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CME examination
CME examination Instructions for this examination can be found on the answer sheet that follows.
1. Women with polycystic ovary syndrome will always manifest which of the following symptoms? a. Menstrual irregularities and infertility b. Hirsutism and acne c. Weight gain and obesity d. All the above e. None of the above 2. Which of the following is not among the consequences of hyperinsulinemia in patients with polycystic ovary syndrome? a. Hyperthyroidism b. Diabetes mellitus c. Abdominal obesity d. Cardiovascular disease e. Hyperlipidemia 3. Treatment goals for patients with polycystic ovary syndrome not desiring pregnancy immediately should probably include which of the following? a. Symptom management of hirsutism, acne, and oligomenorrhea b. Annual screening of all patients with polycystic ovary syndrome ≥18 years old for breast cancer c. Assessment for cardiovascular disease d. Both a and b e. Both a and c 4. Nonmedical treatment for polycystic ovary syndrome may include each of the following except a. electrolysis. b. nutritional and weight loss counseling. c. exercise. d. high colonic enemas. 5. The differential diagnosis of polycystic ovary syndrome should include which of the following? a. Other causes of hyperandrogenism, such as ovarian or adrenal tumors, congenital adrenal hyperplasia, and Cushing’s syndrome and disease b. Hyperprolactinemia c. Acromegaly d. Hypothyroidism or hyperthyroidism e. All the above
8. Which of the following tests should be performed to determine whether the patient with polycystic ovary syndrome is at risk for other comorbid conditions? a. Fasting glucose level, glycosylated hemoglobin level, and, if warranted, 3-hour glucose tolerance test with insulin levels b. Lipoprotein profiles c. Body mass index and waist/hip ratio d. All the above 9. What is the prevalence of polycystic ovary syndrome? a. 1% to 2% b. 2% to 4% c. 5% to 10% d. 15% to 20% 10. Oral contraceptives for the patient with polycystic ovary syndrome are a. not indicated if the patient has dyslipidemia because oral contraceptives will aggravate dyslipidemia. b. appropriate with lipid profiles usually seen in patients with polycystic ovary syndrome because oral contraceptives will not significantly change lipid profiles. c. not indicated if the patient has insulin resistance because oral contraceptives will reduce insulin sensitivity. d. not indicated if the patient has either insulin resistance or dyslipidemia. 11. In studies of troglitazone for women with polycystic ovary syndrome, all the following were noted except a. acne improved. b. fasting and 2-hour glucose declined significantly. c. glycosylated hemoglobin levels fell. d. insulin sensitivity improved. e. androgen levels fell.
6. The most common cause(s) of anovulation is/are a. polycystic ovary syndrome. b. functional hypothalamic anovulation. c. 17α-hydroxylase deficiency. d. bacterial vaginosis. e. both a and b.
12. Hypotheses regarding the pathogenesis of polycystic ovary syndrome include each of the following except a. a rapid gonadotropin-releasing hormone pulse frequency. b. insulin resistance. c. oversecretion of androgens by the ovary. d. variant of multiple endocrine neoplasia syndrome.
7. In patients with polycystic ovary syndrome, compromised insulin action is noted in which of the following tissues? a. Muscle only b. Fat only c. Hair follicle only d. Muscle and fat e. Fat and hair follicles
13. Weight loss programs in patients with polycystic ovary syndrome have been shown to achieve each of the following except a. reduced insulin secretion. b. reduced androgen secretion. c. improved mean follicle-stimulating hormone and luteinizing hormone pulse frequencies. d. more regular menstrual cycles.
