th day):** This would be the ovulation day for a 34-day cycle. * **Option D (30th day):** This would imply a luteal phase of only 10 days, which is generally considered a "Luteal Phase Defect" and is not the physiological norm. **NEET-PG High-Yield Pearls:** * **Variable Phase:** The Follicular phase is the variable part of the cycle; its length determines the overall cycle length. * **Ovulation Marker:** The most reliable indicator that ovulation has occurred is a rise in **Basal Body Temperature (BBT)** due to the thermogenic effect of Progesterone. * **LH Surge:** Ovulation occurs **24–36 hours** after the onset of the LH surge and **10–12 hours** after the LH peak. * **Best Timing for Biopsy:** If performing an endometrial biopsy to check for ovulation, it is traditionally done on Day 21–23 of a 28-day cycle (Mid-luteal phase).

Q: A 20-year-old girl presents with a history of rapidly developing hirsutism and amenorrhea. Which of the following blood tests would be most appropriate to establish the diagnosis?

Testosterone. **Explanation:** The clinical presentation of **rapidly developing hirsutism** (virilization) and amenorrhea in a young woman is a "red flag" that strongly suggests an **androgen-secreting tumor** (ovarian or adrenal), rather than a functional disorder like PCOS. 1. **Why Testosterone is correct:** Serum **Total Testosterone** is the most appropriate initial test to screen for ovarian tumors (like Sertoli-Leydig cell tumors). A testosterone level **>200 ng/dL** is highly suggestive of a malignancy. In cases of rapid onset virilization, testosterone is the most potent androgen responsible for the clinical symptoms and is the primary marker for ovarian sources of androgen excess. 2. **Why other options are incorrect:** * **17-hydroxyprogesterone:** This is the screening test for **Congenital Adrenal Hyperplasia (CAH)**, specifically the 21-hydroxylase deficiency. While CAH causes hirsutism, it is usually present from childhood/puberty and is rarely "rapidly progressive." * **DHEA/DHEAS:** DHEAS is a marker for **adrenal tumors**. While it should be measured alongside testosterone, testosterone is generally considered the first-line marker for overall androgen excess in this clinical context. (Note: DHEAS >7000 µg/dL suggests an adrenal tumor). * **LH:FSH ratio:** An elevated ratio (>2:1 or 3:1) is characteristic of **PCOS**. However, PCOS typically presents with a slow, chronic progression of symptoms since puberty, not a rapid onset of virilization. **High-Yield Clinical Pearls for NEET-PG:** * **Slow onset hirsutism:** Think PCOS or Idiopathic. * **Rapid onset + Virilization:** Think Androgen-secreting tumors. * **Source Localization:** If Testosterone is markedly elevated but DHEAS is normal, the source is likely **Ovarian**. If DHEAS is markedly elevated, the source is **Adrenal**. * **Ferriman-Gallwey Score:** Used to clinically quantify hirsutism (Score ≥8 is significant).

Q: All are true about hormonal levels in Polycystic Ovarian Disease except?

Decreased testosterone level. **Explanation:** Polycystic Ovarian Syndrome (PCOS) is characterized by a state of **hyperandrogenism** and chronic anovulation. The correct answer is **D (Decreased testosterone level)** because, in PCOS, testosterone levels are typically **elevated** or at the high end of the normal range, rather than decreased. **Why the other options are incorrect (True for PCOS):** * **A. Increased androstenedione:** The ovaries and adrenal glands produce excess androgens. Androstenedione is a key precursor that is elevated, contributing to hirsutism and acne. * **B. Reduced FSH/LH ratio:** In PCOS, there is an increased frequency of GnRH pulses, leading to **increased LH** and relatively **low/normal FSH**. This results in a classic **LH:FSH ratio of >2:1 or 3:1**. Since the denominator (FSH) is lower than the numerator (LH), the FSH/LH ratio is mathematically reduced. * **C. Increased oestrone (E1):** Due to peripheral aromatization of excess androstenedione in adipose tissue, levels of oestrone (E1) are elevated. This leads to a state of "unopposed estrogen," increasing the risk of endometrial hyperplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Rotterdam Criteria (requires 2 out of 3: Hyperandrogenism, Ovulatory dysfunction, Polycystic ovaries on USG). * **SHBG Levels:** Sex Hormone Binding Globulin is **decreased** in PCOS (often due to hyperinsulinemia), which further increases the "Free Testosterone Index." * **Insulin Resistance:** Hyperinsulinemia stimulates the ovarian theca cells to produce more androgens and inhibits hepatic SHBG production. * **USG Hallmark:** "String of pearls" appearance (12 or more follicles measuring 2–9 mm).

Q: Which of the following is an ovarian cause of hirsutism?

Polycystic Ovarian Disease (PCOD). **Explanation:** **Polycystic Ovarian Disease (PCOD/PCOS)** is the most common cause of hirsutism in women. The underlying pathophysiology involves an increase in the pulse frequency of Gonadotropin-Releasing Hormone (GnRH), leading to an elevated **LH:FSH ratio**. High 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 skin, which stimulates terminal hair growth in male-pattern areas. **Analysis of Incorrect Options:** * **Ovarian Carcinoma:** Most ovarian cancers (like epithelial tumors) are non-functional and do not produce hormones. While specific "Sertoli-Leydig cell tumors" can cause virilization, they are rare compared to PCOD. * **Dysgerminoma:** This is a germ cell tumor that typically produces **LDH** or occasionally hCG. It does not produce androgens and therefore does not cause hirsutism. * **Endometriotic Cyst:** Also known as a "chocolate cyst," this is a benign condition where endometrial tissue grows on the ovary. It is associated with pelvic pain and infertility, not androgen excess. **High-Yield Clinical Pearls for NEET-PG:** * **Ferriman-Gallwey Score:** Used to clinically quantify hirsutism (Score ≥8 is significant). * **Hyperthecosis:** A more severe form of PCOD characterized by nests of luteinized theca cells, often leading to frank virilization. * **HAIR-AN Syndrome:** A subset of PCOS characterized by **H**irsutism, **A**canthosis nigricans, **I**nsulin **R**esistance, and **A**ndrogen excess. * **First-line Treatment:** Combined Oral Contraceptive Pills (OCPs) are the first-line medical management for hirsutism in PCOS.

