Hormonal Therapy for Transgender Patients — MCQs
Which among the following is an absolute contraindication of Hormone replacement therapy?
Which is true about Sex hormone-binding globulin (SHBG):
Absolute contraindication of hormone replacement therapy is:
A teenage girl presented with irregular cycles and increased facial hair. Her ovaries showed increased volume. Which of the following are used in the first line treatment? 1. Laparoscopic ovarian drilling 2. Anti-androgens 3. Lifestyle modifications 4. Combined oral contraceptive pills
A GSP4 woman comes for routine sonography for the first time. She has four daughters and expresses a desire for a boy this time, asking for sex determination. To abide by ethical guidelines, what should you do?
Which of the following hormones are required during puberty?
What is the definitive management for adenomyosis?
ER positivity is used as which of the following in the context of breast carcinoma?
What should be done next in an 18-year-old girl with primary amenorrhea, a karyotype of 45,X0, and an infantile uterus on ultrasound?
Gynecomastia is seen in all except;
Hormonal Therapy for Transgender Patients Indian Medical PG Practice Questions and MCQs
Question 1: Which among the following is an absolute contraindication of Hormone replacement therapy?
- A. Endometriosis
- B. Heart disease
- C. Breast carcinoma (Correct Answer)
- D. Osteoarthritis
Explanation: ### Breast carcinoma - Hormone replacement therapy (HRT) is **contraindicated** in breast carcinoma because many breast cancers are **estrogen-receptor positive**, meaning estrogen can stimulate their growth [1]. - Using HRT in patients with a history of breast cancer significantly increases the risk of **recurrence** or **progression** of the disease [1]. *Endometriosis* - Endometriosis is not an **absolute contraindication**; HRT can sometimes be used in women with a history of endometriosis, especially if a hysterectomy and bilateral oophorectomy have been performed. - However, unopposed estrogen therapy might **exacerbate** remaining endometrial implants, so a combined estrogen-progestin regimen is typically preferred [1]. *Heart disease* - While HRT has been shown to have **risks** in women with established coronary heart disease, it is not an absolute contraindication for all forms of heart disease. - The **Women's Health Initiative study** demonstrated increased cardiovascular events in older women initiating HRT, but current guidelines suggest that timing of initiation is crucial and benefits may outweigh risks for younger postmenopausal women. *Osteoarthritis* - Osteoarthritis is **not a contraindication** to HRT; in fact, some studies suggest that estrogen may have protective effects on cartilage [2]. - HRT is neither a treatment nor a contraindication for osteoarthritis and does not significantly impact its progression or severity [2].
Question 2: Which is true about Sex hormone-binding globulin (SHBG):
- A. Stimulates the secretion of inhibin
- B. Binds testosterone with a higher affinity than estradiol (Correct Answer)
- C. Reduces the total amount of circulating testosterone
- D. Decreases the half-life of testosterone
Explanation: ***Binds testosterone with a higher affinity than estradiol*** - SHBG has a **higher binding affinity for androgens** (**testosterone** and dihydrotestosterone) than for estrogens like **estradiol**. - This difference in affinity is crucial for regulating the **bioavailability of sex hormones**. *Stimulates the secretion of inhibin* - **Inhibin** secretion is primarily stimulated by **follicle-stimulating hormone (FSH)** and local factors in the gonads, not by SHBG. - SHBG's main role is to transport sex steroids, not to directly stimulate other hormone productions. *Reduces the total amount of circulating testosterone* - SHBG **binds circulating testosterone**, but it does not *reduce* the total amount; rather, it *regulates the free fraction* of testosterone. - The liver produces SHBG, which then acts as a **carrier protein**, affecting the bioavailability of **sex hormones**. *Decreases the half-life of testosterone* - By binding to testosterone, SHBG **increases the half-life** of testosterone by protecting it from rapid metabolic degradation and excretion. - **Bound hormones** are less readily metabolized and excreted, thus prolonging their circulation time.
