IM Ratio – Endo 1-10: Charlie Samplex
1. Which of the following regarding causes
of infertility is/are FALSE?
a. Female causes> male causes
b. In males, unknown causes >
secondary hypogonadism
c. In females, ovulatory dysfunction >
endometriosis
d. In females with amenorrhea,
premature ovarian failure >
pituitary causes
e. All of the above
2. A couple sought consult due to infertility.
After a thorough history and physical
examination, the initial diagnostic work up
for the husband is/are:
a. FSH, LH
b. total testosterone
c. Semen analysis
d. All of the above
e. A and B only
3. In the evaluating the above (no. 2)
patient's wife. It was noted that she has
oligomenorrhea, BMI is 23, high LH, with
normal prolactin, FSH and estradiol. Which
of the following is the most probable
diagnosis:
a. Polycystic Ovarian Syndrome
Harrisons Principles of Internal Medicine, 19th Edition, p. 2388
MALE CAUSES OF INFERTILITY
Known causes of male infertility include primary testicular
disease, genetic disorders (particularly Y chromosome
microdeletions), disorders of sperm transport, and hypothalamic-
pituitary disease resulting in secondary hypogonadism. However,
the etiology is not ascertained in up to one-half of men with
suspected male factor infertility. The key initial diagnostic test is
a semen analysis. Testosterone levels should be measured if the
sperm count is low on repeated examination or if there is clinical
evidence of hypogonadism. Gonadotropin levels will help to
determine a gonadal versus a central cause of hypogonadism.
(Harrisons Principles of Internal Medicine, 19th Edition, p. 2388)
A careful history and physical examination and a limited
number of laboratory tests will help to determine whether the
abnormality is (1) hypothalamic or pituitary (low follicle-
stimulating hormone [FSH], luteinizing hormone [LH], and estradiol
with or without an increase in prolactin), (2) polycystic ovary
syndrome (PCOS; irregular cycles and hyperandrogenism in the
absence of other causes of androgen excess), (3) ovarian (low
estradiol with increased FSH), or (4) a uterine or outflow tract
 b. Pituitary Hypogonadism abnormality. The frequency of these diagnoses depends on
c. Primary Ovarian Failure whether the amenorrhea is primary or occurs after normal puberty
d. Prolactinoma and menarche. (Harrisons Principles of Internal Medicine, 19th Edition, p.
e. none of the above 2388)

…patients with PCOS generally have high LH levels in the

presence of normal to low levels of FSH and estradiol. (Harrisons
Principles of Internal Medicine, 19th Edition, p. 337)

4. To induce ovulation in the above patient Medications used for ovulation induction include agents that
(no. 3), the following agent is indicated increase FSH through alteration of negative feedback,
gonadotropins, and pulsatile GnRH. Clomiphene citrate is a
a. Bromocriptine nonsteroidal estrogen antagonist that increases FSH and LH levels
b. Clomiphene citrate by blocking estrogen negative feedback at the hypothalamus. The
c. Recombinant FSH efficacy of clomiphene for ovulation induction is highly dependent
d. Ethinyl Estradiol on patient selection. In appropriate patients, it induces ovulation
e. Progestin in ~60% of women with PCOS and has traditionally been the
initial treatment of choice. (Harrisons Principles of Internal Medicine,
19th Edition, p. 2389)

5. True regarding the period before PERIMENOPAUSE

menopause
a. Preceding menopause, menstrual
cycle irregularity increases and
fertility wanes
b. A consistently high FSH and low
estradiol levels characterize
perimenopause
c. Hot flushes, night sweats, and
irregular bleeding are symptoms
associated with perimenopause
d. All of the above
e. A and C only
Perimenopause refers to the time period preceding menopause,
when fertility wanes and menstrual cycle irregularity
increases, until the first year after cessation of menses.
In contrast to the consistently high FSH and low estradiol
levels seen in MENOPAUSE, perimenopause is characterized by
“irregularly irregular” hormone levels. With transition into
menopause, estradiol levels fall markedly, whereas estrone levels
are relatively preserved, a pattern reflecting peripheral
aromatization of adrenal and ovarian androgens. Levels of FSH
increase more than those of luteinizing hormone, presumably
because of the loss of inhibin as well as estrogen feedback.
SYMPTOMS
There is strong evidence that the menopausal transition can
cause hot flashes, night sweats, irregular bleeding, and vaginal
dryness, and there is moderate evidence that it can cause sleep
disturbances in some women. (Harrisons Principles of Internal Medicine, 19th
Edition, p. 2382)

