332. A mother brings her 12-year-old daughter to your office for consultation. She is concerned because most of the other girls in her daughter’s class have already started their period. She thinks her daughter hasn’t shown any evidence of going into puberty yet. Knowing the usual first sign of the onset of puberty, you should ask the mother which of the following questions?

333. A 9-year-old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at the age of 7 and adrenarche at the age of 8. Which of the following is the most common cause of this condition in girls?

334. A 68-year-old Caucasian woman comes to your office for advice regarding her risk factors for developing osteoporosis. She is 5 ft 1 in tall and weighs 105 lb. She stopped having periods at the age of 42 years. She is healthy and walks on a treadmill daily. She does not take any medications. She has never taken hormone replacement therapy (HRT). Her mother died at the age of 71 after she suffered a spontaneous hip fracture.

Which of the following will have the least effect on this patient’s risk for developing osteoporosis?

335. A 68-year-old Caucasian woman comes to your office for advice regarding her risk factors for developing osteoporosis. She is 5 ft 1 in tall and weighs 105 lb. She stopped having periods at the age of 42 years. She is healthy and walks on a treadmill daily. She does not take any medications. She has never taken hormone replacement therapy (HRT). Her mother died at the age of 71 after she suffered a spontaneous hip fracture.

The patient asks how and if she should be tested for osteoporosis. What is the best method to screen her for osteoporosis?

336. A 68-year-old Caucasian woman comes to your office for advice regarding her risk factors for developing osteoporosis. She is 5 ft 1 in tall and weighs 105 lb. She stopped having periods at the age of 42 years. She is healthy and walks on a treadmill daily. She does not take any medications. She has never taken hormone replacement therapy (HRT). Her mother died at the age of 71 after she suffered a spontaneous hip fracture.

The patient has a DEXA study that demonstrates a T-score of–2.0. What is the best next step in management?

337. A 17-year-old consults you for evaluation of disabling pain with her menstrual periods. The pain has been present since menarche, and is accompanied by nausea and headache. Her medical history is otherwise unremarkable, and pelvic examination is normal. She is not currently sexually active, and she has not tried any therapy for her dysmenorrhea.

Select the most ideal treatment for dysmenorrhea.

338. A 19-year-old college student is seen for severe primary dysmenorrhea. She has no medical problems and a normal pelvic examination. A heating pad has not helped her pain. She has recently become sexually active and does not currently desire pregnancy.

Select the most ideal treatment for dysmenorrhea.

339. An 18-year-old patient presents to you for evaluation because she has not yet started her period. On physical examination, she is 5 ft 7 in tall. She has minimal breast development and no axillary or pubic hair. On pelvic examination, she has a normally developed vagina. A cervix is visible. The uterus is palpable, as are normal ovaries. Which of the following is the best next step in the evaluation of this patient?

340. A 7-year-old girl is brought in to see you by her mother because the girl has developed breasts and a few pubic hairs. Evaluation demonstrates a pubertal response to a GnRH-stimulation test and a prominent increase in luteinizing hormone (LH) pulses during sleep.

These findings are characteristic of patients with which of the following?

341. A 7-year-old girl is brought in to see you by her mother because the girl has developed breasts and a few pubic hairs. Evaluation demonstrates a pubertal response to a GnRH-stimulation test and a prominent increase in luteinizing hormone (LH) pulses during sleep.

Which of the following is the best treatment for the girl’s condition?

342. A mother brings her daughter to see you for consultation. The daughter is 17 years old and has not started her period. She is 4 ft 10 in tall. On physical examination, she has no breast buds or pubic hair. Her pelvic examination demonstrates a uterus and cervix, but the ovaries are not palpable. As part of the workup, serum FSH and LH levels are drawn and both are high. Which of the following is the most likely reason for delayed puberty in this patient?

343. While evaluating a 30-year-old woman for infertility, you diagnose a bicornuate uterus. You explain that additional testing is necessary because of the woman’s increased risk of congenital anomalies in which organ system?

344. A 47-year-old G3P3 complains of severe menstrual cramps and heavy menstrual bleeding. Her dysmenorrhea has worsened since the birth of her last child. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Results of endometrial biopsy are normal. Which of the following is the most likely diagnosis?

345. A 28-year-old G3P0 has a history of severe menstrual cramps, prolonged, heavy periods, chronic pelvic pain, and painful intercourse. All of her pregnancies were spontaneous abortions in the first trimester. A hysterosalpingogram (HSG) she just had as part of the evaluation for recurrent abortion showed a large uterine septum. You have recommended surgical repair of the uterus. Of the patient’s symptoms, which is most likely to be corrected by resection of the uterine septum?

346. In the evaluation of a 26-year-old patient with 4 months of secondary amenorrhea, you order serum prolactin and β-hCG assays. The β-hCG test is positive, and the prolactin level is 100 ng/mL (normal is < 25 ng/mL in nonpregnant women in this assay). This patient requires which of the following?

