sgect the one best answer or completion, following side effects of gonadotrophin- + Mang homone (GARED ager tee fheleast common is” A. hot flashes- & B hot flushes insomnia we bone mineral content - E vaginal dryness - . 1 na2S-year-old with pelvic pain, endometriosis is best confirmed A the initial history = 4 arepeat pelvic examination on the first iy tmenstnal fw. laparoscopic visualization and biopsy D. speculum visualization E hysterosalpingogram The most common site for endomettiosis is the A rectosigmoid ee} *A2yeaold gravi Sravida 0 undergoes laparoscopy HiPPerestve dysmenomhesend cleonie Joc Pain. She is found to have minimal ng qnttiosis. She is not sexually active, uses but in6 onthe gue sot But does plan to marry laperon , Peotomy and resection of the endometriosis dometriosis and Adenomyosis — id Sravida 3, para 3, is found to have endo- ‘PY metriosis with extensive ovarian involvement, ‘The recommended therapy should be. A. danazol aa : 6 The chemical structire of danazotis depicted in AX Figure 19-1, 4 : B. Figure 19-1, B C. Figure 19-1, ¢ D. Figure 19-1, D E. Figure 19-1, E = Of the five photomicrographs shown in the figures listed below, the one diagnostic of endometriosis is A. Figure 19-2 B. Figure 19-3 . Figure 19-4 D. Figure 19-5 E Figure 19-6 Of the five photomicrographs shown in the figures listed below, the one dieereues to adenomyosis is A. Figure 19-2 B. Figure 19-3, C. Figure 19-4 D. Figure 19-5 E. Figure 19-6 =quae 18-4" Grom Karma 3), Norte 4 Tah te Fen Gel Verng 1982) FIOURE 18-2. From Friedrich EG, Wilkinson E}: The vulva. In Busunen A, ed: Pathology ofthe Female Genital Tract, 2nd ed, New ‘York, Springer Vera, 1962) FIGURE: 19-6 (From Janoveli NA; Dubranaahy V: Also ‘and Obstetric Diagnostic Histopathology New Yet. ‘McGrawHil, 1967, p. 217) 9, A d2-year-ald gravida 4, para 4, has bothersome dysmenorrhea and menorthagis. On pelvic examination the uterus is globu boggy, and approximately twice normal size, ‘The most likely diagnosis is A, endometriosis HF adenomyosis : C. leiomyoma uteri TIGURE 18-9 From Stenchever MA, Drogemutler W, Herb _D- leiomyosarcoma Septal DR: Comprehensive Gyneceogy th et Lou E. endometrial carcinoma oxy 2001)cadet old patient has documented milé lometriosis and chooses high-dase-coritinuous Progestin therapy over the alternative medical atments offered. She should be informed that le chance of having abnormal bleeding with Progestin therapy is approximately eB. A23. AL 5% B 10% S 20% y. 40% E. 60% 14. Effects of GnRH therapy for endometriosis Include all he followin A. decreased folie stimula Hw. ROURE 19-8 (From Clement PB, Scully RE . ollicle-stimulating ho#hioné {eee Ratlogic ype. Semin Oncol 92st toeaseamsneme the _SecTEaSed luteinizing hormone (UH). 15. Danazol treatment of endometriosis is - associated with an i 10. Ina patient with end: : aut ae £1 Undergone 6 months efit “« lowers popoen YHOU. “GnRH agonist, ovarian function will" Nata Pe ete generally return within : 7 16, ‘Which treatment for endometriosis A BA weeks appéars to:altet imsiunblogic function? B. weeks (danazol Sk : Aeon weeks : & GnRH ene : weeks C. coral contraceptives E. 24-30 weeks D. Depo-Provera IL Of the following, the least common symptom. 17. What is the postulated level of estradiol that associated with endometriosis involving the protects against bone loss while not interferin gastrointestinal tract is : with the suppressive effects of GnRH agonist A. abdominal-cramping i A 10 pg/ml. . B, lower abdominal pain By 20. pg/mL. : C. pain with defecation : &H pg/mL : i} D. constipation D. 40 pg/ml : i termittent rectal bleeding . : : leeds tent 18. The choice of medical therapy for any given "12 A30-yearold has completed her child-bearing. patient depends on + She has mild endometriosis, which was A. cost of treatment confirmed by laparoscopy 1 year aga. Since that By drug side effects procedure, the patient's dyspareunia and C. patient compliance dysmenorrhea have gotten worse. te most yall the above Teast tive procedure at this Same ds 19, If GnRH therapy is begun in the follicular A. dilatation and curettage (D&C) phase, amenorrhea is induced in . dilatation and cut B. uterine suspension . eel & total abdominal hysterectomy arene Presa tomy , ei Presacral ete uterosacral Ligaments ZEB weeks + stout 4etriosia include 4 Co sat nodiultity ral SE Tras ore enlargemeny Bate ae cnination 20. Lf GnRH therapy iss amenorrhea is induced 1 ion ct week jen aerren sae eee . doguinentation ofthe extent of 2 eS weeks a gis Anelides D 6-8 wee isan 1. Which of the following * suprotide acetate (Lupron) arelin acetate Synarel) _ goserelin acetate (Zoladen) D. all the above . 22, Tre most common surgical appro#h endometriosis is ‘A hysteroscopy laparoscopy te D. transvaginal : caw 23. Endometriosis is associated with all the: so. rye capt ffect of danazol is due to its following except binding » ‘A. anovulation pops mero 2 tasimestersbrton Bs ag lobln ee ae BB. allthe above ier Sctometdos Seal tarted taking danazol Mu Nour eer aisk for endomettiosis - a Aasyeiald wotian has ssi arte a ng bs includesll the following except tee ie treatment A war ‘girl with imperforate hymen She should be instructed to -year-old woman with regular. menses A taka 200 mg 4 ay B. 2-year eee - B. use mechanical contraceptives during Foor) aa a first month" Sates © stirt teataenié on the first day of the D. all the above . menstrual %. allthe above a In an effort torxplain the etiologic basis a o of endometrioif, {thas been postulitedthit 32. A2oyearold gravida O presents witha chief A. endometriosis is due to implantation of complaint.of progressive dysmenorthea for erdometral cells shed as'X result ot years: She has'fad dyspareunia for 12 months, 2 vel take the duration of her marriage. She has never used nil ; : 4 coelomic epithelium, undergo metaplasia contraception, Blerciniderlying groblem is to form endometrial tissue Probably:dus to C. endometrial tissue can be transplanted via. ‘A. adenortiVosis’ both the lymphatic and the vascular system B, chronic pélvic inflammatory disease _Dr all the above & endometriosis” D. leiomyoma 26, Laparoscopy for pelvic pain reveals several lesions. Those that should undergo biopsy to confirm a diagnosis of endometriosis include a A. 05-cm blood-filled cyst 33, Surgery is mandatory in the treatment of endometriosis for cases in which there is B. powder burn area a ‘ureteral obstruction C clear vesicle ~ Compromise of large’ bowel fuinction Ball the above S an bem onan cele ; PF all the above \t - {me glands and stroma of adenomyosis are served from aberrant glands of the basal layer of the endometrium Sasalis, comparable in estrogen and 5 ceceptors with the glands peg of the endometrium primarily confined to that part of the myometrium néarest the endometrium, p. more responsive to hormone stimulation than the glands and stroma of the endometrium. ss, Steroid hormone therapy after definitive cal treatment for endometriosis ghould be used to manage ‘A:menopausal symptoms B. residual macroscopic endometriosis eee he agonist therapy for endoinétriosis is when “ Av there is severe adhesive disease B. there is only one endometrioma that is <4 cm in diameter . £ allesions are < 1 cm in diameter . D. all the above ; - 5 : 37. The side effects of GnRH agonists can be made more tolerable with the =~ addition of &, danazol BO low-dose estrogen C: triphasic oral contraceptives 1D. monophasic oral contraceptives 38, In patients with moderate to severe endometriosis, in what percentage of cases is the cervix deviated/laterally displaced? 15% B. 33% C. 73% D.-90% 39, How long does it take to recover the boné - density lost with 6:months therapy With GnRH agonist ~ A, 1-3 months B,6-9 months 12-24 months, 'D. 36-48 monthsInfertility TIONS: piAEO is 1-32: Select t tit oe sng ihe evaluation of an infertile coupl , oartsband’s nitial semen analysis is received ge hose information is listed belove The , Moral parameter is 2 a volume: 25 sal 5. p75 ili Liem ces 15 million/mL EET emoity: 75% have good to excellent " motility . ° em Tnorphologic features: 65% normal , Based on the previous semen analysis results, and assuming that the husband has a normal medical history, thé most appropriate recommendation is A repeat the semen analysis immediately peat the semen analysis in 1 month C begin clomiphene citrate therapy D. begin tetracycline therapy E, refer the patient to a urologist i The only direct evidence of ovulation is A. a serum progesterone level of 10 ng/mL 8. ahistory of regular menstrual cycles anendometrial biopsy revealing a secretory endometrium D ‘biphasic basal body temperature (BBT) chart *) Pregnancy the : one best answer or completion, 4A ‘i A2syesrald gravida 1, para 1, is undergoing, scopy for infertility of 2 years’ duration. ‘You notice fou: L-mm superficial imy ° e for iperficial implants of ndometriosjs on the left ovary and a few filmy adhesions around both ovari ovaries. If it is assumed that the rest of her workup is normal, the most appropriate treatment for this patient is to A. perform laparotomy immediately B. perform laparotomy in 6 months C. begin danazol postoperatively D. recommend in vitro fertilization (IVF) Er Tulgurate and delay medical or other surgical intervention at least 12 months 5, The poorest prognosis for conception is associated with A. intrauterine adhesions B. leiomyome C. abicormuate uterus bs utero DES exposure pelvic tuberculosis 6. Acouple with primary. infertility inquires about possible sexually transmitted diseases associated with artificial insemination with a donor's semer (AID), You. should inform them that semen iS frozen for 6 ‘months to allow the detection of Chlamydia trachomatis ; ‘ lm rode) virus (HIV) C. Neisseria gonorrhoeae D. syphilis E. serum hepatitis B"7. A 2-yearold nulligravida is scheduled to begin, clomiphene citrate treatment for anovulation. She should be informed that, compared with the general population, conception following clomiphene treatment is associated with an increased incidence of A. spontaneous abortion B. ectopic pregnancy _& multiple gestation D. congenital malformation E. intrauterine fetal death 8. Aa3-yearold with a history of 2 years of infertility undergoes hysteroselpingography, which is reproduced in Figure 41-1. The most efficacious treatment for this problem would be A. transcervical balloon tuboplasty B. intrauterine insemination (1U1 C. gamete intrafallopian transfer (GIFT) D. tubal reanastomosis VF 9. As used in the past, IUI with washed semen ‘would be most appropriate for couple with A. ceryical stenosis Se ligospermia C. inadequate mucus D. small semen volume E. bilateral.cornual obstruction FIGURE 41-1 ed 10, A 30-year-old gravida 1, pars 1, is receiving Glomiphene citrate, 50 mg/day, on days § through 9 of the cycle for the treatment of anovulation. A serum progesterone drawn on day 23 is 16 ng/mL. During the next cycle, the dose of clomiphene prescribed per day on days $ through 9 should be ASO mg B. 100 mg C. 150 mg D. 200 mg E, 250mg 1-12. Match the infertility investigation with the best menstrual cycle day to perform it. (A) 1 (B) 7. © 13 (0) 17 ©) 26 11, Hysterosalpingogram B “42. Endometrial biopsy & 1, Asthenospermia is defined as A. abnormal sperm morphologic features B. low sperm count "reduction of sperm motility D. inability of sperm to fertilize egg E 14. Clomiphene citrate is classified as a A. natural estrogen B. natural progesterone 2&X synthetic testosterone D, synthetic progestin 2 synthetic estrogen 15, The most ominous sequela of ovarian hyperstimulation syndrome (OHSS) is A, abdominal distention B. ascites C. oliguria D. pleural effusion “hy percoagulability 16. Which of the following treatments has improved the fecundability rates in couples with unexplained infertility? A. controlled ovarian hyperst A. con 'yPerstimulation “Il the alee...Wrequency as a cause of infertiin w 5% © @ 8% Fo 3% t (D) 50% |p B% |, anowsaton B | abnormal semen@ |p, Impairment of tubal motility C- |p apnonnal sperm tranepor through he ces | ig. All test results from a couple undergoi a Allen el ro oul desing | instructions regarding coitus should they be given? A. every other day over 6 days at mia: BC aaily for 3 consecutive days at midge C. weekly throughout the month D. every other day during the middle 2 weeks of the month k t 22, Which of tHe following is the best method to predict ovulation? A. BBT B. serum progesterone yptoms of mittelschmerz rrinary luteinizing hormone (LH) 23, What is the minimum number of hours of sleep recommended to provide accurate information fora BBT chart? A. 4 hours 36 hours C. 8 hours D. 10 hours 24, If follicle-stimulating hormone is drawn, when is the optimal time in the cycle? days 1-3 B. days 8-10 C. days 13-15 D. days 24-26 25, Oil-soluble contrast media are preferable to water-soluble media in performing, terosalpingography in what cases? 