Abnormal Uterine Bleeding: Classification Indian Medical PG Practice Questions and MCQs
Practice Indian Medical PG questions for Abnormal Uterine Bleeding: Classification. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 1: Most common uterine tumor is:-
- A. Adenomyoma
- B. Endometrial cancer
- C. Leiomyosarcoma
- D. Leiomyoma (Correct Answer)
Abnormal Uterine Bleeding: Classification Explanation: ***Leiomyoma***
- **Leiomyomas**, also known as **fibroids**, are the most **common benign tumors of the uterus**.
- They are composed of **smooth muscle cells** and can vary in size and location within the uterus.
*Adenomyoma*
- An **adenomyoma** is a benign uterine tumor characterized by the presence of **endometrial glands and stroma** within the myometrium.
- While it is a uterine tumor, it is significantly **less common** than leiomyomas.
*Endometrial cancer*
- **Endometrial cancer** is a **malignant tumor** arising from the endometrium and is the most common gynecologic malignancy.
- However, malignant tumors are generally **less common** than benign tumors like leiomyomas.
*Leiomyosarcoma*
- **Leiomyosarcoma** is a **rare and aggressive malignant tumor** of the smooth muscle tissue of the uterus.
- It accounts for a very small percentage of uterine masses and is much less common than benign leiomyomas.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 2: 35 yr old lady attends gynaec OPD with excessive bleeding since 6 months, not controlled with non hormonal drugs. USG and clinical examination reveals no abnormality. Next step is?
- A. Hysterectomy
- B. Endometrial sampling (Correct Answer)
- C. Endometrial ablation
- D. Hormonal therapy
Abnormal Uterine Bleeding: Classification Explanation: ***Endometrial sampling***
- In a 35-year-old with **excessive uterine bleeding** not controlled by non-hormonal drugs and with normal imaging/clinical exam, endometrial sampling is crucial to **rule out endometrial hyperplasia or malignancy**.
- This diagnostic step is essential before considering definitive treatments, as it provides a **histological diagnosis** of the endometrial lining.
*Hysterectomy*
- Hysterectomy is a **definitive surgical treatment** for excessive bleeding, but it is typically reserved for cases where conservative or less invasive treatments have failed, or if there's a serious underlying pathology like malignancy.
- It involves removing the uterus and is a **major surgery** with potential complications, thus not usually the first step given an otherwise normal examination and imaging.
*Endometrial ablation*
- Endometrial ablation is a procedure to destroy the lining of the uterus, aiming to **reduce or stop menstrual bleeding**.
- It is a treatment option for **abnormal uterine bleeding (AUB)**, but it's typically performed after other diagnostic steps (like endometrial sampling) have ruled out malignancy or high-risk hyperplasia, and when conservative medical management has failed.
*Hormonal therapy*
- Hormonal therapy (e.g., combined oral contraceptives, progestin-only pills, levonorgestrel-releasing intrauterine device) is often a **first-line medical treatment** for excessive uterine bleeding.
- However, the question states that non-hormonal drugs have already failed, and without a clear diagnosis, initiating new hormonal therapy without **evaluating the endometrium** is not the next best step for persistent bleeding.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 3: Most useful investigation in a 55-year-old postmenopausal woman with diabetes mellitus and hypertension who has presented with postmenopausal bleeding is:
- A. Pap test
- B. Endometrial biopsy (Correct Answer)
- C. Transvaginal ultrasound examination
- D. CA-125 blood test
Abnormal Uterine Bleeding: Classification Explanation: ***Endometrial biopsy***
- This is the **most crucial investigation** for postmenopausal bleeding to rule out **endometrial cancer** or **hyperplasia**, especially in a patient with risk factors like diabetes and hypertension.
- An endometrial biopsy directly samples the **uterine lining** for histological examination, providing a definitive diagnosis of any abnormal tissue changes.
*Pap test*
- A Pap test, or **Papanicolaou test**, primarily screens for **cervical cancer** by examining cells from the cervix.
- It is **not effective** for detecting uterine (endometrial) abnormalities or cancer, which is the main concern with postmenopausal bleeding.