S114
Volume 179, Number 6, Part 2 Am J Obstet Gynecol
14. In polycystic ovary syndrome, why should short-term symptom-based treatment be complemented by long-term treatment that addresses the underlying pathophysiology? a. To limit the development of cardiovascular disease b. To decrease the risk of ovarian cancer c. To preserve reproductive status in women who may eventually desire pregnancy d. All the above e. Both b and c 15. Regarding fat deposition, which of the following has been noted in patients with polycystic ovary syndrome? a. Male pattern abdominal fat deposition b. Higher waist/hip ratio c. Female pattern abdominal fat deposition d. Higher hip/waist ratio e. Both a and b 16. Hyperinsulinemia in patients with polycystic ovary syndrome is secondary to a. a defect in insulin secretion related to a primary beta cell defect. b. peripheral insulin resistance. c. a defect in insulin binding. d. a decrease in tyrosine phosphorylation at the insulin receptor. e. Choices a, b, and d. 17. The menstrual irregularity of polycystic ovary syndrome is characterized by which of the following? a. It typically begins after 35 years of age. b. It is typically an acute problem for 3 to 5 years. c. Heavy, frequent bleeding d. It begins at menarche.
CME examination S115
21. Evaluation of patients with polycystic ovary syndrome should include each of the following except a. monitoring of body weight, counseling to maintain body weight, and aggressive treatment of obesity. b. hypertension screening. c. fasting lipid screening. d. fasting glucose screening and, if indicated, glucose tolerance test. e. cardiac catheterization in all women with suspected polycystic ovary syndrome. 22. What percentage of healthy women have ovarian polycystic morphologic characteristics on ultrasonography? a. 2% b. 5% c. 20% d. 50% 23. What percentage of obese women with polycystic ovary syndrome can be characterized as insulin resistant? a. 10% b. 40% c. 90% d. 100% 24. Regarding ovulation induction in the patient with polycystic ovary syndrome, which of the following is true? a. Calorie restriction is an important part of infertility management. b. Gonadotropin preparations are potentially dangerous because of the recruitment of multiple follicles and the risk of ovarian hyperstimulation syndrome. c. Patients with polycystic ovary syndrome rarely need ovulation induction. d. Insulin-sensitizing agents are currently used as first-line therapy for restoration of ovulation. e. Both a and b
18. The direct action of troglitazone is to a. decrease insulin resistance. b. suppress hepatic gluconeogenesis. c. stimulate insulin secretion from pancreatic beta cells. d. lower insulin secretion.
25. Key features of polycystic ovary syndrome include all the following except a. insulin resistance. b. androgen excess. c. cyclic changes in estrogen levels that often mimic ovulation. d. abnormal gonadotropins.
19. The direct action of metformin is to a. suppress hepatic gluconeogenesis. b. stimulate insulin secretion from pancreatic beta cells. c. lower insulin secretion. d. decrease insulin resistance.
26. The inherent paradox specific to polycystic ovary syndrome is: a. that patients with polycystic ovary syndrome are metabolically inefficient. b. that insulin resistance and impaired glucose tolerance do not seem to lead to the development of type 2 diabetes. c. that although insulin action is compromised in muscle and fat, it is not compromised in the ovary. d. None of the above
20. Which of the following has been noted regarding the relationship between hyperinsulinemia and hyperandrogenism in polycystic ovary syndrome? a. Insulin affects ovarian androgen secretion but not adrenal androgen secretion. b. Suppression of insulin levels results in suppression of androgen levels. c. Improving peripheral insulin sensitivity has no effect on the menstrual cycle. d. The primary defect in polycystic ovary syndrome appears to be hyperandrogenism, which secondarily leads to hyperinsulinemia.