27. The most ettec, ‘ 4 pototat terse go Sagronic eae £88 Sperm poheration » Stinaty LH ne sneas monitoring of ate luteal sen (Ser edit Progesterone measure, 28. A hysterosalpin = Rommal. It wou patient that A agORETE a no pelvic adhesions there is no evi i RegeIE no evidence of apingtsisthmica C. there is no endometrio sis D, she has normal fertility ngogram is interpret be conect is infor ig 29. A 25-year-old patient has unc infertility investigation, ee rogestezone, semen analysis, posto and hysteosalpingogram, Allert rer oece normal. A.diag:stic laparoscopy is now scheduled, Tests performed at the time of laparoscopy that would likely provide additional information about the etiologic a complex of infertility include a A. hysteroscopy B, acervical culture 2 transcervical insufflation with indigo carmine D. ovarian biopsy : “4 30. Under.what circumstances is treatment of hyperprolactinemia helpful in managing epee? ‘A. The patient is 35 years eld or older. B. The male pa-tpey has a low sperm count. The patient ‘latory. 3 D. The prolactin is above 100 ng/ml. i tency of _. Hysterosalpingography shows pat : Byer in pant being evaated ’ cafertlity. All ether study results are normal) Based on this finding, the next most approp' step in the management of this patient is ‘A. advise continued timed intercourse | ‘ diagnostic la i|. A woman complaining of menorth: lasting a total of 10 days. Most of broeainal blood loss most likely occurs _AX within the first 3 days of menstruation during the 4th, Sth, and 6th days of” menstruation C. during the last 3 days of menstruation D. ata different time each month* 2 A 38-year-old gravida 3, para 3, has a histoty of progressive menorrhagia over the past 8 months. This has ever happened previously. The patient weighs 170 pounds and is 5'feet 2 inches tall She has no rash, but her skin is diy. Al endometrial aspirate at her initial-vi ago revealed proliferative endome! hemoglobin was 10.8 g- The systemicdisease most likely to be associated with these findings is A. systemic lupus erythematosus (SLE) B, idiopathic thrombocytopenic Pupure amp) C. von Willebrand disease : hypothyroidism = menor1agi~ E, diabetes mellitus 3. The mechanisms that normally stop menstrual Hood loss include all the following except 4. localized vasoconstriction formation of a platelet plug * Vascular fibrin deposition - fibrinolysis ™yometrial contraction aviek bleedit than ovulatory patients because onlatoe patients appear to have-a deficiency in 4. Anovulatory patients have AX prostaglandin! B. prostaglandin By C., thromboxane D. prostacyclin E,, arachidonic acid * 5. A 2bijeaitold grivida 1, para, with imiérionchagia over the past 6 months had an, endometrium sample’ taken: or:day 22.0f her’ ‘cycle: The rep ort states-“secretory: ‘endomettial fragments.” Since the biopsy, her menstrual flow has been heavier and'longer. & workup + for other potential causes of this bleeding is uunrevealing. The next step’in her management should be A. a repeat office endometrial aspir B. dilatation and curettage (D&C) = C. vaginal, probe ultrasonography y yysteroscopy “ . . E. amidlutéal progesterone le 6, In tréating patients with severe mengrhagia secondary to anovulation, theoretic advantage of high-dose conjugat estrogens over a high-dose combination oral contraceptive is that estrogen:alore. / promotes rapid endometrial growth . increases spiral artery recoil C. increases platelet aggregation D. promotes synthesis of prostaglandin F. E, can be given intravenously 8—— See. eee 1 AY «teu pieedi 2 ie 13-year-old virgin complains A 11, The mean volume of blood lost during norma, istory of menometrorshagia. The ret - menstruation 1s minal ean ia, The reetal abdo ‘examination result is normal. Office urine A. 15mL Pregnancy test results are negative. The hemo- B. 35 mL globin and hematocrit are 9.8 g and 29%, respec” ‘55 mL tively. The treatment of choice for this patient is ‘p. 75:mL E, 95m ‘A, combination ofal contraceptives ya exec progestin therapy for “0 days every va, Adeyearoldrovda2, pre ab 1st ta Dec She has had heavy vaginal bleeding for 9 days, 5 aa h Her pulse is 110, blood pressure i 60/60, and a Ngh-dore conju ted oral estrogen Jivic examination is normal. A titer for E. dally high-dose conjugted c=) SIF Biuman chorionic gonadotropin (®-RCG) is 8. An 16-year-old gives a 2-month history of negative, hemoglobin is 1S ffcacous intermittent, irregular bleeding. Her last normal nn : menstrual pgiod-was 3 months ago. Before thal treatment i$ , her cycle wasitegularat.28:days Relvicexamina- A parenteral high-dose conjugated estrogens ‘norinal: The next step-in for 10 days management should be C D&C. 7 “A endonnetil aspiration 7D edroxyprogesterone acetate, 20mg /day for ” pelvi yund i 10 days az Mf eae D. danazol, 400, mg/day for 10 days D. iaporoscopy E. oral contraceptive tablets, four tablets per day E. hysteroscopy for 10 days e * i i the emergency aA did gravida 3, para3, whohashgd— © 13+ A Teyearold comes to the emerge ; Sencagie Zor6 months underwent a hyster- department with a Sxday history: pf excessive ostopy-and D&C 4 weeks ago. The wl menstrual flow. Her. jis 8.2 g, and owas: vas smoot out Ker hematocrit is 23%, ‘The pregnancy. ered i ogist re ~ gesult is negative. Th are is 80/40, ey 0 i hi 10. andthe pulse js/120. The most likely