Primary Ovarian Insufficiency — MCQs
Which of the following is the platinum-based chemotherapeutic agent used as first-line treatment for ovarian carcinoma?
A patient has dyspareunia, and dysmenorrhea with adnexal tenderness. What is the first step of investigation?
Which hormone is known to be elevated in Polycystic Ovary Syndrome (PCOS)?
Which serum level is increased in premature ovarian failure?
A 35-year-old woman presents with 4 months of amenorrhea, increased FSH, LH, and decreased estrogen. What is the most likely diagnosis?
A 21-year-old woman presents with complaints of primary amenorrhea. Her height is 153 cm, and her weight is 51 kg. She has well-developed breasts. She has no pubic or axillary hair and no hirsutism. Which of the following is the most probable diagnosis?
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?
A 16-year-old female presents with primary amenorrhea and raised FSH. On examination, her height was 58 inches. What would be the histopathological finding in the ovary?
In Stein-Leventhal syndrome, which hormone is raised?
A 17-year-old girl is seen for primary amenorrhea. There is no development of breasts or hair in the pubic or axillary region. Her height is 155 cm, and her weight is 48 kg. She has bilateral inguinal masses. The uterus, fallopian tube, and Ovary are absent on ultrasound examination. What is the most likely diagnosis?
Primary Ovarian Insufficiency Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is the platinum-based chemotherapeutic agent used as first-line treatment for ovarian carcinoma?
- A. Cyclophosphamide
- B. Methotrexate
- C. Cisplatin (Correct Answer)
- D. Dacarbazine
Explanation: ***Cisplatin*** - **Cisplatin** is a platinum-based chemotherapy drug that forms **DNA cross-links**, inhibiting DNA synthesis and leading to the death of rapidly dividing cells, making it highly effective against **ovarian carcinoma**. - It is a cornerstone of chemotherapy regimens for ovarian cancer, often used in combination with other agents such as paclitaxel. *Methotrexate* - **Methotrexate** is an **antimetabolite** that inhibits dihydrofolate reductase, thereby interfering with DNA synthesis. - While it is used in various cancers like leukemia, lymphoma, and some solid tumors (e.g., breast cancer, gestational trophoblastic disease), it is **not a primary recommended drug for ovarian carcinoma**. *Cyclophosphamide* - **Cyclophosphamide** is an **alkylating agent** that causes DNA damage, leading to cell death. - It is used in many cancers, including lymphoma, breast cancer, and some leukemias, but it is **not a first-line or primary agent for ovarian carcinoma** in contemporary treatment guidelines. *Dacarbazine* - **Dacarbazine** is an **alkylating agent** primarily used in the treatment of **malignant melanoma** and Hodgkin lymphoma. - It is **not indicated for the treatment of ovarian carcinoma**.
Question 2: A patient has dyspareunia, and dysmenorrhea with adnexal tenderness. What is the first step of investigation?
- A. Colposcopy
- B. Diagnostic laparoscopy
- C. Transvaginal USG (Correct Answer)
- D. Transabdominal pelvic ultrasound
Explanation: ***Transvaginal USG*** - This is the **first-line investigation** for evaluating pelvic pain, dyspareunia, dysmenorrhea, and adnexal tenderness due to its ability to provide **high-resolution images** of the uterus, ovaries, and surrounding structures to identify potential pathology like **endometriomas** or other adnexal masses. - It allows for detailed assessment of **ovarian cysts**, fibroids, and other pelvic abnormalities, which can explain the patient's symptoms. *Colposcopy* - This procedure is primarily used to closely examine the **cervix, vagina, and vulva** for abnormal cells, often following an abnormal Pap test. - It is not the initial step for investigating generalized pelvic pain, dyspareunia, or adnexal tenderness. *Diagnostic laparoscopy* - While a **diagnostic laparoscopy** can provide a definitive diagnosis for conditions like **endometriosis**, it is an **invasive surgical procedure** and typically reserved for cases where non-invasive imaging, such as transvaginal ultrasound, has not yielded a clear diagnosis or when conservative management has failed. - It is not considered the first-step investigation due to its **invasive nature** and associated risks. *Transabdominal pelvic ultrasound* - A **transabdominal pelvic ultrasound** provides a broader view of the pelvic organs but often has **lower resolution** and is less accurate for detailed assessment of the uterus, ovaries, and adnexa compared to transvaginal ultrasound, especially in obese patients. - It is often used if a transvaginal ultrasound is not feasible or for assessing larger pelvic masses, but the **transvaginal approach** is superior for detailed evaluation of the female reproductive organs.
