Order these events in the correct sequence of sexual differentiation: 1. Differentiation of labial scrotal folds into a scrotum 2. Genetic sex 3. Formation of seminiferous tubules 4. Formation of a testis

2. Genetic sex --\> 4. Formation of a testis --\> 3. Formation of seminiferous tubules --\> 1. Differentiation of labial scrotal folds into a scrotum

Patients with PCOS are at risk for all of the following except: Endometrial cancer Type 2 Diabetes Cardiovascular disease Unwanted pregnancy Pituitary adenoma

Patients with PCOS are at risk for all of the following except: Endometrial cancer Type 2 Diabetes Cardiovascular disease Unwanted pregnancy •Pituitary adenoma

REVIEW QUESTIONS Flashcards by Jennifer Cromwell

Order these events in the correct sequence of sexual differentiation:

Differentiation of labial scrotal folds into a scrotum
Genetic sex
Formation of seminiferous tubules
Formation of a testis

Genetic sex –>
Formation of a testis –>
Formation of seminiferous tubules –>
Differentiation of labial scrotal folds into a scrotum

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T/F: the number of germ cells rapidly increases to a max several months after birth

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T/F: There are two precursors, one precursor of the male and one precursor of the female ductal systems, that lie beside the indifferent gonads.

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T/F: Germ cells migrate after the primordial gonads have developed into a testis or ovary

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T/F: the indifferent bi-potential gonads have both sperm and oocytes

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T/F: The ductal system develops and sends signals to the gonad to facilitate formation of either a testis or ovary

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Which of the following causes the indifferent gonad to dev into an ovary?

A. Absence of testosterone

B. Presence of oocytes

C. Stimulation of early estrogen production

D. None

Which of the following causes the indifferent gonad to dev into an ovary?

A. Absence of testosterone

B. Presence of oocytes

C. Stimulation of early estrogen production

D. None

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In a given fetus the indifferent ductal system in a 46XY fetus surprisingly develops into a uterus and vagina. Where is the MOST LIKELY defect responsible for formation of a uterus and vagina?

A. The 46XY fetus likely was missing a portion of the Y chromosome

B. The 46XY fetus could not produce testosterone

C. The 46XY fetus produced estrogen

D. The 46XY fetus produced AMH but given an estrogen milieu it was not functional

E. The 46XY fetus had a mutation in the AMH gene

In a given fetus the indifferent ductal system in a 46XY fetus surprisingly develops into a uterus and vagina. Where is the MOST LIKELY defect responsible for formation of a uterus and vagina?

A. The 46XY fetus likely was missing a portion of the Y chromosome

B. The 46XY fetus could not produce testosterone

C. The 46XY fetus produced estrogen

D. The 46XY fetus produced AMH but given an estrogen milieu it was not functional

E. The 46XY fetus had a mutation in the AMH gene

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A 46XX fetus is surprisingly found to have a testis. Which of the following structures is the fetus also likely to have?

A. enlarged clitoris

B. hymen

C. vagina

D. seminal vesicle

E. cloaca

A 46XX fetus is surprisingly found to have a testis. Which of the following structures is the fetus also likely to have?

A. enlarged clitoris

B. hymen

C. vagina

D. seminal vesicle

E. cloaca

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Knowing what you do about the normal HPO axis, androgen excess is most likely related to increased:

A. Granulosa cells in the ovary

B. Adrenal reticularis function

C. Pituitary release of LH

D. Pituitary release of FSH

E. Sensitivity to negative feedback

Knowing what you do about the normal HPO axis, androgen excess is most likely related to increased:

A. Granulosa cells in the ovary

B. Adrenal reticularis function

C. Pituitary release of LH (The high LH overstimulates the ovarian theca cells to make higher levels of androgens in PCOS patient.)

D. Pituitary release of FSH

E. Sensitivity to negative feedback

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Of the following, the increased LH to FSH ratio in PCOS is most likely related to:

A. Increased sensitivity to positive feedback

B. Increased pulses of GnRH

C. Direct effect of testosterone on the pituitary

D. Increased inhibin secretion of FSH with a normal LH

Of the following, the increased LH to FSH ratio in PCOS is most likely related to:

A. Increased sensitivity to positive feedback

B. Increased pulses of GnRH (As GnRH (LHRH) pulse amplitude and pulse frequency are increased, the effect of this increased LHRH is an increase in secretion of LH. FSH is slightly decreased.)

C. Direct effect of testosterone on the pituitary

D. Increased inhibin secretion of FSH with a normal LH

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The polycystic ovaries in PCOS are likely caused by:

A. Decreased FSH

B. Increased ovarian androgens

C. Increased LH

D. Metabolic factors

E. All of the above

The polycystic ovaries in PCOS are likely caused by:

A. Decreased FSH

B. Increased ovarian androgens

C. Increased LH

D. Metabolic factors

E. All of the above

The slightly decreased FSH levels are still enough to recruit follicles (thus polycystic), but now not high enough to recruit a dominant follicle from the cohort– most of the time. The increased ovarian androgens in the ovarian microenvironment cause atrophy of follicles (thus preventing a dominant follicle as well from developing). The increased LH drives the androgen production to prevent a dominant follicle to appear. And insulin resistance seems to work directly at the ovary to accentuate androgen production (likely through the IGF receptor).

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The abnormal bleeding in PCOS is best related to:

A. The presence of estrogen withdrawal

B. The presence of progesterone withdrawal

C. Nonfunctional feedback in H-P-O axis

D. Androgen excess

The abnormal bleeding in PCOS is best related to:

A. The presence of estrogen withdrawal

B. The presence of progesterone withdrawal

**C. Nonfunctional feedback in H-P-O axis **

D. Androgen excess

The H-P-O circuit is dysfunctional in PCOS patients preventing (most of the time) a spontaneously operative negative or positive feedback mechanism to endogenous hormones. As a result, the patients usually don’t ovulate and have long periods of unopposed estrogen and thus endometrial proliferation. Unlike the anovulatory adolescent menstrual cycles where negative feedback is functional and allows for drops in estrogen and estrogen withdrawal, the PCOS endometrium continues to grow unabated until it is so unstable it begins to shed— this may happen over 1 – 3 or more weeks and be excessively heavy. They are missing the compaction and stabilization effect of progesterone that in ovulatory cycles allows a very orderly and timely shedding. Another note: While the HPO axis is usually not functional for feedback from endogenous levels of hormones, it does work when given pharmacologic levels of hormones (like birth control pills) to suppress gonadotropins and thus ovarian androgen production.