cigaretes por day. The preferred management diagnosis is. PE arevanorgest -AL-vor Willebrand disease device UD) us B.. prothrombin deficiency B.’ continuous medroxyprogesterone acetate C,-leukemia : G. continuous conjugated estrogens 2B andvulation E. endometrial polyp D. cycli¢danazol:... E, combination, oral contraceptives jout 7 days late 14. A26-yearold woman:has been abi , for 10, An 18-year-old has hiad one extremely heavy. for her period three or four times per year period for which she was prescribed conjugated the past 2 years. The flow eventually starts with estrogens, 10 mg in ‘divided doses. Her pregnancy spotting: A B-HCG titer is negative at the time of test result is negative, The patient denies sexual her office visit. An endometrial biopsy done on Tate flow” reveals mixed activity. Assuming that the bleeding is markedly diminished within 24 hours, the next step in the treatment of this patient should be the fourth day of her” proliferative and secretory endometrium. These findings indicate C conjugated estrogens; 10 mg/day in divided i A. an inadequate c doses plus itdroxyprogesterone acetate, 10 nonunion mg/day for 2 weeks B. conjugated estrogens, 20 mg/day in divided doses for 2 weeks ©. a cycle of oral contraceptives containing 30 to 35 mg of ethi D. vitamin E for 30 days E. office endometrial aspiration repetitive subclinical abortions chronic ectopic pregnancy "a persistent corpus luteum (Halban syndrome)15. A 41-year-old, 5-feet 4-inch, 135-pound gravida: ‘1 2, para 2, woman has a 4-month history of irregular menstruation. She has very heavy flow ‘every 60 to 120 days. A B-ACG titer is negative. ‘The pelvic examination result is riormal: The next step in management should be A. office hysteroscopy Z. office endometrial aspiration C. serum clotting studies D. hysterosalpingogram . pelvic ultrasound imaging 16. After successful treatment of an acute episode of anovulatory bleeding in a 1i-year-old, long-term treatment is best accomplished by A. D&C B. cyclic oral contraceptives C. cyelic conjugated estrogens /B cyclic medroxyprogesterone acetate E. eyelic danazol for Questions 19-21: For each numbered item, select the one heading most:closely: associated lettered heading may be used once, more than once, or not at all. 19-21, Appropriate therapeutic.agent (A) danazol {B) ergot alkaloid (©) tranexamic acid (AMCA) (D) medroxyprogesterone acetate * 49, Which is an inhibitor of fibrinolysis and is associated with a 60% reduction in menstrual blood loss in patients with menorthagia? DIRECTIONS: 4 $e S07 AW ddpearatd woman with class HP valvular’ heart disease has a history of progressive i menarrhagia aver the past 8 montis: Previous, atteillts to decrease the bleeding with medroxy- Progestitone acetate Nave failed: An eridat metrial aspiration is reported ta be proliferative endometrium without inflammation: The hemoglobin is 10.8 g. At this point you would A. start cyclic oral contraceptives B.-start nonsteroidal anti-inflammatory drugs (NSAIDs) C. start an‘ibiotic therapy perform gn endometrial ablation procedure E. perform D&C" 18. The rationale for the therapeutic uée of conjugated estrogens for the immedi: treatment of dysfunttional ute bleeding is based-on the fact that it" ‘A. stabilizes endogenous serum clotting factors B. causes a decrease in platelet adtiesiveniess C.,causes decidudlization of the endoinetrium 2D? leads to rapid proliferation ofthe endcmetsium . is followed by a uniform endometrial slough on withdrawal Ry 20.- Which is an inhibitor and’does not reduce menstrual blood loss in patients treated for menorrhagia? . ‘21. Which is an'inhibitor and enhances activity of 17-a-dehydrogenase:to favor conversion of estradiol to estrone? . for Questions 22-31: Select the one best answer or completion. 2. In assessing the quantity of blood loss. during Menstruation, the most reliable feature. obtained by history is the ‘A number of days of flow. umber of sanitary pads used Patient's description of passage of blood ¢lots, - patient's quantification as “heavy” 23, The histologi¢ appearance of the endometrium of a patient who is anovulatory is likely to show all the following except _ACAn eosinophilic infiltrate B, areas of necrosis of the endometrium, C. lack af spiraling arterioles D. proliferation of the endometrium Y_ 308-_ REPRODUCTIVE ENDOCRINOLOGY. AND INFERTILITY, ‘a, “24, Complications that are more conunonly associated with endometrial ablation than with hysterectomy include all the following except A. fluid overload B, hematomnetra LB infection D. thermal damage E. uterine perforation 25, A 35-yeanold gravida 2, para 2, with a negative workup is having persistent menorrhagia despite medical management. An endometrialieblaticniselétted'as « the:treatinent approach. Which‘of- the. °° following techniques does nof require pretreatment? of A. laser ablation B, roller-ball thermal ablation & thermal balloon ablation 'D. none.of the abowe; they all require. | |. prétreatinent’~ : 26. The following are all pharmacologic actions. of NSAIDs.used-in treating menorrhagia exept... A. plotixing forttiation.of prostacyclin inhitition pttlrinclss CC. intefferesi¢e’in' the conversion‘of™ arachidonic.acid-to prostaglandin D. inhibition of platelet aggregation 27, The hematologic profile of a group of women who lose moretHian 0 ml of blood ach - menstrual eyclé{would: typically include all the following except... PC increased bleeding time B. lower mean corpuscular volum: C. lower mean hemoglobin level D. lower mean hematocrit level E, reduced serum iron levels.» 