1. What do coactivators and corepressors bind to? (2007, 2011, 2012, 2018) - C region/domain of receptor - A/B region of receptor - TAF - E region of receptor - 3COOH 2. What is the function of corepressors & coactivators? (2018 NIH) 3. How do promoters and repressors exert activity? (2011) - Binding TAFs - Binding zinc fingers - Dimerizing hormones

1. TAF 2. Act on TAFs 3. Binding TAFs

1. A mutation in DAX1 most likely results in what? (2003, 2007, 2011, 2012, 2014, 2018, 2018 NIH, 2019, 2021) - Ovarian failure - Adrenal hypoplasia/failure - Delayed puberty - Failed testicular development - Failure to express SRY and SOX9 - Sulfatase deficiency 2. What happens in males with DAX1 inactivating mutations? (2014, 2016, 2017, 2018) 3. What happens in females with DAX1 inactivating mutations? (2014, 2016, 2017, 2018)

1. Adrenal hypoplasia/failure 2. Adrenal hypoplasia 3. Delayed puberty

Remembrances Flashcards by Ashley Kim

What prevents polyspermy?
- Capacitation
- Cortical reaction
- Acrosome reaction

Cortical reaction

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(In the regulatory zone) What is the upstream DNA sequence that leads to increased transcription? (2021, 2022)

Coactivator
Coregulator
Enhancer
Inhibitor

Enhancer

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What do coactivators and corepressors bind to? (2007, 2011, 2012, 2018)

C region/domain of receptor
A/B region of receptor
TAF
E region of receptor
3COOH

What is the function of corepressors & coactivators? (2018 NIH)
How do promoters and repressors exert activity? (2011)
- Binding TAFs
- Binding zinc fingers
- Dimerizing hormones

TAF
Act on TAFs
Binding TAFs

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What is the binding site of corepressors and coactivators on hormone responsive genes? (2014, 2018 NIH)

3’ untranslated region
CpG
5’ upstream region
Hinge region
DNA-binding domain

5’ upstream region

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What mediates differences in estrogen receptor alpha (ER-alpha) and estrogen receptor beta (ER-beta)? (2013, 2016, 2017, 2018)

Coactivators and corepressors

Presence of TAF-1 on ER-alpha (A/B region)

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Where does binding on DNA occur with the hormone response element? (2011)

On mRNA
Upstream to 5’ transcription

Upstream to 5’ transcription

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What enzyme converts progesterone to dihydroprogesterone? (2017, 2018, 2022)

5-alpha-reductase
7-alpha-hydroxylase (7-alpha-OH)

5-alpha-reductase

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A mutation in DAX1 most likely results in what? (2003, 2007, 2011, 2012, 2014, 2018, 2018 NIH, 2019, 2021)

Ovarian failure
Adrenal hypoplasia/failure
Delayed puberty
Failed testicular development
Failure to express SRY and SOX9
Sulfatase deficiency

What happens in males with DAX1 inactivating mutations? (2014, 2016, 2017, 2018)
What happens in females with DAX1 inactivating mutations? (2014, 2016, 2017, 2018)

Adrenal hypoplasia/failure
Adrenal hypoplasia
Delayed puberty

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What enzyme is the rate limiting step of steroid hormone synthesis? (2018 NIH, 2020)

StAR
P450scc
17-beta-hydroxysteroid dehydrogenase (17-beta-HSD)
Aromatase

StAR

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What is the availability of gonadotropin beta subunits based on? (2020)

GnRH pulse amplitude
GnRH pulse frequency

GnRH pulse frequency

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What is increasing sialic acid (residue) (silanization) content associated with? (2011, 2017, 2018, 2018 NIH, 2019)

Diminished half-life
Diminished clearance/excretion
Increasing pH
Decreased bioactivity

Diminished clearance/excretion

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What is the biological effect of sialic acid residues? (2013, 2014)

Increase urinary vs. recombinant hormone
Increase pH
Decrease half-life
Increased during follicular phase

Increased during follicular phase

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What setting do you see hyperglycosylated hCG? (2013)
- Pregnancy (first trimester)
- Male

Pregnancy (first trimester)

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What setting do you see persistent hyperglycosylated hCG? (2018 NIH)
- Pregnancy
- Mole
- Pituitary small cell carcinoma
- Choriocarcinoma

Both mole and choriocarcinoma

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What is the correct order of relative half-lives arranged from greatest to least? (2007, 2009, 2011, 2012, 2014, 2015, 2017, 2018, 2018 NIH)

hCG>FSH>GnRH>LH
LH>FSH>hCG>GnRH
hCG>FSH>LH>GnRH
FSH>hCG>LH>GnRH

hCG>FSH>LH>GnRH

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What hormone receptor class uses phospholipase C (PLC)? (2007, 2011, 2018)
- FSH
- IGF
- TSH
- GnRH

GnRH

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What is the least likely reason why hormones readily pass through the cell membrane? (2009, 2018, 2023 NIH)

High polarity
Protein binding
Fat solubility
Small size

High polarity

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What causes failure to iodinate a new protein? (2001, 2007, 2018, 2018 NIH)

Excess tyrosine residues
Increased TSH
No tyrosine residues available
Abnormal receptor binding

No tyrosine residues available

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Where does the TAF act? (2009, 2018, 2018 NIH)

5’ untranslated region
Initiation codon
3’ end of DNA
DNA-binding domain

5’ untranslated region

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Which is most true about SHBG? (2018, 2018 NIH)

Strongly binds progesterone
Each molecule binds to a single steroid molecule
Levels increased by IGF-1

Each molecule binds to a single steroid molecule

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SHBG is best described by which of the following? (2011)

Forms a homodimer with binding of a single hormone
Binds estradiol in greater affinity than testosterone

Forms a homodimer with binding of a single hormone

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What increases SHBG? (2003, 2018, 2018 NIH)

Insulin
Hyperthyroidism
Obesity
Growth hormone

Hyperthyroidism

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What decreases SHBG? (2003, 2018, 2018 NIH)

Estrogen
T4
IGF
Anorexia

IGF

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What is necessary for prostaglandin production? (2018, 2018 NIH)

Lipolysis
Protein synthesis
Arachidonic acid
PGE2

Arachidonic acid

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Which has the highest affinity for the corticotropin receptor? (2010, 2011, 2012, 2018, 2018 NIH) - Androstenedione - Progesterone - Mifepristone (RU-486) - Estrogen What is the most potent glucocorticoid antagonist? (2016, 2017, 2018, 2018 NIH)

1. Mifepristone (RU-486) 2. Mifepristone (RU-486)

Which inhibits the progesterone receptor (PR) the most? (2009, 2010, 2018, 2018 NIH) - Estrogen - Progesterone - 17-hydroxyprogesterone (17-OHP) - Mifepristone (RU-486) - Danazol

Mifepristone (RU-486)

An orphan receptor (i.e. SF-1, DAX1) is defined by the lack of? (2011, 2018) - Known gene - Known ligand - Known antibodies - Known DNA-binding site - Location of gene is unknown

Known ligand

Which of the following is least likely to be an orphan receptor? (2007, 2023 NIH) - SF-1 - DAX1 - IGF-1

IGF-1

Somatic cell response to androgens is determined by the gene that is present on what chromosome? (2011, 2012, 2014, 2018) - Xp - Xq - Y - 22 - 13

What is the production rate of estradiol? (2018)

100-300ug/day

What is the production rate of androstenedione? (2018)

3 mg/day

How do nuclear receptors quickly exert actions? (2011) - Transcription of mitochondrial DNA - Duplication of DNA - Activating transcription of genomic DNA - Protein synthesis on ribosomes

Activating transcription of genomic DNA

What is the first event after insulin receptor binding? (2003, 2005, 2007, 2018, 2018 NIH) - (Tyrosine) Auto-phosphorylation of receptor - Conformational change of cytoplasmic domain of receptor - Kinase activation of receptor - Phosphatase activation of receptor

Conformational change of cytoplasmic domain of receptor

A nuclear receptor transmits its signal via? (2023 NIH) - Translation - Transcription - Opening of calcium channels - Protein kinase A (PKA)

Transcription

What does an insulin receptor defect cause? (2003)

Increased androgen secretion from the ovary

What is the immediate effect after a (steroid) hormone binds DNA? (2014, 2015, 2023 NIH) - Dimerization - Ribosomal DNA transcription - Genomic DNA replication - mRNA translation - Genomic (mRNA) transcription

Genomic (mRNA) transcription

What does T3 use as its receptor? (2011, 2012) - Phospholipase C (PLC) - cAMP - Steroid receptor

Steroid receptor

Which of the following has a nuclear receptor? (2009, 2011, 2012, 2018, 2018 NIH, 2022) - T4 - T3 - FSH - GnRH - ACTH - TRH

T4 T3*** both are correct

Which of the following has a nuclear receptor? (2018 NIH) - Steroid hormones - Peptide hormones

Steroid hormones

Which of the following has an intracellular receptor? (2003, 2012) - T3 - TSH - FSH - LH - hCG - GnRH

Which of the following has the least number of amino acids? (2007) - GnRH - GHRH - Oxytocin

Oxytocin

The hormone binding domain is important for which of the following? (2007, 2023 NIH) - HSP binding - Dimerization - Nuclear localization

- HSP binding - Dimerization *** both are correct

Where is the least likely place to find synthesis of steroids? (2007, 2023 NIH) - Mitochondrial membrane - Cytoplasm - Nucleus - Endoplasmic reticulum

Nucleus

Which of the following pairs do not act at the same type of receptor? (1999) - Growth hormone and prolactin - Insulin and IGF-1 - Progesterone and levonorgestrel - Inhibin and TGF-alpha

Inhibin and TGF-alpha

Which of the following has a tyrosine kinase receptor? (1999) - Growth hormone - ACTH - FSH - GnRH - IGF-1

IGF-1

Where is the steroid receptor DNA-binding domain located? (2012)

5’ upstream region

What initiates the DNA-binding of the hormone receptor? (2001)

Enhancer region

Progesterone action on stromal cell Where does the most androgen production take place in women? (2010) - Ovary - Adrenal

Ovary

What is one of the first events after ligand binding to a tyrosine kinase receptor? (2007) - G-protein activation - Phosphorylation - IP3

Phosphorylation

How are estrogen receptor alpha (ER-alpha) and estrogen receptor beta (ER-beta) different? (2013, 2015, 2017, 2018) What is the difference in function of estrogen receptor alpha (ER-alpha) and estrogen receptor beta (ER-beta)? (2023 NIH) - Methylation - Dimerization - Co-Binding - Coregulator binding site

Co-regulators Co-Binding Coregulator binding site

The gene that binds to the steroid hormone receptor to cause transcription of the hormone-responsive gene is modulated by transcription factors that act where? (2003)

5’ upstream region

How is estrogen receptor beta (ER-beta) different from estrogen receptor alpha (ER-alpha)? (2019)

Estrogen receptor beta (ER-beta) lacks TAF-1

How are estrogen receptor alpha (ER-alpha) and estrogen receptor beta (ER-beta) the same (most homologous)? (2012, 2013, 2014, 2015, 2018) - Regulatory - DNA-binding domain - Hinge - Hormone binding domain - F region Which domain is most highly conserved in estrogen receptors? (2023 NIH) - DNA-binding domain - Hinge - Ligand binding domain Which part of the estrogen receptor alpha (ER-alpha) and estrogen receptor beta (ER-beta) are most homologous? (2018) - A/B - C - D - E - F

DNA-binding domain DNA-binding domain C

Where are zinc fingers located? (2001, 2003, 2023 NIH) - DNA-binding domain - Hormone response element - Ligand binding domain

DNA-binding domain

What type of receptor do growth hormone and prolactin bind to? (2003) - Tyrosine kinase associated receptor - JAK/STAT (aka cytokine receptor)

JAK/STAT (aka cytokine receptor)

Which of the following tissues has the highest ratio of estrogen receptor alpha (ER-alpha) to estrogen receptor beta (ER-beta)? (2001, 2003, 2005, 2023 NIH) - Bone - Brain - Uterus - Ovary

Uterus

Which androgen is most produced by peripheral conversion? (2003, 2005, 2023 NIH) - Testosterone - DHEAS - Androstenedione - DHEA

Testosterone

ACTH acts by binding to which type of receptor? (2007) - G-protein, c-AMP - G-protein, IP3 - Cytokine

G-protein, c-AMP

What does estrogen and progesterone priming lead to in progesterone receptor A (PR-A) and progesterone receptor B (PR-B) knockout mice? (2003, 2010, 2018, 2023 NIH) - Lordosis - Endometrial glandular hyperplasia - Breast development

Endometrial glandular hyperplasia

What does not happen in a mouse model with a progesterone receptor (PR) knockout? (2018)

Decidualization

What is the mechanism of action of progesterone receptor B (PR-B)? (2005, 2007) - Acts on progesterone elements - Modulation of estrogen receptor (ER) - Inhibition progesterone receptor A (PR-A) function by binding to progesterone receptor A (PR-A) - Inhibiting homodimer formation - Stimulate progestin-related actions - Other

Stimulate progestin-related actions

What works though a G protein using phospholipase C (PLC)? (2007) - GnRH - Dopamine - CRH

GnRH

Which is a decapeptide? (2023 NIH)

GnRH

What does CYP2R1 do in the liver? (2023 NIH)

Vitamin D conversion to 25-hydroxyvitamin D

What gene is associated with ovarian development (differentiation)? (2014, 2017, 2018, 2020) - FOXL2 - HOXA 8/10 (HOX)

FOXL2

Which of the following genes are not involved in promoting ovarian development? (2018) - WNT4 - RSPO1 - DAX1 - WT1 - FOXL2

WT1

What happens in oocyte meiotic arrest? (2013) - Inhibiting factor from granulosa cells/functioning granulosa cells - Gap junctions

Inhibiting factor from granulosa cells/functioning granulosa cells

What happens during embryo development? (2018) - Demethylation of imprinted genes - Demethylation of non-imprinted genes

Demethylation of non-imprinted genes

What enzyme is the granulosa cell missing? (2009, 2018, 2023 NIH) - 3-beta-hydroxylase (3-beta-OH) - 17-alpha-hydroxylase (17-alpha-OH) - 17-beta-hydroxysteroid dehydrogenase (17-beta-HSD) - Aromatase

17-alpha-hydroxylase (17-alpha-OH)

What other malignancy do you check for in a patient with uterine and cutaneous fibroids? (2014, 2015, 2017, 2018, 2019, 2021) - Renal cell carcinoma - Colon cancer - Endometrial cancer - Medullary thyroid cancer - Ovarian cancer

Renal cell carcinoma (HLRCC: Hereditary leiomyomatosis and renal cell cancer)

Patient has a 0.5cm fundal indentation and a 2cm portion of tissue extending from the interostial line into the cavity. What is the diagnosis? (2021) - Septum - Bicornuate - Arcuate - Didelphys

Septum

What is the least helpful in distinguishing a uterine septum from a bicornuate uterus? (2003, 2005, 2009, 2010, 011, 2012, 2018, 2023 NIH) - Transvaginal ultrasound (US) - Sonohysterogram - HSG - MRI - Laparoscopy and hysteroscopy

HSG

What is the most helpful in distinguishing a uterine septum from a bicornuate uterus? (2023 NIH) - Transvaginal ultrasound (US) - Sonohysterogram - HSG - MRI - Laparoscopy and hysteroscopy

MRI

What is the most common complication of a unicornuate uterus? (2001, 2018, 2023 NIH) - First trimester pregnancy loss - Second trimester pregnancy loss - Preterm delivery - Preeclampsia

First trimester pregnancy loss

A patient is found to have a longitudinal vaginal septum. What is the best next step? (2020) MRI Hysteroscopy Laparoscopy Ultrasound (US)

Ultrasound (US) MRI

What is least likely to occur with progesterone resistance? (2014, 2016) - Endometrial synechiae - Endometrial hyperplasia - Endometrial polyps What is least likely to result from inadequate response to progesterone? (2023 NIH) - Synechiae - Polyps - Endometritis - Luteal defect Which is the least likely to exhibit progesterone resistance? (2013, 2014) - Endometriosis - Endometritis - Endometrial synechiae

Endometrial synechiae Synechiae Endometritis Endometrial synechiae

What is true about leiomyosarcoma? (2015, 2023 NIH) - >10 mitoses per 10 high power fields - Med 12 somatic mutation - Some gene mutation that I had never heard of

>10 mitoses per 10 high power fields

What is true about ethnic differences in fibroids? (2015) - Black women have younger age of onset than white women - More aneuploidy in fibroid cells

Black women have younger age of onset than white women

What do you give for fibroids in patients who have bleeding despite OCPs? (2015) - Levonorgestrel IUD (Mirena) - High dose progestin - Uterine artery embolization (UAE) - Rollerball ablation

Levonorgestrel IUD (Mirena)

What happens at menses? (2015, 2016) - Vasoconstriction and coagulation - Stromal breakdown

Stromal breakdown

(Lateral) Fusion defects are due to fusion abnormalities of which of the following? (2011, 2012, 2018, 2023 NIH) - Mesonephric ducts - Paramesonephric ducts - Metanephric ducts - Wolffian ducts - Vaginal platea - Metanephric ducts - Urogenital sinus

Paramesonephric ducts

For which of the following conditions is an endometrial biopsy least useful for? (2007, 2012, 2023 NIH) - Chronic endometritis - RPL workup - Test for ovulation - PCOS - Thickened endometrium >12mm - Luteal phase deficiency - Infertility workup

RPL workup Luteal phase deficiency Infertility workup

What is the most likely cause of bilateral (proximal) tubal occlusion on HSG? (2011) - PID - Tuberculosis - Tubal spasm - Salpingitis isthmica nodosa (SIN)

Tubal spasm

Salpingitis isthmica nodosa (SIN) causes which of the following? (2011) - Hyperplasia of the mucosa - Inflammation of the tubal epithelium - Tubal scarring

Tubal scarring

Which of the following is the least useful test for salpingitis? (2010) - HSG - Mycoplasma

Mycoplasma

What is the mechanism of growth of fibroids? (2001, 2007, 2023 NIH) - Acquired genetic abnormality - TGF-beta dysregulation - Others

TGF-beta dysregulation

What has uterus didelphys been associated with? (2022) - Increased spontaneous miscarriage, increased preterm birth - Increased infertility, increase in preterm birth - Failure to progress, increase in preterm birth - Decreased spontaneous abortion, increased preterm birth

Increased spontaneous miscarriage, increased preterm birth

Which of the following gene mutations is associated with mullerian anomalies in genetic females? (2022) - HOXA13 - WNT4 - LIM1 - MIS

MIS

What is a consequence of an uncorrected vaginal septum in a sexually-active woman discovered incidentally on routine pap testing? (2022) - Spontaneous miscarriage - Infertility - Endometriosis - Labor dystocia

Labor dystocia

What is the most common finding in conjunction with Mullerian agenesis? (2003) - Vertebral column abnormalities - Foot deformity - Pulmonary stenosis

Vertebral column abnormalities

Diethylstilbestrol (DES) exposure is least likely to cause which of the following? (2003, 2010) - Cervical dysplasia - Uterine septum - Ectopic pregnancy - Others

Uterine septum

What of the following has the highest likelihood of repair for the fallopian tubes? (2007) - Extensive ovarian adhesions - Hydrosalpinx involving 3cm of tube - Salpingitis isthmica nodosa (SIN) - Rugation of tubes on HSG

Extensive ovarian adhesions

What type of fallopian tube abnormality is easiest to correct? (2005) - Bilateral hydrosalpinges - Salpingitis isthmica nodosa (SIN) - Tubal rugae on HSG

Bilateral hydrosalpinges

An infertility patient has an 8cm fibroid that is partially submucosal and Hct 22%. What is the best plan of management? (2005) - Expectant management - Hysteroscopic myomectomy - GnRH agonist then abdominal myomectomy - Others

GnRH agonist then abdominal myomectomy

Which of the following has the worst prognosis? (2023 NIH) - Uterine septum - Adenomyosis - Unicornuate uterus

Uterine septum

Which receptor uses protein kinase C (PKC) as a second messenger? (2022, 2023 NIH) - CRH - GnRH - Activin

GnRH

What activates phospholipase C (PLC)? (2011) - Dopamine - GnRH - CRH - Insulin

GnRH

What is the first action after GnRH binding? (2018) - Autophosphorylation of the receptor - Conformational change in the receptor - GTP replaces GDP - Activation of the adenylate cyclase

GTP replaces GDP

Which occurs first when GnRH binds to its receptor? (2011) - Phospholipase C (PLC) activation - G protein binding - Others

G protein binding

What is the first action after GnRH binds its receptor? (2014, 2023 NIH) - Protein kinase C (PKC) - cAMP release - Phospholipase C (PLC) - IP3 and calcium release What is initial action of GnRH binding to receptor (2015, 2018) - Phospholipase C (PLC) - Protein kinase C (PKC) - Gq/G11 What is initial action of GnRH binding to receptor (2017) - IP3/Ca - Protein kinase C (PKC) - Gq/G11

Phospholipase C (PLC) Phospholipase C (PLC) IP3/Ca vs Gq/G11

What is the intracellular immediate second messenger for GnRH? (2015, 2019) - Phospholipase C (PLC) - IP3 - DAG - Protein kinase C (PKC) - Protein kinase A (PKA)

Phospholipase C (PLC)

What mediates rapid response in GnRH receptor signaling? (2012) - Protein kinase C (PKC) - Protein kinase A (PKA) - Calcium release - DAG inhibition

Calcium release

How is GnRH able to exert immediate effects? (2011) - cAMP - Nuclear binding - Calcium - IP3 - Tyrosine kinase

Calcium

What is the immediate next step after GnRH binds its receptor? (2023 NIH)

Activation of Gq aka G11

What is most likely seen with LH pulses? (2009, 2010, 2011, 2012, 2018, 2023 NIH) - Highest pulse frequency in the early follicular phase - Lowest pulse frequency in the mid luteal phase - Highest pulse amplitude in the early luteal phase - Lowest pulse amplitude in the late luteal phase

Highest pulse amplitude in the early luteal phase (Highest pulse frequency in late follicular phase)

What is the first action after FSH and LH bind to their receptor? (2003) - Autophosphorylation of the receptor - Conformational change in the receptor - GTP replaces GDP - Activation of the adenylate cyclase

Conformational change in the receptor Speroff Ch 1 pg 39 Hormone-receptor interaction and binding change the a-subunit conformation GTP replaces GDP on the a-subunit, freeing b- and gamma-subunits Allows the GTP a-subunit to bind to the catalytic unit of adenylate cyclase, forming the active enzyme.

Which pattern of GnRH secretion is most likely to cause elevation in FSH? (2014, 2023 NIH) - Low amplitude, low frequency - Low amplitude, high frequency - High amplitude, high frequency - High amplitude, low frequency

High amplitude, low frequency

What is the pattern of GnRH frequency seen in the luteal phase? (2005, 2015, 2023 NIH) - Low amplitude, low frequency - Low amplitude, high frequency - High amplitude, high frequency - High amplitude, low frequency

High amplitude, low frequency

How does LH pulsatile secretion in the luteal phase compare to the follicular phase? (2003, 2005, 2007, 2009, 2010, 2011, 2012, 2018, 2023 NIH) - Increased pulse frequency and increased amplitude - Decreased pulse frequency and decreased amplitude - Increased pulse frequency and decreased amplitude - Decreased pulse frequency and increased amplitude

Decreased pulse frequency and increased amplitude

What controls FSH secretion? (2012, 2018, 2023 NIH) - GnRH pulse amplitude - GnRH pulse frequency - Estradiol pulses - GnRH-LH interaction

GnRH pulse frequency

How does the frequency of LH in the early follicular compare to the late follicular and early luteal? (2017)

Increase in late follicular, decrease in late luteal

What do you measure in a patient with a pituitary adenoma and large feet and hands? (2018) - ACTH - FSH - IGF-1 - TSH

IGF-1

A woman presents with galactorrhea and is found to have a 2cm mass and prolactin 87ng/mL. What is most likely increased? (2023 NIH) - Growth hormone - IGF-1 - TSH - DHEAS

A patient presents with a 10mm adenoma and is found to have hyperprolactinemia. What test will you order next? (2009) - IGF-1 - TSH - Cortisol - FSH - Alpha subunit A woman presents with a 2 cm adenoma and prolactin 40 ng/mL. What is an appropriate lab test to order? (2007) - Growth hormone - IGF-1 - Big prolactin - Something with cortisol

IGF-1 Speroff: ~10% of adenomas that secrete prolactin also secrete GH, leading some to recommend measuring the serum IGF-1 concentration, even in women with microadenomas. Women with pituitary macro-adenomas require additional evaluation (to hCG, TSH, prolactin, FSH, estradiol), including a serum FT4, IGF-1, and AM cortisol level.

What happens with hyperprolactinemia and hypothyroidism? (2016) - Block GnRH release - Modify sensitivity

Block GnRH release

What does hyperprolactinemia increase? (2003, 2011) - Estrogen - Testosterone - DHEAS - DHEA

DHEAS

A pregnant patient has a 7mm mass, bilateral peripheral vision loss, elevated prolactin, and severe headache. How do you manage these findings? (2007, 2011, 2015, 2016, 2017, 2018) - Bromocriptine - C-section and transsphenoidal surgery - Transsphenoidal surgery now

Bromocriptine

A 32wk pregnant woman presents with a 7mm prolactinoma and visual disturbances. Steroids (dexamethasone) were given for fetal lung maturity. What is the next step? (2009, 2011, 2018, 2023 NIH) - C-section and transphenoidal resection - Transphenoidal resection - Bromocriptine - C-section and bromocriptine

Bromocriptine

A 28yoF who is not trying to conceive presents with amenorrhea, prolactin 45ng/mL, and no galactorrhea. What is the most appropriate treatment? (2007, 2011) - Bromocriptine - OCPs - No treatment - HRT

OCPs

What is the mechanism of action of metoclopramide? (1999) - Aromatase inhibitor - 18-hydroxylase (18-OH) (aldosterone synthase) inhibitor - 17-hydroxylase (17-OH) inhibitor - Dopamine antagonist

Dopamine antagonist

What medication does not increase prolactin? (2011) - Valium - Levothyroxine (Synthroid) - Metoclopramide (Reglan) - Methyldopa What is least likely to be associated with hyperprolactinemia? (2011, 2023 NIH) - Diazepam - Chlorpromazine - Estradiol - Levothyroxine (Synthroid)

Levothyroxine (Synthroid)

What is the most potent glucocorticoid? (2013) - Cortisone - Progesterone - Dexamethasone - Prednisone

Dexamethasone

A woman presents with a pituitary adenoma. She has a normal TSH and prolactin 35ng/mL (normal 5-30ng/mL). What is the most likely diagnosis? (2014, 2015) - Non-functioning pituitary adenoma - Craniopharyngioma

Non-functioning pituitary adenoma

What happens if a large pituitary tumor that extends to the left to the cavernous sinus is resected? (2015) - Hypopituitarism - CSF rhinorrhea - Cavernous sinus thrombosis - Hyperprolactinemia

Hypopituitarism

Ablation of which nucleus causes hypernatremia? (2009, 2011, 2012, 2018, 2023 NIH) - Optic nucleus - Arcuate nucleus - Supraoptic nucleus - Paraventricular nucleus - Preoptic nucleus - Ventromedial nucleus - Mediolateral nuclues

Supraoptic nucleus

GnRH secretion is most impacted with ablation of which nucleus? (2014) - Preoptic nucleus - Paraventricular nucleus - Ventromedial nucleus - Arcuate nucleus

Arcuate nucleus

What is least likely to be required to be replaced in panhypopituitarism? (2009, 2011, 2014, 2018, 2023 NIH) - TSH - Growth hormone - Glucocorticoids - Gonadotropins - Estradiol - Mineralocorticoids

Mineralocorticoids

A woman adopts a child and wants to breastfeed. Which of the following, along with nipple stimulation, is most likely to induce lactation? (2014, 2015)

Metoclopramide (Reglan)

What is pituitary feedback conducted via? (2015) - Portal circulation - Systemic circulation

Systemic circulation

A woman presents with a pituitary mass and is found to have elevated FSH 42mIU/mL, normal LH, and increased alpha subunits. What is the diagnosis? (2007, 2011, 2012) - Prolactinoma - Thyrotroph adenoma - Gonadotroph adenoma/Non-functioning adenoma - FSH-oma - POI - Pregnancy

Gonadotroph adenoma/Non-functioning adenoma

What is an increased FSH:LH ratio most likely due to? (2005, 2011) - Increased GnRH pulse frequency - Decreased GnRH pulse frequency - Increased GnRH pulse amplitude

Decreased GnRH pulse frequency

A patient presents with a 12 mm adenoma, galactorrhea, normal cycles, and prolactin 35ng/mL. What is the most likely cause? (2007) - Non-functioning adenoma - Empty sella syndrome - Craniopharyngioma

Non-functioning adenoma

A woman’s pituitary stalk is transected. What hormone will increase because of this? (2003, 2007) Ablation of the median eminence (pituitary stalk) will create a rise in which hormone? (2007, 2023 NIH) - TSH - FSH - Prolactin - Oxytocin

Prolactin

The ultrashort feedback loop works because of which of the following? (2007, 2023 NIH) - Retrograde flow - Capillary fenestrations - CSF fluid in 3rd ventricle What is the explanation for the rapid feedback mechanism for pituitary hormones? (2023 NIH) - Retrograde flow in the portal system - Brain barrier - Axo-neuronal transport of hormones

Retrograde flow Retrograde flow in the portal system

How do pituitary hormones feedback on the hypothalamus? (2023 NIH) - Systemic circulation - Pituitary portal vessels - Tanycytes

Pituitary portal vessels

Which of the following is a typical finding of craniopharyngioma on imaging? (1999) - Intracranial calcifications - Suprasellar extension - Unilateral lesion - Sellar erosion

Intracranial calcifications

Where is vasopressin made? (2007, 2023 NIH)

Supraoptic and paraventricular nuclei in hypothalamus

Which of the following is least likely to increase prolactin secretion? (2003) - Sleep - Exercise - Suckling - Others

Others

Ablation of which nucleus leads to changes in ADH? (2011) - Preoptic nucleus - Paraventricular nucleus - Ventromedial nucleus

Paraventricular nucleus

Prolactin secretion is increased by which of the following? (2003) - Estrogen - Progesterone - T4 - Others

Estrogen

IGF-1 works through which type of receptor? (2003)

Tyrosine kinase

Which of the following does not cause elevated prolactin? (2005) - Hyperthyroidism - Chronic renal failure - Cushing disease - Hypothyroidism

Hyperthyroidism

A 22yo F has an elevated prolactin level and an 8mm pituitary adenoma noted on MRI. What additional test should you order? (2007) - Growth hormone - IGF-1 - Cortisol - TSH

Growth hormone

What causes histamine release? (1999, 2003) - GnRH antagonists - GnRH agonists - Cyproterone acetate - Spironolactone - Insulin

GnRH antagonists

What is the most likely to cause hypernatremia if ablated? (2007) - Amygdala - Oxytocin cell - Periventricular nucleus

Periventricular nucleus

What is the most likely to cause a decrease in gonadotropins if ablated? (2007) - Amygdala - Arcuate nucleus

Arcuate nucleus

Dopamine inhibits which of the following in vivo? (2003) - GnRH - FSH - LH - TSH

GnRH

What causes the transition from preantral/secondary to antral follicle? (What is required for antral progression (antrum progression)?) (2001, 2003, 2007, 2009, 2011, 2012, 2013, 2014, 2015, 2018, 2022, 2023 NIH) - FSH - GDF-9 - c-KIT - Kit ligand - Inhibin - BMP15 - AMH - LH

FSH

What directs development from the primary to preantral/secondary follicle? (2005, 2007, 2009, 2018, 2023 NIH) - GDF-9 - FSH - Inhibin - AMH - LH

GDF-9

What is the role of the granulosa cells in the primordial follicle? (2009, 2011, 2012, 2014, 2015, 2016, 2017, 2018, 2021, 2023 NIH) - Secrete GDF-9 - Prevent atresia of the oocyte - Secrete inhibin - Secrete activin - Secrete AMH - To make kit ligand

Prevent atresia of the oocyte

In a primordial follicle, the oocyte is surrounded by which of the following? (2003) - Single layer of granulosa cells - Multiple layers of granulosa cells - Others

Single layer of granulosa cells

What is connexin 37 used for communication between? (2020) - Granulosa and oocyte - Theca interna and externa - Theca cell to granulosa cell

Granulosa and oocyte

When is peak estradiol in the menstrual cycle? (When is the ovary making the most estradiol?) (2019, 2023 NIH) - Early follicular - Late follicular - Early luteal - Midluteal - Late luteal - Menses

Late follicular

When is the maximum expression of the progesterone receptor (PR) during the menstrual cycle? (2023 NIH) - Menses - Late follicular - Late luteal

Late follicular

What is a progesterone >5ng/mL most associated with? (2014) - Ovulation - Receptive endometrium - Ectopic

Ovulation

What progesterone level is most consistent with ovulation? (2015) - 1.5ng/mL - 3 ng/mL - 5 ng/mL - 10 ng/mL

10 ng/mL

What phase of the menstrual cycle has the highest concentration (maximum expression) of progesterone receptors (PR)? (2001, 2011, 2012, 2013, 2014, 2015, 2016, 2018) - Early follicular/proliferative - Late follicular/proliferative - Early luteal/secretory - Mid luteal/secretory - Late luteal/secretory

Late follicular/proliferative

What hormone decreases during luteolysis (regression of the corpus luteum)? (1999, 2003, 2005, 2007, 2009, 2011, 2012, 2013, 2014, 2018, 2023 NIH) - FSH - Inhibin A - Inhibin B - Activin - PGF2-alpha

Inhibin A

What peaks in the luteal phase? (2015, 2016, 2018, 2023 NIH) - Inhibin A - Inhibin B

Inhibin A

What is least important for oocyte (follicular) development? (2011, 2013, 2014, 2023 NIH) - BMP15 - GDF-9 - c-KIT - Follistatin

Follistatin

What is the action of P4 on the endometrium at the start of menses? (2014, 2015)

Withdrawal leads to endometrial breakdown

What is the first event after IGF-1 binds to its receptor? (2007)

Tyrosine kinase phosphorylation

What is the most reliable marker of ovulation? (2016) - Basal body temperature - Urinary LH surge - Progesterone > 3ng/mL 1wk before menses

Progesterone > 3ng/mL 1wk before menses

When does the zona pellucida first form? (2009, 2018, 2023 NIH) - Primordial follicle - Primary follicle - Preantral follicle - Antral follicle

Preantral follicle

What agent is responsible for theca interna development? (2007, 2018, 2023 NIH) - GDF-9 - Inhibin - Activin - FOXL2 - FSH - IGF-1

GDF-9

Which enzyme is lowest in theca cells? (2007, 2023 NIH) - Aromatase - All other enzymes in steroidogenesis

Aromatase

What enzyme is most likely involved with ovulation/follicular rupture? (2003, 2005, 2007, 2009, 2011, 2018, 2023 NIH) - PIP2 - BMP15 - Collagenase - Decrease in PGE2 - Decrease in PGF2-alpha - Proteinase - Cumulus hyaluronidase Which of the following is most likely to cause of follicular rupture? (2007, 2023 NIH) - Increase in proteoglycan - Increase in collagenase - Increase in follicular pressure

Collagenase Increase in collagenase

What events occur at ovulation? (2018) - Decrease in plasminogen activator - Increase in plasminogen activator inhibitor - Increase in plasminogen activator - Decrease in matrix metalloproteinases

Increase in plasminogen activator

Granulosa cells in the follicular phase use which enzyme the least? (2007, 2023 NIH) - Aromatase - 17-hydroxylase (17-OH) - P450scc

17-hydroxylase (17-OH)

