QUESTION: 117

An obese 21-year-old woman complains of increased growth of coarse hair on her lip, chin, chest, and abdomen. She also notes menstrual irregularity with periods of amenorrhea. Which of the following is the most likely cause of this patient's symptoms?

polycystic ovary disease
an ovarian tumor
an adrenal tumor
Cushing disease
familial hirsutism

Answer(s): A

Explanation:

As many as 85% of women with hirsutism, obesity, and menstrual irregularities have polycystic ovary disease (Stein-Leventhal syndrome). Women with this disorder have chronic anovulation and frequent infertility despite the presence of adequate amounts of estrogen. Excessive luteinizing hormone (LH) response to gonadotropin-releasing hormone is thought by many to be the primary problem, resulting in ovarian theca-cell hyperplasia and hypersecretion of androgens. Others have found deficiencies of the ovarian enzymes involved in estrogen biosynthesis. Diagnosis is based on an elevated LH level, decreased follicle-stimulating hormone (FSH) level, and an LH/FSH ratio greater than 2:5. Combination estrogen- progestin therapy suppresses the androgen production. Less common causes of hirsutism are drug induced (e.g., testosterone, anabolic steroids), adrenal tumor or hyperplasia, Cushing disease, and ovarian tumors. Familial hirsutism is not associated with menstrual abnormalities or obesity.

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QUESTION: 118

A27-year-old woman has used oral contraceptives (OCs) without problems for 5 years. However, she just read an article about complications of OCs in a popular women's magazine and asks you about the risks and hazards of taking OCs.

You correctly tell her which of the following?

The risk of developing ovarian cancer is increased.
The risk of developing pelvic inflammatory disease (PID) is increased.
The risk of developing endometrial cancer is decreased.
The risk of bearing a child with major congenital anomalies is increased if taken while pregnant.
The risk of ectopic pregnancy is increased.

Answer(s): C

Explanation:

The incidence of ovarian cancer in OC users is 50% less than that found in nonusers. The incidence of PID is also decreased by 50% in OC users. The risk of endometrial cancer is decreased by 50% after 1 year of OC use, and the protective effect seems to persist after stopping the OC. In well-controlled studies, there is no increase in the risk of having a child with a major malformation, cardiac malformation, or limb abnormality. The risk of ectopic pregnancy is reduced by 90%, perhaps because the risk of any pregnancy approaches zero when the OC is taken correctly.

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QUESTION: 119

The mother of a 3-year-old girl brings her daughter to see you because the girl developed breasts 6 months ago. The girl has had no vaginal bleeding, and there is no pubic hair. She takes no medication.

Which of the following is the most appropriate next diagnostic step?

an ultrasound of the pelvis
a pelvic examination under general anesthesia
computed tomography (CT) scan of her head
a serum estradiol concentration
a serum follicle-stimulating hormone (FSH) concentration

Answer(s): D

Explanation:

Breast development in an infant or young child is the consequence of increased estrogen secretion, exposure to exogenous estrogens, or increased response of breast tissue to normal, prepubertal amounts of estrogen. After excluding exposure to exogenous estrogens (e.g., OCs, estrogen creams), increased response to estrogen is more common than increased estrogen secretion from the ovaries or adrenal glands when breast development is the only sign of precocious puberty. The uterus and adnexa can be palpated abdominally in prepubertal girls if
they are pathologically enlarged. For this reason, an estrogen-secreting ovarian tumor (granulosa cell is the most common type) is usually palpable, and an ultrasound examination is unnecessary. For the same reason, a pelvic examination under anesthesia is not necessary, especially if the serum estradiol concentration is normal. CT scan of the head and a serum FSH concentration are unnecessary if breast development is the only sign of precocious puberty, and the serum estradiol concentration is normal in the prepubertal range.

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QUESTION: 120

The mother of a 3-year-old girl brings her daughter to see you because the girl developed breasts 6 months ago. The girl has had no vaginal bleeding, and there is no pubic hair. She takes no medication

The tests you ordered are normal for a prepubertal girl. Which of the following is the most likely diagnosis?

ingestion of the mother's OC pills
a granulosa cell tumor
21-hydroxylase deficiency
polycystic ovary syndrome
premature thelarche

Answer(s): E

Explanation:

Premature thelarche is a disorder that probably occurs as a consequence of increased sensitivity of breast tissue to the low levels of circulating estradiol in prepubertal girls. The disorder occurs most commonly before the age of 3 years. The estradiol concentration may be normal in young girls ingesting estrogen if the serum estrogen concentration is not obtained at the time the estrogen is ingested. A negative medication history is helpful to exclude this possibility. The absence of a palpable lower abdominal mass and a prepubertal concentration of estradiol exclude a granulosa cell tumor. Adrenal 21-hydroxylase deficiency and polycystic ovary syndrome are function disorders that require the stimulation of adrenocorticotropic hormone (ACTH) and pituitary gonadotropins (FSH and LH), respectively, to become clinically apparent. Neither disorder appears until after the onset of puberty. Moreover, both are associated with androgen excess and masculinization, not estrogen excess and precocious breast development.

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QUESTION: 117

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