uworld OBGY question thread - ck_hue

[ArchivalUser]

Q id 4154

A 50-year-old woman presents to your office complaining of severe insomnia. hot flashes. and mood swings.
She also states that her mother had a hip fracture at 65 years of age. She is afraid of developing
osteoporosis and having a similar incident. Her last menstrual period was six months ago. Her past medical
history is significant for hypothyroidism diagnosed seven years ago. She takes L-thyroxine and the dose of
the hormone has been stable for the last several years. Her blood pressure is 120/70 mmHg and her heart
rate is 75/min. Serum TSH level is normal. You consider estrogen replacementtherapy for this patient.
Which of the following is most likely concerning estrogen replacement therapy in this patient?
r A. The level of total thyroid hormones would decrease
r B. The metabolism of thyroid hormones would decrease
r C. The requirement for L-thyroxine would increase
r D. The volume of distribution of thyroxine would decrease
r E. The level of TSH would decrease

Explanation: User ld:
Estrogen replacementtherapy affects the metabolism of thyroid hormones. The requirement for L-thyroxine
increases. although the exact mechanism that leads to this effect is not completely understood. The most
probable cause is increased metabolism of thyroid hormones due to induction of P450 ( CYP3A4) in the liver
(Choice B). Several other medications (e.g .. rifampin. carbamazepine. and phenytoin). act in the same way.
Other mechanisms that can explain an increase in the requirement for L-thyroxine in patients receiving
estrogen replacement therapy. include an increased level of thyroid-binding globulin (TBG) and an increased
volume of the distribution of thyroid hormones (Choice D).
(Choice A) Due to the increase in the TBG. the level of total thyroid hormones would not decrease
substantially. although the free hormone level would decrease.
(Choice E) Serum TSH level represents a sensitive marker of hypothyroid state and would increase if the
dose of L-thyroxine is not adjusted accordingly.
Educational objective:
The requirement for L-thyroxine in patients receiving estrogen replacement therapy increases. The potential
causes may include induction of liver enzymes. increased level of TBG. and an increased volume of the
distribution of thyroid hormones. In pregnancy. also. thyroid hormone requirements will be increased. and the patient should be monitored every 4-6 weeks for dose adjustments.


( has a table)

[ArchivalUser]

Interaction of estrogen therapy and thyroid hormone replacement in postmenopausal women.
Authored By: Mazer Norman A

Based on the use of estrogen therapy/hormone therapy (ET/HT) in postmenopausal women and the prevalence of hypothyroidism in this population, it is estimated that approximately 5% of all postmenopausal women receive treatment with both ET/HT and thyroid hormone replacement.

Hormone therapy generally refers to the combined use of estrogens and progestins, the latter administered on a continuous or intermittent basis.

HT is indicated for the treatment of postmenopausal women with intact uteri, whereas ET is used in women who have had hysterectomies.

Because of its hepatic first-pass effect, oral estrogen therapy, the most commonly used modality of ET/HT, raises the circulating levels of thyroxine-binding globulin (TBG), thereby increasing the bound fraction and decreasing the free (bioactive) fraction of circulating thyroxine (T(4)). As a consequence, oral ET/HT may increase the T(4) dosage requirements of women being treated for primary hypothyroidism as well as alter the pituitary-thyroid axis in euthyroid women.

This paper reviews the potential interaction between ET/HT and thyroid hormone replacement based on the prevalence of their concomitant use, mechanistic aspects of the interaction, and recent clinical studies of the effects of oral ET in euthyroid and hypothyroid women.

Other agents known to interact with thyroid hormone replacement, including soy supplements, are also reviewed. Because transdermal ET does not affect TBG levels and would not be expected to alter thyroid function, it may be a preferable modality for postmenopausal women who require concomitant treatment with ET/HT and T(4).

[ArchivalUser]

q id 3869

A 30-year-old G2 P 1 woman at 38 weeks gestation comes to the hospital because of regular and painful
uterine contractions that started two hours ago. Pelvic examination reveals bulging membranes. and her
cervix is 50% effaced and dilated to 3 em. Her pregnancy was complicated by first trimester hemorrhage of
unknown cause. Her past medical history is unremarkable. Upon observing the fetal heart rate monitor and
an external tocometer for 20 minutes. you note 6 contractions. You also note 4 separate 15 - 20 beat/min
decreases in the fetal heart rate with every contraction. The depth and duration of decelerations vary with
successive uterine contractions. Which of the following is the most appropriate next step in the management
of this patient?
r A. Oxygen administration and change in maternal position
r B. Artificial rupture of membranes
r C. Amnioinfusion
r D. F eta I scalp pH testing
r E. Emergent cesarean section

