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ABOG Reproductive Endocrinology and Infertility study materials
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ABOG Reproductive Endocrinology and Infertility practice questions

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Question 1Reproductive Endocrinology and Neuroendocrinology

Which hypothalamic hormone is the primary stimulator of pituitary gonadotroph secretion?

  1. Thyrotropin-releasing hormone
  2. Gonadotropin-releasing hormone Correct answer.
  3. Corticotropin-releasing hormone
  4. Dopamine

Explanation

Gonadotropin-releasing hormone (GnRH) from the arcuate nucleus is released in pulses into the hypophyseal portal system and drives synthesis and release of LH and FSH from gonadotrophs. The other listed hypothalamic factors regulate distinct pituitary axes or act as inhibitors.

Question 2Reproductive Endocrinology and Neuroendocrinology

In the normal menstrual cycle, the mid-cycle LH surge is triggered primarily by which event?

  1. Rising prolactin from the anterior pituitary
  2. Sustained high estradiol from a mature follicle Correct answer.
  3. A fall in circulating inhibin B
  4. A surge in progesterone from the corpus luteum

Explanation

Sustained elevated estradiol from the dominant follicle exerts positive feedback on the hypothalamus and pituitary, producing the preovulatory GnRH and LH surge. Progesterone rises only after ovulation, and inhibin B falls rather than rising as the surge approaches.

Question 3Reproductive Endocrinology and Neuroendocrinology

Which pattern of GnRH delivery to the pituitary best stimulates gonadotropin secretion?

  1. Continuous infusion
  2. Bolus dosing every 12 hours
  3. Pulsatile delivery at roughly hourly intervals Correct answer.
  4. Constant high-dose administration

Explanation

Physiologic pulsatile GnRH, typically every 60-120 minutes, maintains gonadotroph responsiveness and sustains LH/FSH secretion. Continuous or non-pulsatile exposure desensitizes and downregulates pituitary GnRH receptors, suppressing gonadotropins.

Question 4Reproductive Endocrinology and Neuroendocrinology

Pulsatile GnRH secretion in the normal menstrual cycle is generated by which hypothalamic structure?

  1. Supraoptic nucleus
  2. Ventromedial nucleus
  3. Arcuate nucleus Correct answer.
  4. Paraventricular nucleus

Explanation

The arcuate nucleus contains the GnRH pulse generator, a coordinated network of kisspeptin and neurokinin B neurons that produces episodic GnRH release. The supraoptic and paraventricular nuclei primarily produce oxytocin and vasopressin.

Question 5Reproductive Endocrinology and Neuroendocrinology

Which hormone is the principal inhibitor of pituitary FSH secretion during the mid-to-late follicular phase?

  1. Activin
  2. Follistatin
  3. Inhibin B Correct answer.
  4. Leptin

Explanation

Inhibin B, secreted by small antral follicles, selectively suppresses pituitary FSH release via negative feedback. Activin stimulates FSH, while follistatin binds activin and modulates rather than directly suppressing FSH.

Question 6Reproductive Endocrinology and Neuroendocrinology

A 24-year-old with primary amenorrhea and anosmia is found to have low gonadotropins and low estradiol. Which diagnosis best fits?

  1. Polycystic ovary syndrome
  2. Kallmann syndrome Correct answer.
  3. Asherman syndrome
  4. Premature ovarian insufficiency

Explanation

Kallmann syndrome is hypogonadotropic hypogonadism caused by defective GnRH neuronal migration, classically accompanied by anosmia due to olfactory bulb involvement. Low gonadotropins with low estradiol confirm a central rather than ovarian cause.

Question 7Reproductive Endocrinology and Neuroendocrinology

The preovulatory LH surge depends most directly on which ovarian steroid acting via positive feedback?

  1. Estradiol Correct answer.
  2. Progesterone
  3. Testosterone
  4. 17-hydroxyprogesterone

Explanation

Sustained high estradiol from the mature dominant follicle switches hypothalamic-pituitary feedback from negative to positive, producing the GnRH/LH surge. Progesterone and 17-hydroxyprogesterone rise after ovulation and mediate negative feedback in the luteal phase.