Question 3: Absolute contraindication of hormone replacement therapy is:
- A. Fibroadenoma
- B. Thrombosis (Correct Answer)
- C. Fibrocystic disease
- D. Hemorrhage
Explanation: ***Thrombosis*** - A history of **thrombosis** (e.g., DVT, pulmonary embolism) is an **absolute contraindication** to hormone replacement therapy (HRT) due to the increased risk of further **thromboembolic events**, as estrogen can promote coagulation [1], [2]. - HRT can increase the risk of **blood clot formation**, making it unsafe for individuals with a prior or current thrombotic condition [1]. *Fibroadenoma* - **Fibroadenomas** are **benign breast lumps** and are generally not considered an absolute contraindication for HRT. - While HRT can potentially cause some **breast density** changes, fibroadenomas do not typically preclude its use, though monitoring may be advised. *Fibrocystic disease* - **Fibrocystic breast disease** is a common **benign breast condition** characterized by lumpy, tender breasts, and it is **not an absolute contraindication** for HRT. - HRT might occasionally exacerbate breast tenderness in some women with fibrocystic changes, but it does not pose a severe health risk. *Hemorrhage* - Acute or uncontrolled **vaginal hemorrhage**, especially of undetermined etiology, is a contraindication to initiating HRT until the cause is identified and managed. - However, once the hemorrhage is controlled and its cause is determined not to be uterine cancer, previous hemorrhage itself is **not an absolute contraindication** to long-term HRT.
Question 4: A teenage girl presented with irregular cycles and increased facial hair. Her ovaries showed increased volume. Which of the following are used in the first line treatment? 1. Laparoscopic ovarian drilling 2. Anti-androgens 3. Lifestyle modifications 4. Combined oral contraceptive pills
- A. 2,3,4 (Correct Answer)
- B. 1,2,3
- C. 1,2,4
- D. 1,3,4
Explanation: ***2,3,4 (Correct Answer)*** - **Lifestyle modifications (3)** are the foundational first-line intervention for all PCOS patients, particularly those who are overweight or obese, as they improve insulin sensitivity, reduce androgen levels, and improve both metabolic and reproductive outcomes. - **Combined oral contraceptive pills/COCs (4)** are the first-line pharmacological treatment for menstrual irregularity and hyperandrogenism in PCOS when fertility is not desired. They regulate cycles, suppress ovarian androgen production, and reduce hirsutism and acne. - **Anti-androgens (2)** such as spironolactone are used in first-line management of moderate-to-severe hirsutism and acne in PCOS, typically in combination with COCs. They block androgen receptors or inhibit androgen synthesis, providing additional benefit for hyperandrogenic symptoms like the increased facial hair in this patient. *1,2,3* - **Laparoscopic ovarian drilling (1)** is a second-line surgical treatment reserved for anovulatory infertility in PCOS patients who fail to respond to ovulation induction with clomiphene citrate. It is NOT a first-line treatment for menstrual irregularity and hirsutism. - While lifestyle modifications (3) and anti-androgens (2) are appropriate first-line components, the inclusion of ovarian drilling makes this combination incorrect as a first-line approach. *1,2,4* - **Laparoscopic ovarian drilling (1)** is an invasive procedure indicated only as second-line therapy for specific cases of anovulatory infertility, not for initial management of irregular cycles and hirsutism. - Although anti-androgens (2) and COCs (4) are appropriate first-line pharmacological treatments, the inclusion of ovarian drilling excludes this from being a correct first-line treatment combination. *1,3,4* - This combination includes two appropriate first-line treatments: **lifestyle modifications (3)** and **combined oral contraceptive pills (4)**. - However, **laparoscopic ovarian drilling (1)** is a second-line or third-line surgical intervention for very specific indications (anovulatory infertility resistant to medical management), making this combination incorrect as a first-line approach for this clinical presentation.
Question 5: A GSP4 woman comes for routine sonography for the first time. She has four daughters and expresses a desire for a boy this time, asking for sex determination. To abide by ethical guidelines, what should you do?
- A. Check routine ANC and sex for developmental abnormalities and do not reveal gender to the patient (Correct Answer)
- B. Check routine ANC and sex for developmental abnormalities and do reveal gender to the patient
- C. Do reveal gender if a girl
- D. Check only routine ANC, do not check sex
Explanation: ***Check routine ANC and sex for developmental abnormalities and do not reveal gender to the patient*** - It is **illegal** and **unethical** to reveal the sex of the fetus in many countries, including India, to prevent **sex-selective abortions**. - The primary purpose of a routine antenatal ultrasound is to assess fetal **health** and **developmental abnormalities**, not to determine sex for parental preference. *Check routine ANC and sex for developmental abnormalities and do reveal gender to the patient* - Revealing the gender to the patient directly facilitates **sex-selective abortion**, which is medically unethical and illegal due to the potential for harm to the fetus and society. - This practice would violate the **Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act** in India, which prohibits gender determination. *Do reveal gender if a girl* - Revealing the gender, regardless of whether it is a boy or a girl, can lead to **gender-biased selective abortions**, particularly in cultures with a strong preference for male offspring. - This action undermines the ethical principles of **non-maleficence** and **justice** by potentially facilitating harm based on gender preference. *Check only routine ANC, do not check sex* - While the primary focus is routine antenatal care, avoiding the assessment of fetal sex entirely could lead to **missing potential developmental abnormalities** that might be identifiable through observation of external genitalia. - A thorough ultrasound examination routinely includes a visual check of fetal anatomy, which can incidentally reveal gender, but this information should not be shared with the parents for selection purposes.