Question 3: Which hormone is known to be elevated in Polycystic Ovary Syndrome (PCOS)?
- A. FSH
- B. Estrogen
- C. TSH
- D. Luteinizing Hormone (LH) (Correct Answer)
Explanation: ***Luteinizing Hormone (LH)*** - In **Polycystic Ovary Syndrome (PCOS)**, there is often an elevated **Luteinizing Hormone (LH)** level, leading to an increased **LH:FSH ratio**. - This high LH level contributes to **increased androgen production** by the ovaries, a key feature of PCOS. *FSH* - **Follicle-stimulating hormone (FSH)** levels are typically normal or even low in PCOS, contributing to the **imbalance with LH**. - This relative deficiency of FSH impairs proper **follicle maturation**, leading to anovulation and cyst formation. *Estrogen* - While **estrogen** levels can be normal or slightly elevated due to peripheral conversion of androgens, they are not primarily responsible for the characteristic hormonal imbalance in PCOS. - The elevated **androgens** in PCOS are converted to estrogen in adipose tissue, but this is a secondary effect. *TSH* - **Thyroid-stimulating hormone (TSH)** is involved in thyroid function and is generally unrelated to the **pathophysiology of PCOS**, although thyroid disorders can co-exist with PCOS. - Elevated TSH suggests **hypothyroidism**, a distinct endocrine condition that would present with different symptoms.
Question 4: Which serum level is increased in premature ovarian failure?
- A. Serum Inhibin
- B. Serum FSH (Correct Answer)
- C. Serum Estradiol
- D. Serum Progesterone
Explanation: ***Serum FSH*** - In **premature ovarian failure**, the ovaries fail to produce sufficient estrogen and inhibin, leading to a loss of negative feedback on the pituitary gland. - This lack of negative feedback results in continuously **elevated levels of FSH** as the pituitary tries to stimulate the non-responsive ovaries. *Serum Inhibin* - **Inhibin** is a hormone produced by ovarian granulosa cells, which normally inhibits FSH secretion. - In premature ovarian failure, due to ovarian dysfunction, **inhibin levels are typically decreased**, not increased. *Serum Estradiol* - **Estradiol** is the primary estrogen produced by the ovaries. - In premature ovarian failure, the ovaries are failing, resulting in **decreased production of estrogen/estradiol**. *Serum Progesterone* - **Progesterone** is primarily produced after ovulation by the corpus luteum. - In premature ovarian failure, ovulation is impaired or absent, leading to **low or undetectable progesterone levels**.
Question 5: A 35-year-old woman presents with 4 months of amenorrhea, increased FSH, LH, and decreased estrogen. What is the most likely diagnosis?
