Quiz 1 repro

An 11-year-old girl is brought to the physician for a physical examinationprior to participating in sports at school. She is at the 50th percentile forheight and weight, has a normal female body habitus, a slight increase inareolar diameter with nipple protrusion, and normal appearing externalgenitalia with sparse straight hair on the labia majora. The physicianconcludes that the patient's breast and external genitalia are at the samestage of sexual development. Which of the following best describes thesexual development of this patient? A. Tanner stage 1 B. Tanner stage 2 C. Tanner stage 3 D. Tanner stage 4 E. Tanner stage 5

B. Tanner stage 2

A 17-year-old girl is brought to the physician because she has notexperienced menarche. Personal and family medical history areunremarkable. Upon examination, BMI is 22 kg/m2. She has normal breastdevelopment. Scant axillary hair is present. Abdominal examination reveals afirm nontender left inguinal mass. Pelvic examination reveals a blind vaginalpouch; uterus and ovaries are absent on pelvic ultrasound. Which of thefollowing is the most likely cause of this patient's presenting complaint? A. SRY gene defect B. Mullerian duct agenesis C. 5 alpha-reductase deficiency D. Sex chromosome mosaicism E. Sex chromosome monosomy F. Androgen insensitivity

F. Androgen insensitivity

A 16-year-old girl is brought to the physician by her mother because she has not yetstarted her periods. At birth, the girl had partial labial fusion and clitoromegaly.During the pregnancy, the mother noted abnormal hair growth on her chin. Threeyears ago, the girl broke her wrist after minor trauma. Last year she sustained aspinal compression fracture. She currently takes oral isotretinoin for severe acne.She is 97th percentile for height and 50th percentile for weight. Vital signs arenormal. Acne lesions are present. Breast development is Tanner stage 1. Thepatient refuses a pelvic exam. Pelvic US shows multiple ovarian cysts and a normaluterus. Which of the following is the most likely diagnosis? A. Polycystic ovary syndrome B. Congenital adrenal hyperplasia C. Mullerian agenesis D. Imperforate hymen E. Turner syndrome F. Aromatase deficiency

F. Aromatase deficiency

A 36-year-old woman desires contraception. She is currently sexually activewith one male partner. She has no significant past medical history and takesno medications. She continues to smoke 1 pack of cigarettes daily and hasdone so since she was 15 years old. She is allergic to latex and copper. Aurine pregnancy test is negative. Which of the following contraceptivemethods is contraindicated in this patient? A. Progestin injection B. Diaphragm with spermicide C. Progestin-only pill D. Intrauterine device E. Condoms F. Combined oral contraceptive pill

F. Combined oral contraceptive pill

A 14-year-old girl is brought to the physician because of a 12-day history of vaginalbleeding. Flow is heavy with passage of clots. Menarche was at age 12 ½; menses havebeen irregular at 26- to 32-day intervals and last 3-6 days with moderate bleeding. LMPwas 4 weeks ago. Past medical history and family history are unremarkable. Vital signs arenormal. Pelvic exam confirms vaginal bleeding and no abnormalities. Hgb is 13.1 g/dL.Urine pregnancy test is negative. Which of the following is the most appropriate next step? A. Endometrial biopsy B. Tranexamic acid C. Endometrial ablation D. Uterine artery embolization E. Uterine curettage F. Conjugated estrogen therapy G. Intrauterine tamponade

F. Conjugated estrogen therapy

An 18-year-old woman seeks contraceptive advice. She is healthyexcept for significant acne that is responding poorly to topical tretinointreatment. Her primary care provider prescribes combined oralcontraceptive pills. In addition to helping her acne, which of thefollowing risks will be significantly lowered proportional with theduration of use? A. Breast cancer B. Cardiovascular disease C. Cervical cancer D. Pelvic inflammatory disease E. Infertility F. Endometrial cancer