( table)

Repetitive variable decelerations represent a non-reassuring fetal heart rate (FHR) pattern. They are
characterized by the erratic onset of abrupt slowing of the FHR in association with uterine contractions and a
rapid return to baseline. Variable decelerations are common and are thought to be the result of umbilical cord
compression. Cord compression can occur from low amniotic fluid levels or a nuchal cord. Intermittent
variable decelerations are usually well-tolerated by the fetus. Repetitive (~50% in a 20 min period) variable
decelerations require prompt intervention.
The first step in the presence of any non-reassuring heart rate is to administer oxygen and change maternal
position. In addition. uterotonic drugs need to be discontinued and maternal hypotension evaluated and
treated. Variable decelerations may require amnioinfusion. which consists of infusion of fluid into the amniotic
cavity.
(Choice B) Rupture of the membranes will result in the loss of amniotic fluid and may worsen fetal cord
compression.
(Choice C) Amnioinfusion may be indicated if persistent variable decelerations are present. but should be
used only after the appropriate first steps are initiated.
(Choice D) F eta I scalp pH testing should be performed to assess for fetal hypoxia if the abnormal FHR
pattern persists after the initial measures of position change. oxygen administration. and discontinuation of
oxytocin have been tried.
(Choice E) Cesarean section is indicated when the non-reassuring pattern is not remediated by conservative
measures.
Educational objective:
Variable decelerations represent a non-reassuring fetal heart rate pattern and are the result of umbilical cord
compression. They are characterized by the erratic onset of abrupt slowing of the FHR in association with
uterine contractions and a rapid return to baseline. The most appropriate first steps in the management of
variable decelerations are oxygen administration and change in maternal position.

( q has media and is updated )

[ArchivalUser]

VEAL CHOP
VARIABLE -cord prolapse
EARLY DECELER-head compression
ACCELARATION-ok(normal)
LATE DECELAR-placental insufficiency

[ArchivalUser]

Q id 4915-6

The following vignette applies to the next 2 items.
A 25-year-old female presents to the office for a prenatal visit. She is gravida 3. para 0. ab 2. Her first
abortion was an elective abortion at 18 weeks gestation. Her second abortion was a spontaneous abortion at
17 weeks gestation. She has had a cervical loop electrosurgical excision(LEEP) procedure. 8 months ago.
for severe cervical dysplasia. Her LMP was 16 weeks ago. She does not use tobacco. alcohol or illicit drugs.
She has had an uneventful pregnancy thus far and denies any concerns at this visit. Her temperature is
98 .6 F . blood pressure is 1 00/64. heart rate is 72/minute and respirations are 17/minute. Her uterine
fundus measures 14.5 em and is consistent with a 15-16 weeks gestation. The fetal heart rate is 140/minute.
Item 1 of2
This patient is at greatest risk for which of the following complications?
r A. Abruptio placentae
r B. Cervical insufficiency
r C. Uterine rupture
r D. Polyhydramnios
r E. Small for gestational age fetus

Question 2 of2
On pelvic examination. the cervix is closed but shorter than normal. Which of the following is the most
appropriate next step in management?
r A. Abdominal ultrasonography
r B. F eta I nonstress test
r C. Repeat digital vaginal examination in several days
r D. Transvaginal ultrasonography
r E. Sterile vaginal speculum examination

Explanation:
Risk factors for cervical insufficiency ( cervical incompetence) include prior gynecological surgery especially a LEEP procedure or cone biopsy of the cervix. Other risk factors include prior obstetrical trauma. multiple
gestation. Mullerian anomalies and a history of a preterm birth or a second-trimester pregnancy loss. The
patient's prior history of an elective abortion. LEEP procedure and prior 17 week spontaneous abortion all
increase her risk for an incompetent cervix.
(Choice A) Risk factors for abruptio placentae include a history of maternal trauma. chronic hypertension.
maternal smoking and a history of an external cephalic version.
(Choice C) The main risk factors for uterine rupture include multiparity. advanced maternal age. and previous
cesarean sections or myomectomy operations.
(Choice D) The main risk factors for polyhydramnios include fetal malformations and genetic disorders.
maternal diabetes mellitus. multiple gestation. and fetal anemia.
(Choice E) A small for gestational age infant is one whose birth weight is below the 1 oth percentile for that
gestational age. The most common risk factors include impaired placental perfusion. maternal smoking.
alcohol or drug abuse. maternal malnutrition. multiple gestation. infections. genetic disorders. and teratogen
exposure.