*Transvaginal ultrasound examination*
- While useful for assessing **endometrial thickness** and identifying structural abnormalities like polyps or fibroids, it is **not diagnostic** on its own.
- An abnormal ultrasound finding, such as a thickened endometrium (usually >4-5mm in postmenopausal women), would typically prompt an endometrial biopsy for definitive diagnosis.
*CA-125 blood test*
- **CA-125** is a tumor marker primarily used for monitoring the response to treatment in **ovarian cancer** and can be elevated in other conditions like endometriosis or fibroids.
- It is **not a screening tool** for endometrial cancer and is **not specific or sensitive enough** to be the primary investigation for postmenopausal bleeding.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 4: A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :
- A. Malignancy of the vulva
- B. Malignancy of the cervix
- C. Malignancy of the endometrium (Correct Answer)
- D. Malignancy of the ovary
Abnormal Uterine Bleeding: Classification Explanation: ***Malignancy of the endometrium***
- **Postmenopausal bleeding** is the classic presenting symptom of **endometrial cancer**, which must be ruled out in all such cases.
- **Diabetes** is a known risk factor for endometrial cancer, along with obesity, hypertension, and unopposed estrogen exposure.
*Malignancy of the vulva*
- Vulvar cancer typically presents with a **pruritic lesion**, lump, or ulcer on the vulva, rather than solely with vaginal bleeding.
- While bleeding can occur from an advanced vulvar lesion, it is not the primary or most common presentation for new onset postmenopausal bleeding.
*Malignancy of the cervix*
- Cervical cancer often presents with **postcoital bleeding** or irregular vaginal bleeding in premenopausal women, or less commonly, postmenopausal bleeding.
- Screening with **Pap smears** typically detects precancerous changes or early cervical cancer, making it less likely to be the first presentation with postmenopausal bleeding in a well-screened population.
*Malignancy of the ovary*
- Ovarian cancer is often asymptomatic in its early stages and presents with non-specific symptoms like **abdominal distension**, bloating, or pelvic pain.
- **Vaginal bleeding** is not a typical symptom of ovarian cancer, unless the tumor is very large, involves adjacent structures, or is a hormone-producing tumor.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 5: Identify the pathological condition shown in the image:
- A. Intramural fibroid
- B. Adenomyoma (Correct Answer)
- C. Endometriosis
- D. Myomatous polyp
Abnormal Uterine Bleeding: Classification Explanation: ***Adenomyoma***
- The image distinctly shows **endometrial glands and stroma** embedded within the **myometrium** (smooth muscle layer of the uterus), which is the hallmark of adenomyoma [1].
- This condition is essentially a localized form of **adenomyosis**, presenting as a mass [1].
*Intramural fibroid*
- An intramural fibroid (leiomyoma) is a **benign tumor of smooth muscle cells**, typically showing a proliferation of uniform spindle cells with characteristic swirling patterns [2].
- It would lack the presence of **endometrial glands and stroma** within the lesion [2].
*Endometriosis*
- Endometriosis involves the presence of **endometrial tissue outside the uterus**, such as on the ovaries, peritoneum, or bowel.
- While it involves similar tissue, its location is **extrauterine**, whereas the image depicts a lesion within the uterine wall.
*Myomatous polyp*
- A myomatous polyp (or submucosal fibroid) is a **fibroid that protrudes into the uterine cavity**, often covered by endometrial tissue [2].
- The image does not show a polypoid growth extending into the cavity but rather glandular tissue directly within the muscle wall.
**References:**
[1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 475-476.
[2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1024-1025.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 6: An 18-year-old unmarried girl comes with complaints of heavy, prolonged bleeding during menses. Which among the following investigations is NOT usually advised?
- A. Urine pregnancy test
- B. Coagulation profile
- C. Dilatation and curettage (Correct Answer)
- D. Ultrasound uterus and adnexa
Abnormal Uterine Bleeding: Classification Explanation: ***Dilatation and curettage***
- This is an **invasive surgical procedure** used diagnostically and therapeutically for heavy uterine bleeding, but it is generally *not* the initial or routinely advised investigation for an 18-year-old unmarried girl with heavy menstrual bleeding.
