Williams Gynecology, Second Edition (Schorge,Williams Gynecology), 2nd Edition

CHAPTER 16
Amenorrhea

16–1. Which of the following clinical scenarios meets the definition of amenorrhea?

a. 12-year-old with Tanner stage I breast development

b. 16-year-old with Tanner stage II breast development

c. 14-year-old with Tanner stage III breast development

d. 18-year-old with Tanner stage V breast development and cessation of menses for the last two cycles

16–2. Inhibin inhibits synthesis and secretion of which of the following hormones?

a. Luteinizing hormone (LH)

b. Follicle-stimulating hormone (FSH)

c. Corticotropin-releasing hormone (CRH)

d. Gonadotropin-releasing hormone (GnRH)

16–3. Which of the following hormones can have a negative as well as a positive feedback at the level of the pituitary?

a. Cortisol

b. Oxytocin

c. Estradiol

d. Progesterone

16–4. Which of the following hormones “rescues” the corpus luteum from luteolysis?

a. Luteinizing hormone (LH)

b. Human placental lactogen (hPL)

c. Follicle-stimulating hormone (FSH)

d. Human chorionic gonadotropin (hCG)

16–5. Which of the following conditions is considered the most frequent cause of primary amenorrhea?

a. Turner syndrome

b. Asherman syndrome

c. Androgen insensitivity syndrome

d. Mayer-Rokitansky-Küster-Hauser syndrome

16–6. An 18-year-old nulligravid female presents with primary amenorrhea. During examination, Tanner stage IV breast development and sparse pubic and axillary hair are noted. Also, a blind-ending vagina is identified. What is the likely diagnosis in this patient?

a. Müllerian agenesis

b. Premature ovarian failure

c. Androgen insensitivity syndrome

d. Congenital adrenal hyperplasia (CAH)

16–7. The patient in question 16–6 undergoes laparoscopy. The white oval structure above the blunt probe represents which of the following?

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a. Ovary

b. Testis

c. Oophoron

d. Epoophoron

16–8. What is the expected testosterone level in a patient with müllerian agenesis?

a. Male level

b. Female level

c. Not measurable

d. Significantly elevated (> 1000 ng/dL)

16–9. What follicle-stimulating hormone (FSH) threshold is needed to diagnose a patient with premature ovarian failure?

a. 15 mIU/mL with a persistently elevated repeat test result 1 month later

b. 20 mIU/mL with a persistently elevated repeat test result 1 month later

c. 30 mIU/mL with a persistently elevated repeat test result 1 month later

d. 40 mIU/mL with a persistently elevated repeat test result 1 month later

16–10. Findings classic for Turner syndrome include all EXCEPT which of the following?

a. Macrognathia

b. Neck webbing

c. Aortic coarctation

d. Shield-like chest shape

16–11. A 28-year-old nulligravida presents with primary amenorrhea. She is diagnosed with 46,XY gonadal dysgenesis. During pelvic laparoscopy, what is the expected finding?

a. Streak gonads and male internal genitalia

b. Streak gonads and female internal genitalia

c. Empty pelvis (no gonads or internal genitalia)

d. Bilateral abdominal testes and male internal genitalia

16–12. A 20-year-old female is diagnosed with gonadal dysgenesis, and her karyotype reveals 45,X/46,XY mosaicism. Laparoscopy is performed for which of the following reasons?

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Figure B: Reproduced, with permission, from Halvorson LM: Amenorrhea. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 16-4.

a. Gonadectomy due to increased risk of malignant transformation in retained gonads

b. Oophoropexy due to increased rate of torsion

c. Endometriosis ablation due to increased rate of endometriosis

d. None of the above

16–13. An 18-year-old female with primary amenorrhea and sexual infantilism presents for evaluation. During examination, she is noted to be hypertensive, and a patent vagina and a cervix is visualized. Pelvic sonography confirms presence of a uterus, but gonads could not be visualized. Laboratory evaluation is significant for hypokalemia. Which of the following conditions is likely her diagnosis?

a. 5α-Reductase deficiency

b. 21-Hydroxylase deficiency

c. 17-Hydroxylase deficiency

d. 3β-Hydroxysteroid dehydrogenase deficiency

16–14. Which of the following chemotherapeutic classes is the most damaging to the ovaries?

