Reproductive Endocrinology Practice Questions

Q: What is the most reliable test to confirm ovulation after it has occurred?

Serum progesterone. ***Serum progesterone*** - A **serum progesterone level** of greater than **3 ng/mL (or 10 nmol/L)** in the mid-luteal phase (approximately 7 days after the presumed ovulation) reliably indicates that ovulation has occurred. - After ovulation, the **corpus luteum** forms and produces progesterone, causing a characteristic rise in its serum level. *Serum estrogen* - Estrogen levels **peak before ovulation** to trigger the LH surge and also rise during the luteal phase, but a single measurement is not a reliable indicator that ovulation has successfully occurred. - Estrogen levels can fluctuate due to various factors and do not directly confirm the **formation and function of a corpus luteum** as progesterone does. *Both serum estrogen and progesterone* - While both hormones are involved in the menstrual cycle, relying on both simultaneously for confirming *occurred* ovulation is not the most precise method. - A significant rise in **progesterone** *after* the presumed ovulatory event is the key reliable biomarker. *None of the options* - This option is incorrect because **serum progesterone** is a well-established and reliable test for confirming ovulation.

Q: All are causes of anovulatory amenorrhea except which of the following?

Gonadal dysgenesis. ***Gonadal dysgenesis*** - This condition is a cause of **primary ovarian insufficiency**, leading to amenorrhea but not primarily due to anovulation in a previously cycling individual. - In gonadal dysgenesis, the **ovaries are malformed or absent**, resulting in a lack of follicles and thus no ovulation or estrogen production from the start. *PCOD* - **Polycystic Ovarian Disease** (PCOD/PCOS) is a common cause of anovulatory amenorrhea, characterized by **oligo- or anovulation**, clinical or biochemical hyperandrogenism, and polycystic ovaries on ultrasound. - The hormonal imbalance (e.g., elevated **androgens**, high **LH/FSH ratio**) disrupts normal follicular development and ovulation. *Hyperprolactinemia* - **Elevated prolactin levels** inhibit the pulsatile secretion of **GnRH (Gonadotropin-Releasing Hormone)** from the hypothalamus, which in turn reduces FSH and LH release from the pituitary. - This suppression of gonadotropins leads to impaired follicular development and **anovulation**, resulting in amenorrhea. *Drugs* - Various medications can cause anovulatory amenorrhea by interfering with the **hypothalamic-pituitary-ovarian axis**. - Examples include antipsychotics (which can increase **prolactin levels**), certain antidepressants, opioids, and chemotherapy agents that can damage ovarian function.

Q: 35 yr old with 4 months amenorrhea with increased FSH, decreased estrogen. What is the diagnosis?

Premature ovarian failure. ***Premature ovarian failure*** - The combination of **amenorrhea** for 4 months in a 35-year-old, with **increased FSH** and **decreased estrogen**, is characteristic of premature ovarian failure, indicating the ovaries are no longer responding to FSH stimulation. - This condition signifies the cessation of ovarian function before the age of 40, leading to menopausal symptoms and infertility. *Pituitary dysfunction* - Pituitary dysfunction might lead to **decreased FSH** (hypogonadotropic hypogonadism) due to insufficient stimulation of the ovaries, not increased FSH. - In cases of pituitary adenomas, increased prolactin can cause amenorrhea, but FSH would not be elevated in the manner described. *Hypothalamic dysfunction* - Hypothalamic dysfunction, such as **functional hypothalamic amenorrhea**, typically presents with **low or normal FSH and LH levels** (hypogonadotropic hypogonadism) due to reduced GnRH pulsatility. - This condition is often associated with stress, excessive exercise, or low body weight, and would not cause elevated FSH as seen here. *Polycystic Ovary Syndrome* - **Polycystic Ovary Syndrome (PCOS)** is characterized by **anovulation**, resulting in amenorrhea or oligomenorrhea, but typically involves **elevated androgens** and a **high LH-to-FSH ratio**, with FSH levels generally normal or low, and estrogen levels often normal or slightly elevated. - It would not present with simultaneously high FSH and low estrogen, which points to ovarian failure rather than anovulation with intact ovarian reserve.

Q: Spinnbarkeit is maximum shown at which phase?

