MCQs for Specialty Certificate Examination (SCE)

in Endocrinology and Diabetes

MCQs (31 - 45)

Collected by : Dr . AHMED ELKONDI

MRCGP int
Specialty Certificate in Endocrinology and Diabetes
31- An 18-year-old woman with idiopathic isolated GH deficiency was referred from the pediatric endocrinologist to
the adult endocrinology clinic. She had no other chronic diseases. In the past 12 months, her height had not changed.
She had had her first menstrual period at the age of 14. She was taking somatropin 1.5 mg daily.
On examination, her height was 169 cm.
What is the most appropriate next step in management?
A: continue somatropin at the same dose
B: increase somatropin dose
C: measure serum insulin-like growth factor 1
D: MR scan of pituitary
E: reassessment of GH status

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31-Correct answer: E
reassessment of GH status.
32- All of the following represent examples of hypothalamic pituitary negative feedback EXCEPT:
A. Cortisol on the CRH-ACTH axis
B. Gonadal steroids on the GnRH-LH/FSH axis
C. IGF-1 on the growth hormone–releasing hormone (GHRH)-GH axis
D. Renin-angiotensin-aldosterone axis
E. Thyroid hormones on TRH-TSH axis

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32 -Correct answer: D
Feedback control may be either positive or negative. The primary means of hormone control
within the endocrine system is negative feedback. For example, when a steroid hormone level is
sensed to be low by the hypothalamus, a releasing hormone is released, which effects the release
of a stimulatory hormone from the pituitary, and the target gland secretes the steroid hormone
and plasma levels rise. The hypothalamus then senses this and decreases the release of the
releasing hormone
33 - Secretion of gonadotropin-releasing hormone (GnRH) normally stimulates the release of luteinizing hormone (LH) and follicle-
stimulating hormone (FSH), which promote the production and release of testosterone and estrogen. Which mechanism best explains
how long-acting gonadotropin-releasing hormone agonists (e.g., leuprolide) decrease testosterone levels in the management of
prostate cancer?
A. GnRH agonists also promote the production of sex hormone–binding globulin, which decreases the availability of testosterone.
B. Negative feedback loop between GnRH and LH/FSH.
C. Sensitivity of LH and FSH to pulse frequency of GnRH.
D. Translocation of the cytoplasmic nuclear receptor into the nucleus with constitutive activation of GnRH

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33 -Correct answer: C
Intermittent pulses of GnRH are necessary to maintain pituitary sensitivity to the hormone.
Continuous exposure to GnRH causes pituitary gonadotrope desensitization, which ultimately
leads to decreased levels of testosterone.
34- All of the following hormones are produced by the anterior pituitary EXCEPT:
A. Adrenocorticotropic hormone
B. Growth hormone
C. Oxytocin
D. Prolactin
E. Thyroid-stimulating hormone

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34- Correct answer : C

Hormones produced by the anterior pituitary include adrenocorticotropic hormone, thyroid-
stimulating hormone, luteinizing hormone, follicle-stimulating hormone,
prolactin, and growth hormone. The posterior pituitary
produces vasopressin and oxytocin
 35 - A 22-year-old woman who is otherwise healthy undergoes an uneventful vaginal delivery of a full-term infant. One
day postpartum she complains of visual changes and severe headache. Two hours after these complaints, she is found
unresponsive and profoundly hypotensive.
She is intubated and placed on mechanical ventilation. Her blood pressure is 68/28 mmHg,
heart rate is regular at 148 beats/min, and oxygen saturation is 95% on FiO2 0.40.
Physical exam is unremarkable. Her laboratories are notable for glucose of 49 mg/dL and normal hematocrit and white
blood cell count.
Which of the following is most likely to reverse her hypotension?
A. Activated drotrecogin alfa
B. Hydrocortisone
C. Piperacillin/tazobactam
D. T4
E. Transfusion of packed red blood cells

