Reproductive Endocrinology — MCQs

Reproductive Endocrinology Indian Medical PG Practice Questions and MCQs

Question 51: The Ferriman-Gallwey scoring system is used to quantify which of the following?

A. Hypertrichosis
B. Galactorrhea
C. Hirsutism (Correct Answer)
D. Virilization

Explanation: 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 52: What is the earliest morphological evidence of ovulation on endometrial biopsy?

A. Pseudostratification
B. Basal vacuolation (Correct Answer)
C. Decrease in glycogen content
D. Predecidual reaction

Explanation: **Explanation:** The correct answer is **Basal vacuolation**. **1. Why Basal Vacuolation is Correct:** Ovulation marks the transition from the follicular phase to the luteal phase. Following ovulation, the corpus luteum produces **progesterone**, which induces secretory changes in the endometrium. The earliest histological sign of this progesterone effect is the appearance of **subnuclear (basal) vacuoles** containing glycogen within the glandular epithelium. This occurs approximately **36 to 48 hours after ovulation** (Day 16 of a classic 28-day cycle). **2. Analysis of Incorrect Options:** * **A. Pseudostratification:** This is a feature of the **proliferative phase** (estrogen-dominant). Under the influence of estrogen, nuclei are crowded and appear layered; this disappears once progesterone induces secretory activity. * **C. Decrease in glycogen content:** This is incorrect because glycogen content actually **increases** during the secretory phase to prepare for potential embryo implantation. * **D. Predecidual reaction:** This refers to the enlargement of stromal cells around spiral arterioles. It is a **late secretory phase** change, typically occurring around Day 23–25 of the cycle. **3. NEET-PG High-Yield Pearls:** * **Dating the Endometrium:** The standard criteria used for histological dating is the **Noyes Criteria**. * **Best time for biopsy:** To confirm ovulation, the biopsy is ideally performed on **Day 21–23** (mid-luteal phase) to observe maximal secretory changes. * **Spiral Arterioles:** These become prominent and coiled under progesterone influence, reaching their peak development just before menstruation. * **Summary Sequence:** Basal vacuoles (Day 16) → Luminal secretion (Day 19) → Stromal edema (Day 21) → Predecidual change (Day 24).

Question 53: All of the following assist in predicting ovulation except:

A. Basal body temperature
B. Cervical mucus
C. Serum progesterone in follicular phase (Correct Answer)
D. Endometrial biopsy

Explanation: To predict or confirm ovulation, we look for physiological changes driven by the shift from estrogen dominance to progesterone dominance. **Explanation of the Correct Answer:** **Option C (Serum progesterone in follicular phase)** is the correct answer because progesterone levels are **low (<1 ng/mL)** during the follicular phase. Progesterone only begins to rise significantly *after* the LH surge and peaks during the mid-luteal phase (day 21). Therefore, measuring it during the follicular phase has no predictive value for ovulation. To confirm ovulation, serum progesterone must be measured in the **mid-luteal phase**; a value >3 ng/mL suggests ovulation has occurred. **Analysis of Other Options:** * **Basal Body Temperature (BBT):** Progesterone is thermogenic. A rise of 0.4°F to 1.0°F (biphasic pattern) occurs *after* ovulation. While it confirms ovulation retrospectively, monitoring the chart helps predict future cycles. * **Cervical Mucus:** Under estrogen influence (pre-ovulatory), mucus becomes thin, profuse, watery, and shows **spinnbarkeit** (stretchability) and **ferning**. These changes peak just before ovulation (the "peak mucus day"). * **Endometrial Biopsy:** Historically used to confirm ovulation by identifying a **secretory endometrium** (due to progesterone). If performed on Day 21-23, it confirms that ovulation has already taken place. **NEET-PG High-Yield Pearls:** * **Gold Standard for timing ovulation:** Serial Transvaginal Ultrasound (TVS) to monitor follicular size (disappearance of follicle/collapse). * **Best biochemical predictor:** Urinary LH surge (ovulation occurs 24–36 hours after the surge). * **Spinnbarkeit Effect:** Maximum stretchability (10–12 cm) occurs at ovulation. * **Mittelschmerz sign:** Pelvic pain experienced mid-cycle due to follicular rupture.