F. Endometrial cancer

A 15-year-old girl reports to the physician because of episodic pelvic pain radiating to herback and thighs for 4 months. The pain starts a few hours before the onset of her mensesand lasts for about 2 days. Ibuprofen has provided some relief. Menarche was at age 12and menses have been regular every 28 days. She is sexually active with 2 male partnersand uses condoms inconsistently. Vital signs are normal and physical examination,including pelvic exam, is normal. Which of the following is the most likely cause of thispatient's symptoms? A. Endometrial sloughing and uterine contractions mediated by prostaglandin B. Endometriotic cell implants in the ovaries, fallopian tubes, and cervix C. Activation of lymphatic cells in the intestinal walls and local tissue damage D. Ascending infection of the uterus, fallopian tubes, ovaries and surrounding tissues E. Fluid filled cyst within the ovary that is episodically leaking F. Ectopic pregnancy G. Endometrial tissue in the uterine wall H. Ascending infection of the urinary tract I. Hormone sensitive smooth muscle tumor of the myometrium

A. Endometrial sloughing and uterine contractions mediated by prostaglandin

A 32-year-old woman comes to the physician because of a 5-day history of abdominal pain,nausea and vomiting. She states she has gained 7# over the past week with no dietarychange. She has a history of PCOS and started gonadotropin therapy for infertility 4 monthsago. 10 days ago, she received an ovulatory dose of hCG. She is in moderate distress. T is37°C, HR is 86/min, RR is 16/min, BP is 120/80 mm Hg. Abdomen is distended and diffuselytender to palpation without rebound or guarding. Pelvic exam is unremarkable. Lab studiesare shown below. Transvaginal ultrasonography shows enlarged ovaries and free fluid inthe pouch of Douglas. Which of the following is the most likely underlying cause of thispatient's condition? A. Granulosa cell luteinization B. Ovarian cyst rupture C. Ovarian pedicle torsion D. Extrauterine oocyst implantation E. Bacterial infection

A. Granulosa cell luteinization

A 6-year-old African American girl is noted by the physician to have axillary andpubic hair and adult body odor, as well as mild facial acne. She has not had her firstmenses yet. She is 95th percentile for height and 99th percentile for weight and BMI.She has no palpable glandular breast tissue. External genitalia are normal. X-ray ofher wrist and hand show a bone age of 9 years. Basal LH concentration is normaland does not increase following GnRH agonist stimulation. Early morning serumstudies show normal 17 OH progesterone. Adrenal glands are normal on abdominalUS. Pelvic US shows normal female internal genitalia. Which of the following is themost likely explanation for this patient's examination findings? A. Obesity-related hyperandrogenemia B. Adrenal enzyme deficiency C. Overproduction of leptin D. Pituitary tumor E. Ovarian cyst F. Adrenocortical tumor

A. Obesity-related hyperandrogenemia

A 27-year-old man reports to the physician with his wife because they have been unable to conceive.They have had regular unprotected sex for the past 18 months without using contraception. His wife hascompleted her evaluation and no fertility problem. Patient has been healthy except for a Chlamydiainfection 10 years ago treated with azithromycin. He is a professional cyclist and trains at least 3-4 hoursdaily. He is stressed preparing for upcoming national championships. Upon examination, T is 36.5° C, HR48/min, BP 154/92 mm Hg. Physical examination reveals a lean athletic stature with uniforminflammatory papular skin eruptions on his face, back and chest. Genital examination shows small testes.Which of the following is the most likely underlying cause of this patient's infertility? A. Cushing syndrome B. Anabolic steroid use C. Testicular exposure to excess heat D. Chronic pudendal nerve pressure E. Primary hypertension F. Chronic chlamydia infection G. Anorexia nervosa H. Psychogenic erectile dysfunction I. Kallmann syndrome

B. Anabolic steroid use

A 39-year-old woman reports to the physician with a 6-month history ofintermittent vaginal bleeding every 2-3 weeks lasting 2-5 days, consisting ofheavy flow and passage of clots. Menarche was at age 10 and her menseswere previously regular, every 28 days, with normal flow. She takes amultivitamin. Family history is positive of ovarian cancer in her mother,diagnosed at age 60. BMI is 34 kg/m2. Vital signs are normal. Pelvicexamination reveals a normal sized nontender uterus. Lab, including CBC,TSH, T3, T4 and coagulation studies are within reference ranges. Urinepregnancy test is negative. Which of the following is the most appropriatenext step? A. Endometrial ablation B. Endometrial biopsy C. Abdominal ultrasonography D. Combined oral contraceptives E. Hysteroscopy with uterine dilation and curettage