- In a young, unmarried patient, less invasive methods are preferred unless other investigations point to a structural abnormality requiring tissue diagnosis or therapeutic intervention.
*Urine pregnancy test*
- A urine pregnancy test is **essential** to rule out pregnancy-related complications (e.g., ectopic pregnancy, miscarriage) as a cause of heavy vaginal bleeding, even in unmarried individuals.
- **Abnormal uterine bleeding** can be the presenting symptom of an early pregnancy loss.
*Coagulation profile*
- Heavy and prolonged bleeding, especially from a young age (as suggested by "18-year-old girl"), raises suspicion for an **underlying coagulopathy** (e.g., Von Willebrand disease).
- A coagulation profile (including PT, aPTT, platelet count, and sometimes specific factor assays) is crucial to **assess bleeding risk** and guide management.
*Ultrasound uterus and adnexa*
- An ultrasound is a **non-invasive imaging technique** that can identify structural causes of abnormal uterine bleeding, such as **fibroids, polyps, adenomyosis**, or ovarian pathologies.
- It helps in assessing the **uterine lining and ovarian morphology**, which is important in evaluating the cause of heavy menstrual bleeding.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 7: Dysfunctional uterine bleeding (DUB) is best treated by:
- A. Curettage of uterus
- B. Progestogen (Correct Answer)
- C. Estrogen
- D. Clomiphene
Abnormal Uterine Bleeding: Classification Explanation: ***Progestogen***
- **Progestogen** therapy helps stabilize the **endometrium**, reducing excessive or irregular bleeding in DUB by counteracting unopposed estrogen.
- It induces a more organized shedding of the uterine lining, which can regularize the menstrual cycle.
*Curettage of uterus*
- While **curettage** can provide temporary relief by removing the endometrial lining, it is primarily a diagnostic procedure to rule out pathology rather than a primary long-term treatment for DUB.
- It does not address the underlying hormonal imbalance that causes DUB, leading to a high recurrence rate of symptoms.
*Estrogen*
- **Estrogen** therapy alone is generally not used to treat DUB because unopposed estrogen is often the cause of DUB, leading to **endometrial overgrowth** and irregular shedding.
- Administering estrogen without a progestin could exacerbate the condition and increase endometrial proliferation.
*Clomiphene*
- **Clomiphene** is an anti-estrogen medication primarily used to induce **ovulation** in women with infertility.
- It is not indicated for the management of dysfunctional uterine bleeding or for regulating menstrual cycles directly.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 8: A 32-year-old woman presents with irregular, heavy menstrual bleeding. After thorough evaluation including pelvic ultrasound, hormonal assays, coagulation profile, and endometrial sampling, no structural abnormalities, systemic disorders, or medication-related causes are identified. This clinical scenario is best described as:
- A. Presence of systemic causes
- B. Presence of iatrogenic causes
- C. No identifiable causes present (Correct Answer)
- D. Presence of identifiable organic causes
Abnormal Uterine Bleeding: Classification Explanation: ***No identifiable causes present***
- As per its definition, **dysfunctional uterine bleeding (DUB)** is diagnosed when no structural, systemic, or iatrogenic etiology for abnormal uterine bleeding can be found.
- The diagnosis of DUB is essentially a **diagnosis of exclusion**, meaning it is made after ruling out other potential causes of bleeding.
*Presence of systemic causes*
- If systemic causes, such as **coagulation disorders** or **thyroid dysfunction**, are identified, the bleeding is attributed to these conditions, and it is not considered DUB.
- DUB specifically implies that systemic factors have been investigated and found to be absent or not the primary cause of the bleeding.
*Presence of iatrogenic causes*
- **Iatrogenic causes** refer to abnormal bleeding induced by medical interventions, such as specific medications (e.g., anticoagulants, hormonal contraceptives) or medical devices (e.g., IUDs).
- If such causes are identified, the bleeding is categorized accordingly, and the diagnosis of DUB is excluded.
*Presence of identifiable organic causes*
- **Organic causes** include structural abnormalities of the uterus or reproductive tract, such as **fibroids**, **polyps**, **adenomyosis**, or **malignancy**.