Question 54: All of the following are true regarding folliculogenesis and ovulation EXCEPT?

A. Follicular development and differentiation takes about 85 days.
B. AMH supports monofollicular development.
C. The first phase of follicular growth is gonadotropin insensitive.
D. Elevated and static levels of estradiol are essential for ovulation. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D**. To trigger the mid-cycle LH surge (and subsequent ovulation), estradiol levels must be **elevated and rising**, not static. Specifically, estradiol must reach a threshold of >200 pg/mL for at least 48 hours to exert **positive feedback** on the pituitary and hypothalamus. Static levels, even if high, would fail to trigger the surge. **Analysis of Options:** * **A. Follicular development takes about 85 days:** This is **true**. Folliculogenesis is a long process. It takes approximately 3 months (85-90 days) for a primordial follicle to reach the pre-ovulatory (Graafian) stage. The final "recruitment" seen in a menstrual cycle is only the last 14 days of this journey. * **B. AMH supports monofollicular development:** This is **true**. Anti-Müllerian Hormone (AMH) is produced by granulosa cells of pre-antral follicles. It acts as a "brake," inhibiting excessive recruitment of primordial follicles and decreasing the sensitivity of follicles to FSH, thereby ensuring only the dominant follicle matures. * **C. First phase is gonadotropin insensitive:** This is **true**. The initial stages (primordial to primary and secondary follicles) are **gonadotropin-independent**. FSH is only required for the later stages of antral follicle growth and selection. **High-Yield Clinical Pearls for NEET-PG:** * **LH Surge:** Occurs 32–36 hours before ovulation. * **Meiosis I:** Completion of the first meiotic division occurs just before ovulation, triggered by the LH surge, resulting in the first polar body. * **Stigma:** The site on the ovarian surface where rupture occurs. * **AMH:** Best marker for ovarian reserve as its levels remain constant throughout the menstrual cycle.

Question 55: In women with Polycystic Ovarian Disease (PCOD) and irregular menstrual cycles, what is the effect of combined oral contraceptive pills?

A. Increase sex hormone-binding globulin (Correct Answer)
B. Cause endometrial hyperplasia
C. Increase luteinizing hormone
D. Increase insulin

Explanation: **Explanation:** Combined Oral Contraceptive Pills (COCPs) are the first-line management for menstrual irregularities and hirsutism in PCOD. The primary mechanism involves the **estrogen component (Ethinyl Estradiol)**, which stimulates the liver to **increase the production of Sex Hormone-Binding Globulin (SHBG)**. Increased SHBG levels lead to a higher binding capacity for circulating androgens, thereby **decreasing the levels of Free Testosterone**. This reduction in free androgens is the key mechanism by which COCPs improve clinical symptoms like acne and hirsutism. **Analysis of Incorrect Options:** * **B. Cause endometrial hyperplasia:** COCPs actually **protect** against endometrial hyperplasia. In PCOD, "unopposed estrogen" causes the lining to thicken; the progestogen in COCPs antagonizes this effect, inducing regular withdrawal bleeds and reducing the risk of endometrial carcinoma. * **C. Increase luteinizing hormone:** COCPs exert negative feedback on the pituitary, **decreasing LH and FSH** secretion. This suppresses ovarian androgen production. * **D. Increase insulin:** COCPs do not increase insulin; in fact, some older formulations may slightly worsen insulin resistance, though low-dose pills are generally considered metabolic-neutral. **NEET-PG High-Yield Pearls:** * **DOC for Hirsutism in PCOD:** COCPs (specifically those containing anti-androgenic progestins like Cyproterone acetate or Drospirenone). * **Rotterdam Criteria:** Diagnosis requires 2 out of 3: Oligo/anovulation, Clinical/Biochemical hyperandrogenism, and Polycystic ovaries on USG. * **LH:FSH Ratio:** Classically >2:1 or 3:1 (though no longer a primary diagnostic criterion).