B. Endometrial biopsy

For a 22-year-old graduate student taking combined oral contraceptivepills, which of the following is the most important mechanism of actionof this drug for pregnancy prevention? A. Thickening of cervical mucus B. Inhibition of rise in luteinizing hormone C. Suppression of ovarian folliculogenesis D. Increase in sex-hormone binding proteinE. Prevention of endometrial proliferation

B. Inhibition of rise in luteinizing hormone

A 26-year-old woman, G1, P0, A1, reports to the physician for evaluation ofirregular menstrual periods. Menarche was at age 12 and menses havealways been irregular with spotting between periods. LMP was 7 monthsago. Her one previous pregnancy resulted in a spontaneous, incompleteabortion at 12 weeks' gestation, managed with dilation and curettage.Medical history is otherwise unremarkable. She has 3 alcoholic drinks perweek and does not smoke. BMI is 31 kg/m2. Vital signs are normal as is herphysical examination including pelvic exam. Serum pregnancy test isnegative. Prolactin, FSH and TSH levels are within normal limits. Which of thefollowing is the most appropriate next step in management? A. Oral contraceptive therapy B. Progesterone withdrawal test C. Hysteroscopy D. Gonadotropin therapy E. Dexamethasone suppression test F. MRI of the brain

B. Progesterone withdrawal test

10 days after delivering a healthy male newborn, a 29-year-old woman visitsthe clinic for a postpartum follow-up evaluation. Labor and delivery wereuncomplicated. One week after delivery, she was diagnosed with postpartumendometritis for which she is currently receiving treatment with ampicillinand sulbactam. The newborn has been breastfed since birth. She isinterested in a reliable contraceptive method. Which of the following is themost appropriate option for this patient at this time? A. Spermicide B. Progestin-only contraceptive C. Intrauterine device D. Combined oral contraceptive E. Not needed since she is breastfeeding

B. Progestin-only contraceptive

A 33-year-old woman sees her physician because of a 1-year history of infertility. She has ahistory of anorexia nervosa and has received both dietary and behavioral therapy for over6 months with some improvement in her symptoms. Her BMI remains low at 17 kg/m2.Upon physical examination, she has soft depigmented hair on her arms and back. Afterextensive work-up, including her husband, the physician recommends pulsatile GnRHtherapy. At follow up examination 1 week after initiating therapy a pelvic ultrasound showsa 24 mm hypoechogenic cavity in the right ovary. The patient subsequently receives a drugthat results in the resumption of meiosis and the loss of gap junction between the cumulusgranulosa cells and the oocyte. Which of the following drugs was likely received? A. Leuprolide B. Mifepristone C. Human chorionic gonadotropin D. Ethinyl estradiol E. Medroxyprogesterone F. Cyproterone acetate

C. Human chorionic gonadotropin

A 14-year-old boy sees the physician for a well-child visit. He was born at 38weeks' gestation via vaginal delivery after a normal pregnancy. He has beenhealthy. He is having some difficulties in middle school academically. Heightis 90th percentile and weight is 50th percentile. Vital signs are normal. Amidsystolic click is heard at the left sternal border. He has long extremitiesand some excess breast tissue bilaterally. No axillary hair is present. He hasreduced scrotal size and a normal sized penis. Which of the following testsis mostly likely to diagnosis the patient's underlying disorder? A. Bone age assessment B. Urinalysis C. Karyotyping D. Slit-lamp examination E. Serum IGF-1 measurement