28, Medroxyprogesterone acetate has all the following actions except that it ‘A. activates 17-hydroxyster ! Lehydrogenase alter high-density lipoprotein, . ‘eaey Tipaprotein (HDL/ LDL) levels as much as the 19-nortestosterones C. inhibits replenishment of estrogen receptors in he cell reduces vascularity in the basalis layer of the endometrium 29; Therapeutic agents that are efficacious in reducing mean menstrual blood loss include all the following except A. cyclic'synthetic progestins B._danazol #“ methylergonovine maleate D. NSAIDs E. progestin-releasing IUDs 30. The advantages of “roller-ball” electrocautery ablation of the endometrium over laser ablation include the fact that the former ' "A, canbe done with a paracervical bldck B. involves considerably shorter operative time C. has fewer long-term complications D, hormonal “pretreatment” is not necessary “is less expensive 31. A-20-year-old gravida 0 complains of “heavy menstruation,” which is now in its seventh day. The pelvic examination result is normal except for the presence of clotted blood filling the posterior fornix. A B-NCG titer is negative, and an office hematocrit is 35%. The recognized standard management options include all the following except . ODES “B. high-dose conjugated estrogen therapy (10 img/day in divided doses until bleeding stops) C.‘medroxyprogesterone acetate (10 mg/day for p ladeys) contraceptive pill (50 mg of estrogen) f times a'day until bleeding is ee feteMenopause ——— EE for Questions 1-24: Select the one best ariswer or completion. 1. A 45-year-old diabetic, hypertensive patient complains of severe hot flashes following a recent hysterectomy and bilateral salpingo- ‘oophorectomy performed for large uterine leiomyomata, Without medication, the patient's blood pressure is 145/95. This woman has a history of thrombophlebitis at age 30 due toa femur fracture during a motor vehicle accident. Prior to her surgery, her blood lipids were measured. This woinan’s low-density lipoprotein (LDL) cholesterol was high, and her high-density lipoprotein (HDL) cholesterol low. You would” 2. The increase in facial hair noted in postmeno- pausal women is a direct consequence of A. increased levels of testosterone B. increased levels of androstenedione C. increased sensitivity of the'hair follicles D. increased luteinizing hormone (LH) a decrease in the estrogen/androgen ratio 3. AS3-yearold white woman with type 2 diabetes has been undergoing hormonal replacement for her hot flashes. These are ‘unbearable unless she takes at least 1.25 mg per day of conjugated equine estrogen. Previously, AW prescribe estrogen the patient had not been taking a progestin. She B. prescribe a regimen of estrogen and would prefer not to-have withdrawal bleeding, progesterone Of the following regimens listed, the one that C. not prescribe estrogen because of her blood will most likely meet her request and still lipid profile provide protection to the endometrium is D. not prescribe estrogen because of her history of thrombophlebitis E. not prescribe estrogen because of her hypertension Number of Number-of Estrogen estrogen Progestin rogestin & amount days/month & amount daysintonth ‘A. Conjugated equine estrogen First 25 Medroxyprogesterone Firs 625 8 0408 = 2 Risto B. Estrone sulfate 0.625 my rst 25 _ atone. 8 gfetrosyprogestrone Last 10 Estrone sulfate 1.25 mg First 21 Medi C. Egtrone sulfate 8 irs Mroypmge vine SEE i mg eK nized estradiol 2 mg Continuous Media ‘ Medroxyprogesterone est 42 E, Usterifivd estrogen 125 my, Continuous ae fhe ge lethyltestosterane . mg ‘ontinuous \Av A 67-year-old gravida 5, para 5, has urgency, urge incontinence, and stress incontinence. The stress incontinence is confitmed by urodynamic testing. Urinalysis results are normal, and the urine culture is negative. The patient has a pale atrophic vagina. She takes No medication or vitamin supplementation and otherwise feels well. At this point you should A. perform retropubic suspension B. perform vaginal hysterectomy and anterior colporthaphy C. start a Bradrenergic agent D. start an anticholinergic agent BX start vaginalestrogen 5. The mean age of'menopause for nonsmoking women in the United States is ASS B. 47 C49 wot E. 53 6. Ina patient whose major complaint.is hot flashes that greatly interfere with her daily life, you would expect to find all the following, except A. less'than ideal body weight B. decreased estrone C. decreased estradiol increased sex hormone-binding globulin (GHBG)-bound estradiol E. increased follicle-stimulating hormone (FSH) 7. In those womenvat risk for osteoporosis who are not properly treated, the percentage of lost bone mass each year after menopause is 25%-0.5% 1% -2% C. 3% 4% D. 5%-6% E. 8%-10% §. Estrogen replacement therapy causes A. adenocarcinoma of the endometriam 8. hypertension _SAirombosis ‘ thickened vaginal epithelium F. ductal carcinoma of the breast J AM At ins 49, Multiple prospective and retrospective studies have considered the likelihood of endometrial cancer in women who have been undergoing estrogen replacement, The niain conclusion reached is-that postmenopausal estrogen is associated with a(n) ‘A. endometrial adenocarcinoma that is relatively differentiated ACeeative risk of more than 5.0 of developing adenocarcinoma of the endometrium C. tisk of adenocarcinoma of the endometrium that has no correlation with the length of therapy D. risk of adenocarcinoma of the endometrium that has no correlation with the dose of estrogen prescribed E. higher risk in those women who have taken oral contraceptives before menopause 10, A 42-year-old woman complains of hot flashes. Her periods are fairly regular, every 26'to 30 days. Flow lasts 3 to.7 days. In the past, her periods were exactly 28 to 29-days and flow lasted 3 to 4-days, A serum FSH level was elevated, and thé serum progesterone was 10 ng/mL. Your advice would be that this patient should: A. stop worrying about contraception B. use progestin supplementation C. consider herself menopausal D, yindergo LH determination ~ begin estrogen supplementation 11. Of the several women listed below, which one is unlikely-to experience hot flashes? A, a 50-year-old 45,X who had been taking img of micronized estradiol daily until 3 months ago B. a SS-year-old Caucasian woman, 5 feet 2 inches tall, 100 pounds C. a 50-year-old Asian woman, § feet tall, 85 pounds D. a 38-year-old Caucasian woman, 5 feet 4 inches tall, 180 pounds, who has just undergone total abdominal hysterectomy ‘an 18-year-old woman with pure gonadal dysgenesis who has just undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy va bilateral salpingo-oophorectomy12. Postmenopausal serum levels of A. calcium are decreased B._phosphorus ae decreased E-taletonin are decreased e Parathyroid hormone are increased . 