Sex Hormones: Estrogens and Progestins — MCQs
Which of the following statements is not true about tamoxifen?
A patient on tamoxifen therapy is most likely to develop which of the following?
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
Which of the following is not a known adverse effect of tamoxifen used in breast cancer treatment?
What is the most common gastrointestinal side effect of oral contraceptives?
Which of the following is a selective progesterone receptor modulator?
The mechanism of action of emergency contraception includes the following except:
Contraceptive of choice in a woman with Rheumatic heart disease.
What is the management for women with polycystic ovary syndrome (PCOS) and hirsutism?
Drug of choice for precocious puberty:
Sex Hormones: Estrogens and Progestins Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following statements is not true about tamoxifen?
- A. It can cause endometrial carcinoma.
- B. Tamoxifen is useful in post-menopausal and aromatase inhibitors in premenopausal patients. (Correct Answer)
- C. It is used for visceral metastasis.
- D. Dose is 20 mg for 5 years.
Explanation: ***Tamoxifen is useful in post-menopausal and aromatase inhibitors in premenopausal patients.*** - This statement is **incorrect** because **tamoxifen** is typically used in both pre- and post-menopausal women with **hormone receptor-positive breast cancer**, acting as a **selective estrogen receptor modulator (SERM)** [1]. - **Aromatase inhibitors** are primarily used in **post-menopausal women** because they block the peripheral conversion of androgens to estrogens, a process which is the primary source of estrogen in post-menopausal women, unlike pre-menopausal women where ovaries produce significant estrogen. *It can cause endometrial carcinoma.* - This statement is **true** because tamoxifen acts as an **estrogen agonist** in the uterus, which can lead to **endometrial hyperplasia** and increase the risk of **endometrial carcinoma** [1]. - This side effect is a significant consideration, especially with **long-term use** and in **post-menopausal women** [1]. *It is used for visceral metastasis.* - This statement is **true** as tamoxifen is an effective endocrine therapy for **hormone-sensitive breast cancer**, including those with **visceral metastases** [1]. - Its systemic action helps control disease progression in various organs affected by metastatic spread. *Dose is 20 mg for 5 years.* - This statement is **true** as the standard dose of tamoxifen for the adjuvant treatment of **hormone receptor-positive breast cancer** is indeed **20 mg daily for 5 years** [1]. - In some cases, treatment may be extended up to 10 years for additional benefit, but 5 years is the commonly recommended initial duration [1].
Question 2: A patient on tamoxifen therapy is most likely to develop which of the following?
- A. Increased risk of breast cancer
- B. Increased LDL cholesterol levels
- C. Endometrial hyperplasia (Correct Answer)
- D. Increased risk of myocardial infarction
Explanation: ***Endometrial hyperplasia*** - Tamoxifen acts as an **estrogen receptor agonist** in the uterus, stimulating endometrial proliferation and increasing the risk of hyperplasia, polyps, and endometrial cancer. - This effect is particularly seen in **postmenopausal women** and is a major concern with long-term use. *Increased risk of breast cancer* - Tamoxifen is primarily used to **reduce the risk of breast cancer recurrence** and as a chemopreventive agent in high-risk individuals. - It acts as an **estrogen receptor antagonist** in breast tissue, blocking estrogen's proliferative effects. *Increased LDL cholesterol levels* - Tamoxifen typically has a favorable effect on lipids, often causing a **decrease in total and LDL cholesterol** levels. - This effect is due to its estrogenic activity in the liver. *Increased risk of myocardial infarction* - While tamoxifen can increase the risk of **thromboembolic events** (e.g., DVT, pulmonary embolism), it generally does not increase, and may even decrease, the risk of myocardial infarction due to its beneficial effects on lipid profiles. - Its overall cardiovascular risk profile is complex, but MI is not a commonly cited side effect.
Question 3: 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 4: Which of the following is not a known adverse effect of tamoxifen used in breast cancer treatment?
- A. Nausea and vomiting
- B. Endometrial carcinoma
- C. Carcinoma in the contralateral breast (Correct Answer)
- D. Cataract
Explanation: ***Carcinoma in the contralateral breast*** - Tamoxifen, a **selective estrogen receptor modulator (SERM)**, actually **reduces the risk** of new primary breast cancer in the contralateral breast. - This protective effect is one of the significant benefits of tamoxifen in high-risk women and those with a history of breast cancer. *Nausea and vomiting* - While tamoxifen is generally well-tolerated, **gastrointestinal side effects** like nausea and vomiting can occur, though typically mild compared to chemotherapy. - These side effects are often manageable and tend to diminish over time. *Endometrial carcinoma* - Tamoxifen acts as an **estrogen agonist** in the uterus, increasing the risk of **endometrial hyperplasia** and **endometrial carcinoma**. - This is a significant, well-documented adverse effect requiring regular monitoring, especially in postmenopausal women. *Cataract* - Tamoxifen has been linked to an increased risk of developing **cataracts**, particularly in long-term users. - The mechanism is not fully understood, but it is considered a known ocular side effect.