Ovulatory. ***Ovulatory*** - **Spinnbarkeit** refers to the stringy, stretchy quality of cervical mucus, which is maximal during the ovulatory phase due to high **estrogen levels**. - This highly elastic mucus facilitates **sperm transport** to the uterus and fallopian tubes for fertilization. *Menstrual phase* - During the menstrual phase, **cervical mucus** is typically minimal and sticky, making it unfavorable for sperm survival. - This phase is characterized by low estrogen and progesterone levels, leading to the **shedding of the uterine lining**. *Post ovulatory* - After ovulation, under the influence of **progesterone**, cervical mucus becomes thick, sticky, and opaque, decreasing **spinnbarkeit**. - This change in mucus consistency forms a **barrier to sperm penetration** into the uterus. *Follicular phase* - In the early follicular phase, **estrogen levels** are low, resulting in thick, scanty, and opaque cervical mucus with low **spinnbarkeit**. - As the follicular phase progresses and estrogen levels rise, the mucus gradually becomes more **watery and elastic**, but it doesn't reach its peak stretchiness until ovulation.

Q: What is the best method to assess endometrial activity?

Endometrial biopsy. ***Biopsy*** - **Endometrial biopsy** provides direct tissue samples, allowing for histological examination of the endometrial glands and stroma to assess their phase (proliferative, secretory) and underlying pathology. - This method is considered the **gold standard** for accurately determining endometrial activity and diagnosing conditions like hyperplasia or carcinoma. *HSG* - **Hysterosalpingography (HSG)** is primarily used to evaluate the patency of the fallopian tubes and the shape of the uterine cavity, not the functional activity of the endometrium itself. - It involves injecting contrast dye and taking X-rays, which helps identify structural abnormalities but does not provide microscopic details of endometrial tissue. *USG* - **Transvaginal ultrasonography (USG)** measures endometrial thickness and identifies gross structural abnormalities like polyps or fibroids. - While it can suggest the endometrial phase based on thickness, it does not offer the definitive cellular-level detail of endometrial activity that a biopsy provides. *Colposcopy* - **Colposcopy** is a procedure used to visualize the cervix and vagina with a magnified view, primarily for detecting and evaluating abnormal cells that may lead to cervical cancer. - It is **not used** for assessing the endometrial lining or its physiological activity.

Q: A 15-year-old female presents with primary amenorrhea. Her breasts are Tanner stage 4, but she has no axillary or pubic hair. What is the most likely diagnosis?

Complete Androgen Insensitivity Syndrome (CAIS). ***Complete Androgen Insensitivity Syndrome (CAIS)*** - Previously known as **Testicular Feminization Syndrome**, this condition presents with **breast development (due to peripheral conversion of androgens to estrogens)** but **absent pubic/axillary hair** due to **androgen receptor insensitivity**. - Affected individuals are **genetically male (46, XY)** but have a female external phenotype and **no uterus**, leading to **primary amenorrhea**. *Turner's syndrome* - Characterized by **gonadal dysgenesis (streak gonads)**, leading to **absent or rudimentary breast development** and **primary amenorrhea**. - Individuals are typically **45, XO** and often present with short stature and characteristic physical features like a webbed neck. *Mullerian agenesis* - Involves the **agenesis or hypoplasia of the Mullerian ducts**, resulting in an **absent or hypoplastic uterus and vagina**. - Patients have **normal breast and pubic/axillary hair development** because their ovaries are functional and produce hormones. *Premature ovarian failure* - Involves the **cessation of ovarian function before age 40**, leading to **menopausal symptoms** and **amenorrhea**. - However, patients would have initially gone through **normal puberty**, including the development of pubic/axillary hair, which is absent in this case.

Q: A 20-year-old average-weight female complains of oligomenorrhea along with facial hair. Preliminary investigation reveals raised free testosterone levels. Which of the following could be a likely etiology?

PCOD. ***PCOD*** - The triad of **oligomenorrhea**, **hirsutism** (facial hair), and **elevated free testosterone** levels is highly suggestive of **Polycystic Ovarian Disease (PCOD)** [1]. - **PCOD** is characterized by **anovulation**, leading to menstrual irregularities, and **hyperandrogenism** which causes hirsutism [1]. *Idiopathic hirsutism* - While idiopathic hirsutism causes **facial hair** and other androgenic symptoms, it is characterized by **normal androgen levels**, which contradicts the elevated free testosterone in this case. - **Oligomenorrhea** is not a typical feature of idiopathic hirsutism. *Adrenal hyperplasia* - **Adrenal hyperplasia**, particularly **Congenital Adrenal Hyperplasia (CAH)**, can cause hyperandrogenism and menstrual irregularities due to **enzymatic defects** in adrenal steroidogenesis. - However, it typically presents with **markedly elevated 17-hydroxyprogesterone** levels, which are not mentioned here, and often has an earlier onset or more severe virilization. *Testosterone secreting tumour* - A **testosterone-secreting tumor** (e.g., of the ovary or adrenal gland) would cause **sudden-onset**, rapid progression of **severe hirsutism** and **virilization**, often with **very high testosterone levels** [1]. - The gradual onset implied by "complains of" and the average weight of the patient make a tumor less likely than PCOD, though it would need to be ruled out if testosterone levels were extremely high [1].

