Reproductive Endocrinology Practice Questions

Q: All of the following are diagnoses of PCOS except?

Reduced serum insulin level. **Explanation:** Polycystic Ovary Syndrome (PCOS) is a complex metabolic and endocrine disorder. The hallmark of its metabolic profile is **insulin resistance**, which leads to **compensatory hyperinsulinemia** (elevated serum insulin levels). Therefore, **Option D (Reduced serum insulin level)** is incorrect and the right answer for this "except" question. **Analysis of Options:** * **Elevated LH (Option A):** In PCOS, there is an increased frequency of GnRH pulses, leading to high LH levels and a high LH:FSH ratio (typically >2:1 or 3:1). This stimulates theca cells to produce excess androgens. * **Reversed Estradiol:Estrone Ratio (Option B):** In a normal cycle, Estradiol (E2) is the dominant estrogen. In PCOS, peripheral aromatization of excess androgens in adipose tissue leads to high levels of **Estrone (E1)**. This results in a reversed E2:E1 ratio (E1 > E2). * **Reduced SHBG level (Option C):** Hyperinsulinemia and high androgens suppress the hepatic production of Sex Hormone Binding Globulin (SHBG). Low SHBG increases the fraction of **free (active) testosterone**, worsening hirsutism and acne. **NEET-PG High-Yield Pearls:** * **Rotterdam Criteria (2 of 3):** 1. Hyperandrogenism (clinical/biochemical), 2. Ovulatory dysfunction (Oligo/Anovulation), 3. Polycystic ovaries on ultrasound (≥12 follicles or volume >10cc). * **Gold Standard for Insulin Resistance:** Hyperinsulinemic-euglycemic clamp (though rarely used clinically). * **Key Hormone Change:** Hyperinsulinemia is the primary driver that decreases SHBG and increases 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: Which of the following is an ovarian reserve test?

Follicle-stimulating hormone (FSH). **Explanation:** Ovarian reserve refers to the quantity and quality of the remaining oocytes in the ovaries. Testing is crucial for assessing fertility potential and predicting response to controlled ovarian stimulation. **Why FSH is the Correct Answer:** Day 3 (early follicular phase) **Follicle-stimulating hormone (FSH)** is a classic biochemical marker of ovarian reserve. As the pool of follicles declines with age, the production of Inhibin B and estradiol decreases. This loss of negative feedback causes the pituitary gland to secrete higher levels of FSH to stimulate the remaining follicles. Therefore, an **elevated basal FSH level (>10–12 mIU/mL)** is indicative of diminished ovarian reserve (DOR). **Analysis of Incorrect Options:** * **A. Luteinizing hormone (LH):** While LH is involved in ovulation and androgen production, it is not a primary marker for oocyte quantity. It is more relevant in diagnosing PCOS (LH:FSH ratio) or detecting the mid-cycle surge. * **C. Plasma progesterone:** This is used to confirm that **ovulation** has occurred (measured on Day 21 of a 28-day cycle). It does not reflect the total remaining egg supply. * **D. Endometrial biopsy:** Historically used to diagnose "Luteal Phase Defect" or endometrial dating, it assesses the response of the uterus to hormones, not the ovarian reserve. **High-Yield Clinical Pearls for NEET-PG:** * **Best Marker:** **Anti-Müllerian Hormone (AMH)** is currently considered the most reliable biochemical marker because it is cycle-independent (can be tested any day). * **Best Imaging Marker:** **Antral Follicle Count (AFC)** via transvaginal ultrasound (TVUS) on Day 2–5. * **Clomiphene Citrate Challenge Test (CCCT):** A provocative test where FSH is measured before and after Clomiphene; an exaggerated FSH rise indicates poor reserve. * **Poor Prognosis:** FSH >20 mIU/mL usually suggests a very poor response to IVF.

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: Time of ovulation is detected by all EXCEPT:

Urine FSH. **Explanation:** The detection of ovulation is based on identifying the physiological changes triggered by the hypothalamic-pituitary-ovarian axis. **Why Urine FSH is the correct answer:** While Follicle Stimulating Hormone (FSH) does show a small peak just before ovulation (concomitant with the LH surge), it is **not** used clinically to detect or predict the time of ovulation. FSH levels are primarily used to assess ovarian reserve (Day 3 FSH) or to diagnose menopause. Because the FSH surge is less pronounced and less specific than the LH surge, urine FSH kits do not exist for ovulation monitoring. **Why the other options are incorrect:** * **Urine LH:** This is the "gold standard" for home prediction. The **LH surge** occurs 24–36 hours before ovulation. Detecting the surge in urine is highly predictive of the fertile window. * **Serum Progesterone:** A mid-luteal phase (Day 21) serum progesterone level >3 ng/mL is a reliable retrospective indicator that ovulation has occurred. Progesterone rises immediately after the rupture of the follicle and the formation of the corpus luteum. * **Basal Body Temperature (BBT):** Due to the thermogenic effect of progesterone, there is a slight rise in body temperature (0.5–1.0°F) following ovulation. This creates a **biphasic pattern** on a temperature chart. **Clinical Pearls for NEET-PG:** * **Earliest indicator of ovulation:** The LH surge (starts ~32–36 hours before ovulation). * **Most accurate single-day test for ovulation:** Mid-luteal serum progesterone. * **Best ultrasound method:** Serial Transvaginal Sonography (TVS) showing the disappearance of a mature follicle (Folliculometry). * **Cervical Mucus:** Becomes thin, watery, and shows **"Spinnbarkeit"** (high elasticity) and **ferning** under the influence of peak estrogen just before ovulation.

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).

Question 1

A 30-year-old married female diagnosed with prolactinoma, showing a 5 mm microadenoma on pituitary MRI, is currently taking bromocriptine. Her urine pregnancy test has turned positive. What is the best advice for her?

Accepted Answer

Stop bromocriptine

Answer

Start cabergoline

Answer

Advise trans-sphenoidal surgery anticipating increase in tumor size during pregnancy

Answer

Advise abortion considering the teratogenic potential of bromocriptine

Question 2

All of the following are diagnoses of PCOS except?

Accepted Answer

Reduced serum insulin level

Answer

Elevated LH

Answer

Reversed estradiol:estrone ratio

Answer

Reduced SHBG level

Question 3

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 4

Which side effect of clomiphene necessitates its immediate discontinuation?

Accepted Answer

Visual symptoms

Answer

Hot flashes

Answer

Multiple pregnancy

Answer

Teratogenic effects

Question 5

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 6

Which of the following is an ovarian reserve test?

Accepted Answer

Follicle-stimulating hormone (FSH)

Answer

Luteinizing hormone (LH)

Answer

Plasma progesterone

Answer

Endometrial biopsy

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

Time of ovulation is detected by all EXCEPT:

Accepted Answer

Urine FSH

Answer

Urine LH

Answer

Serum progesterone

Answer

Basal body temperature

Question 9

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 10

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.

Reproductive Endocrinology — MCQs

Reproductive Endocrinology — MCQs

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