1,25-dihydroxyvitamin D are increased 1. The histologic appearance ofthe ovaries of a -year-old woman who had her last notmal ‘menstrual period 1 year ago would reveal Ae Tack of ovarian follicles B. proliferation of the theca C. proliferation of the granulosa D. degeneration of the stroma E. absence of surface epithelial cysts 14. A’ typical 55-year-old woinan who has hot flashes describes them to you. She is likely to tell you that hot flashes A, have interfered with her activities for 6 to 7 years _Beare otcasionally followed by profuse perspiration C. come on gradually over’a 15-minute period D. rarely occur more than once in 24 hours E, last 10 to 15 minutes bone can be accurately established by all the following except ‘A. computed tomography (CT) Besingle-photon absorptionietry C. dual-photon absorptiometry f | D. xray examination | E dual-energy x-ray absorptiometry (DEXA) f | 15, The diagnosis of osteoporosis in trabecular e t 16, The major mechanism responsible for the: reduction in cardiovascular disease noted in women receiving estrogen replacement is ‘A. decreased LDL cholesterol B. ‘increased HDL cholesterol C. increased serum triglycerides D, decreased total cholesterol direct action on the arterial wall 1. The addition of 10 to 12 days of a synthetic Progestin to a cyclic postmenopausal estrogen Tegimen | A. tenders it less effective in the prevention of hot flashes Aegates the beneficial effect that estrogen has on bone density frhances the beneficial effect that estroge” 46 on serum lipids : TAY cause mild depression and irvtability Prevents vaginai atrophy 18, A factor that appears to affect the age of a woman's menopause is A. weight B. use of oral contraceptives C. number of term pregnancies Brsnoking E. age at menarche 19. FSH is elevated in the postmenopausal woman because of decreased levels of A. estradiol B_estrone ibin DL E, prolactin 20. A hot flash is followed by ‘A. increases in digital perfusion increases in peripheral skin temperature . decreases in LH D. decreases in heart rate E." decreases in cortisol 21, A number of complaints, such as anxiety and ‘worry about oneself, have been attributed to menopause. Recent studies suggest that postmenopausal patients who receive exogenous estzogen improve because the estrogen A. increases prolactin B, decreases testosterone L were plasma Brendorphin D, increases estrogen receptors E. decreases LH i whose 22, A @p-yeanold gravida, para 4, woman ¥ last period was 10 years prarand who is postmenopausal presents 7 7 re inati ‘medical history and physical Seat ible. Because of bed 7 intolerance of progesterone agents, shes ark on only conjugated estrogen i rgd for he denies any Va Pua ination and Pap smeat, cddition to routine examina ane ofthe following should be done except ‘A. gaetometrial sampling C. beliak challenge test ), sonohystogram peer z rensvegital ultrasonography for ev stripe23. A 50-year-old woman, gravida 2, para 2, whose 24, A 49-year-old gravida 0, para 0, last period was 3 months ago, complains of ” Pres evaluation for hormone replacemes ef . ment aa increasingly severe’hot flashes that are Although the patient is currently heath nye markedly compromising daily activity, Her has a strong family history for Tultipte. Me medical and surgical history findings are medical Problems. She is knowledgeabie negative except for a diagnosis of a deep about the issues of hormone Teplacement venous thrombophlebitis during her second therapy and breast cancer, Osteoporosis pregnancy at age 32. This occurred after some Prevention, and lipid status. She wants to trauma and was treated with anticoagulation know more about other possible side effects for the remainder of the pregnancy and for of hormone replacement therapy. She a few months postpartum. She is now should be told that there is an association interested in estrogen replacement therapy. with hormone replacement therapy use rasa Management should be an increase in trogen replacement only A, solon cancer 2 estrogenand progesterone replacement gallbladder disease C. no hormonal treatment of the flashes C. hypertension D. oral contraceptives, low dose D. non-insulin-dependent (type 2) diabetes E. referral for herbal alternatives E. weight gain for Questions 25-29: For each numbered item, select the one headin, lettered heading may be used once, 1g Most closely associated with it Bach more than once, or not at all, 25-27; For the following, select the percent affected 28-29. For the following, select the daily dose. without hormonal replacement, (A) 03 mg (A) 5% . B) 0.625 mg (B)10% © 25mg (©:18% ©) 700 mg (D):20% ©) 1500mg ©) 3% A 28. The minimum amount of conjugated equine estrogen that will prevent osteoporosis in Patients who ingest at least 1500 mg of E 25. Caucasian or Asian women who experience spinal compression fractures by age 60 ‘alelum in their diet or through calciuni “C 26. 80-year-old-icmen with a hip fracture who die supplementation : ’ from the hipifracture or its contplications within E e 6 months = {) 29. The minimum recommended amount of daily wg supplemental vitamin D necessary to.retard (y 77- 80-year-old white women who will experience osteoporosis ‘hip fractures DIRECTIONS: for Questions 30-40: Select the one best answer or completion, 30. Factors known to increase the risk of 31. In the postmenopausal woman, osteoporosis include all the following except androstenedione a diet high in alcohol A. is secreted primarily by the ovary B. early spontaneous menopauie Bis secreted primarily by the adrenal C. .cigarette smoking y ~& obesity is converted to B-estradiol in peripheral body fat E. sedentary lifestyle D. acts as an estrogen32. Compared with the bone loss that occurs With aging, which of the following patterns characterizes the bone loss associated with estrogen withdrawal? Cortical bone A._Unchanged Plighely