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Patients with PCOS are at risk for all of the following except:

Endometrial cancer
Type 2 Diabetes
Cardiovascular disease
Unwanted pregnancy
Pituitary adenoma

Patients with PCOS are at risk for all of the following except:

Endometrial cancer
Type 2 Diabetes
Cardiovascular disease
Unwanted pregnancy

•Pituitary adenoma

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A 28 year old patient is diagnosed with PCOS and is most concerned about her hirsutism. The best immediate treatment for her is:

A. Laser hair treatment

B. Weight loss

C. Anti-androgen creams

D. Combined hormonal contraceptives

E. Anti-androgen medications

A 28 year old patient is diagnosed with PCOS and is most concerned about her hirsutism. The best immediate treatment for her is:

A. Laser hair treatment

B. Weight loss

C. Anti-androgen creams

**D. Combined hormonal contraceptives **

E. Anti-androgen medications

These patients need suppression of their ovarian androgens first and foremost. Combined hormonal contraceptives is the best way to begin this suppression. It takes 4 – 6 months, however, before they will begin to notice that hair growth has slowed and new hair is not appearing. Patients are instructed that once the hormones have suppressed androgens and new hair is not appearing then they can have the hair present removed by such treatment as laser or electrolysis. Sometimes adding an anti-androgen (e.g spironolactone) adds sufficiently to the hormone therapy. It must never be given by itself in the rare situation that if pregnancy did occur the male genitalia may be underdeveloped. Weight loss helps at least 50% of these patients to reduce insulin resistance and break the vicious cycle that perpetuates the syndrome and they may begin to cycle on their own but this takes time and is very difficult. Finally, some but not all women find anti-androgen creams to be helpful in slowing the hair process— but these are expensive.

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A patient with PCOS presents with heavy bleeding for the last 3 weeks not having had a menses in the prior 18 months. The best immediate treatment for her is:

A. Estrogen

B. Progesterone

C. Weight loss

D. Insulin sensitizing agent

A patient with PCOS presents with heavy bleeding for the last 3 weeks not having had a menses in the prior 18 months. The best immediate treatment for her is:

A. Estrogen

**B. Progesterone **

C. Weight loss

D. Insulin sensitizing agent

These patients, when usually anovulatory, lack the stabilizing and compaction effects of progesterone. They thus first and foremost need progesterone to stop the bleeding. We usually given them progesterone over 2 – 3 weeks. When we stop the progesterone, a withdrawal subsequent menses will result. While they primarily need progesterone, if they have bled for a prolonged time, they may also need some estrogen to allow a bit of growth and “healing” effect along with the progesterone.

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A female will achieve her maximum number of oocytes:

A. In-utero

B. By mid childhood years

C. Sometime after puberty

D. By age 40 years

E. At the menopause

A female will achieve her maximum number of oocytes:

**A. In-utero **

B. By mid childhood years

C. Sometime after puberty

D. By age 40 years

E. At the menopause

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A male will achieve his maximum number of spermatocytes:

A.In-utero

B. By mid childhood years

C. Sometime after puberty

D. By age 40 years

E. After age 50 years

A male will achieve his maximum number of spermatocytes:

A.In-utero

B. By mid childhood years

**C. Sometime after puberty **

D. By age 40 years

E. After age 50 years

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An adult woman is given a constant infusion of GnRH. At the conclusion of this study blood is drawn. Which of the following would be possible?

A. FSH levels are elevated

B. No change in FSH levels

C. FSH levels are suppressed

An adult woman is given a constant infusion of GnRH. At the conclusion of this study blood is drawn. Which of the following would be possible?

A. FSH levels are elevated

B. No change in FSH levels

C. FSH levels are suppressed

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A 26 year old woman and her 27 year old husband volunteer for a study and are each given an IV bolus of GnRH. Thirty minutes later a blood sample for FSH and LH levels would find:

A. Both levels increased and LH > FSH levels

B. Both levels increased and FSH > LH levels

C. LH and FSH levels unchanged and equivalent

D. LH and FSH levels decreased and equivalent

E. FSH levels increased and LH levels suppressed

A 26 year old woman and her 27 year old husband volunteer for a study and are each given an IV bolus of GnRH. Thirty minutes later a blood sample for FSH and LH levels would find:

**A. Both levels increased and LH > FSH levels **

B. Both levels increased and FSH > LH levels

C. LH and FSH levels unchanged and equivalent

D. LH and FSH levels decreased and equivalent

E. FSH levels increased and LH levels suppressed

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A 4 year old male with precocious penile development was diagnosed with an androgen producing adrenal tumor. When compared to levels before this tumor appeared, his LH levels would most likely be:

A. Unchanged

B. Elevated

C. Suppressed

A 4 year old male with precocious penile development was diagnosed with an androgen producing adrenal tumor. When compared to levels before this tumor appeared, his LH levels would most likely be:

A. Unchanged

B. Elevated

C. Suppressed

Too much testosterone suppresses GnRH production in the hypothalamus.