At what stage does the follicle develop a blood supply? (2011) - Primordial follicle - Preantral follicle - Antral follicle - Atretic follicle

Preantral follicle

What happens to the follicle immediately prior to ovulation? (2014, 2015, 2016) - Oocyte maturation inhibitor expressed - Resumption of meiosis II - Increase in prostaglandin

Increase in prostaglandin

At what stage does vascularization of the follicle start? (2009) - Primary follicle - Secondary follicle - Antral follicle

Secondary follicle

What precursor must you have when going from cholesterol to estradiol? (2023 NIH) - 17-hydroxyprogesterone (17-OHP) - Testosterone - Pregnenolone - Progesterone

Testosterone

Which of the following is most likely in regard to the menstrual cycle? (2023 NIH) - Progesterone in mid-cycle augments estradiol; feedback on LH - Estradiol in early follicular phase increases GnRH receptors at pituitary

Progesterone in mid-cycle augments estradiol; feedback on LH

Where is the spindle most likely to be after extrusion of the 2nd polar body? (2021) - Near 2nd polar body - Opposite 2nd polar body - Degraded - Outside oocyte

- Near 2nd polar body

When does the cortical reaction occur? (2018) - Sperm bind ZP2 - Sperm binds ZP3 - Sperm fusion to oocyte membrane

Sperm fusion to oocyte membrane

During implantation and uterine invasion, what cell gets replaced in trophoblast invasion? (2013, 2014, 2015, 2017, 2018) - Vascular endothelium - Endometrium - Myometrium

Vascular endothelium

In pregnancy, trophoblast replaces which of the following? (2005, 2014, 2015) - Glandular epithelium - Luminal epithelium - Stroma - Endometrial glands

Luminal epithelium

What does the cytotrophoblast/trophoblast replace? (2007, 2009) - Stroma - Endothelium - Decidua - Myometrium

Endothelium

What is a progesterone receptor-regulated (PR-regulated) gene essential for implantation and decidualization? (2018)

HOXA8, HOXA10

How many chromosomes in an MI oocyte? (2009) - 46 double chromatids - 46 double chromosomes

How many chromosomes in an MI oocyte? (2009) 46 double chromosomes

How many chromosomes are there in prophase of meiosis I? (2003) - 23 single-stranded chromosomes - 23 double-stranded chromosomes - 46 single-stranded chromosomes - 46 double-stranded chromosomes - 92 single-stranded chromosomes

46 double-stranded chromosomes

How many chromosomes are in an MI oocyte? (2018, 2023 NIH) - 23 - 46 - 92 - Depends on which stage in meiosis I

How many chromatids are in an MII oocyte? (2007, 2010, 2023 NIH) 23 46 92

What is the number of chromatids present in a metaphase II oocyte? (2007) - 23 single - 46 single - 23 double - 46 double

46 single

What is the chromosome number of a euploid MII oocyte? (2007, 2023 NIH) 22 23 45 46

What is the number of chromosomes when an oocyte is arrested in meiosis I? (2009) 23 double stranded 46 double stranded

46 double stranded

What is the number of chromosomes in the primary oocyte? (2001) - 23 - 46 - 92

What is the number of chromatids present in the oocyte immediately after ovulation? (2005, 2023 NIH) - 23 - 46

What is the number of chromosomes present in the oocyte just prior to ovulation? (2005, 2023 NIH) - 23 double - 46 double

46 double

When does the oocyte complete meiosis II? (2018) - Ovulation - LH surge - Fertilization - Acrosome reaction - Cortical granule reaction

Fertilization

What least characterizes the inner cell mass (ICM)? (2010, 2011, 2012, 2018) - Proliferation - Pluripotency - Apoptosis - Exponential growth - hCG production

hCG production

Mesenchymal stem cells are? (2011, 2012, 2018, 2023 NIH) - Totipotent - Pluripotent - Multipotent - Unipotent

Multipotent

What sugar is used when the embryonic genome turns on (is activated)? (What is the preferred nutrient when the maternal genome is not longer governing the development of the oocyte) (2007, 2010, 2012) - Glucose - Lactate - Pyruvate

Glucose Precompaction (Day 1-3) prior to embryonic genome activation, primary energy source is anaerobic with lactate and pyruvate Post compaction (Day 4-6) after embryonic genome activation, embryo switches to aerobic with increased glucose utilization

What is the first step in sex determination? (What is the first embryonic event leading to the development of a male phenotype?) (Which is the earliest requirement for normal male gonadal development?) (1999, 2003, 2005, 2010, 2012) - Y chromosome - SRY (TDF) gene expression/activation - Testosterone production - AMH

SRY (TDF) gene expression/activation

Which hormone most likely keeps immune suppression down for implantation? (2007, 2023 NIH) - ACTH - Cortisol - Progesterone - Estrogen

Progesterone

The oocyte is in which of the following stages just prior to fertilization? (2003, 2005, 2007, 2023 NIH) - Prophase I - Prophase II - Metaphase I - Metaphase II

Metaphase II

What is the first thing that happens in human embryos at implantation? (2023 NIH) - Apposition - Invasion - Adhesion

Apposition

Which least accurately characterizes maternal thyroid physiology? (2003) - Increased TSH secretion - Decreased T4 secretion

Decreased T4 secretion

What enzyme does the fetus lack? (2013, 2015, 2017, 2019, 2022) - 3-beta-hydroxysteroid dehydrogenase (3-beta-HSD) - 17-alpha-hydroxylase (17-alpha-OH)

3-beta-hydroxysteroid dehydrogenase (3-beta-HSD)

What enzyme does the placenta lack?

17-alpha-hydroxylase (17-alpha-OH)

Rank corticosteroids in order of increasing potency

"Cold Hands Palpate My Dead Body" Cortisone Hydrocortisone Prednisone Methylprednisone Dexamethasone Betamethasone

Which hormone decreases mid-gestation/second trimester in a male fetus? (2009, 2010, 2011, 2012, 2013, 2015, 2017, 2018, 2019) - LH - TSH - Prolactin - Estrogen - Testosterone - ACTH - Prolactin - Growth hormone - hPL - E2

Which hormone is least likely to decrease mid-gestation/second trimester? (2007) - LH - ACTH - CRH - Prolactin

Prolactin

All of the following will rise in pregnancy except? (1999, 2012, 2013, 2018, 2023 NIH) - hPL - CRH - ACTH - Estriol - Progesterone - Growth hormone - Prolactin - Cortisol - T4

Growth hormone

Where is estetrol made? (2014, 2018) - Fetal adrenal - Fetal ovary - Fetal liver - Placenta

Fetal liver

Where is proopiomelanocortin (POMC) found? (2014, 2018) Placenta

Placenta

What makes (increases) maternal (serum) CRH in pregnancy? (2003, 2005, 2007, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2018, 2023 NIH) - Maternal hypothalamic activity - Maternal pituitary activity - Fetal hypothalamic activity - Placental function - Decidua

Placental function

What doesn’t come from POMC? (2015) - Enkephalin - Beta lipotropin - Beta endorphin - ACTH - MSH - Melatonin

Melatonin

What is the differential diagnosis of high estriol? (2018) - Acute fetal hypoxia - Multiple gestation - Risk for preterm labor/pending labor - CAH

Multiple gestation CAH

What is the differential diagnosis of low estriol? (2018) - Impending or present fetal demise - Adrenal hypofunction - ACTH deficiency - Placental sulfatase deficiency - Placental aromatase deficiency - Drug-related effects (material corticoid therapy) - Anencephaly

1. Best answer per MFM: anencephaly 2. Next best answer: present fetal demise 3. 3rd best answer: placental sulfatase deficiency

What allows increased communication between cells at the time of delivery? (2014, 2017) - Increased gap junctions - Increased P4

Increased gap junctions

What happens at parturition? (2015) - Functional depletion of progesterone receptors (PR) - Increased estradiol in myometrium - Decreased cortisol

Functional depletion of progesterone receptors (PR)

What triggers parturition? (2015) - Fall in P4 and E2 - Depletion of progesterone receptor B (PR-B)

Depletion of progesterone receptor B (PR-B)

What causes virilization of a female fetus? (2023 NIH)

Danazol

What is the most common cause of maternal virilization in the first trimester? (2003, 2005, 2010, 2011, 2012, 2014, 2015, 2016, 2018, 2022) - Sertoli-Leydig cell tumor - Hyperreactio luteinalis (theca-lutein cysts) - Luteoma of pregnancy - Aromatase deficiency - SHBG decrease - PCOS - Exogenous androgens

Luteoma of pregnancy

A pregnant woman has a testosterone (androgen) producing tumor. What is the most likely phenotype for a female fetus? (2005, 2011, 2012, 2015, 2018) - Normal - Virilized fetus - Ambiguous genitalia - Mixed gonadal dysgenesis

Normal

A woman has a twin pregnancy and develops hirsutism, what is the most likely cause? (2003, 2005, 2018) - Nonclassical CAH - Luteoma of pregnancy - Hyperreactio luteinalis (theca-lutein cysts) - Aromatase deficiency

Hyperreactio luteinalis (theca-lutein cysts)

A woman with hyperthecosis is least likely to have which of the following? (2009) - Hypertension - Dyslipidemia - Acanthosis nigricans - Virilization

Hypertension

The placenta synthesizes progesterone from what precursor? (2012, 2018) - Maternal LDL - Maternal HDL - Acetate - Fetal DHEAS

Maternal LDL

On a molar basis (In a molar pregnancy), what androgen does the theca cell produce the most? (2003, 2005, 2007, 2009, 2011, 2012, 2014, 2018, 2023 NIH) - Androstenedione - Testosterone - DHEAS - DHEA

Androstenedione

What is the least likely to cross placenta? (2005, 2018) - T4 - TSH - TRH - Propylthiouracil (PTU) - Thyroid antibody

TSH

What substances do not cross placenta? (2018) - Glucose - Amino acids - Ketones - Insulin - IGF-1

Insulin

What is the best test to diagnose Addison disease in pregnancy? (2005, 2012, 2018) - ACTH stimulation test - Metyrapone test - Insulin tolerance test (ITT) - Glucose tolerance test (GTT)

ACTH stimulation test

What is the least likely mechanism of AIS at the receptor level? (2013, 2018)

Altered bioactivity of testosterone

What does a defect in the androgen receptor result in? (2015) - AIS - Klinefelter syndrome - SMA - 17-alpha-hydroxylase deficiency (17-alpha-OHD)

AIS

What is the inheritance pattern of AIS? (2013, 2020, 2021, 2022) - Autosomal dominant - Autosomal recessive - X-linked dominant - X-linked recessive

X-linked recessive

What is the most important requirement (principal determinant) for Wolffian duct differentiation? (2007, 2011, 2012, 2013, 2014, 2018) - Testosterone - SRY - Y chromosome - Androstenedione - AMH - DHT

Testosterone

What are the internal structures of a 46,XY individual with 17-alpha-hydroxylase deficiency (17-alpha-OHD)?

No internal structures (Unless testes is an option then pick that because these individuals will have some kind of cryptorchidism)

What is the pattern of Wolffian and Mullerian structures in complete AIS? (2014, 2015, 2017, 2018) Normal Wolffian structures Normal Mullerian structures Both Wolffian and Mullerian structures No Wolffian or Mullerian structures

No Wolffian or Mullerian structures

What is the gene loci responsible for androgen resistance? (2011) - 46,XX - 46,XY (13/15) - 46,XY (11) - 46,XY (t5)

46,XY (11)

Abnormality on which chromosome can cause (clinical features of AIS)? (2013, 2014) - X - Y - 13

What chromosome is the androgen receptor gene located? (2014, 2018, 2023 NIH) - Xq - Xp

A 27yoF postpartum presents with fatigue and constipation, yellow coloring, TSH normal 1mIU/mL, T4 0.3mcg/dL. What is the best next step (2007) - TRH stimulation test - Prolactin - Check T3 resin uptake - MRI

Check T3 resin uptake

What causes most of insulin resistance in pregnancy? (2007)

hPL

What changes in fetal hormones in the third trimester? (2011) - TSH can’t remember if it was increase or decrease - Decreased FSH*** - Increased LH - Cortisol can’t remember if it was increase or decrease

When is the soonest thyroid levels should be checked after an increase in levothyroxine (Synthroid) dose? (2012) - 1wk - 2wk - 4wk - 8wk

6-8 weeks

What is the earliest time to make a possible change in thyroid medication doses in pregnancy? (2014) - 1wk - 2wk - 4wk - 8wk

Should initiate as soon as pregnancy diagnosed, but increased need for T4 by 5 weeks

What are the normal changes to maternal thyroid function in the first trimester of pregnancy? (2010, 2012, 2014) Increase in TSH, increase in T4 Increase in TSH, decrease in T4 Decrease in TSH, decrease in T4 Decrease in TSH, increase in T4

Decrease in TSH, increase in T4 (Due to mimicry of hCG)

What is the most likely cause of increased maternal urinary estriol? (2014) - Placental sulfatase deficiency - Fetal P450c17 deficiency - Fetal 21-hydroxylase deficiency (21-OHD) - Fetal 11-beta-hydroxylase deficiency (11-beta-OHD)

Fetal 21-hydroxylase deficiency (21-OHD)

What causes high estriol in pregnancy? (2013, 2014, 2015, 2016, 2017, 2018) - Sulfatase - Aromatase - 21-hydroxylase deficiency (21-OHD)

21-hydroxylase deficiency (21-OHD)

What is the immediate precursor to estradiol in pregnancy? (2018) - Testosterone - DHEAS - 16-hydroxy-dehydroepiandrosterone-sulfate (16-OH-DHEAS) - 16-hydroxy-androstenedione (16-OH-androstenedione) - Estriol

Testosterone

A pregnant woman at 16wk presents with low estriol levels on screening. What is the best next step? (2021) - Check sulfated estriol - Amnio for 17-hydroxyprogesterone (17-OHP) level - cffDNA - CVS - Ultrasound (US)

Ultrasound (US)

What enzyme does the placenta lack? (1999, 2001, 2003, 2005, 2007, 2010, 2011, 2012, 2013, 2015, 2018, 2019, 2020, 2022) - 17-alpha-hydroxylase (17-alpha-OH) and 17,20-lyase - 17-beta-hydroxysteroid dehydrogenase (17-beta-HSD) - 3-beta-hydroxysteroid dehydrogenase (3-beta-HSD) - Aromatase - Sulfatase - 11-beta-hydroxylase (11-beta-OH)

17-alpha-hydroxylase (17-alpha-OH) and 17,20-lyase

Which is a fetal enzyme needed for production of estriol? (2018) - 15-alpha-hydroxylase (15-alpha-OH) - 16-alpha-hydroxylase (16-alpha-OH) - 3-beta-hydroxysteroid dehydrogenase (3-beta-HSD) - 17-beta-hydroxysteroid dehydrogenase (17-beta-HSD) - 17-alpha-hydroxylase (17-alpha-OH) and 17,20-lyase

16-alpha-hydroxylase (16-alpha-OH)

What enzyme is exclusively produced by the fetal adrenal? (2018) - 16-alpha-hydroxy-dehydroepiandrosterone-sulfate (16-alpha-OH-DHEAS) - 16-alpha-hydroxy-dehydroepiandrosterone (16-alpha-OH-DHEA) - Estriol - Others

16-alpha-hydroxy-dehydroepiandrosterone-sulfate (16-alpha-OH-DHEAS)

What does a defect in the androgen receptor result in? (2015) - AIS - Klinefelter syndrome - SMA - 17-alpha-hydroxylase deficiency (17-alpha-OHD)

AIS

What is the least likely mechanism of AIS at the receptor level? (2013, 2018)

Altered bioactivity of testosterone

What is the likely mechanism of complete AIS? (2018) - Mutation in androgen receptor gene - Mutation in 5-alpha-reductase enzyme - Failure of SF-1 to interact with SRY - Dysgenesis of gonad

Mutation in androgen receptor gene

Translocation of the SRY from the Y to the X chromosome is due to the fact that the SRY is most closely located near which of the following? (2021, 2022) - Pseudoautosomal region - AZFa - AZFb - AZFc

Pseudoautosomal region

When should gonads be removed in AIS?

In patients with complete AIS, gonadectomy generally is best delayed until after puberty is completed (approximately age 16–18) because pubertal development generally proceeds more smoothly in response to endogenous hormone production and because the overall risk for tumor development is quite low (5–10%), particularly before puberty.

What is the pseudoautosomal region? Where is it located? Why is it significant?

The “pseudoautosomal” region constitutes only approximately 5% of the entire Y chromosome and is the only region that normally pairs and recombines during meiosis. A single copy of the one gene most critical to testis differentiation, SRY (Sex-determining Region on Y), is located on the distal short arm of the Y (Yp11.3), immediately adjacent to the pseudoautosomal region. Because it is so close to the SRY gene, translocation of SRY to the X chromosome is more likely

An infant presents with a 46,XX karyotype, (right) labioscrotal mass, and ambiguous genitalia. What is the MOST likely diagnosis? (2005, 2007, 2009, 2011, 2012, 2013, 2015, 2016, 2017, 2018, 2019, 2022) - 46,XX, ovotesticular DSD (true hermaphroditism) - 46,XX, testicular DSD (sex reversal; de la Chapelle syndrome) - 46,XX, aromatase deficiency - 46,XX, AMH deficiency - Mixed gonadal dysgenesis - Complete AIS

46,XX, ovotesticular DSD (true hermaphroditism)

An infant presents with ambiguous genitalia. There is no labioscrotal mass on exam. What is the MOST likely diagnosis if the karyotype is 46,XX? (2013, 2018) - CAH - Finasteride exposure during pregnancy - Luteoma during pregnancy - 46,XX, testicular DSD (sex reversal; de la Chapelle syndrome) - 46,XX, ovotesticular DSD (true hermaphroditism)

CAH

An infant presents with ambiguous genitalia and a labioscrotal mass. What is the LEAST likely diagnosis if the karyotype is 46,XX? (2007, 2013, 2014, 2018) - 5-alpha-reductase deficiency - 46,XX male - 46,XX, ovotesticular DSD (true hermaphroditism) - CAH

CAH

A woman presents with fatigue, increased pigmentation, weight loss, and no androgen excess. What is the diagnosis? (2011, 2012, 2018) - Autoimmune disease - Diabetes - Late onset 21-hydroxylase deficiency (21-OHD)

Autoimmune disease

A young man presents with hyperpigmentation, hyponatremia, and hyperkalemia. What is the most likely etiology? (2014, 2015) - Autoimmune disease - 3-beta-hydroxysteroid dehydrogenase deficiency (3-beta-HSDD) - 11-beta-hydroxysteroid dehydrogenase deficiency (11-beta-HSDD) - Sjogren disease

Autoimmune disease

What is the most likely phenotype in an activating LH receptor defect (LH receptor activating mutation, constitutive activation of the LH receptor)? (2003, 2005, 2009, 2011, 2012, 2014, 2015, 2016, 2017, 2018, 2020, 2021, 2022) - Female with PCOS and elevated FSH - Normal female - Normal puberty - Precocious puberty in a male (with low FSH and arrested spermatogenesis) - Isosexual precocious puberty in female - Precocious female puberty

Precocious puberty in a male (with low FSH and arrested spermatogenesis)

What is the risk of mortality from aortic dissection in pregnancy and postpartum in patients with Turner syndrome? (2018) - 2/10 - 2/100 - 2/1000 - 2/10000

2/100 (2%)

What is the gene defect causing short stature in Turner syndrome (46,X, or 46,X/46,XX mosaic, or 46,X/46,XY mosaic)? (2018) - SHOX - SRY - FMR1 - Anosmin-1 - AR (androgen receptor)

SHOX

A patient presents with primary amenorrhea and short stature. What is the most likely diagnosis? (2010)

Turner syndrome

An 18yoF with Tanner stage 5 breast development, pubic hair development, and primary amenorrhea. What is the best first test? (2005, 2020) - Testosterone - FSH - 17-hydroxyprogesterone (17-OHP) - Karyotype

FSH

What is the most likely phenotype in an AMH receptor defect? (2019) - Persistence of Mullerian structures - POI - Precocious puberty

Persistence of Mullerian structures

An adolescent girl with primary amenorrhea is found to have Mullerian agenesis and a 1cm vaginal dimple. Which is the most appropriate treatment when she is ready to become sexually active? (2003, 2010) - Frank dilators - Ingram procedure - McIndoe procedure - Vecchietti procedure

Frank dilators

What is least likely with an 11beta-hydroxylase (11-OH) deficiency mutation? (2014) - Hypertension - Hyperkalemia - Hypernatremia

Hyperkalemia

What do you find in male newborn with 21-hydroxylase deficiency (21-OHD)? (2012) - Scrotal testes - Hypospadias - Café-au-lait spots - Ambiguous genitalia

Scrotal testes

What is the mechanism of complete AIS? (2009, 2014, 2015) - Hormone cannot bind receptor (decrease biologic activity)/Delta-5 androgens do not bind to receptor - Receptor cannot bind to DNA? - Other things about the receptor but nothing about a receptor defect

Hormone cannot bind receptor (decrease biologic activity)/Delta-5 androgens do not bind to receptor

What is an activating receptor mutation most likely to cause? (2012, 2018, 2023 NIH) - Kallmann syndrome - AIS - CAH - MEN2 - Myotonic dystrophy

MEN2

A 5yo African American girl presents with has pubic hair, Tanner stage 1 breasts, and growth 60th percentile. What do you do next? (2003, 2012, 2021) - Estradiol level - DHEA - Testosterone - Bone age

Bone age

A 5yoF presents with Tanner stage 3 pubic hair (pubarche). What is the next step? (2005, 2009, 2010, 2011, 2012, 2018) - Depot medroxyprogesterone acetate (DMPA) (Depo-Provera) - Depot GnRH - Check testosterone level - Check 17-hydroxyprogesterone (17-OHP) - Pelvic ultrasound (US) - Pituitary MRI

Check 17-hydroxyprogesterone (17-OHP)

A child presents with isolated precocious adrenarche. What is the best test to order? (2012) 17-hydroxyprogesterone (17-OHP)

17-hydroxyprogesterone (17-OHP)

What level do you need to optimize in the follicular phase of a patient with 21-hydroxylase deficiency (21-OHD)? (2021) - Progesterone - 17-hydroxyprogesterone (17-OHP) - DHEAS - Testosterone

Progesterone

What is most likely to cause a false positive 17-hydroxyprogesterone (17-OHP)? (2005, 2009, 2011, 2010, 2012, 2018) - Not fasting/Postprandial - Recent LH surge/Recent ovulation - Pulsing of 17-hydroxyprogesterone (17-OHP) - Luteal phase Diurnal variation

Luteal phase

A 12yo presents with complete ovarian failure (POI). How do you supplement hormones? (2023 NIH) - Slow incremental estrogen - Estrogen and progesterone - Growth hormone

Slow incremental estrogen

What is the cause of Turner mosaicism? (2020) - Postzygotic mitotic error - Oocyte mitotic error - Maternal meiotic error - Paternal meiotic error

Postzygotic mitotic error

Where does the error occur in mosaic Turner 46,X/46,XX? (2018, 2022) - Meiosis II (paternal) - Meiosis II (maternal) - Mitosis after fertilization

Mitosis after fertilization

17yo presents with amenorrhea, normal electrolytes, and Tanner stage 3 breasts. Where is the most likely defect? (2007) 5-alpha-reductase Androgen receptor

Androgen receptor

A young girl is found to have elevated FSH and progesterone. What else do you expect to find on evaluation? (2013) A 17yo with primary amenorrhea and female external genitalia is found to have FSH 50mIU/mL, and progesterone 25ng/mL. What else do you expect to find on evaluation? (2007, 2011, 2012, 2018, 2023 NIH) - Hypercortisolism - Hypertension - Absent uterus

Hypertension

What is the most likely way to diagnose 17-alpha-hydroxylase deficiency (17-alpha-OHD) in a child? (2019) - Hyponatremia - Hypokalemia - Premature adrenarche - Salt wasting

Hypokalemia

What is most likely to be seen in a teenager with 17-alpha-hydroxylase deficiency (17-alpha-OHD)? (2011) - Hypertension - Hyperkalemia - Hirsutism

Hypertension

What is the least likely way to diagnose 17-alpha-hydroxylase deficiency (17-alpha-OHD) in a child? (2005, 2011) - Hyponatremia - Hypokalemia - Hypertension - Premature adrenarche - Salt wasting

Hyponatremia/salt wasting

What enzyme deficit will not cause salt wasting? (2014, 2015, 2018) - 17-alpha-hydroxylase (17-alpha-OH) - 11-beta-hydroxylase deficiency (11-beta-OHD)

17-alpha-hydroxylase (17-alpha-OH)

What enzyme deficiency is least likely to cause precocious puberty? (2013, 2014, 2023 NIH) - 17-hydroxylase deficiency (17-OHD) - 3-beta-hydroxysteroid dehydrogenase deficiency (3-beta-HSDD) - 17-beta-hydroxysteroid dehydrogenase deficiency (13-beta-HSDD) - Aromatase deficiency

17-hydroxylase deficiency (17-OHD)

What is the best management of long-term amenorrhea in nonclassical CAH? (2016, 2017, 2018) - OCPs - Hydrocortisone

OCPs

What is the order of hormone repletion in thyroid and adrenal disorders? (2007, 2009, 2013, 2015, 2016, 2018) - Glucocorticoid then mineralocorticoid and last thyroid replacement - Mineralocorticoids and glucocorticoids; then thyroid - Thyroid, then mineralocorticoids and glucocorticoids - Glucocorticoids, then thyroid, then mineralocorticoids - Only glucocorticoids and mineralocorticoids What do you first treat in a patient with both adrenal insufficiency and hypothyroidism? (A patient is diagnosed with both Addison disease and Hashimoto thyroiditis. What is the next best step in treatment?) (2003, 2005, 2007, 2011, 2012, 2014, 2023 NIH) - Replace all three at once - Thyroid and cortisol then watch see if mineralocorticoid replacement is needed - Thyroid then watch and see if others require replacement - Replace glucocorticoids and mineralocorticoids then thyroid

Glucocorticoid then mineralocorticoid and last thyroid replacement

How do you monitor mineralocorticoid activity? (2015, 2017) How do you monitor and titrate someone on mineralocorticoid replacement (for adrenal insufficiency)? (2011, 2013, 2014) - Plasma renin level - Sodium - Potassium - 17-hydroxyprogesterone (17-OHP)

Plasma renin level

What are patients with 46,XY complete gonadal dysgenesis (Swyer syndrome) most likely to have? (2014) - Normal breast development - Vagina - Low FSH - Normal sperm - High P4

Vagina

What is the most likely etiology of a 46,XX male? (2005, 2009, 2011, 2012, 2014, 2015, 2017) - Recombination or translocation - Inversion - Nondisjunction - Deletion What type of event causes a 46,XX male? (2018) - Chromosomal substitution - Abnormal recombination event during embryonic development - Abnormal recombination/translocation during male meiosis - Developmental mutation

Recombination or translocation Abnormal recombination/translocation during male meiosis

What region on the Y chromosome is most likely affected by crossover? (2013, 2014, 2018) - Pseudoautosomal region - SRY - Yp - AZF region

Pseudoautosomal region

A patient presents with hirsutism and 17-hydroxyprogesterone (17-OHP) >800. What test would you do next? (2016, 2017) - Cosyntropin stimulation test - 24-hour urinary cortisol - CRH stimulation

Cosyntropin stimulation test

What is the effect of flutamide in pregnancy? (2018) - Teratogen – abnormalities in male fetus - Teratogen – decreased estrogens in female fetus - No effect - Teratogen – abnormal prostate function later in life

Teratogen – abnormalities in male fetus

What is the first determinant of male development? (2009, 2018) - Differentiation of Leydig cells - Sertoli cell development from SF-1 and SRY - Peritubular myoid cell development - Testicular formation

Sertoli cell development from SF-1 and SRY

What is the next step when streak gonads are found during an appendectomy? (2018) - Removal - Sequence AR gene - Sequence SRY gene - Karyotype

Karyotype

What is the most common chromosomal abnormality in gonadal dysgenesis? (2003, 2018) - 46,XY complete gonadal dysgenesis (Swyer syndrome) - 46,X, Turner syndrome - 46,XXY, Klinefelter syndrome - 46,X, 46,XY Turner mosaic

46,X Turner syndrome

Which has the highest risk for tumor formation? (2018) - Mixed gonadal dysgenesis - 46,XY complete gonadal dysgenesis (Swyer syndrome) - 45,X/46,XY (Turner mosaic) - AIS - 45,X

46,XY complete gonadal dysgenesis (Swyer syndrome)

What genetic mutation can cause abnormal female structures in 46,XX? (2012, 2018) - SRY - SOX9 - FGF-9 - GDF-15 - FOXL2

FOXL2

How do you clinically define 46,XX DSD? (2018) - SRY and cell expression - Absence of Mullerian ducts and presence of Wolffian ducts - Presence of ovarian tissue (follicles) and testicular tissue (seminiferous tubules)

Presence of ovarian tissue (follicles) and testicular tissue (seminiferous tubules)

Picture of ambiguous genitalia, with a 46,XY karyotype. What is the least likely diagnosis? (2018) - 46,XY complete gonadal dysgenesis (Swyer syndrome) - CAH - AMH deficiency - AIS - 5-alpha-reductase deficiency - Testicular regression syndrome - 17-hydroxylase deficiency (17-OHD) - 17-beta-hydroxysteroid dehydrogenase deficiency (17-beta-HSDD)

CAH Usually normal male at birth

What do you find in male newborn with 21-hydroxylase deficiency (21-OHD)? (2012) - Scrotal testes - Hypospadias - Café-au-lait spots - Ambiguous genitalia

Scrotal testes

What are you most likely to see with 21-hydroxylase deficiency (21-OHD)? (2012, 2018, 2023 NIH) - Decreased progesterone and 17-hydroxyprogesterone (17-OHP) - Decreased deoxycorticosterone (DOC) and 11-deoxycortisol - Increased aldosterone - Low cortisol

Decreased deoxycorticosterone (DOC) and 11-deoxycortisol Low cortisol

What test is best for diagnosing nonclassical 21-hydroxylase deficiency (21-OHD)? (2015) - ACTH stimulated 17-hydroxyprogesterone (17-OHP) - ACTH stimulated 17-hydroxypregnenolone - 17-hydroxypregnenolone

ACTH stimulated 17-hydroxyprogesterone (17-OHP)

What is most important for testosterone production in the male fetus after 20wk? (2014, 2018) - Maternal androstenedione production - Fetal LH

Fetal LH

What is least likely to be seen in 11-beta-hydroxylase deficiency (11-beta-OHD)? (1999, 2003, 2011, 2012, 2014, 2015, 2018) - Hypertension - Elevated 11-deoxycortisol - Elevated ACTH - Salt wasting - Hypokalemia - Precocious puberty - Virilization - Anovulation - Irregular cavity with adhesions

Salt wasting

What is the inheritance pattern in 17-alpha-hydroxylase deficiency (17-alpha-OHD)? (2018)

Autosomal recessive (AR)

Why is ACTH elevated (in 17 alpha hydroxlase deficiency)? (2018)

Cortisol is a much stronger glucocorticoid than corticosterone or deoxycorticosterone (DOC)

What class of steroids are produced in excess in 17-alpha-hydroxylase deficiency (17-alpha-OHD)? (2018) - Mineralocorticoids - Glucocorticoids

Mineralocorticoids

A 17 yo patient presents with primary amenorrhea, 95th percentile growth, Tanner stage 1 breasts, and Tanner stage 1 pubic hair. What is the enzyme defect ? (2018, 2023 NIH)

17-alpha-hydroxylase deficiency (17-alpha-OHD)

A 16yo presents with Tanner stage 1 hair and breasts, FSH 35 mIU/mL, progesterone 23 ng/mL. What is the most likely etiology? (2011) - Isolated gonadotropin deficiency - FSH receptor defect - Turner syndrome - 17-hydroxylase deficiency (17-OHD)

17-hydroxylase deficiency (17-OHD)

A 17 yo F presents with Tanner stage 1 everything, 90th percentile height and weight, a small uterus, and no adnexal masses. What is the most likely diagnosis? (2010, 2023 NIH) - Isolated gonadotropin deficiency - DAX1 mutation - AIS

DAX1 mutation

A 16 yo presents with Tanner stage 1 everything, 90th percentile height, a uterus, and a cervix. What is the most likely diagnosis? (2023 NIH)

46,XY complete gonadal dysgenesis (Swyer's)

A 16yo presents with primary amenorrhea, 90th percentile height, Tanner stage 1 pubic hair and Tanner stage 1 breasts, cervix, and small uterus. What is the enzyme deficiency? (2007, 2011, 2012, 2018) - CYP17 - CYP21 - 3-beta-hydroxysteroid dehydrogenase deficiency (3-beta-HSDD)

CYP17 - AR inheritance - Chromosome 10 - Delayed puberty, primary amenorrhea, hyper hypo, HTN (increased mineralocorticoids)

A 16yo presents with primary amenorrhea, elevated FSH, and elevated progesterone 25ng/mL? What condition does she have? (2012, 2018) - 45,X - 46,XY, complete gonadal dysgenesis - CYP21 deficiency - CYP17 deficiency

CYP17 deficiency

Where is the CYP17A1 enzyme located? (2015) - Mitochondria - Endoplasmic Reticulum

Endoplasmic Reticulum

How is CYP21 inherited? (2018)

- Chromosome 6 - Autosomal Recessive (CYP21A1 pseudogene, CYP21A2 gene)

What is 17-hydroxylase deficiency (17-OHD) most associated with? (2020) - Hyponatremia - Hypotension - Hyperkalemia - Ambiguous genitalia

Ambiguous genitalia

List the CAH enzyme deficiencies in order of most common to least common. (2018)

1. 21-hydroxylase (21-OH) 2. 11-hydroxylase (11-OH) 3. 3-beta-hydroxysteroid dehydrogenase (3-beta-HSD)

46,XX, ambiguous genitalia most common condition? (2018) - Ovotesticular DSD (true hermaphroditism) - Testicular DSD (sex reversal; de la Chapelle syndrome) - CAH

CAH

(Image of an infant with a small phallus, opening on underside of phallus, scrotal mass on the right) Karyotype is 46,XX. What is the most likely diagnosis? (2014, 2015) - Ovotesticular DSD (true hermaphroditism) - 5-alpha-reductase deficiency - Mixed gonadal dysgenesis - AIS - CAH

Ovotesticular DSD (true hermaphroditism)

(Image of an infant with a small phallus, opening on underside of phallus, scrotal mass on the right) Karyotype is 46,XY. What is the least likely diagnosis? (2014, 2015)

CAH

A baby is born with ambiguous genitalia including a phallus with a urogenital sinus at its base and a unilateral palpable inguinal mass. Karyotype 46,XX. What is the most likely diagnosis? (1999, 2003, 2010) - CAH - 46,XX male - 5-alpha-reductase deficiency - Mixed gonadal dysgenesis

46,XX male

What is least likely with an 11beta-hydroxylase (11-OH) deficiency mutation? (2014) - Hypertension - Hyperkalemia - Hypernatremia

Hyperkalemia

All but which of the following will not result in ambiguous genitalia? (2012) - CYP11 deficiency - CYP17 deficiency - CYP21 deficiency - 3-beta-hydroxysteroid dehydrogenase deficiency (3-beta-HSDD)

CYP17 deficiency

How do you monitor a 14yo on glucocorticoid and mineralocorticoid replacement? (2007) - Cortisol - ACTH - ACTH stimulation test - ACTH after CRH stimulation test - Renin/angiotensin

Renin/angiotensin

Frank dilators

What is the least common finding in Turner syndrome? (2003) - Hypothyroidism - Diabetes - Fragment of Y chromosome