Question 56: Hirsutism is seen in all of the following conditions EXCEPT:

A. Stein leventhal syndrome
B. Cushing syndrome
C. Testicular feminizing syndrome (Correct Answer)
D. Congenital adrenal hyperplasia

Explanation: **Explanation:** The core concept in this question is the requirement of **androgen receptors** for the manifestation of hirsutism. Hirsutism is defined as the presence of terminal hair in females in a male-pattern distribution, driven by excess androgens acting on sensitive hair follicles. **Why Option C is correct:** **Testicular Feminizing Syndrome (Complete Androgen Insensitivity Syndrome - CAIS)** is characterized by a 46,XY karyotype with a mutation in the androgen receptor gene. Although these individuals have high levels of circulating testosterone (produced by undescended testes), their end-organ receptors are completely non-functional. Without functioning receptors, androgens cannot stimulate hair follicles; consequently, these patients typically have **absent or scanty pubic and axillary hair** and no hirsutism. **Why the other options are incorrect:** * **A. Stein-Leventhal Syndrome (PCOS):** The most common cause of hirsutism. It involves hyperandrogenism due to increased LH stimulation of ovarian theca cells. * **B. Cushing Syndrome:** Excess ACTH or cortisol leads to increased production of adrenal androgens (like DHEAS), resulting in hirsutism. * **D. Congenital Adrenal Hyperplasia (CAH):** Specifically the 21-hydroxylase deficiency form, where a "shunting" of precursors occurs, leading to massive overproduction of adrenal androgens. **NEET-PG High-Yield Pearls:** * **Ferriman-Gallwey Score:** Used to quantify hirsutism (Score ≥8 is significant in Indians). * **CAIS Clinical Triad:** Primary amenorrhea, 46,XY karyotype, and a blind-ending vagina with absent uterus/ovaries. * **Drug-induced Hirsutism:** Phenytoin, Cyclosporine, and Minoxidil (though these often cause generalized hypertrichosis rather than patterned hirsutism). * **Rapid onset hirsutism** with virilization should always raise suspicion of an androgen-secreting tumor (Ovarian or Adrenal).

Question 57: Which of the following tests is NOT helpful in determining the occurrence of ovulation in a woman?

A. Ultrasound (USG)
B. Progesterone levels
C. Basal body temperature changes
D. Estradiol levels (Correct Answer)

Explanation: **Explanation:** The determination of ovulation relies on identifying physiological changes triggered by the **luteal phase** (post-ovulatory) or the physical disappearance of a follicle. **Why Estradiol (D) is the correct answer:** Estradiol levels peak *before* ovulation to trigger the LH surge and remain elevated during the luteal phase. However, a high estradiol level only indicates follicular maturity; it does not guarantee that the follicle has ruptured. Because estradiol fluctuates throughout the cycle and does not provide definitive proof of follicle release, it is not a reliable marker for confirming that ovulation has actually occurred. **Analysis of Incorrect Options:** * **Ultrasound (USG):** Serial transvaginal scans (Follicular monitoring) are the gold standard. Ovulation is confirmed by the sudden disappearance of a mature follicle, the appearance of internal echoes (corpus luteum formation), or free fluid in the Pouch of Douglas. * **Progesterone levels:** Progesterone is secreted by the corpus luteum *after* ovulation. A mid-luteal phase (Day 21) serum progesterone level **>3 ng/mL** is a reliable indicator that ovulation has taken place. * **Basal Body Temperature (BBT):** Progesterone has a thermogenic effect on the hypothalamus. A rise in BBT by 0.4–1.0°F in the second half of the cycle (biphasic curve) indicates ovulation. **NEET-PG High-Yield Pearls:** * **Best time for Progesterone test:** Day 21 of a 28-day cycle (Mid-luteal phase). * **Best indicator of "Imminent" Ovulation:** LH Surge (detected in urine or blood). * **Gold Standard for Ovulation:** Ultrasound or Pregnancy. * **Endometrial Biopsy:** If performed, a "secretory endometrium" confirms ovulation (historically important, now rarely used for this purpose).