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Which of the following best demonstrates positive feedback:

A. FSH stimulates estrogen production

B. Rising estrogen levels stimulate LH secretion

C. Decreasing estrogen levels increase FSH secretion

D. Rising estrogen levels inhibit FSH production

Which of the following best demonstrates positive feedback:

A. FSH stimulates estrogen production (this is an example of feedforward)

**B. Rising estrogen levels stimulate LH secretion **

C. Decreasing estrogen levels increase FSH secretion

D. Rising estrogen levels inhibit FSH production

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A patient has radiation therapy that destroys all of her primordial follicles. This will result in:

A. Loss of oocytes (with anovulation) but continuation of estrogen production.

B. Continued ovulation but cessation of estrogen production.

C. Loss of oocytes (with anovulation) and cessation of estrogen production.

A patient has radiation therapy that destroys all of her primordial follicles. This will result in:

A. Loss of oocytes (with anovulation) but continuation of estrogen production.

B. Continued ovulation but cessation of estrogen production.

C. Loss of oocytes (with anovulation) and cessation of estrogen production.

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A male works in a battery factory and his exposure to lead destroys his seminiferous tubules. This will result in:

A. Loss of sperm but continuation of androgen production.

B. Continued sperm production but cessation of androgen production.

C. Loss of sperm production and cessation of androgen production.

A male works in a battery factory and his exposure to lead destroys his seminiferous tubules. This will result in:

A. Loss of sperm but continuation of androgen production. (unlike in the female, these functions are separate in the male)

B. Continued sperm production but cessation of androgen production.

C. Loss of sperm production and cessation of androgen production.

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A 27 year old woman presents with 38 day menstrual cycles and bad menstrual cramps. She is concerned that she doesn’t ovulate because her cycles are long. Her physician explains that the menstrual cramps suggest that she in fact ovulates and that she likely ovulates on cycle day: A. 14 B. 18 C. 20 D. 24 E. 30

A blood sample revealed FSH of 4 mIU/ml and LH of \< 2 mIU/ml. It was likely drawn from which of the following individuals? ## Footnote A. 5 year old female child B. 16 year old menstruating adolescent C. 52 year old menopausal woman. D. Adult male

A blood sample revealed FSH of 4 mIU/ml and LH of \< 2 mIU/ml. It was likely drawn from which of the following individuals? **A. 5 year old female child (LHRH not being secreted)** B. 16 year old menstruating adolescent C. 52 year old menopausal woman. D. Adult male

A mother brings her fraternal twins for counseling at age 13 6/12 years. Which of them, if normally developing, is more likely capable of becoming a parent if sexually active? ## Footnote A. Her daughter B. Her son

A mother brings her fraternal twins for counseling at age 13 6/12 years. Which of them, if normally developing, is more likely capable of becoming a parent if sexually active? A. Her daughter **B. Her son**

A 6 year old male presents with Tanner 4 penile and pubic hair development. His testes are normal for age. Of the following, he most likely has: ## Footnote A. Hamartoma B. Constitutional precocious puberty C. McCune Albright syndrome D. Testitoxicosis (LH receptor mutation in testes) E. Adrenal testosterone secreting tumor

A 6 year old male presents with Tanner 4 penile and pubic hair development. His testes are normal for age. Of the following, he most likely has: A. Hamartoma B. Constitutional precocious puberty C. McCune Albright syndrome D. Testitoxicosis (LH receptor mutation in testes) **E. Adrenal testosterone secreting tumor**

18 month old child presents with premature breast development. She is in 75% of height as she has been since birth. She has no other symptoms. The breast development regressed after age 4 years without intervention. A. Idiopathic central precocious puberty B. Peripheral precocious puberty from granulosa cell tumor C. Peripheral precocious puberty from ingestion of exogenous estrogen D. Unusual estrogen production during infancy when FSH is usually elevated

18 month old child presents with premature breast development. She is in 75% of height as she has been since birth. She has no other symptoms. The breast development regressed after age 4 years without intervention. A. Idiopathic central precocious puberty B. Peripheral precocious puberty from granulosa cell tumor C. Peripheral precocious puberty from ingestion of exogenous estrogen **D. Unusual estrogen production during infancy when FSH is usually elevated**

3 year old with breast, pubic hair, and advanced growth as evidenced by growth velocity chart and bone age hand film (see next slide). What does she likely have? A. Idiopathic central precocious puberty B. Peripheral precocious puberty from granulosa cell tumor C. Peripheral precocious puberty from ingestion of exogenous estrogen D. Unusual estrogen production during infancy when FSH is usually elevated

3 year old with breast, pubic hair, and advanced growth as evidenced by growth velocity chart and bone age hand film (see next slide). What does she likely have? A. Idiopathic central precocious puberty **B. Peripheral precocious puberty from granulosa cell tumor (A is possible, but B is more likely)** C. Peripheral precocious puberty from ingestion of exogenous estrogen D. Unusual estrogen production during infancy when FSH is usually elevated

Just before menopause the cycle length begins to decrease. Why? a. FSH is rising earlier b. FSH is rising later c. Too many follicles are in the cohort d. E2 is higher e. In menopause the menses last longer

Just before menopause the cycle length begins to decrease. Why? **a. FSH is rising earlier (****The follicular reserve is in decline, so estrogen declines earlier, allowing FSH to rise quicker.)** b. FSH is rising later c. Too many follicles are in the cohort d. E2 is higher e. In menopause the menses last longer

A 16 year old non sexually active female is on Oral contraceptives for what is apparently exercise associated oligo ovulation (infrequent, irreg ovulation) which was diagnosed when she presented with irregular menses. She has been on the pill for 6 months and at a return visit states she is bleeding all the time on and off. She hates the pill! Which of the following tests is the most appropriate first step in evaluation of her abnormal bleeding? ## Footnote a. TSH b. Estradiol c. hCG d. FSH e. FSH and LH

A 16 year old non sexually active female is on Oral contraceptives for what is apparently exercise associated oligo ovulation (infrequent, irreg ovulation) which was diagnosed when she presented with irregular menses. She has been on the pill for 6 months and at a return visit states she is bleeding all the time on and off. She hates the pill! Which of the following tests is the most appropriate first step in evaluation of her abnormal bleeding? a. TSH b. Estradiol **c. hCG (because all women are pregnant until proven otherwise!)** d. FSH e. FSH and LH

PCOS patients don’t ovulate regularly and have irregular cycles. Adolescents typically have several years after menarche and they don’t ovulate. Why do adolescents in the first two years after menarche have cycles that are between 21 to 45 days. Why? ## Footnote A. They have intact feedback positive feedback between LH and Estradiol B. They have intact negative feedback between LH and estradiol C. Their basalis and functionalis endometrium break apart as the uterine cavity is full D. They have intact negative feedback between estradiol and FSH E. They have intact positive feedback between estradiol and FSH