C. Karyotyping

A 17-year-old girl reports to the physician because right lower abdominal pain for one day, 5/10intensity. She has had this pain every month for the last year or so, lasing 1 - 2 days total. Menarchewas at age 11 ½; menses are regular, every 28 days, with moderate bleeding lasting 5-6 days. LMPwas 2 weeks ago. She is sexually active with her boyfriend, and they use condoms consistently. Theyboth had STI testing 1 month ago at Planned Parenthood at her insistence and all tests werenegative. Medical history and family history are unremarkable. Upon examination she is afebrile.Abdominal examination reveals mild tenderness to palpation over the right lower quadrant.Bimanual examination reveals a mildly tender right adnexa. Urine pregnancy test is negative.Ultrasound shows a follicle with irregular margins in the right ovary and a trace of anechoic freefluid in the pouch of Douglas. Which of the following is the most appropriate next step inmanagement? A. Oral contraceptive pills and NSAIDs B. Laparoscopic adnexal detorsion C. Reassurance and NSAIDs D. Intravenous antibiotic therapy E. Progesterone eluting IUD F. Serial serum β HCG concentrations

C. Reassurance and NSAIDs

A 32-year-old nulligravid woman and her 34-year-old husband report to thephysician because they have been unable to conceive for the past 6 months. Theyhave been having unprotected intercourse four times weekly. The woman has had4 previous male sexual partners and her husband had one previous sexual partner.Neither of them have conceived a child. The woman's menses occur regularly at 30-day intervals. LMP was 3 weeks ago. The man had uncomplicated gonorrhea 10years ago treated with ceftriaxone. Neither of them take any medication. Physicalexaminations of both patients is completely normal. Urine pregnancy test isnegative. Which of the following is the most appropriate next management step forthis couple? A. Clomiphene citrate challenge test B. Serum testosterone and FSH levels C. Reassurance and follow-up in 6 months D. Semen analysis E. Hysterosalpingogram F. Antisperm antibody test

C. Reassurance and follow-up in 6 months

A newborn baby is noted to have normal male genitalia with only asingle palpable testicle in the right hemiscrotum. US of the abdomenand pelvis shows an undescended left testicle, seminal vesicles, uterusand fallopian tubes. Chromosomal analysis is 46,XY. Which of thefollowing sets of changes is most likely found in this newborn?

D. Normal gene Decresed MIF Normal Test. Normal DTest

A 26-year-old woman presents for evaluation of infertility. She hasbeen trying to conceive for over one year. Physical examination shows amoderately obese patient with facial hirsutism and acne. She alsoreports having an irregular menstrual cycle. Laboratory testing confirmsa diagnosis of polycystic ovarian syndrome. The physician recommendsclomiphene to help treat her infertility. Which of the following bestdescribes the mechanism of clomiphene as an ovulation inducer? A. Decreases androgen production B. Antagonizes progesterone receptor C. Mimics prostaglandin E1 D. Acts as estrogen receptor agonist/antagonist E. Stimulates dopamine D2 receptor

D. Acts as estrogen receptor agonist/antagonist

A 15-year-old girl comes to the physician because of a 2-year history ofirregular menstrual bleeding. Menses have occurred at irregular 45-60 daysintervals since menarche at age 13 years. Her LMP was 5 weeks ago andlasted 7 days with heavy flow and no cramping. She is not sexually active.BMI is 20 kg/m2. Vital signs are normal. Pelvic examination shows a normalvagina and cervix; bimanual exam shows a normal-sized uterus and nopalpable adnexal masses. Her physical examination is completely normal.Urine pregnancy test is negative. Which of the following is the most likelyexplanation for this patient's symptoms? A. Pituitary adenoma B. Endometriosis C. Polycystic ovary syndrome D. Anovulation E. Ovarian Insufficiency

D. Anovulation

A 24-year-old woman reports to her physician because she has notmenstruated in 6 months. She is a competitive marathoner and has beentraining heavily for the past year for the Boston Marathon. She has no familyor personal history of serious illness. She has not been sexually active for thepast 2 years. Vital signs are within normal limits except for a resting HR of50/minute. BMI is 18 kg/m2. Which of the following is the most likely causeof her amenorrhea? A. Autoimmune destruction of thyroid cells B. Poor synthetic response of ovarian cells to circulating LH and FSH C. Increased prolactin secretion D. Decreased frequency of GnRH release from the hypothalamus E. Intrauterine adhesions F. Increased LH release and increased ovarian androgen production