- A. Premature ovarian insufficiency (Correct Answer)
- B. Menopause
- C. Late menopause
- D. Perimenopause
Explanation: ***Premature ovarian insufficiency (POI)*** - The patient's age (35 years) combined with 4 months of **amenorrhea**, increased **FSH** and **LH**, and decreased **estrogen** is characteristic of premature ovarian insufficiency (also called premature ovarian failure). - The hormonal profile (**hypergonadotropic hypogonadism**) indicates ovarian failure occurring before the age of **40 years**, which defines POI. - POI affects approximately **1% of women under 40** and can present with amenorrhea, infertility, and symptoms of estrogen deficiency. *Menopause* - Menopause is diagnosed after **12 consecutive months of amenorrhea** in a woman, typically occurring around age **51 years** (natural menopause). - While the hormonal profile of elevated FSH/LH and low estrogen is consistent with menopause, the patient's **age of 35 years** and **only 4 months of amenorrhea** do not meet the criteria for natural menopause. *Late menopause* - Late menopause refers to menopause occurring at a later age than average, typically after age **55 years**. - This diagnosis is completely inconsistent with the patient's age of 35 years. *Perimenopause* - Perimenopause is the transitional phase leading up to menopause, characterized by **irregular menstrual cycles** and **fluctuating hormone levels**. - While FSH levels may be elevated at times, perimenopause typically shows **variable hormone levels** rather than the sustained pattern of high FSH/LH with low estrogen seen in this case. - The **sustained amenorrhea** and pronounced hormonal shifts indicate ovarian failure (POI) rather than perimenopausal transition.
Question 6: A 21-year-old woman presents with complaints of primary amenorrhea. Her height is 153 cm, and her weight is 51 kg. She has well-developed breasts. She has no pubic or axillary hair and no hirsutism. Which of the following is the most probable diagnosis?
- A. Turner's syndrome
- B. Stein-Leventhal syndrome
- C. Premature ovarian failure
- D. Complete androgen insensitivity syndrome (Correct Answer)
Explanation: ***Complete androgen insensitivity syndrome*** - This syndrome presents with **primary amenorrhea**, **well-developed breasts**, and **absent pubic/axillary hair** due to the inability of androgen receptors to respond to testosterone. - Patients are typically **genetically male** (XY) but phenotypically female, with undescended testes and a blind-ending vagina. *Turner's syndrome* - Characterized by **short stature**, a **webbed neck**, and **ovarian dysgenesis**, leading to absent breast development and amenorrhea. - Lacks the feature of well-developed breasts noted in the patient. *Stein-Leventhal syndrome* - Also known as **Polycystic Ovary Syndrome (PCOS)**, this typically presents with secondary amenorrhea or oligomenorrhea, **hirsutism**, acne, and obesity. - The patient's lack of hirsutism and primary amenorrhea make PCOS less likely. *Premature ovarian failure* - Involves the **cessation of ovarian function before age 40**, leading to primary or secondary amenorrhea. - Patients typically present with symptoms of **estrogen deficiency**, including poor breast development, which contradicts the well-developed breasts in this case.
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?
- A. Turner's syndrome
- B. Complete Androgen Insensitivity Syndrome (CAIS) (Correct Answer)
- C. Premature ovarian failure
- D. Mullerian agenesis
Explanation: ***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.
Question 8: A 16-year-old female presents with primary amenorrhea and raised FSH. On examination, her height was 58 inches. What would be the histopathological finding in the ovary?
- A. Hemorrhagic Corpus Luteum
- B. Mucinous cystadenoma
- C. Absence of oocytes in the ovaries (streak ovaries) (Correct Answer)
- D. Psammoma bodies
Explanation: ***Absence of oocytes in the ovaries (streak ovaries)*** - The presentation of **primary amenorrhea** with **raised FSH** and short stature strongly suggests **Turner syndrome (45, XO)**. - In Turner syndrome, the ovaries typically fail to develop properly, resulting in **streak gonads** that lack functional oocytes and follicular structures. *Hemorrhagic Corpus Luteum* - A hemorrhagic corpus luteum is a normal physiological finding in a cycling ovary, usually associated with menstruation or early pregnancy. - It is inconsistent with primary amenorrhea and elevated FSH, which indicates ovarian failure rather than ovulation. *Mucinous cystadenoma* - A mucinous cystadenoma is a benign ovarian neoplasm that would typically present as an ovarian mass, potentially causing symptoms like abdominal pain or bloating. - It does not explain primary amenorrhea or elevated FSH, which reflect a lack of ovarian function, not a structural tumor. *Psammoma bodies* - **Psammoma bodies** are concentric calcifications found in various tumors, most notably **serous ovarian carcinomas** and papillary thyroid carcinoma. - Their presence would indicate a malignant or benign epithelial tumor, which is not suggested by the clinical picture of primary amenorrhea and ovarian failure.