Question 58: A 19-year-old patient presents with primary amenorrhea. She has well-developed breasts and axillary and pubic hair. The uterus and vagina are absent. What is the most likely diagnosis?

A. XYY syndrome
B. Gonadal dysgenesis
C. Mullerian agenesis (Correct Answer)
D. Klinefelter's syndrome

Explanation: **Explanation:** The clinical presentation of **primary amenorrhea** in a patient with **well-developed secondary sexual characteristics** (breasts and pubic hair) but an **absent uterus and vagina** is the classic hallmark of **Mullerian Agenesis** (Mayer-Rokitansky-Küster-Hauser or MRKH syndrome). **1. Why Mullerian Agenesis is Correct:** * **Breast Development:** Indicates a functional Hypothalamic-Pituitary-Ovarian (HPO) axis. The ovaries are derived from the genital ridge (not the Mullerian ducts), so they function normally, producing estrogen for breast development. * **Pubic/Axillary Hair:** Indicates normal adrenal/ovarian androgen production and functional androgen receptors. * **Absent Uterus/Vagina:** The Mullerian ducts fail to develop, leading to the absence of the fallopian tubes, uterus, and upper 2/3rd of the vagina. * **Karyotype:** 46, XX. **2. Why Other Options are Incorrect:** * **XYY Syndrome:** These individuals are phenotypically male, usually tall, and do not present with primary amenorrhea. * **Gonadal Dysgenesis (e.g., Turner Syndrome):** Patients typically have "streak ovaries," leading to estrogen deficiency. This results in **absent breast development** and elevated gonadotropins (Hypergonadotropic hypogonadism). * **Klinefelter’s Syndrome (47, XXY):** These are phenotypic males with small testes, gynecomastia, and infertility; they do not present with a female phenotype or primary amenorrhea. **Clinical Pearls for NEET-PG:** * **Differential Diagnosis:** Always differentiate MRKH from **Androgen Insensitivity Syndrome (AIS)**. In AIS (46, XY), there is **absent/scanty** pubic and axillary hair due to androgen resistance. * **Associated Anomalies:** 30-40% of MRKH patients have **renal anomalies** (e.g., renal agenesis, ectopic kidney). Always order a Renal Ultrasound. * **Ovaries:** In MRKH, ovaries are normal and located intra-abdominally; ovulation occurs normally.

Question 59: A patient presents with a 46, XY chromosomal pattern, presence of a uterus and cervix, but poorly developed breasts. What is the most likely diagnosis?