Question 6: Which of the following hormones are required during puberty?
- A. Testosterone
- B. LH
- C. Leptin
- D. All of the options (Correct Answer)
Explanation: ***All of the options*** - All three hormones — **testosterone**, **LH** (Luteinizing Hormone), and **leptin** — are required during puberty, each playing distinct but complementary roles in the initiation and progression of pubertal development. **Testosterone** - Essential sex steroid hormone responsible for development of **male secondary sexual characteristics** including deepening of voice, muscle mass increase, facial and body hair growth, and genital development - In females, androgens (including testosterone) contribute to pubertal growth spurt and development of pubic and axillary hair - Required throughout puberty for ongoing sexual maturation **LH (Luteinizing Hormone)** - Critical gonadotropin that stimulates the gonads to produce sex steroids - In males: stimulates **Leydig cells** to produce testosterone - In females: triggers ovulation and stimulates ovarian production of estrogen and progesterone - Part of the HPG (hypothalamic-pituitary-gonadal) axis activation that initiates puberty **Leptin** - Acts as a **metabolic gate** for puberty — signals adequate energy reserves and nutritional status to the hypothalamus - Permissive hormone for **GnRH pulsatility** — low leptin levels delay or prevent puberty onset - Critical for the timing of pubertal initiation; links nutritional status with reproductive maturation - Explains why malnutrition or low body fat delays puberty, while adequate nutrition permits its onset
Question 7: What is the definitive management for adenomyosis?
- A. Endometrial ablation.
- B. Hysterectomy (surgical removal of the uterus). (Correct Answer)
- C. Hormonal therapy (e.g., Danazol) for temporary symptom relief.
- D. Hormonal therapy (e.g., GnRH analogue) for temporary symptom relief.
Explanation: ***Hysterectomy (surgical removal of the uterus)*** - This is considered the **definitive management** for adenomyosis because it completely removes the uterine tissue where the ectopic endometrial glands are found. - Hysterectomy effectively eliminates the source of symptoms such as **heavy menstrual bleeding** and **pelvic pain** by removing the uterus entirely. *Endometrial ablation* - Endometrial ablation involves destroying the **lining of the uterus** and is primarily used for heavy menstrual bleeding. - It is **ineffective for adenomyosis** since the endometrial tissue is embedded deep within the myometrium and is not fully reached by ablation. *Hormonal therapy (e.g., Danazol) for temporary symptom relief* - **Danazol** (an androgen derivative) can suppress ovarian function and reduce symptoms of adenomyosis by shrinking endometrial tissue. - However, its effects are **temporary**, and symptoms typically return upon cessation of treatment, making it not a definitive solution. *Hormonal therapy (e.g., GNRH analogue) for temporary symptom relief* - **GnRH analogues** induce a temporary menopausal state, which can significantly reduce symptoms by inhibiting estrogen production, leading to atrophy of the adenomyotic tissue. - This treatment is also **temporary**, and symptoms often recur once the medication is stopped; it's often used as a bridge to surgery or for women nearing menopause.
Question 8: ER positivity is used as which of the following in the context of breast carcinoma?
- A. Treatment option
- B. Prognostic marker (Correct Answer)
- C. Molecular marker
- D. Diagnostic marker
Explanation: ***Prognostic marker*** - **ER positivity** in **breast carcinoma** is primarily used as a **prognostic marker** indicating more favorable disease outcome [1]. - ER-positive tumors generally **grow more slowly**, are **less aggressive**, and have **better overall survival** compared to ER-negative tumors [2]. - While ER status also has **predictive value** for endocrine therapy response, its classification as a prognostic indicator reflects its association with inherently better tumor biology and patient outcomes [1]. - ER positivity correlates with **well-differentiated tumors** and **lower grade** malignancies. *Treatment option* - ER positivity is not a treatment itself, but rather a **biomarker** that guides treatment selection. - It identifies patients who may benefit from **endocrine therapy** (tamoxifen, aromatase inhibitors) [1]. *Molecular marker* - While ER is indeed a molecular marker (receptor protein detected by immunohistochemistry), this term is too **broad and non-specific**. - The question asks for the **specific clinical utility** of ER positivity, not its general classification. *Diagnostic marker* - ER status is **not used for initial diagnosis** of breast carcinoma. - Diagnosis requires **histopathological examination** of tissue biopsy. - ER testing is performed **after diagnosis** to characterize the tumor and guide management. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1059-1060. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Breast, pp. 1064-1066.