Educational objective:
There is an increased risk for maternal cervical insufficiency with a history of maternal obstetrical trauma.
past gynecologic procedures including a cervical LEEP or cone biopsy. DES exposure or multiple gestation.
A previous history of a preterm birth or a second trimester pregnancy loss are also risk factors for an
incompetent cervix.

Explanation:
A transvaginal ultrasound is considered the "gold standard" for evaluating the cervix for possible cervical
incompetence. The transvaginal ultrasound is used to look for the presence of funneling of the cervix or
shortening of the cervical length. Cervical length should be more than 25mm at 24 weeks. A cervical length
below the 1 oth percentile for the gestational age is considered a short cervix.
(Choice A) An abdominal ultrasound is not as accurate as a transvaginal ultrasound in evaluating the cervical
length in pregnancy.
(Choice B) A fetal nonstress test is used to evaluate fetal well-being. Its role is later in pregnancy. in the
presence of maternal or fetal factors that increase fetal morbidity or mortality (maternal hypertension.
diabetes. infections. previous stillborn). It is not of any value in evaluating for possible cervical incompetence.
(Choice C) A repeat digital vaginal exam may reveal some evidence of change in the cervical length or
dilatation. However. it is not the method of choice to diagnose possible cervical incompetence.
Ultrasonography better evaluates the internal os and proximal cervix. areas that are difficult to evaluate by
vaginal exam alone.
(Choice E) A sterile vaginal speculum examination is not an accurate way to evaluate the cervix for
effacement or dilatation. It is often used to assist in the diagnosis of ruptured fetal membranes.

Educational objective:
Transvaginal ultrasound is the gold standard for evaluating the cervix for cervical incompetence in pregnancy.
A cervical length below the 1 oth percentile for gestational age is considered a short cervix. This includes
cervices less than 25mm at gestational age 23-28 weeks.

[ArchivalUser]

qid 4791-2

The following vignette applies to the next 2 items. The items in the set must be answered in sequential
order. Once you click Proceed to Next Item. you will not be able to add or change an answer.
A 26-year-old woman comes to the physician·s office for evaluation of a vulvar ulcer that she noticed two days ago. Initially she had a small painless papule that later became ulcerated. Upon further questioning she
reluctantly admits to using sex to obtain drugs. She also reports using oral contraceptives to prevent
pregnancy. On vulvar examination there is a 2-cm ulcer with a non-exudative base and a raised. indurated
margin. Painless bilateral inguinal lymphadenopathy is present.
Item 1 of2
Which of the following is the most likely diagnosis?
r A. Syphilis
r B. Chancroid
r C. Herpes genitalis
r D. Granuloma inguinale
r E. Basal cell carcinoma

ltem2 of2
Which of the following tests will most likely reveal a diagnosis in this patient?
r A. Serum RPR
r B. Dark field microscopy
r C. Culture of the ulcer base
r D. Lymph node biopsy
r E. Tzanck smear

Explanation: User ld:
This patient's high risk sexual behavior and physical exam findings raise strong suspicion for primary
syphilis. Two to three weeks after infection with Treponema pallidum. patients develop a painless papule at
the site of inoculation. This papule ulcerates. forming a chancre with punched-out base and raised. indurated
margins. Most lesions occur on the genitalia. and are accompanied by painless inguinal adenopathy. If left
untreated. the chancre of primary syphilis heals spontaneously within one to three months.
(Choices B & C) The genital ulcers seen in chancroid and herpes genitalis differ from the ulcer of primary
syphilis in that both are painful. Chancroid is also characterized by a ulcers with a deep. purulent base and
painful lymphadenopathy. Genital herpes presents with multiple vesicles following a prodrome of burning and
pruritus. Within days. these vesicles become painful ulcers.
(Choice D) Like syphilis. Granuloma inguinale (Donovanosis) presents with painless genital ulcers. These
ulcers have a red. beefy base and there is no associated adenopathy. Unlike primary syphilis. the ulcer of
granuloma inguinale does not resolve without antibiotic treatment.
(Choice E) The greatest risk factor for basal cell carcinoma (BCC) is sun exposure. The most common
sites of BCC are the face and trunk. Involvement of the genitalia is rare. BCC lesions appear as pearlycolored
papules covered with telangiectasias.
Educational objective:
The genital ulcers seen in chancroid and herpes genitalis differ from the ulcer of primary syphilis in that both
are painful.