Question 8Reproductive Endocrinology and Neuroendocrinology

Kisspeptin neurons in the arcuate nucleus regulate GnRH secretion primarily by which mechanism?

  1. Inhibiting hypothalamic dopamine release
  2. Directly stimulating gonadotrophs in the pituitary
  3. Acting upstream to stimulate GnRH neurons Correct answer.
  4. Suppressing pituitary FSH synthesis

Explanation

Kisspeptin neurons project to GnRH neurons and stimulate GnRH release, serving as a key upstream regulator of the pulse generator and of estradiol feedback. Kisspeptin does not act directly on pituitary gonadotrophs to any significant degree.

Question 9Reproductive Endocrinology and Neuroendocrinology

Which finding is most consistent with hyperprolactinemia as a cause of amenorrhea?

  1. Elevated LH with high testosterone
  2. Normal gonadotropins with elevated inhibin B
  3. Elevated FSH with low estradiol
  4. Low gonadotropins with low estradiol Correct answer.

Explanation

Prolactin suppresses hypothalamic GnRH release, producing hypogonadotropic hypogonadism with low LH/FSH and low estradiol. This distinguishes it from ovarian failure, where gonadotropins are elevated.

Question 10Reproductive Endocrinology and Neuroendocrinology

Which pituitary hormone is tonically inhibited by hypothalamic dopamine?

  1. Prolactin Correct answer.
  2. Luteinizing hormone
  3. Growth hormone
  4. Adrenocorticotropic hormone

Explanation

Prolactin is unique among anterior pituitary hormones in being under dominant tonic inhibition by dopamine from the tuberoinfundibular pathway. Interruption of dopamine delivery, as with stalk lesions or dopamine antagonists, raises prolactin.

Question 11Reproductive Endocrinology and Neuroendocrinology

A patient with a prolactin-secreting pituitary macroadenoma develops amenorrhea. Which mechanism best explains the hypogonadism?

  1. Increased hepatic sex hormone-binding globulin
  2. Autoimmune gonadotroph destruction
  3. Suppression of GnRH pulsatility Correct answer.
  4. Direct ovarian destruction

Explanation

Elevated prolactin suppresses hypothalamic GnRH pulse generation, reducing LH/FSH and estradiol. The hypogonadism is functional and central, and it typically reverses when prolactin is normalized.

Question 12Reproductive Endocrinology and Neuroendocrinology

Which statement best describes the normal feedback of progesterone during the luteal phase?

  1. It has no effect on the hypothalamic-pituitary axis
  2. It exerts positive feedback to generate a second LH surge
  3. It exerts negative feedback that suppresses gonadotropins Correct answer.
  4. It directly stimulates pituitary FSH release

Explanation

Luteal progesterone, together with estradiol, exerts negative feedback on GnRH and gonadotropin secretion, suppressing new follicular recruitment. Positive feedback for the LH surge is an estradiol effect in the late follicular phase.

Question 13Reproductive Endocrinology and Neuroendocrinology

Which hypothalamic-pituitary change most directly accounts for the rise in FSH at the time of the luteal-follicular transition?

  1. Decline in ovarian inhibin A and estradiol with loss of negative feedback Correct answer.
  2. Rising progesterone positive feedback
  3. Increased pituitary responsiveness to dopamine
  4. A surge in hypothalamic GnRH pulse amplitude only

Explanation

Luteolysis reduces inhibin A, estradiol, and progesterone, releasing the pituitary from negative feedback and allowing FSH to rise and recruit a new cohort of follicles. This intercycle FSH rise is a key driver of follicular recruitment.

Question 14Reproductive Endocrinology and Neuroendocrinology

Which two-cell, two-gonadotropin concept correctly describes ovarian steroidogenesis?

  1. Granulosa cells produce androgens under LH; theca cells aromatize them under FSH
  2. Both cell types produce estradiol directly under LH stimulation
  3. Theca cells produce androgens under LH; granulosa cells aromatize them under FSH Correct answer.
  4. Theca cells aromatize androgens produced by granulosa cells under FSH

Explanation

LH stimulates theca cells to synthesize androgens, which diffuse to granulosa cells where FSH induces aromatase to convert them to estrogens. This division of labor underlies the dependence of follicular estrogen production on both gonadotropins.