A. Swyer syndrome (Correct Answer)
B. Turner syndrome
C. Androgen insensitivity syndrome
D. Klinefelter syndrome

Explanation: **Explanation:** The key to solving this question lies in the discordance between the genotype (**46, XY**) and the internal anatomy (**presence of uterus/cervix**). **1. Why Swyer Syndrome is Correct:** Swyer syndrome (Pure Gonadal Dysgenesis) is caused by a mutation in the **SRY gene** or other genes involved in testis determination. Because the testes fail to develop (forming "streak gonads"), there is **no production of Anti-Müllerian Hormone (AMH)** or testosterone. In the absence of AMH, the Müllerian ducts do not regress, leading to the development of a **uterus, cervix, and fallopian tubes**. Since there is no estrogen production from the streak gonads, the patient presents with primary amenorrhea and **poorly developed breasts** (delayed puberty). **2. Why the other options are incorrect:** * **Turner Syndrome (45, XO):** While these patients have streak gonads and a uterus, their genotype is 45, XO, not 46, XY. * **Androgen Insensitivity Syndrome (AIS):** These patients are 46, XY, but they have functioning testes that produce AMH. Therefore, the **uterus and cervix are absent**. They typically have well-developed breasts due to the peripheral conversion of testosterone to estrogen. * **Klinefelter Syndrome (47, XXY):** These patients have a male phenotype with small testes and gynecomastia, not a female phenotype with a uterus. **High-Yield Clinical Pearls for NEET-PG:** * **Müllerian Structures:** Present in Swyer and Turner; Absent in AIS and MRKH syndrome. * **Gonadectomy:** In Swyer syndrome, there is a high risk (approx. 25-30%) of developing **Gonadoblastoma**; therefore, prophylactic gonadectomy is indicated as soon as the diagnosis is made. * **Height:** Patients with Swyer syndrome are typically of normal or tall stature (unlike the short stature in Turner syndrome).

Question 60: Primary amenorrhea with absent uterus, normal breasts, and scanty pubic hair is seen in which condition?

A. Mayer Rokitansky Kuster Hauser Syndrome
B. Turner Syndrome
C. Noonan Syndrome
D. Testicular feminizing syndrome (Correct Answer)

Explanation: **Explanation:** The clinical presentation described—**Primary amenorrhea, absent uterus, normal breasts, and scanty pubic hair**—is the classic triad for **Testicular Feminizing Syndrome (Androgen Insensitivity Syndrome - AIS).** **Why Option D is correct:** In AIS, the individual has a **46, XY** karyotype. Due to a defect in androgen receptors, the body is unresponsive to testosterone. 1. **Absent Uterus:** Testes are present (intra-abdominal) and produce **Anti-Müllerian Hormone (AMH)**, which causes regression of the Müllerian ducts (uterus, tubes, upper vagina). 2. **Normal Breasts:** High levels of testosterone are peripherally converted to estrogen, leading to breast development (Thelarche). 3. **Scanty Pubic Hair:** Since pubic and axillary hair growth is androgen-dependent, the receptor insensitivity results in sparse or absent hair. **Why other options are incorrect:** * **A. MRKH Syndrome:** Also presents with primary amenorrhea and absent uterus (46, XX). However, since androgen sensitivity is normal, these patients have **normal pubic and axillary hair**. * **B. Turner Syndrome (45, XO):** Characterized by "streak ovaries," leading to estrogen deficiency. This results in **absent breast development** and short stature. The uterus is present but prepubertal. * **C. Noonan Syndrome:** Often called "Male Turner's," it presents with similar features to Turner (webbed neck, short stature) but usually has normal pubertal development and a present uterus. **High-Yield Clinical Pearls for NEET-PG:** * **Karyotype:** AIS is 46, XY; MRKH is 46, XX. * **Gonads:** In AIS, testes are present (risk of gonadoblastoma; require gonadectomy post-puberty). In MRKH, ovaries are normal and functional. * **Vagina:** Both conditions present with a short, blind-ending vaginal pouch. * **Testosterone levels:** In AIS, testosterone levels are in the **normal male range**, which is a key diagnostic differentiator from other forms of primary amenorrhea.

Practice by Chapter

Hypothalamic-Pituitary-Ovarian Axis

Practice Questions

Disorders of Puberty

Practice Questions

Hirsutism and Virilization

Practice Questions

Primary Ovarian Insufficiency

Practice Questions

Hyperprolactinemia

Practice Questions

Hyperandrogenism

Practice Questions

Metabolic Dysfunction in PCOS

Practice Questions

Neuroendocrine Disorders and Reproduction

Practice Questions

Hormonal Evaluation and Testing

Practice Questions

Ovulation Induction

Practice Questions

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