PCOS patients don’t ovulate regularly and have irregular cycles. Adolescents typically have several years after menarche and they don’t ovulate. Why do adolescents in the first two years after menarche have cycles that are between 21 to 45 days. Why? A. They have intact feedback positive feedback between LH and Estradiol B. They have intact negative feedback between LH and estradiol C. Their basalis and functionalis endometrium break apart as the uterine cavity is full **D. They have intact negative feedback between estradiol and FSH** E. They have intact positive feedback between estradiol and FSH

A 11 year old female with menarche 10 months ago presents on Feb 22 with a menstrual calendar showing the following: LMP Feb 1 PMP Dec 25 PPMP Dec 2 Her sister who is 22 years of age has periods exactly every 29 days and told her to see you “because something is messed up"! You tell her: A. Everything is fine B. She likely started ovulating C. We need to check her FSH D. We should do a pregnancy test E. She cant take Oral Contraceptives to straighten out her menses, she is too young.

A 11 year old female with menarche 10 months ago presents on Feb 22 with a menstrual calendar showing the following: LMP Feb 1 PMP Dec 25 PPMP Dec 2 Her sister who is 22 years of age has periods exactly every 29 days and told her to see you “because something is messed up"! You tell her: **A. Everything is fine** B. She likely started ovulating C. We need to check her FSH D. We should do a pregnancy test **(also a possible answer!)** E. She cant take Oral Contraceptives to straighten out her menses, she is too young.

-A 16 year old G0P0 menarche at 11 became sexually active having vaginal coitus 3 months ago. She uses condoms most of the time. -Her cycles came every month until 2 months ago when she began bleeding every day. Her aunt is a medical assistant and told her to keep track of her bleeding and she brings the following menstrual calendar (this pattern has persisted for a few months). What is most likely? ## Footnote A. PCOS B. cervicitis C. anovulation from hypothyroid D. pregnancy E. stress related anovulation

- A 16 year old G0P0 menarche at 11 became sexually active having vaginal coitus 3 months ago. She uses condoms most of the time. - Her cycles came every month until 2 months ago when she began bleeding every day. Her aunt is a medical assistant and told her to keep track of her bleeding and she brings the following menstrual calendar (this pattern has persisted for a few months). What is most likely? A. PCOS **B. cervicitis** C. anovulation from hypothyroid D. pregnancy E. stress related anovulation

A 12 year old began menses 4 months ago. She is not sexually active and has no significant medical problems. Her periods have occurred every 4-5 weeks and have lasted around one week. This period has now lasted 9 days and she is dizzy. Her pulse is 104. Is her problem likely related to an HPO axis abnormality?

Johanna a 17 year old female comes in to your office with amenorrhea for 8 months. Menarche was at 12, she had regular menses for 2 years and then has had irregular menses. (Picture: she is super skinny) She is a straight A student. Physical exam includes a **BMI of 17**, a pulse of 52, and BP of 90/60. Which of the following best explains the origin of the patients amenorrhea? 1. Abnormal GnRH production 2. Low estrogen production 3. Low FSH and LH 4. Changes in neurotransmitters 5. Increased inhibin (Review: glycoprotein produced by granulosa or sertoli under influence of FSH; it suppresses FSH primarily at pituitary level)

4. Changes in neurotransmitters

Jane is a 37 year old G2P1. She has amniocentesis for maternal age. She is found to have a 45 X fetus. For a term birth, what would you expect that the child will have for a gonad, internal ductal system and external genitalia? A. Testis / Epidymis and VD / Urogenital slit B. Testicular steak / Uterus and Vagina / absent clitoris C .Ovarian streak / Uterus and vagina / clitoris D. Ovary / Uterus and vagina / genital tubercule E. Ovary / Epidymis and VD / scrotum

Jane is a 37 year old G2P1. She has amniocentesis for maternal age. She is found to have a 45 X fetus. For a term birth, what would you expect that the child will have for a gonad, internal ductal system and external genitalia? A. Testis / Epidymis and VD / Urogenital slit B. Testicular steak / Uterus and Vagina / absent clitoris **C .Ovarian streak / Uterus and vagina / clitoris** D. Ovary / Uterus and vagina / genital tubercule E. Ovary / Epidymis and VD / scrotum

Sarah is a 15 year old accompanied by her mother. She is seeing you in regard to never having a menstrual period. She is not sexually active. Sarah's mom had an amniocentesis for advanced maternal age and knows Sarah has a 46XX karotype. She is a cross country runner and is already being recruited by the Oregon Ducks. Her coach told her it is common to not have periods when you are a “world class” runner. She began having breast development around age 10. She shaves her pubic hair weekly. Her eating disorder screen is negative. She runs around 50 miles a week. Her only significant PMH is that she had UTIs as a child and was found to have an absent kidney. What will you most likely find on evaluation? a. Fused scrotal folds or abnormal labia b. Absence of a clitoris c. Defect in androgen synthesis or receptors d. A enzyme deficiency in steroidogensis that decreased androgens with a X linked recessive inheritance e. Absence of the vagina

You are the resident for pediatrics and are called to the delivery room to evaluate an infant with ambiguous genitalia. The infant has an enlarged clitoris and a single perineal opening high at the top of fused labial scrotal folds. No masses were palpable within the labial scrotal folds. The labial scrotal folds have marked increased pigmentation. What is the most likely etiology? a. A defect in steroidogenesis that increases androgen production b. A defect in MIS/AMH production c. 5 alpha reducatase deficiency which is autorecessive d. Absence of testicular determinants e. Paramesonephric (mullerian) lateral fusion defect