Question 15Reproductive Endocrinology and Neuroendocrinology

Administration of a GnRH antagonist during the late follicular phase produces which immediate endocrine effect?

  1. Immediate positive feedback with an LH surge
  2. Direct inhibition of ovarian aromatase
  3. Rapid competitive blockade of GnRH receptors with decline in LH and FSH Correct answer.
  4. Prolonged receptor downregulation over weeks

Explanation

GnRH antagonists compete with endogenous GnRH at pituitary receptors, producing rapid and reversible suppression of gonadotropins without the initial flare seen with agonists. This makes them useful for prompt LH suppression in controlled ovarian stimulation.

Question 16Reproductive Endocrinology and Neuroendocrinology

Which feature distinguishes the initial response to a GnRH agonist from that to a GnRH antagonist?

  1. Antagonists cause an initial gonadotropin flare before suppression
  2. Agonists act directly on the ovary to block steroidogenesis
  3. Agonists cause an initial gonadotropin flare before suppression Correct answer.
  4. Antagonists permanently destroy pituitary gonadotrophs

Explanation

GnRH agonists initially overstimulate receptors, producing a transient gonadotropin flare, then desensitize and downregulate the axis. Antagonists block receptors immediately without a flare.

Question 17Reproductive Endocrinology and Neuroendocrinology

Which anterior pituitary cell type secretes both FSH and LH?

  1. Gonadotrophs Correct answer.
  2. Somatotrophs
  3. Corticotrophs
  4. Lactotrophs

Explanation

Gonadotrophs are the pituitary cells that synthesize and secrete both LH and FSH in response to GnRH. The other cell types secrete growth hormone, prolactin, and ACTH respectively.

Question 18Reproductive Endocrinology and Neuroendocrinology

Which change in the hypothalamic-pituitary-ovarian axis is expected after menopause?

  1. Elevated estradiol with suppressed FSH
  2. Normal gonadotropins with high inhibin B
  3. Low gonadotropins with low estradiol
  4. Elevated gonadotropins with low estradiol Correct answer.

Explanation

Loss of ovarian follicles after menopause removes estradiol and inhibin negative feedback, causing marked elevations in FSH and LH. The hypergonadotropic hypogonadal pattern is the hallmark of primary ovarian insufficiency.

Question 19Reproductive Endocrinology and Neuroendocrinology

Which hormone is produced by the corpus luteum and is essential for maintaining the secretory endometrium in early pregnancy?

  1. Inhibin B
  2. GnRH
  3. FSH
  4. Progesterone Correct answer.

Explanation

The corpus luteum secretes progesterone, which transforms and maintains the endometrium to support implantation. Early pregnancy depends on luteal progesterone until the placenta assumes production.

Question 20Reproductive Endocrinology and Neuroendocrinology

A woman with hypothalamic amenorrhea from excessive exercise has low LH pulsatility. Which finding would most support a functional hypothalamic cause?

  1. Elevated FSH with low estradiol
  2. Markedly elevated prolactin
  3. Low or normal gonadotropins with low estradiol and low-normal prolactin Correct answer.
  4. Elevated testosterone with elevated LH

Explanation

Functional hypothalamic amenorrhea reflects suppressed GnRH pulsatility, giving low or inappropriately normal gonadotropins with low estradiol. Prolactin is typically normal, distinguishing it from prolactinoma, and testosterone is not elevated.

Question 21Reproductive Endocrinology and Neuroendocrinology

Which best explains why estrogen-only replacement is avoided in a woman with an intact uterus?

  1. Estrogen causes immediate ovarian torsion
  2. Estrogen blocks progesterone receptors irreversibly
  3. Estrogen unopposed by progesterone increases endometrial hyperplasia and cancer risk Correct answer.
  4. Estrogen directly suppresses pituitary TSH secretion

Explanation

Unopposed estrogen stimulates endometrial proliferation, raising the risk of hyperplasia and carcinoma; adding a progestin opposes this effect. This is why women with a uterus receive combined therapy.

Question 22Reproductive Endocrinology and Neuroendocrinology

Which mechanism explains the effectiveness of continuous combined oral contraceptives in suppressing ovulation?