27. Which of the following cardiovascular risk factors has/have been found in women with polycystic ovary syndrome? a. Increased systolic BP b. Decreased high-density lipoprotein (HDL) and HDL2 cholesterol c. Increased triglycerides d. Increased low-density lipoprotein e. All the above
S116 CME examination
28. Syndrome X is a constellation of symptoms that includes all the following except a. insulin resistance. b. abdominal obesity. c. hyperthyroidism. d. hypertension. e. hyperlipidemia (except hypertriglyceridemia). 29. A 14-year-old girl is brought to your office by her mother. She had menarche at 12 years 8 months of age, but her menses have been irregular since then. Specifically, cycles usually occur within 50 to 60 days, with rare 30-day cycles. Bleeding during the typical 40- to 60-day cycle lasts approximately 10 days. Moreover, the girl has had facial hair and moderate acne develop, which distresses her greatly. On physical examination, the patient is lean with hair in a male pattern of distribution. Laboratory results are unremarkable. The most appropriate course of treatment for this patient is a. clomiphene citrate. b. oral contraceptives. c. expectant management. d. gonadotropins. e. Both a and b
December 1998 Am J Obstet Gynecol
30. A perimenopausal 46-year-old woman (nulligravid, nulliparous) with a history of polycystic ovary syndrome diagnosed at 34 years of age comes in for a routine Papanicolaou smear and reports flushing, insomnia, irritability, and oligomenorrhea (3-day cycles). The insomnia is particularly distressing to the patient, who reports that she rarely sleeps >3 hours per night. She is concerned because she believes that the insomnia and irritability are affecting her job performance, and she reports that her supervisor has had several talks with her. She has read about perimenopausal symptoms and wishes to begin treatment with oral contraceptives. The rest of her medical history and physical examination are unremarkable, except that she is obese (height 63 in, weight 180 lbs) and has brown-to-black hyperpigmented, thickened skin on the dorsum of the neck and in the axilla. Her fasting glucose level is 125 mg/dL and her hemoglobin A1c level is 7.2%. Her fasting lipid profile includes high-density lipoprotein cholesterol 35 mg/dL, low-density lipoprotein cholesterol 159 mg/dL, total cholesterol 239 mg/dL, and triglycerides 150 mg/dL. The most appropriate course of action to pursue with this patient would include each of the following except a. glucose tolerance test, including measurement of serum insulin level. b. diet and exercise program. c. oral contraceptives. d. nutritional counseling, especially regarding lowfat diet. e. bone density tests.
1. Women with polycystic ovary syndrome will always manifest which of the following symptoms? a. Menstrual irregularities and infertility b. Hirsutism and acne c. Weight gain and obesity d. All the above e. None of the above 2. Which of the following is not among the consequences of hyperinsulinemia in patients with polycystic ovary syndrome? a. Hyperthyroidism b. Diabetes mellitus c. Abdominal obesity d. Cardiovascular disease e. Hyperlipidemia 3. Treatment goals for patients with polycystic ovary syndrome not desiring pregnancy immediately should probably include which of the following? a. Symptom management of hirsutism, acne, and oligomenorrhea b. Annual screening of all patients with polycystic ovary syndrome ≥18 years old for breast cancer c. Assessment for cardiovascular disease d. Both a and b e. Both a and c 4. Nonmedical treatment for polycystic ovary syndrome may include each of the following except a. electrolysis. b. nutritional and weight loss counseling. c. exercise. d. high colonic enemas. 5. The differential diagnosis of polycystic ovary syndrome should include which of the following? a. Other causes of hyperandrogenism, such as ovarian or adrenal tumors, congenital adrenal hyperplasia, and Cushing’s syndrome and disease b. Hyperprolactinemia c. Acromegaly d. Hypothyroidism or hyperthyroidism e. All the above
8. Which of the following tests should be performed to determine whether the patient with polycystic ovary syndrome is at risk for other comorbid conditions? a. Fasting glucose level, glycosylated hemoglobin level, and, if warranted, 3-hour glucose tolerance test with insulin levels b. Lipoprotein profiles c. Body mass index and waist/hip ratio d. All the above 9. What is the prevalence of polycystic ovary syndrome? a. 1% to 2% b. 2% to 4% c. 5% to 10% d. 15% to 20% 10. Oral contraceptives for the patient with polycystic ovary syndrome are a. not indicated if the patient has dyslipidemia because oral contraceptives will aggravate dyslipidemia. b. appropriate with lipid profiles usually seen in patients with polycystic ovary syndrome because oral contraceptives will not significantly change lipid profiles. c. not indicated if the patient has insulin resistance because oral contraceptives will reduce insulin sensitivity. d. not indicated if the patient has either insulin resistance or dyslipidemia. 11. In studies of troglitazone for women with polycystic ovary syndrome, all the following were noted except a. acne improved. b. fasting and 2-hour glucose declined significantly. c. glycosylated hemoglobin levels fell. d. insulin sensitivity improved. e. androgen levels fell.