You are the resident for pediatrics and are called to the delivery room to evaluate an infant with ambiguous genitalia. The infant has an enlarged clitoris and a single perineal opening high at the top of fused labial scrotal folds. No masses were palpable within the labial scrotal folds. The labial scrotal folds have marked increased pigmentation. What is the most likely etiology? **a. A defect in steroidogenesis that increases androgen production** b. A defect in MIS/AMH production c. 5 alpha reducatase deficiency which is autorecessive d. Absence of testicular determinants e. Paramesonephric (mullerian) lateral fusion defect

Tiffani progressed to full dilation about 8 hours after arrival on the Labor and Delivery area, she pushed for 1.5 hours before having a healthy baby girl, and the placenta delivered about 5 minutes later. The best description of her labor is: A precipitous labor B normal labor C prolonged labor D TV labor

Mrs. Q has quantitative hCGs drawn every other day starting at week 4 from LMP. Which of the following series of values (mIU) is most likely to be associated with a normal, singleton pregnancy? A. 30, 60, 150, 400 B. 30, 120, 390, 900 C. 30, 33, 38, 31 D. none of the above

Ans: A

During pregnancy, a woman produces more estrogen than a normal ovulatory (non-pregnant) woman could produce in more than 150 years. A. True B. False

True

Ms. Trescott is a 16 y.o. G1 Po, who chose to have screening for aneuploidy and neural tube defects (NTD) risk assessment. Her a priori risk of T21 is 1:1129. Results: AFP 4.06 MoM; hCG 2.02 MoM; uE3 0.39 MoM; DIA 2.63 MoM. Which of the following is true: A. Risk NTD: 1:24 B. Risk of T21: 1:470 C. Risk of T18: 1:4658 D. All of the above

Ans: D because = AFP is 4 multiples of median (MoM) – elevated relative to normal = hCG is 2 MoM = DIA is 2.63 MoM = uE3 is lower

Which of the following statements are true? A. The role of maternal oxytocin in pregnancy and parturition remains unclear B. Oxytocin receptors increase dramatically in number shortly before onset of labor C. Initiation of parturition is a complex interplay between the fetus, placenta and maternal compartments D. A, B &C E. None of the above

Ans: D

The hormone produced by the syncytiotrophoblast is? A estradiol B 17-hydroxyprogesterone C human chorionic gonadotropin D human placental lactogen

Ans: C

A 24 year old G0 at 36 weeks c/o 6 lb weight gain over 1 week, headache and scotoma (visual floaters). She has a BP of 150/110, 3+ pedal edema and 3+ proteinuria. You recommend A start anti-hypertensive B bedrest C diuretic D expectant management E induction of labor

A 41 yo female with a remote history of chlamydia and a tubal ligation presents to the ER complaining of 6/10 lower abdominal pain and light vaginal bleeding. Urine pregnancy test is positive. Her most likely diagnosis is: A. Appendicitis B. Ectopic pregnancy C. Spontaneous abortion D. Acute diverticulitis E. It cannot be determined from the information above

Ans: E; this case is actually a typical presentation of a uterine pregnancy

Diagnostic tests helpful to establish her diagnosis of ectopic preg include all of the following except: A. Ultrasound B. Quantitative B-hCG C. Serum progesterone D. T&S (type and screen) E. Culdocentesis

Ans: D: to establish patient’s blood type. Will be helpful later to determine if she’s Rh+/- and if she needs transfusion, but won’t be diagnostic.

The hormone produced by the syncytiotrophoblast is? A estradiol B 17-hydroxyprogesterone C human chorionic gonadotropin D human placental lactogen

Ans: E; this case is actually a typical presentation of a uterine pregnancy

Ans: D: to establish patient’s blood type. Will be helpful later to determine if she’s Rh+/- and if she needs transfusion, but won’t be diagnostic.

41 yo G6 P5 at 32 weeks presents after having no prenatal care to labor and delivery complaining of vaginal bleeding. She awoke from sleep to go to the bathroom and when she urinated she filled to toilet bowel with bright red blood. She has mild cramping. Her vital signs are stable. Her exam shows blood stained clothes and active bleeding from her vagina. Her uterus is soft, non-tender to palpation, and a FHR is auscultated. The most likely cause of her bleeding is… A. Complete abruption B. Partial abruption C. Urinary tract infection D. Placenta previa E. Chorioamnionitis

36 yo G1P0 at 36 weeks presents via ambulance with vaginal bleeding and painful contractions. Her BP is 170/112 and there is 3+ protein on urine analysis. On exam she appears uncomfortable, her uterus is firm and tender. A FHR is auscultated at 180 BPM. There are contractions every 1-2minutes on the tocodynamometer. You see active bleeding from her vagina. The most likely cause of her bleeding is… A. Complete abruption B. Partial abruption C. Preeclampsia D. Placenta previa E. Uterine rupture

Ans: B, but at risk for C

26 yo G2P1 s/p 1st trimester abortion presents complaining of heavy vaginal bleeding and cramping. She reports that she had bleeding after the procedure 2 days ago but now it is heavier. On exam her vitals are stable. On speculum exam you see bright red blood coming from the cervix os and some irregular spongy tissue in the canal. The most likely cause of her bleeding is… A. Complete abruption B. Partial abruption C. Retained products of conception D. Placenta previa E. Genital tract laceration

29 yo G2 P1 presents 5 days s/p 28 week delivery by emergent cesarean for malpresentation, preterm labor and prolonged rupture of membranes c/o of chills, foul smelling lochia, bleeding, and abdominal pain. Her vitals are Tc 100.7, HR 108, BP 100/50. She appears uncomfortable. Her exam shows clear lungs, breasts engorged, abdomen soft, and incision clean, dry, intact with out erythema. Her uterus is 2 finger breadths below her umbilicus and exquisitely tender to light palpation. The most likely cause of her fever and discomfort is… A. Mastitis B. Chorioamnionitis C. Urinary tract infection D. Wound infection E. Endomyometritis

You are a third year student on your OBGYN rotation and are rounding on a postpartum patient on PPD2. She is concerned about the tender masses in her axilla bilaterally. You think the most likely diagnosis is: A. Lymphadenopathy from breast cancer B. Lymphadenopathy from an intrauterine infection C. Accessory mammary tissue D. Engorgement related to initiation of lactation E. Lymphadenopathy from an irritated IV site in her arm