  1. Direct inhibition of ovarian aromatase
  2. Blockade of endometrial progesterone receptors
  3. Stimulation of pituitary FSH release
  4. Suppression of hypothalamic GnRH and pituitary gonadotropins via negative feedback Correct answer.

Explanation

Continuous estrogen-progestin exposure provides negative feedback that suppresses GnRH pulsatility and gonadotropin secretion, preventing the LH surge and follicular maturation. The resulting low gonadotropins are central to contraceptive efficacy.

Question 23Reproductive Endocrinology and Neuroendocrinology

Which change in gonadotropin secretion is characteristically seen in polycystic ovary syndrome?

  1. Increased LH pulse frequency and LH-to-FSH ratio Correct answer.
  2. Decreased LH pulse frequency with low LH-to-FSH ratio
  3. Absent GnRH pulsatility
  4. Markedly elevated FSH with low LH

Explanation

PCOS is associated with increased GnRH pulse frequency favoring LH over FSH, producing an elevated LH-to-FSH ratio and driving ovarian androgen production. This contrasts with the low GnRH pulsatility of hypothalamic amenorrhea.

Question 24Reproductive Endocrinology and Neuroendocrinology

Which hormone secreted by the placenta is responsible for maintaining the corpus luteum in early pregnancy before the luteal-placental shift?

  1. Human chorionic gonadotropin Correct answer.
  2. Relaxin
  3. Placental lactogen
  4. Corticotropin-releasing hormone

Explanation

hCG from the syncytiotrophoblast binds LH receptors on the corpus luteum, sustaining progesterone production until the placenta takes over steroidogenesis. Placental lactogen and relaxin have other roles and do not maintain the corpus luteum.

Question 25Ovulation, Menstrual Disorders, and Anovulation

Which hormonal pattern is the primary cause of anovulation in polycystic ovary syndrome?

  1. Rapid pulses of gonadotropin-releasing hormone with elevated luteinizing hormone and androgens Correct answer.
  2. Elevated follicle-stimulating hormone with low luteinizing hormone
  3. Hyperprolactinemia suppressing gonadotropin-releasing hormone
  4. Primary ovarian insufficiency with elevated follicle-stimulating hormone

Explanation

In PCOS, increased GnRH pulse frequency favors LH over FSH, driving theca androgen production and follicular arrest. The resulting intrafollicular androgen excess and relative FSH deficiency prevent dominant follicle selection.

Question 26Ovulation, Menstrual Disorders, and Anovulation

A woman with regular 28-day cycles has a serum progesterone of 12 ng/mL drawn 7 days before expected menses. What does this most directly indicate?

  1. Recent ovulation has occurred Correct answer.
  2. An anovulatory cycle is occurring
  3. A corpus luteum cyst has ruptured
  4. A luteal phase defect is present

Explanation

A mid-luteal progesterone above roughly 3 ng/mL is the standard biochemical marker that ovulation occurred. Higher values reflect a functioning corpus luteum but do not by themselves diagnose luteal adequacy.

Question 27Ovulation, Menstrual Disorders, and Anovulation

Which finding best distinguishes hypothalamic amenorrhea from polycystic ovary syndrome?

  1. Presence of acne
  2. Elevated dehydroepiandrosterone sulfate
  3. Oligomenorrhea on history
  4. Low or normal luteinizing hormone with low estradiol Correct answer.

Explanation

Hypothalamic amenorrhea reflects reduced GnRH drive, producing low gonadotropins and hypoestrogenism. PCOS typically shows normal or elevated LH with estrogen exposure and hyperandrogenism.

Question 28Ovulation, Menstrual Disorders, and Anovulation

Which statement about the LH surge is correct?

  1. It directly causes endometrial shedding
  2. It is triggered by a decline in estradiol
  3. It induces resumption of meiosis in the oocyte Correct answer.
  4. It occurs only if progesterone rises first

Explanation

The midcycle LH surge triggers resumption of meiosis I, follicle rupture, and luteinization. It is provoked by sustained high estradiol from the mature dominant follicle, not by an estradiol decline.

Question 29Ovulation, Menstrual Disorders, and Anovulation

A 24-year-old with BMI 17, intense endurance training, and 9 months of amenorrhea has negative pregnancy testing, normal prolactin, and low FSH. What is the most appropriate initial management?