6. The most common cause(s) of anovulation is/are a. polycystic ovary syndrome. b. functional hypothalamic anovulation. c. 17α-hydroxylase deficiency. d. bacterial vaginosis. e. both a and b.
12. Hypotheses regarding the pathogenesis of polycystic ovary syndrome include each of the following except a. a rapid gonadotropin-releasing hormone pulse frequency. b. insulin resistance. c. oversecretion of androgens by the ovary. d. variant of multiple endocrine neoplasia syndrome.
7. In patients with polycystic ovary syndrome, compromised insulin action is noted in which of the following tissues? a. Muscle only b. Fat only c. Hair follicle only d. Muscle and fat e. Fat and hair follicles
13. Weight loss programs in patients with polycystic ovary syndrome have been shown to achieve each of the following except a. reduced insulin secretion. b. reduced androgen secretion. c. improved mean follicle-stimulating hormone and luteinizing hormone pulse frequencies. d. more regular menstrual cycles.
S114
Volume 179, Number 6, Part 2 Am J Obstet Gynecol
14. In polycystic ovary syndrome, why should short-term symptom-based treatment be complemented by long-term treatment that addresses the underlying pathophysiology? a. To limit the development of cardiovascular disease b. To decrease the risk of ovarian cancer c. To preserve reproductive status in women who may eventually desire pregnancy d. All the above e. Both b and c 15. Regarding fat deposition, which of the following has been noted in patients with polycystic ovary syndrome? a. Male pattern abdominal fat deposition b. Higher waist/hip ratio c. Female pattern abdominal fat deposition d. Higher hip/waist ratio e. Both a and b 16. Hyperinsulinemia in patients with polycystic ovary syndrome is secondary to a. a defect in insulin secretion related to a primary beta cell defect. b. peripheral insulin resistance. c. a defect in insulin binding. d. a decrease in tyrosine phosphorylation at the insulin receptor. e. Choices a, b, and d. 17. The menstrual irregularity of polycystic ovary syndrome is characterized by which of the following? a. It typically begins after 35 years of age. b. It is typically an acute problem for 3 to 5 years. c. Heavy, frequent bleeding d. It begins at menarche.
CME examination S115
21. Evaluation of patients with polycystic ovary syndrome should include each of the following except a. monitoring of body weight, counseling to maintain body weight, and aggressive treatment of obesity. b. hypertension screening. c. fasting lipid screening. d. fasting glucose screening and, if indicated, glucose tolerance test. e. cardiac catheterization in all women with suspected polycystic ovary syndrome. 22. What percentage of healthy women have ovarian polycystic morphologic characteristics on ultrasonography? a. 2% b. 5% c. 20% d. 50% 23. What percentage of obese women with polycystic ovary syndrome can be characterized as insulin resistant? a. 10% b. 40% c. 90% d. 100% 24. Regarding ovulation induction in the patient with polycystic ovary syndrome, which of the following is true? a. Calorie restriction is an important part of infertility management. b. Gonadotropin preparations are potentially dangerous because of the recruitment of multiple follicles and the risk of ovarian hyperstimulation syndrome. c. Patients with polycystic ovary syndrome rarely need ovulation induction. d. Insulin-sensitizing agents are currently used as first-line therapy for restoration of ovulation. e. Both a and b
18. The direct action of troglitazone is to a. decrease insulin resistance. b. suppress hepatic gluconeogenesis. c. stimulate insulin secretion from pancreatic beta cells. d. lower insulin secretion.
