, Question 1
A patient with PCOS by Rotterdam criteria has a fasting glucose of 108 mg/dL,
HbA1c 5.9%, and BMI 34. She desires cycle regulation and does not currently
want pregnancy. Which intervention BEST addresses both her metabolic risk
and menstrual irregularity with the strongest evidence for ovulatory
restoration?
A. Combined oral contraceptive pills alone
B. Metformin 1500-2000 mg/day plus lifestyle modification
C. Spironolactone 100 mg/day monotherapy
D. Cyclic medroxyprogesterone acetate 10 mg × 10 days monthly
Correct Answer: B - Metformin 1500-2000 mg/day plus lifestyle
modification
RATIONALE
Metformin combined with lifestyle modification improves insulin
sensitivity, restores ovulatory cycles in a substantial proportion of
PCOS patients, and addresses prediabetes-making it the best
dual-purpose intervention. COCs regulate cycles but do not improve
insulin resistance; spironolactone is antiandrogenic but not ovulatory;
cyclic progestin only protects endometrium.
Question 2
A patient with deeply infiltrating endometriosis reports severe dysmenorrhea
refractory to NSAIDs and combined OCs. MRI shows rectovaginal nodule
with bowel involvement. Which statement BEST reflects current evidence
regarding management?
A. GnRH antagonist (elagolix) is first-line for bowel DIE due to superior
pain control
B. Surgical excision by an experienced multidisciplinary team offers the
most durable pain relief for DIE
C. LNG-IUS alone is sufficient for rectovaginal disease
Page 2
, D. Aromatase inhibitors should replace all other therapies in DIE
Correct Answer: B - Surgical excision by an experienced
multidisciplinary team offers the most durable pain relief for DIE
RATIONALE
For deeply infiltrating endometriosis with bowel involvement
refractory to medical therapy, complete surgical excision by an
experienced multidisciplinary team provides the most durable
symptom relief and addresses the structural disease. GnRH antagonists
and LNG-IUS are useful adjuncts but do not treat bowel DIE
definitively; aromatase inhibitors are reserved for select refractory
cases.
Question 3
Which finding BEST distinguishes adenomyosis from leiomyoma on pelvic
imaging and supports a diagnosis of adenomyosis?
A. Well-circumscribed hypodense mass with bridging vessels on MRI
B. Diffuse heterogeneous myometrium with asymmetric thickening and
increased junctional zone thickness on MRI
C. Multiple calcified fibroids on plain radiograph
D. Endometrial stripe >20 mm on transvaginal ultrasound
Correct Answer: B - Diffuse heterogeneous myometrium with
asymmetric thickening and increased junctional zone thickness on
MRI
RATIONALE
Adenomyosis is characterized on MRI by diffuse heterogeneous
myometrium, asymmetric thickening of the anterior/posterior wall,
and junctional zone thickness >12 mm, reflecting ectopic endometrial
tissue within myometrium. Leiomyomas appear as well-circumscribed
masses with bridging vessels; calcification is nonspecific; endometrial
stripe thickness reflects endometrial pathology, not myometrial
disease.
Page 3
, Question 4
A patient with premature ovarian insufficiency (POI) at age 32 has a normal
karyotype and negative FMR1 premutation. Which management strategy
BEST aligns with current ASRM/ESHRE guidance to reduce long-term
morbidity?
A. Observation with annual FSH monitoring until spontaneous
menopause
B. Physiologic estrogen replacement therapy (transdermal estradiol 100
mcg/day) until at least age 50-51
C. Low-dose COCs indefinitely as first-line
D. Calcium and vitamin D alone without hormone therapy
Correct Answer: B - Physiologic estrogen replacement therapy
(transdermal estradiol 100 mcg/day) until at least age 50-51
RATIONALE
For POI, physiologic transdermal estradiol replacement (100 mcg/day)
is recommended until the natural age of menopause (~50-51) to reduce
cardiovascular, osteoporotic, and cognitive risks. Observation, calcium
alone, or low-dose COCs are inadequate for the estrogen deficiency
state and do not provide physiologic replacement.
Question 5
Which mechanism BEST explains the menstrual irregularity associated with
hypothyroidism?
A. Direct suppression of ovarian steroidogenesis by TSH
B. Elevated TRH stimulating prolactin, which disrupts GnRH pulsatility
C. Increased sex hormone-binding globulin reducing free estradiol
D. Autoimmune destruction of the corpus luteum
Correct Answer: B - Elevated TRH stimulating prolactin, which
disrupts GnRH pulsatility
Page 4
A patient with PCOS by Rotterdam criteria has a fasting glucose of 108 mg/dL,
HbA1c 5.9%, and BMI 34. She desires cycle regulation and does not currently
want pregnancy. Which intervention BEST addresses both her metabolic risk
and menstrual irregularity with the strongest evidence for ovulatory
restoration?