Explanation: User ld:
Serologic testing is used as a screening test for syphilis. and depends on identification of antibodies to
Treponema pallidum. Many patients with primary syphilis have yet to form antibodies against the organism.
Therefore. serologic testing in primary syphilis results in a high rate of false-negatives. Because of this.
diagnosis of primary syphilis is best made via spirochete identification on dark field microscopy (Choice B).
(Choice A) RPR (Rapid Plasma Reagin) is a nontreponemal serologic test used in the diagnosis of syphilis.
Serologic tests including RPR should be avoided in suspected cases of primary syphilis due to the high rate
offalse negative results.
(Choice C) Syphilis cannot be cultured in the laboratory. and therefore culture of the ulcer base will not be
diagnostic.
(Choice D) Lymph node biopsy is not a standard test used in the diagnosis of syphilis.
(Choice E) Tzanck smear is a dermatologic test in which scrapings are taken from the ulcer base. It is used
in the diagnosis of Herpes simplex. Varicella. and Cytomegalovirus. Multinucleated giant cells on Tzanck
smear are characteristic of Herpes and Varicella.
Educational objective:
Nontreponemal serologic tests (VDRL. RPR) are used as a screening test for syphilis. and treponemal
serologic tests (FTA-ABS) are used for confirmation. Darkfield microscopy is also an effective method of
diagnosing syphilis. but requires proper equipment and clinical expertise. In primary syphilis. there is a high
rate of false-negative results to serologic testing. and therefore darkfield microscopy is necessary.

[ArchivalUser]

qid 4775-6

The following vignette applies to the next 2 items. The items in the set must be answered in sequential
order. Once you click Proceed to Next Item. you will not be able to add or change an answer.
A 27-year-old primigravid woman at 28 weeks gestation comes to the physician·s office because she has not
felt any fetal movements for the past 48 hours. Her pregnancy thus far has been uncomplicated. Prenatal
ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates and showed
no abnormalities. She has no history of trauma. She has no history of serious illness. Review of systems
reveals no abnormalities. She does not use tobacco. alcohol or drugs. F eta I heart tones are not heard by
Doppler. Vital signs are normal.
Item 1 of2
Which of the following is the most appropriate next step in management?
r A. Induction of labor
r B. Non-stress test
r C. Serial beta-hCG
r D. Monitor coagulation profile
r E. Real-time ultrasonogram

ltem2 of2
Real time ultrasonography shows no fetal movements and no fetal heart motion. A maternal coagulation
profile shows no abnormalities. Induction of labor is performed and the dead fetus is evacuated. Looking at
her antenatal chart you noticed that the mother had missed 2 monthly appointments. Which of the following is
the most appropriate statement at this time?
r A. "Don•t worry. there is no increased risk of having a still birth in future pregnancies"
r B. "We need to monitor a serial beta-hCG level for next 3 months"
r C. "We need to monitor serial fibrinogen levels for next four weeks"
r D. "I would recommend an autopsy of fetus and placenta"
r E. "It would not have happened if you had good antenatal care"

Explanation: User ld:
The patient described has most likely had an intrauterine fetal demise (IUFD). IUFD is the death of a fetus in
utero that occurs after 20 weeks gestation and before the onset of labor. I UFO is suspected when the patient
reports the disappearance of fetal movements. a decrease or stagnation in uterine size or when fetal heart
sounds are no longer heard. Beta-hCG levels may continue to be elevated due to ongoing placental
production of that hormone. Ultrasonography is a more reliable tool for confirming the diagnosis; it
demonstrates an absence of fetal movement and fetal cardiac activity.
(Choice A) The diagnosis of I UFO requires confirmation with ultrasonography before any further action can be taken.
(Choice B) A non-stress test is irrelevant since it is suspected that the fetus is dead. IUFD needs to be
confirmed by demonstrating the absence of fetal heart movement on ultrasonogram.
(Choice C) Serum beta-hCG levels are not useful because they usually remain elevated due to ongoing
placental production.
(Choice D) Monitoring the coagulation profile should be done as IUFD can cause maternal coagulopathy. The
diagnosis should first be confirmed by ultrasonography.

Educational objective:
The most appropriate test to confirm the diagnosis of intrauterine fetal demise (IUFD) is real time
ultrasonography to demonstrate an absence of fetal movement and cardiac activity.