347. You have just performed diagnostic laparoscopy on a 28-year-old patient with chronic pelvic pain and dyspareunia. At the time of the laparoscopy, there were multiple implants of endometriosis on the uterosacral ligaments and ovaries. At the time of the procedure, you ablated all of the visible lesions on the peritoneal surfaces with the CO2 laser. Because of the extent of the patient’s disease, you recommend postoperative medical treatment. Which of the following medications is the best option for the treatment of this patient’s endometriosis?

348. A 28-year-old nulligravid patient complains of bleeding between her periods and increasingly heavy menses. Over the past 9 months, a trial of oral contraceptives and NSAIDs have failed to decrease the heavy bleeding. Which of the following options is most appropriate at this time?

349. A 26-year-old P0 presents to you for evaluation of infertility. She and her husband have been trying to get pregnant for 2 years. As part of the workup, her husband had a normal semen analysis. The patient has a history of endometriosis diagnosed by laparoscopy at the age of 17 due to severe pelvic pain and dysmenorrhea. After the surgery, the patient was told she had a few small implants of endometriosis on her ovaries and fallopian tubes and several others in the posterior cul-de-sac. She also had a left ovarian cyst, filmy adnexal adhesions, and several subcentimeter subserosal fibroids. You have recommended that she should have an HSG as part of her evaluation for infertility. Which of the patient’s following conditions can be diagnosed with an HSG?

350. During the evaluation of infertility in a 25-year-old woman, a HSG showed evidence of Asherman syndrome. Which one of the following symptoms would you expect this patient to have?

351. During the evaluation of secondary amenorrhea in a 24-year-old woman, hyperprolactinemia is diagnosed. Which of the following conditions could cause increased circulating prolactin concentration and amenorrhea in this patient?

352. A 36-year-old morbidly obese woman presents to your office for evaluation of irregular, heavy menses occurring every 3 to 6 months. An office endometrial biopsy shows complex hyperplasia of the endometrium without atypia. The hyperplasia is most likely related to the excess formation in the patient’s adipose tissue of which of the following hormones?

353. A couple presents for evaluation of primary infertility. The evaluation of the woman is completely normal. The husband is found to have a left varicocele. If the husband’s varicocele is the cause of the couple’s infertility, what would you expect to see when evaluating the husband’s semen analysis?

354. Your patient delivers a 7-lb male infant at term. On physical examination, the baby has normal-appearing male external genitalia. However, the scrotum is empty, and no testes are palpable in the inguinal canals. At 6 months of age, the boy’s testes still have not descended. A pelvic ultrasound shows the testes in the pelvis, and there appears to be a uterus present as well. The presence of a uterus in an otherwise phenotypically normal male is caused by which of the following?

355. A 45-year-old G2P2 presents for management of heavy menses. She reports her periods occur once a month, last 6 days, and are very heavy and painful. She has tried oral contraceptives, but she does not like having to take a pill every day. She had a levonorgestrel-containing intrauterine device (IUD) in the past, but did not like it due to symptoms of cramping. Her medical history is unremarkable, and her only surgery is a postpartum tubal ligation. Her evaluation has included a normal Pap smear, normal endometrial biopsy, and normal pelvic ultrasound.

What is the best next step in management of this patient’s bleeding?

356. A 45-year-old woman who had two normal pregnancies 15 and 18 years ago presents with the complaint of amenorrhea for 7 months. She expresses the desire to become pregnant again. After exclusion of pregnancy, which of the following tests is next indicated in the evaluation of this patient’s amenorrhea?

357. A 22-year-old woman consults you for treatment of hirsutism. Physical examination demonstrates facial acne, as well as dark, course hair on her upper lip, chin, and midsternum. She has a BMI of 35 kg/m2. Serum LH level is 35 mIU/mL and FSH is 9 mIU/mL. Androstenedione and testosterone levels are mildly elevated, but serum DHEA-S is normal. The patient does not wish to conceive at this time.

Which of the following single agents is the most appropriate treatment of her condition?

358. A 22-year-old woman consults you for treatment of hirsutism. Physical examination demonstrates facial acne, as well as dark, course hair on her upper lip, chin, and midsternum. She has a BMI of 35 kg/m2. Serum LH level is 35 mIU/mL and FSH is 9 mIU/mL. Androstenedione and testosterone levels are mildly elevated, but serum DHEA-S is normal. The patient does not wish to conceive at this time.

The patient returns 3 years later. She discontinued the oral contraceptives 1 year ago because she and her husband wanted to get pregnant. Since that time, her periods have been very unpredictable, usually every 3 to 6 months. She would like your advice about the best way to conceive. Which of the following is the most appropriate first line therapy to help her conceive?