Fragment of Y chromosome

What excludes the diagnosis of 21-hydroxylase deficiency (21-OHD) in a patient with new onset hirsutism at puberty? (2005) - ACTH stimulation test - 17-hydroxyprogesterone (17-OHP)

17-hydroxyprogesterone (17-OHP)

A 22yo is 60in tall with a broad/wide/shield chest, breast development, and menstrual irregularities. What is the most likely diagnosis? (2005, 2007, 2023 NIH) - 45,X - 45,X/46,XX - 45,X/46,XY - 46,XX

45,X/46,XX

What is the most likely karyotype for a patient with gonadal dysgenesis? (2003, 2007) - 45,X - 45,X/46,XX - 47,XYY

45,X/46,XX

What is the most likely phenotype in an AMH receptor defect? (2019) - Persistence of Mullerian structures - POI - Precocious puberty

Persistence of Mullerian structures

How do you calculate the expected adult height of a child based on parental heights in centimeters? (2010)

Add height of both parents +/-5 depending on sex / 2

What is the correct order of pubertal events in girls? (2010, 2012, 2013, 2014, 2016, 2018) - Maximal growth, thelarche, pubarche, menarche - Thelarche, menarche, pubarche, maximal growth - Thelarche, pubarche, maximal growth, menarche - Pubarche, thelarche, maximal growth, menarche

Thelarche, pubarche, maximal growth, menarche AG-BPM Adrenarche Growth spurt Breast Pubarche *final growth spurt Menarche

What is the first hormone to rise during adrenarche? (2011, 2018) - DHEAS - Androstenedione - Testosterone - Estradiol - ACTH

What is the first hormone to rise during puberty? (2018) - Estrogen - LH - FSH - Androstenedione

What is the change in LH seen as the first sign of puberty? (2009, 2012, 2018) - LH in daytime - LH in nighttime - LH while asleep

LH in nighttime

What test do you order from isolated precocious adrenarche? (2011, 2018) - DHEAS - Androstenedione - 17-hydroxyprogesterone (17-OHP) - FSH - E2

17-hydroxyprogesterone (17-OHP)

What is the first change seen in adrenarche? (2018) - Increase in testosterone - Increase in DHEA - Increase in androstenedione - Increase in ACTH proportional to reticularis growth

Increase in DHEA

What hormone is highest in adrenarche? (2018) - DHEA - Androstenedione - Total testosterone

DHEA

What best describes adrenarche? (2011) - Increased ACTH with enlargement of the zona reticularis - Increased DHEAS at 6-7 yo

Increased DHEAS at 6-7 yo

What is the first sign of male puberty? (2007, 2018) - Hair growth around testicles - Testicle enlargement - Phallus enlargement

Testicle enlargement

What is the most common presentation in the setting of an inactivated alpha subunit GPCR? (2021) - Delayed puberty - Precocious puberty - Ambiguous genitalia in a male - Ambiguous genitalia in a female

Delayed puberty

What is the most common cause of delayed puberty and primary amenorrhea in females? (2011, 2012, 2017, 2018, 2022) - (Stress induced) Hypergonadotropic hypogonadism (hyper-hypo) - Hypogonadotropic hypogonadism (hypo-hypo) - MRKH - Constitutional delay - Cushing syndrome - Craniopharyngioma (CNS tumors) - Turner syndrome - Prolactinoma

(Stress induced) Hypergonadotropic hypogonadism (hyper-hypo)

What is the most common cause of delayed puberty in females? (2015, 2021) - Eugonadal/Constitutional - Hypergonadotropic hypogonadism (hyper-hypo)) - Hypogonadotropic hypogonadism (hypo-hypo)

Hypergonadotropic hypogonadism (hyper-hypo))

What is the most common cause of primary amenorrhea? (2003, 2010, 2011, 2014, 2015, 2023 NIH) - Hypergonadotrophic hypogonadism (hyper-hypo) - Hypogonadotropic hypogonadism (hypo-hypo) - Mullerian agenesis - 46,XY, complete gonadal dysgenesis - CAH - AIS - Hyperprolactinemia

Hypergonadotrophic hypogonadism (hyper-hypo) per 2003, 2010, 2014, 2023 NIH

A patient presents with anosmia and amenorrhea. Where is the defect most likely located? (2007, 2023 NIH)

KAL

What gene causes autosomal dominant Kallman syndrome? (2013, 2014, 2015, 2017, 2018, 2022, 2023 NIH) - FGFR1 - KAL1 - KAL2 - PROK - KISS

FGFR 1 = KAL2

What is the inheritance pattern of Kallmann syndrome with KAL1? (2021) - X-linked recessive - Autosomal dominant - Autosomal recessive

X-linked recessive

All of the following are associated with the KAL1 gene except? (1999) - Guides gonadotroph cell migration - Is found on the distal end of the X chromosome - Is sometimes associated with congenital short stature - Is adjacent to region encoding for congenital ichthyosis

Is sometimes associated with congenital short stature

In a woman with Kallmann syndrome picture (hypo-hypo and anosmia) what is the most likely mutation? (2021) - KAL1 - KAL2 - FGFR1 - PROK2

KAL2 = FGFR1

What is the most likely inheritance of KAL2? (2015, 2018) - Autosomal dominant - Autosomal recessive - X-linked

Autosomal dominant

What is the most common transmission of Kallmann syndrome? (2011, 2012, 2013, 2018, 2023 NIH) - X-linked - Autosomal recessive - Autosomal dominant - Sporadic mutation

X-linked (anosmin, KAL1)

Kallmann syndrome is a disorder of what? (2005, 2018, 2023 NIH) - Neuronal synthesis - Neuronal migration - Olfactory placode tumor - GnRH synthesis

Neuronal migration

A 16yo F presents with delayed puberty. What is the best first test? (2021) - FSH - E2 - Testosterone A 16yo F presents with delayed puberty. Thyroid testing and prolactin are normal. What is the best next test? (2003) - FSH - E2 - Testosterone

FSH

A 15yo F with male build, new onset clitoromegaly. Most likely diagnosis? (2019, 2021)

5-alpha-reductase deficiency

A 15yo presents with primary amenorrhea, has Tanner stage 1 breasts, clitoromegaly, no uterus, and a male body habitus. What test is most likely elevated? (2016, 2017, 2022) - 17-hydroxyprogesterone (17-OHP) - T/DHT ratio - 11-deoxycorticosterone (11-DOC) - FSH - DHEAS/androstenedione ratio

T/DHT ratio (5 alpha reductase deficiency)

What are the internal and external structures of a patient who is 46,XY with 17-hydroxylase deficiency (17-OHD)? (2013, 2016, 2018) - Internal male, external male - Internal male, external female - Internal female, external male - Internal female, external female

Internal male, external female

A 5yoF with a pigmented lesion that does not cross the midline presents with vaginal bleeding. What is the most likely cause? (2011, 2021) - GnRH pulsatility - CAH - Ovarian cysts A 5yoF with skin spots that don’t cross the midline presents with precocious puberty and 90th percentile for height. What is the most likely cause? (2003, 2007) - GnRH pulsatility - CAH - Ovarian cysts

Ovarian cysts (McCune Albright)

What is likely seen in a GNAS activating mutation? (2023 NIH) What does an error in the GNAS gene lead to? (2018)

Increase in protein kinase A (PKA) McCune-Albright syndrome

What is being overproduced in McCune-Albright syndrome? (2009, 2010, 2015) - Protein kinase C (PKC) - Protein kinase A (PKA) - DAG

Protein kinase A (PKA)

What occurs in McCune-Albright syndrome? (2011) - Cytochrome P450 enzyme activation - Protein kinase A (PKA) activation - Others

Protein kinase A (PKA) activation

What is the most effective treatment of McCune-Albright syndrome? (1999) - GnRH analog - GnRH agonist - Testolactone - Ketoconazole - Spironolactone

- Testolactone is no longer available - Use anastrozole, though loses effect over time - GnRH agonist may work if GnRH independent > dependent - Other: tamoxifen

A patient presents with café-au-lait spots, bone lesions, and precocious puberty. Which of the following is most likely to be activated? (2005) Protein kinase A (PKA) Cytochrome P450 Others

Protein kinase A (PKA)

A young girl presents with precocious puberty, café au lait spots, and polyostotic fibrous dysplasia. These findings are most likely caused by which of the following? (2003) - Hypersecretion in multiple endocrine organs - A lesion leading to constitutive activation of adenylate cyclase

A lesion leading to constitutive activation of adenylate cyclase

What is AMH in patients with hypogonadotropic hypogonadism (hypo-hypo)? (2020) - High - Low - Normal

Normal

What is the most common autosomal dominant genetic defect for hypogonadotropic hypogonadism (hypo-hypo)? (2014, 2018, 2023 NIH) - KAL1 mutation - FGFR1 mutation - Androgen receptor mutation - SRY mutation - AZF mutation

FGFR1 or KAL2 for Kallman

What is the best way to establish a diagnosis in a patient with hypogonadotropic hypogonadism (hypo-hypo) and anosmia? (2020) - MRI - Gene sequencing

Gene sequencing

A female patient has Kallman syndrome. What mutation is most likely to affect 50% of her offspring? (2019) - KAL2 - FGFR2

KAL2 or FGFR1 (AD)

What hormone “turns on” the HPO axis in puberty? (2019) - Kisspeptin - Leptin - GABA

Kisspeptin

What is the most important signal for the initiation of GnRH pulses to start puberty? (2023 NIH) - Leptin - Kisspeptin

Kisspeptin

Which substance is not responsible for the rise in GnRH with puberty? (2012, 2014, 2018) - GABA - Leptin - Kisspeptin - Endogenous opioids - Glutamate

GABA

What will a mutation in the kisspeptin receptor most likely cause? (2015, 2023 NIH) - Decreased LH/Failure of LH release - Elevated TSH - Elevated LH - Elevated GnRH

Decreased LH/Failure of LH release

What is most likely associated with the onset of puberty? (2011, 2014, 2015, 2017, 2018) - Kisspeptin - Leptin - Neuropeptide Y (NPY)

Kisspeptin

What is the most likely mechanism of precocious puberty at 6yo with pigmented skin lesions? (2019)

Constitutively active GPCR

What is the treatment for McCune-Albright syndrome? (2007, 2009, 2011, 2012, 2018, 2019) - Aromatase inhibitor - OCPs - Progesterone - Estradiol

Aromatase inhibitor

A patient presents with precocious puberty and is found to have bone and hyperpigmented skin lesions. What would you treat this patient with? (2003, 2007, 2009, 2011, 2012) - Anastrozole - Flutamide - GnRH agonist - Ketoconazole - Progestin - Testolactone

Testolactone (no longer available) Anastrozole

A young female presents with advanced bone age. What is the single best test to determine activation of the HPO axis? (2015) - LH - Estrogen

LH (GnRH stim testing)

What is the most common cause of hypogonadotropic hypogonadism (hypo-hypo) boys? (2017) - Constitutional delay - Kallmann syndrome

Constitutional delay

What is the most common mutation in familial hypogonadotropic hypogonadism (hypo-hypo)? (2016, 2018)

Kisspeptin loss of function

A male patient presents with signs of hypogonadism. What is the best test for evaluation? (2015) - Serum total testosterone - Serum total free testosterone - FSH - LH

Serum total testosterone

What is the most common cause of GnRH dependent precocious puberty? (2015) - Idiopathic - McCune-Albright syndrome

Idiopathic

A patient presents with precocious puberty and elevated gonadotropins. How is this treated? (2018) - Aromatase inhibitors - Danazol - GnRH antagonists, daily preparations - GnRH agonists, depot preparations

- GnRH agonists, depot preparations This is GnRH-dependent precocious puberty (McCune Albright has low gonadotropins due to elevated sex steroids)

What are the indications for treatment of precocious puberty? (2018) - Thelarche - Pubarche - Progression to the next stage in 3-6 months - Current isolation from friends

Progression to the next stage in 3-6 months

A 5yoF presents with precocious puberty and an ovarian cyst. What is the most likely diagnosis? (2014, 2018) - Granulosa cell tumor - Theca cell tumor (thecoma)

Granulosa cell tumor

Which of the following can be used to monitor for recurrence of a granulosa cell tumor? (2003) - Inhibin B

Inhibin B

What is the best tumor marker for a granulosa cell tumor? (2003, 2005, 2023 NIH) - Estradiol - Inhibin B - AFP - hCG - CA125

Inhibin B

What is the most likely diagnosis of a patient presenting with precocious puberty and delayed bone age? (2009, 2013, 2014, 2015, 2016, 2017) - Hypothyroidism - McCune-Albright syndrome

Hypothyroidism

A patient presents with isolated precocious pubarche. What lab should be ordered next? (2007)

17-hydroxyprogesterone (17-OHP)

What is the mechanism of action of McCune-Albright syndrome? (2009, 2012, 2015, 2016, 2018) - Constitutive protein kinase A (PKA) - Phospholipase C (PLC) - IP3/DAG

Constitutive protein kinase A (PKA)

What is the mechanism of action of McCune-Albright syndrome? (2011, 2012) - G inhibitory stimulation - GsAlpha stimulation - GPR40 mutation - Gq stimulation - PLC

GsAlpha stimulation

What is responsible for McCune-Albright syndrome symptoms? (2009, 2012) - Increased cytochrome P450 enzyme activities - Increased protein kinase A (PKA) - Decreased protein kinase C (PKC)

Increased protein kinase A (PKA)

What is the mechanism of McCune-Albright syndrome? (2007, 2018) - Inactivating mutation of the LH receptor - Activating mutation of the beta subunit of the G-protein - Constitutively active adenylate cyclase due to somatic mutation alpha subunit of the G-protein GNAS1 gene - Inactivating mutation of the alpha subunit of the G-protein

Constitutively active adenylate cyclase due to somatic mutation alpha subunit of the G-protein GNAS1 gene

What is the best (most sensitive) test for growth hormone deficiency? (2014, 2015, 2017, 2023 NIH) - Insulin tolerance test (ITT) - Glucose stimulation test - IGF-1 level

IGF-1 level

What is the best hormonal evaluation in puberty? (2016) - LH:FSH ratio <1 in a prepubertal patient - LH <1 during GnRH stimulation test - AMH undetectable in a prepubertal patient - Inhibin undetectable in a prepubertal patient

LH <1 during GnRH stimulation test

What does the presence of breasts indicate? (2016, 2018) - Estrogen exposure at some point - Testosterone

Estrogen exposure at some point

Children with sexual precocious puberty at most risk for which of the following? (2016) - Sexual molestation - Depression and behavior disorders - Short stature

Depression and behavior disorders

Why has the age at puberty decreased in the United States? (2014, 2015) - Increased health - Increased fat mass

Increased fat mass

How do you give HRT to patients with delayed puberty? (2015, 2016, 2017) - E2 slowly increase over 1-2yr - E2 and P4 - E2 plus growth hormone

E2 slowly increase over 1-2 yr

What condition can be seen as virilization at puberty? (2005, 2007, 2009, 2011, 2012, 2018) - 5-alpha-reductase deficiency - Complete AIS - 46,XY complete gonadal dysgenesis (Swyer syndrome) - 17-beta-hydroxylase deficiency (17-beta-OHD) - FSH activating receptor

5-alpha-reductase deficiency

What adrenal enzyme deficiency is least likely to cause virilization at puberty? (2011) - 17-beta-hydroxysteroid dehydrogenase deficiency (17-beta-HSD) - 17-hydroxylase deficiency (17-OHD) - Aromatase deficiency

17-hydroxylase deficiency (17-OHD)

A 14 yo presents with primary amenorrhea, Tanner stage 4 pubic hair, Tanner stage 5 breasts, 2 cm blind vagina with dimple, normal hymen, no bulging, and no pain. What is the most likely diagnosis? (2012, 2018) - Androgen insensitivity - Imperforate hymen - Transverse vaginal septum - Mullerian aplasia

Mullerian aplasia

A 14yo presents with amenorrhea, Tanner stage 4 breasts, Tanner stage 5 pubic hair, 2cm vaginal dimple, no bulge, no pain, and 63in height. What is the most likely diagnosis? (2023 NIH) - Mullerian anomaly - AIS - Imperforate hymen

Mullerian anomaly

A 14 yo presents with primary amenorrhea, Tanner stage 4 breasts, 2cm vaginal dimple, no bulge, no pain, and 63in height. What is the best test to make the diagnosis? (2023 NIH) - MRI - Serum testosterone level

Serum testosterone (to distinguish from AIS)

A 17yo presents with amenorrhea, Tanner stage 4 breasts, Tanner stage 5 pubic hair, normal external genitalia, intact hymen, and 2cm vaginal pouch (vaginal dimple). What is the best next step? (2011, 2012, 2018, 2023 NIH) - Vaginoscopy - Exam under anesthesia - Pelvic ultrasound (US) - CT scan of pelvis

Pelvic ultrasound (US)

A patient presents with labs consistent with hypogonadotropic hypogonadism (hypo-hypo). What is the least likely cause? (2009) - DAX1 - FMR1 - Leptin

FMR1

An 18 yo 46,XY female presents with new onset breast (and pubic hair) development. What is the most likely cause? (2009, 2011, 2018) - Dysgerminoma - Gonadoblastoma - Activating LH mutation - Sertoli-Leydig cell tumor - Seminoma - Granulosa cell tumor - Theca-lutein cyst

Gonadoblastoma

A 30yo 46,XY female presents with new onset breast and pubic hair development. What is the most likely diagnosis? (2011) - Gonadoblastoma - Seminoma - Granulosa cell tumor

Gonadoblastoma

What is the most likely cause of cancer before 30yo in a phenotypic female with a genotype of 47,XY? (2009) - Mixed gonadal dysgenesis - 46,XY, complete gonadal dysgenesis (Swyer syndrome) - 46,XX, ovotesticular DSD (true hermaphroditism) - 46,XY, gonadal dysgenesis - Complete AIS - Incomplete AIS

46,XY, complete gonadal dysgenesis (Swyer syndrome)

Which of the following is the most likely to develop a gonadoblastoma (before 30yo)? (2005, 2011) - Mixed gonadal dysgenesis - 46,XX, ovotesticular DSD (true hermaphroditism) - 46,XY, gonadal dysgenesis - Complete AIS - Incomplete AIS

46,XY, gonadal dysgenesis

Which of the following is the most likely to develop gonadal cancer? (2009) - 46,XY complete gonadal dysgenesis (Swyer syndrome) - Mixed gonadal dysgenesis - AIS - 45,X

46,XY complete gonadal dysgenesis (Swyer syndrome)

What is the least important in the work-up of small testes? (2018) - Karyotype - Prolactin - LH/FSH - Testosterone - DHEAS

DHEAS

A patient presents with labs consistent with hypogonadotropic hypogonadism (hypo-hypo). What is the most common cause? (2011) - Increased endogenous opioids leading to GnRH suppression - Hyperprolactinemia - Increased cortisol

Hyperprolactinemia

A 2yo has a bone age of 4.5 yo and breast development. What is the best test to determine if there has been premature activation of the HPO axis? (2014, 2015) - LH - GnRH - Estradiol

A young girl presents with vaginal bleeding, Tanner stage 3 breasts, and 90th percentile for height and weight. What is the most likely diagnosis? (2011, 2014, 2015) - Exogenous hormone ingestion - Ovarian cyst

Ovarian cyst

A 23 yo F presents with new onset of hypogonadotropic hypogonadism (hypo-hypo). What is the most likely etiology? (2011, 2015) - Pituitary tumor - Hyperprolactinemia - Hypothalamic tumor - Idiopathic

Hyperprolactinemia

A woman is found to have hypogonadotropic hypogonadism (hypo-hypo) with a normal prolactin and TSH. What do you do next? (2011, 2012, 2023 NIH) - GnRH stimulation test - MRI - ACTH stimulation test

MRI

A woman recently finished tuberculosis treatment and now has weight loss, hyper-pigmented lesions, and fatigue. What is the best next test? (2011) - 24hr urine free cortisol - ACTH stimulation test - Dexamethasone suppression test

ACTH stimulation test (for adrenal insufficiency)

A patient recently had transsphenoidal surgery for a growth hormone tumor. She now has weight loss, hyperpigmented lesions, and fatigue with a normal TSH and ACTH. What do you do next? (2009) - IGF with cortisol - ACTH stimulation test - Dexamethasone suppression test

ACTH stimulation test

A patient presents with bilateral adrenal cysts and an elevated ACTH after high dose dexamethasone suppression test. What is the most likely diagnosis? (2011) - Pituitary tumor - Adrenal tumor - Ectopic ACTH production

Ectopic ACTH production

What is the most common location of ectopic ACTH production? (2009) - Lung - Liver - Ovary - Kidney

Lung

A (receptor inactivating) mutation in which of the following is most likely to have increased ovarian androgen production? (2009, 2023 NIH) - Insulin receptor - IGF-1 receptor - Leptin - 21-hydroxylase (21-OH)

Insulin receptor (IGF-1 promotes androgen production, Leptin inhibits, 21-hydroxylase does not exist in ovary) Primary pathology in women with HAIR-AN and hyperthecosis is severe insulin resistance, resulting in grossly elevated insulin levels that stimulate ovarian androgen production in theca cells (via insulin, IGF-1, and hybrid receptors) and markedly decrease hepatic SHBG production, thereby greatly increasing the amount of circulating free androgen.

What causes abnormal puberty? (2009) - Craniopharyngioma - Prolactinoma - Hamartoma

Hamartoma Craniopharyngioma > hypo hypo > delayed puberty Prolactinoma > hypo hypo > delayed puberty Hypothalamic hamartomas, congenital malformations composed of a heterotropic mass of nerve tissue usually located on the floor of the 3rd ventricle or attached to the tuber cinereum, are a common etiology of precocious gonadarche.

An 18yoF comes to the office prior to going to college. While she has had normal breast development, she has never had a period. She has been a swimmer throughout middle and high school and was told this prevented her periods from starting. Given she swims every day, she hasn’t cared about not having a period but her mother wants this evaluated prior to her starting college. Which of the following is least likely to be the etiology of her amenorrhea? (2022) - Hypothalamic dysfunction - POI - Mullerian agenesis - AIS - Delayed puberty

Delayed puberty

A physical exam on the 18yoF with primary amenorrhea after being a competitive swimmer through middle and high school reveals normal breast development but no uterus. Which lab evaluations would be the most appropriate next step? (2022) - FSH, LH, estradiol - FSH, TSH, prolactin - TSH, prolactin, testosterone - Testosterone, karyotype

Testosterone, karyotype

A 30yoF comes to the office to begin treatment for infertility. She had menarche at 14yo and regular menstrual cycles until starting OCPs at 21yo. She has continued OCPs until 6mo ago and has not had menses since. What is the least likely diagnosis? (2022) - Post-pill amenorrhea - POI - PCOS - Hypothyroidism - Hyperprolactinemia

Post-pill amenorrhea

In a patient with amenorrhea, presence of breasts and a uterus, with a normal laboratory evaluation (FSH, TSH, prolactin), which of the following would be most helpful in determining the etiology? (2022) - Presence of PCOS on ultrasound (US) - Estrogen status - History of bleeding while on OCPs - Patient weight

Estrogen status

A 17yoF presents with normal thelarche and adrenarche and primary amenorrhea. What will serum estradiol levels most likely reveal? (2022) - Elevated levels of estradiol due to tissue resistance - Very low (menopausal) levels of estradiol - Levels in the normal range for a 17yoF - Undetectable levels due to inhibitor antibodies

Levels in the normal range for a 17 yo F (Mullerian agenesis)

A 17 yo F presents with normal thelarche and adrenarche and primary amenorrhea. What will serum testosterone levels most likely reveal? (2022) - Levels in the normal range for a 17yoF - Levels in the normal range for a 17yoM - Elevated levels due to mutation of the androgen receptor - Low levels due to increased aromatase - Low levels due to gonadal failure

Levels in the normal range for a 17 yo F (Mullerian agenesis)

A 17yo presents with primary amenorrhea, normal secondary sexual characteristics, and a blind vaginal pouch on pelvic exam. What is the most appropriate next step? (2022) - Office cystoscopy - CT scan of the pelvis - Serum testosterone - MRI of the olfactory bulbs - Office hysteroscopy

Serum testosterone (to distinguish between AIS and Mullerian anomaly)

A 17 yo presents with primary amenorrhea, normal secondary sexual characteristics, a blind vaginal pouch, and a uterus but no cervical tissue on MRI. What is the most appropriate surgical procedure? (2022) - Laparoscopic resection of the non-functioning uterine remnants - Robotic resection of the non-functioning uterine remnants - Laparoscopic resection of all uterine and ovarian structures to avoid neoplasia - Laparoscopic resection of any functional uterine remnants

Laparoscopic resection of any functional uterine remnants

What is the first steroid hormone to increase in a pubertal girl? (2003) DHEAS 17-beta-estradiol

DHEAS

Which is least likely to be seen in the ovaries of a prepubertal girl? (2003) - Antral follicles - Corpus albicans

Corpus albicans

A 15yo F presents with primary amenorrhea and is phenotypically prepubertal on exam. What do you evaluate first? (2003, 2023 NIH) - FSH - Prolactin - MRI - Bone age

Bone age

A 6yoF has growth hormone deficiency. She would be most expected to have which of the following additional consequences (2003)

Pubertal delay

A 16 yo F has primary amenorrhea and anosmia. What is the most likely cause of her problem? (2003)

Mutation of the X chromosome Interfering with migration of neurons

Which null mutation is most likely to result in hypergonadotropic hypogonadism (hyper-hypo)? (2005) - LH receptor - FSH receptor

LH receptor

A young patient presents with Tanner stage 1 adrenarche, Tanner stage 3 breasts, and a blind vagina. What is the most likely genetic defect? (2005) - AMH - Androgen receptor

androgen receptor

18yo boy presents with delayed puberty and hypothalamic hypogonadism. What intra-cellular effect would likely be found in his GnRH neurons? (2024) - Increased cAMP activity - Decreased Ca - Decreased protein kinase A (PKA) - Decreased tyrosine phosphorylation

Decreased Ca

A 5 yo African American girl presents with has pubic hair, Tanner stage 1 breasts, and growth 60th percentile. What do you do next? (2003, 2012, 2021) - Estradiol level - DHEA - Testosterone - Bone age

Bone age

What is the least likely to cause amenorrhea? (2023 NIH) - Hypothyroid - Elevated prolactin - PCOS - Hypopituitarism

Hypothyroid

What percentage of adolescents with POI and secondary amenorrhea have an abnormal karyotype? (2023 NIH) - 50% - 13%

13%

Patients with Sheehan syndrome or pituitary apoplexy are most likely to have which hormone is affected? (2018, 2022) - FSH/LH - ACTH - Growth hormone - TSH

GH *Anterior pituitary defect: Prolactin, GH, and GnRH deficiencies are most common with Sheehan, but ACTH and TSH also possible. Oxytocin and vasopressin (ADH) are not compromised

Sheehan syndrome least associated with deficiency in? (2011, 2018, 2023 NIH) - Oxytocin - Growth hormone - Prolactin - ACTH - TSH - Estrogen - FSH - LH

Oxytocin

What is least likely to be affected in Sheehan syndrome? (2011) - Growth hormone - Prolactin - TSH - ACTH

TSH Most common deficiencies in Sheehan: GH, prolactin Less common deficiencies: ACTH > TSH (corticotrophs are more sensitive to ischemia)

What is the first sign of postpartum pituitary apoplexy? (2013, 2015)

Severe headaches

How will a woman with Sheehan syndrome present? (2015) - Decreased breastfeeding with little pubic hair - Decreased breastfeeding with hypercalcemia

Decreased breastfeeding with little pubic hair *Sheehan a/w hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, and hypophosphatemia

How will a woman with Sheehan syndrome present? (2015) - Galactorrhea and hypermenorrhea - Amenorrhea, difficulty nursing, and hypercalcemia - Amenorrhea, difficulty nursing, and decreased pubic hair

Amenorrhea, difficulty nursing, and decreased pubic hair

Described large postpartum hemorrhage. What would you expect to see as a consequence? (2023 NIH) - Failed lactation - Failed nursing, amenorrhea, loss of pubic hair - Failed nursing alone - Galactorrhea, amenorrhea, HTN

Failed nursing, amenorrhea, loss of pubic hair

What is least likely to cause bilateral hemianopsia 3wk postpartum? (2003, 2010, 2012, 2023 NIH) - Sheehan syndrome - Lymphocytic hypophysitis - Rathke pouch cyst - Craniopharyngioma

Sheehan syndrome

A 32wk pregnant patient with prolactinoma and visual changes, how do you treat? (2014, 2019, 2021) - Bromocriptine - Transsphenoidal surgery - Deliver then transsphenoidal surgery

Bromocriptine

A 32wk pregnant woman gestation with a known 12mm prolactinoma from before pregnancy. Her prolactin is 35ng/dL and she now has headache and bitemporal hemianopsia. What is the best course of action? (2014) - Delivery and then transsphenoidal surgery - Transsphenoidal surgery - Bromocriptine

Bromocriptine

When you give bromocriptine to a pregnant woman what happens to prolactin? (2003, 2005, 2009, 2011, 2018, 2023 NIH) - Increased maternal prolactin - Increased fetal prolactin - Decreased fetal prolactin - Altered/Decreased in amniotic fluid - Decreased maternal TSH - Decreased placental prolactin

Decreased fetal (and maternal) prolactin (Amniotic fluid prolactin is not altered)

What is the most common side effect of cabergoline? (2021, 2022, 2023 NIH) - GI upset - Headache - Cardiac valvulopathy

GI upset

What steroid is most likely to be increased with elevated prolactin? (2005, 2014, 2015) - DHEAS - Androstenedione

DHEAS *Some women with hirsutism also have mild hyperprolactinemia. Elevated serum prolactin concentrations can be associated with increased serum DHEA-S levels. Prolactin receptors have been identified in the human adrenal, and prolactin can increase adrenal DHEA production in vitro. Although DHEA-S is a weak androgen, it can be converted in the periphery to potent androgens such as testosterone and DHT. Prolactin stimulation of adrenal androgen production, excessive ovarian androgen production due to the chronic anovulation that often results from hyperprolactinemia (discussed in Chapter 4), and increased free testosterone levels consequent to anovulation may all be relevant to causation of hirsutism in women with chronic hyperprolactinemia.

An increased prolactin is associated with which of the following? (2019, 2020) - DHT - Testosterone - Androstenedione - DHEA - DHEAS

DHEA-S

What do you check next in a patient who has prolactin 30ng/dL (upper limit of normal 24ng/dL)? (2021) - Repeat prolactin - TSH - FSH - LH

Repeat prolactin

What hormone is most likely to be also elevated with a prolactinoma? (1999, 2003, 2005, 2007, 2009, 2010, 2012, 2019, 2021) - Cortisol - FSH - Inhibin - Growth hormone - ACTH - T4 - TRH

Growth hormone

What hormone is most likely to be affected after a pituitary infarction? (2016, 2019, 2021) - Growth hormone - TSH - ACTH - FSH - Gonadotropins

What type of WBC most commonly infiltrates the ovary in autoimmune oophoritis? (2021) - Lymphocyte - Neutrophil - Eosinophil - Macrophage

Lymphocyte

What is the most important test in suspected autoimmune oophoritis? (2014, 2015) - Anti-21-hydroxylase (21-OH) antibodies - Antithyroid antibodies - Antiovarian antibodies

Anti-21-hydroxylase (21-OH) antibodies

Most important test in suspected autoimmune oophoritis? (2023 NIH) - Adrenal antibodies - Ovarian antibodies - Thyroid antibodies

Adrenal antibodies

What antibody is most highly associated with POI? (2003, 2005, 2007, 2009, 2010, 2014, 2018, 2023 NIH) - Antithyroid antibodies - Antiadrenal antibodies - Antiovarian antibodies - Antinuclear antibodies

Anti-thyroid abs (more common) Anti-adrenal abs (help confirm diagnosis)

Having a positive finding of which of the following antibodies would be most related to autoimmune POI? (2011, 2012) - Antithyroid antibodies - Antiadrenal antibodies - Antiovarian antibodies

Anti-adrenal antibodies

The most likely cause of POI? (2021) - 45,X - 45,X/46,XX - FGFR1 - FMR1

45,X/46,XX

What is most likely to be found on evaluation of a 22 yo F with POI? (2014, 2015) - Increased number of CGG repeats in FMR1 - Antiovarian antibodies - Karyotype 46,XX - Karyotype 46,X

Karyotype 46,XX *Idiopathic POI is most common

A 22 yo F presents with POI. What is the most likely cause? (2014, 2020) - FOXL2 mutation - FMR1 premutation - FSH receptor mutation - LH receptor mutation

FMR1 pre-mutation

What is the most common abnormality with POI? (2007, 2011, 2023 NIH) - Adrenal crisis - Hypothyroidism - Insulin resistance - Ovarian antibodies

Hypothyroidism

What is most likely to be abnormal in a female with galactosemia? (2012, 2014, 2015, 2018, 2019) - AMH - TSH - Prolactin - Glucose

AMH Galactosemia: - Very rare - Autosomal recessive - Deficiency of galactose 1-phosphate uridyl transferase - Toxicity of galactose metabolites in primordial follicles (decreased)

A 30 yo F presents with galactosemia. What else is she at risk for? (2023 NIH)

POI

What is the least likely cause of amenorrhea? (2013, 2014, 2015, 2023 NIH) - Swimming - Biking - Running - Ballet - Gymnastics

Swimming

What is the most likely to cause anovulation? (2013)

PCOS

What is the most likely to cause anovulation? (2011) - Hyperprolactinemia - Hyperandrogenism - Hypogonadotropic hypogonadism (hypo-hypo) - Hypothyroidism

Hyperprolactinemia

What hormone do you measure in a patient with a prolactin secreting macroadenoma? (2013, 2018, 2023 NIH) - TSH - Cortisol - IGF-1 - Alpha subunit - FSH

IGF-1

What hormone level is most important to check after transsphenoidal surgery for a macroadenoma? (2016, 2022) - Cortisol - ACTH - TSH - FSH

Cortisol

Which test is least useful in evaluation of a macroadenoma? (2009, 2018, 2023 NIH) - Prolactin - FSH - Alpha subunit - IGF-1 - Cortisol

FSH Gonadotrophs may secrete alpha-subunit instead of undetectable FSH

What do you expect to happen if polyethylene glycol (PEG) is added to a pretreatment serum sample of a patient with macroprolactinemia? (2023 NIH) - Monomer - Monomer <40% - Polyethylene glycol (PEG) not the appropriate test - Others

Precipitation of macroprolactin to allow appropriate measurement of free prolactin

A G2P0020 presents following two D&Cs with new onset hypomenorrhea. TVUS with a sagittal view of the uterus shows adhesions. What is the best next step? (2023 NIH) - HSG - Hysteroscopy - Serum hCG

Hysteroscopy

How do you diagnose macroprolactinemia? (2023 NIH)

Pretreat the serum with polyethylene glycol (PEG)

A woman has experienced 9 mo of amenorrhea while nursing. What is the most likely diagnosis? (2005, 2023 NIH) - Lactational amenorrhea - Sheehan syndrome - Prolactinoma

Lactational amenorrhea

What is the most likely karyotype in a patient with Turner syndrome presenting with secondary amenorrhea? (2005) - 45,X - 46,XX/45,X

46,XX/45,X

What antibody is most associated with POI? (2013, 2014, 2017) - 21-hydroxylase (21-OH) - Anti-TPO

Anti-TPO (commonly associated but not diagnostic) 21-hydroxylase (diagnostic)

What is most diagnostic of immune mediated POI? (2018) - 21-hydroxylase (21-OH)

21-hydroxylase (21-OH)

A woman is found to have a mutation in a gene. What gene would her father need to be concerned about in terms of delayed disease? (2011) - FMR1 - CFTR - NCQV - GnRH