Question 5: What is the most common gastrointestinal side effect of oral contraceptives?
- A. Decreased appetite
- B. Weight loss
- C. Nausea (Correct Answer)
- D. Constipation
Explanation: ***Nausea*** - **Nausea** is a very common gastrointestinal side effect of oral contraceptives, especially during the initial weeks of use, due to the **estrogen component**. - This side effect often **improves over time** as the body adjusts, or can be managed by taking the pill with food or at bedtime. *Weight loss* - Oral contraceptives are **not typically associated with weight loss**; in fact, some users may experience slight weight gain, although studies show no consistent significant effect. - Changes in weight are more often due to **fluid retention** rather than true fat loss. *Decreased appetite* - **Decreased appetite** is not a common side effect of oral contraceptives; rather, some individuals might experience an increased appetite due to hormonal fluctuations. - The hormonal effects on metabolism and appetite are **varied and not consistently demonstrated** to lead to decreased appetite. *Constipation* - **Constipation** is not a frequent gastrointestinal side effect of oral contraceptives; rather, some users may experience changes in bowel habits, but **diarrhea is more commonly reported** than constipation when GI issues occur. - Hormonal contraceptives primarily affect the gut through **estrogen and progestin**, leading to various effects, but constipation is not a predominant one.
Question 6: Which of the following is a selective progesterone receptor modulator?
- A. Onapristone
- B. Ulipristal (Correct Answer)
- C. Nomegestrol
- D. Toremifene
Explanation: ***Ulipristal*** - **Ulipristal acetate** is a **selective progesterone receptor modulator (SPRM)** that acts as a progesterone receptor agonist/antagonist. - It is primarily used for **emergency contraception** and for the pre-operative treatment of **uterine fibroids**. *Onapristone* - **Onapristone** is an **antiprogestin** and a **progesterone receptor antagonist**, not a selective modulator. - It has been primarily investigated for its potential role in **breast cancer** treatment but is not approved for general clinical use. *Nomegestrol* - **Nomegestrol** is a **synthetic progestin** used in hormonal contraception. - It functions as a **progesterone receptor agonist** and does not exhibit selective modulation properties. *Toremifene* - **Toremifene** is a **selective estrogen receptor modulator (SERM)**, not a progesterone receptor modulator. - It is used in the treatment of **estrogen receptor-positive metastatic breast cancer** in postmenopausal women.
Question 7: The mechanism of action of emergency contraception includes the following except:
- A. Degeneration of corpus luteum (Correct Answer)
- B. Prevention of implantation of fertilized egg.
- C. Inhibition of fertilization
- D. By preventing or delaying ovulation
Explanation: ***Degeneration of corpus luteum*** - Emergency contraception primarily works by interfering with ovulation and fertilization. It does **not directly cause degeneration of the corpus luteum**. - The **corpus luteum** forms after ovulation, and its degradation is a natural process (luteolysis) if pregnancy does not occur. Emergency contraception acts earlier in the reproductive process and does not target the corpus luteum. - This is the **correct answer** as it is NOT a mechanism of emergency contraception. *By preventing or delaying ovulation* - This is the **primary mechanism** of action for most forms of emergency contraception, particularly those containing **levonorgestrel (LNG)** and **ulipristal acetate (UPA)**. - By delaying the release of an egg from the ovary, it prevents the possibility of fertilization. - This is the most established and clinically significant mechanism. *Inhibition of fertilization* - Emergency contraception may affect fertilization by altering **cervical mucus** thickness, making it less penetrable to sperm. - Some evidence suggests effects on **sperm motility** or function, though this mechanism is less well-established than ovulation inhibition. - This represents a possible secondary mechanism. *Prevention of implantation of fertilized egg* - **Current evidence does NOT support this as a mechanism** for levonorgestrel or ulipristal acetate emergency contraception. - Studies by **WHO, ACOG, FIGO, and ICMR** have shown that LNG-EC is ineffective once fertilization has occurred. - The **copper IUD** used for emergency contraception may have some anti-implantation effects due to its inflammatory action on the endometrium. - However, for hormonal EC (the most common form), prevention of implantation is **not an established mechanism** based on current medical evidence.
Question 8: Contraceptive of choice in a woman with Rheumatic heart disease.