D. Decreased frequency of GnRH release from the hypothalamus

A 30-year-old man sees a physician for evaluation of infertility. He doesnot smoke, drink alcohol or take any medication. Physical examinationis entirely within normal limits. Serum analysis shows anti-spermantibodies. What is the most likely cause of this serum finding? A. Increase in testicular temperature B. Dysgenesis of seminiferous tubules C. Dysgenesis of vas deferens D. Defect in Sertoli cell function E. Defect in the dynein arm of cilia F. Defect in GnRH production

D. Defect in Sertoli cell function

A 35-year-old woman sees her physician because she has been unable to conceivefor more than a year. Conception by in vitro fertilization was attempted once, 3months ago, but was unsuccessful. Her husband's semen analysis is normal. Shehas a 6-year-old daughter who was born at term after an uncomplicated pregnancy.Past medical history is unremarkable; she exercises 1 hour each day. Menses areregular every 28 days and last 5-6 days; LMP started 2 days ago. Physicalexamination, including pelvic examination, is normal. Which of the following is themost likely cause of this patient's inability to conceive? A. Polycystic ovarian syndrome B. Pelvic inflammatory disease C. Asherman syndrome D. Diminished ovarian reserve E. Hypogonadotropic hypogonadism F. Primary ovarian insufficiency

D. Diminished ovarian reserve

A 28-year-old woman reports to her physician because she has been unable to conceive for3 years. She and her partner have intercourse at least once weekly and do not usecontraception. They had an initial assessment 6 months ago: his semen analysis wasentirely normal and hormonal assays for both partners were normal. She has regularmenses every 28 days that last 5-6 days. LMP was 2 weeks ago. She had a single UTI 4 yearsago treated with oral antibiotics. Vaginal examination is normal and bimanual examinationshows a normal sized uterus and no palpable adnexal pathology. Rectal examination isnormal. Which of the following is the most appropriate next step? A. Psychological counseling B. Postcoital testing C. Hysteroscopy D. Hysterosalpingogram E. Chromosomal karyotyping F. Endometrial biopsy

D. Hysterosalpingogram

A 14-year-old boy is brought to the physician for evaluation of his sense of smell.Two days ago, his mother found that he had left on an unlit gas burner on theirkitchen stove and could not smell the odor of the gas. As a child he was consistentlyin the 40th percentile for height; now he is in the 15th percentile. He had bilateralorchiopexy for cryptorchidism as an infant. Upon examination, the patient is unableto identify several common odors (peppermint, ground coffee, garlic) whenpresented to him with his eyes shut. Physical examination shows sparse axillary andpubic hair and Tanner stage 1 genitals. Which of the following is the most likelyunderlying cause of the patient's condition? A. Constitutional delay of puberty B. Compression of pituitary stalk C. Hyperprolactinemia D. Impaired migration of GnRH neurons E. Sex chromosome trisomy F. Decreased thyroxine production

D. Impaired migration of GnRH neurons

A 14-year-old girl reports to the physician because of heavy and prolonged menses.Since menarche at age 13, her menses have been irregular, every 20 - 45 days,each lasting 8-9 days with passage of clots. Her LMP was 5 weeks ago. Past medicaland family history are unremarkable. She is not taking any medication. Height is50th percentile and weight is 20th percentile. PE, including pelvic examination,shows no abnormalities. Urine pregnancy test is negative. Which of the following isthe most likely cause of this patient's symptoms? A. Embryonal rhabdomyosarcoma B. Endometrial polyp C. Decreased thyroxine production D. Inadequate gonadotropin production E. Inflammation of the endometrium F. Defective von Willebrand factor G. Excessive androgen production H. Uterine fibroid