FMR1

How many repeats are in Fragile X premutations? (2017) - 5-36 - 38-54 - 55-200 - >200

55-200

A woman has a brother with Fragile X syndrome. She has 100 CGG repeats on testing. What are the chances of her having POI? (2018) - 0% - 10% - 20% - 50% - 100% If a woman has a son or brother with mental retardation and negative work-up for Fragile X but she herself has 100 CGG repeats on FMR1 testing. What are the chances of her having POI? (2007, 2011) - 10% - 20% - 40% - 90-100%

20% 15% have pre-mutations in familial POI 1-7% have pre-mutations in sporadic POI

25 yo F has a son with mental retardation and a negative work-up for Fragile X. She gets screened and has 100 triplet repeats. What does this mean clinically? (2007, 2023 NIH) - The son does have Fragile X - The patient is at risk for POI

The patient is at risk for POI

A female patient is found to have a Fragile X pre-mutation. Which of the following is most likely to be true? (2011) - 20% risk of POI - Mental retardation - Skeletal abnormalities - Renal aplasia

20% risk of POI

What is the least common product in a hormonally active pituitary adenoma? (2014, 2015, 2023 NIH) - Growth hormone - ACTH - Alpha subunit - TSH

TSH

What genes are not involved with pituitary development? (2015) - PIT-1 - PROP-1 - HESX1 - PTX (LHX) - BMP15

BMP15

What gene is most associated with pituitary development? (2016, 2017) - PIT-1 - PROP-1 - HESX1 - PTX (LHX) - BMP15

PROP-1

What is the least likely congenital malformation in pituitary disease (2015) - PROP-1 - PIT-1 - HOX genes - BMP15 - Others

BMP15

What is most associated with POI/gonadal failure? (2003, 2014, 2015, 2016, 2017, 2018, 2023 NIH) - Galactosemia - Blepharophimosis inversus syndrome (FOXL2)

Galactosemia

A woman presents with elevated FSH, normal LH, increased alpha subunit, and a pituitary mass. What is the diagnosis? (2018) - Prolactinoma - TSH secreting adenoma - Non-functional pituitary tumor - FSH secreting adenoma

Non-functional pituitary tumor 80-90% of nonfunctional pituitary tumors derive from gonadotrophs. FSH tumors are rare (high FSH, low LH) Gonadotroph tumors may secrete large amounts of the a subunit Gonadotroph tumors affect HPO axis via stalk compression - interrupting GnRH - blocking dopamine > increasing prolactin LH/FSH secreted by same cell Common a subunit (LH, FSH, TSH, hCG), different b subunit GnRH stimulates common a and different b subunits vi g protein second messenger, calcium dependent system Rate limiting step is synthesis of b subunits of each gonadotropin (prior question; remember, alpha subunits are common and secreted with non-functional tumors)

A patient presents in the third trimester of pregnancy with a new onset headache and prolactin 126ng/mL. What is the next step? (2005, 2012, 2018) - Bromocriptine - Neurosurgery consult - MRI brain - TSH level

MRI brain

Which is least likely to cause hypothalamic amenorrhea? (2003) - Weight training - Aerobic exercise - Eating disorders

Weight training

A 25yoF is 9mo postpartum and breastfeeding. She has not had a menstrual cycle since before pregnancy. What is the least likely cause of her secondary amenorrhea? (2003) - POI - Sheehan syndrome

Sheehan syndrome

Which of the following is most likely to lead to amenorrhea with long term use? (2003) - Fluoxetine - Chlorpromazine

Chlorpromazine (anti-psychotic causing hyperprolactinemia)

A 30yoF presents with 3mo amenorrhea, FSH 35mIU/mL, LH 3mIU/mL, prolactin 15ng/mL, TSH 4mIU/L, and excess alpha subunit. What is the most likely diagnosis? (2007, 2023 NIH) - POI - Gonadotroph adenoma

Gonadotroph adenoma

How is bleeding induced in secondary amenorrhea? (2010)

Medroxyprogesterone (Provera)

A 37yoF presents with secondary amenorrhea for 3mo. She is found to have FSH 3mIU/mL, LH 54mIU/mL, and prolactin 18ng/mL. What do you check next? (2007

Pregnancy test

Which substance inhibits prolactin? (2018, 2023 NIH) - GABA*** - TRH - Glutamate - VIP - Angiotensin II - Estrogen

GABA

Which of the following will increase prolactin? (2005, 2007, 2023 NIH) - GABA - CRH - Angiotensin II per 2023 NIH - Neuropeptide Y (NPY) - Vasopressin

Angiotensin II

Which of the following most inhibits (most potent inhibitor of) prolactin release? (2011, 2012, 2014, 2015, 2017, 2018, 2019, 2023 NIH) - VIP - Angiotensin - TRH - Oxytocin - GABA

GABA

A 30yoF has secondary amenorrhea after using OCPs for the past 9yrs and discontinuing them 6mo ago. Her exam revealed the presence of a normal uterus and breasts but low local estrogen in the vagina. Which lab evaluations would be the most appropriate diagnostic evaluation? (2022) - FSH, LH, estradiol - FSH, TSH, prolactin - TSH, prolactin, testosterone - Testosterone, karyotype

FSH, TSH, prolactin

A 30yoF has secondary amenorrhea after using OCPs for the past 9 yrs and discontinuing them 6mo ago. Her exam revealed the presence of a normal uterus and breasts but low local estrogen in the vagina. Labs demonstrate FSH 68mIU/mL, TSH 5.2mIU/L, and prolactin 2.5 ng/mL. What is the most appropriate next step? (2022) - Repeat FSH and TSH in 4 wk - Pituitary MRI - Begin treatment of hypothyroidism - Discuss oocyte donation

Repeat FSH and TSH in 4 weeks

A 30yo F has secondary amenorrhea after using OCPs for the past 9 yrs and discontinuing them 6 mo ago. Her exam revealed the presence of a normal uterus and breasts but low local estrogen in the vagina. Labs demonstrate FSH 68mIU/mL, TSH 5.2mIU/L, and prolactin 2.5ng/mL. Repeat FSH 4wk later is 75mIU/mL. Which of the following is inappropriate to perform at this time? (2022) - Antiadrenal and antiadrenal antibodies - TSH, free T4, calcium, phosphate, CBC, fasting blood sugar - Fragile X screening - Ovarian biopsy

Ovarian biopsy

A 30yoF comes to the office to begin treatment for infertility. She had menarche at 14yo and regular cycles until starting OCPs at 21yo. She continued OCPs until 6mo prior to today’s visit. She has had no menses since. Lab evaluations reveal FSH 2.5mIU/mL, TSH 13mIU/L, and prolactin 52ug/L. What is the most appropriate next step in the evaluation? (2022) - Repeat prolactin mid-morning - Pituitary MRI - Medroxyprogesterone acetate (MPA) (Provera) withdrawal - Treatment with thyroid replacement - Treatment with bromocriptine

Treat with thyroid replacement

Which of the following has the lowest risk for a young patient with POI treated with estrogen replacement, compared to women her age who are still cycling regularly? (2022) - Breast cancer - Endometrial cancer with unopposed estrogen - Infertility - Depression

Breast cancer

What is the best treatment for an infertile patient with hypothalamic amenorrhea with normal prolactin levels? (2003) - Bromocriptine - Clomiphene citrate (Clomid) - hMG

hMG

What is the most common cause of oligo-ovulation? (2016, 2023 NIH) - Weight loss/anorexia - Hypothyroidism - Hyperprolactinemia

Hyperprolactinemia

A 24 yo F with PCOS and a BMI 24 kg/m2 wants to get pregnant. What is the best way to do this? (2007, 2011) - Clomiphene citrate (Clomid) - Clomiphene citrate (Clomid) and metformin - Metformin - IVF

Clomiphene citrate (Clomid)

A 30 yo F with PCOS has infertility. What is the most appropriate therapy? (2011) - Gonadotropins - Metformin - IVF - Clomiphene citrate (Clomid) - Letrozole

Letrozole

A woman with PCOS desiring fertility, fails clomiphene citrate (Clomid) therapy. What is the best next step? (2018) - Ovarian drilling - Gonadotropins - Clomiphene citrate (Clomid) and -metformin - Extended clomiphene citrate (Clomid)

Clomid + metformin

What test is least accurate for assessing insulin resistance? (2007) - Fasting glucose:fasting insulin ratio - HbA1c - Euglycemic clamp - 2hr oral glucose tolerance test (GTT) - Fasting glucose

Fasting glucose

What is the best test to screen for insulin resistance? (2005, 2018) - Frequently sampled IV glucose tolerance test - Insulin tolerance test (ITT) - Oral glucose tolerance test (GTT) - HOMA-IR - QUICKI

OGTT

What is the best/most accurate clinical test for glucose tolerance? (2003, 2005, 2010, 2011) - Euglycemic clamp - 2 hr oral glucose tolerance test (GTT) - Fasting insulin:glucose ratio

Euglycemic clamp

What is the most accurate way to diagnose insulin resistance in PCOS? (2011) - Insulin:glucose ratio - HbA1c - Oral glucose tolerance test (GTT) - Fasting insulin

OGTT

What is the best test to evaluate glucose intolerance in PCOS? (2011) - Fasting glucose - 1hr glucose tolerance test (GTT) - 2hr glucose tolerance test (GTT) - HbA1c

2 hour GTT

What is the best screening for insulin resistance in PCOS? (2023 NIH) - 2hr oral glucose tolerance test (GTT) - Fasting glucose:insulin ratio - HbA1c

2 hour OGTT

What causes increased insulin resistance in theca cells in women with PCOS? (2012, 2018) - Decreased serine phosphorylation of insulin receptor - Increased serine phosphorylation of the insulin receptor - Increased tyrosine phosphorylation of the insulin receptor - Decreased number of insulin receptors

Increased serine phosphorylation of the insulin receptor

What causes increased insulin with insulin resistance? (2012, 2014, 2015) - Decreased number of insulin receptors - Abnormality in insulin receptor - Serine phosphorylation of insulin receptor cascade

Serine phosphorylation of insulin receptor cascade

What is the mechanism of hyperinsulinemia in PCOS? (2013, 2015, 2017, 2018) - Increased serine phosphorylation of insulin receptor - Insulin receptor polymorphism - Insulin receptor defect

Increased serine phosphorylation of insulin receptor

A patient is on metformin. Which of the following is the best reason to stop it 24hr in advance? (2009, 2011, 2012, 2014, 2015, 2018, 2023 NIH) - MRI - HSG - Intravenous pyelogram (IVP) - VOR

IVP Contrast dye can cause renal failure, which results in build up of lactic acidosis (restart metformin 48 hours after dye)

What is least likely to occur if ovarian drilling is performed on a patient with PCOS? (2014, 2015) - Drop androstenedione - Decrease dopaminergic inputs - Decrease LH - Decrease LH/FSH ratio

Decrease dopaminergic inputs

How does insulin primarily increase androgen production in the ovary? (2010, 2012, 2018) - Insulin action on IGF-1 receptors of theca cells - Insulin action on insulin receptors in theca cells - Insulin action on androgen receptor - Insulin upregulates CYP17 enzymes

Insulin acts via which of the following to increase androgen production in theca cells? (2023 NIH) - Insulin receptor - Stimulation of CYP17 transcription - IGF-1 receptor

Insulin receptor

What causes hyperinsulinemia with insulin resistance in PCOS? (2018) - Less insulin receptors - Intrinsic abnormality in the receptor - Defects in the post-receptor signaling pathway

Defects in the post-receptor signaling pathway

What is least useful in diagnosis of PCOS? (2007, 2011, 2012, 2018) - LH:FSH ratio - Ultrasound (US) - Ovarian volume - Serum androgen levels - Ferriman-Gallwey scores - Menstrual history

LH:FSH ratio

PCOS patients are at increased risk for which of the following? (2012, 2018) - Ovarian cancer - Breast cancer - Colon cancer - Renal cancer

Breast cancer

What is the most common abnormality in PCOS? (2014) - Elevated free testosterone - Elevated total testosterone - Elevated DHEA - LH:FSH ratio >3

Elevated free testosterone

A college student has PCOS. What is the most appropriate therapy? (2011) - Progestins - Dexamethasone - Metformin - OCPs

OCPs

A first year college student has BMI 34, oligomenorrhea, and hirsutism. What is the best first treatment? (2023 NIH) - OCPs - Metformin - Cyclic progesterone

OCPs

What is metformin least likely to do? (2003, 2007) - Increase triglycerides - Decrease HDL - Increase insulin sensitivity - Decrease serum testosterone - Increase testosterone clearance - Decrease serum insulin

Increase testosterone clearance

What circulating androgen has the biggest impact on hair growth? (2018)

DHT

Which of the following drugs is most likely to result in abnormal liver function tests? (2013, 2014, 2015, 2018, 2021, 2023 NIH) - Finasteride - Flutamide - OCPs - Spironolactone - Cyproterone acetate - Fulvestrant Which antiandrogen therapy has the greatest risk of affecting liver enzymes (hepatotoxicity)? (2003, 2013, 2014, 2016, 2017, 2018, 2023 NIH) - Finasteride - Flutamide - OCPs - Spironolactone

Flutamide

What is the weakest antiandrogen therapy? (2010) - Finasteride - Flutamide - Cimetidine - Spironolactone - Cyproterone acetate

Cimetidine

What is the most potent antiandrogen? (2023 NIH) - Levonorgestrel - Drospirenone - Norethindrone

Drospirenone

What drug inhibits 5-alpha-reductase? (2005, 2013, 2019) - Spironolactone - Cyproterone acetate - Flutamide - Finasteride

Finasteride

Which drug does not inhibit the androgen receptor? (1999, 2009, 2011, 2023 NIH) - Flutamide - Spironolactone - Finasteride - Cyproterone acetate - Danazol Which of the following is least likely to bind the androgen receptor? (2023 NIH) - Flutamide - Cyproterone acetate - Spironolactone - Finasteride

Finasteride

What is the mechanism of action of finasteride? (1999, 2009) - Androgen receptor antagonist - Aromatase inhibitor - 5-alpha-reductase inhibitor - 17-beta-hydroxysteroid dehydrogenase (17-beta-HSD) inhibitor

5-alpha-reductase inhibitor

What is not a mechanism of spironolactone? (2003, 2005, 2011, 2012, 2018) - Aldosterone antagonist - Androgen receptor antagonist - Inhibits ovarian and adrenal androgen synthesis - Inhibits 5-alpha-reductase activity - Decrease aromatase activity - Increase aromatase activity

Increase aromatase activity Decrease aromatase activity

Which is the least effect of spironolactone? (2007, 2023 NIH) - Androgen receptor complete inhibition - Increased aromatase - Decreased P450scc

increased aromatase

Which has the greatest binding affinity for the androgen receptor? (2015, 2023 NIH) - Flutamide - Finasteride - Danazol - Drospirenone

Flutamide (Danazol also picked)

What binds the androgen receptor best? (2012, 2015, 2016) - Flutamide - Testosterone - DHEA

Testosterone

What has the strongest affinity for the androgen receptor? (2023 NIH) - Flutamide - DHT - Testosterone - DHEAS

DHT

A 50yoF with new onset hirsutism is suspicious for an androgen secreting tumor. What do you check? (2014, 2015, 2018) - Testosterone - Free testosterone - Androstenedione - DHT - DHEAS

Testosterone

What pattern of hair growth would make you most suspicious for an androgen secreting tumor? (2017) - Areolar hair - Pubic hair extending up to the umbilicus - Chin, upper and lower lip - Balding

Balding

A 60 yo F presents with male pattern balding and a deepening voice. What is happening to hormones? (2013, 2018) - Testosterone - Free testosterone - 17-hydroxyprogesterone (17-OHP) - Androstenedione - DHT

Testosterone

A 60yoF presents with male pattern balding and a deepening voice. What test do you order next? (2014) - Testosterone - 17-hydroxyprogesterone (17-OHP) - Androstenedione - DHT

Testosterone

What is the best test to discriminate to determine if a 60yoF has an ovarian androgen secreting tumor? (2018) - Testosterone - Free testosterone - 17-hydroxyprogesterone (17-OHP) - Androstenedione - DHT

Testosterone

A 60 yo F presents with hyperandrogenism. What test do you order? (2013, 2014, 2016, 2018) - 17-hydroxyprogesterone (17-OHP) - Total testosterone - Free testosterone - Androstenedione

Total T

A 60 yo F presents with new onset hirsutism. What is the best test to order? (2014) - Ultrasound (US) of ovaries - MRI

US of ovaries

A 60 yo with presents with virilization, acanthosis, and other symptoms suggestive of hyperthecosis versus androgen secreting tumor. What is the best test to confirm ovarian androgen source? (2023 NIH) - Free T4 - Total T4 - Androstenedione - DHEAS

Total T4

What is the best test for an ovarian tumor found in 50yoF? (2014, 2015, 2016, 2018) - Total testosterone - DHT - Free testosterone - Androstenedione - DHEAS

Total T

What is most associated with peripheral testosterone? (2011, 2014, 2015, 2016) - 3-alpha-androstanediol glucuronide (3-alpha-AG) - DHT - Testosterone - Androstenedione How is androgen activity measured in the periphery? (2007, 2018) What is the best measure of peripheral testosterone activity? (2018) - Androstenedione - DHT - Testosterone - 3-alpha-androstanediol (3-alpha-A) - 3-alpha-androstanediol glucuronide (3-alpha-AG) What is the best measure of peripheral androgen activity? (2007, 2010, 2023 NIH) - DHEA - DHT - Testosterone - Androstenedione - 3-alpha-androstanediol glucuronide (3-alpha-AG)

3-alpha-androstanediol glucuronide (3-alpha-AG)

Density of hair follicles is based on which of the following? (2018) - Number of follicles at birth - Testosterone concentration at puberty - Testosterone concentration at birth - DHT concentration at birth

Number of follicles at birth

Density of hair follicles is based on which of the following? (2011, 2012, 2023 NIH) - Gender - Ethnicity - Age

Ethnicity

What is the best marker of androgen receptors at the skin? (2023 NIH) - DHEA - DHT - Testosterone - Androstenedione - 3-alpha-androstanediol glucuronide (3-alpha-AG)

3-alpha-androstanediol glucuronide (3-alpha-AG)

Which androgen is produced by the ovary in the greatest quantity? (2012, 2014, 2018) - Androstenedione - DHEA - DHEAS - Testosterone

Androstenedione

Which of the following enzyme deficiencies does not result in hirsutism? (2018) - 21-hydroxylase deficiency (21-OHD) - 11-hydroxylase (11-OH) - 5-alpha-reductase

5 alpha reductase

An 18yoF who presents with moderate to severe hirsutism. What is the next step? (2018) - Serum 17-hydroxyprogesterone (17-OHP) - Adrenal CT - 3-alpha-androstanediol glucuronide (3-alpha-AG) - Free testosterone - Total testosterone - No lab or imaging studies

Total testosterone

Which is least likely in ovarian thecosis? (2007, 2023 NIH) - Virilization - Insulin resistance - Acanthosis nigricans - Hirsutism - Hypertension

Hypertension

A patient with a 5cm mass and testosterone 300ng/ml is subsequently found to have a cystadenoma. What is the cell type responsible for the elevated androgen level? (1999) - Capsule - Stromal - Granulosa cell - Glandular cells of the cystadenoma - Hilar

Stromal

Most common genetic mechanism defect for CYP21A2? (2021) - Point mutation - Pseudogene replacement

Pseudogene replacement

What is the best initial treatment for adrenal crisis? (2019, 2021) - Prednisone 5mg - Hydrocortisone 100mg - Dexamethasone 25mg

Hydrocortisone 100 mg

What is the most potent glucocorticoid? (2013) - Cortisone - Progesterone - Dexamethasone - Prednisone

Dexamethasone

What hormone is made in the fasciculate layer of adrenal? (2019) - Aldosterone - Cortisol - DHEA

Cortisol

What is the next step after confirmation of positive antiadrenal antibodies? (2018)

AM cortisol level (>18 ug/dL excludes adrenal insufficiency)

What is the next step after positive antiadrenal antibodies are confirmed and AM cortisol level is low? (2018)

ACTH stimulation test (stimulated cortisol > 18 is a normal response)

Which enzyme deficiency is most likely to require glucocorticoids? (2005, 2011, 2018, 2023 NIH) - Nonclassical 21-hydroxylase deficiency (21-OHD) - 17-hydroxylase deficiency (17-OHD) - 3-beta-hydroxysteroid dehydrogenase deficiency (3-beta-HSDD) - Classical 21-hydroxylase deficiency (21-OHD)

Classical 21-hydroxylase deficiency (21-OHD)

What is a dexamethasone suppression test used to diagnose? (2016, 2017) - Cushing syndrome - 21-hydroxylase deficiency (21-OHD)

Cushing syndrome

What is the best initial test to DIAGNOSE Cushing syndrome? (2007, 2010, 2011, 2023 NIH) - 24hr urine free cortisol - AM serum cortisol - Cosyntropin stimulation test - Late night serum cortisol

24 hour urine free cortisol

You suspect adrenal insufficiency. What is the best initial diagnostic test? (2023 NIH) - ACTH stimulation test - ACTH - AM serum cortisol - 24hr urine free cortisol

AM serum cortisol

A patient is diagnosed with Cushing syndrome based on a 24hr urine free cortisol. What is the next test? (2009, 2011, 2023 NIH) - ACTH - Adrenal sampling - High dose dexamethasone suppression test - CT scan of the adrenals

ACTH

A patient is found to have elevated 17-hydroxyprogesterone (17-OHP). What is the next step? (2020) - Overnight dexamethasone suppression - 24hr urine free cortisol - 2d suppression - ACTH stimulation test

ACTH stim test

You do an overnight dexamethasone suppression test on a patient with Cushing syndrome. What is the most likely to cause a false positive? (2007) - Depot medroxyprogesterone acetate (DMPA) (Depo-Provera) - OCPs - Obesity

OCPs

A pregnant patient is found to have very elevated 24hr urine free cortisol. What is the next step? (2010) - Morning cortisol - PM cortisol - CBG - ACTH

ACTH

How do you determine the cause of Cushing syndrome? (2018)

Measure ACTH

What is the least accurate test for Cushing disease? (2018) - High dose dexamethasone suppression test - Low dose dexamethasone suppression test - Random serum cortisol - 24 hour urinary cortisol - Late night salivary cortisol

Late night salivary cortisol

What is the most common symptom of Cushing syndrome? (2017, 2018, 2021, 2022) - Centripetal obesity/adiposity - Moon facies - Fatigue - Amenorrhea - Hirsutism

Central obesity/adiposity

What is the difference between iatrogenic and endogenous Cushing? (2001, 2003, 2005, 2007, 2009, 2011, 2012, 2014, 2015, 2017, 2018, 2023 NIH) - Moon facies - Buffalo hump - Hypertension - Hyperandrogenism/Hirsutism - Glucose intolerance - Psychosis What is seen with endogenous but not exogenous steroid excess? (2003) - Hypertension - Hyperglycemia - Obesity - Hyperandrogenism

Hyperandrogenism/Hirsutism (Iatrogenic Cushing due to exogenous steroids not hirsuit)

What finding distinguishes 17-hydroxylase deficiency (17-OHD) from Cushing syndrome? (2007) - Hypertension - Others

Hypertension

What treatment reduces the synthesis of cortisol in refractory Cushing disease? (2014, 2019, 2021, 2023 NIH) - Ketoconazole - Octreotide

Ketoconazole

In resistant Cushing disease, which of the following treatment options stops cortisol production best? (2023 NIH) - Mifepristone (RU-486) - Hydrocortisone - Prednisone - Others

Mifepristone

What is the most common cause of primary adrenal insufficiency? (2018) - Idiopathic - Autoimmune - Mineralocorticoid administration - Exogenous steroids

Autoimmune

What is the most common cause of secondary adrenal insufficiency? (2011, 2012, 2018, 2023 NIH) - Idiopathic - Auto-immune - Mineralocorticoid administration - Exogenous steroids/Iatrogenic - Tuberculosis - Pituitary tumor

Exogenous steroids/Iatrogenic

How do you monitor adequacy of fludrocortisone replacement? (2012, 2018) - 17-hydroxyprogesterone (17-OHP) - Serum testosterone - Plasma renin - 11-deoxycorticosterone (11-DOC) levels

Plasma renin

What layer of adrenals has CYP21? (2009, 2018, 2023 NIH) - Granulosa - Fasciculata - Reticularis - Medulla

Fasciculata (Glomerulosa which makes mineralocorticoids has it also)

Where is CYP11B2 located (most active in the adrenal)? (2007, 2009, 2023 NIH) - Glomerulosa - Fasciculata - Reticularis - Medulla

Glomerulosa CYP11B1 - 11 beta hydroxylase CYP11B2 - 11 beta hydroxylase and aldosterone synthase (for mineralocorticoid production)

What adrenal hormone is most likely to decrease with aging? (2011, 2012, 2014, 2015, 2023 NIH) - Androstenedione - DHEAS - Testosterone - Cortisol

DHEAS All the androgens decrease with age, but cortisol increases. DHEAS decreases the most (70%)

A patient has bilateral adrenal enlargement with the same ACTH level after 2d of treatment with 2mg dexamethasone q6hr. What is the most likely diagnosis? (2011) - ACTH-secreting small cell tumor of the lung - ACTH-secreting adenoma of the pituitary - Adrenal adenoma - CRH-secreting tumor of the lung

Adrenal adenoma

Which of the following is most likely to mean there is an adrenal secreting tumor? (2010) - Testosterone >200ng/dL - DHEA(S)? >700mcg/mL - Virilization What is the best marker for an adrenal androgen producing tumor? (2003) - Testosterone > 200ng/dL - DHEAS >700ug/dL - Rapid-onset virilization

DHEAS

A patient presents with hypotension, fatigue, and low AM cortisol. After giving them metyrapone you see an increased CRH and ACTH but no change in cortisol. What is the most likely diagnosis? (2022) - Pituitary failure - Addison disease - Chronic steroids

Addison disease Metapyrone blocks 11-beta hydroxylase (so cant make cortisol via 11-DOC or corticosterone). After giving metapyrone, people with adrenal failure have increased CRH and ACTH and stably low cortisol. If secondary adrenal failure, CRH will increase but ACTH will not and cortisol will stay low. Note: is a tx for Cushing's syndrome! Note- chronic steroid user would have rise in cortisol!

What is the most common cause of secondary Addison disease in the United States? (2003, 2010) - Sheehan syndrome - Corticosteroid therapy - Radiation therapy

Corticosteroid therapy

Which of the following is least compatible with Addison disease in a 25yoF with fatigue? (1999, 2003) - Nausea and vomiting - Hyperpigmentation in the buccal mucosa - Alopecia - Antiadrenal antibodies - Hyponatremia - Hyperkalemia

Alopecia Anti-adrenal abs present in 60-70% of those with Addison

Which enzyme deficiency is not associated with hypocortisolism? (2003) - 20,22-desmolase - 7-alpha-hydroxylase (7-alpha-hydroxylase) - 3-beta-hydroxysteroid dehydrogenase (3-beta-HSD) - 18-hydroxylase (18-OH) (aldosterone synthase)

18-hydroxylase (18-OH) (aldosterone synthase)

What is most associated with adrenal failure? (2005, 2023 NIH) - Thyroiditis - Ovarian

Ovarian

What is most likely to cause a false positive cortisol elevation? (2005, 2023 NIH)

Obesity

What does low aldosterone result in? (2013)

Hyponatremia and hypercalcemia

A patient presents with hyperpigmentation, fatigue, and electrolyte abnormalities. What do you check next? (2021) - Cortisol - ACTH stimulation test - Urine metanephrines

Cortisol

Autoimmune disease

What is the order of hormone repletion in thyroid and adrenal disorders? (2007, 2009, 2013, 2015, 2016, 2018, 2023 NIH) - Glucocorticoid then mineralocorticoid and last thyroid replacement - Mineralocorticoids and glucocorticoids; then thyroid - Thyroid, then mineralocorticoids and glucocorticoids - Glucocorticoids, then thyroid, then mineralocorticoids - Only glucocorticoids and mineralocorticoids What do you first treat in a patient with both adrenal insufficiency and hypothyroidism? (A patient is diagnosed with both Addison disease and Hashimoto thyroiditis. What is the next best step in treatment?) (2003, 2005, 2007, 2011, 2012, 2014, 2023 NIH) - Replace all three at once - Thyroid and cortisol then watch see if mineralocorticoid replacement is needed - Thyroid then watch and see if others require replacement - Replace glucocorticoids and mineralocorticoids then thyroid

GC > MC > thyroid Replace glucocorticoids and mineralocorticoids then thyroid *Thyroid first will increase metabolism and worsen crisis

How do you monitor mineralocorticoid activity? (2015, 2017, 2023 NIH) How do you monitor and titrate someone on mineralocorticoid replacement (for adrenal insufficiency)? (2011, 2013, 2014, 2023 NIH) - Plasma renin level - Sodium - Potassium - 17-hydroxyprogesterone (17-OHP)

Plasma renin level

A patient with clinical signs of Cushing syndrome undergoes a 2d dexamethasone suppression test and is found to still have elevated ACTH afterwards. What is the most likely cause? (2023 NIH) - Small cell lung tumor - CRH bronchial tumor - ACTH pituitary adenoma - Adrenal adenoma

Small cell lung tumor Small cell lung tumor – ectopic, basal ACTH high, does NOT suppress CRH bronchiole tumor – basal ACTH high, but suppresses with Dexa ACTH pituitary adenoma – basal ACTH high, but suppresses with Dexa Adrenal adenoma – basal ACTH LOW Low dose dexa suppression test is used to differentiate Cushing’s from those who do not have Cushing’s. High dose tests are used after the diagnosis of CS is made to distinguish patients with pituitary hyper-secretion from those with ectopic ACTH secretion (pituitary ACTH will suppress, ectopic won’t).

A patient presents with excessive hair growth, hypertension, and moon facies. What is the diagnosis? (2023 NIH) - Hirsutism - PCOS - Cushing syndrome

Cushing syndrome

A pregnant patient presents with yellow skin, malaise, and. buccal pigmentation. A 24hr urine free cortisol is elevated to 700. What is the best next best step? (2023 NIH) - ACTH stimulation test - Serum ACTH

Serum ACTH *Cushing’s syndrome - elevated cortisol, suspect elevated ACTH --> buccal pigmentation (acts via direct ACTH action on MSH receptors, most common in ectopic and less often in pituitary overproduction of ACTH) but confirm ACTH- dependence with serum ACTH. Next step would be to do a CRH stim test or high dose dexa suppression test to distinguish pituitary from ectopic.

What is the most common cause of secondary Cushing syndrome? (2023 NIH)

Iatrogenic

What is the most common complaint of a Cushing syndrome patient? (2023 NIH) Generalized weakness Centripetal obesity Hypertension

Centripetal obesity

How do you monitor a 14yo on glucocorticoid and mineralocorticoid replacement? (2007, 2023 NIH) - Cortisol - ACTH - ACTH stimulation test - ACTH after CRH stimulation test - Renin/angiotensin

Renin/angiotensin

A 30yoF presents with primary adrenal failure with new onset hypotension, fatigue, and hyperpigmentation. What is the most likely enzyme deficiency? (2023 NIH)

21-hydroxylase deficiency (21-OHD)

What is the best treatment for PMDD? (2019) - SSRI - Benzo What is the most effective treatment for PMS? (2003, 2012) - SSRI - OCPs

SSRI

What receptor does danazol bind least to? (2001, 2003, 2005, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2018, 2023 NIH) - Androgen receptor - Progesterone receptor (PR) - Glucocorticoid receptor - Estrogen receptor (ER) - Prolactin receptor

The most common cause of irregular vaginal bleeding is which of the following? (2003)

Pregnancy

What is the definition of abnormal uterine bleeding (AUB)? (2011, 2012, 2018) - Increased bleeding volume to >95th percentile - Menorrhagia - Bleeding for >8d - Bleeding >80mL

Previous years answered: - Increased bleeding volume to >95th percentile vs Bleeding > 80 mL

What is the least likely definition of AUB? (2011, 2023 NIH) Bleeding >7d Preferred name for DUB Same as menorrhagia Bleeding >80mL Bleeding volume >95th percentile

Same as menorrhagia (regular, but heavy) (DUB = dysfunctional uterine bleeding)

What is the most likely cause of AUB in a teenager? (2005, 2019, 2021) Anovulation Inherited coagulopathy Pregnancy complication Cervical polyp

Anovulation

A 16yoF presents with profuse, heavy vaginal bleeding. Hemodynamically stable with Hct 26%. What is the best next step in management? (2021) - One tab of combined oral contraceptive today and then one pill daily x30d - IV estrogen q4h x24hr - Tranexamic acid (TXA) - D&C What is the best treatment for a 13yoF with profuse vaginal bleeding but is hemodynamically stable with Hct 26%? (2020) - IV estrogen - OCPs - D&C - Endometrial biopsy then progesterone treatment

IV estrogen Q4H x 24H IV estrogen

What marker is highest in patients with menorrhagia? (2021) - Thromboxane - PGI2 - PGE2 - Something else

PGI2 = prostacyclin

Which of the following is most commonly associated with endometrial cancer due to unopposed estrogen? (2020, 2021) - PTEN mutation - Smoking - Advanced age - MSH2

PTEN mutation vs Age

What is the most sensitive finding for adenomyosis? (2021) - Increased thickness of the junctional zone - Myometrial cysts and hyper (or hypo?) echogenic opacities on ultrasound (US) - Diffusely thickened myometrial layer on MRI - Abnormally soft uterine tone on laparoscopy

Increased thickness of the junctional zone

What is vasodilation after IV estrogen due to? (Why do coronary arteries dilate within 25sec of IV infusion of estradiol?) (1999, 2020) - Genomic effects of estrogen - Non-genomic effects of estrogen - Effect of the estrogen response unit - Release of endothelin-1 - Formation of estrogen receptor (ER) dimer - Other

Non-genomic effects of estrogen Estrogen increases NO synthesis (vasodilator)

What is the mechanism by which IV estrogen stops acute bleeding? (2005) - Clotting - Re-epithelialization - Others

Clotting Re-epithelialization Both, but probably pick re-epithelialization for denuded endometrium

What is not a good treatment for a perimenopausal woman with menorrhagia? (2013)

Copper IUD (ParaGard)

A 14 yo F presents with persistent severe and heavy bleeding with menses. What do you do? (2018) - Check a CBC - TSH - Wait 6 mo re-evaluate

Check a CBC

What is a contraindication for tranexamic acid (TXA) use? (2016) Smoking Retinal artery thrombosis Uterine artery embolization (UAE) AVM Uterine septum Infertile patient with intramural fibroids Submucosal fibroids

Retinal artery thrombosis

What is the best treatment for heavy bleeding and anemia? (2016) - Levonorgestrel IUD (Mirena) - Tranexamic acid (TXA)

Mirena

A 16yoF girl has AUB. What is the most likely finding? (2003) - Von Willebrand - Others

Von Willebrand

A healthy 46yoF has AUB with Hgb 10g/dL. What is the best treatment? (2003) Prostaglandin synthesis inhibitor Endometrial ablation OCPs

OCPs *Prostaglandin synthesis inhibitor = NSAIDs

An 18yoF has abnormally heavy menses. What is the most likely etiology of her AUB? (2005)

Coagulopathy

A 35yoF presents with persistent AUB for 1yr. What is the most likely etiology? (2003, 2005, 2007, 2023 NIH) Coagulopathy Endometrial polyp Increase in prostacyclin production Fibroids

Fibroids

A 25/35yoF has AUB. What is the least likely cause? (2007) Endometrial polyp Fibroids Factor V Leiden IInsufficient luteal phase progesterone secretion

Factor V Leiden *Clotting disorder, not bleeding

What is least likely to cause AUB (menorrhagia) from endometrial overgrowth (a thickened endometrium)? (2007, 2023 NIH) - Conjugated estrogen - Mifepristone (RU-486) - Raloxifene

Raloxifene *Acts as antagonist on endometrium

What is the best way to quantitate menses if doing a research trial on the menstrual cycle? (2013) - Pictorial - Diary - Hgb

Diary

What is the best treatment for decreasing bleeding in women with fibroids distorting the uterine cavity? - Levonorgestrel IUD (Mirena) - Depot medroxyprogesterone acetate (DMPA) (Depo-Provera) - UAE - Ablation

UAE

What is increased in menstrual fluid in women with menorrhagia? (2023 NIH) Prostacyclin Thromboxane PGE2

Both prostacyclin, PGE2

Which of the following is the best indication for a UAE? (2023 NIH) - AV malformation - Multiple submucosal fibroids - Intramural fibroids with infertility

AV malformation

What is the most likely outcome after an endometrial ablation? (2023 NIH) - Future hysterectomy - Light vaginal bleeding with the menstrual cycle - Amenorrhea

Light vaginal bleeding with the menstrual cycle

A patient presents with irregular cycles and a 12mm homogenous stripe. What is the best next step? (2023 NIH) - Endometrial biopsy - Combined OCPs - Saline sonogram (SIS)

COCs

What is the effect of tamoxifen on bone density (BMD)? (2007)

Increases BMD in post-meno women but decreases BMD in pre-meno women

What is the effect of raloxifene on bone density (BMD)? (2007)

Increases

What is the effect of tamoxifen on cholesterol? (2007)

Increase: HDL, SHBG (--> lower free E2) Decrease: LDL, cholesterol, ATIII

What is the effect of raloxifene on cholesterol? (2007)

lowers LDL

What should you not give someone for vasomotor symptoms who is taking tamoxifen for breast cancer? (2021, 2022) Paroxetine Citalopram Escitalopram Sertraline

Paroxetine *In order to be fully effective, tamoxifen must be metabolized to an active metabolite, endoxifen, by the liver enzyme cytochrome P450 2D6 (CYP2D6). Consequently, any co-administered agent (e.g. paroxetine, fluoxetine, bupropion) that inhibits this enzyme will reduce the conversion of tamoxifen to endoxifen, thereby potentially reducing the efficacy of tamoxifen as a breast cancer therapy.

