Clinical Vignettes

Vignette 1
An 8-year-old African American girl is brought to your ofce by her
parents concerned that she has started developing breasts too soon.
Physical examination reveals a Tanner stage II breast and pubic hair
growth.
1. Breast bud development is the beginning of what stage of
puberty?
a. Thelarche
b. Adrenarche
c. Pubarche
d. Menarche
e. Accelerated growth
2. You reassure the parents that this is normal. What is typical
pubertal sequence?
a. Menarche, pubarche, thelarche, accelerated growth
b. Pubarche, thelarche, accelerated growth, menarche
c. Thelarche, pubarche, accelerated growth, menarche
d. Accelerated growth, thelarche, pubarche, menarche
e. Pubarche, accelerated growth, thelarche, menarche
3. When can the patient expect her rst menses?
a. At 14 years of age
b. At 12 years of age
c. At 11 years of age
d. At 13 years of age
e. Its impossible to tell from the data provided

Vignette 2
A 28-year-old patient is in your ofce to discuss the possibility of
getting pregnant. As part of her history you take thorough menstrual
history. She states that she had menarche at age 12. Initially her menses was irregular, but since she was 16 her menses has been every
30 days and last for 5 days. She uses four to ve tampons a day and
denies dysmenorrhea.
1. The menstrual cycle is divided into which two phases when
describing the endometrium?
a. Follicular and secretory phases
b. Follicular and luteal phases
c. Proliferative and luteal phases
d. Proliferative and secretory phases
e. Atrophic and menstrual

2. Which of these structures does NOT produce progesterone?

a. Placenta
b. Endometrium
c. Corpus luteum
d. Follicle
e. Adrenal cortex
3. The patient comes back to your ofce and she is pregnant. What
hormone does the developing trophoblast produce?
a. Human chorionic gonadotropin (hCG)
b. Progesterone
c. Androstenedione
d. LH
e. Estrogen

Vignette 3
A 51-year-old woman presents to your ofce amenorrhea for the
past year. Since she has not had any hot ashes, she is wondering if
she is menopausal.
1. What blood test would conrm the diagnosis of menopause?
a. FSH
b. Estrogen
c. Testosterone
d. Human chorionic gonadotropin (hCG)
e. Prolactin
2. Early menopause is more common in all of the following except:
a. in nulliparous women
b. women with hypertension
c. women who smoke
d. women with type 1 diabetes
e. women with family history of early menopause
3. Which of the following is NOT a symptom of menopause?
a. Hot ashes
b. Insomnia
c. Visual changes
d. Vaginal atrophy
e. Night sweats

Vignette 4
A 51-year-old woman presents to your ofce to discuss hormone
replacement therapy (HRT). She has been amenorrheic for more
than a year. She reports hot ashes multiple times a day and daily

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night sweats. These symptoms are interfering with her concentration and sleep.
1. Which of the following is NOT a contraindication to HRT?
a. History of a deep vein thrombosis
b. History of breast cancer
c. Cirrhosis
d. Smoking
e. History of pulmonary emboli
2. What is the ONLY indication for HRT?
a. Osteoporosis prevention
b. Vaginal dryness treatment

c. Hot ashes and night sweats interfering with quality of life

d. Cardiovascular disease prevention
e. Dementia prevention
3. The patient has not had a hysterectomy. If the patient is started
on estrogen replacement, what other hormone also needs to be
prescribed?
a. Progesterone
b. FSH
c. Human chorionic gonadotropin (hCG)
d. Testosterone
e. Vaginal estrogen cream