A. Combined oral contraceptive pills alone
B. Metformin 1500-2000 mg/day plus lifestyle modification
C. Spironolactone 100 mg/day monotherapy
D. Cyclic medroxyprogesterone acetate 10 mg × 10 days monthly
Correct Answer: B - Metformin 1500-2000 mg/day plus lifestyle
modification
RATIONALE
Metformin combined with lifestyle modification improves insulin
sensitivity, restores ovulatory cycles in a substantial proportion of
PCOS patients, and addresses prediabetes-making it the best
dual-purpose intervention. COCs regulate cycles but do not improve
insulin resistance; spironolactone is antiandrogenic but not ovulatory;
cyclic progestin only protects endometrium.
Question 2
A patient with deeply infiltrating endometriosis reports severe dysmenorrhea
refractory to NSAIDs and combined OCs. MRI shows rectovaginal nodule
with bowel involvement. Which statement BEST reflects current evidence
regarding management?
A. GnRH antagonist (elagolix) is first-line for bowel DIE due to superior
pain control
B. Surgical excision by an experienced multidisciplinary team offers the
most durable pain relief for DIE
C. LNG-IUS alone is sufficient for rectovaginal disease
Page 2
, D. Aromatase inhibitors should replace all other therapies in DIE
Correct Answer: B - Surgical excision by an experienced
multidisciplinary team offers the most durable pain relief for DIE
RATIONALE
For deeply infiltrating endometriosis with bowel involvement
refractory to medical therapy, complete surgical excision by an
experienced multidisciplinary team provides the most durable
symptom relief and addresses the structural disease. GnRH antagonists
and LNG-IUS are useful adjuncts but do not treat bowel DIE
definitively; aromatase inhibitors are reserved for select refractory
cases.
Question 3
Which finding BEST distinguishes adenomyosis from leiomyoma on pelvic
imaging and supports a diagnosis of adenomyosis?
A. Well-circumscribed hypodense mass with bridging vessels on MRI
B. Diffuse heterogeneous myometrium with asymmetric thickening and
increased junctional zone thickness on MRI
C. Multiple calcified fibroids on plain radiograph
D. Endometrial stripe >20 mm on transvaginal ultrasound
Correct Answer: B - Diffuse heterogeneous myometrium with
asymmetric thickening and increased junctional zone thickness on
MRI
RATIONALE
Adenomyosis is characterized on MRI by diffuse heterogeneous
myometrium, asymmetric thickening of the anterior/posterior wall,
and junctional zone thickness >12 mm, reflecting ectopic endometrial
tissue within myometrium. Leiomyomas appear as well-circumscribed
masses with bridging vessels; calcification is nonspecific; endometrial
stripe thickness reflects endometrial pathology, not myometrial
disease.
Page 3
, Question 4
A patient with premature ovarian insufficiency (POI) at age 32 has a normal
karyotype and negative FMR1 premutation. Which management strategy
BEST aligns with current ASRM/ESHRE guidance to reduce long-term
morbidity?
A. Observation with annual FSH monitoring until spontaneous
menopause
B. Physiologic estrogen replacement therapy (transdermal estradiol 100
mcg/day) until at least age 50-51
C. Low-dose COCs indefinitely as first-line
D. Calcium and vitamin D alone without hormone therapy
Correct Answer: B - Physiologic estrogen replacement therapy
(transdermal estradiol 100 mcg/day) until at least age 50-51
RATIONALE
For POI, physiologic transdermal estradiol replacement (100 mcg/day)
is recommended until the natural age of menopause (~50-51) to reduce
cardiovascular, osteoporotic, and cognitive risks. Observation, calcium
alone, or low-dose COCs are inadequate for the estrogen deficiency
state and do not provide physiologic replacement.
Question 5
Which mechanism BEST explains the menstrual irregularity associated with
hypothyroidism?
A. Direct suppression of ovarian steroidogenesis by TSH
B. Elevated TRH stimulating prolactin, which disrupts GnRH pulsatility
C. Increased sex hormone-binding globulin reducing free estradiol
D. Autoimmune destruction of the corpus luteum
Correct Answer: B - Elevated TRH stimulating prolactin, which
disrupts GnRH pulsatility
Page 4