Q: The Ferriman-Gallwey scoring system is used to quantify which of the following?

Hirsutism. The **Modified Ferriman-Gallwey (mFG) score** is the gold standard clinical tool used to quantify **Hirsutism**—the presence of excess terminal hair in females in a male-pattern distribution. ### Why Hirsutism is Correct Hirsutism is a clinical sign of androgen excess. The mFG system evaluates **9 androgen-sensitive body areas** (upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, upper arms, and thighs). Each area is scored from 0 (no hair) to 4 (frankly virile), with a maximum score of 36. In most populations, a score of **≥8** is considered diagnostic of hirsutism, though some guidelines suggest ≥3 or ≥5 depending on ethnicity. ### Why Other Options are Incorrect * **A. Hypertrichosis:** This refers to generalized excessive hair growth that is **not** androgen-dependent (e.g., due to metabolic disorders or drugs like Minoxidil). It affects non-sexual areas and is not measured by the mFG score. * **B. Galactorrhea:** This is spontaneous milk secretion unrelated to childbirth, usually due to hyperprolactinemia. It is evaluated via serum prolactin levels and breast examination. * **C. Virilization:** This is a more severe state of masculinization (clitoromegaly, deepening of voice, male-pattern baldness). While hirsutism is a component, the mFG score specifically measures hair, not these broader systemic changes. ### High-Yield NEET-PG Pearls * **Most common cause of Hirsutism:** Polycystic Ovary Syndrome (PCOS). * **Drug of choice for Hirsutism:** Combined Oral Contraceptive Pills (COCPs) are first-line; Spironolactone is the most common anti-androgen added if needed. * **Rapid onset hirsutism + Virilization:** Always suspect an androgen-secreting tumor (Adrenal or Ovarian). * **Ethnicity matters:** The mFG cutoff is lower in Asian women (≥3) compared to Caucasian or Hispanic women.

Question 1

Determination of serum progesterone level to document ovulation. For the evaluation, select the most appropriate day of a normal 28-day menstrual cycle for a woman with 5-day menstrual periods.

Accepted Answer

Day 21

Answer

Day 3

Answer

Day 8

Answer

Day 14

Question 2

A patient presents with a history of amenorrhea and hirsutism. Ultrasound of the ovary is provided. What is the most likely diagnosis?

Accepted Answer

Polycystic Ovary Syndrome (PCOS)

Answer

Endometriosis

Answer

Choriocarcinoma

Answer

Adenomyosis

Question 3

A 16-year-old female has not yet started having menstrual cycles. Her secondary sex characteristics appear normal, as does external examination of her genitalia. She is given an intramuscular injection of progesterone, and 5 days later she has her first period. What is the most likely mechanism responsible for the delay in menses?

Accepted Answer

A normal constitutional delay in menarche

Answer

Hypoestrogenism

Answer

Hypopituitarism

Answer

An end-organ abnormality

Question 4

In a 40-day menstrual cycle, at which day does ovulation typically occur?

Accepted Answer

26th day

Answer

14th day

Answer

20th day

Answer

30th day

Question 5

A 23-year-old woman presents for evaluation of a 7-month history of amenorrhea. Examination discloses bilateral galactorrhea and normal breast and pelvic examinations. Pregnancy test is negative. Which of the following classes of medication is a possible cause of her condition?

Accepted Answer

Phenothiazines

Answer

Antiestrogens

Answer

Gonadotropins

Answer

Prostaglandins

Question 6

In Swyer syndrome, what is typically found?

Accepted Answer

Testes are present

Answer

Ovaries are present

Answer

Short stature

Answer

Decreased FSH and LH

Question 7

A 20-year-old girl presents with a history of rapidly developing hirsutism and amenorrhea. Which of the following blood tests would be most appropriate to establish the diagnosis?

Accepted Answer

Testosterone

Answer

17-hydroxyprogesterone

Answer

Dehydroepiandrosterone (DHEA)

Answer

Luteinizing hormone (LH): Follicle-stimulating hormone (FSH) ratio

Question 8

All are true about hormonal levels in Polycystic Ovarian Disease except?

Accepted Answer

Decreased testosterone level

Answer

Increased androstenedione

Answer

Reduced FSH/LH ratio

Answer

Increased oestrone

Question 9

Which of the following is an ovarian cause of hirsutism?

Accepted Answer

Polycystic Ovarian Disease (PCOD)

Answer

Ovarian carcinoma

Answer

Dysgerminoma

Answer

Endometriotic cyst

Question 10

The Ferriman-Gallwey scoring system is used to quantify which of the following?

Accepted Answer

Hirsutism

Answer

Hypertrichosis

Answer

Galactorrhea

Answer

Virilization

Reproductive Endocrinology — MCQs

Reproductive Endocrinology — MCQs

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