D. Inadequate gonadotropin production

A 29-year-old woman G1P1 reports to her physician because of inability to conceive for the lastyear. She is sexually active with her husband 4-5 times weekly. Her first pregnancy and delivery were3 years ago and uncomplicated. She returned to work as an event coordinator about 12 months agoand the transition has been stressful. Menses previously occurred at 30-day intervals and lasted 3-4days with moderate flow. Her LMP was 3 months ago. She has occasional vaginal dryness. She runsfor exercise 5-10 miles daily. BMI is 19 kg/m2. Vital signs are normal. Abdominal examination isnormal. Pelvic examination is normal except for dry vaginal mucosa. Serum pregnancy test isnegative. Serum studies are shown below.Ultrasound of the pelvis is unremarkable. In addition to diet and exercise counseling, which of thefollowing is the most appropriate step for this patient who wishes to conceive? A. Offer clomiphene citrate therapy B. Offer in vitro fertilization C. Offer combined estrogen and progestin therapy D. Offer pulsatile gonadotropin releasing hormone therapy E. Offer human chorionic gonadotropin F. Reassess serum beta HCG in one week G. Obtain MRI of the pituitary gland

D. Offer pulsatile gonadotropin releasing hormone therapy

A 16-year-old girl comes to the physician because of episodic lower abdominal painfor several months, starting a few hours before her menses and lasting for 2-3 days.Ibuprofen worked initially but has not helped over the last few months. She hasmissed school because of severe pain. Menarche was age 14, menses occurregularly every 29 days. She is sexually active with one male partner; they usecondoms inconsistently. Upon examination, vital signs are normal. Externalgenitalia are normal. No vaginal discharge is present, cervix appears normal;bimanual examination reveals normal uterus and no palpable masses. Urinepregnancy test is negative. Which of the following is most appropriate next step? A. Diagnostic laparoscopy B. Ceftriaxone and doxycycline therapy C. Pelvic ultrasonography D. Oral contraceptive pills E. Urinalysis

D. Oral contraceptive pills

A healthy 31-year-old visits her physician as she and her husband aretrying to conceive. She is currently timing intercourse with a homeovulation test kit. An increase in the levels of which of the following isthe best indicator that ovulation has already occurred? A. Estrogen B. Gonadotropin releasing hormone C. Follicle stimulating hormone D. Progesterone E. Luteinizing hormone

D. Progesterone

If an endometrial biopsy was obtained from a 28-year-old woman withcompletely normal 28-day menstrual cycles, what findings would beexpected between days 26 and 28? A. Surface epithelium with short, straight glands and only a few mitotic figures B. Long, tortuous glands, cells with numerous mitotic figures inglandular epithelium, and stromal edema C. Glandular cells with subnuclear vacuoles and a few mitotic figures D. Stromal edema and glycogen rich vacuoles at the cellular apex E. Apoptosis of endometrial cells and sloughing of the functional layerof the endometrium

D. Stromal edema and glycogen rich vacuoles at the cellular apex

A 34-year-old woman sees her physician because of no menses for 6 months. She has alsonoted milky white discharge from her nipples, frequent headaches, and blurred vision forthe past 4 months. Menses were previously every 30 days, lasted 4-5 days with moderateflow. She is not taking any medications. She has 2 healthy children in middle school. HerBMI is 26 kg/m2. Vital signs are normal; CVS exam normal. Pelvic examination showsvaginal atrophy, normal uterus. CBC, electrolytes, creatinine and glucose are all withinnormal limits. Urine hCG is negative. Serum studies are most likely to show which of thefollowing sets of findings? Prolactin FSH LHA A Normal Decreased Decreased B Decreased Increased Increased C Increased Increased Increased D Decreased Decreased Decreased E Normal Increased Increased F Increased Decreased Decreased

F Increased Decreased Decreased

A 15-year-old girl sees her physician because has not menstruated for 3 months. Mensespreviously occurred at irregular intervals, every 15-45 days, with moderate to heavy flow.Menarche was at age 14 years. She started having sexual intercourse with her boyfriend about 3months ago. Six months ago, she had a manic episode, which was treated with risperidone. Hermother has PCOS and her father has type 2 diabetes mellitus. She is very conscious of her weightand appearance. BMI is 27 kg/m2. Vital signs are normal. Abdomen is soft and nontender. Pelvicexamination shows a normal vagina and cervix; bimanual examination is normal. Lab studies areshown below. Urine pregnancy test is negative. Which of the following is the most likely cause ofher symptoms? A. Uterine fibroids B. Congenital defect of the Mullerian ducts C. Purging behavior D. Polycystic ovaries E. Anovulation F. Drug-induced hypogonadism G. Primary ovarian insufficiency