Q: What does the cornification index indicate in the context of vaginal epithelium?

Estrogenic effect. ***Estrogenic effect*** - The **cornification index** measures the percentage of **superficial cornified squamous cells** in a vaginal smear. - These superficial cells undergo cornification specifically due to **estrogen stimulation**. - A **higher cornification index** indicates greater estrogenic activity on the vaginal epithelium. - This is a key cytological marker used to assess **estrogenic status** in clinical practice. *Progesterone effect* - Progesterone causes **intermediate and parabasal cells** to predominate, not superficial cornified cells. - It results in a **lower cornification index** with folded intermediate cells and increased cellular exfoliation. - The maturation index shifts leftward under progesterone influence. *Effect of LH* - **Luteinizing hormone (LH)** acts on the ovary to trigger ovulation and corpus luteum formation. - LH has **no direct effect** on vaginal epithelial cornification. - The cornification index reflects hormonal effects at the tissue level, not pituitary gonadotropins. *Effect of FSH* - **Follicle-stimulating hormone (FSH)** stimulates ovarian follicle development and estrogen synthesis. - While FSH promotes estrogen production indirectly, the cornification index specifically measures the **direct estrogenic effect** on vaginal cells, not FSH levels. - FSH itself does not cause epithelial cornification.

Question 1

What is the most reliable test to confirm ovulation after it has occurred?

Accepted Answer

Serum progesterone

Answer

Serum estrogen

Answer

Both serum estrogen and progesterone

Answer

None of the options

Question 2

All are causes of anovulatory amenorrhea except which of the following?

Accepted Answer

Gonadal dysgenesis

Answer

Hyperprolactinemia

Answer

Drugs

Answer

PCOD

Question 3

35 yr old with 4 months amenorrhea with increased FSH, decreased estrogen. What is the diagnosis?

Accepted Answer

Premature ovarian failure

Answer

Pituitary dysfunction

Answer

Hypothalamic dysfunction

Answer

Polycystic Ovary Syndrome

Question 4

Spinnbarkeit is maximum shown at which phase?

Accepted Answer

Ovulatory

Answer

Menstrual phase

Answer

Post ovulatory

Answer

Follicular phase

Question 5

What is the best method to assess endometrial activity?

Accepted Answer

Endometrial biopsy

Answer

HSG

Answer

USG

Answer

Colposcopy

Question 6

In an amenorrheic patient who has had pituitary ablation for a craniopharyngioma, which of the following regimens is most likely to result in an ovulatory cycle?

Accepted Answer

Human menopausal or recombinant gonadotropin, followed by hCG

Answer

Continuous infusion of GnRH

Answer

Letrozole

Answer

Clomiphene citrate

Question 7

A 15-year-old female presents with primary amenorrhea. Her breasts are Tanner stage 4, but she has no axillary or pubic hair. What is the most likely diagnosis?

Accepted Answer

Complete Androgen Insensitivity Syndrome (CAIS)

Answer

Turner's syndrome

Answer

Premature ovarian failure

Answer

Mullerian agenesis

Question 8

A 20-year-old average-weight female complains of oligomenorrhea along with facial hair. Preliminary investigation reveals raised free testosterone levels. Which of the following could be a likely etiology?

Accepted Answer

PCOD

Answer

Testosterone secreting tumour

Answer

Adrenal hyperplasia

Answer

Idiopathic hirsutism

Question 9

Which of the following statements is true regarding Stein-Leventhal syndrome?

Accepted Answer

It is associated with enlarged ovaries and multiple follicular cysts.

Answer

It is only characterized by oligomenorrhea and amenorrhea.

Answer

It is only characterized by amenorrhea.

Answer

It does not involve ovarian cysts.

Question 10

What does the cornification index indicate in the context of vaginal epithelium?

Accepted Answer

Estrogenic effect

Answer

Progesterone effect

Answer

Effect of LH

Answer

Effect of FSH

Reproductive Endocrinology — MCQs

Reproductive Endocrinology — MCQs

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