- The presence of any of these identifiable pathology rules out DUB, as DUB is by definition non-organic.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 9: A 45 year old woman presents with continuous vaginal bleeding for 15 days. Her bleeding should be controlled by:
- A. Synthetic progestogens (Correct Answer)
- B. Testosterone propionate
- C. Curettage followed by progestogens
- D. Conjugated equine oestrogens
Abnormal Uterine Bleeding: Classification Explanation: ***Synthetic progestogens***
- **Synthetic progestogens** are the **classic first-line medical treatment** for dysfunctional uterine bleeding (DUB) in the perimenopausal age group.
- They work by **stabilizing the endometrium**, counteracting unopposed estrogen effects, and inducing organized withdrawal bleeding.
- For **continuous moderate bleeding**, cyclic or continuous progestogens (e.g., norethisterone 5 mg BD for 21 days) are effective and non-invasive.
- This represents the **traditional textbook approach** for anovulatory DUB management.
*Testosterone propionate*
- **Testosterone propionate** is an androgen with no role in managing dysfunctional uterine bleeding in women.
- Its use is limited to male hypogonadism and specific anabolic requirements.
*Curettage followed by progestogens*
- While **curettage (D&C)** is both diagnostic and therapeutic, it is an **invasive procedure**.
- In clinical practice, especially for a **45-year-old woman**, endometrial sampling is often warranted to rule out hyperplasia or malignancy, making this a reasonable clinical approach.
- However, **medical management with progestogens alone** is traditionally considered first-line when the patient is hemodynamically stable and malignancy risk is low.
- This option represents sound clinical practice but is not the classic "first choice" in exam contexts.
*Conjugated equine oestrogens*
- **High-dose estrogens** (25 mg IV every 4-6 hours) are actually used for **acute severe bleeding** and can stop bleeding within 24 hours by rapidly proliferating the endometrium.
- However, for **continuous moderate bleeding** over 15 days in a perimenopausal woman, estrogen alone would not address the underlying issue of **unopposed estrogen** causing anovulatory cycles.
- Estrogen is reserved for acute emergency management, not for the scenario described in this question.
Abnormal Uterine Bleeding: Classification Indian Medical PG Question 10: A 20-year-old married woman anxious to get pregnant has cyclical cramps and sharp lower abdominal pain which lasts for 3 days starting from the day of her menstrual flow. Her menstrual periods are regular but heavy. On clinical examination, her pelvis is normal. The most probable diagnosis is
- A. Primary dysmenorrhoea (Correct Answer)
- B. Adenomyosis
- C. Uterine leiomyomata
- D. Endometriosis
Abnormal Uterine Bleeding: Classification Explanation: ***Primary dysmenorrhoea***
- This is the **most probable diagnosis** given the classic presentation of **cyclical cramping pain starting on day 1 of menstruation** lasting 3 days.
- Primary dysmenorrhea is caused by **excessive prostaglandin production** from the endometrium, leading to uterine cramping and can be associated with **heavy menstrual bleeding**.
- The **normal pelvic examination** is a key feature distinguishing primary from secondary causes of dysmenorrhea.
- Typically affects young women in their **late teens to early 20s**, shortly after menarche when ovulatory cycles are established.
*Endometriosis*
- While endometriosis causes cyclical pain, the pain typically begins **1-2 days before menstruation** rather than starting precisely on day 1.
- Associated symptoms often include **dyspareunia, dyschezia, and infertility**, which are not mentioned in this case.
- Though pelvic examination can be normal in early endometriosis, the **pain timing pattern** does not fit the classic presentation.
*Adenomyosis*
- Characterized by **endometrial tissue within the myometrium**, typically presents with a **diffusely enlarged, tender, boggy uterus** on examination.
- More common in women over 30 years, particularly those with **previous pregnancies**.
- The patient's **normal pelvic examination** and young age make adenomyosis unlikely.
*Uterine leiomyomata*
- These **benign fibroids** typically cause heavy menstrual bleeding with **pressure symptoms** rather than severe cyclical cramping pain.
- Usually result in an **irregularly enlarged uterus** on pelvic examination.
- The patient's **normal pelvic examination** excludes this diagnosis.
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