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35 - Correct answer: B
The patient has evidence of Sheehan’s syndrome postpartum.
In this syndrome, the hyperplastic pituitary postpartum is at increased risk for hemorrhage
and/or infarction - This leads to bilateral visual changes, headache, and meningeal signs
Pituitary CT or MRI may show signs of sellar hemorrhage
The hypoglycemia and hypotension present in this case suggest failure of the glucocorticoid
system; thus treatment with a corticosteroid is indicated.
36- A 55-year-old woman presents with her husband to the endocrine clinic. She has distressing symptoms of
sweating, and her husband noticed increased prominence of her jaw when he was archiving photos from
recent years. Last year she was diagnosed with type-2 diabetes. Other past history of note is that she has
recently been operated on for carpal tunnel syndrome.
Which of the following most likely to fit with her condition?
A. IGF-1 levels are likely to be normal
B. Growth-hormone levels are likely to remain above 2 mU/l after a 75-g glucose load
C. Random growth-hormone level is likely to be < 1 mU/l
D. Hypertension coexists in 20% of patients with this condition
E. 1-25-OH vitamin D level is invariably normal

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36 -Correct answer: B
The diagnosis here is acromegaly.
A random growth hormone level of < 1 mU/l excludes the diagnosis, growth-hormone levels
usually remain above 2 mU/l after an oral glucose tolerance test.
37- A 30-year-old woman presents to her GP with a history of amenorrhoea and galactorrhoea. She is keen to become
pregnant and has been trying for 9 months to conceive without success. She is of normal weight and has no other
constitutional symptoms.
Which of the following is most likely to be the reason for her symptoms?
A. Drug treatment she is on for asthma
B. Pituitary microadenoma
C. Hypothyroidism
D. Previously undiagnosed hepatic impairment
E. Hyperthyroidism

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37 -Correct answer: B
Her symptoms are consistent with hyperprolactinaemia. Hyperthyroidism is not associated with hyperprolactinaemia
and galactorrhoea, although it can cause amenorrhoea and fertility problems.
While hyperprolactinaemia can be present in hypothyroidism it is usually associated with menorrhagia rather than
amenorrhoea
38 - A 34-year-old woman with a long history of type-1 diabetes, microalbuminuria and diabetic eye disease
presents for review. She has been amenorrhoeic for 12 months and recent pregnancy tests have been negative. She
has a healthy 1-year-old child but suffered a postpartum haemorrhage just after his birth. Over the past few months
she has also been increasingly tired and has noticed thinning of her pubic and axillary hair.
On examination she is slim and pale, with small breasts and thin or largely absent pubic and axillary hair. ACTH,
FSH, LH are all low, with TSH just below the normal range. MRI of the pituitary gland reveals an empty sella.
What diagnosis fits best with this clinical picture?
A. Polyglandular syndrome
B. Metastatic carcinoma
C. Prolactinoma
D. Sheehan’s syndrome
E. Weight-related pituitary failure

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38 -Correct answer: D
Sheehan’s syndrome is well known to occur in women due to postpartum haemorrhage and hypovolaemic
shock, but the risk of it occurring is increased in women with type-1 diabetes who have microvascular
disease, and in patients with sickle-cell anaemia. It is said to occur in 1 in 10,000 deliveries.
Initial management includes immediate steroid therapy with later full endocrine assessment and
replacement of pituitarydependent hormones (eg thyroxine) as required.
39-A 16 year old girl complains of constant headache and general lethargy. On inspection she is noted to be short for her age. On examination she is
found to have bilateral temporal field deficits. Her GH, ACTH and TSH levels are low. Her plasma level of prolactin is increased. Radiographic
examination shows retarded bone age. The most likely diagnosis is :
A. Constitutional delay
B. Hypothyroidism
C. Ovarian dysgenesis
D. Optic chiasm glioma
E. Craniopharyngioma

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39 - Correct answer: E
Craniopharyngioma is the most common brain neoplasm of nonglial origin and the most common brain tumor
associated with hypothalamic-pituitary dysfunction and sexual infantilism.
Clinical manifestations include headache, visual disturbances, short stature, symptoms of diabetes insipidus, and
weakness of one or more limbs. Physical findings include visual defects (including bilateral temporal field deficits),
optic atrophy or papilledema, and signs of GH deficiency, delayed puberty, and hypothyroidism.
Although only a few patients seek evaluation because of short stature, most are below the mean in height and height
velocity at the time of diagnosis.
Laboratory evaluation often indicates deficiencies in one or more pituitary hormones, including gonadotropins, GH,
thyrotropin (thyroid-stimulating hormone [TSH]), corticotropin, and vasopressin (AVP). The plasma level of
prolactin may be normal or increased. Radiographic examination often shows retarded bone age.
40 -A mutation affecting the development of the diencephalon could interfere with the secretion of which of
the following hormones?
A. Adrenocorticotrophic hormone (ACTH)
B. Epinephrine
C. Oxytocin
D. Prolactin
E. Thyroid stimulating hormone (TSH)