E. Anovulation

A 24-year-old woman comes to the physician for a follow-up visit. She had aspontaneous abortion 4 months ago. Her LMP was three weeks ago. Shereports feeling sad occasionally but has continued attending social events.She is not a smoker. Physical exam including pelvic examination shows noabnormalities. She is interested in a reliable contraception method. Thephysician prescribes a combined oral contraceptive. The patient is likely toexperience which of the following adverse effects? A. Menorrhagia B. Irregular menstrual cycle C. Dysmenorrhea D. Metrorrhagia E. Breast tenderness

E. Breast tenderness

A 36-year-old woman visits her gynecologist because of a 4-month history of irregularmenses, varying between 14- and 45-day intervals and lasting only 1-2 days with minimalflow. She also has a milk-like bilateral nipple discharge for the last 3 months, fatigue,muscle pain and joint aching. She denies abdominal pain, fever or headache. She hasgained about 5# in the last 3 months. She was diagnosed with schizophrenia and started onan antipsychotic medication 8 months ago. Past medical history is positive forhypothyroidism, but she has not taken her thyroxine for 6 months. Denies smoking oralcohol use. She appears anxious. Pelvic examination reveals vaginal atrophy. Visual fieldand skin examinations are normal. Investigations are shown below. Which of the followingis the most likely explanation for her nipple discharge? A. Thyrotropic pituitary tumor B. Ectopic prolactin production C. Antipsychotic medication D. Cushing disease E. Hypothyroidism F. Prolactinoma

E. Hypothyroidism

A 30-year-old woman, G1P1, reports to her physician because she has been unable toconceive for the past year. She has also not had a menstrual period during this time. Shereports episodic pelvic pain that occurs every 4 weeks and lasts for several days. Mensespreviously occurred at regular 28-day intervals. She has sex at least twice weekly with herhusband and does not use contraceptives. Her child was born at term after vaginal delivery14 months ago. Postpartum course was complicated by hemorrhage from retainedplacental products requiring uterine curettage. Vital signs are normal. Speculumexamination shows a normal vagina and cervix. Uterus in normal size and there is nopalpable adnexal pathology. Remainder of exam is normal. Midcycle serum studies areshown below. Which of the following is most likely to confirm her diagnosis? A. Measurement of midluteal serum progesterone B. Diagnostic laparoscopy C. MRI of the brain D. Thyroid antibody screening E. Hysteroscopy

E. Hysteroscopy

A 27-year-old woman reports to her physician for an infertility evaluation.She has been unable to conceive for the past 2 years. Menses are irregular at45 to 80-day intervals. BMI is 27 kg/m2. Physical examination shows facialacne and pigmented hair on her upper lip. Serum studies show elevatedlevels of testosterone and an LH:FSH ratio of 4:1. Treatment with theappropriate drug for this patient's infertility is begun. Which of the followingis the primary mechanism of action of this drug? A. Activation of pituitary dopamine receptors B. Inhibition of endometrial progesterone receptors C. Activation of ovarian luteinizing hormone receptors D. Activation of granulosa cell aromatase E. Inhibition of hypothalamic estrogen receptors

E. Inhibition of hypothalamic estrogen receptors

A 7-year-old girl is brought to the physician because of scant painless vaginalbleeding that started 6 hours ago. She has no history of illness or trauma.Her older sister had her first menses at age 11. The patient is 80th percentilefor height and 95th percentile for weight and BMI. She has greasy facial skinand sparse axillary hair; breast development is Tanner stage 3 and pubic hairis Tanner stage 2. External genitalia are normal. Serum glucose is 189 mg/dL.IV leuprolide causes an increased in serum LH. Which of the following is thelikely cause of this patient's findings? A. Overproduction of adrenal cortisol B. Deficiency of 21-hydroxylase C. Ectopic hormone production D. Compensatory hyperinsulinism E. Pulsatile GnRH release