- A. Progesterone only pills
- B. IUCD (Correct Answer)
- C. Condom with spermicidal jelly
- D. OCPs
Explanation: ***IUCD*** - **Intrauterine contraceptive devices (IUCDs)** are highly effective and do not involve systemic hormones, making them safe for women with **rheumatic heart disease**. - Both copper and hormonal IUCDs can be used, as they pose no additional risk of **thromboembolism** or worsen cardiac function. *Progesterone only pills* - While generally safer than combined oral contraceptives for women with cardiac issues, **progesterone-only pills** still carry a slight risk of **thrombosis**, especially in women with certain heart conditions. - Their effectiveness can be slightly lower than IUCDs, and adherence to strict daily timing is crucial for optimal contraception. *Condom with spermicidal jelly* - **Condoms with spermicidal jelly** are a barrier method and do not pose any direct risk to a woman with rheumatic heart disease. - However, they have a significantly **higher failure rate** compared to highly effective methods like IUCDs, making them less ideal as a primary contraceptive for a condition where pregnancy could be high-risk. *OCPs* - **Combined oral contraceptive pills (OCPs)** containing both estrogen and progestin are generally **contraindicated** in women with rheumatic heart disease, particularly those with valvular lesions or a history of **embolism**. - Estrogen increases the risk of **thromboembolic events**, which can be dangerous for individuals with compromised cardiac function.
Question 9: What is the management for women with polycystic ovary syndrome (PCOS) and hirsutism?
- A. Ethinyl estradiol + Cyproterone Acetate (Correct Answer)
- B. Ethinyl estradiol
- C. Levonorgestrel
- D. Ethinyl estradiol + Levonorgestrel
Explanation: ***Ethinyl estradiol + Cyproterone Acetate*** - This combination is effective for managing **hirsutism** in PCOS because ethinyl estradiol suppresses **gonadotropins** and ovarian androgen production, while **cyproterone acetate** is a potent **anti-androgen** that blocks androgen effects at the receptor level. - The anti-androgenic properties of cyproterone acetate directly address the excess androgen activity responsible for hirsutism. *Ethinyl estradiol* - While ethinyl estradiol (an estrogen) can suppress **gonadotropins** and thus reduce ovarian androgen production, it alone is not primarily effective in directly addressing and reversing existing hirsutism. - It would not sufficiently counteract the effects of high androgens on hair follicles without an additional anti-androgen. *Levonorgestrel* - Levonorgestrel is a **progestin** with **androgenic properties**, particularly at higher doses. - This would potentially worsen hirsutism rather than improve it, as it contributes to androgenic effects. *Ethinyl estradiol + Levonorgestrel* - This combination is a common component of oral contraceptive pills, but **levonorgestrel** has some **androgenic activity**, which means it could worsen or fail to improve hirsutism. - While ethinyl estradiol lowers androgens, the mild androgenic effect of levonorgestrel might counteract the desired anti-androgenic effect needed to treat hirsutism effectively.
Question 10: Drug of choice for precocious puberty:
- A. GnRH agonists (Correct Answer)
- B. Tamoxifen
- C. Cyproterone acetate
- D. Medroxyprogesterone
Explanation: ***GnRH agonists*** - **GnRH agonists** are the drug of choice for central precocious puberty as they **downregulate GnRH receptors** on the pituitary. - This downregulation leads to a **reduction in gonadotropin release** (LH and FSH), thereby suppressing sex hormone production and halting pubertal progression. *Tamoxifen* - **Tamoxifen** is a **selective estrogen receptor modulator (SERM)** primarily used in **breast cancer treatment**. - While it has **antiestrogenic effects** in breast tissue, it has **estrogenic effects** in other tissues and would not be appropriate for treating precocious puberty as it **does not suppress the central hypothalamic-pituitary-gonadal axis** and may have unpredictable effects on pubertal development. *Cyproterone acetate* - **Cyproterone acetate** is an **antiandrogen** with some progestational effects, mainly used to treat conditions caused by excess androgens, such as hirsutism or severe acne. - While it can suppress some aspects of sexual development by blocking androgen receptors, it **does not directly inhibit the central pubertal cascade** in the same way GnRH agonists do. *Medroxyprogesterone* - **Medroxyprogesterone** is a **progestin** that can suppress gonadotropin release in certain contexts, primarily in managing endometrial hyperplasia or contraception. - It is sometimes used in specific forms of precocious puberty (e.g., peripheral) but is **not the first-line treatment for central precocious puberty** as GnRH agonists are more effective at suppressing the entire hypothalamic-pituitary-gonadal axis.
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