A patient with hot flashes is on tamoxifen to reduce risk of breast cancer recurrence. What do you add? (2017, 2021) Paroxetine Norethindrone Venlafaxine Citalopram Escitalopram Gabapentin Valerian root

Gabapentin *Paroxetine, Venlafaxine, Citalopram, Escitalopram are all contraindicated as they would reduce effectiveness of tamoxifen

Which of the following drugs is most likely to interfere with the action of tamoxifen? (2021) - SSRI can’t remember which one - Benzodiazepine of some kind - Clonazepam - OCPs

OCPS (but why would someone on tamoxifen be on OCPs) SSRIs also interfere

What hormonal changes do you see in a premenopausal woman on tamoxifen? (2018, 2023 NIH) - Increased FSH - Increased inhibin - Decreased estrogen

Increased FSH

Which of the following has the least effect on endometrial thickness? (2012, 2014, 2015, 2023 NIH) Raloxifene Tamoxifen Mifepristone (RU-486) Clomiphene citrate (Clomid) Estriol Which of the following is least likely to lead to (vaginal bleeding from) endometrial hyperplasia? (2009, 2011, 2012, 2014, 2015, 2018) Raloxifene Tamoxifen Mifepristone (RU-486) Clomiphene citrate (Clomid) Estradiol Which one of the following does not lead to vaginal bleeding with endometrial side effects? (2023 NIH) Tamoxifen Raloxifene Estradiol Mifepristone (RU-486)

Raloxifene

What is the least likely effect of raloxifene? (2001, 2007, 2014, 2015, 2023 NIH) - HDL (up or down) - Triglycerides (up or down) - Hot flashes - VTE

No effect on HDL

What is the least likely effect of raloxifene? (2001, 2007, 2011) DVT Increased LDL Decreased HDL Increased cholesterol Hot flashes Fracture

Fracture

What is the most common side effect of tamoxifen? (2007, 2013, 2014) Hot flashes Arthralgias

Hot flashes

What is the most common side effect of aromatase inhibitors? (2007, 2009, 2013, 2014) Hot flashes Arthralgias Fractures

Arthralgias

What risk is associated with raloxifene? (2003, 2007, 2009, 2011, 2012, 2015, 2016, 2017, 2018, 2019, 2023 NIH) Endometrial hyperplasia Weight loss Increases DVT risk Stroke Reduced hot flashes Increased total cholesterol Increased LDL

Increases DVT risk

How does a risk reducing BSO affect the cancer risk of a patient with a BRCA? (2017, 2018) Decreases ovarian cancer by 90% Decreases breast cancer by 90% No change

Decreases ovarian cancer by 90%

Mechanism of action of tamoxifen

TAF-1 and TAF-2 areas can both activate transcription, but TAF-2 activates transcription only when it is bound by estrogen. The individual transactivating abilities of TAF-1 and TAF-2 depend on the promoter and cell context. Tamoxifen’s agonistic ability is due to activation of TAF-1; its antagonistic activity is due to competitive inhibition of the estrogen-dependent activation of TAF-2 (Figure 1.25). Tamoxifen (SERM): Agonist or antagonist at estrogen receptor a. Agonist due to TAF-1 activation i. Estrogen agonist effect – TAF-1 too weak to activate transcription when TAF-2 inactivated in most cell types EXCEPT endometrium, bone, liver (due to overcoming competitive inhibition of TAF-2) b. Antagonist activity due to competitive inhibition of TAF-2 action i. Anti-estrogen effect occurs in tissues when response to estrogens is mediated by TAF-2

Each of the following is an established risk factor for breast cancer except? (Which of the following does not increase breast cancer risk?) (1999, 2005, 2023 NIH) First pregnancy after age 30yo Nulliparity OCPs First degree relative with breast cancer Cigarette smoking

OCPs

How is testosterone replacement managed in a woman? (2011, 2012, 2018) Keep testosterone levels in normal range Keep giving testosterone until patient feels better Increased libido Give as much testosterone as needed, even if blood levels are high

Keep testosterone levels in normal range

What does testosterone replacement in postmenopausal women most likely result in? (2011, 2012, 2018, 2023 NIH) Improvement in UTI Increased ovarian androstenedione production Improved sense of wellbeing Improved lipid panel Increased skin elasticity Increased thrombotic events

Improved sense of wellbeing

What is the mechanism of hot flashes in postmenopausal women? (2017, 2018, 2020, 2021, 2022) Decreased endorphins Narrowing of the central thermoregulatory zone Increased catecholamines

Narrowing of the central thermoregulatory zone

What medication increases osteoblast activity? (2013, 2014, 2015, 2016, 2018, 2022, 2023 NIH) Teriparatide Raloxifene Bisphosphonates E2 SERMs Denosumab Calicitonin Which of the following increases osteoblast activity? (2011, 2023 NIH) Estrogen Calcium Calcitonin Bisphosphonates PTH What directly stimulates osteoblast activity? (2012, 2014, 2018) Vitamin D Estrogen Tamoxifen Raloxifene Bazedoxifene

Teriparatide*** is a recombinant PTH PTH Estrogen

Which one is least associated with osteoporosis? (2003, 2009, 2012, 2014, 2018, 2023 NIH) Steroids Hypothyroidism Hyperparathyroidism Renal failure Smoking

Hypothyroidism *Hyperthyroidism causes osteoporosis

A 75yoF with coronary heart disease (CHD) and TSH 10mU/mL. What therapy do you initiate? (2007, 2021, 2022, 2023 NIH) 15mg desiccated thyroid (Armour) 20mg desiccated thyroid (Armour) 25ug levothyroxine (Synthroid) 50ug levothyroxine (Synthroid)

25ug levothyroxine (Synthroid)

What should the starting levothyroxine (Synthroid) dose be for a 60yoF with hypertension when her needed dose is 150ug? (2023 NIH) 12.5ug 25ug 100ug 150ug

25ug

What does transdermal HRT do differently compared to oral HRT? (2021) Decreases triglycerides

Decreases triglycerides

Postmenopausal woman with known cardiovascular disease (CVD) and hot flashes. What will provide the best relief of symptoms? (2021) Some specific SSRI (paroxetine maybe) Vaginal E2 Transdermal E2 Black cohosh

Transdermal E2

What is least likely to be elevated with a transdermal estrogen patch? (2009) SHBG LDL Triglycerides HDL

Triglycerides

What is the least effect of estrogen (HRT) on cardiovascular disease (CVD)? (2003, 2005, 2007, 2009, 2011, 2012, 2018, 2023 NIH) Increase in NO synthase Decrease in NO synthase Inhibits oxidation of LDL Increase in HDL Increase in prostacyclin

Decrease in NO synthase (*E2 increases NO, which is anti-atherogenic)

What will most effectively reduce hot flashes in a perimenopausal woman? (2021) Vaginal E2 Systemic E2 Some SSRI Clonazepam

Systemic E2

What is an absolute contraindication to initiation of testosterone therapy in a hypogonadal male? (2021, 2023 NIH) PSA 2.5ng/mL Hct 45% Breast cancer Obesity CHF Class 1

Breast cancer

What is absolutely contraindicated for men with breast cancer? (2018)

Testosterone therapy

What complication is bisphosphonate treatment associated with? (2012, 2014, 2015, 2018, 2021) Increased serum calcium levels Osteonecrosis of the mandible Atypical fractures of the femoral head Something else about bones

Osteonecrosis of the mandible

What is the best treatment for vasomotor symptoms when HRT is contraindicated? (2019) Paroxetine Neurontin Black cohosh

Paroxetine

Which of the following is the best treatment for vasomotor symptoms? (2014, 2015) Venlafaxine Clonidine Black cohosh

Venlafaxine

What is the best way to protect bones (prevent bone loss) of a 35yoF patient with POI? (2018, 2019) OCPs Transdermal HRT Calcium and vitamin D Weight-bearing exercise

OCPs

How do you treat hot flashes and vaginal dryness in a 52yoF with prior hysterectomy? (2017, 2018) Systemic estrogen Vaginal estrogen Systemic estrogen and progesterone

Systemic estrogen

A 63yoF presents with a T-score of -3 and Z-score of -2.5. What is the least likely cause? (2009, 2011, 2012, 2013, 2014, 2015, 2018, 2023 NIH) Normal menopause Chronic renal disease Multiple myeloma Hyperparathyroidism Hyperthyroidism Hypothyroidism Vitamin D deficiency

Normal menopause

A 65yoF has a T-Score of -3 and Z-Score of -2.5. What is the least likely reason? (2023 NIH) Menopause Vitamin D deficiency Hypoparathyroidism

Menopause

A 60yoF has a T-score of -2, normal PTH, normal calcium, and vitamin D 9ng/dL (low). What is the best initial treatment? (2011) Bisphosphonates Calcium Vitamin D DEXA in 2yr

Vitamin D

What is least effective at treating osteoporosis? (2013) Vitamin D supplementation Calcitonin Bisphosphonates HRT

Vit D supplementation

What is the highest food source of vitamin D? (2016, 2023 NIH) Raw milk Hard cheese Cod liver oil Spinach

Cod liver oil

What is least effective at treating osteoporosis? (2013, 2014, 2015, 2018) High dose calcium Calcitonin Bisphosphonates HRT What treatment will not increase bone density (BMD)? (2011, 2013, 2014, 2015) High dose calcium Calcitonin Risedronate HRT What is least likely to increase bone density (BMD)? (2023 NIH) High dose calcium Calcitonin Estradiol Bisphosphonates

High dose calcium

What is least likely to improve bone density (BMD)? (2005, 2007, 2009) Calcitonin Raloxifene Tamoxifen

Calcitonin

What is the best way to determine bone loss? (2010) Vitamin D TFTs Renal function tests DEXA

DEXA

What is most likely to result in negative calcium balance? (2023 NIH) Hyperprolactinemia Renal insufficiency Hyperthyroidism Progesterone treatment Hyperparathyroidism

Renal insufficiency

What is most likely to have a negative calcium balance? (2013, 2014, 2017) Hypercortisolism Hyperprolactinemia Hyperparathyroidism

Hypercortisolism

What is the best predictor of perimenopause within 10yr? (2014, 2018, 2023 NIH) AMH FSH Inhibin

AMH

What does HRT do to cardiovascular disease (CVD)? (2015) Primary and secondary prevention of cardiovascular disease (CVD) Primary prevention only

Primary prevention only

When is HRT most likely to have a protective effect? (2015) Obesity PCOS Hyperlipidemia Perimenopause

Perimenopause

What hormone decreases in menopause? (2015, 2016, 2017, 2018) DHEAS Androstenedione Testosterone 3-alpha-androstanediol glucuronide (3-alpha-AG)

DHEAS

Measured at any time during the menstrual cycle, which is most likely to predict menopausal status? (2014, 2015) FSH LH AMH Inhibin

AMH

A 50yoF with prior TAH-BSO wants medications for hot flashes but does not want to take anything that increases her risk of breast cancer. What do you give her? (2014, 2015, 2023 NIH, 2023 NIH) Gabapentin Venlafaxine Conjugated equine estrogens (CEE) (Premarin)

Venlafaxine

Who is most likely to have hot flashes? (2017) African American Asian Pacific Islander Hispanic

African American

Which route of HRT gives the most constant levels? (2012, 2015, 2017, 2018) Transdermal Oral IM

Transdermal

Compared to placebo, which was increased in the estrogen only arm of the Women’s Health Initiative (WHI)? (2015, 2016) Breast cancer Stroke DVT Lung cancer Urinary incontinence Vertebral Fraction

Stroke C-EE and E-P arms: - Increased CVA - Decreased hip fracture E-P arm: - Increased VTE > increased BC > inc CHD - Decreased colon ca

Compared to the increased risk seen in the estrogen only arm, what differed in the estrogen and progestin arm of the Women’s Health Initiative (WHI)? (2005, 2007, 2010, 2023 NIH) Breast cancer risk Cardiovascular disease (CVD) risk VTE risk

Breast cancer risk

A postmenopausal woman has been on estrogen HRT for years. If she continues, her risk of which of the following will continue to increase? (2012) Stroke VTE

Stroke

Why is hirsutism common after menopause? (2018)

Change in androgen/estrogen ratio

What is least likely to affect circulating estrone levels? (2012, 2018) - Liver disease - Hypothyroidism - Aging - Obesity

Hypothyroidism

What is least likely to cause osteoporosis? (2023 NIH)

Hyperprolactinemia

How do you monitor response to treatment of osteoporosis after 3mo of treatment? (2007, 2010, 2012) Serum C-telopeptide Procollagen Osteocalcin DEXA scan

Serum C-telopeptide

What is the worst marker of bone resorption? (2010, 2011, 2012, 2018, 2023 NIH) Urinary N-telopeptide Serum N-telopeptide Serum C-telopeptide Serum hydroxyproline Urinary hydroxyproline Hydroxypyridine Urinary C-phosphatidylcholine Urinary N-phosphatidylcholine What is the least useful test for measuring the efficacy of osteoporosis treatment? (2023 NIH) N-telopeptide C-telopeptide Hydroxyproline

Serum hydroxyproline

What is least likely to reflect bone resorption? (2011) N-telopeptide C-telopeptide Urinary hydroxyproline Serum N-terminal propeptide of type 1 collagen

Serum N-terminal propeptide of type 1 collagen

A patient begins treatment for osteopenia. How can you best assess if the regimen is preserving bone density (BMD) 3mo later? (2003) DEXA of spine DEXA of hip Osteocalcin:creatinine ratio C-telopeptide:creatinine ratio

C-telopeptide:creatinine ratio

Adiponectin is secreted by ___ Increased/decreased adiponectin is assoc w metabolic syndrome, insulin resistance and obesity. (2023 NIH)

Adipose Decreased

Which of the following scenarios would be most appropriate to initiate treatment with metformin? (2021) Obesity Abnormal glucose tolerance test (GTT) Insulin resistance PCOS

What is least likely to have a negative calcium balance? (2003, 2011, 2012, 2013, 2014, 2018, 2023 NIH) Hypercortisolism Hyperprolactinemia Hyperthyroidism Progesterone therapy Hyperparathyroidism Alcohol Anorexia

Hyperparathyroidism

What is the best way to check bone density (BMD) 3mo post treatment? (2023 NIH) DEXA spine DEXA hip Telopeptides Serum hydroxyproline What is the best test after 3mo of osteoporosis therapy? (2023 NIH) DEXA spine DEXA hip C-telopeptide Urinary CTX/creatinine ratio

Telopeptides

If a teenager is getting a DEXA scan as there is a concern for bone mass. What score do you use? (2007, 2011, 2012, 2014, 2017, 2018, 2022, 2023 NIH) T-score Z-score Age adjusted tables Growth chart Telopeptide Single ray photon

Z-score

What is the best test for bone density (BMD) in a 16yo girl? (2023 NIH) DEXA scan with T-Score DEXA scan with Z-Score Heel ultrasound (US) Telopeptide

DEXA scan with Z-Score

An 18yoF college student gets a DEXA and her T-score of -2.5. What is the most likely cause? (2009, 2018, 2023 NIH) Low BMI Age Exercise OCPs

Age T-score compares against healthy 30 year old female (bone mass peaks in 20s) Z-score compares against sex, age, weight matched controls

What is the least likely to help a 61yo postmenopausal woman with severe osteopenia? (2005, 2012, 2018) Estradiol Alendronate High dose calcium Raloxifene Calcitonin Risedronate

High dose calcium

A 58yoF presents with osteopenia. What is the least likely cause? (2011) Chronic renal insufficiency Smoking Hyperparathyroidism Hyperthyroidism

Hyperparathyroidism

What occurs less with aromatase inhibitors compared to tamoxifen? (2011, 2012, 2013, 2014, 2018, 2023 NIH) Hot flashes Nausea and vomiting Thromboembolism Arthralgias Fractures

Thromboembolism

What occurs less with aromatase inhibitors compared to tamoxifen? (2023 NIH) Hot flashes Arthralgias Fractures

Hot flashes

What occurs more with aromatase inhibitors compared to tamoxifen? (2011) Hot flashes Myalgias Bone density (BMD) DVT risk

Myalgias

What is the earliest sign of perimenopause? (2007) Increasing FSH Decreasing inhibin What is the earliest sign of perimenopause? (2023 NIH) Increasing FSH Decreasing inhibin Decreasing AMH

Decreasing inhibin (if AMH is not an answer) Decreasing AMH

Which is least likely to occur during the perimenopause? (2005, 2018, 2023 NIH) Amenorrhea Oligomenorrhea Menorrhagia Regular cycles

Regular cycles

Which of the following hormonal changes is most likely found in a perimenopausal woman? (1999) Increased estradiol Increased androstenedione Decreased post-ovulatory progesterone Decreased FSH

Decreased post-ovulatory progesterone

A patient wants HRT but wants the least amount of variability in dosing as she has night sweats and hot flashes in the evening. Which of the following would be best? (2012, 2015) - Transdermal patch - IM - Oral cyclic - Oral continuous

Transdermal patch

What do you check to diagnose vitamin D deficiency? (2012) 25 Vitamin D 1,25 Vitamin D

25 vit D

Which hormone is least likely to decrease with age? (2007) Insulin DHEA Growth hormone

Insulin

What is the most important risk factor for stroke in women? (1999) Cigarette smoking OCPs Hypertension Hypercholesterolemia

HTN

What does oophorectomy in a postmenopausal woman have the greatest effect on? (1999) DHEAS Testosterone Estrone Androstenedione Estradiol

Testosterone

What does the post-menopausal ovary make most? (2023 NIH)

Androstenedione

What is an LDL receptor defect most likely to cause? (2003, 2005)

Atherogenesis

What is the primary function of HDL? (What is a consequence of processing HDL?) (1999, 2001, 2003, 2010, 2023 NIH) - Atherogenesis - Decreased hepatic lipase - Reverse cholesterol transport - Act as a scavenger transporting cholesterol back to the liver

Reverse cholesterol transport

Which hormone would not be expected to decrease in aging? (Which hormone is least likely to decrease with aging?) (2003, 2010, 2023 NIH) Testosterone Insulin TSH FSH

FSH

Which hormone does not change during menopause? (2005, 2023 NIH) Insulin Testosterone DHEA Androstenedione Estrogen

Insulin

For a woman taking cyclic HRT, which progestin will be least likely to have androgenic side effects? (2003) Norethindrone Micronized progesterone Medroxyprogesterone acetate (MPA) (Provera)

Micronized progesterone

HRT is most likely to decrease the risk of which of the following? (2003) Colon cancer Ovarian cancer Endometrial cancer

Colon cancer

Which of the following daily regimens is least likely to preserve bone density (BMD)? (2003) Ethinyl estradiol 20μg and norethindrone 1mg Conjugated estrogens 0.625mg and methyltestosterone 1.25mg Conjugated estrogens 0.3mg Medroxyprogesterone acetate (MPA) (Provera) 10mg

Medroxyprogesterone acetate (MPA) (Provera) 10mg

What substance is least likely to be increased in a patient with low bone mass? (2005) Vitamin D IL-6 PTH Calcitonin

Vit D

42yoF with a history of previously regular menses presents with recent increased frequency of menses. What is the next step? (2005, 2023 NIH)

Observation *Perimenopause *In another recall list, OCP was listed – would choose OCPs*** 2005

Which clinical presentation does not require further evaluation? (2005, 2023 NIH) - 52yoF on cyclic OCP with endometrial thickness 8mm - 60yoF with fluid in the endometrial cavity

52yoF on cyclic OCP with endometrial thickness 8mm

What is postmenopausal HRT therapy for? (2023 NIH) Primary and secondary prevention Primary prevention only Prevention of heart disease Others

Primary and secondary prevention

How would you titrate the dose of testosterone in a female using it for sexual dysfunction? (2023 NIH) Titrate to testosterone levels Titrate to clinical improvement despite high levels

Titrate to testosterone levels

A woman in her late 40s had regular menses followed but her next cycle started 17d later then her most recent cycle was 65d after that. What do you do? (2023 NIH) FSH AMH Ultrasound (US) Endometrial biopsy Menstrual period calendar

Menstrual period calendar

What is the most common ocular complaint in menopause? (2023 NIH) Macular degeneration Glaucoma Cataracts Dry eyes

Dry eyes

A 50yo menopausal patient presents with hot flashes and vaginal dryness. What is the best treatment? (2023 NIH) Vaginal estrogen SSRI Clonidine Systemic estrogen

Systemic estrogen

What is estrogen in HRT is least associated with? (2023 NIH) Decreased cholesterol Increased HDL Increased LDL Plaque formation

Increased LDL

What is the best strategy for lasting weight loss in an obese woman with a BMI 56 kg/m2? (2018) - Diet - Exercise - Medications - Bariatric surgery What is the best strategy for lasting weight loss in an obese woman with a BMI 56kg/m2? (2018, 2023 NIH) Gastric bypass Lap band Others

Bariatric surgery Gastric bypass

What leads to obesity? (2015) Defect in leptin Defect in leptin receptor

Defect in leptin receptor

What is most common with obesity? (2015, 2023 NIH) Defect in leptin receptor High adiponectin Decreased adiponectin Low leptin High ghrelin

Decreased adiponectin

Which of the following does not increase in obese women? (2012) Leptin Insulin Hyperandrogenism SHBG

SHBG

A patient had gastric bypass surgery. What is the most likely change? (2014, 2023 NIH) Decreased leptin Neuropeptide Y (NPY) Decreased ghrelin Adiponectin

Decreased ghrelin

What happens if a patient is on the Atkins diet? (2011, 2023 NIH) Fat intake suppresses appetite Decrease in insulin Decreased total calories

Decrease in insulin

What is the most likely effect of leptin in a normal weight person? (2023 NIH) Change ghrelin Decrease appetite

Decrease appetite

Ghrelin is an endogenous ligand for which receptor? (2015) Insulin Growth hormone

Growth hormone

What do TPO antibodies bind to? (2021, 2022) Thyroid microsomes TBG T4 TSH

Thyroid microsomes

What is the best test to diagnose recurrence of [papillary] thyroid carcinoma? (2021) - Thyroglobulin - TPO antibody - TSH - Free T4

When is the soonest thyroid levels should be checked after an increase in levothyroxine (Synthroid) dose? (2012) 1wk 2wk 4wk 8wk

8 weeks

What are the changes in thyroid function tests in early pregnancy (In a woman with known hypothyroidism)?: (2018, 2021) Elevated TSH, decreased T4 Elevated TSH, decreased T3 Low TSH, increased T4 Low TSH, normal T3

Low TSH, increased T4

What is the best next step for a palpable 2cm painless thyroid nodule/mass in the right lobe with normal thyroid function tests? (2005, 2007, 2011, 2014, 2019) Ultrasound (US) with doppler Open core biopsy Fine needle aspiration (FNA) Thyroidectomy Uptake scan

US with Doppler

How do you evaluate a malignant thyroid nodule? (2011) Ultrasound (US) with doppler Open core biopsy Fine needle aspiration (FNA) Thyroidectomy Uptake scan

FNA

What is the best diagnostic test for a thyroid nodule? (2023 NIH) Fine needle aspiration (FNA) TFTs Thyroid scan Open biopsy

FNA

A patient presents with a painful diffusely enlarged thyroid, elevated TSH, decreased T4, and fatigue. What is the diagnosis? (2011, 2023 NIH) Subacute thyroiditis (viral, deQuervain) Hashimoto thyroiditis Graves disease A patient presents with symptoms of hyperthyroidism and a painful, enlarged thyroid gland. What is the most likely cause? (2011) Graves disease Subacute (DeQuervain) thyroiditis Postpartum thyroiditis Thyroid cancer

Subacute thyroiditis (viral, deQuervain) Subacute (DeQuervain) thyroiditis

What is the most common cause of hyperthyroidism in the United States? (2010) Graves disease

Graves disease

What kind of receptor does T3 use? (2013, 2014, 2018) Cell surface receptor Nuclear receptor Combination of cell surface and nuclear receptor Endoplasmic reticulum receptor

Nuclear receptor

What happens to fetal thyroid hormones in pregnancy? (2007, 2011, 2012, 2016, 2018) Elevated TSH Elevated T3 Elevated rT3 Low T4

Elevated rT3

What is the fetal thyroid function profile at 20wk? (2012, 2018) Decreased TSH, increased T4, increased rT3 Increased TSH, increased T4, decreased rT3 Increased TSH, stable T4, increased rT3 Increased TSH, increased T4, increased rT3

Increased TSH, increased T4, increased rT3

Which is true about the fetal thyroid? (2014, 2015) TSH maxes out at 10wk with peak in hCG Resembles pattern seen in cachexia Other thyroid options What is the neonatal thyroid panel characterized by? (2023 NIH)

Resembles pattern seen in cachexia (high rT3, low T3) Similar to patients with eating disorders (increased rT3, low T3)

A woman with hyperthyroidism presents with fever to 101F and tachycardia to 110s. What do you do first? (2014, 2015, 2017) Glucocorticoids Give T4 Beta blocker Radioablation

Beta blocker

A patient presents in thyroid storm. What do you do first? (2005, 2015, 2023 NIH) Propranolol (Beta blocker) Radioactive iodine Propylthiouracil (PTU)

Propranolol (Beta blocker)

A healthy 23yoF presents with new onset hyperthyroidism. TSH <0.1 mU/mL, high T3, and radioactive iodine was <3% (low). What is the most likely diagnosis? (2018) Graves disease Thyroiditis Hot thyroid nodule

Thyroiditis

What is most likely to occur in a 60yoF with hypothyroidism? (2003, 2005, 2011, 2012, 2014, 2018) Elevated total cholesterol Elevated HDL Elevated LDL Decreased LDL Decreased conversion/metabolism/clearance of T4 to T3

Elevated total cholesterol

What is least likely to be seen in a 69yoF with hypothyroidism? (2011) Elevated cholesterol Elevated HDL Decreased conversion/metabolism/clearance of T4 to T3

Elevated HDL

What is the most common cause of hyperthyroidism in pregnancy? (2018) Gestational trophoblastic disease Graves disease Subclinical hyperthyroidism Idiopathic hyperthyroidism

Graves disease

What is the best next test when a patient with symptoms of hypothyroidism is found to have low/normal TSH and low free T4? (2007, 2009, 2011, 2012, 2018, 2023 NIH) TSH stimulation test Free T4 rT3 TRH stimulation test Thyroglobulin Radio-Iodine uptake

TRH stimulation test

What are the changes in TSH that occur within the fetus during gestation? (2021) Increases progressively until term Increases until midgestation and then decreases Increases until midgestation and then plateaus Increases in first trimester then progressively decreases until term

Increases until midgestation and then plateaus *TSH starts to increase at 20 weeks, plateaus at 28 weeks, peaks shortly after birth

A patient with a history of hypothyroidism has a positive pregnancy test. How do you adjust dosing of their levothyroxine (Synthroid)? (2011, 2012, 2013, 2014, 2015, 2016, 2017, 2018, 2020, 2022) Increase 2 doses per week Increase by 30% and then check monthly Measure TSH, treat based on value Measure TSH, free T4; treat based on value Measure hCG, TSH, free T4; treat based on value No change A patient with a history of hypothyroidism has a positive pregnancy test. What do you do next? (2017 and 2018 was on a second time with different answer options) Increase 2 doses per week Check T4 every 8-10 weeks No change Increase T4 dose Check TSH Counsel on increased risk SAB A patient with hypothyroidism on levothyroxine (Synthroid) has positive pregnancy test. How do you manage her? (2023 NIH) Increase dose empirically Check thyroid antibodies Check TSH Check T4 A patient with a TSH of 4.5mU/mL has a positive pregnancy test. What do you do next? (2013, 2014) Increase 2 doses per week Increase by 30% and then check monthly Measure TSH, treat based on value Measure TSH, free T4; treat based on value Measure hCG, TSH, free T4; treat based on value

Increase by 30% then check monthly Increase dose empirically Increase by 30% then check monthly

How do you monitor hypothyroidism in a pregnant patient? (2023 NIH) Free T4 TSH Thyroid antibodies

TSH

A pregnant patient presents with Graves in the first trimester, but no symptoms. What do you do next? (2021) Expectant management Start propylthiouracil (PTU) Start methimazole Biopsy

Start PTU

What is postpartum thyroiditis most commonly associated with? (2020, 2021) Diffusely enlarged thyroid Thyroid nodule Anti-TPO antibodies Antithyroglobulin antibodies

Anti-TPO abs

What is postpartum thyroiditis most likely associated with? (2017, 2018)

T1DM

What is the least important lab to get in postpartum thyroiditis? (2011, 2012, 2018) TSH Free T4 Free T3 Antithyroglobulin Thyroglobulin

Postpartum thyroiditis is least associated with which of the following? (2007, 2009, 2018, 2023 NIH) Anti-TPO Hyperthyroidism Hypothyroidism Decrease rT3

Hyperthyroidism

Which laboratory test is least helpful in patients with postpartum thyroiditis? (2023 NIH) TSH, T4 TPO, T3 TBG

TBG

What do you give a pregnant female with hyperthyroidism in the first trimester? (2018) Methimazole Propylthiouracil (PTU)

PTU

What is impact on thyroid hormone levels and TSH if a fetus is exposed to propylthiouracil (PTU)? (1999, 2003, 2007, 2010, 2011, 2012, 2013, 2014, 2015, 2016, 2018, 2023 NIH) Decreased T4, increased TSH, clinically euthyroid at birth and quickly recover Congenital hypothyroidism Clinical hypothyroidism Goiter Hyperthyroidism A pregnant woman is taking 100-200mg PTU, what is the effect on the fetus? (1999, 2011, 2012, 2018) Decrease fetal TSH Increase fetal TSH Increase fetal T4 Increase fetal T3

Decreased T4, increased TSH, clinically euthyroid at birth and quickly recover Increase fetal TSH

What makes the most antithyroid antibodies? (2007, 2023 NIH) Thyroid peroxidase (TPO) Thyroglobulin Apical iodine transporter rT3

TPO

Thyroid antibody is least likely to develop against which of the following? (2007, 2023 NIH) Peroxidase Microsomal rT3 ALT

rT3

A 30yoF G1P0 wants to conceive immediately. What abnormality would you treat immediately with levothyroxine (Synthroid)? (2012, 2018) Hyperprolactinemia Free T4 in normal range TPO (antimicrosomal antibodies) Antithyroglobulin

TPO

What is the most common cause of hypothyroidism arising in the United States? (2003) Autoimmune thyroiditis Hyperemesis gravidarum

Autoimmune thyroiditis

Iodination of thyroglobulin occurs at which residue? (2003) Serine Leucine Valine Tyrosine

Tyrosine

A patient presents with fatigue, constipation, and pretibial edema. You suspect pituitary etiology. What is the best test to order? (2003) TSH Free T4

TSH

A patient has low TSH with symptoms of hyperthyroidism. What is the best diagnostic test? (2023 NIH) T3 Radio-iodine uptake Ultrasound (US) Antimicrosomal antibody

What is the next most appropriate test to diagnose a patient with an abnormal low TSH and T4? (2023 NIH) TRH stimulation test Free T3 ACTH stimulation test

Free T3

What is the next step in a patient with clinical signs of hypothyroidism and hypocarotenemia who is found to have normal thyroid testing? (2023 NIH)

TRH stim test

What is true of TBG (2023 NIH?) Carries 95% of T4 & T3 Carries 75% of T4 and T3

Carries 75% of T4 and T3

What is true of TBG (2023 NIH?) Lower affinity for T4 than T3 Higher affinity for T4 than T3

Higher affinity for T4 than T3

What is true of TBG (2023 NIH?) Decreases in pregnancy Increases in pregnancy

Increases in pregnancy

What are the 4th generation OCPs? (2018)

Drospirenone, dienogest, nomegestrol acetate

What is the mechanism of Factor V Leiden deficiency? (How does Factor V Leiden deficiency lead to increased clot formation?) (2019, 2020, 2022, 2023 NIH) Activated protein C resistance Activated protein C interaction with estrogen Elevated prothrombin activity

Activated protein C resistance

What is the most potent progestin? (2001, 2003, 2005, 2010, 2011, 2012, 2013, 2014, 2018, 2021) Levonorgestrel Norethindrone Norethindrone acetate Medroxyprogesterone acetate (MPA)

Levonorgestrel

What is the most potent progesterone? (2001, 2003, 2005, 2007, 2023 NIH) Gestodene Levonorgestrel Norethindrone Norethindrone acetate Medroxyprogesterone acetate (MPA)

Gestodene

What progesterone has the greatest progestational effect on endometrium? (Which of the following would have the most potent effect on endometrial progesterone receptors (PR)?) (2003, 2005, 2014, 2015, 2016, 2018) Levonorgestrel Norethindrone Gestodene

Levonorgestrel

Which OCP theoretically leads to the lowest levels of circulating free androgens? (2021) 20ug ethinyl estradiol and norethindrone 30ug ethinyl estradiol and norethindrone acetate 50ug ethinyl estradiol and levonorgestrel 35ug ethinyl estradiol and some progestin

50ug ethinyl estradiol and levonorgestrel

What is the serum level of estradiol most likely associated with ethinyl estradiol use in OCPs? (2007, 2009, 2011, 2012, 2014, 2018, 2023 NIH) 20-40pg/ml <30pg/ml >40pg/ml

<30pg/ml

What is the most potent androgen (in a female)? (2009, 2011, 2014, 2017, 2018, 2021, 2023 NIH) Testosterone DHT DHEA 19-nor testosterone Androstenedione DHEAS

DHT

What is the most potent androgen from the ovary? (2015) Androstenedione DHEA DHEAS Testosterone

Testosterone *Potency (greatest > least): DHT>T>Androstendione>DHEAS

What is the most potent androgen CIRCULATING in females? (2013, 2018, 2023 NIH) Testosterone DHT DHEA 19-nor testosterone Androstenedione DHEAS

Testosterone

What is the most androgenic progesterone (on primed endometrium)? (2012, 2013, 2014, 2015, 2017, 2018, 2019, 2023 NIH) Levonorgestrel Norethindrone Desogestrel Medroxyprogesterone acetate (MPA) Etonogestrel

Levonorgestrel

What determines the efficacy of OCPs? (2005, 2007, 2009, 2010, 2011, 2012, 2013, 2014, 2015, 2018, 2023 NIH) Estrogen dose Progestin dose Type of estrogen Type of progestin Estrogen:progesterone ratio

Progestin dose *The progestational agent in the pill suppresses LH (prevents ovulation), while estrogenic agent suppresses FSH (prevents emergence of a dominant follicle). Even if follicular growth and development were not sufficiently inhibited, the progestational component would prevent the surge-like release of LH necessary for ovulation.