  1. Weight restoration and reduced training load Correct answer.
  2. Metformin therapy
  3. Combined oral contraceptives
  4. Laparoscopic ovarian drilling

Explanation

Functional hypothalamic amenorrhea from energy deficiency is treated first by restoring energy balance and reducing exercise intensity. Pharmacologic ovulation induction is reserved for patients who do not recover or who desire immediate fertility.

Question 30Ovulation, Menstrual Disorders, and Anovulation

Which laboratory pattern is characteristic of primary ovarian insufficiency?

  1. Normal FSH with elevated anti-Mullerian hormone
  2. Low FSH with low estradiol
  3. Elevated prolactin with low TSH
  4. Elevated FSH on two occasions at least 4 weeks apart Correct answer.

Explanation

POI is defined by amenorrhea with elevated gonadotropins reflecting loss of follicular reserve, confirmed on repeat testing separated by at least 4 weeks. Estradiol is typically low.

Question 31Ovulation, Menstrual Disorders, and Anovulation

Which parameter is required to diagnose polycystic ovary syndrome under the Rotterdam criteria when oligo-ovulation and hyperandrogenism are both present?

  1. Polycystic ovarian morphology on ultrasound Correct answer.
  2. Elevated LH to FSH ratio
  3. Elevated anti-Mullerian hormone
  4. Insulin resistance on testing

Explanation

Rotterdam requires two of three features: oligo-anovulation, clinical or biochemical hyperandrogenism, and polycystic ovarian morphology. When the first two are present, ovarian morphology must be confirmed to reach two criteria.

Question 32Ovulation, Menstrual Disorders, and Anovulation

Which medication is a competitive antagonist at hypothalamic estrogen receptors used for ovulation induction?

  1. Letrozole
  2. Metformin
  3. Clomiphene citrate Correct answer.
  4. Gonadotropin-releasing hormone agonist

Explanation

Clomiphene citrate binds estrogen receptors in the hypothalamus, blocking negative feedback and increasing GnRH and gonadotropin secretion. Letrozole instead lowers estrogen via aromatase inhibition.

Question 33Ovulation, Menstrual Disorders, and Anovulation

Why is letrozole often preferred over clomiphene for ovulation induction in polycystic ovary syndrome?

  1. It requires no monitoring of follicular response
  2. It avoids estrogen receptor depletion and yields higher live birth rates Correct answer.
  3. It reliably induces ovulation in hypogonadotropic women
  4. It carries no risk of multiple gestation

Explanation

Letrozole has a short half-life and does not deplete estrogen receptors, and trials show higher live birth rates than clomiphene in PCOS. It still carries multiple gestation risk and requires monitoring.

Question 34Ovulation, Menstrual Disorders, and Anovulation

A patient with PCOS has not ovulated after escalating doses of clomiphene. Which next step is most appropriate before considering gonadotropins?

  1. Gonadotropin-releasing hormone antagonist
  2. Bilateral ovarian wedge resection
  3. Danazol
  4. Letrozole or metformin add-on therapy Correct answer.

Explanation

Clomiphene resistance is commonly managed by switching to letrozole or adding metformin, particularly in insulin-resistant patients, before moving to gonadotropins or drilling. Wedge resection is obsolete.

Question 35Ovulation, Menstrual Disorders, and Anovulation

Which feature most strongly suggests a diagnosis other than polycystic ovary syndrome in a woman with oligomenorrhea and hirsutism?

  1. Rapid onset of virilization with clitoromegaly Correct answer.
  2. Acne on the jawline
  3. History of irregular cycles since menarche
  4. BMI of 31

Explanation

Rapid virilization, clitoromegaly, or a very high testosterone suggest an androgen-secreting tumor rather than PCOS. PCOS typically has gradual onset of hyperandrogenic signs from the peripubertal years.

Question 36Ovulation, Menstrual Disorders, and Anovulation

Which is the most common cause of anovulation in women with normal or low body weight and no hyperandrogenism?

  1. Thyroid dysfunction
  2. Hyperprolactinemia
  3. Polycystic ovary syndrome
  4. Functional hypothalamic dysfunction Correct answer.

