The following statement(s) is/are true about liver disorders in women with PCOS:

• a)

  Non-alcoholic fatty liver disease (NAFLD) is the most common liver disorder in women with PCOS.

• b)

  High body mass index level is the major risk factor to link the association between PCOS and NAFLD.

• c)

  Waist circumference and central obesity are more sensitive than the presence of NAFLD in predicting the complications of metabolic disturbances in women with PCOS.

• d)

  Elevated aminotransferase levels in women with PCOS may represent a higher severity of NAFLD.

• e)

  Caspase 3-cleaved fragment of cytokeratin 18 has been found to be associated with progressive hepatocyte injury in women with PCOS

Women with PCOS have been reported to have higher prevalence of NAFLD and NASH diagnosed by which of the following investigations?

• a)

  Liver biopsy

• b)

  Magnetic resonance spectroscopy

• c)

  Computed tomography

• d)

  Abdominal ultrasonography

• e)

  Positron emission tomography

Biochemical or clinical hyperandrogenism is one of the most clinical characteristics of women with PCOS and is associated with the elevated risk of metabolic disturbance and liver disorder. The following statement(s) is/are true about hyperandrogenism and anti-androgen treatment in relationship to hepatic steatosis in women with PCOS:

• a)

  Statins, a lipid lowering agent, are effective in reducing hyperandrogenemia in women with PCOS

• b)

  Statins are effective in reducing biopsy-proved liver-related morbidity and mortality in women with PCOS.

• c)

  Both elevated adrenal and ovarian androgen levels in women with PCOS are associated with an increased risk of NAFLD.

• d)

  Flutamide, a potent anti-androgen, used for treating acne and hirsutism in women with PCOS, should be used with caution due to the concern of hepatotoxicity.

• e)

  Oral contraceptives and spironolactone could be beneficial in treating menstrual irregularity, hyperandrogenism and NAFLD in women with PCO

The following is/are the criteria required to diagnose polycystic ovarian syndrome:

• a)

  Hirsutism

• b)

  Insulin resistance

• c)

  Elevated low density lipoprotein cholesterol

• d)

  Elevated testosterone

• e)

  Ovary volume > 10 cm ³

With regards to the prevalence of PCOS which of the following is/are true?

• a)

  It is variable due to the different diagnostic criteria used

• b)

  It is higher in Caucasians compared to East Asian women

• c)

  The prevalence of PCOS in the Chinese population is 5%

• d)

  Utilizing the Rotterdam criteria reduces the number of women diagnosed with PCOS

• e)

  Subjective variation in clinical assessment of hirsutism can have an impact on making the diagnosis of PCOS in women

With regards to hirsutism in women which of the following is/are true?

• a)

  Thai women have the lowest value of mFG score amongst women of Asian ethnicities

• b)

  South Asian women have the highest mFG score amongst women of Asian ethnicities

• c)

  Caucasian women are more hirsute than Middle Eastern women

• d)

  Hirsutism is a good marker of androgen excess

• e)

  It is not a requirement to diagnose PCOS based on the NIH 1990 criteria

The following is/are true regarding the ultrasound assessment of ovarian morphology for women in making the diagnosis of PCOS?

• a)

  The threshold value for measurement of ovarian volume to diagnose PCOS in Asian women is more than 7 cm ³

• b)

  Ovarian follicles numerically more than 12, measuring 2 to 9 mm, is a prerequisite of the NIH 1990 criteria to diagnose PCOS

• c)

  Higher prevalence of the polycystic ovarian morphology has been reported in East Asian PCOS populations compared to Caucasian PCOS subjects

• d)

  The ovary reaches its maximum volume after puberty

• e)

  Age-related decline in antral follicle count (AFC) among women with PCOS is slower than in those without PCOS

Which sonographic parameter(s) is/are included in the ultrasound criteria of PCOM?

• a)

  Follicle number per ovary (FNPO)

• b)

  Ovary volume

• c)

  Stromal echogenicity

• d)

  Stromal volume

• e)

  Stromal blood flow

In the updated criteria, AEPS guideline suggested which of the following?

• a)

  Increase the threshold of follicle number per ovary to 25

• b)

  Lower the threshold of ovarian volume to 8 cm ³

• c)

  Add follicular distribution as a junctive marker

• d)

  Include ratio of ovarian stroma to total ovarian size >0.32 for PCOM definition

• e)

  Use the follicle counts in a single cross section (FNPS) ≥9 to define PCOM

The following statement(s) is/are true about the ovarian volume?

• a)

  Ovarian volume remains relatively constant in healthy young girls and women until the menopause.