What progestin is like an estrane? (2009. 2014, 2015, 2018, 2023 NIH) Levonorgestrel Norgestimate Ethynodiol diacetate Norethindrone Desogestrel

Ethynodiol diacetate Norethindrone *** Estranes: 1st generation progestins, C18 derivate of norethindrone * Norethindrone (Ovcon, Ortho Novum, Micronor) * Norethindrone acetate (Loestrin) * Ethynodiol diacetate (Kelnor) Gonanes: 2nd generation progestins, C17 derivatives, biologically more potent * Levonorgestrel (Tri Levlen, Seasonale, Plan B, Mirena) * Norgestrel (Ovral) * 3rd generation progestins (lower androgenicity than LNG and estranes) * Gestodene * Desogestrel (Kariva) * Norgestimate (Ortho Cyclen) * Etenogestrel (metabolite of desogestrel, Implanon, NuvaRing) The latest progestin to be developed is drosperinone. Drosperinone: progestin analogue of spironolactone with high affinity for the mineralocorticoid receptor and anti-androgenic activity. Pregnane family: C21 derivatives of 17α-acetoxyprogesterone * MPA: structurally most closely related to progesterone instead of testosterone, LESS androgenic activity, rapidly metabolized to progesterone All Synthetic Estrogens & Progestins have an ethinyl group at position C17→ enhances the oral activity

What 19-nortestosterone is known as estrane? (2023 NIH) Ethynodiol diacetate Levonorgestrel Destrogen Desogestrel Norgestimate

Ethynodiol diacetate

Which progesterone is a gonane? (2007, 2009, 2015) Levonorgestrel Norethindrone Ethynodiol diacetate Norethisterone

Levonorgestrel

Desogestrel and norgestimate are related to which progesterone? (2007, 2009, 2011, 2012, 2018, 2023 NIH) Medroxyprogesterone acetate (MPA) Levonorgestrel Drospirenone Dienogest Nomegestrol acetate

Levonorgestrel

Which of the following is levonorgestrel most closely related to? (2011) Norethindrone Norgestimate Norgestrel Gestodene

Norgestrel

Which of the following could act at the same receptor as desogestrel? (2007) Levonorgestrel Others

Levonorgestrel

What is the main mechanism of decreased androgenicity in gestodene and desogestrel? (2018)

Increased SHBG leading to decreased free testosterone

Which of the following is gestodene most similar to? (2003, 2023 NIH) Norethisterone Levonorgestrel

Levonorgestrel

What is an absolute contraindication to OCP use? (2018) Unexplained vaginal bleeding 1 ppd smoker Obesity

1 ppd smoker if > 35 years old Other absolute contraindications: - Liver disease - VTE, stroke, ischemic heart disease - pregnancy - complicated valvular heart disease - migraines with aura

What is the best choice for contraception in a woman with lupus? (2018) Systemic progesterone OCPs Levonorgestrel IUD (Mirena)

Mirena IUD

What drug is most likely to interfere with OCPs and decrease efficacy? (2001, 2009, 2011, 2012, 2014, 2015, 2018) Rifampin Tetracycline Ampicillin Captopril

Rifampin

What is the best test for ovarian reserve testing in a woman on OCPs? (2023 NIH) Day 3 FSH/LH AMH AFC What is the best marker of ovarian reserve to measure on someone on OCPs? (2017) AFC FSH AMH Inhibin

AMH

What is the effect of decreasing the pill-free interval from 7d to 4d? (2015, 2016, 2017) Increased GnRH suppression Decrease breakthrough bleeding Increased efficacy

Decrease breakthrough bleeding

What is the expected serum estradiol level in a patient using estrogen vaginal ring contraception? (2009) <30pg/mL 30-60pg/mL 60-120pg/mL >120pg/mL

<30pg/mL

What is the vaginal ring most likely to decrease? (2007, 2023 NIH) SHBG Triglycerides Total cholesterol HDL

HDL

What is most likely to be elevated with vaginal combined contraception use? (2009) SHBG 17-beta-estradiol LDL HDL Other

SHBG

What are “new” progestins (third generation)? (2018) Desogestrel Gestodene Norgestimate

All are 3rd gen

Drospirenone is most like what medication? (2015, 2023 NIH)

Spironolactone

Why does transvaginal contraception not need a conductance layer? (2011, 2012) Less adipose More areolar tissue No keratinocytes

No keratinocytes

Which of the following has the most potent antiproliferative effect on an estrogen primed endometrium? (1999) Norethindrone Norgestrel Levonorgestrel Medroxyprogesterone acetate (MPA) Desogestrel

Levonorgestrel

What hormone is present in the greatest quantity in conjugated equine estrogens (CEE) (Premarin)? (1999) Estrone sulfate Equilin Estriol

Estrone sulfate

A woman has been taking OCPs for 5yrs and she now wishes to conceive. She asks if it’s okay to try to conceive immediately upon discontinuing the pills. You advise her which of the following? (2003, 2010) Immediate conception will lead to a greater chance of congenital anomalies It is harder to calculate gestational age if conception occurs before the second menses off the pills

It is harder to calculate gestational age if conception occurs before the second menses off the pills

A healthy 25yoF develops a pulmonary embolism while on OCPs. She will be most likely found to have what on evaluation? (2003, 2010) Lupus anticoagulant Antithrombin III deficiency Protein C deficiency Protein S deficiency Factor V Leiden mutation

Factor V Leiden mutation

When administered in the follicular phase, mifepristone (RU-486) is most likely to do which of the following? (2003)

Induce menstrual changes in the endometrium

What induces LH receptors on granulosa cells just before ovulation? (2014, 2016, 2022, 2023 NIH) Progesterone Estrogen LH Activin Inhibin A

Estrogen

What is the strongest contraindication to OCP use in a 40yoF? (2007) Diabetes Migraines Controlled hypertension Mother with breast cancer Lupus

Controlled HTN

Which form of estrone is found in the highest circulating levels? (2023 NIH) Estrone Estrone sulfate 16-alpha-hydroxyestrone

Estrone sulfate

What is a pregnancy with copper IUD (ParaGard) most likely to result in? (2021, 2022) Previa Preeclampsia GDM

Previa

What is least likely to happen with a levonorgestrel IUD (Mirena)? (2007, 2013, 2014) Amenorrhea 3mo after removal Ovulation

Amenorrhea 3 mo after removal

What is most likely to happen with a levonorgestrel IUD (Mirena)? (2007, 2011, 2014, 2015, 2023 NIH) Amenorrhea 3mo after removal Ovulation Abnormal bleeding

Ovulation

What is the best emergency contraception 5 days after unprotected intercourse? (2003, 2007, 2011, 2012, 2013, 2014, 2015, 2016, 2018, 2023 NIH) Yuzpe method High dose levonorgestrel Mifepristone IUD

IUD

What is true about IUDs? (2014, 2015) Do not cause PID Contraindicated in HIV Increases absolute rate of ectopic pregnancy

Do not cause PID

What is least true about the levonorgestrel IUD (Mirena)? (2012, 2015) Effect limited to the uterus Decrease ovarian cysts Improved dysmenorrhea

Decrease ovarian cysts

What is the levonorgestrel IUD (Mirena) least useful for? (2014) Dysmenorrhea Menorrhagia Reducing endometrial cancer risk

Dysmenorrhea

What form of contraception has the lowest failure rate with typical use? (2011, 2023 NIH) Subdermal implant IUD OCPs Condoms

Subdermal implant

What is the least likely time in the menstrual cycle for a single act of intercourse to result in pregnancy? (2014, 2015) 2 days before ovulation 4 days before ovulation 1 day after ovulation

1 day after ovulation

What is the most likely time in the menstrual cycle for a single act of intercourse to result in pregnancy? (2007, 2015, 2023 NIH) At ovulation 2 days before ovulation 2 days after ovulation 4 days after ovulation 1 day before ovulation 1 day after ovulation

1 day before ovulation

What is the most common abnormality found in a normal fertile couple? (2005, 2007, 2011, 2012, 2018, 2023 NIH) Abnormal semen analysis Out of phase endometrial biopsy Antisperm antibodies FSH Ultrasound (US) Glucose tolerance

Abnormal SA

What is the most likely reason for bilateral hydronephrosis in a woman from India? (2019) Chlamydia Gonorrhea Tuberculosis

What percentage of women with chlamydia are asymptomatic? (2015) 10% 50-60% 70-80% >90%

70-80%

What doesn’t change AMH? (2023 NIH) PCOS 3rd trimester of pregnancy Ovulation Hypothalamic amenorrhea

Hypothalamic amenorrhea

What is the best initial screening test for intracavitary abnormality in infertility evaluation? (2023 NIH) HSG SIS Ultrasound (US)

SIS

A patient is undergoing vasectomy reversal and there is no sperm present in the vas remnant aspiration. What is the next best step? (2021, 2022) Vaso-vasotomy Vasoepididymostomy MESA microTESE

Vasoepididymostomy

What is the most important factor of vasectomy and reversal when predicting successful pregnancy? (2007, 2009, 2011, 2018, 2023 NIH) Type of reversal Time since vasectomy Antisperm antibodies Age of patient Previous fertility Length of vas

Time since vasectomy

A male is found to have CBAVD with a normal cystic fibrosis screen. What do you do next? (2012, 2013, 2014, 2015, 2017, 2018, 2019, 2020, 2022, 2023 NIH) (Expanded carrier) screen the partner for cystic fibrosis YCMD testing Karyotype analysis Biopsy Expanded testing of the patient No further testing is needed

(Expanded carrier) screen the partner for cystic fibrosis

Male patient presents with CBAVD, what is the best next step of workup on him? (2021) CFTR gene sequencing Expanded CF carrier sequencing panel mTESE

CFTR gene sequencing

When do primary spermatocytes appear (begin differentiation)? (2018, 2019, 2021, 2023 NIH) 8wk gestation 20wk gestation At birth Adrenarche Puberty

Puberty

What is the most common/likely cause of azoospermia? (2005, 2007, 2009) Cystic fibrosis carrier 47,XXY 47,XYY

47,XXY

What male genetic diseases with azoospermia has the highest incidence? (2023 NIH) Kallman syndrome AZYa and AZYb AZYc Klinefelter syndrome

Klinefelter

Male presents with non-obstructive azoospermia (NOA), what is the best surgical procedure? (2021) MESA PESA mTESE

mTESE

What is more likely to be associated with abnormal male karyotype? (2011, 2013, 2014, 2017, 2018) Oligospermia 0% morphology Teratospermia CBAVD Low motility Y chromosome micro-deletion (YCM)

Oligospermia

What is more likely to be associated with abnormal male karyotype? (2011, 2012, 2023 NIH) 1% normal morphology 4 million sperm/mL CBAVD Low motility

4 million sperm/mL

Which is most likely to be associated with chromosomal abnormality in a male? (2014, 2015) 0% normal forms (strict) Morphology 4% or less 10% motile

What is the most likely semen analysis defect associated with abnormal karyotype in man? (2014, 2018)

Oligospermia

What is the most likely genetic defect in a male with azoospermia, low testosterone, high LH, and high FSH? (2014, 2015) XX+XY Yp11 Yq11 Yp15 SRY

Yq11 - AZF microdeletion

What is the most common karyotype in a man with azoospermia and elevated FSH? (2009, 2012, 2018, 2023 NIH) AZFa or AZFb 47,XXY AZFc 46,XY DSD

47,XXY

What karyotype is most likely in azoospermia? (2012) 46,XY 46,XY, del(Yq11)

46,XY, del(Yq11) *AZF microdeletion

Which finding is associated with azoospermia? (2012, 2013, 2014, 2017, 2018) AZFa and AZFb AZFc

AZFa and AZFb

A man presents with azoospermia. What gene deletion is he most likely to have? (2013, 2018) AZFa or AZFb DAX FOXL2 AZFc

AZFa or AZFb

What is an inactivating FSH receptor mutation most likely associated with? (2023 NIH) Male hypogonadism Normal sperm parameters Normal female fertility

Male hypogonadism

What is the effect of antisperm antibodies? (2013, 2018) Sperm agglutination and infertility

Sperm agglutination and infertility

What is the most likely diagnosis for a male with azoospermia, normal size testes, palpable vas, and FSH 5mIU/mL? (2019, 2021) CBAVD 47,XXY AZFa Ejaculatory duct obstruction Exogenous steroids Gonadal failure Testicular cancer

Ejaculatory duct obstruction

What is least likely in a 47,XXY male? (2005, 2007, 2018, 2023 NIH) Cryptorchid testis Hypergonadotrophic hypogonadism Infertility Oligospermia Small testes Delayed puberty*** per 2007, 2009, 2018, 2023 NIH

Delayed puberty

An infertile couple presents. The male has isolated teratospermia and female with normal workup. What is the best recommendation for treatment? (2021) Expectant management Ovulation induction with IUI Ovarian stimulation with conventional insemination Ovarian stimulation with ICSI

Ovulation induction with IUI

What is the most likely semen analysis defect with an abnormal male karyotype? (2023 NIH) Abnormal morphology Abnormal motility Abnormal number

Abnormal number

Which chromosome is the regulator of all androgen activity? (2023 NIH) X Y 11 13 18

What most increases free testosterone? (2023 NIH) SHBG Total testosterone

SHBG

What hormone change do you see in conjunction with decreased total testosterone in an aging man? (2018, 2023 NIH) Increased free testosterone Increased DHEAS Decreased LH Increased SHBG

Increased SHBG

What is the most important determinant of testosterone production as men age? (2014) Age SHBG Albumin CBG

Age

How do you obtain sperm from a man with a spinal cord injury? (2013, 2017, 2023 NIH) MESA TESA Electroejaculation

Electroejaculation

What is the most likely finding in a male with atrophic testes and hypergonadism? (2014, 2018) Klinefelter syndrome

Klinefelter syndrome

What is least likely in Klinefelter syndrome? (2007) Cryptorchidism Small testes Low testosterone Pubertal delay

Pubertal delay

A man with Klinefelter syndrome undergoes testicular biopsy to obtain sperm for ICSI with his partner. What is the most likely karyotype of a resulting fetus? (2007) Normal 47,XXY 47,XYY 46,XY XY mosaic

Normal

A patient is found to have a testicular volume of 5mL. What is the most likely deletion? (2023 NIH) Y X

What is the most likely karyotype of a man with 5cc testicles, elevated LH, elevated FSH, and testosterone 150ng/dL? (2011, 2018, 2022) A. 46,XX B. 46,XY; del Yp C. 46,XY; del Yq D. 46,XY; del 15

C. 46,XY; del Yq

A male is found to have a testosterone 117ng/dL, LH 3mIU/mL, FSH 4mIU/mL, azoospermia, and atrophied testes. What is the most likely etiology? (2014) Microdeletion of Y chromosome CBAVD Fragile X Kallmann Syndrome

Kallmann Syndrome

What causes CGG repeat (alpha subunit) deficiency? (2014, 2018)

Fragile X

What disorder is most associated with adult onset disease in males? (2012, 2014, 2015, 2018) Sulfatase deficiency Aromatase deficiency Klinefelter syndrome Fragile X

Fragile X

A woman has a son who is affected by Fragile X. What will her father most likely experience as late onset disease? (2012, 2018)

Ataxia

What is the most common mutation in men with CBAVD? (2017)

Point mutation

What is the mechanism of action of sildenafil (Viagra)? (2015, 2016) NO synthase inhibitor Phosphodiesterase inhibitor

Phosphodiesterase inhibitor

What side effect is sildenafil (Viagra) least likely to have? (2023 NIH) Ptosis Priapism Colored vision (blue vision, cyanopsia) Dyspepsia

Ptosis

What other medication should men not take if they are using a phosphodiesterase inhibitor? (2017) Nitroglycerin SSRI ASA

Nitroglycerin

What is the chance of CBAVD in offspring of a delta F508 carrier father and 5T allele carrier mother? (2007, 2009, 2010, 2011, 2018) 100% 50% 25% Depends on other factors

25%

How do you counsel a couple about risks to offspring when the father is a delta F508 carrier and the mother is a 5T allele carrier? (2007, 2023 NIH)

They are not at increased risk for having a child with CF, but if they have a male, he is at increased risk of CBAVD

A male patient with Kallman syndrome wants children. How do you induce spermatogenesis? (2012, 2015)

hCG followed by HMG

A couple presents with a delta F508 heterozygous/carrier father and 5T allele heterozygous/carrier mother. How do you counsel them regarding male offspring? (2007) 100% chance of CBAVD 25% chance of CBAVD 100% chance of classic cystic fibrosis and CBAVD If the male child has cystic fibrosis, 10% chance of CBAVD If the male child has cystic fibrosis, 100% chance of CBAVD If the male inherits 5T and delta F508 on same chromosome, then will have classic cystic fibrosis (pancreatic involvement/respiratory involvement) 25% chance of classic cystic fibrosis

25% chance of CBAVD

What initiates spermatogenesis in a male with hypogonadotropic hypogonadism (hypo-hypo)? (2023 NIH) FSH hCG Clomiphene citrate (Clomid) LH

hCG

What mutation is found in a late onset hereditary condition in males with this disorder? (2014, 2015, 2023 NIH) FMR1 KAL1 KCNQ1

FMR1

What is least likely to decrease in a man as he ages? (2011, 2012) Insulin Growth hormone DHEAS Androstenedione

Insulin

Which mutation has a risk to male relatives later in life? (2011) Angelman Beckwith-Wiedemann Kallman Fragile X

Fragile X

Semen volume is least affected by which of the following? (2011) Hypogonadotropic hypogonadism (hypo-hypo) Obstruction CBAVD Vasectomy

Vasectomy

What is the most likely cause of erectile dysfunction if a man still achieves morning erections? (2007) Depression Diabetes Spinal cord injury Vascular disease Psychogenic

Psychogenic

An initial screening of the male partner of an infertile couple is indicated for which of the following? (2022) If the man questions his reproductive potential After 1yr of contemplating having children After 1yr if his partner is >35yo After 1yr if the couple is using birth control

If the man questions his reproductive potential

What is true regarding the evaluation for retrograde ejaculation? (2022) Is necessary if the man has CBAVD Should be performed in men with azoospermia due to hypogonadism Is indicated for all men with ejaculate volume <1mL Consists of microscopic evaluation of centrifuged pellet of a post-ejaculate urine sample

Consists of microscopic evaluation of centrifuged pellet of a post-ejaculate urine sample***

What is true regarding ultrasonography (US) of the male genital tract? (2022) Can detect prostate cancer Is performed as a part of the initial male evaluation for infertility Can show if spermatogenesis is occurring within the testicle Is indicated for men with azoospermia, normal vasa, and low volume ejaculate Is never indicated in the evaluation of male infertility

Is indicated for men with azoospermia, normal vasa, and low volume ejaculate

What is included in a thorough male infertility evaluation? (2022) A physical exam by a specialist in male reproduction Three semen analyses Mandatory genetic testing Scrotal ultrasound (US)

A physical exam by a specialist in male reproduction

Men with azoospermia or severe oligospermia should have which of the following? (2022) CFTR gene testing Genetic counseling A karyotype and Y chromosome microdeletion testing before IVF Intact AZFc region

A karyotype and Y chromosome microdeletion testing before IVF

When is sperm viability testing indicated? (2022) Count <10million/mL Most sperm are immotile There are an increased number of round cells Most sperm have abnormal morphology There is excess sperm DNA fragmentation

Most sperm are immotile

What semen analysis value is most likely to be associated with a chromosomal abnormality in male? (2023 NIH) Total motile sperm 1 million sperm/mL Morphology 0% normal

Total motile sperm 1 million sperm/mL

What is true regarding antisperm antibody testing? (2022) Should be performed in men with azoospermia Is best performed on serum May be indicated in a man with a history of orchitis Involves mixing the patient’s serum with his sperm

May be indicated in a man with a history of orchitis

Patient instructions for semen analysis should include which of the following? (2022) Cooling to room temperature after collection Collection in a standard latex condom Abstinence for no more than 24hr Analysis within 1hr after collection

Analysis within 1hr after collection

A 35yoM presents with azoospermia, a history of delayed puberty, sparse facial hair, erectile dysfunction, and small testes. Which test is most likely to reveal the cause of his infertility? (2022) Antisperm antibody testing Hormonal evaluation CFTR genetic testing Scrotal ultrasound (US) Quantification of leukocytes in the semen

Hormonal evaluation

Which is true of sperm DNA fragmentation testing? (2022) Can measure the number of breaks in sperm DNA that can’t be repaired Is indicated in the routine evaluation of all men with infertility Tests for sperm damage due to improper lab storage Is indicated in men with azoospermia

Can measure the number of breaks in sperm DNA that can’t be repaired

Which is the most common sex chromosome disorder in men? (2022) Kallmann syndrome Myotonic dystrophy Kartagener syndrome Klinefelter syndrome Noonan syndrome

Klinefelter syndrome

Most men with CBAVD have which of the following? (2022) Hypogonadism CFTR gene mutations Low testosterone levels Decreased sperm production Small testes

CFTR gene mutations

Which of the following is a manifestation of Kallmann syndrome in men? (2022) Increased FSH production Azoospermia Testicular dysgenesis Normal spermatogenesis Absent epididymis

Azoospermia

Sertoli cell-only syndrome is manifested by which of the following? (2022) Germ cell hyperplasia Only occurs as a congenital disorder Absence of germ cells Presence of Sertoli cells outside of the seminiferous tubules Lack of ability to smell

Absence of germ cells

What is the best next treatment for a couple trying to conceive when the male partner is 15yr post vasectomy? (2005, 2009, 2010, 2011, 2014, 2018, 2023 NIH) Vasectomy reversal TESE Vaso-vasotomy MESA with ICSI Percutaneous epididymal sperm extraction (PESA) and ICSI Donor sperm

MESA with ICSI

Which of the following is true regarding antisperm antibodies? (2022) Are due to varicoceles Result in hormone deficiencies May result from testicular surgery Cause FSH deficiency Cause disruption of the blood-testis barrier

May result from testicular surgery

Patients with Y chromosome microdeletions have which of the following? (2022) An abnormality in the long arm of the Y chromosome Are always azoospermic Experience delayed puberty Mental retardation

An abnormality in the long arm of the Y chromosome

What is most true of patients with cryptorchidism? (2022) Always have abnormal semen parameters Are more likely infertile if both testicles are undescended If full term, always have an identifiable cause of the condition Usually have elevated LH levels Have absent vas deferens

Are more likely infertile if both testicles are undescended

Which of the following is usually a congenital cause of male infertility? (2022) Anejaculation Pituitary tumors Erectile dysfunction AIS

AIS

A 32yoM with infertility is found to have azoospermia with a normal FSH. What is the most likely cause? (2022) CBAVD Kallmann syndrome Klinefelter syndrome Myotonic muscular dystrophy Hypospermatogenesis

CBAVD

Which of the following is true of varicoceles? (2022) Always bilateral Most common correctable cause of male infertility Due to dilated veins in the pelvic plexus Present in 25% of all men Usually right sided

Most common correctable cause of male infertility

What does the male reproductive tract develop from embryologically? (2022) Mullerian ducts Seminiferous tubules Wolffian ducts Corpus cavernosum

Wolffian ducts

Which testicular cells produce testosterone? (2022) Seminiferous tubules Epididymis Seminal vesicles Rete testis

Seminiferous tubules

What is the part of the sperm maturation process in which the round spermatids are engulfed by Sertoli cells and transformed into elongated spermatozoa with tails? (2022) Spermatogenesis Spermiogenesis Spermiation Mitosis

Spermiogenesis

Which hormone regulates testosterone synthesis? (2022) FSH LH GnRH Inhibin

Sertoli cells perform which function? (2022) Regulate testicular blood flow Provide blood-testis barrier Synthesize testosterone Fluid absorption

Provide blood-testis barrier

What is the predominant regulator of penile erection? (2022) Blood flow Testosterone Vas deferens cAMP Hypogastric nerve

Blood flow

What accessory sex gland aids in semen liquefaction? (2022) Seminal vesicle Prostate gland Bulbourethral gland Epididymis

Prostate gland

What is the site of sperm maturation, concentration, and storage? (2022) Epididymis Vas deferens Seminiferous tubules Seminal vesicle

Epididymis

Which sperm structure provides enzymes for penetrating the oocyte? (2022) Midpiece mitochondria Acrosome Cytoplasmic droplet Centrioles

Acrosome

What percent of couples with infertility have a male factor component? (2022) 10% 25% 33% 50% 75%

50%

What is the proposed mechanism for varicoceles being associated with male infertility? (2022) Reflex of toxic metabolites to the testes from the renal vein Disruption of the countercurrent heat exchange of the testes preventing cooling Stagnation of the blood in the testes, leading to the build up of toxic waste Hypoxia of the testes due to decreased blood flow

Disruption of the countercurrent heat exchange of the testes preventing cooling

What is the average length of time to improvement following varicocele repair and why? (2022) 2wk due to post-operative swelling 2mo due to transient decrease in testis function 3mo due to the length of the spermatogenic cycle 4mo due to the time required for full healing 6mo due to the length of the spermatogenic cycle

3mo due to the length of the spermatogenic cycle

Which of the following is the best predictor of success for vasectomy reversal? (2022) More than 10yr since vasectomy Female partner age <35yr Method of vasectomy Shorter testicular vasal remnant

Female partner age <35yr

A couple presents to discuss fertility options after a vasectomy. The vasectomy was performed 8yr ago. Prior to this, the patient had conceived two children with his previous wife. He is now remarried to a 32yoF who has never been pregnant. Which of the following would preclude the performance of a vasectomy reversal? (2022) Female partner with irregular cycles, felt to have PCOS Patient had a post-operative infection The couple only wants one child Female partner had a previous tubal ligation None of the above are contraindications for vasectomy reversal

Female partner had a previous tubal ligation

Which of the following statements regarding men with non-obstructive azoospermia (NOA) is true? (2022) Sperm may be obtained from the testes, even if a previous biopsy does not show mature sperm A markedly elevated FSH means that no sperm will be retrieved Percutaneous epididymal sperm aspiration (PESA) is a highly successful procedure in this patient population If sperm are obtained, they typically will not fertilize an egg, even with ICSI

Sperm may be obtained from the testes, even if a previous biopsy does not show mature sperm

A 28yoM comes in for evaluation for male factor infertility. His history and physical exam are normal. His semen analysis demonstrates oligospermia and his hormonal parameters are all normal except for a mildly decreased testosterone level. Which one of the following treatment options is the most reasonable? (2022) Testosterone replacement therapy with either injectable or topical testosterone preparation Scrotal ultrasound (US) to identify subclinical varicoceles with subsequent varicocele repair Injection of hMG or other FSH-like medication Scrotal exploration to identify subclinical obstruction Clomiphene citrate (Clomid) administration to increase endogenous testosterone production

Clomiphene citrate (Clomid) administration to increase endogenous testosterone production

Which one of the following patients is most likely to respond to hCG/hMG injection? (2022) 25yoM with Kallmann syndrome 28yoM with large grade 3 varicocele and normal hormones 35yoM currently with substance abuse including marijuana and cocaine use on a daily basis 30yoM who is morbidly obese with metabolic syndrome

25 yo M with Kallmann syndrome

Which one of the following describes a significant mechanism of injury to a male’s fertility secondary to testicular cancer? (2022) Cancer decreases sexual desire which leads to decreased fertility Loss of 10% of testicular tissue due to orchiectomy Damage due to adjuvant treatments (chemotherapy or radiation) Damage to the autonomic nerve trunk during lymph node dissection Changes in sperm DNA

Damage due to adjuvant treatments (chemotherapy or radiation)

A 22yo single male presents with 3wk of painless left testicular swelling. An ultrasound (US) demonstrates a solid mass suspicious for testicular neoplasm. What is the most appropriate next step? (2022) Sperm banking Testosterone injection Antibiotics for 2-3wk Percutaneous scrotal biopsy of mass Reassurance

Sperm banking

Cystic fibrosis is commonly associated with which of the following? (1999) CBAVD Testicular atrophy Oligospermia

CBAVD

Which of the following is an indication for testicular biopsy? (1999) Azoospermia with absence of fructose in semen Oligospermia with FSH 2mIU/mL Oligospermia with prolactin 110ng/mL Azoospermia with FSH 7.5mIU/mL

Azoospermia with FSH 7.5mIU/mL

An alcoholic man presents with gynecomastia. What is the cause of his gynecomastia? (2007, 2023 NIH) Decrease free estradiol/free testosterone production Decrease SHBG production Increase binding of estradiol to SHBG Increase liver conjugation of estradiol to estrone glucuronide Decrease in renal clearance of estradiol An alcoholic man presents with gynecomastia? What is the cause of his gynecomastia? (2007, 2023 NIH) Low testosterone High testosterone Low SHBG High SHBG Low estrogen

Decrease SHBG production

ICSI is most likely to be successful with what mutation? (2017, 2020, 2022, 2023 NIH) AZFa AZFb AZFc CFTR 47,XXY SRY

AZFc or CFTR

What mutation can’t be treated by ICSI? (2012, 2018) AZFa/AZFb AZFc CFTR 47,XXY SRY

AZFa/AZFb

Which is least likely to cause decreased libido in older men? (2003) Decreased testosterone Increased incidence of chronic diseases Others

Others

Which of the following is the least useful test for oligospermia? (2003) LH Testosterone Testicular biopsy Prolactin Seminal fructose

seminal fructose

Which of the following is the best way to differentiate CBAVD from spermatogenic arrest? (2003) LH Karyotype Inhibin Seminal fructose Post-ejaculatory examination of the urine How do you differentiate between germ cell arrest and cystic fibrosis? (2005, 2010, 2023 NIH)

Seminal fructose

What is Klinefelter syndrome least characterized by? (2003) Small testes Low testosterone Low estrogen Others

Low estrogen

What is an activating LH receptor mutation most likely associated with? (2023 NIH) Precocious puberty Decreased FSH Azoospermia

Precocious puberty

What initiates spermatogenesis? (2005, 2023 NIH) Testosterone and FSH Testosterone and LH Testosterone

Testosterone and LH

What is the risk of a karyotype abnormality in a fetus conceived by ICSI whose father has severe oligospermia? (2003, 2005, 2014, 2023 NIH) 10-11% 6-7% 2-4%

6-7%

Vasodilatory treatment helps erectile dysfunction except in which of the following? (2005, 2023 NIH) Spinal cord injury Peripheral neuropathy Peripheral vasculopathy Psychologic

Peripheral vasculopathy

A man presents with normal testicular volume, normal FSH, palpable vas deferens, and azoospermia. What is the most likely cause? (2023 NIH)

Idiopathic, normal karyotype

How do you treat persistent teratospermia? (2023 NIH) DNA fragmentation analysis Controlled ovarian hyperstimulation with IUI Repeat semen analysis Clomiphene citrate (Clomid) ICSI

DNA fragmentation analysis

What is the primary feedback on the hypothalamus with regards to testicular androgens? (2023 NIH) Testosterone Estradiol DHT Inhibin A

Testosterone

25yo w/ azoospermia T1200ng, FSH and LH undetectable, PRL and TSH normal. Most common cause? (2019) Testosterone-secreting tumor Cannabis use Steroid abuse Smoking

Steroid abuse

What is an absolute contraindication to initiation of testosterone therapy in a hypogonadal male? (2021, 2023 NIH) PSA 2.5ng/mL Hct 45% Breast cancer Obesity CHF Class 1

Breast cancer

What is absolutely contraindicated for men with breast cancer? (2018)

Testosterone therapy

What is the next step for a patient with unexplained infertility after three unsuccessful clomiphene citrate (Clomid)/IUI cycles? (2021) Continue clomiphene citrate (Clomid)/IUI Letrozole/IUI Gonadotropins/IUI IVF

IVF

How does tamoxifen work as an ovulation induction agent? (2021) At the adipocyte level Interrupting HPO axis feedback

Interrupting HPO axis feedback

What is the mechanism of action of clomiphene citrate (Clomid) in anovulatory women? (2021) Increasing GnRH pulse amplitude Increasing GnRH pulse frequency Decreasing GnRH pulse amplitude Decreasing GnRH pulse frequency

Increasing GnRH pulse amplitude *increases pulse frequency in already ovulatory women

What is the mechanism of action of clomiphene citrate (Clomid)? (2015) Increased estrogen synthesis in the ovary Decreased GnRH pulse amplitude Increased GnRH pulse frequency Increased LH pulse amplitude

Increased GnRH pulse frequency *increases amplitude in anovulatory women

Aromatase inhibitors lead to ovulation by what mechanism? (2021) Inhibition of negative feedback on the HPO axis Decreased aromatization at the level of the adipocytes (this is true but I find it hard to believe it leads to ovulation mostly from action at fat cells) Inhibition of the estrogen receptor (ER) at the level of the hypothalamus Inhibition of the estrogen receptor (ER) at the level of the pituitary

Inhibition of negative feedback on the HPO axis

What is the first step for ovulation induction in a patient with PCOS, BMI 40kg/m2, and oligomenorrhea? (2020) Weight loss Gonadotropins Ovarian drilling

Weight loss

What is the difference between follitropin alpha and beta? (2019)

Follitropin beta is more potent

An infertile male is found to have a moderate varicocele. What is true? (2023 NIH) Improved fertility with correction Venous reflux leads to testicular dysfunction Uncommon finding Unilateral varicocele is super common Oligospermia then that is enough of an indication to correct surgically

Oligospermia then that is enough of an indication to correct surgically

A 32yoF with 1yr of infertility, normal semen analysis, and mild endometriosis. What is the next step? (2014, 2018) SOH/IUI Clomiphene citrate (Clomid)/IUI Repeat l/s

Clomiphene citrate (Clomid)/IUI

What is the best treatment to induce ovulation in PCOS with a normal BMI? (2009, 2010, 2018, 2023 NIH) Metformin Clomiphene citrate (Clomid) and metformin Clomiphene citrate (Clomid) Letrozole

Letrozole

A 24yoF with anovulation (or oligo-ovulation) and a BMI 25kg/m2 presents for infertility. Her workup is negative. What medication would you use for ovulation induction? (2016) Clomiphene citrate (Clomid) Letrozole Gonadotropins No medications

Clomiphene citrate (Clomid)

What is the most cost effective for ovulation induction and IUI in unexplained infertility? (2007) IUI x2 IUI x1 ICI with IUI ICI x2

IUI x 1

Which of the following accounts for clomiphene citrate’s (Clomid) less than expected rate of pregnancy per ovulation? (1999) Decreased endometrial receptivity Others

Decreased endometrial receptivity

What is the conception rate of a patient with idiopathic anovulation treated with clomiphene citrate (Clomid)? (2005, 2023 NIH) 15% 45-50% Others

15%

A 30yoF with a religious objection to IVF is found to have phimosis on laparoscopy. What treatment will provide the best chance of pregnancy? (2012, 2018) GIFT Salpingectomy Tubal cannulation Fimbrioplasty