25. Key features of polycystic ovary syndrome include all the following except a. insulin resistance. b. androgen excess. c. cyclic changes in estrogen levels that often mimic ovulation. d. abnormal gonadotropins.
19. The direct action of metformin is to a. suppress hepatic gluconeogenesis. b. stimulate insulin secretion from pancreatic beta cells. c. lower insulin secretion. d. decrease insulin resistance.
26. The inherent paradox specific to polycystic ovary syndrome is: a. that patients with polycystic ovary syndrome are metabolically inefficient. b. that insulin resistance and impaired glucose tolerance do not seem to lead to the development of type 2 diabetes. c. that although insulin action is compromised in muscle and fat, it is not compromised in the ovary. d. None of the above
20. Which of the following has been noted regarding the relationship between hyperinsulinemia and hyperandrogenism in polycystic ovary syndrome? a. Insulin affects ovarian androgen secretion but not adrenal androgen secretion. b. Suppression of insulin levels results in suppression of androgen levels. c. Improving peripheral insulin sensitivity has no effect on the menstrual cycle. d. The primary defect in polycystic ovary syndrome appears to be hyperandrogenism, which secondarily leads to hyperinsulinemia.
27. Which of the following cardiovascular risk factors has/have been found in women with polycystic ovary syndrome? a. Increased systolic BP b. Decreased high-density lipoprotein (HDL) and HDL2 cholesterol c. Increased triglycerides d. Increased low-density lipoprotein e. All the above
S116 CME examination
28. Syndrome X is a constellation of symptoms that includes all the following except a. insulin resistance. b. abdominal obesity. c. hyperthyroidism. d. hypertension. e. hyperlipidemia (except hypertriglyceridemia). 29. A 14-year-old girl is brought to your office by her mother. She had menarche at 12 years 8 months of age, but her menses have been irregular since then. Specifically, cycles usually occur within 50 to 60 days, with rare 30-day cycles. Bleeding during the typical 40- to 60-day cycle lasts approximately 10 days. Moreover, the girl has had facial hair and moderate acne develop, which distresses her greatly. On physical examination, the patient is lean with hair in a male pattern of distribution. Laboratory results are unremarkable. The most appropriate course of treatment for this patient is a. clomiphene citrate. b. oral contraceptives. c. expectant management. d. gonadotropins. e. Both a and b
December 1998 Am J Obstet Gynecol
30. A perimenopausal 46-year-old woman (nulligravid, nulliparous) with a history of polycystic ovary syndrome diagnosed at 34 years of age comes in for a routine Papanicolaou smear and reports flushing, insomnia, irritability, and oligomenorrhea (3-day cycles). The insomnia is particularly distressing to the patient, who reports that she rarely sleeps >3 hours per night. She is concerned because she believes that the insomnia and irritability are affecting her job performance, and she reports that her supervisor has had several talks with her. She has read about perimenopausal symptoms and wishes to begin treatment with oral contraceptives. The rest of her medical history and physical examination are unremarkable, except that she is obese (height 63 in, weight 180 lbs) and has brown-to-black hyperpigmented, thickened skin on the dorsum of the neck and in the axilla. Her fasting glucose level is 125 mg/dL and her hemoglobin A1c level is 7.2%. Her fasting lipid profile includes high-density lipoprotein cholesterol 35 mg/dL, low-density lipoprotein cholesterol 159 mg/dL, total cholesterol 239 mg/dL, and triglycerides 150 mg/dL. The most appropriate course of action to pursue with this patient would include each of the following except a. glucose tolerance test, including measurement of serum insulin level. b. diet and exercise program. c. oral contraceptives. d. nutritional counseling, especially regarding lowfat diet. e. bone density tests.