• b)

  The calculation of ovarian volume has been performed using the formula for a prolate ellipsoid (π/6 × length × width × thickness of the ovary)

• c)

  Compared to FNPO, the diagnostic accuracy of ovarian volume is lower when discriminating between PCOS and normal controls.

• d)

  The use of internal reference normal values of ovarian volume for diagnosis of PCOM is recommended.

• e)

  3D measurement of ovarian volume is recommended in PCOM diagnosis since it is more accurate and reproducible.

What feature(s) make ultrasound diagnosis of PCOM challenging in adolescents?

• a)

  Lack of normative data on ovarian morphology

• b)

  Poor image quality provided by transabdominal ultrasound

• c)

  Considerable variation in ovarian morphology in adolescents

• d)

  Polycystic morphological changes of the ovaries not beginning in adolescence

• e)

  The difficulty of differential diagnosis from the multi-cystic ovary

The component features of Metabolic Syndrome (MbS) include which of the following?

• a)

  Raised BP

• b)

  Raised serum TG

• c)

  Raised serum HDL-C

• d)

  PCOS

• e)

  Raised serum glucose

Metabolic surveillance in PCOS includes which of the following?

• a)

  BP

• b)

  Waist Circumference (WC)

• c)

  BMI

• d)

  OGTT

• e)

  Fasting serum insulin

Regarding lifestyle intervention in PCOS which of the following is/are true?

• a)

  Weight loss of >20% total body weight is required to improve both metabolic and reproductive outcomes

• b)

  Exercise can improve metabolic parameters in the absence of weight loss

• c)

  Modification of macronutrient content can augment weight loss

• d)

  Combined exercise and dietary advice should be limited to overweight/obese women

• e)

  The metabolic benefits of exercise between PCOS women and non-PCOS controls are comparable

Regarding other therapies in PCOS which of the following is/are true?

• a)

  Bariatric surgery should be avoided in women who plan to fall pregnant in the future

• b)

  Metformin has been associated with reductions in BMI and adiposity in meta-analysis data

• c)

  Metformin reduces the risk of OHSS with assisted reproductive technologies

• d)

  Metformin is recommended as second-line therapy in overweight/obese PCOS women with persistent menstrual irregularity despite lifestyle intervention

• e)

  Thiazolidinediones such as rosiglitazone are recommended in PCOS women who cannot tolerate metformin due gastrointestinal upset

The following is/are true in relation to serum AMH?

• a)

  The correlation between AMH and the current diagnostic PCOS criteria is not robust

• b)

  There is a significant correlation between serum AMH and the antral follicle count (AFC)

• c)

  There is lack of international standardisation of the AMH assay.

• d)

  Each AMH result needs to interpreted depending upon the specific assay

• e)

  It has been suggested that AMH could be used interchangeably with the AFC as a diagnostic criterion for PCOS

Which of the following statements is/are true regarding AMH?

• a)

  AMH is expressed by the granulosa cells in the ovarian antral follicles.

• b)

  Serum AMH is significantly higher in women with PCOS than those with normal ovaries.

• c)

  High serum AMH values in PCOS are due to an increased concentration of antral follicles.

• d)

  High serum AMH values in PCOS are due to an increased production of AMH per antral follicle.

• e)

  Serum AMH values are significantly higher in the ovulatory phenotypes of PCOS as compared to those with anovulation.

Which of the following serum levels are considered to be the single most sensitive test for biochemical hyperandrogenism?

• a)

  Total T

• b)

  Free T

• c)

  DHEAS

• d)

  DHEA

• e)

  A4

Which of the following should be included in the differential diagnosis of hyperandrogenism?

• a)

  21-hydroxylase deficient non-classic congenital adrenal hyperplasia

• b)

  Hypogonadotropic hypogonadism

• c)

  Androgen-secreting neoplasms

• d)

  Cushing’s disease

• e)

  5α-reductase deficiency

Which of the following should be considered as first line treatment for hirsutism?

• a)

  Hormonal contraceptives

• b)

  Insulin sensitizers

• c)

  5α-reductase agonists

• d)

  Spironolactone

• e)

  Glucocorticoids

The following statement(s) is/are true about polycystic ovarian morphology (PCOM):

• a)

  There is an increased number of primordial follicles in polycystic ovaries compared with normal ovaries

• b)

  Growth differentiation factor (GDF)-9 is under-expressed in polycystic ovaries compared with normal ovaries

• c)

  Anti-müllerian hormone (AMH) expression is greater in the primordial and primary follicles from polycystic ovaries compared with the same stage follicles from normal ovaries

• d)

  AMH expression is greater in the antral follicles from polycystic ovaries compared with the same stage follicles from normal ovaries

• e)

  Vascular endothelial growth factor (VEGF) is over-expressed in the stroma of polycystic ovaries compared with the stroma of normal ovaries

Insulin resistance leading to compensatory hyperinsulinaemia in PCOS results in increased endogenous androgen levels via which of the following mechanisms?