GIFT

How many oocytes do you implant in GIFT? (2022) One in each tube Two in each tube One in one tube, one in the other tube

One in one tube, one in the other tube

What is the highest risk factor for OHSS? (2018, 2020, 2022) PCOS AMH >3ng/mL AFC 18 BMI 40kg/m2

PCOS

What is most predictive of OHSS? (2009) Day 3 FSH AFC Day 3 E2 Day 3 Inhibin Other

AFC

What medications may be necessary in OHSS? (2018) IV hydration (normal saline, possibly albumin) Anticoagulation

Both may be necessary

What is the most likely cause of OHSS? (2023 NIH) hCG excess High peak E2 VEGF

VEGF

What procedures may be necessary in OHSS? (2018) Paracentesis Thoracocentesis

Paracentesis

What electrolyte abnormality is most commonly seen in OHSS? (1999, 2003, 2011, 2012, 2013, 2014, 2018, 2022, 2023 NIH) Hyponatremia Hypernatremia Hyperkalemia Hypokalemia Hypocalcemia

Hyponatremia

What is ICSI most indicated for? (2010, 2011, 2018, 2019, 2021, 2023 NIH) Unexplained infertility with prior failed IVF PGT-A PGT-M Elevated sperm DNA fragmentation AMA (Maternal age of 40yo) Strict morphology <4% Low oocyte number

PGT-M

Which of the following is not an indication for ICSI? (2018, 2023 NIH) Morphology <4% Prior failed IVF Maternal age >40yo <4 oocytes

Maternal age >40yo

What is the most important reason to do ICSI? (2011, 2023 NIH) PGT-A PGT-M Low morphology Unexplained infertility

PGT-M

What is an indication for ICSI? (2015, 2016, 2018, 2023 NIH) Low oocyte yield Unexplained infertility with failed IVF previously PGT-A PGT-M for cystic fibrosis

PGT-M for cystic fibrosis

What is least likely to matter to do ICSI? (2007, 2023 NIH) Morphology <4% PGT-M Oligospermia

Oligospermia

Which of the following is the best indication for ICSI? (2003, 2010) Klinefelter syndrome Radiation and chemotherapy for Hodgkin lymphoma

Klinefelter

What is the best/most likely reason to do ICSI? (2023 NIH) Thawed oocytes Unexplained infertility with history of IVF AMA (Maternal age of 40yo) Low oocyte yield

Thawed oocytes

What is associated most with low sperm morphology? (2012, 2018, 2023 NIH) Low fertilization with ICSI Low fertilization with IVF

Low fertilization with IVF

What is the most important determinant of fertilization with ICSI? (2007, 2011, 2018, 2023 NIH) Culture media Injection technique Sperm media Number of oocytes Age Method of specimen collection

Injection technique

What would make you do ICSI? (2023 NIH) Prolactinoma Hypothyroidism High FSH Low FSH Testosterone

High FSH

Who is the best candidate for freeze all with subsequent FET? (2021) E2 >3000pg/mL AMH 2.0ng/dL 15 oocytes retrieved AFC 25

E2 >3000pg/mL

What is the most common imprinting syndrome associated with IVF? (2013, 2014, 2017, 2019, 2021) Beckwith- Wiedemann Prader Willi Retinoblastoma Maternal hypermethylation Angelman

Beckwith- Wiedemann

What is the least common imprinting syndrome associated with IVF/ICSI? (2011, 2023 NIH) Beckwith-Wiedemann Prader Willi Retinoblastoma Maternal hypermethylation Angelman

Prader Willi

FET cycle is more likely to be associated with increased risk of following compared to fresh transfer? (2021) Preterm labor Small for gestational age Preeclampsia Birth defects

Preeclampsia

What is the most effective way to reduce risk of OHSS? (2019, 2021) Leuprolide acetate (Lupron) trigger Reduced dosing Cabergoline A patient undergoing IVF with a GnRH antagonist protocol is a high responder. What is the most effective way to reduce the risk of OHSS? (2013) Single embryo transfer Dopamine agonist GnRH agonist trigger

Leuprolide acetate (Lupron) trigger GnRH agonist trigger

Which of the following would be the best reason to cancel a patient for a fresh embryo transfer after ovarian stimulation? (2021) Progesterone 1.5ng/mL Known endometrial polyp E2 5000pg/mL

E2 5000pg/mL

What has led to the most improvement in pregnancy rates (implantation) following embryo transfer? (2009, 2011, 2012, 2014, 2015, 2018, 2021, 2023 NIH) Use of soft-tipped catheter PGT-A Assisted hatching Embryo glue Progesterone supplementation during luteal phase and early pregnancy What has led to the most improvement in pregnancy rates (implantation) following embryo transfer? (2009) Use of soft-tipped catheter Ultrasound (US) guidance Volume of fluid in the catheter Distance from the fundus

Use of soft-tipped catheter US guidance

What is least important for pregnancy rates (implantation) following an embryo transfer? (2009, 2023 NIH) Use of a soft-tipped catheter Ultrasound (US) guidance Distance from the fundus Uterine contractions Blood in catheter Embryo culture media

Blood in catheter

What is the least likely to impact pregnancy rates (implantation) following an embryo transfer? (2007) Ultrasound (US) guidance Retained embryo Uterine size Blood in catheter

Retained embryo

When is the least appropriate time to initiate progesterone supplementation? (2014) Intramuscular injection on day of trigger Vaginal suppository on day prior to retrieval Intramuscular injection day after trigger Vaginal suppository on day of retrieval

Intramuscular injection on day of trigger

What is the best predictor of ovarian response to gonadotropins in a woman with PCOS? (2021) AMH Day 3 FSH AFC Inhibin B

AFC

What is the least predictive of implantation? (2007, 2009, 2023 NIH) Early cleavage Cell number Fragmentation Number of embryos Symmetry Vacuolization

Vacuolization

What is the biggest advantage to an antagonist stimulation cycle compared to a GnRH agonist downregulation cycle? (2021)

Decreased OHSS risk

Where does a GnRH agonist work? (2012, 2018) Binding to the pituitary receptors Binding to the hypothalamic receptors Binding to the ovarian receptors Binding to the adrenal receptors

Binding to the pituitary receptors

What is the GnRH agonist protocol most associated with? (2015) Decreased OHSS Decreased dose of FSH during stim Increased pregnancy rates Decreased need for luteal support

Decreased need for luteal support

How do GnRH antagonists work? (2015) Competitive inhibition Prevent dimerization of receptor Others

Competitive inhibition

What is the mechanism of GnRH agonists? (2005, 2009, 2011, 2018, 2023 NIH) Downregulation of hypothalamic receptors Downregulation of ovarian receptors Depletion of pituitary receptors Competitive inhibition of pituitary receptors Immediate internalization of receptor

Depletion of pituitary receptors

What is the mechanism of GnRH antagonists? (2014, 2015) Downregulation of hypothalamic receptors Downregulation of ovarian receptors Depletion of pituitary receptors Competitive inhibition of pituitary receptors Immediate internalization of receptor

Competitive inhibition of pituitary receptors

The most common reason for monozygotic twinning related to IVF is a splitting event that occurs from which of the following? (2021) 2PN 8 cell blastomere Inner cell mass (ICM) Trophectoderm

ICM

When is best time for biopsy if the father has cystic fibrosis? (2023 NIH) 8 cell embryo Blastocyst Morula 1st polar body, then 2nd polar body

Blastocyst

What O2 tension in embryology is best? (2021) 5% 10% 15% 20%

PGT is most likely to do which of the following? (2020) Increase cumulative live birth rate Increase SIR per embryo transfer Others

Increase sustained implantation rate per embryo transfer

What is the best choice of trigger for a patient on GnRH antagonist protocol and whose E2 6000pg/mL? (2016, 2017, 2018, 2019, 2023 NIH) Leuprolide acetate (Lupron) 1mg hCG Dual/Co-trigger with leuprolide acetate (Lupron) and 1500 hCG hCG and cabergoline Coast for a few days

Lupron only trigger (if correct dosing listed)

A couple goes through IVF and 2PNs develop but none progress to the cleavage stage. Why would a 2PN not progress? (2013, 2015, 2016, 2017, 2023 NIH) Failure to release 2nd polar body Failure to have cortical granule reaction Thickened zona pellucida Failure of paternal genome to activate Abnormal sperm

Failure of paternal genome to activate

A couple goes through IVF and 2PNs develop but none progress to the cleavage stage. Why would a 2PN not progress? (2013)

Decreased oocyte quality

What is the least likely cause of this (image of poly-fertilization with three nuclei) in IVF? (2013, 2015, 2016) Digeny Polyspermy ICSI Poor oocyte quality Post-mature oocyte MII

ICSI

What is the most likely cause of 3PN? (2023 NIH) Perivitelline space debris Teratospermia Post-mature oocyte Thickened zona pellucida

Post-mature oocyte

What is the least likely to cause 3PN during IVF? (2013, 2014, 2015, 2023 NIH) Polyspermy ICSI Post-mature oocyte Oocyte quality Digeny Regular IVF

ICSI

What is the least likely predictor of poor response to ovarian stimulation? (2011, 2013) Clomiphene citrate (Clomid) challenge test (CCCT) FSH AMH AFC Inhibin

Inhibin

What is the most likely predictor of a good response to ovarian stimulation? (2012, 2013, 2014, 2016, 2017, 2018, 2023 NIH) Day 3 FSH Prior response to stimulation/Prior cycle response Inhibin A Inhibin B

Prior response to stimulation/Prior cycle response

Measurement of which of the following on cycle day 3 is most predictive of the number of oocytes that will be retrieved? (2007, 2023 NIH) FSH LH AMH AFC

AFC

What is the worst test for IVF predictive response? (2023 NIH) Inhibin B

Inhibin B

What is the best predictor of IVF response? (2023 NIH) Clomiphene citrate (Clomid) challenge test (CCCT) FSH AMH Prior IVF response

Prior IVF response

What is most predictive of IVF outcomes in a specific IVF cycle? (2007) Day 3 FSH*** AFC*** Day 3 estradiol Day 3 inhibin

What is most predictive of IVF outcomes in a specific IVF cycle? (2007) Day 3 FSH AFC Day 3 estradiol Day 3 inhibin

AFC

What are cleavage stage (day 3) embryos less likely to have compared to blastocysts? (2012, 2013, 2018, 2020, 2023 NIH) Monozygotic twinning Live birth Ectopic pregnancy

Monozygotic twinning

What was the most common malignancy associated with IVF? (2012, 2013, 2014, 2015, 2017, 2023 NIH) Borderline Breast cancer In situ breast cancer Ovarian cancer What is increased in patients who have had IVF compared to patients who didn’t have IVF? (2012, 2018) Borderline ovarian tumors Invasive ovarian carcinoma Invasive breast cancer DCIS Low malignant potential (LMP) tumor

Borderline

A patient who previously had RPL is diagnosed with a DVT in pregnancy. What is the most likely etiology for all of these issues? (2010)

APLS

What is the best predictor of ovarian response to gonadotropins in a woman with PCOS? (2021) AMH Day 3 FSH AFC Inhibin B

AMH

How do you prevent OHSS in a patient who is obese with PCOS and has a midcycle E2 6000pg/mL? (2018, 2023 NIH) Metformin GnRH antagonist Letrozole Albumin

Metformin vs letrozole

What is the best time for the fertilization check? (2015) 4hr after 12hr after 18hr after 24hr after

18 hours after

In what way is rFSH is most like FSH? (What is most likely to be similar between recombinant versus endogenous gonadotropins?) (2003, 2007, 2009, 2011, 2012, 2013, 2018, 2023 NIH) Amino acid sequence/structure/bioactivity Post-translational modifications Glycosylation Carboxy content Similar presence of urinary contaminants

Amino acid sequence/structure/bioactivity

What is the difference between follitropin-alpha (Follistim) and follitropin-beta (Puregon)? (2023 NIH) Structurally different Difference in glycosylation Difference at the 6th amino acid CHO vs. HELA cells

Difference in glycosylation

What is the treatment for a patient with low/normal FSH and low LH? (2023 NIH) Menotropins (Repronex) FSH (Follistim)

Menotropins

PGT is most indicated for which of the following? (2014, 2018) Age Balanced translocation RPL Implantation failure

Balanced translocation

What is the primary energy source for blastocysts? (2005, 2011, 2012, 2018) Pyruvate Non-essential amino acids Glucose Cholesterol

Glucose

What is the least responsible for OHSS? (2007, 2011, 2012, 2018, 2023 NIH) rFSH uFSH u-hCG r-hCG rLH Use of which of the following would decrease the risk of OHSS? (2007, 009) rFSH uFSH u-hCG r-hCG rLH

rLH

What is the biggest impact on reduction of multiple rates in the United States? (2009, 2018, 2023 ASRM) Single day 3 embryo transfer Single blastocyst transfer Mandated insurance SART/CDC registry What is the biggest impact on reduction of multiple rates in the United states? (2011, 2023 ASRM) Single day 3 embryo transfer ASRM guidelines Mandated insurance SART/CDC registry/reporting

Single blastocyst transfer ASRM guidelines

What is the least important factor in deciding on the number of embryos to transfer? (2007, 2009, 2018, 2023 NIH) Maternal age Number of prior cycles Number of surplus embryos left to freeze Day 3 FSH Embryo morphology Embryo grading

Day 3 FSH

What is a benefit of using GnRH antagonists in IVF? (2015) Decreased OHSS risk Less total gonadotropin used Others

Both

What is the best reason to use a GnRH antagonist in IVF? (2014) Reduced risk of OHSS Reduced need for luteal support Improved implantation rates Improved pregnancy rates

Reduced risk of OHSS

What is the best prognosticator of risk for OHSS? (2015) AFC Age AMH FSH

AMH

A 38yoF with an AMH 0.4ng/mL and AFC of 5 presents. What is the best treatment? (2014, 2023 NIH) IVF with donor oocytes Clomiphene citrate (Clomid) IVF with autologous oocytes

IVF with donor oocytes

A 46,XY woman presents. What IVF treatment will benefit her the most? (2012) Gestational carrier Sperm donor Oocyte donor

Oocyte donor

What is most advantageous about using a GnRH antagonist cycle? (2012) Better IR Better PR No need for luteal support Can use a leuprolide acetate (Lupron) trigger

Can use a leuprolide acetate (Lupron) trigger

What has the highest increased risk of imprinting disorders? (2011, 2012) Culture to day 3 Blastocyst culture Embryo culture Oocyte maturation Gonadotropins Sperm something

Blastocyst and embryo culture

What are imprinting disorders most related to in IVF? (2011) Time of in vitro embryo culture Blastocyst culture Ovarian stimulation Infertility

Blastocyst culture

What has IVF increased the risk of the most? (2007, 2012, 2023 NIH) Chromosomal abnormality Low birth weight in singletons Male to female sex ratio Congenital abnormality Imprinting disorder

Low birth weight in singletons

What is the most common bad outcome in an IVF singleton pregnancy? (2023 NIH) Chromosomal abnormality Preterm birth Low birth weight in singletons Male to sex ratio Congenital abnormality Imprinting disorder

Preterm birth Low birth weight in singletons

What is the most important factor in the success of a fresh transfer donor cycle? (1999, 2007, 2010, 2011) Estrogen duration Estrogen timing Progesterone duration Progesterone timing Age of the recipient

Progesterone timing

What is true when counseling about the potential effects of ICSI with respect to offspring? (2011, 2023 NIH) Increased risk of anomalies of X and Y Increased risk of congenital abnormalities of autosomes Can be attributed to ovarian stimulation, not ICSI itself Congenital abnormalities can be attributable to epigenetic modifications

Congenital abnormalities can be attributable to epigenetic modifications

What is ICSI associated with increased risk of? (2011) C-section Post-term pregnancy Sex chromosome abnormalities Other types of chromosomal disorders also listed

Sex chromosome abnormalities

What is the least reliable test for ovarian reserve? (2007, 2011) Day 3 FSH AFC Inhibin Clomiphene citrate (Clomid) challenge test (CCCT)

Inhibin

What is the most likely chromosomal make-up of offspring after ICSI is used for a 47,XXY male and 46,XX female? (2009, 2010, 2023 NIH) 45,X 46,XY 46,XX 47,XXY 47,XYY

46,XY 46,XX (Normal)

Which substrate is most important in extended culture media? (2007, 2023 NIH) Addition of glucose and essential amino acids Some amino acid

Addition of glucose and essential amino acids

What criteria is least important when deciding to perform assisted hatching? (2007, 2010, 2023 NIH) >37yo Thickened zona Repeated IVF failures Unexplained infertility

Unexplained infertility

What is the least likely to improve results in IVF? (2003) Antibiotics in the culture media Preculture of sperm in yolk-rich media Percoll gradient Swim-up

Antibiotics in the culture media

What is most likely semen analysis abnormality associated with failed fertilization in IVF? (2023 NIH) Abnormal morphology Abnormal motility Abnormal number

Abnormal morphology

A couple undergoes IVF twice with failed fertilization. What is the next most appropriate step? (1999, 2003) hMG with IUI ICSI Others

ICSI

Measurement of which of the following on day 3 of the menstrual cycle is most predictive of response to gonadotropin stimulation? (1999) Estradiol FSH Inhibin B LH Activin

FSH

What is the most important factor to embryo viability with cryopreservation? (1999) Time taken to thaw Time taken to freeze Maternal age Paternal age

Maternal age

The most success with cryopreservation has come from the use of which of the following? (1999) Oocytes Ovarian slices Cleavage stage embryos Blastocyst Morula

Blastocyst

What are the preferred energy sources for blastocysts? (2005, 2007) Lactate Pyruvate and nonessential amino acids Glucose and essential amino acids

Glucose and essential amino acids

What are the preferred energy sources for pre-compaction embryos? (2005, 2007) Lactate Pyruvate and nonessential amino acids Glucose and essential amino acids

Pyruvate and nonessential amino acids

What is least likely to be true in a blastocyst? (2003) Inner cell mass (ICM) is rapidly dividing Cells in the inner cell mass (ICM) undergo apoptosis Inner cell mass (ICM) secretes hCG

Inner cell mass (ICM) secretes hCG

What is the purpose of cryoprotectants? (1999, 2003, 2010) Preventing formation of cytoplasmic ice crystals Preventing disruption of the cell membrane Others

Preventing formation of cytoplasmic ice crystals

Which of the following findings is most predictive of ART failure in a 31yoF? (2003) Day 3 FSH 8.7mIU/mL, day 3 estradiol 75pg/ml Day 3 estradiol 45pg/mL Day 3 inhibin 180pg/mL Day 9 FSH 9mIU/mL after five days of clomiphene citrate (Clomid) 100mg/day

Day 3 FSH 8.7mIU/mL, day 3 estradiol 75pg/ml

What is the best predictor of successful pregnancy in a 39yoF undergoing IVF? (2005) Clomiphene citrate (Clomid) challenge test (CCCT) Day 3 FSH FSH:E2 ratio

Day 3 FSH

A woman undergoing IVF is incidentally found to have a positive anticardiolipin antibody. What is indicated? (2023 NIH) Heparin Luteal phase progesterone Nothing

Nothing

What infectious disease screening do you need to do for anonymous oocyte donors? (2013, 2014, 2015, 2016) Hepatitis B core antibody Hepatitis B surface antigen HIV antibody Hepatitis C nucleic acid antibody HSV T. cruzi

All except HSV, T cruzi

What screening do you need to do for anonymous oocyte donors (2015, 2017, 2018) T. palladium CMV HTLV1 West Nile virus

T. palladium West Nile Virus

What do you not need to do for anonymous oocyte donor screening? (2022)

HTLV

What virology is not needed for an intimate partner? (2023 NIH)

HSV1 and HSV2

Patient with new diagnosis of breast cancer and wants to pursue fertility preservation with oocyte cryopreservation. What is the most important factor in considering which stimulation protocol to use? (2021) Tumor receptor status Current status within the menstrual cycle Specific histologic/pathologic breast cancer diagnosis BRCA1 status

Specific histologic/pathologic breast cancer diagnosis

Who is eligible for leuprolide acetate (Lupron) protection of ovaries? (2021) 7yo with cancer 15yo with cancer 28yo with cancer 33yo with cancer

28yo with cancer

A patient with breast cancer needs fertility preservation right away, how do you stimulate? (2021)

Letrozole and random start

What is least affected in oocyte cryopreservation? (2012, 2013, 2014, 2018) Zona pellucida Cortical reaction Cortical granules Mitotic spindle Cytoskeleton Mitochondria What cellular structure is most resistant to damage with cryopreservation? (2023 NIH) Zona pellucida Cortical granule Spindle Mitochondria

Mitochondria

What cryopreservatives are used for 2PN embryos? (2005, 2009, 2018, 2023 NIH) Glycerol Glycine Pyruvate-free DMSO Propanediol

DMSO Propanediol

Which chemotherapy has the most toxic effect on the ovaries/oocytes? (2012, 2023 NIH) Anthracyclines Antimetabolites Vinca alkaloids Alkylating agents

Alkylating agents

What tumor is most likely to produce ectopic hCG as a tumor marker? (2007, 2011, 2023 NIH) Ovary Liver Brain Breast Lung

Ovary

Malignancy/Cancer in which organ is most likely to cause ectopic erythropoietin production? (2009) Lung Ovary Liver Kidney

Kidney

What is the best method to conserve a 35yoF’s fertility before cyclophosphamide? (2007, 2019, 2023 NIH) GnRH agonist OCPs Embryo cryopreservation Ovarian tissue cryopreservation

Embryo cryopreservation

What is the most common finding in RPL evaluations? (2022) Cytogenetics Uterine anomaly APLS

Uterine anomaly

What is the most common finding in a spontaneous abortion? (2022) Aneuploidy of POCs

Aneuploidy of POCs

What uterine anomaly is most related to spontaneous abortions? (2023 NIH) Septate Bicornuate Didelphys Arcuate

Septate

What is the estimated incidence of mullerian anomaly in a woman with recurrent first trimester pregnancy losses (RPL)? (2022) 2-3% 5-10% 25-30% 50-60%

5-10%

What is the most likely reason for two consecutive clinical losses? (2020, 2021) Aneuploidy Translocation Uterine anomaly Acquired thrombophilia APLS

Aneuploidy

What is the chance that a first trimester loss is due to a chromosomal abnormality? (2003) 25% 40-60% 80%

40-60%

Which of the following is the least useful test for RPL? (2003) HSG Karyotype Mycoplasma

Mycoplasma

What is the most likely diagnosis (cause) for a couple with RPL? (2013, 2014, 2016, 2017, 2019, 2021, 2023 NIH) Endocrine abnormality Uterine anomaly (Anatomic) Translocation Immunologic Acquired thrombophilia

Uterine anomaly (Anatomic)

A 35yoF with three consecutive biochemical losses. What is the best next step? (2020, 2021) APS/Karyotype Prolactin/TSH PGT-A Continue to attempt spontaneous conception

APS/Karyotype Prolactin/TSH

A patient with RPL after three spontaneous abortions and has a negative work-up. What is the next step? (2007, 2009, 2010, 2012, 2013, 2018, 2023 NIH) IVF with PGT-A Attempt spontaneous conception Natural killer (NK) cell test Aspirin and heparin A patient has had three spontaneous abortions after one full term pregnancy. What is the best treatment? (2011) IVF with PGT-A Attempt spontaneous conception Sperm fragmentation Aspirin and heparin

Attempt spontaneous conception

What is the worst prognosis uterine structural defect associated with RPL (three prior first trimester spontaneous abortions)? (2005, 2007, 2012, 2013, 2018) Arcuate Septum Submucosal fibroids Adenomyosis

Septum

What medication has been shown to be helpful for RPL associated with APLS (with no history of DVT)? (2012, 2013, 2014, 2016, 2015, 2017, 2018, 2023 NIH) ASA and twice daily unfractionated heparin ASA Therapeutic heparin LMWH heparin Immunoglobulin

ASA and twice daily unfractionated heparin

Which is most specific for APLS? (2023 NIH) Increased APTT Decreased clotting time Anticardiolipin IgA Anti-beta-2-glycoprotein IgM

Anti-beta-2-glycoprotein IgM

What is the best treatment for somebody with APLS? (2013, 2014) ASA Heparin

Heparin

What test is least likely to help with diagnosing APLS? (2011, 2012, 2013, 2014, 2015, 2016, 2023 NIH) Anti-beta-2-glycoprotein Anticardiolipin antibodies Russell’s venom aPTT Antiphosphatidyl serine

Antiphosphatidyl serine

What test is most likely to diagnose APLS? (2012, 2013, 2015, 2017, 2018) Anti-beta-2-glycoprotein IgM Anticardiolipin IgA PT corrected for phospholipid

Anti-beta-2-glycoprotein IgM

A patient who previously had RPL is diagnosed with a DVT in pregnancy. What is the most likely etiology for all of these issues? (2010)

APLS

What are recurrent late first trimester losses most likely due to abnormalities in? (2011) Factor V Leiden Prothrombin gene mutation Antithrombin II Protein C MTHFR

Factor V Leiden

A patient presents with a history of full term delivery complicated by VTE/clot in the 3rd trimester. Since then, she has been diagnosed with RPL. Which of the following is most likely etiology? (2007, 2023 NIH) Factor V Leiden APLS Protein S

APLS

What is the prevalence of APLS in women with RPL? (2018)

3-5%

What is the mechanism of late loss (>10wk) in women with APLS? (2018)

Thrombosis

What is the mechanism of early loss (<10wk) in women with APLS? (2018)

Trophoblast invasion

Which HLA in the endometrium allows for implantation? (2014, 2015) A B D G

A patient had three early spontaneous abortions following a full term delivery. What is the least likely reason for her recurrent losses? (2005, 2010, 2011, 2018, 2023 NIH) Embryotoxic factor Uterine septum Lupus anticoagulant antibodies Male balanced translocation

Embryotoxic factor

A patient had three early spontaneous abortions following a full term delivery. What is the least likely reason for her recurrent losses? (2003, 2011, 2009) APLS Rh sensitization Uterine septum Abnormal male karyotype Didelphys Unicornuate

Rh sensitization

A patient has three prior first trimester losses. What is the most likely mechanism? (2005, 2014, 2015) Anatomical abnormality APLS Balanced translocation

Anatomical abnormality

What is the least common cause of spontaneous abortions? (2010) Fetal aneuploidy Parental chromosome abnormality Endometritis

Endometritis

A couple with normal karyotypes experiences three consecutive losses. What is the most likely cause? (1999, 2011) Autosomal trisomy Triploidy Diploidy Monosomy 45,X

Autosomal trisomy

What is the most common karyotype of a spontaneous abortion in a woman with recurrent loss? (2003, 2018) Autosomal trisomy Monosomy X Polyploidy 46,XX or 46,XY

Autosomal trisomy

A patient with RPL presents following a recent spontaneous abortion whose karyotype was 47,XX,+22. What is the most likely reason for this finding? (2018) Oocyte nondisjunction Reciprocal translocation Robertsonian translocation Embryotoxic factor Uterine septum

Oocyte nondisjunction

What is the most common cause of familial clotting? (2018) Prothrombin gene mutation MTHFR homozygous with elevated homocysteine Antithrombin III Protein C deficiency Protein S deficiency

Prothrombin gene mutation

What is the single most common genetic finding in an abortus? (1999) 45,X 46,XXY 46,XYY Trisomy 18 Trisomy 21

45,X (if T16 unavailable as most common)

A couple have a history of a full term vaginal delivery followed by three consecutive first trimester losses. How do you counsel them? (1999) Their chances are increased since they had one successful pregnancy Others

Their chances are increased since they had one successful pregnancy

A 30yo couple has just had two consecutive spontaneous abortions, the last of which had a trisomy 15 karyotype. How do you counsel them? (1999) Their risk of subsequent miscarriage is 50% Their risk of subsequent miscarriage is 20-30% They will not be able to have a successful pregnancy without donor gametes They should undergo genetic testing

Their risk of subsequent miscarriage is 20-30%

What is the least likely finding APLS? (2003) Thrombocytopenia Elevated PTT None of the above

Elevated PTT

What is the least useful test when evaluating RPL? (2005)

EMB

What is the most sensitive imaging study for RPL? (2007) HSG Saline sonogram (SIS) Ultrasound (US)

Saline sonogram (SIS)

Which of the following is the most common abnormality with history of DVT and three first trimester spontaneous abortions? (2007, 2023 NIH) Factor V Leiden APLS

APLS

A 28yoF G3P1021 has a history of two losses at 8wk after fetal heart rate as well as a history of a term delivery complicated by a VTE in the third trimester. What test would be diagnostic? (2007) Factor V Leiden Lupus anticoagulant/Anticardiolipin antibody

Lupus anticoagulant/Anticardiolipin antibody

What is the most likely cause of RPL at <10wk? (2023 NIH) Anatomic Immune Thrombotic Environmental

Anatomic

Which uterine abnormality has the worst prognosis for someone with three prior 1st trimester losses? (2023 NIH) Uterine septum Arcuate Subserosal leiomyoma

Uterine septum

Which of the following is most likely to be associated with three 1st trimester losses? (2023 NIH) Prothrombin mutation MTHFR Activated Protein C

Prothrombin mutation

How do you determine the number of Fragile X repeats in a patient? (2016)

PCR

What mechanism is responsible for environmental impact on genetics? (2021) Methylation Post-transcriptional histone modification

Methylation

What is the correct order of events in PCR? (2011, 2013, 2021, 2022, 2023 NIH)

Denaturation, annealing, synthesis, extension

What is the correct order of events in RT-PCR? (2013, 2017, 2018) Make cDNA, denature, anneal, extension Denature, anneal, extension, make cDNA Extension, anneal, denature, make cDNA

Make cDNA, denature, anneal, extension

What is PCR most likely to miss? (2011, 2021, 2023 NIH) Nonsense Missense Large deletion Small three nucleotide repeat

Large deletion

What is the best use of aCGH? (2021) Comparing mitochondrial DNA between two individuals Comparing genomic DNA between two populations Comparing mRNA transcripts Comparing tRNA transcripts

Comparing genomic DNA between two populations

What is CGH best for? (2012) Gain or loss of DNA SNP Uniparental disomy

Gain or loss of DNA

Karyotype is able to detect which of the following that aCGH cannot? (2021) Aneuploidy Deletion Unbalanced translocations Inversion

Inversion

What PGT-A platform has the most mosaicism rates? (2021) qPCR NGS aCGH

NGS

How do you locate a gene on a chromosome? (2012, 2018) Southern blot FISH PCR Southwestern blot

FISH

What is the most labor intensive application of FISH? (2007, 2023 NIH) Polyploidy Sex typing DNA inversions/translocations DNA point mutations

Polyploidy

FISH is most labor intensive with which kind of evaluation? (2007, 2023 NIH) Chromosome number Translocations Single gene mutation Sex chromosome abnormalities

Chromosome number

What is the most labor intensive test to attempt to perform using FISH? (2007) Identification of single gene mutations Identification of sex-linked disorders Identification of trisomies Other

Identification of trisomies

Which of the following can FISH best detect? (2005, 2023 NIH) Sex aneuploidy Single gene defect Y chromosome microdeletion Reciprocal translocation

Sex aneuploidy * PCR is used for single gene defects and FISH for sex selection, structural anomalies and aneuploidy screening.

What heterozygote is least likely to be detected on PCR gene sequencing? (2023 NIH) Large deletion Missense mutation Nonsense mutation Silent mutation

Large deletion

There is a gene mutation that generates a protein. What is the best way to identify the “gene product” (protein)? (2005, 2009, 2013, 2015, 2016, 2018, 2021) Western blot Northern blot Southern blot Southwestern blot PCR What is the best test to evaluate for a genetic mutation that creates a protein? (2023 NIH) Western immunoblot analysis Northern immunoblot analysis Southern immunoblot analysis

Western blot

How do you detect mutant protein that is significantly shorter in length? (2011, 2015, 2018) PCR Western blot Northern blot Southern blot

Western blot

A mutant gene with a shorter amino acid sequence produces a mutant protein in Sertoli cells. What is the best test to identify the gene product? (2023 NIH) Southern blot Western blot PCR

Western blot

There are Sertoli cells that have a mutation in the gene for protein G and produce a shorter product (shorter protein G). How do you detect the mutated product of Sertoli cells? (2007, 2011) Northern blot Western blot Southern blot RT-PCR

Western blot

How do you verify the integrity of isolated RNA? (2003, 2005) Western blot Northern blot Southern blot Southwestern blot

Northern blot

What is involved in a Northern blot? (2003, 2010) Complementary DNA binding to radiolabeled RNA Genomic DNA binding to radiolabeled RNA Radiolabeled DNA binding to RNA Hybridize radiolabeled DNA to RNA What is involved in a Northern blot? (2007) Radiolabeled cDNA combining with RNA Radiolabeled RNA combining with DNA Radiolabeled RNA combining with protein Other

Radiolabeled DNA binding to RNA Hybridize radiolabeled DNA to RNA Radiolabeled cDNA combining with RNA

Which of the following uses antibodies for hybridization identification of proteins? (2001) Northern blot Southern blot Southwestern blot Western blot

Western blot

What is the recommended parental genetic screening for all couples attempting conception? (2021) CF, spinal muscular atrophy CF, spinal muscular atrophy, Fragile X CF, spinal muscular atrophy, Fragile X, familial autosomal something Another option with something added to the familial autosomal something

CF, SMA

A 30yoF with POI wants to use her 22yo sister’s oocytes for IVF. What screening is most likely to reveal the cause of the patient’s POI? (2009, 2023 NIH) Karyotype Fragile X Cystic fibrosis A 30yoF with POI wants to use her 22yo sister’s oocytes for IVF. What test would most likely exclude her? (2009) Karyotype Fragile X Cystic fibrosis

Karyotype

What is the best way to determine copy number? (2018)

Amount of DNA

What is the best test to detect copy number variants? (2012, 2013, 2014, 2015, 2020, 2023 NIH) Karyotype FISH aCGH Southern blot

aCGH *Takes up to 72h to perform due to long hybridization step. Can only detect copy number changes (only changes that result in loss or gain of chromosome material). Less sensitive than PCR.

What is CGH useful for? (2015, 2017) Copy number variants Uniparental disomy Ploidy

CNVs *This technology is also particularly useful as a complementary diagnostic test to detect large deletions in genes related to mitochondrial disorders.