359. A 20-year-old woman with Müllerian agenesis is undergoing laparoscopic appendectomy by a general surgeon. You are consulted intraoperatively because the surgeon sees several lesions in the pelvis suspicious for endometriosis. You should tell the surgeon which of the following?

360. A 19-year-old patient presents to your office with primary amenorrhea. She has normal breast and pubic hair development, but the uterus and vagina are absent. Diagnostic possibilities include which of the following?

361. A 23-year-old woman presents for evaluation of a 7-month history of amenorrhea. She has no other major medical problems. Examination discloses bilateral galactorrhea and normal breast and pelvic examinations. Pregnancy test is negative. Serum prolactin is ordered and the result is elevated at 47ng/mL.

What is the next step in management?

362. A 23-year-old woman presents for evaluation of a 7-month history of amenorrhea. She has no other major medical problems. Examination discloses bilateral galactorrhea and normal breast and pelvic examinations. Pregnancy test is negative. Serum prolactin is ordered and the result is elevated at 47ng/mL.

Which of the following classes of medication is also a possible cause of galactorrhea?

363. Which of the following pubertal events in girls is not estrogen dependent?

364. An infertile couple presents to you for evaluation. A semen analysis from the husband is ordered. The sample of 2.5 cc contains 25 million sperm per mL; 65% of the sperm show normal morphology; 20% of the sperm show progressive forward mobility. You should tell the couple which of the following?

365. A 21-year-old woman presents to you for management of menstrual migraines. She has no other medical problems, does not smoke, and does not take any medications routinely. Her periods are regular and last 5 days. She says the flow is moderate and she does not have dysmenorrhea. She is sexually active with her partner of 1 year, and she uses condoms for contraception. She says she develops a debilitating migraine for the first 2 days of her period every month. She describes her headaches as unilateral, throbbing, and associated with nausea and photophobia. She has missed work due to these symptoms.

What is the best next step in management of her migraines?

366. A 21-year-old woman presents to you for management of menstrual migraines. She has no other medical problems, does not smoke, and does not take any medications routinely. Her periods are regular and last 5 days. She says the flow is moderate and she does not have dysmenorrhea. She is sexually active with her partner of 1 year, and she uses condoms for contraception. She says she develops a debilitating migraine for the first 2 days of her period every month. She describes her headaches as unilateral, throbbing, and associated with nausea and photophobia. She has missed work due to these symptoms.

What change in her management would be indicated if she reported that 2 days before the onset of her migraine, she develops an aura consisting of bright spots in her vision?

367. A 16-year-old P0 presents to your office accompanied by her mother to discuss options for management of heavy menstrual bleeding. She has been on oral contraceptives for the last 9 months, but admits she often forgets to take her pills and develops breakthrough bleeding. They have both researched the options on the Internet, and are interested in depo provera (depot medroxyprogesterone acetate, or DMPA) because of the possibility of amenorrhea and the ease of use. How should you counsel this patient?

368. You ask a patient to call your office during her next menstrual cycle to schedule an HSG as part of her infertility evaluation. Which day of the menstrual cycle is best for performing an HSG?

369. You have recommended that your infertility patient return to your office during her next menstrual cycle to have her serum progesterone level checked. Which is the best day of the menstrual cycle to check her progesterone level if you are trying to confirm ovulation?

370. Your patient is 43 years old and is concerned that she may be too close to menopause to get pregnant. You recommend that her FSH level be tested. Which is the best day of the menstrual cycle to check an FSH in this situation?

371. A 26-year-old G0P0 comes to your office with a chief complaint of being “too hairy.” She reports that her menses started at the age of 13 years, and have always been very irregular, occurring every 2 to 6 months. She also complains of acne, but reports no other medical problems. Her only surgery was an appendectomy at the age of 8 years. Her height is 5 ft 5 in, her weight is 180 lb, and her blood pressure is 100/60 mm Hg. On physical examination, there are a few coarse, dark hairs around the nipples, chin, and upper lip. No galactorrhea, thyromegaly, or temporal balding is noted. Pelvic examination is normal and there is no evidence of clitoromegaly.

Which of the following is the most likely explanation for this patient’s problem?

372. A 26-year-old G0P0 comes to your office with a chief complaint of being “too hairy.” She reports that her menses started at the age of 13 years, and have always been very irregular, occurring every 2 to 6 months. She also complains of acne, but reports no other medical problems. Her only surgery was an appendectomy at the age of 8 years. Her height is 5 ft 5 in, her weight is 180 lb, and her blood pressure is 100/60 mm Hg. On physical examination, there are a few coarse, dark hairs around the nipples, chin, and upper lip. No galactorrhea, thyromegaly, or temporal balding is noted. Pelvic examination is normal and there is no evidence of clitoromegaly.

Which of the following blood tests has no role in the evaluation of this patient?