At birth, the breast of a male baby and the breast of a female baby are identical. True False

True

The most common obstacle to successful lactation in the US is: A. Poor latch either because of baby or mom’s anatomy B. History of breast augmentation or reduction surgery C. Lack of supportive family- “the mother in law effect” D. Lack of knowledgeable medical providers/hospital practices that may adversely effect lactation E. Society’s view of the breast as a sex object

all is true

The risk of death from having an abortion exceeds the risk of death from a full term delivery. True False

False. * Risk of death from a legal abortion is 0.67/100,000 (2003-2009) * Risk of death from a term pregnancy is 9/100,000

A 15 year old adolescent young woman presents with absent breast and pubic hair development. Your assessment is that: A. Pubic hair is usually absent when breast development is delayed. B. It is likely that the defect is limited to the HPG axis. C. She likely has one of the more significant problems found in delayed puberty

A 15 year old adolescent young woman presents with absent breast and pubic hair development. Your assessment is that: A. Pubic hair is usually absent when breast development is delayed. B. It is likely that the defect is limited to the HPG axis. **C. She likely has one of the more significant problems found in delayed puberty**

Decreased availability of oral contraceptive in adolescents is most likely associated with: a. Decreased rates of teen sexuality b. Increase utilization of more effective methods c. Decreased rates of abortion d. Increase in abstinence e. Increase use of withdrawal

You are counseling a 15 year old female with irregular periods regarding contraception. She is interested in oral contraceptives, vaginal contraceptive ring, an IUD, and withdrawal. Which of the following is the most accurate counseling? a. Withdrawal is not a contraceptive method b. The IUD is not appropriate for teens c. None of these methods prevent STDs so she should also use a condom d. The contraceptive ring and IUD are similar in effectiveness e. Her partners preference doesn’t matter f. She doesn’t need contraception until her periods become regular as regular periods signal fertility

D (i think..?)

A patients mom tells you she read that an abstinence only approach worked really well in young teens and that is why she does not want you to discuss any contraception. What is your most appropriate response? a. I would like to see the article and read the study b. A government study showed definitely that abstinence only education does not work c. They likely used “scare tactics” (e.g. showed genital warts and herpes pictures) which has been shown to be effective

ARS: Sarah is a premedical student at Dartmouth and wants to know how an oral contraceptive prevents pregnancy. Which of the following is the most accurate description of the most important mechanism to prevent a pregnancy? A. OCs prevents ovulation through the estrogen component preventing the LH surge B. The progestin prevents the endometrium from being receptive to a blastocyst C. The progestin prevents a LH surge D. The estrogen prevents the selection of a dominant follicle E. The FSH is increased and prevents the LH surge F. The estrogen prevents the corpus luteum from producing progesterone

A Note several of these are true but are not the most important mechanism

ARS: Sarah is a premedical student at Dartmouth and wants to know how an oral contraceptive prevents pregnancy. Which of the following is the most accurate description of the most important mechanism to prevent a pregnancy? a. OCs prevents ovulation through the estrogen component preventing the LH surge b. The progestin prevents the endometrium from being receptive to a blastocyst c. The progestin prevents a LH surge d. The estrogen prevents the selection of a dominant follicle e. The FSH is increased and prevents the LH surge f. The estrogen prevents the corpus luteum from producing progesterone

Sarah a 20 year old has lupus and has CVA at age 17 when she was found to have antiphospholipid antibody syndrome. She has recently become sexually active. Which of the following is the most appropriate contraceptive method to prevent an unintended pregnancy? A. Medroxyprogesteone acetate injection B. Contraceptive Patch C. Oral contraceptives D. Vaginal contraceptive ring E. Bilateral tubal ligation given the major risk of pulmonary emboli during a pregnancy

Ans: A – progestin only method bc thrombosis is an ESTROGEN event

A 45 year old is sexually active and referred to you for an adnexal mass. She has used oral contraceptives for 20 years and now is using a copper IUD for several years . Which of the following is accurate regarding her adnexal mass? A. Use of oral contraceptives decreases her baseline risk of the mass being ovarian cancer B. The mass could be an ectopic pregnancy. Iuds increase risk of ectopic. C. She is not ovulating so this is not a corpus lutein cyst. D. The mass is likely an endometrioma as long term oral contraceptive risk increases her risk.

A 16 year old female says her partner will not use condoms and she doesn’t want hormones. She would like to use a diaphragm. Which of the following is the most accurate counseling regarding the advantages of diaphragms? A. They are more effective than condoms B. They prevent STD transmission as effectively as condoms C. They can be reinserted for multiple coital encounters occurring over a few hours. D. They are female controlled. E. EBM has shown they are not associated with an increased risk of UTIs.

Jane is on an OC. She hates the idea of taking estrogen;” that sounds like a dangerous hormone”. You tell her that: A. Estrogen is the main component that inhibits ovulation B. Progesterone increases estrogen receptors so the estrogen is low in amount but very effective C. Progesterone is the main component that inhibits ovulation D. Endometrial cancer is only slightly increased in women who have taken the pill for more than 20 year. E. Estrogen is not associated with any life threatening side effects

Which of the following patients is not a good candidate for depo medroxyprogesterone acetate for contraception? A. A 13 year old who is sexually active B. A patient with a history of a blood clot during pregnancy C. A 24 year old who wants to get pregnant in ~ 12-14 months D. A patient with migraines E. A patient 45 year old patient who has a family history of early menopause

You are seeing a 28 year old woman for her annual exam. When you ask about sexual issues, she responds that she and her husband rarely have intercourse because she “just isn’t that interested.” She is concerned that this is becoming a problem in their relationship. She relates the onset of her symptoms to the birth of her second child 11 months ago. She notes that when they do attempt intercourse she sometimes has discomfort. Which is your diagnosis? A. sexual aversion (no longer classified as a sex disorder; now reclassified as a phobia) B. dyspareunia (primarily discomfort, but her main complaint is that she’s not interested) C. female sexual interest/arousal disorder D. vaginismus (spasm: intercourse is sometimes not possible) E. premature ovarian failure