increased farkedly increased D. Markedly increased E. Markedly decreased Trabecular bone Unchanged Markedly increased Slightly increased Markedly increased Markedly decreased 35. OF the following, which has the highest level of dietary calcium? A. chocolate mili, 1 cup B. cottage cheese, low-fat, 1 cup C. ice cream, vanilla, 1 cup D. frozen yogurt, vanilla, 1 cup F© tonat yogurt, plain, 8 ounces 34, A SI-year-old woman, gravida 1, |, present with perimenopausal complaints including te flashes. She has multiple risk factors for osteoporosis but is very hesitant to take estrogen replacement because of fears of breast cancer, Her only family history of breast cancer is a maternal grandmother, in whom the diagnosis was made when she was 73 years old. Which of the following statements regarding breast cancer is most correct? A. Addition of progesterone to estrogen replace- ment therapy clearly protects from breast cancer. 8. Baseline risk of breast cancer is decreased in obese women, C. Her positive family history clearly adds. additional risk. D. Risk of mortality from breast cancer found in sae estrogen uses ig increased. + ie smalll reported increased risk of breast cancer may be a detection bias. * A4syeanoid patient who is $ feet 9 inches tall ieighs 155 pounds (70 kg) is concemed cant the Possibility of weight gain if she a _ ¢strogen therapy. You should advise her wig OBEN replacement therapy is associated A 3 gettin body weight and body ft ease in by i; “ in ety fat ody weight and an increase 2 ay RttBein body weight or body fat © an ineeis® it body weight and body fat ing . bog 7eése in body weight and a decrease in 36. A 52-year-old woman with a history of migraine headaches seeks your opinion regarding the itnpact of menopause. You should advise her that stiidies indicate that ménopause is associated with . A. a significant increase, in migraine headaches B, a mild increase in migraine headaches C. no change in the frequency of migraine headaches D. a mild decrease in migraine headaches Be“ significant decrease in migraine headaches 37, Oral estrogen-testosterone therapy is associated with’ A. increased HDL cholesterol levels B. increased libido 2c Increased frequency of acne D. decreased LDL cholesterol levels E. decreased hair growth 38, Meitopause that occurs before the age of 45 is most closely associated with which of the following factors? Avsmoking .: B. low body weight C. early menarche, Prchromosomal abnormality E. prolonged lactation 39. A 53-year-old woman presents for consultation regarding continuing estrogen replacement therapy. Her history is remarkable for a total - abdominal hysterectomy for dysfunctional uterine bleeding at age 42, When she was 49, she itad a “mild heart attack” and was found to have elevated lipids. She was placed on statins Jow-dose aspirin, exercise,-and estrogen replacement therapy since she was.also perimenopausal. She-has done well'on the regimen. She now hears in the news that estrogen replacement therapy in patients with known cardiac disease increases their risk of death. This patient should be A. advised to switch to herbal estrogen warations that have not been shown to this effect ; B. aed tq immediately discontinue the use replacement therapy eran cecurges to contin He nt dose D. tld that the news reports are wrong and to ignore themHyperprolacti emia, Galactorrhea, and Pituitary Adenomas for Questions 1~% : Select the one best anss 1, As7-year-old woman with galactoithéa h ; 2 prolactin level of 40 gin on paetlcie a ec Larbeer srg aan Her thyroid function results are torial: the ma next step would be to : Ppystel examination results ‘A. observe for 3 months the galactorshea, a eee Tepor- 3B, obtain anteroposterior and lateral coiied-down ted fo be 18 nig/siL. At this point you recommend oe of the sella turcica : ACT “ “perform magnetic resonance imaging (M0) B.-hypocycloidal tomography C.-pneumoencephalography visual field-txagninatior: -ETollow-up in l:year D. start bromocriptine E, refer for surgical resection 2. A patient who had been treated for a prolactin- secreting microadenoma has just delivered 5. "Big-big” protactin oe to breast-feed. You would ‘Avis the principal form of prolactin measured in bioassays : A, not to breast-feed : B. is the principal form of prolactin measured in oo take bromocriptine while breast-feeding immunoassays soar ARR, take bromocriptine for 2 to'3 weeks after C. isa dimer of the small imonomerie'form * | breast-feeding wat _Defas redaced:binding tomamarianytissue | D.toundergo a serum prolactin determination ” membranes compared with the’monameric before you decide what to advise form i E ioundergo computed tomography (CT) constitutes S0sof the secrete form» me you sii what oa 6, Select the patient in Figure 39-7 ‘whose serum 5 All the following can cause galactorthea and prolactin devel is most typical of thenormal yPerprolactinemia except patient. j ote 2 A Cushing disease A. patient A ~ low-dose oral contraceptives B. patient B See agcitonic renal disease nC oh Ep berthyroidism chest trauma$24 REPRi 2 Sduerive ENDOCRINOLOGY AND INFERTILITY 5 ; 10. Ina woman who recently has had trouble oa/ml) PROLACTIN ae 7, In the healthy. patient; lactation does not commence yitil after delivery because A+ prolactinis not secreted-untilafter delivery: B. “placental lactogemis only weakly lactogenic’ CC: B human chorionic gonadotcopin (B-hCG) blocks the actior'-of prolactin on the breast Deitheihitredse'int Cortisol-assiciated witK the # delivet)process is importart in the initiation lactation i estfdgeniinhibits the action of prolactin on the ~ breast ’** conn 8, A33-year-old.woman, who is,5 feet 3:inches tall andsweighs:180:pounds;has galactorthea, oligonienorrhea, a serum*prolaictin level of 18 ngimlyand'anorchal thyroid-stimulating hormone (TSH) Jevel. At this point you would A. do nothing for a year B. -order an infusion of thyrotropin-releasing hormone (TRH) as 4 provocative Stimulus of + prolactin or C. initiate bromocriptine therapy D_atder MRior.