Answers

Vignette 1 Question 1
Answer A: The rst stage of STET thelarche is breast bud development
and is the rst phenotypic sign of puberty. Adrenarche is when the
adrenal gland begins regeneration of the zona reticularis, which is
responsible for the secretion of sex steroid hormones. Pubarche is the
onset of pubic hair growth. Menarche is the rst menses.
Vignette 1 Question 2
Answer D: The normal pubertal sequence is initiated with
accelerated growth. Breast development (thelarche) is next, followed
by appearance of pubic hair (pubarche). Onset of menstruation
(menarche) is at the end. A normal variant seen most commonly with
African American girls is that pubarche precedes thelarche.
Vignette 1 Question 3
Answer C: Average length of time from breast bud development to
menstruation in typically 2.5 years and so you would expect her to
have her menses between 10 and 11 years of age. The other ages are
all later than you would expect.
Vignette 2 Question 1
Answer D: The menstrual cycle is divided into the follicular and luteal
phases in respect to changes in the ovary over the length of the
cycle. The proliferative and secretory phases describe the concurrent
changes in the endometrium. Options A and C are both wrong
because these describe a phase in respect to both the ovary and
endometrium. Atrophic and menstrual are terms used to describe the
status of the endometrium but this terminology is not used for phases
of the menstrual cycle.
Vignette 2 Question 2
Answer B: The endometrium does not produce progesterone. The
corpus luteum produces progesterone to maintain the endometrium
until the placenta takes over at 8 to 10 weeks gestation. In the absence
of fertilization, the corpus luteum degenerates and the progesterone
levels fall, so the endometrium is unable to be maintained resulting
in a menstruation. The follicle produces progesterone in response to
the LH surge and results in ovulation. This follicle then becomes the
corpus luteum after ovulation.
Vignette 2 Question 3
Answer A: The trophoblast produces hCG to maintain the corpus
luteum. Without this rise in hCG it signals to the corpus luteum that
fertilization has not occurred and triggers the cascade that results
in menstruation. The follicle produces progesterone in response to
the LH surge and results in ovulation. This follicle then becomes
the corpus luteum after ovulation. The corpus luteum produces

progesterone to maintain the endometrium until the placenta

takes over at 8 to 10 weeks gestation. Androstenedione is produced
by the theca interna cells. LH is produced by the anterior pituitary
gland.
Vignette 3 Question 1
Answer A: An FSH level greater than 40 IU/L is diagnostic of
menopause. Estrogen levels do not consistently predict menopause,
especially if there is peripheral conversion of estrogen in the morbidly
obese patient. Testosterone has no role in predicting menopause. If
there is a presence of hCG at this age, pregnancy (though unlikely)
and gestational trophoblastic disease must be ruled out. Prolactin
is produced in the anterior pituitary and causes milk secretion
from the breast and preventing ovulation in lactating women. High
prolactin levels (hyperprolactinemia) may result in galactorrhea and/
or amenorrhea. It is not diagnostic of menopause.
Vignette 3 Question 2
Answer B: The average age of menopause is 51, with 90% of women
experiencing this change between ages 47 and 55. Hysterectomy and
tubal ligation are associated with a slightly earlier menopause (1-2 years).
Early menopause is dened as occurring between ages 40 and 45. Early
menopause is more common in women with a history of cigarette
smoking, short cycles, nulliparity, type 1 diabetes, in utero exposure
to diethylstilbestrol (DES), and family history of early menopause.
Hypertension has not been shown to increase the risk of early menopause.
Menopause occurring before age 40 is considered premature ovarian
insufciency (previously termed premature ovarian failure).
Vignette 3 Question 3
Answer C: Hot ashes, insomnia, and vaginal atrophy are all common
symptoms of menopause and are a result of the diminished estrogen
production. Visual changes are age related and not a direct effect of
menopause.
Vignette 4 Question 1
Answer D: Contraindications to HRT include chronic liver impairment,
pregnancy, known estrogen-dependent neoplasm (breast, ovary,
uterus), history of thromboembolic disease (DVT, PE, CVA), and
unevaluated vaginal bleeding. Oral contraceptives, but not HRT, are
contraindicated in elderly smokers. However, the principal conclusion
of the Womens Health Initiative (WHI) study was that the lowest dose
possible should be chosen, especially in patients with an increased
cardiovascular risk, as is the case in smokers.
Vignette 4 Question 2
Answer C: Currently, the only clinical indication for HRT is moderate
to severe vasomotor symptoms including hot flashes and night

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sweats. An added benefit of HRT is the prevention and treatment

of osteoporosis, however, HRT should not be a first-line therapy
for the prevention or treatment of osteoporosis HRT use should
be limited to the lowest dose necessary to control vasomotor
symptoms and for the shortest period of time needed. If vaginal
dryness is the primary symptom, this patient would best be
treated with lubricants and moisturizers first, followed by low-dose
vaginal estrogen so that there is minimal systemic absorption. HRT

should not be used to treat or prevent cardiovascular disease or

dementia.
Vignette 4 Question 3
Answer A: When estrogens are being used to treat menopausal
symptoms in women who still have uterus in situ, progestins must
be used to decrease the risk of endometrial hyperplasia and cancer.
None of the other options would be protective of the endometrium.