She currently uses combined oral contraceptive pills for contraception. She notes that she continues to be very fatigued and has noted some difficulty with sleeping. She is not on any medications other than the OCPs and a multivitamin. What will you do first? A) Stop OCPs as they may be affecting her desire (Raise SHBG which decrease desire but generally there is not agreement on effect) B) Testosterone therapy C) Refer for marital counseling (Not yet but perhaps eventually) D) Assess further for possible depression E) Begin topical estrogen therapy

D – she is having sx that are consistent with somatic symptoms that are consistent with depression

You are seeing a 42 year old who complains that she can no longer reach orgasm. She experiences arousal, lubricates well, and has no pain or other discomfort with sexual activity. However, she finds that even prolonged stimulation does not lead to orgasm which is a frustrating change for her. “It’s just too exhausting” she says. You review her past medical history and medication list. Which is most likely to be related to her complaint? A. Mirena IUS for contraception B. Hydroclorathiazide for hypertension C. Zolipidem (Ambien) as needed for insomnia D. Fluoxetine (Prozac) for depression E. Albuterol inhaler for asthma

ans: D - SSRIs are common cause of female orgasmic disorder

Your patient is a 58 year old postmenopausal woman with a history of breast cancer. When asked about sexual function, she replies that things are “OK.” During her pelvic exam, however, you note that she is somewhat tense and she complains of discomfort when the speculum is inserted. You discuss this, and she says that she often has pain when attempting intercourse and has noted that she is not as well lubricated as before. She does feel interested in sex and aroused until penetration is attempted. What would be your first recommendation? A. Use of a vaginal lubricant B. Trial of systemic hormone replacement (don’t do this due to history of breast cancer) C. Trial of topical estrogen therapy D. Pelvic floor physical therapy E. Reassure her this is a normal part of aging (having pain with sex is not a normal part of aging)

You are seeing a couple for preconception counseling. They are in their 30’s and have been married for about 2 years. They are both healthy and you review your standard recommendations. You note that she has not had cervical cytology testing for 8 years. When you comment on this, she becomes tearful and her husband says they have a problem. They have not been able to have intercourse – “she just closes up,” he says. What is your initial diagnosis? A) Sexual aversion B) Hypoactive sexual desire disorder C) Dyspareunia D) Vaginismus E) Priapism

Ans: D - Vaginal spasm – she doesn’t not have desire, they just can’t do it.

On further questioning, you learn that she was the victim of a sexual assault 8 years ago. Although she “had counseling and all that” at the time, she was unable to tolerate a pelvic exam when she went for her gyn exam six months later and she has not sought gyn care since. She discussed this with her husband and he “has been great about it” but they are now interested in having children. What are your next steps? A) Perform an exam today; obtain cervical cytology B) Ask her permission to assess via external examination; discuss referrals for physical therapy and counseling C) Refer to sex therapist; prescribe use of vaginal dilators D) Refer to infertility specialist for IVF E) Schedule examination under anesthesia

Ans: B - They may need a sex therapist + vaginal dilators at some point; too invasive now.

A 21 yo G3 P2 is found on her 28 week labs to have a Hgb of 10.9gm/dL. This is most likely due to… ## Footnote A. Insufficient iron intake B. Intermittent bleeding C. Decreased iron absorption **D. Increased red blood cell production and a greater increased plasma volume** *(remember both RBCs and plasma vol increase w pregnancy, but greater increase in plasma vol -\> physiologic anemia of pregnancy. We define anemia in preg as Hgb \< 10.5)* E. Decreased red blood cell production and increased plasma volume

•A 38 yo G1 recent immigrant from Haiti to the US presents for a first prenatal visit at 16 weeks. Which of her cardiac exam finding(s) is/are likely to be abnormal during pregnancy? ## Footnote A. Grade 2 systolic murmur at LSB B. Diastolic murmur at cardiac apex C. Split S1, S2, and S3 gallop D. S4 gallop E. Souffle heard L or R 2 or 3rd intercostal space in diastoli and systoli

•A 38 yo G1 recent immigrant from Haiti to the US presents for a first prenatal visit at 16 weeks. Which of her cardiac exam finding(s) is/are likely to be abnormal during pregnancy? ## Footnote A. Grade 2 systolic murmur at LSB **B. Diastolic murmur at cardiac apex** C. Split S1, S2, and S3 gallop **D. S4 gallop** *(diastolic murmurs are never normal during pregnancy)* E. Souffle heard L or R 2 or 3rd intercostal space in diastoli and systoli

•A 30 yo G1 with incompletely corrected congenital heart disease presents for prenatal care. You explain that pregnancy may cause complications for her due to which normal pregnancy changes… ## Footnote A. increased heart rate, increased stroke volume, and increased cardiac output B. decreased heart rate, increased stroke volume, increased cardiac output C. increased heart rate, decreased stroke volume, decreased cardiac output

•A 30 yo G1 with incompletely corrected congenital heart disease presents for prenatal care. You explain that pregnancy may cause complications for her due to which normal pregnancy changes… ## Footnote **A. increased heart rate, increased stroke volume, and increased cardiac output** B. decreased heart rate, increased stroke volume, increased cardiac output C. increased heart rate, decreased stroke volume, decreased cardiac output

•A 25 yo G1 presents at 22 weeks and her blood pressure is 90/50. This is concerning to her because when she saw you at 6 weeks her blood pressure was 110/70. You explain that a healthy pregnant woman’s blood pressure decreases in a linear fashion throughout all trimesters of pregnancy. Are you correct? ## Footnote A. Yes B. No

•A 20 yo healthy G1 at 32 weeks complains of persistent breathlessness. Her physical exam is normal. Because she is insistent that something “might be wrong” you obtain a blood gas. Which ABG is most likely to be from her? ## Footnote A. 7.35/85/40/24 B. 7.42/99/30/20 C. 7.30/55/70/24 D. 7.24/15/59 E. 7.39/80/45/22