• a)

  Excess insulin binds to the insulin-like growth factor (IGF)-1 receptors

• b)

  Excess insulin increases the synthesis of sex hormone binding globulin (SHBG) by the liver

• c)

  Excess insulin stimulates the hepatic secretion of insulin-like growth factor binding protein (IGFBP)-1

• d)

  Excess insulin acts synergistically with luteinising hormone (LH)

• e)

  Excess insulin increases cytochrome P450c17α enzyme activity

The following statements about the hypothalamic-pituitary ovarian axis is/are true:

• a)

  Throughout the normal menstrual cycle, the GnRH pulse frequency and amplitude remains consistent

• b)

  The kiss 1 system located in the arcuate nucleus of the hypothalamus acts as the GnRH pulse generator

• c)

  Serum LH concentrations are universally elevated in women with PCOS

• d)

  In women with PCOS, high levels of androgens directly affect LH pulsatility

• e)

  Increased opioid and dopaminergic tone results in tonic hypersecretion of LH

The following is/are true regarding women with PCOS:

• a)

  They present with high endometrial cancer risk that is only related to obesity

• b)

  They present with three to fivefold risk for endometrial cancer

• c)

  They present with an increased endometrial cancer risk especially after the menopause

• d)

  Obesity aggravates endometrial cancer risk

• e)

  They have increased endometrial cancer risk already at younger ages

In healthy women estrogen receptors are which of the following?

• a)

  Absent in the secretory phase of the menstrual cycle

• b)

  Expressed the highest levels in the secretory phase of the menstrual cycle

• c)

  Downregulated by progesterone

• d)

  Upregulated by progesterone

• e)

  May have synergistic activation with insulin

The following is/are further true regarding women with PCOS:

• a)

  Have been suggested to have an impaired endometrial steroid hormone response and shallow placentation that may lead to pregnancy complications

• b)

  Have a lower risk for pre-eclampsia and preterm delivery compared with controls

• c)

  Have increased HOXA10 expression in secretory phase endometrium

• d)

  May have decreased IGFBP-1 response to progesterone during decidualization

• e)

  Present with an altered inflammatory endometrial profile

Which of the following is/are true regarding screening for markers related to altered endometrial function?

• a)

  There are several clinically validated specific markers related to impaired implantation process or endometrial cancer in women with PCOS

• b)

  In clinical practice women with PCOS should be regularly screened for endometrial markers related to impaired endometrial function

• c)

  More studies should be conducted to identify endometrial markers that have clinical relevance in order to establish recommendations for clinical practice

• d)

  Women with PCOS should be screened for endometrial cancer if they present with several risk factors

• e)

  Women with PCOS should be informed about their risk for endometrial cancer

Treating women with PCOS for endometrial abnormalities includes which of the following?

• a)

  The factors impairing the peri-conceptual environment should be discussed with women with PCOS prior to conception

• b)

  Women with PCOS and with amenorrhea/oligomenorrhea should be treated with progestins to protect the endometrium

• c)

  Metformin has been shown to have beneficial effects on endometrial health

• d)

  Women should be encouraged to make life style changes to decrease weight

• e)

  Progestins may not be enough to rescue normal endometrial health in PCOS

Which enzyme(s) regulates the first rate limiting reaction in the steroid biosynthesis pathway?

• a)

  P450 side chain cleavage enzyme, which is found in the inner mitochondrial membrane

• b)

  Steroidogenic acute regulatory protein, which is found in the outer mitochondrial membrane

• c)

  3β-hydroxysteroid dehydrogenase type 2, that catalyzes multiple steps in the steroidogenesis pathway

• d)

  Aromatase, which converts testosterone to estradiol

• e)

  Cytochrome P450 17A1, which has both 17alpha-hydroxylase and 17, 20-lyase enzymatic activities

For which of the following reasons is/are 8-Bromoadenosine 3′, 5′-cyclic monophosphate (8Br-cAMP) added to the adrenal NCI-H295R cells?

• a)

  To mimic the physiological LH stimulation of adenylyl cyclase activity in adrenal cells

• b)

  8Br-cAMP increases the steroidogenic capacity by encouraging the adrenal cells to proliferate

• c)

  8Br-cAMP results in decreased gonadotropin-releasing hormone via negative feedback thus resulting in increased expression of steroidogenic enzymes

• d)

  To mimic the physiological ACTH stimulation of adenylyl cyclase activity in adrenal cells

• e)

  8Br-cAMP is also a substrate for the StAR enzyme in the absence of cholesterol and can be imported into the cells to initiate steroidogenesis