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40 - Correct answer: C
The neurohypophysis (posterior pituitary) is derived from an evagination of diencephalic neurectoderm.
This structure is responsible for releasing oxytocin and vasopressin to the general circulation.
Both hormones are synthesized in cell bodies contained within the hypothalamus.
ACTH (choice A), prolactin (choice D), and TSH (choice E) are all synthesized and released by the
anterior pituitary, or adenohypophysis, which is derived from an evagination of the ectoderm of Rathke's
pouch, a diverticulum of the primitive mouth. Remnants of this pouch may give rise to a
craniopharyngioma in later life.
Epinephrine (choice B) is synthesized and released into the circulation by the adrenal medulla, a neural
crest derivative.
41- The secretion of hormones from the adrenal gland is regulated by various hormones, extracellular fluid
volume status, electrolyte levels, and cytokines.
Which of the following factors/hormones do not play a part in the regulation of synthesis and secretion of
mineralocorticoids (aldosterone) from zona glomerulosa?
A. ACTH
B. Adrenaline
C. Angiotensin 2
D. Atrial natriuretic peptide
E. Potassium

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41- Correct answer B .

The secretion of mineralocorticoids from the zona glomerulosa is regulated primarily by angiotensin 2, serum
potassium levels, and ACTH. Atrial natriuretic peptide and dopamine can also influence the secretion of
mineralocorticoids.
ACTH plays a key part in regulation of glucocorticoid secretion from the zona fasciculata. Cytokines such as
interleukin-1, interleukin-6, and TNFα, along with catecholamines, also have a minor role in the regulation of
glucocorticoid secretion by the zona fasciculata.
42 -Adrenal gland development starts at about week 6 of embryological development, with the cortex
developing from mesoderm of the posterior abdominal wall, while the inner medulla is derived from
neuroectoderm.
Which one of the following statements regarding adrenal gland physiology and development is correct?
A. Cholesterol is an essential substrate for catecholamine synthesis
B. Conversion of pregnenolone to progesterone is driven by ACTH
C. Plasma lipoproteins are a major source of cholesterol to adrenals
D. The foetal adrenal glands are smaller than the adult glands
E. Zona glomerulosa contains 17α-hydroxylase enzyme

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42- Correct answer C.
At about 4 months’ gestation, the adrenal glands are about four times the size of the kidneys, although there is
significant regression of the adrenal cortex at birth. The zona fasciculata starts to develop from the age of 4–5 years
in children.
Plasma lipoproteins are the major source of cholesterol to the adrenal glands. The conversion of cholesterol to
pregnenolone is the major site of action of ACTH. The zona glomerulosa is deficient in 17α-hydroxylase and, as a
result, it cannot produce cortisol or androgens.
The zona reticularis continues to develop until the age of 20–25 years, with adrenal androgens playing a role in the
development of pubic and axillary hair. This layer undergoes regression after the reproductive phase of life. The
adrenal androgens do not play any significant role in adult males, although in adult females they are the main source
of androgens. Excess adrenal androgen production in women may result in menstrual irregularities, acne, and
features of hirsutism. The adrenal androgens are secreted in increasing amounts at the age of 6–7 years in girls and
7–8 years in boys. The axillary and pubic hair regions are the most sensitive androgen- dependent areas.
43-The hypothalamic–pituitary–adrenal axis plays a key part in maintaining homeostasis, metabolism, and energy consumption.
There is increased production of cortisol when faced with stressors which, in turn, leads to the regulation of multiple functions
essential for maintaining homeostasis and cellular integrity.
Which one of the following physiological changes is attributed to stress- related activation of the hypothalamic–pituitary–adrenal
axis leading to enhanced cortisol production?
A. Decreased free T4 levels
B. Decreased glycogenolysis
C. Decreased GnRH
D. Increased appetite
E. Increased GH levels

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43- Correct answer C.
The stress-mediated response to increased cortisol production (due to activation of the hypothalamic–pituitary–adrenal (HPA)
axis) includes CRH-induced anorexia, GnRH, and GH suppression. The stress-induced increased levels of endogenous
glucocorticoids result in increased glycogenolysis, hepatic gluconeogenesis, and increased LDL cholesterol levels
TSH secretion, as well as peripheral conversion of FT4 to biologically active FT3, is reduced, although the FT4 levels remain
within the normal limit
44- Adrenal steroid hormones are derived from cholesterol, with plasma lipoproteins acting as the main source
for it. The conversion of cholesterol to pregnenolone is one of the key steps in adrenal steroid hormone
synthesis.
Which one of the following enzymes mediates the conversion of cholesterol to pregnenolone in adrenal
mitochondria?
A. 17α-hydroxylase
B. 11β-hydroxylase
C. 3 β-hydroxyl steroid dehydrogenase (3 β-HSD)
D. 21-hydroxylase
E. P450 side chain cleavage enzyme (P450 scc)