373. A patient in your practice calls you in a panic because her 14-year-old daughter has been bleeding heavily for the past 2 weeks. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency department so that you can evaluate her. When they arrive, you note that she appears fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure and pulse remain stable. While in the emergency room, you obtain a more detailed history. She reports no medical problems or prior surgeries, and is not taking any medications. She says that she has never been sexually active. On physical examination, her abdomen is soft and nontender. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5 ft 4 in tall and weighs 95 lb.

Which of the following blood tests is not indicated in the evaluation of this patient?

374. A patient in your practice calls you in a panic because her 14-year-old daughter has been bleeding heavily for the past 2 weeks. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency department so that you can evaluate her. When they arrive, you note that she appears fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure and pulse remain stable. While in the emergency room, you obtain a more detailed history. She reports no medical problems or prior surgeries, and is not taking any medications. She says that she has never been sexually active. On physical examination, her abdomen is soft and nontender. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5 ft 4 in tall and weighs 95 lb.

What is the most appropriate next step in management?

375. A 32-year-old P0 morbidly obese diabetic woman presents to your office with a chief complaint of prolonged vaginal bleeding. Her periods were regular, monthly, and light until 2 years ago. At that time, she started having periods every 3 to 6 months. Her last normal period was 5 months ago. She started having vaginal bleeding again 3 weeks ago. It started as light bleeding, but over the last week, she has been bleeding heavily and passing large clots. On pelvic examination, the external genitalia is normal. The vagina is filled with blood and large clots. A large clot is seen protruding through the cervix. On bimanual examination, the uterus is at the upper limit of normal size, and the ovaries feel normal. Her urine pregnancy test is negative. Which of the following is the most likely cause of her abnormal uterine bleeding (AUB)?

376. A 26-year-old P0 with PCOS presents to the emergency department with a chief complaint of prolonged, heavy vaginal bleeding. She was taking oral contraceptives to regulate her periods until 4 months ago, when she stopped taking them because she and her spouse want to try to get pregnant. She thought she might be pregnant because she had not had a period since her last one on the birth control pills 4 months ago. She started having vaginal bleeding 8 days ago. Her bleeding has been very heavy, requiring her to double up on her sanitary napkins and change them five to six times daily since the bleeding began. In the emergency department, the patient has a supine blood pressure of 102/64 mm Hg with a pulse of 96 beats per minute. Upon standing, the patient feels light-headed. Her blood pressure while standing is 108/66 mm Hg with an increase in her pulse to 126 beats per minute. While you wait for laboratory work to come back, you order intravenous hydration. After 2 hours, she is no longer orthostatic. Her pregnancy test comes back negative, and her Hct is 31%.

A transvaginal ultrasound showed an atrophic appearing endometrial stripe. Which of the following is the best next step in the management of this patient?

377. A 29-year-old P0 presents to your office with a chief complaint of symptoms of premenstrual syndrome (PMS). A detailed history reveals that she experiences emotional lability and depression for about 10 days prior to her menses. Once her period starts, she feels “back to normal.” She also reports a long history of premenstrual fatigue, breast tenderness, and bloating. Her previous physician prescribed oral contraceptives to treat her PMS 6 months ago, and she reports that the pills have alleviated all her PMS symptoms except for the depression and emotional symptoms. Which of the following is the best next step in the treatment of this patient’s problem?

378. A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; and she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning HRT, but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She has no medical problems, and the only medication she takes are calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb.

In counseling this patient regarding the risks and benefits of HRT, you should tell her that HRT (estrogen and progesterone) has been associated with which of the following?

379. A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; and she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning HRT, but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She has no medical problems, and the only medication she takes are calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb.

She tells you she is worried about how HRT might impact her lipid panel. You should counsel her to expect which of the following?

380. A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; and she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning HRT, but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She has no medical problems, and the only medication she takes are calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb.

The patient asks you what she should expect in regard to her hot flushes if she does not take hormone replacement. How should you counsel her?

381. A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; and she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning HRT, but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She has no medical problems, and the only medication she takes are calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb.

What should you tell her regarding the psychologic symptoms of menopause?

382. Defined by the presence of virilizing signs in girls, select the type of precocious puberty with which it is most likely to be associated.

383. Characterized by the presence of premature adrenarche, pubarche, or thelarche, select the type of precocious puberty with which it is most likely to be associated.

384. Can arise from cranial tumors or hypothyroidism, select the type of precocious puberty with which it is most likely to be associated.

385. Results from premature activation of the hypothalamic-pituitary system, select the type of precocious puberty with which it is most likely to be associated.

386. Is frequently caused by ovarian tumors, select the type of precocious puberty with which it is most likely to be associated.

387. Match each HSG with the correct description.

388. Match each HSG with the correct description.

389. Match each HSG with the correct description.

390. Match each HSG with the correct description.

391. Match each HSG with the correct description.