Question 9: What should be done next in an 18-year-old girl with primary amenorrhea, a karyotype of 45,X0, and an infantile uterus on ultrasound?
- A. Vaginoplasty
- B. Clitoroplasty
- C. B/L gonadectomy
- D. Hormone therapy to induce puberty (Correct Answer)
Explanation: ***Hormone therapy to induce puberty*** - The patient has **Turner syndrome (45,X0)**, which causes **gonadal dysgenesis** and thus a lack of **estrogen** and **progesterone** production, leading to primary amenorrhea and an infantile uterus. - **Hormone replacement therapy** with estrogen and progestin is essential to induce secondary sexual characteristics, promote uterine development, and achieve cyclical bleeding, which mimics puberty. *Vaginoplasty* - **Vaginoplasty** is a surgical procedure to create or lengthen the vagina, typically considered for conditions like **Mayer-Rokitansky-Küster-Hauser syndrome** where the vagina is absent or underdeveloped but ovaries are functional. - This patient has an infantile uterus, not vaginal agenesis as the primary issue, and the underlying problem is **hormonal deficiency**, not a structural one that would be addressed by vaginoplasty first. *Clitoroplasty* - **Clitoroplasty** is a surgical procedure to reduce the size of an enlarged clitoris, usually performed in cases of **ambiguous genitalia** or **congenital adrenal hyperplasia**. - There is no indication of clitoromegaly or ambiguous genitalia in this patient's presentation; her primary issue is the absence of puberty. *B/L gonadectomy* - **Bilateral gonadectomy** is indicated in patients with **Y chromosome material** and **gonadal dysgenesis** (e.g., Swyer syndrome or mixed gonadal dysgenesis) due to the high risk of **gonadoblastoma**. - While this patient has **gonadal dysgenesis** associated with **Turner syndrome**, she lacks a **Y chromosome**, meaning the risk of malignant transformation in her streak gonads is low, and therefore prophylactic gonadectomy is not typically performed.
Question 10: Gynecomastia is seen in all except;
- A. Kidney failure
- B. Liver failure
- C. Stilbestrol therapy for prostate cancer
- D. Teratoma of the testis
- E. Hormonal
- F. Leprosy (Correct Answer)
- . Idiopathic
- . Anorchism and After castration
- . Klinefelter's syndrome
Explanation: Leprosy - While leprosy can affect various endocrine glands, **gynecomastia is not a typical or direct manifestation** of the disease. - Its primary impact is on the peripheral nerves, skin, and upper respiratory tract, not directly on estrogen-androgen balance. *Kidney failure* - **Chronic kidney disease** often leads to **hormonal imbalances**, including increased prolactin and decreased testosterone, which can cause gynecomastia. - The altered metabolism and excretion of hormones contribute to this endocrine dysfunction. *Liver failure* - The liver is crucial for metabolizing **estrogens** and other hormones; **liver failure** leads to reduced estrogen breakdown and elevated circulating levels. - This **increased estrogen-to-androgen ratio** promotes breast tissue development in males. *Stilbestrol therapy for prostate cancer* - **Stilbestrol is a synthetic estrogen** often used as part of androgen deprivation therapy for prostate cancer. - Administering exogenous estrogen directly **stimulates breast tissue growth**, causing gynecomastia. *Teratoma of the testis* - Certain **testicular tumors**, including some teratomas, can produce **human chorionic gonadotropin (hCG)** [1]. - Elevated hCG can **stimulate Leydig cells to produce estrogen** and can also directly stimulate aromatase activity, leading to gynecomastia. *Hormonal* - This category generally refers to conditions where there is an **imbalance between estrogen and androgen levels**, favoring estrogenic effects. - **Any condition that increases estrogen or decreases testosterone** can lead to gynecomastia. *Idiopathic* - **Idiopathic gynecomastia** refers to cases where no identifiable underlying cause can be found despite thorough investigation. - It's a diagnosis of exclusion, signifying that the exact hormonal imbalance or mechanism remains unknown. *Anorchism and After castration* - Both anorchism (absence of testes) and castration (surgical removal of testes) result in a **severe deficiency of testosterone**. - Without sufficient androgen production, the **relative effect of even normal estrogen levels becomes dominant**, leading to gynecomastia. *Klinefelter's syndrome* - **Klinefelter's syndrome (47, XXY)** is a chromosomal disorder characterized by **testicular dysfunction**, leading to primary hypogonadism [2]. - This results in **low testosterone and relatively high estrogen levels** [3], a classic hormonal imbalance that causes gynecomastia.
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