6. Definite risks of Postmenopausal DEFINITE RISKS PROBABLE OR UNCERTAIN

Hormone Therapy 1. Endometrial cancer RISKS
a. Coronary heart disease 2. Pulmonary embolism 1. CHD, MI, Stroke
b. Venous thromboembolism 3. Deep Vein Thrombosis 2. Ovarian/Endometrial cancer
c. Colorectal Cancer 4. Breast cancer 3. Urinary Incontinence
d. Diabetes Mellitus 5. Gallbladder disease 4. Colorectal cancer
e. All of the above Harrisons Principles of Internal Medicine, 5. Type 2 diabetes
19th Edition, p. 2384, TABLE 413-1
6. Dementia (age ≥65)
7. The following decreases with advancing ANDROPAUSE (The answer here should be AOTA)
age in males The age-related decline in testosterone is due to defects at all
a. free testosterone levels of the hypothalamic-pituitary testicular axis: pulsatile GnRH
b. LH response to GnRH secretion is attenuated, LH response to GnRH is reduced, and
c. Appendicular muscle mass testicular response to LH is impaired.
d. All of the above In epidemiologic surveys, low total and bioavailable
e. A and C only testosterone concentrations have been associated with
decreased appendicular skeletal muscle mass and strength,
decreased self-reported physical function, higher visceral fat mass,
insulin resistance, and increased risk of coronary artery disease
and mortality, although the associations are weak. (Harrisons Principles
of Internal Medicine, 19th Edition, p. 2367)

8. Testosterone replacement is The benefits of testosterone replacement therapy have only been
contraindicated in the following: proven in men who have documented androgen deficiency.
a. Erythrocytosis Testosterone administration is contraindicated in men with:
b. Breast Cancer
c. Prostate Cancer 1. History of prostate or breast cancer
d. A and C only 2. PSA >4 ng/mL or >3 ng/mL in men at high risk for prostate
e. B and C only CA
3. Baseline hematocrit ≥50%
4. Severe untreated obstructive sleep apnea
5. Uncontrolled or poorly controlled CHF
6. MI, Stroke, Acute coronary syndrome in the preceding
6mos
(Harrisons Principles of Internal Medicine, 19th Edition, p. 2372)
9. Klinefelter's syndrome is characterized KLINEFELTER’S SYNDROME (47,XXY), has an incidence of at least
by 1 in 1000 men.
a. 46 XY
b. Increase 100, 000 incidence Eunuchoidism means hypogonadism or deficiency of either the
c. Eunuchoid proportions testes or its secretions. Dorland’s Medical Dictionary 29th ed.
d. Ovotestis
e. All of the above Clinical Features
1. Small testes, azoospermia
2. Decreased facial and axillary hair
3. Decreased libido
4. Tall stature and increased leg length
5. Decreased penile length
6. Learning difficulties, speech delay and decreased verbal IQ
7. Obesity

Ovotestis is formerly called true hermaphroditism; have a 46, XX

10. True of Turner's Syndrome
a. 45 X or 45 X/ 46 XX\
b. Gynecomastia
c. Increase risk for breast
cancer
d. Variable internal genitalia
e. B and C only
karyotype.
TURNER’S SYNDROME
1. 45,X or 45,X/46,XX
2. Breast dev’t: Immature female
3. Genitalia
o Internal: Hypoplastic female
o External: Female
4. Increase risk for colon CA
Gynecomastia is a feature of the following: Klinefelter’s and
Ovotesticular DSD
Variable genitalia is a feature of the following: 45,X/46,XY
mosaicism and Ovotesticular DSD