E. Pulsatile GnRH release

A 16-year-old is brought to the physician because she has not yetexperienced menarche. Past medical history is unremarkable. She is 50thpercentile for height and weight. No glandular breast tissue is palpable, andshe has no pubic hair. Remainder of her examination is normal. Urinepregnancy test is negative. Pelvic US shows a normal uterus. Which of thefollowing is the most appropriate next step in evaluation/management? A. GnRH stimulation test B. Reassurance C. Progesterone challenge test D. MRI of the brain E. Serum FSH level F. Serum testosterone levels

E. Serum FSH level

A 27-year-old nulligravid woman reports for an infertility evaluation. She has beenunable to conceive for 1 years despite regular intercourse with her husband. Hissemen analysis is normal. Two years ago, she had a febrile illness with lowerabdominal pain that resolved with antibiotic treatment. Menarche was at age 12and menses have been regularly every 28 days with 4-5 days of normal flow. Shehad 6 sexual partners before she married her husband a year ago, and used OCPsconsistently until her marriage, with barrier protection inconsistently. BMI is 28kg/m2. Physical examination, including pelvic exam, is normal. Which of thefollowing is the most likely cause of this patient's infertility? A. Polycystic ovary syndrome B. Long-term use of oral contraceptives C. Endometriosis D. Primary ovarian insufficiency E. Tubal scarring F. Cervical insufficiency

E. Tubal scarring

A 14-year-old girl is brought to the physician for evaluation of shortstature. Length and weight at birth were normal, 45th percentile. She isnow at the 3rd percentile for height and 40th percentile for weight. Shehas not yet attained menarche. Both parents are of average height. Onexam, vital signs are normal. Breast and pubic hair development areTanner stage 2. Physical examination is otherwise normal. Which of thefollowing is the most appropriate next step in diagnosis? A. Measurement of serum insulin-like growth factor B. Measurement of serum FSH, LH, and testosterone C. Genetic karyotyping D. Measurement of TSH and thyroid hormones E. X-ray of hand and wrist F. MRI of the brain

E. X-ray of hand and wrist

A 25-year-old woman reports to the physician because of headache and difficulty sleepingfor the last 2 days. She has had these symptoms recurrently each month for the last year.Episodes are associated with decreased concentration, irritability and anger, and cravingsfor sweet foods. She feels impaired and inefficient and struggles at work during theseepisodes; she is uncharacteristically argumentative with colleagues and friends. Mensesare regular every 26 days and last for 5 days with normal flow. LMP was about 3 weeks ago.She smokes a pack of cigarettes daily for the past 8 years. Physical examination and mentalstatus are normal on today's examination. Which of the following is the most appropriatetreatment? A. Cognitive behavioral therapy B. Copper intrauterine device C. Bilateral oophorectomy D. Avoidance of nicotine E. NSAID therapy F. Fluoxetine therapy

F. Fluoxetine therapy

A 15-year-old girl is brought to the physician for a well-child exam. She feels welland is performing well in school. She is 4 ft. 10 in. tall and weighs 132 pounds.Temperature, HR and RR are normal. BP is 138/82 mm Hg in the left arm and 110/74 mm Hg in the left leg. She has an unusually short and broad neck withbilateral excess skin folds that extend to the shoulders and low-set ears. There is anincreased carrying angle when she fully extends her arms at her sides. X-ray of thechest shows inferior rib-notching. Which of the following is also likely in thispatient? A. Horseshoe adrenal gland on abdominal CT B. Prolonged activated partial thromboplastin time C. Triphalangeal thumb on upper extremity x-ray D. Mitral valve prolapse on echocardiogram E. Uterine agenesis on pelvic exam F. Mutation of FBN1 on genetic testing G. Streak ovaries on pelvic ultrasound

G. Streak ovaries on pelvic ultrasound