Explanation: User ld:
Intrauterine fetal demise (IUFD) is the death of a fetus in utero that occurs after 20 weeks gestation and before
the onset of labor. It can be caused by a multitude of conditions such as hypertensive disorders. diabetes
mellitus. placental and cord complications. antiphospholipid syndrome. congenital anomalies and fetal
infections such as the TORCH infections or listeriosis. However. the cause remains unknown in 50% of
cases. It is very important to try to diagnose the cause of the fetal demise after the first episode in order to
prevent. if possible. a recurrence of the same issue in any subsequent pregnancies. Autopsy of the fetus and
placenta should be performed.
(Choice A) There is a 1 to 8 % risk of recurrent still birth in mothers who have previously experienced I UFO.
(Choice B) Serial beta-HCG monitoring is required if there is a suspicion for molar pregnancy.
(Choice C) Serial testing of fibrinogen levels is performed to detect a consumptive coagulopathy early in its
course in patients with IUFD managed with watchful expectancy. The fetus in this case has already been
evacuated. so the risk of coagulopathy has been addressed.
(Choice E) Blaming the parent for fetal death is inappropriate under any circumstances. If actions taken by
the parent possibly caused inadvertent demise of their fetus. then education should be undertaken to ensure
that such a parent will have an improved chance at a successful subsequent pregnancy.

Educational objective:
A search should be undertaken to determine the cause after the first episode of intrauterine fetal demise.
Autopsy of the fetus and placenta should be performed in all cases of stillbirth with the permission of the
parents.

[ArchivalUser]

qid 3280

A 36-year-old woman. gravida 3. para 2. comes to the physician for a prenatal checkup. According to her last
menstrual period and an ultrasonography performed at 16 weeks gestation. she is at 30 weeks gestation.
She missed two antenatal appointments. She does not use tobacco. alcohol. or drugs. Examination shows a
fundal height of 26 em (9 .8 in). F eta I heart tones are heard by Doppler. Repeat ultrasound shows a fetal
biparietal diameter consistent with 30 weeks and an abdominal circumference below the 1Oth percentile.
Which of the following could most likely be responsible for the observed fetal findings?
r A. Chromosomal abnormalities
r B. Intrauterine infection
r C. Hypertension
r D. Fetal anomalies
r E. Inaccurate dates

Explanation:

Etiology of intrauterine growth restriction
Symmetric causes
Fetal factors
• Chromosomal abnormalities
• Congenital anomalies
• Congenital infections (TORCH)

Asymmetric causes
Maternal factors
• Maternal hypertension
• Preeclampsia
• Uterine anomalies
• Maternal antiphospholipid syndrome
• Collagen vascular disease
• Maternal cigarette smoking

Intrauterine growth restriction (IUGR) is defined as an estimated fetal weight~ 1Oth percentile. It can be
symmetric or asymmetric. In symmetric growth restriction. the insult to the fetus often begins before 28-
weeks gestation. and growth of both the head and the body are similarly lagging behind dates. It is usually
caused by fetal factors such as chromosomal abnormalities. congenital infections. and congenital
anomalies. Asymmetric IUGR is the result of fetal adaptation to non-ideal maternal factors. It is caused by
fetal redistribution of blood flow to vital organs. such as the brain. heart. and placenta atthe expense of less
vital organs. such as the abdominal viscera. Maternal factors such as hypertension. hypoxemia. cigarette
smoking. vascular disease. and preeclampsia can lead to asymmetric IUGR. Asymmetric IUGR has a better
prognosis than symmetric IUGR.
(Choice A) The fetus in this case has a normal biparietal diameter and a reduced abdominal circumference.
which indicate asymmetric IUGR. Congenital anomalies and chromosomal abnormalities usually result in
symmetric growth restriction.
(Choice B) An infection by TORCH organisms would have resulted in a symmetric growth restriction. as
they usually affect the fetus during early part of pregnancy. Bacterial infections late in pregnancy have not
been strongly correlated with IUGR.
(Choice D) Gross fetal anomalies are usually identifiable on ultrasound.
(Choice E) Ultrasonography performed in the first trimester as well as the date of the last menstrual period
make the most accurate estimation of dates. It is unlikely thatthe dating in this case in unreliable enough to
explain the discrepancies found on ultrasound.

Educational objective:
Asymmetric intrauterine growth restriction is a result of a late exposure to a maternal factor that does not
allow optimal fetal growth. It is characterized by a normal or almost normal head size and a reduced
abdominal circumference. Maternal factors such as hypertension. smoking. hypoxia. vascular disease. and
preeclampsia are typical causes.