•A 20 yo healthy G1 at 32 weeks complains of persistent breathlessness. Her physical exam is normal. Because she is insistent that something “might be wrong” you obtain a blood gas. Which ABG is most likely to be from her? ## Footnote A. 7.35/85/40/24 **B. 7.42/99/30/20** C. 7.30/55/70/24 D. 7.24/15/59 E. 7.39/80/45/22

Which ABG may be from a preg woman having resp issues? ## Footnote A. 7.35/85/40/24 B. 7.42/99/30/20 C. 7.30/55/70/24 D. 7.24/15/59 E. 7.39/80/45/22

Which ABG may be from a preg woman having resp issues? ## Footnote A. 7.35/85/40/24 B. 7.42/99/30/20 C. 7.30/55/70/24 D. 7.24/15/59 **E. 7.39/80/45/22** **(arterial pH in the non-preg range with mild hypoxia and hypercapnia may signify resp failure in preg)**

•A 32 yo G2 P1 at 29 weeks complains of persistent severe right upper quadrant pain and nausea after eating at McDonald’s last night. You perform some laboratory studies. Which liver tests or functions are not increased during normal pregnancy? ## Footnote A. Coagulation factors B. Alkaline phosphatase C. Cytochrome P450 metabolism D. Total, indirect, and direct bilirubin E. Liver transaminases (AST, ALT, GTT)

•A 32 yo G2 P1 at 29 weeks complains of persistent severe right upper quadrant pain and nausea after eating at McDonald’s last night. You perform some laboratory studies. Which liver tests or functions are not increased during normal pregnancy? ## Footnote A. Coagulation factors B. Alkaline phosphatase C. Cytochrome P450 metabolism **D. Total, indirect, and direct bilirubin** **E. Liver transaminases (AST, ALT, GTT)**

14 yo boy brought in by dad for annual physical. Dad brings up that boy is dressing in sister’s clothes. What does this mean? A.He is definitely gay B.He is rehearsing for the school play C.He has Gender Identity Disorder and will need long term counseling by a specialist in gender issues. D.He may be at risk for increased behavioral concerns, e.g. Suicidal risk, drug/EtOH use.

14 yo boy brought in by dad for annual physical. Dad brings up that boy is dressing in sister’s clothes. What does this mean? A.He is definitely gay B.He is rehearsing for the school play C.He has Gender Identity Disorder and will need long term counseling by a specialist in gender issues. **D.He may be at risk for increased behavioral concerns, e.g. Suicidal risk, drug/EtOH use. **

15 y.o. girl, pregnant! You discuss options with the patient, you tell her that A.Her grandmother must be told because she is too young to be a mom B.Her grandmother must be told because pregnancy is a high medical risk condition that might require surgical consent C.Pregnancy is a protected health condition and can be confidential

15 y.o. girl, pregnant! You discuss options with the patient, you tell her that A.Her grandmother must be told because she is too young to be a mom B.Her grandmother must be told because pregnancy is a high medical risk condition that might require surgical consent **C.Pregnancy is a protected health condition and can be confidential**

The workup of erectile dysfunction consists of: a. Measurement of testosterone and thyroid hormones only b. Measurement of blood pressure and testosterone c. A complete history and physical examination to start d. No real workup- just give some meds as per TV

The workup of erectile dysfunction consists of: a. Measurement of testosterone and thyroid hormones only b. Measurement of blood pressure and testosterone **c.A complete history and physical examination to start (ED is a symptom of poor health just as chest pain can be)** d.No real workup- just give some meds as per TV

Correct anatomy of the penis: a. Corpora penosa and corpus urethrososum b. Corpora cavernosa and corpus spongiosum c. Corpora spongiosa and corpus cavernosum d. Corpora glansiosa and corpus spongiosum

Correct anatomy of the penis: a.Corpora penosa and corpus urethrososum **b.Corpora cavernosa and corpus spongiosum (2 caverns, 1 sponge?!)** c. Corpora spongiosa and corpus cavernosum d. Corpora glansiosa and corpus spongiosum

Exogenous testosterone use leads to: a. Increased sperm production b. Increased sperm motility c. Decreased sperm production d. No change in sperm production

Exogenous testosterone use leads to: a. Increased sperm production b. Increased sperm motility **c.Decreased sperm production ** d.No change in sperm production

Which Y microdeletion may have sperm production: a. AZFa microdeletion b. AZFb microdeletion c. AZFc microdeletion d. AZFd microdeletion

Which Y microdeletion may have sperm production: a. AZFa microdeletion b. AZFb microdeletion **c.AZFc microdeletion ** d.AZFd microdeletion

MS is a 51 yo G4P4 woman who presents with complaints of exhaustion and difficulty focusing. Her LMP was about 4 months ago and her periods are variable, sometimes extremely heavy and sometimes just spotting. She wakes up 4 or 5 times per night with intense flushing and sweating. She overall feels unwell and has gained 20 lbs in the last year. Which word best describes her status? A. Perimenopausal B. Early menopause C. Menopausal transition D. Postmenopausal

MS is a 51 yo G4P4 woman who presents with complaints of exhaustion and difficulty focusing. Her LMP was about 4 months ago and her periods are variable, sometimes extremely heavy and sometimes just spotting. She wakes up 4 or 5 times per night with intense flushing and sweating. She overall feels unwell and has gained 20 lbs in the last year. All of the following hormones are likely decreased except which? A. Estrogen B. Inhibin C. FSH D. Progesterone

MS is a 51 yo G4P4 woman who presents with complaints of exhaustion and difficulty focusing. Her LMP was about 4 months ago and her periods are variable, sometimes extremely heavy and sometimes just spotting. She wakes up 4 or 5 times per night with intense flushing and sweating. She overall feels unwell and has gained 20 lbs in the last year. All of the following hormones are likely decreased except which? A. Estrogen B. Inhibin **C. FSH** D. Progesterone

REVIEW QUESTIONS Flashcards

Hi Jullet! I've been aggregating all the ARS questions from all the lectures so far into this one file.... hopefully a good review pre-finals! (93 cards)