Explanation

Functional hypothalamic amenorrhea from stress, weight loss, or exercise is a leading cause of anovulation in lean women without hyperandrogenism. PCOS is the most common overall cause but is associated with hyperandrogenism.

Question 37Ovulation, Menstrual Disorders, and Anovulation

A woman reports 3 months of amenorrhea, negative pregnancy test, normal TSH and prolactin, and a progesterone challenge that produces no withdrawal bleed. What does the absent bleed most directly indicate?

  1. Adequate estrogen priming of the endometrium
  2. Recent ovulation
  3. A normal luteal phase
  4. Insufficient estrogen exposure or an outflow tract problem Correct answer.

Explanation

A negative progesterone challenge means the endometrium was not primed by estrogen or cannot shed, so estrogen deficiency or outflow obstruction must be evaluated. A bleed after progesterone indicates an estrogen-primed endometrium.

Question 38Ovulation, Menstrual Disorders, and Anovulation

Which finding is most consistent with a diagnosis of polycystic ovary syndrome on pelvic ultrasound?

  1. Twelve or more follicles of 2 to 9 mm in one ovary Correct answer.
  2. A 6 cm simple ovarian cyst
  3. A single dominant follicle of 20 mm
  4. Endometrial thickness of 4 mm

Explanation

Polycystic ovarian morphology is defined by numerous small antral follicles, classically 12 or more per ovary, arranged peripherally. A dominant follicle or a large simple cyst does not define this morphology.

Question 39Ovulation, Menstrual Disorders, and Anovulation

Which mechanism explains the anovulation caused by hyperprolactinemia?

  1. Suppression of gonadotropin-releasing hormone release Correct answer.
  2. Blockade of progesterone receptors
  3. Direct inhibition of ovarian aromatase
  4. Increased ovarian androgen production

Explanation

Prolactin inhibits GnRH pulsatility, reducing LH and FSH secretion and leading to hypoestrogenic anovulation. Treatment with a dopamine agonist restores gonadotropin drive.

Question 40Ovulation, Menstrual Disorders, and Anovulation

Which is the most appropriate first-line treatment for a woman with hyperprolactinemic anovulation who wishes to conceive?

  1. Gonadotropin-releasing hormone agonist
  2. Clomiphene citrate
  3. Combined oral contraceptives
  4. Cabergoline Correct answer.

Explanation

Dopamine agonists such as cabergoline lower prolactin and restore normal gonadotropin secretion, often reestablishing ovulation. Ovulation induction agents are used only if prolactin normalization fails to restore ovulation.

Question 41Ovulation, Menstrual Disorders, and Anovulation

Which is an expected consequence of the chronic anovulation seen in polycystic ovary syndrome?

  1. Pituitary adenoma formation
  2. Osteoporosis from chronic hypoestrogenism
  3. Ovarian failure
  4. Endometrial hyperplasia from unopposed estrogen Correct answer.

Explanation

Chronic anovulation with estrogen production but no progesterone exposure leads to endometrial proliferation and increased risk of hyperplasia and carcinoma. Cyclic progestin or combined contraceptives protect the endometrium.

Question 42Ovulation, Menstrual Disorders, and Anovulation

Which test is most useful to confirm ovulation in a woman with irregular cycles who is trying to conceive?

  1. Endometrial biopsy in the follicular phase
  2. A single FSH level on cycle day 3
  3. A single estradiol level
  4. Serial transvaginal ultrasound documenting follicular collapse Correct answer.

Explanation

Serial ultrasound showing growth and subsequent collapse of a dominant follicle directly documents ovulation. Day 3 FSH assesses ovarian reserve rather than confirming that ovulation occurred.

Question 43Ovulation, Menstrual Disorders, and Anovulation

Which statement about the normal luteal phase is correct?

  1. It requires continued LH surge activity throughout
  2. It is typically 14 days and ends with luteolysis and progesterone withdrawal Correct answer.
  3. It lasts approximately 3 days
  4. It is maintained by rising FSH from the pituitary

Explanation

The corpus luteum sustains progesterone for about 14 days, then regresses, causing progesterone withdrawal and menstruation. Luteal length is relatively constant across women.