[ArchivalUser]

qid 4294

A 28-year-old G2. P 1 woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days. and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain. and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5 C (99 .5 F). blood pressure is 130/80 mm Hg. and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness.

Urinalysis shows:
Specific gravity 1 .020
Blood ++

Glucose
Ketones
Protein
Leukocyte esterase
Nitrites

negative
negative
negative
negative
negative

What is the best next step in the management of this patient?
r A. Cervical cultures
r B. Shockwave lithotripsy
r C. Intravenous pyelogram
r D. Ultrasound of the abdomen
r E. CT scan of the abdomen and pelvis

Explanation: User ld:
This pregnant patient's clinical presentation is very suggestive of renal colic. Flank pain that radiates to the
groin and hematuria are very characteristic of nephrolithiasis.
Renal stones in pregnancy require special consideration because many of the investigative and treatment
modalities will expose the fetus to radiation. Since there is no risk of radiation with ultrasound. renal and pelvic ultrasound is the investigative procedure of choice for pregnant patients. In addition to avoiding radiation exposure. ultrasonography is also useful for detecting secondary signs of obstruction. such as
hydronephrosis or hydroureter. Physiological hydronephrosis of pregnancy must be distinguished from
pathological hydronephrosis secondary to obstruction.
(Choices B, C and E) A regular IVP is not performed in pregnancy due to the risks of radiation. Similarly.
abdominal/pelvic CT scans and shockwave lithotripsy are generally contraindicated in pregnancy.
(Choice A) There is no need to perform cervical cultures at this point because there is nothing to suggest that
this patient is suffering from a cervical infection.

Educational objective:
Renal calculi in pregnancy require special consideration because most of the standard investigatory
modalities will expose the fetus to radiation. The modality of choice in such patients is abdominal or pelvic
ultrasonography.

[ArchivalUser]

qid 4756

A 37-year-old woman comes to the physician for evaluation of infertility. She and her 39-year-old husband
have not been able to conceive after 11 months of unprotected and frequent intercourse. She has 28-day
regular menstrual cycles. The patient had a pregnancy with her husband at age 31 . She has no other
complaints. She has no previous history of sexually transmitted diseases or abdominal surgery. The patient
does not use tobacco. alcohol. or illicit drugs. She is an aerobics instructor and teaches 2 3D-minute classes
daily. Her blood pressure is 130/80 mm Hg and pulse is 84/min. Her body mass index is 23 kg/m2 . Complete
physical examination is unremarkable. Which of the following is the most likely cause of her condition?
r A. Adrenal hyperplasia
r B. Decreased ovarian reserve
r C. Fallopian tube obstruction
r D. Hypothyroidism
r E. Intense exercise
r F. Premature ovarian failure
r G. Uterine leiomyomas

Explanation: User ld:
This patient does not meet the strict definition of infertility as she has not been attempting to become pregnant for more than a year. Given this and the fact that she still experiences regular menstrual cycles. she is most likely having trouble conceiving because of her age. An inverse relationship exists between age and fertility.
Women are born with their full complement of oocytes and. as they age. this oocyte reserve slowly depletes.
At birth. a woman possesses approximately 3 million oocytes. butthis number typically decreases to about
300.000 by puberty. A significant drop in oocyte number (ovulatory reserve) takes place during a woman's
fourth decade. One in 5 women age 35-39 is no longer fertile. Infertility due to aging can be assessed using
an early follicular phase FSH level. a clomiphene challenge test. or an inhibin-B level.
(Choices A and D) Endocrine disorders such as adrenal hyperplasia and hypothyroidism are associated
with anovulation.
(Choices C and G) Fallopian tube obstruction and uterine leiomyomas are anatomic factors that may
decrease fertility. This patient's history of a previous normal pregnancy coupled with the absence of sexually
transmitted diseases makes these factors unlikely. A uterine leiomyoma may be present. but the patient has
no symptoms or signs of this condition.
(Choice E) Intense exercise sufficient to induce anovulation would also most likely result in amenorrhea.
Patients at the greatest risk of exercise-induced infertility are long-distance runners. Thirty to 60 minutes of
daily aerobic exercise is considered normal and desirable.
(Choice F) Premature ovarian failure refers to menopause before age 40. Premature ovarian failure causes
amenorrhea and can be due to autoimmune conditions. heritable factors. exogenous factors such as radiation
exposure. and as an idiopathic condition.

Educational objective:
The most common cause for decreased fertility in women in their fourth decade who are still experiencing
menstrual cycles is age-related decreased ovarian reserve.