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44 - Correct answer E.
The free cholesterol transfer from the outer to inner mitochondrial membrane is facilitated by steroid acute
regulatory protein
This is followed by side chain cleavage of cholesterol, mediated by P450 scc enzyme, leading to the formation
of pregnenolone. The conversion of pregnenolone to 17-hyroxy pregnenolone is regulated by 17α-hydroxylase
enzyme. 3β-hydroxyl steroid dehydrogenase enzyme mediates conversion of 17α-pregnenolone to
17α-progesterone.
21-hydroxylase mediates conversion of 17α-progesterone to 11-deoxycortisol, while 11β- hydroxylase leads to
conversion of 11- deoxycortisol to cortisol
45- Conversion of 17-hydroxy progesterone to 11 deoxycortisol is the penultimate step in the synthesis of
adrenal glucocorticoids.
Which one of the following enzymes mediates conversion of 17-hydroxy progesterone to 11 deoxycortisol?
A. 17 α-hydroxylase
B. 11 β-hydroxylase
C. 3 β-hydroxyl steroid dehydrogenase (3 β-HSD)
D. 21-hydroxylase
E. P450 side chain cleavage enzyme (P450 scc)

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45 - Correct answer D.
Enzyme 21-hydroxylase mediates the conversion of 17-hydroxy progesterone to 11deoxycortisol. The
autoimmune adrenal insufficiency is characterized by elevated auto-antibodies to 21-hydroxylase enzyme,
leading to reduced/absent cortisol synthesis in adrenals..
Obesity Screening :
Population
-All adults, children > 6y-old, and adolescents.
Recommendations
-Screen all adults using body mass index (BMI) and offer intensive counselling and behavioral interventions to promote
sustained weight loss in obese adults with BMI >30 kg/m2
-Consider annual measurement of waist circumference.
-Screen for obesity in children aged 6 y and older and adolescents using BMI and refer patients with age- and sex-
specific BMI >95th percentile to comprehensive, intensive behavioral interventions to promote weight loss.
Comments
1. Intensive counseling involves more than one session per month for at least 3 mo.
2. Offer intensive intervention to promote weight loss in :
a. Obese adults (BMI >30 or waist circumference >40 in. [men] or >35 in. [women]).
b. Overweight adults (BMI 25-29.9) with an obesity-associated condition.
(HTN, DM type 2, dyslipidemia, obstructive sleep apnea, degenerative joint disease, or metabolic syndrome.)
Thyroid cancer screening :
Population
-Asymptomatic persons.
Recommendations
-Do not screen asymptomatic people with ultrasound.
-Genetic testing is recommended for patients with a family history of medullary thyroid cancer (MTC), with or without multiple endocrine
neoplasia type 2 (MEN2).
-Be aware of higher risk patients:
• head-and-neck radiation administered in infancy and childhood for benign (thymus enlargement, acne)
or malignant conditions, which results in an increased risk beginning 5 y after radiation and continuing until >20 y later
• nuclear fallout exposure ( eg, Japanese survivors of atomic bombing);
• history of goiter; family history of thyroid disease or thyroid cancer; MEN2;
• female gender;
• Asian race.
Comments
1. Neck palpation for nodules in asymptomatic individuals has sensitivity of15% -38% and specificity of 93% -100%.
Only a small proportion of nodular thyroid glands are neoplastic, resulting in a high false-positive rate.
2. Fine-needle aspiration (FNA) is the procedure of choice for evaluation of thyroid nodules.
Hormone replacement therapy to prevent chronic conditions
Population
- Postmenopausal women.
Recommendation
-Do not use combined estrogen and progestin to prevent chronic conditions, including
 Osteoporosis
 coronary artery disease,
 breast cancer,
 cognitive impairment.
Population
-Postmenopausal women who have had a hysterectomy.
Comment
This recommendation does not apply to women under the age of 50 y who have undergone
a surgical menopause and require estrogen for hot flashes and vasomotor symptoms.