€T. ‘order anteféposterior:and:lateral: coned-down. wiews of te sella:turcica~./ 9. In which of the following patients with galactorthea, all of whom might have an elevated serum prolactin level,,are you most likely to find that the prolactin level actually is elevated? “AP 820-year-old woman with low estrogen and amenorrhea B. 230-year-old woman, 8 months’ postpartum, breast-feeding, with amenorrhea, whose blood. is drawn when the woman is in a basal state C. 2 25-year-old woman with normal estrogen and oligomenorrhea D. 2 30-year-old woman with normal estrogen and amenorrhea E. a 25-year-old woman with normal estrogen and normal menses breast-feeding her 7-month-old infant, the basa} serum prolactin determination is 10 ng/mL. Having been asked for an opinion, you would state that ‘Adahis is too Jow a level for succeésful lactation B. the woman is obviously under stress; if she “relaxed; thé prolactin would increase and she Would be able to breast-feed .¢ prolactin level is compatible with successful breast-feeding D. without knowing the-conditions under which the result was obtained, you cannot offer an opinion E, the patient should be examined for Sheehan syndrome U1, A.25-year-old single woman has oligomencrrhea, > galactorrhed, and hyperprolactinemia (88 ng/mL), Thyroid function is normal. On MRI, a 3-mm microadenoma ig noted. The oligomenorshea and galactorthea aré not of concern to the patient. Recominended therapy for.this patient is A. bromocriptine B, external radiation therapy &- periodic progestin withdrawal D. surgical resection E_ implantation of yttrium-90 zods 12, The major mechanism by which elevated levels of prolactin inhibit ovulation appears tobe A. a direct action of big-big prolactin “alterations in normal gonadotrophin-releasing hormone (GnRH) release . direct inhibition of ovarian secretion of estradiol D, direct inhibition of ovarian secretion of progesterone E. interference, with the positive etrogen effect on midcycle luteinizing hormone(LH) release ; True statements about prolactin include all the following except that it A, is synthesized in chromophobe cells located in the pituitary gland B, is stored in chtomophobe cells located in the pituitary gland is synthesized in decidual tissue synthesized in endometrial tissue has a half-life of 20 hours ryat ma Pou Pituitary user gran (ACTH) of adrenocorticonoFr™ quently secrete prolactin, grovth hormone een reported to occur Kernan the Ferowing coneitions? ‘Cushing disease Acromegaly a Bh x ae 30% zt c 10% as Dm BE 5% 10% ings commonly associated with patients cee yperprotactinemla include all the | following except | A. galactorthea “ |B, amenorrhea ! ©. anovulation’ | DLoligomenorthea polymenorrhea | 16, Bromocriptine (2-Br-o-ergocryptine | mesylate) A. is detectable in the:circulation 24 hours after administration B, frequently (40% to 50% of the time) causes orthostatic hypotension C. frequently (40% to 50% of the time) causes insomnia -BzS a dopamine receptor agonist E, is ineffective when administered other than by mouth U2, A19-yearold college student experienced amenorrhea of 6 months’ duration. A workup atthe student health service revealed a normal.physical examination result, including anormal pelvic examination result," follicle-stimulating hormone (FSH) level in the low normal range, and an early ‘morning serum prolactin level of 70 ng/mL. At this point you would order measurement of _prtuanitative B-hCG TSH ©. repeat serum prolactin in the midafternoon D.LH E MRI ae she will 6: Bea, i esoaa uit ke sts ithe HF ee aml ‘0 £Y You iorieiatly se ig > Bromocpine snot asad a ‘ined arae Evifshe stops bromeptne dari thereis a40% chance that shel detdlop” visual feld changes becuse of ume” growth 19, A20-year-old Caucasian woman who isa Jong-distance track starhas.consulted you + because af amtenorthea: Initially; you thought “thal the amerorthea.was due to her vigorous exercise. Then she experienced galactorthes;. and.you obtained a serum prolactin level. Having diagnosed'aprolactin-seereting, , ~ rmieroadenoma;you wouldiinforni the patient that ifishe is not iéated she verylikely:to experiences Av primary empty. sella.sysidgome Be osteoporosis . visual problems D. hypothyroidism E, adrenal insufficiency fe ional danuing bromocriptine’ 120: The rationals fordiseontinuing bromocr in amoman who becomes prepramband has a prolatinséeetng matrondenin includes all the following except eri experence regnancy ci esses the placer D, prolactin levels incr pregnaney fects of biomocriptine ong BE, the iewoorn are uknowr during21. A 40-year-old woman is found go havea prolactinoma. Her serum prolactin leyel is 250 ng/mL, and she gives a history. af 3 years, of amenorrhea and galactorthea. The patient:kas inquired about surgical correction. In. discussing the possible outcomes of transsphenoidal niicrosurgical resection, it would be correct to tell this patient that A. she will need to.undergo radiation after operation 5 erate B., the risk of permanent diabetes insipidus is greater than-40%. C.. the risk of hypopituitarism is 25%. D. her age and the length of time she has had symptoms are unrelated to the likelihood of a ry AC the Basid defect in dopamine regulation of prolactin gécretion persists,after: removal 22, Prolactin stimiulatés the liferentiation of mammary tissue cretion of milk into the alveoli.of breast 7 afté;amuirradiation failure . only. in patients without visual field impairment D.rwhen the patient wiskes'to preserve the possibility of future breast-feeding 24. Physiologic stimuli that increase prolactin release include Ae Sees : 'B, rediced exercise CC. sleep deprivation D. orgasm E. menstruation 25, A decrease in serum prolactin is usually noted with ‘A, an infusion of thyrotropin-releasing hormone B. acraniopharyngioma C. the empty sella syndrome B. acolo bromocriptine 26.. Which of the following statements about; hyperprolactinemia without macroadenoma is true? Ac Therapy is not required unless estrogen levels are low. B. Pregnancy is contraindicated. C. Macroadenomas develop in the majority of patients with hyperprolactinemia. D. Galactorrhea is rare.