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Reproduced, with permission, from Schorge JO: Principles of chemotherapy. In Hoffman BL, Schorge JO, Schaffer JI, et al (eds): Williams Gynecology, 2nd ed. New York, McGraw-Hill, 2012, Figure 27-1.

a. Hormonal agents

b. Antimetabolites

c. Antibiotic agents

d. Alkylating agents

16–15. What radiation dose is high enough to cause permanent ovarian damage?

a. 100 rads

b. 400 rads

c. 600 rads

d. 800 rads

16–16. Which of the following is true of Kallmann syndrome?

a. Gonadotropin-releasing hormone (GnRH) neurons fail to develop.

b. It is a condition that leads to hypergonadotropic hypogonadism.

c. Intact sense of smell differentiates it from other similar conditions.

d. Can be inherited as an autosomal dominant or autosomal recessive disorder.

16–17. What is the lowest body mass index (BMI) that is required to begin menstruation?

a. 15 kg/m2

b. 20 kg/m2

c. 22 kg/m2

d. 24 kg/m2

16–18. An 18-year-old with previously regular menses, presents with amenorrhea. She is also diagnosed with anorexia nervosa. Which of the following is likely to be seen in this patient?

a. Elevated luteinizing hormone (LH) level

b. Elevated gonadotropin-releasing hormone (GnRH) level

c. Elevated leptin level

d. Elevated neuropeptide Y level

16–19. Which of the following statements is true regarding polycystic ovarian syndrome?

a. Patients typically present with amenorrhea.

b. It is the most common cause of chronic anovulation.

c. It is characterized by hypogonadotropic hypogonadism.

d. It is characterized by persistently elevated follicle-stimulating hormone (FSH) and estradiol levels.

16–20. Congenital adrenal hyperplasia is most commonly caused by mutations in genes coding for which of the following enzymes?

a. 17-Hydroxylase

b. 21-Hydroxylase

c. 11β-Hydroxylase

d. 3β-Hydroxysteroid dehydrogenase

16–21. A 27-year-old nulligravida presents with 6 months of amenorrhea. During evaluation, she is noted to have hyperprolactinemia. Laboratory tests measuring which of the following should also be obtained?

a. Total testosterone

b. 24-hour urinary free cortisol

c. Thyroid-stimulating hormone (TSH)

d. Insulin-like growth factor II (IGF-II)

16–22. A 15-year-old with primary amenorrhea and Tanner stage V breast development presents for evaluation. Assessing levels for which of the following is the appropriate next step in her evaluation?

a. Luteinizing hormone (LH)

b. Follicle-stimulating hormone (FSH)

c. Human chorionic gonadotropin (hCG)

d. Thyroid-stimulating hormone (TSH)

16–23. An 18-year-old nulligravida presents with primary amenorrhea. She reports vaginal bleeding following a progesterone withdrawal test. Which of the following conditions is most likely excluded?

a. Müllerian agenesis

b. Hypothalamic amenorrhea

c. Premature ovarian failure

d. Polycystic ovarian syndrome (PCOS)

16–24. Measurement of which of the following serum levels is helpful in evaluating patients suspected of having late-onset congenital adrenal hyperplasia (CAH)?

a. Follicle-stimulating hormone (FSH)

b. Testosterone

c. 17-Hydroxyprogesterone

d. Dehydroepiandrosterone sulfate (DHEAS)

16–25. In which of the following patients is a karyotype most likely needed?

a. 22-year-old with amenorrhea and hirsutism

b. 25-year-old with amenorrhea and an elevated prolactin level

c. 20-year-old with amenorrhea and no müllerian structures on sonography

d. 16-year-old with amenorrhea and a persistently elevated follicle-stimulating hormone (FSH) level of 80 mIU/mL

16–26. You are presented with a patient with a unicornuate uterus that is similar in shape to the one shown here. What is the next appropriate step in your management?

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Reproduced, with permission, from Cunningham FG, Leveno KL, Bloom SL, et al (eds): Williams Obstetrics, 23rd ed. New York, McGraw-Hill, 2010, Figure 40-3.

a. Renal scan

b. Diagnostic laparoscopy

c. Diagnostic hysteroscopy

d. Brain magnetic resonance (MR) imaging

16–27. Which of the following medications is used for achieving a pregnancy in a patient with hypogonadotropic hypogonadism?

a. Estradiol

b. Letrozole

c. Gonadotropins

d. Clomiphene citrate (Clomid)

Chapter 16 ANSWER KEY

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