ABIM Exam Review Practice Question of the Week: 32 y.o female with amenorrhea

This week’s sample ABIM Exam Review Question straight from the Knowmedge QVault covers amenorrhea, a topic covered in the endocrinology section of the ABIM Board Exam blueprint




32-year-old female presents to the office for amenorrhea which she has been experiencing for the past five months. Prior to this she has had regular periods since the age of 14. She has two kids and one spontaneous miscarriage for which she had a dilatation and curettage performed. She denies facial acne or hirsutism. The patient’s pregnancy test, thyroid function tests, prolactin level, and FSH levels are all within normal limits. She undergoes a progestin withdrawal challenge without having menstruation. Which of the following is the best next step at this time?


A. Perform a hysteroscopy

B. Obtain the patient’s 24-hour urine cortisol level

C. Obtain the patient’s 17-OH progesterone level

D. Perform a transvaginal pelvic ultrasonography

E. Obtain the patient’s estradiol level





The clue in this question is that the patient had a dilation and curettage done and has no menstruation after progestin withdrawal. The history of gynecological surgical procedures increases the risk of anatomic defects, endometrial problems or scarring (Asherman syndrome). When no menstruation occurs after progestin withdrawal, the problem can be classified into either chronic anovulation with low estrogen or an anatomic defect. This indicates that Choice D (Transvaginal pelvic ultrasonography) is the best next step at this time to evaluate the anatomy of the female reproductive tract and to rule out structural abnormalities.


Let’s go over the other answer choices:
  • Choice A (Hysteroscopy) may be done at a later time but not initially since this is invasive and would not be cost effective.
  • Choice B (Obtain the patient’s 24-hour urine cortisol level) and Choice C (17-OH progesterone) would be indicated if we were considering chronic anovulation with estrogen present – that is if the patient had menstruation after progestin withdrawal. In this patient, menstruation did not occur after progestin withdrawal.
  • Choice E (Estradiol level) is used to help us determine if the patient has ovarian failure. In ovarian failure, patients will have decreased estradiol levels and increased FSH levels. The patient’s FSH is normal meaning she does not have ovarian failure – therefore, estradiol does not need to be checked.

    You can see all the previous ABIM Exam Review Questions of the Week at the Knowmedge Blog. You can also find additional topics and questions directly from the Knowmedge Internal Medicine ABIM Board Exam Review Questions QVault.

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