Question 44Ovulation, Menstrual Disorders, and Anovulation

A woman with PCOS and a BMI of 36 is starting ovulation induction. Which intervention has the strongest evidence to improve both ovulatory function and pregnancy outcomes?

  1. High-dose clomiphene as initial therapy
  2. Routine prophylactic antibiotics
  3. GnRH antagonist pretreatment
  4. Weight loss through lifestyle modification Correct answer.

Explanation

Even modest weight loss improves insulin sensitivity, restores ovulatory cycles, and improves pregnancy outcomes in obese women with PCOS. Lifestyle modification is recommended before or alongside pharmacologic induction.

Question 45Ovulation, Menstrual Disorders, and Anovulation

Which condition is defined by the presence of amenorrhea for at least 3 months in a woman who previously had spontaneous menses but now has low gonadotropins and no identifiable organic cause?

  1. Asherman syndrome
  2. Functional hypothalamic amenorrhea Correct answer.
  3. Primary ovarian insufficiency
  4. Polycystic ovary syndrome

Explanation

Functional hypothalamic amenorrhea is a diagnosis of exclusion characterized by hypoestrogenic amenorrhea with low or normal gonadotropins and no organic pathology. It is commonly triggered by stress, weight loss, or excessive exercise.

Question 46Ovulation, Menstrual Disorders, and Anovulation

Which of the following best explains why insulin resistance contributes to anovulation in polycystic ovary syndrome?

  1. It lowers luteinizing hormone pulse frequency
  2. It decreases hepatic sex hormone-binding globulin and increases ovarian androgen production Correct answer.
  3. It increases pituitary FSH secretion
  4. It directly lyses ovarian follicles

Explanation

Compensatory hyperinsulinemia suppresses hepatic SHBG, raising free androgen levels, and acts with LH to increase theca cell androgen synthesis. The resulting hyperandrogenic environment impairs follicular maturation.

Question 47Ovulation, Menstrual Disorders, and Anovulation

A woman with 6 months of amenorrhea has a negative pregnancy test, TSH of 2.0 mIU/L, prolactin of 18 ng/mL, and FSH of 45 IU/L confirmed on repeat testing. What is the most likely diagnosis?

  1. Polycystic ovary syndrome
  2. Functional hypothalamic amenorrhea
  3. Primary ovarian insufficiency Correct answer.
  4. Hyperprolactinemia

Explanation

Amenorrhea with persistently elevated FSH indicates depletion of ovarian follicles, consistent with primary ovarian insufficiency. Normal prolactin and TSH exclude common reversible causes.

Question 48Ovulation, Menstrual Disorders, and Anovulation

Which statement about gonadotropin therapy for anovulation is correct?

  1. It carries a higher risk of multiple gestation and ovarian hyperstimulation than oral agents Correct answer.
  2. It does not require ultrasound monitoring
  3. It works by blocking estrogen receptors
  4. It is first-line therapy for all women with PCOS

Explanation

Injectable gonadotropins directly stimulate multiple follicles, increasing risks of multiple gestation and ovarian hyperstimulation syndrome, so careful monitoring is required. They are reserved for oral agent failures or hypogonadotropic anovulation.

Question 49Infertility Evaluation and Assisted Reproductive Technology

Which hormone is the most direct marker of ovarian reserve and is routinely measured on cycle day 3?

  1. Serum luteinizing hormone
  2. Antral follicle count by transvaginal ultrasound
  3. Serum follicle-stimulating hormone
  4. Serum anti-Müllerian hormone Correct answer.

Explanation

Anti-Müllerian hormone is produced by granulosa cells of small antral follicles and declines predictably with age, making it the most direct circulating marker of remaining follicular pool. It can be drawn on any cycle day, unlike FSH.

Question 50Infertility Evaluation and Assisted Reproductive Technology

A 34-year-old woman has regular 28-day cycles. On which cycle day should serum FSH be drawn for ovarian reserve testing?

  1. Day 21
  2. Day 14
  3. Day 3 Correct answer.
  4. Day 1

Explanation

Baseline FSH is measured in the early follicular phase, conventionally cycle day 2 to 4, when estradiol is low and does not suppress FSH. Day 3 is the standard reference point.