CGH cannot detect which of the following? (2019) Aneuploidy Deletions Unbalanced translocations Inversions

Inversions

What can aCGH cannot distinguish between? (2012, 2018) Euploid and aneuploid karyotype Small deletions in the genome Uniparental disomy Mitochondrial differences

Uniparental disomy

What is the quickest way to determine sex of blastomeres in someone with an X-linked recessive gene mutation? FISH Sequence the pseudoautosomal region of Y chromosome Cytogenetic banding

FISH

What most characterizes whole exome sequencing (WES)? (2016) Only looks at part of the genome Good to look for copy number variation

CNV WES is a form of next-generation sequencing that focuses only on the exons (the protein-coding regions) to detect CNVs, SNPs, and somatic mutations. WES data is useful for the clinical interpretation of genetic variation discovered in exomes

Who is the best candidate for PGT-A? (2017) Recent implantation failure Advanced maternal age Balanced translocation Recurrent pregnancy loss

Balanced translocation

What can you use to determine a single parent polymorphism? (2015)

SNP array

What happens when two acrocentric chromosomes interact? (2007, 2010, 2011, 2012, 2014, 2018, 2023 NIH) Balanced reciprocal translocation Robertsonian translocation Pericentric inversion Meiotic nondisjunction Premature sister chromatid separation

Robertsonian translocation

What do acrocentric chromosomes joined at the centromere cause? (2003) Robertsonian translocation Ring chromosome Inversion Reciprocal translocation

Robertsonian translocation

If a male partner is elderly, what is the most likely karyotypic abnormality in the offspring? (2015) 47,XXY Sex chromosome Autosomal Monosomy X

Autosomal

What is the most likely reason for failure of oligonucleotide binding in PCR based sequencing? (2014) Large deletion Missense mutation Nonsense mutation Silent mutation

Large deletion

What test is the best for finding the chromosomal location of a gene? (2005, 2012) Southern blot PCR Methylation analysis FISH

FISH

CGH would be least likely to determine which of the following chromosomal abnormalities? (2012) Polyploidy Turner syndrome Trisomy

Polyploidy

What is the best test to use in an oocyte donor to rule out a genetic carrier disease? (What is the best microarray for screening of oocyte donors for carrier disease status?) (2009, 2011, 2023 NIH) Genomic DNA Chromatin DNA Proteomics Metabolomic RNA PCR

Genomic DNA

What is cDNA microarray best for? (2011, 2023 NIH) Genomic DNA between two populations Transfer RNA between to individuals mRNA between two different experiments

mRNA between two different experiments

Which of the following clinical scenarios is the best application of PGT-M that will lead to the best outcome? (2005) Translocation Cystic fibrosis carrier Others

CF carrier

What is the best method to assess chromosomal abnormalities? (2023 NIH) PGT-M CGH G banding

CGH

Which test gives the most information about the genome? (2007) FISH PCR Comparative hybridization G-banding

Comparative hybridization

Why does Taq polymerase work? (2015)

Stable at high temperatures

What do you test with a cDNA array? (2014, 2015, 2018, 2023 NIH) mRNA tRNA Genomic DNA

mRNA

What is detected when cDNA is analyzed? (2012, 2018) Complementary strand to known DNA sequence Complementary strand to known RNA sequence Full DNA sequence, including exons and introns Total molecular weight of DNA strand

Complementary strand to known RNA sequence

What is the best test for maternal contamination of POCs? (2014, 2015, 2017, 2018, 2019, 2020, 2021, 2023 NIH) Array CGH (CGH or microarray) SNP array FISH Karyotype cDNA microarray

SNP array

What is the best test for abnormality in POC? (2023 NIH) High density SNP Geimsa staining of metaphase chromosomes microRNA Cell free DNA

High density SNP

How does inflammatory process of endometriosis work? (2021) Increase in suppressive modulators in pelvic fluid Increase in suppressive modulators in abdominal fluid Decrease in suppressive modulators in pelvic fluid Decrease in suppressive modulators in pelvic fluid

Decrease in suppressive modulators in pelvic fluid

A patient is going to begin IVF with an endometrioma. What is the best thing to do? (2011, 2023 NIH) Drain endometrioma at retrieval Avoid endometrioma at retrieval Laparoscopic drainage of endometrioma before IVF Laparoscopic resection of endometrioma before IVF GnRH agonist 3mo before IVF Long term suppression with OCPs

Avoid endometrioma at retrieval

A woman presents with a 4cm endometrioma. What would you do before IVF? (2013, 2014, 2023 NIH) Expectant management Drain endometrioma Robotic cystectomy

Expectant management

A woman presents with a 2cm endometrioma. What would you do before IVF? (2015, 2023 NIH) Proceed with IVF Remove endometrioma Treat with GnRH agonist first then IVF Treat with danazol first then IVF A 38yoF presents with a 2cm endometrioma and no pain. She is planning to do IVF. What is the best management? (2015, 2023 NIH) Surgery Avoid surgery, proceed with IVF GnRH agonist with add back pre-treatment GnRH agonist with no add back A 38yoF presents with a 4cm endometrioma and no pain. She is planning to do IVF. What is the best management? (2012, 2014, 2023 NIH) Surgery Avoid surgery, proceed with IVF Puncture and drain

Proceed with IVF Avoid surgery, proceed with IVF Avoid surgery, proceed with IVF

In GnRH agonist suppression what is the effect of adding norethindrone? (2023 NIH) Decreased flushing, decreased bone mass Decreased flushing, no change in bone Increased flushing, decreased bone Increased flushing, no change in bone

Decreased flushing, no change in bone

What decreases ovarian reserve most in an endometrioma resection? (2012, 2015) Electrocautery of wall Laser ablation of wall Resect endometrioma

Electrocautery of wall

Which therapy is the least likely to provide pain relief from endometriosis? (What is the worst treatment for endometriosis?) (2011, 2018, 2023 NIH) GnRH agonist with add back therapy Cyclic OCPs IM depot medroxyprogesterone acetate (MPA) (Depo-Provera) Surgical destruction Which is the least effective treatment for endometriosis? (2011) GnRH agonist with add back therapy Cyclic OCPs IM depot medroxyprogesterone acetate (MPA) (Depo-Provera) Surgical destruction

Cyclic OCPs

What is the best treatment for (chronic) pelvic pain in a patient with severe endometriosis and dysmenorrhea? (2014) Laparoscopic uterosacral nerve ablation (LUNA) Presacral neurectomy (PSN) Alcohol injection High frequency ultrasound (US) What is the best treatment for (chronic) pelvic pain in a patient with severe endometriosis and dysmenorrhea who has failed surgical intervention? (2012, 2013, 2015) Laparoscopic uterosacral nerve ablation (LUNA) Presacral neurectomy (PSN) Alcohol injection High frequency ultrasound (US)

Presacral neurectomy (PSN)

What is most likely affected by epigenetic regulation of the endometrium? (2014, 2015, 2016, 2017, 2018) Estrogen receptor beta (ER-beta)

Estrogen receptor beta (ER-beta)

Aromatase activity is highest in what type of endometriosis? (2014, 2015) Red implant Black implant White implant Yellow implant Endometrioma cyst wall

Red implant

What is increased in endometrial implants? (2016) Aromatase Estrogen receptor beta (ER-beta)

Aromatase

Endometriosis is most associated with which of the following? (2012, 2018) Increased 17-beta-hydroxysteroid dehydrogenase (17-beta-HSD) Decreased COX-2 Increased estrogen receptor beta (ER-beta)

Increased estrogen receptor beta (ER-beta)

How does danazol induce androgenic effects? (2018, 2023 NIH) Displacement of testosterone from SHBG Binds to estrogen receptor (ER) Induces SHBG Induces ovarian steroidogenesis

Displacement of testosterone from SHBG

What is a side effect of danazol? (2018, 2023 NIH) Completely reversible voice deepening Anovulation Osteoporosis Hyperestrogenemia

Anovulation

Which binds the glucocorticoid receptor best? (2003, 2005, 2010, 2011, 2012, 2014, 2015) Mifepristone (RU-486) Progesterone Estrogen Testosterone (Androgens) Spironolactone

Mifepristone (RU-486)

What is the treatment for catamenial pneumothorax? (2007, 2009, 2018) Depot medroxyprogesterone acetate (DMPA) (Depo-Provera) Aromatase inhibitor Danazol GnRH agonist with add back

GnRH agonist with add back

What is the worst treatment for catamenial pneumothorax? (2009, 2023 NIH) Cyclic OCPs GnRH agonist Depot medroxyprogesterone acetate (DMPA) (Depo-Provera)

Cyclic OCPs

What is the least likely outcome with norethindrone add back for endometriosis? (2014, 2015) Reduction in hot flashes Increase in DVT risk Reduction in bone loss

Increase in DVT risk

What epigenetic changes are seen in endometriosis implants? (2011, 2023 NIH) Decreased aromatase Increased 17-hydroxylase (17-OH) Increased peritoneal macrophages Increased estrogen receptor beta (ER-beta)

Increased estrogen receptor beta (ER-beta)

Endometriosis is associated with all of the following except? (2011) Decreased prostaglandins Increased HOX Increased SF-1

Decreased prostaglandins

What are endometriosis lesions most highly associated with? (2011) IL-beta Abnormal estrogen receptor (ER) expression Abnormal progesterone receptor (PR) expression

Abnormal estrogen receptor (ER) expression

What is the best long term medical treatment of endometriosis? (2009, 2023 NIH) GnRH agonist GnRH antagonist Depot medroxyprogesterone acetate (DMPA) (Depo-Provera)

Depot medroxyprogesterone acetate (DMPA) (Depo-Provera)

A 50yoF had a TAH-BSO 24mo ago and now presents with flares of endometriosis. What is the best treatment? (2007) Medroxyprogesterone acetate (MPA) (Provera) Danazol Mifepristone (RU-486) GnRH agonist GnRH antagonist Anastrozole Ketoconazole

Medroxyprogesterone acetate (MPA) (Provera)

What is the best pre-IVF endometriosis treatment? (2023 NIH) 3mo of OCPs 3mo of GnRH agonist

3mo of GnRH agonist

What is the best treatment for a 38yoF with recent BSO for stage IV endometriosis? (2023 NIH) Nothing Estrogen Progestin Combined estrogen and progestin

Combined estrogen and progestin

What immune cells are found in the peritoneal fluid of patients with endometriosis? (2023 NIH) Neutrophils Macrophages

Macrophages

What is the best chance of fertility with an endometrioma? (2023 NIH) OCPs GnRH agonist post-op Ablate the wall of the endometrioma Remove the endometrioma

Remove the endometrioma

What characterizes endometrium with ectopic pregnancy? (2013, 2014, 2020) Arias-Stella reaction Chorionic tissue Endometrial hyperplasia Secretory Proliferative

Arias-Stella reaction *Arias Stella Reactive and benign phenomenon of the endometrium induced by hormonal stimulation and characterized by cytomegaly and nuclear enlargement of endometrial glands; typically associated with intrauterine or extrauterine pregnancies or with gestational trophoblastic disease

The endometrium associated with ectopic pregnancy is most similar to which of the following? (2014, 2015, 2023 NIH) Early proliferative Late proliferative Early secretory Late secretory Decidualized endometrium

Decidualized endometrium

What does robotic surgery offer best? (2015, 2016, 2018, 2020, 2022, 2023 NIH) Decreased operative time Easier learning curve Improved visualization of pelvic organs More cost effective Less physician fatigue Improved joint dexterity What is an advantage of robotic surgery over laparoscopic surgery? (2012, 2019, 2021) Reduced operative time Better tactile feedback Better visualization Easier learning curve Improved joint dexterity

Improved visualization of pelvic organs Better visualization

What results in the highest patient satisfaction for patients undergoing surgery for AUB? (2007, 2009, 2011, 2012, 2014, 2015, 2018, 2023 NIH) Rollerball ablation Microwave ablation Thermal ablation Hysterectomy Hysteroscopic loop resection

Hysterectomy

Which hysteroscopy fluid causes hyperammonemia? (2022)

Glycine

Which method to perform septoplasty is most likely to result in uterine rupture? (2021, 2022) Morcellator Cold scissors Unipolar cautery/Electrocautery

Unipolar cautery/Electrocautery

What is more likely associated with laparoscopic myomectomy compared to open myomectomy? (2021) Longer recovery More likely for hysterectomy More likely needs another myomectomy

More likely needs another myomectomy

What is the underlying mechanism causing post-op adhesions? (2018, 2019, 2021) Fibrin deposition Vascular constriction Plasmin activation

Fibrin deposition

What is a disadvantage of laparoscopic myomectomy compared to open myomectomy? (2021) Increased operative time Increased risk of infection Increased risk of adhesion formation Higher chance for the patient to require future hysterectomy

Increased operative time

What is the best management for a patient with an asymptomatic 7cm type 6 fibroid and infertility? (2021) Hysteroscopic myomectomy Expectant management Laparoscopic myomectomy Open myomectomy

Expectant management

How does an electrocautery device cause tissue destruction? (2016) Polarity Energy density Wave form Tissue dessication

Tissue dessication

How do you minimize post-op adhesions? (2016, 2017) Barrier Minimize tissue destruction

Minimize tissue destruction

What do you do when you perforate the top of the uterus during a diagnostic hysteroscopy and there is no bleeding? (2018) Re-evaluate and observe in PACU Immediate laparoscopy Transabdominal ultrasound (US) in OR

Re-evaluate and observe in PACU

What is the best treatment for a woman with a 3cm submucosal fibroid desiring future fertility? (2011, 2012, 2018) Hysteroscopic myomectomy Abdominal myomectomy Uterine artery embolization (UAE)

Hysteroscopic myomectomy

A patient develops bleeding at venipuncture sites and gums after surgery. What was the most likely procedure? (What procedure can cause DIC?) (1999, 2003, 2005, 2007, 2009, 2010, 2011, 2018, 2023 NIH) Hysteroscopic septum resection with glycine Hysteroscopic polypectomy with dextran Hysteroscopic myomectomy with loop electrode and CO2 medium Endometrial ablation with YAG laser Laparoscopy with argon beam

Hysteroscopic polypectomy with dextran

What is the least worrisome during hysteroscopy if there is a fluid deficit >1500mL? (2011, 2018) Mannitol 5% Sorbitol 3% Glycine 1.5% Saline 0.9%

Saline 0.9%

What is the least likely complication from hysteroscopic myomectomy using glycine? (1999, 2005, 2011, 2012, 2013, 2014, 2015, 2018, 2023 NIH) CHF Hypervolemia Grand mal seizures Elevated ammonia levels DIC Hyponatremia Pulmonary edema

DIC

What is the first sign of glycine overload? (2005, 2018, 2023 NIH) Hypoxia Bradycardia Seizures

Bradycardia

A 10cm multicystic mass with no excrescences is found in the adnexa 1yr after normal adnexal and tubal ligation with cautery. She had normal ovaries last year. What is the most likely diagnosis? (2003, 2007, 2011) Fallopian tube cancer Hydrosalpinx Cystadenoma Salpingitis isthmica nodosa (SIN) Serous cancer A 10cm complex mass is found in the adnexa 1yr after BTL. What is the most likely diagnosis? (2023 NIH) Hydrosalpinx Cystadenoma Peritoneal inclusion cyst A 17yoF presents with right lower quadrant pain is discovered to have a 10cm multiloculated cystic mass in her right adnexa. One year ago, she underwent laparoscopy where normal ovaries and a small right hydrosalpinx were noted. What is the most likely etiology? (1999) Mature teratoma Cystadenoma Endometrioma Hydrosalpinx

Hydrosalpinx

What is the least likely complication after a submucosal myomectomy? (2011) CHF Hypervolemia DIC Others

DIC

A 31yoF with 2yr of unexplained infertility has a 6cm posterior fibroid. What is the best treatment? (2007, 2023 NIH) IVF Clomiphene citrate (Clomid) IUI Myomectomy

Myomectomy

The successful creation of a functional vagina in a 20yoF with a mullerian anomaly and a vaginal dimple on pelvic exam is best established by which of the following? (2022) Abbe-McIndoe procedure Vecchietti procedure Csokmay bowel interposition Vaginal dilation Split-thickness skin graft

Vaginal dilation

What is the most effective way to improve pregnancy rates for IVF in patients with hydrosalpinges? (2007, 2023 NIH) Proximal occlusion of tubes Salpingectomy Tubal aspiration at time of retrieval

Salpingectomy

Which of the following hysteroscopic distension medias is most commonly associated with anaphylaxis? (1999) Sorbitol Hyskon Glycine Mannitol Saline

Hyskon

Which of the following is true regarding the reformation of adhesions after adhesiolysis? (1999) Expected to be similar for laparoscopy or laparotomy Greater with monofilament suture than with braided Is decreased with lavage using lactated ringers Is definitely decreased with instillation of dextran

Is decreased with lavage using lactated ringers

What is the most common site of injury during laparoscopy? (2007, 2023 NIH) Bowel Ureter Vascular Bladder

Bladder

You are negotiating the endocervical canal with a 30-degree hysteroscope. Where on the monitor screen should you keep the cervical os? (2003, 2010) In the middle of the screen In the lower half of the screen In the upper half of the screen

If camera facing up, os should be on the lower half of the screen

What type of laser can be used to remove endometriosis from the bowel? (2005) YAG KTP CO2 Cautery

CO2

What should be included in the pre-op evaluation of a patient who has POI and is undergoing elective surgery? (2005, 2007, 2023 NIH) ACTH ACTH stimulation test Fasting glucose Serum electrolytes Serum cortisol Antiadrenal antibodies

Serum cortisol

What is the most important test before performing laparoscopy on a patient with Turner Syndrome 45,X? (2023 NIH) Dexamethasone suppression test Electrolytes TSH

Electrolytes

What is the best adhesion barrier? (2007) Dextran IV steroids Cellulose paper Gelfoam

Cellulose paper

What is the first sign of fluid overload in hysteroscopy? (2007) Ventricular arrhythmia Bradycardia Hypoxia Oliguria

Hypoxia

A patient is planning to undergo IVF but has a unilateral hydrosalpinx. What is the best treatment? (2023 NIH) Proximal clips bilaterally Unilateral salpingectomy Bilateral tubal ligation Bilateral salpingectomy Expectant management

Unilateral salpingectomy

What are the two most prevalent immune cells in the uterus? (2012, 2021) Uterine natural killer (uNK) cells and T-helper cells Uterine natural killer (uNK) cells and B cells Uterine natural killer (uNK) cells and something else (macrophages)

Uterine natural killer (uNK) cells and T-helper cells

What is the correct ratio in the uterus compared to peripheral serum? (2021) Elevated uterine natural killer (uNK) Elevated T-helper cells

Elevated uterine natural killer (uNK)

The immunosuppressive characteristics of progesterone include which of the following? (2021) Mitogen-induced proliferation of CD8+ T cytokine secretion by these cells Promotion of Th2-type responses with increased expression of LIF

Promotion of Th2-type responses with increased expression of LIF

Which is most true of endometrial immune cells? (2003, 2005, 2011) Located only in the basalis Located overlying superficial layer Mostly monocytes, macrophages, and T cells Plasma cells Clusters of immune cells within the glandular epithelium Scattered macrophages only in the basalis layer

Mostly monocytes, macrophages, and T cells

What immune cells are in the healthy endometrium? (2023 NIH) B cells Plasma cells Monocytes Macrophages T cells

Macrophages

What cells are seen with chronic endometritis? (2012, 2018) Plasma cells Natural killer (NK) cells Dendritic cells Exhausted glandular cells

Plasma cells

Which of the following is seen during the luteal phase of normal endometrial tissue? (2021) T-helper cells CD8+ Decreased natural killer (NK) cells B lymphocytes

T-helper cells *Also NK cells

What immunologic cell change is characteristic of implantation? (2003, 2005, 2007, 2017, 2018, 2023 NIH) Increased plasma cells Increased B cells Increased natural killer (NK) cells No change

Increased natural killer (NK) cells

What cells are most likely to be found in endometrium at time of implantation? (2005, 2005, 2007, 2011, 2012, 2013, 2014, 2015, 2018) Plasma cells B cells Natural killer (NK) cells Monocytes

Natural killer (NK) cells

Where are endometrial lymphocytes? (2005) Right near endometrial cavity Perivascular

Perivascular

What is a proven treatment for immune related RPL? (2023 NIH) IgG Paternal sperm immunization Paternal leukocyte immunization Aspirin Heparin Nothing

Nothing

How do you make a clinical diagnosis of sexual dysfunction or anorgasmia? (2011, 2013, 2014, 2015, 2017, 2018, 2023 NIH) When symptoms are bothersome to patient/Personal distress Depression Orgasm with masturbation Fear of sexual intercourse

When symptoms are bothersome to patient/Personal distress

What percent of women in the United States have sexual dysfunction? (2015) 5% 11% 25% 35% 50%

11%

What is most common among sexual disorder in women? (2003, 2005, 2007, 2013, 2014, 2015, 2018, 2023 NIH) Low desire Anorgasmia Arousal disorder Sexual pain disorder

Low desire

What is associated with female sexual dysfunction? (2012, 2018) Adrenal hyperplasia Hypothyroidism Diabetes Hyperthyroidism

Diabetes

Female patients with a history of sexual abuse are most likely to have which of the following? (2011) Decreased sexual desire, normal arousal Decreased arousal, normal sexual desire Decreased in arousal, decreased sexual desire Normal arousal, normal sexual desire

Decreased in arousal, decreased sexual desire

Which of the following occurs after the completion of a meal? (2011, 2015, 2018, 2021, 2023 NIH) Increased ghrelin Increased leptin Increased growth hormone Increased glucagon Increased CRH __ somatostatin

Increased leptin

What decreases with food intake? (2011, 2018) Leptin Ghrelin ACTH Aromatase

Ghrelin

What type of receptor is the leptin receptor? (2011, 2013, 2014, 2021, 2022) Tyrosine kinase JAK/STAT (aka cytokine receptor) Phospholipase C (PLC) GPCR

JAK/STAT (aka cytokine receptor)

What change is most commonly seen in anorexia nervosa? (2016, 2020, 2021) Increased T3 Loss of diurnal variation of leptin Reduced cortisol Increased prolactin

Loss of diurnal variation of leptin

What is changed in anorexia? (2012, 2017, 2018) Low rT3 Low cortisol Low leptin

Low leptin

What is the most likely thyroid profile in anorexia? (How are thyroid hormones affected by anorexia?) (2003, 2005, 2007, 2009, 2011, 2013, 2014, 2015, 2018, 2023 NIH) High TSH, low free T4, high T3, normal rT3 Low TSH, low T4, normal T3, normal rT3 Low TSH, high T4, high T3, normal rT3 Normal TSH, normal T4, low T3, high rT3

Normal TSH, normal T4, low T3, high rT3

Anorexia is most associated with what thyroid abnormality? (2023 NIH) Increased rT3 Decreased rT3

Increased rT3

What is the most likely hormone abnormality in anorexia? (2018, 2019) Increased T3 Increased leptin Increased CRH Increased prolactin

Increased CRH

What is the second messenger for leptin? (2014, 2015, 2017, 2018) cAMP STAT

STAT

What is the central mechanism responsible for the decreased gonadotropin secretion in a woman with anorexia? (2005) - Loss of GnRH function - Opioid-mediated decrease in GnRH pulsatility - Increased CRH How does anorexia lead to amenorrhea/hypogonadism? (2009, 2011, 2018, 2022, 2023 NIH) - Opioid inhibition of GnRH pulses - Increased prolactin - Catechol estrogens - Low leptin - CRH/High cortisol How does anorexia lead to anovulation? (2023 NIH) - Opioid on hypothalamus - ACTH stimulates cortisol What potentiates the action of CRH to suppress GnRH in anorexia? (2012) - Neuropeptide Y (NPY) - Ghrelin - Opioids

Opioid-mediated decrease in GnRH pulsatility

What abnormality is seen with anorexia? (2012, 2023 NIH)

High cortisol

What is the least likely to be seen with anorexia? (2012, 2018, 2023 NIH) Diarrhea Lanugo Carotenemia Bradycardia Hypotension

Diarrhea

What changes are seen in ghrelin in anorexia? (2023 NIH) Increased ghrelin Decreased ghrelin

Increased ghrelin

What is most likely in anorexia? (2015, 2023 NIH) Leptin decreased Ghrelin decreased Others

Leptin decreased

What is least likely to be found in anorexia? (2011) Hypercarotenemia Bradycardia Hypotension High TSH Low T3

High TSH

Leptin is most likely to increase which of the following? (2015) Protein kinase A (PKA) JAK Phospholipase C (PLC)

JAK

Hypercarotenemia is associated with which abnormality? (2003, 2010) Hypogonadotropic hypogonadism (hypo-hypo) Hypergonadotropic hypogonadism (hyper-hypo)

Hypogonadotropic hypogonadism (hypo-hypo)

How do you reduce background noise in immunohistochemistry (IHC)? (2021) Increase exposure time Add a second antibody Something about goat milk antigen

Something about goat milk antigen

How do you confirm specificity in immunohistochemistry (IHC)? (2023 NIH)

Positive and negative controls

How do you assure the sensitivity of an antibody when doing immunohistochemistry (IHC)? (2016) Use known antigen Use another antibody

Use known antigen

What does ELISA rely on? (2007, 2020) Radiolabeled antigen Radiolabeled antibody Radiolabeled substrate Chromagen/enzyme complex Second antibody bound to solid matrix

Chromagen/enzyme complex

What is an important component of ELISA? (2001, 2007, 2011, 2012, 2014, 2015) Radiolabeled antigen Radiolabeled antibody Competitive binding Chromogenic

Chromogenic

What is a property of ELISA? (2011, 2014, 2015, 2016, 2017, 2018, 2023 NIH) Chemical reaction (chemogen) Radiolabeled antigen or antibody (ligand) Antibody bound to (a solid) matrix Requires secondary antibody

Requires secondary antibody

What type of assay is ELISA? (2015, 2018, 2023 NIH) Competitive binding assay Use of radioactive antigen Use of radioactive antibody Use of chromogen attached to immunoglobulin

Use of chromogen attached to immunoglobulin

What is the best technique to decrease background noise in the development of an immunoassay? (2021) Longer antigen-antibody binding time Culture in dry milk to prevent nonspecific binding Others What is the best technique to decrease nonspecific binding in the development of an immunoassay (2018) Longer antigen-antibody binding time Culture in dry milk

Culture in dry milk to prevent nonspecific binding

Which hormone assay is affected by the Hook effect? (208) Radioimmunoassay (RIA) Immunoradiometric assay (IRMA)

IRMA

What is the best next step when you suspect influence from the Hook effect? (2015, 2021, 2023 NIH) Serum dilution Develop an antibody complex to bind excess antigen Repeat serum draw Add polyethylene glycol Something about radioimmunoassay (RIA) & something else I can’t remember

Serum dilution

Which assay has an inverse relationship between radiolabeled antigen and patient hormone/sample antigen? (2020) Radioimmunoassay (RIA) Immunoradiometric assay (IRMA) ELISA Which has an inverse relationship between concentration of unknown antigen and percent bound radioactive protein? (2001, 2018) Radioimmunoassay (RIA) Immunoradiometric assay (IRMA) ELISA

Radioimmunoassay (RIA)

What is immunoradiometric assay (IRMA)? (2003, 2011, 2012, 2018) Use of radioactive labeled antibodies to detect and quantify antigen concentration Use of radioactive antigen to detect and quantify antibody concentration Competition assay Colorimetric assay

Use of radioactive labeled antibodies to detect and quantify antigen concentration

Which is correct concerning the immunoradiometric assay (IRMA)? (2009, 2018, 2023 NIH) Radiolabeled antigen Radiolabeled antibody Requires matrix Competition assay

Radiolabeled antibody

Spectrophotometric separation prior to radioimmunoassay (RIA) improves which of the following for the assay? (2003) purifying sample prior to radioimmunoassay Precision Accuracy Reliability Sensitivity Specificity

Specificity

You wish to perform a single tube assay for two similar proteins, protein A and protein B, in the same sample. What must you do before you can begin the assay? (1999) Prove that they have different ligand binding sites Show that it cannot be done Demonstrate that the second antibody has different affinity for the two proteins

Demonstrate that the second antibody has different affinity for the two proteins

The success of an immunosorbent radioimmunoassay (RIA) depends on which of the following? (1999, 2007) The antibody is attached to a matrix, followed by addition of analyte and a second antibody The antibody is linked to a solute reaction The ligand is radiolabeled The antibody is radiolabeled

The ligand is radiolabeled

What will shift the radioimmunoassay (RIA) curve to the left? (2007, 2010) Increased sensitivity Increased specificity Increased accuracy

Increased sensitivity

Which one of the following antibodies is most likely to interfere with an immunoassay? (2007)

Heterophilic antibodies

What is the best way to assess for heterophilic antibodies in a patient who is clinically euthyroid with elevated TSH and works in a lab (is a vet tech)? (2014, 2015, 2019) Serum dilution Plasma dilution Stop working with mice and rabbits Serial collections

Serum dilution

Heterophilic antibodies are most likely to be found in someone with which of the following occupations? (2011, 2023 NIH) Steel worker Nurse Vet tech

Vet tech

A patient is on levothyroxine (Synthroid) and clinically euthyroid, but her TSH is always increased. How do you prove heterophilic antibodies against TSH? (2023 NIH) Serial dilutions Precipitate with polyethylene glycol (PEG)

Serial dilutions

What is the best test to determine apoptosis? (2003, 2005, 2009, 2013, 2014, 2018, 2023 NIH) Caspase gene Frozen tissue section H&E TUNEL assay

TUNEL assay *apoptosis in ovarian tissue: all of these are correct - DNA ladder testing, flow cytometry, TUNEL assay, Comet assay, IHC for caspase-3

How is apoptosis in ovarian tissue quantitated? (2003) In situ hybridization Histochemical testing on frozen section DNA ladder testing

DNA ladder testing

What is least likely to cause an assay shift? (2014, 2015) Too many samples Minimal time putting in stopping reagent Minimizing time between samples

Minimizing time between samples

What is the best strategy to minimize assay drift in a large sample? (2011, 2023 NIH) Put on ice Do small samples Add antibody first Use less antibody in early samples

Put on ice

What is the sandwich assay best for detecting? (2011) Binding of receptors Phosphorylated receptors Density of receptors

Density of receptors

How can you quantify the number of LH receptors on Leydig cells? (2007, 2011) RT-PCR Radioimmunoassay (RIA) Scatchard plot Histochemistry Immunofluorescence

Scatchard plot

How many moles of hormone are in the serum? (2009, 2023 NIH) 10-4 – 10-7 10-7 – 10-9 10-9 – 10-11 10-11 – 10-13

10-7 – 10-9

What is the most accurate way to measure steroid hormones? (2015) Mass spectrometry HPLC Others

Mass spectrometry

What is the best way to identify the action of a newly identified progestin on the endometrium? (2021) Something about mice endometrial tissue (no mention of estrogen priming) Something about estrogen-primed rabbit endometrial tissue ELISA Sounds like the description of an radioimmunoassay (RIA)

Something about estrogen-primed rabbit endometrial tissue

How do you test progestin on an estrogen-primed endometrium? (2015, 2016) Rabbit Mice Others

Rabbit

How to find out what is the most potent progestin? (2023 NIH) Rabbit primed endometrium and see endometrial growth with progesterone Mice decidualization Renal clearance in a monkey Decidua of a monkey

Rabbit primed endometrium and see endometrial growth with progesterone

What is the most specific assay for 17-beta-estradiol? (2011, 2012, 2018) Direct immunoassay Reco LC-MS or GC-MS ELISA Noncompetitive assay Radioimmunoassay (RIA) Gas chromatography

Reco LC-MS or GC-MS

Some type of chromatographic technique is used in a sample with low levels of estradiol to improve what aspect of the assay? (1999) Specificity Accuracy Precision Sensitivity

Sensitivity

Why are testosterone levels so difficult to measure in women? (Why are testosterone assays in women so unreliable?) (2011, 2012) Lack of specificity Lack of sensitivity BMI Why are testosterone levels so difficult to measure in women? (2011, 2018, 2023 NIH) Low assay sensitivity Low assay specificity BMI Fluctuating concentration in menopause Menstrual variation

Lack of sensitivity Low assay sensitivity

What is the most accurate way to detect estradiol? (2023 NIH) HPLC ELISA

HPLC (high performance liquid chromatography or MS)

What is the gold standard for measuring free testosterone? (2013, 2019) Mass spectrometry Equilibrium dialysis Radioimmunoassay (RIA) Immunoradiometric assay (IRMA) Calculating with SHBG

Equilibrium dialysis

You are performing an assay on a new protein using radioiodine and the protein fails to bind to your label (failure of iodination). What is the protein most likely lacking? (1999, 2011, 2012) Histidine or cysteine residues Tyrosine (residues) Correct hormone conformation What causes failure to iodinate a new protein? (2001, 2007, 2018, 2023 NIH) Excess tyrosine residues Increased TSH No tyrosine residues available Abnormal receptor binding Correct amino acid sequence for binding Why would you be unable to label a protein? (2023 NIH) Not enough amino acids No phenylalanine or tyrosine

Tyrosine (residues) No tyrosine residues available No phenylalanine or tyrosine

What is meant by accuracy? (2023 NIH)

The extent to which a given measurement agrees with the actual value

What is the interassay coefficient of variation? (2020) SD/mean for multiple values of one assay SD/mean for multiple values of many assays Other options that didn’t make sense

SD/mean for multiple values of many assays

What is increased if there is a leftward shift in a standard curve? (2007) Sensitivity Specificity Validity Accuracy

Sensitivity

Multiple samples are giving the same result. What is characteristic of this result? (2016, 2017) Precision Accuracy

Precision

What is the specificity of a given assay? (2018) Smallest amount of a substance that can be measured Capacity to measure only the substance in question Ability to distinguish protein (large molecules) from steroid (small molecules) Ability to reproduce test

Capacity to measure only the substance in question

What does an LH in vitro bioassay test for? (2005, 2014, 2023 NIH)

Immunologic specificity

What do you worry about if a test is binding at 5%? (2007) Accuracy Precision

Accuracy

A sample is purified before running an assay. What does this improve? (2010) Accuracy Precision

Accuracy

The best definition of the statistical accuracy of an assay? (2018, 2021) The reproducibility of results over multiple tests from the same patient The reproducibility of results over multiple tests from multiple patients The reproducibility of results compared to a blank tube spiked with known antigen The reproducibility of an assay over time

The reproducibility of results compared to a blank tube spiked with known antigen

What is the formula for plasma production rate? (What is the plasma production rate of a hormone equivalent to?) (2011, 2012, 2014, 2015, 2016, 2017, 2018, 2019, 2023 NIH) (MCR+2C)/C MCR/C MCRxC C/MCR C+MCR

MCRxC

What are the units for MCR? (2012)

L/day

The discipline within clinical pharmacology that broadly describes the changes in the quantity of drug and/or drug metabolite in various body compartments over time. These changes can be described by four processes: absorption, distribution, metabolism, and excretion.

Pharmacokinetics

Study of how a drug affects an organism physiologically and biochemically, such as the relationships between the measured drug concentration and its efficacy and adverse effects

Pharmacodynamics

What is the effect of shifting the curve to the right? (2012, 2013, 2018) Competitive agonist Competitive antagonist Noncompetitive antagonist Irreversible antagonist

Competitive antagonist

The Arias-Stella reaction most commonly occurs in the presence of which of the following? (2021) Chorionic tissue Granulosa cell tumor Theca-luteoma tumor Can’t remember what else

Chorionic tissue

What is found on histology of granulosa cell tumors? (2018)? Call-Exner bodies

Call-Exner bodies

What is seen on histology in endometritis? (2014, 2015, 2017, 2018)

Plasma cells

A 46yoF has an endometrial biopsy performed. She is perimenopausal. (Gave an image of what I thought was simple hyperplasia without atypia) What is the best treatment? (2012, 2023 NIH) Hysterectomy OCPs Cyclic progesterone

Cyclic progesterone

Salpingitis isthmica nodosa (SIN) has which of the following findings? (2011) Endometrial implants on histology Inflammation and tubal scarring Increased smooth muscle hypertrophy

Increased smooth muscle hypertrophy

(A histologic slide showing seminiferous tubule) History notes that the man has azoospermia. What is the diagnosis? (2023 NIH) Sertoli only FSH receptor defect CBAVD

Sertoli only

Which histologic picture would be seen with prolonged progestin treatment? (2003) (photomicrograph of endometrium with atrophic glands)

(photomicrograph of endometrium with atrophic glands)

What is closest to prevalence? (2007) Morbidity rate Mortality rate Disease rate on autopsy Attack rate

Morbidity rate

Referring to a 2x2 table, what does D/D+B represent? (2009, 2023 NIH) Sensitivity Specificity NPV

Specificity

What best characterizes receiver operating characteristic (ROC) curve? (2023 NIH) Shift to left indicates decrease in accuracy The best way to demonstrate interrelationship of sensitivity and specificity Demonstrates that at each point there is a tradeoff between false negatives and sensitivity

The best way to demonstrate interrelationship of sensitivity and specificity

What will shift the receiver operating characteristic (ROC) curve to the left? (2023 NIH) Increased sensitivity Increased specificity Increased accuracy

Increased accuracy