Question 9: In Stein-Leventhal syndrome, which hormone is raised?
- A. LH (Correct Answer)
- B. FSH
- C. GnRH
- D. Progesterone
Explanation: ***LH*** - In **Stein-Leventhal syndrome** (Polycystic Ovary Syndrome, PCOS), there is an elevated **LH (Luteinizing Hormone)** level. - This high LH-to-FSH ratio contributes to increased **androgen production** by the ovarian theca cells, leading to symptoms like hirsutism and anovulation. *FSH* - **FSH (Follicle-Stimulating Hormone)** levels are typically normal or even low in PCOS, contributing to the elevated LH:FSH ratio. - Low FSH levels impair proper follicle maturation, leading to **anovulation** and the characteristic polycystic appearance of the ovaries. *GnRH* - **GnRH (Gonadotropin-Releasing Hormone)** secretion can be altered in PCOS, often showing increased pulse frequency, which preferentially stimulates LH release over FSH. - However, **GnRH levels themselves are not directly measured** as "raised" in the clinical diagnostic criteria for PCOS. *Progesterone* - **Progesterone** levels are often low or absent in PCOS, particularly in the luteal phase, due to **anovulation**. - The lack of regular ovulation means no corpus luteum forms, which is responsible for progesterone production after ovulation.
Question 10: A 17-year-old girl is seen for primary amenorrhea. There is no development of breasts or hair in the pubic or axillary region. Her height is 155 cm, and her weight is 48 kg. She has bilateral inguinal masses. The uterus, fallopian tube, and Ovary are absent on ultrasound examination. What is the most likely diagnosis?
- A. Turner syndrome
- B. Polycystic ovary syndrome
- C. Hypergonadotropic hypogonadism
- D. Complete androgen insensitivity syndrome (Correct Answer)
Explanation: ***Complete androgen insensitivity syndrome*** - This syndrome presents with **primary amenorrhea**, **absent secondary sexual characteristics** (no breast or pubic/axillary hair development), and **inguinal masses** representing undescended testes. - Despite being genetically male (XY), individuals with complete androgen insensitivity develop a female external phenotype due to the **inability of target tissues to respond to androgens**, while Müllerian inhibiting factor from the testes causes the absence of a uterus and fallopian tubes. *Turner syndrome* - Characterized by **short stature** and primary amenorrhea, but typically involves **gonadal dysgenesis** (streaky ovaries), leading to the absence of ovarian function and estrogen production. - Individuals with Turner syndrome are genotypically female (XO) and usually present with distinct physical features like a **webbed neck** and **coarctation of the aorta**, which are not mentioned. *Polycystic ovary syndrome* - Typically presents with primary or secondary amenorrhea, often accompanied by **hirsutism**, acne, and obesity, none of which are consistent with the described lack of secondary sexual characteristics in this case. - While it can cause menstrual irregularities, it does not involve the absence of a uterus or fallopian tubes, nor does it typically present with inguinal masses. *Hypergonadotropic hypogonadism* - This refers to conditions where the gonads fail to respond to pituitary gonadotropins, leading to low sex hormones and high FSH/LH levels (e.g., **premature ovarian failure** or **Turner syndrome**). - While it causes primary amenorrhea and lack of secondary sexual development, it does not explain the presence of inguinal masses or the complete absence of Mullerian structures (uterus, fallopian tubes) as seen in androgen insensitivity syndrome.
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