Gynecologic Care of Transgender Men — MCQs
Which of the following screening methods is NOT effective for early detection of cancer in asymptomatic women?
Which of the following hormones will be affected most after the change in sex hormone binding globulin?
HRT is helpful in all of the following except:
Continuous GnRH therapy is used in All EXCEPT.
What is the recommended treatment for children with mild to moderate symptoms of COVID-19?
A 4-year-old girl weighing 12 kg, with diarrhea, skin pinch that goes back very slowly, and who is unable to drink, is most likely to:
A woman with postmenopausal bleeding has thickened endometrium. Which approach is most suitable for evaluating malignancy risk?
A Post-Menopausal woman complains of spotting per vaginum after 5 years of menopause. USG reveals endometrial thickness of 7 mm and an intramural fibroid of size 3cm. Next step in management is?
Treatment of endometrial hyperplasia with atypia in a 45-year-old female:
The most appropriate management of a 32 weeks pregnant lady with carcinoma cervix stage IIb is.
Gynecologic Care of Transgender Men Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following screening methods is NOT effective for early detection of cancer in asymptomatic women?
- A. Office endometrial washing for endometrial cancer
- B. USG in endometrial cancer
- C. CA-125 for ovarian cancer (Correct Answer)
- D. Pap smear for cervical cancer
Explanation: ***CA-125 for ovarian cancer*** - While elevated in some ovarian cancers, **CA-125 lacks sufficient sensitivity and specificity** as a stand-alone screening tool for early detection in asymptomatic women. - Its use for general population screening has **not been shown to reduce mortality** from ovarian cancer and can lead to **false positives** and unnecessary invasive procedures. - Major trials (UKCTOCS, PLCO) have not demonstrated mortality benefit from CA-125 screening. *Office endometrial washing for endometrial cancer* - While this involves collecting cells from the uterine lining for cytological analysis, **endometrial washing/cytology has poor sensitivity** and is not established as an effective screening method. - However, it has shown **some promise in research settings** for high-risk individuals, though it is not a standard or widely recommended screening approach. - **Endometrial biopsy** remains the gold standard for diagnosis in symptomatic women, but routine screening of asymptomatic women is not recommended. *USG in endometrial cancer* - **Transvaginal ultrasonography (TVUS)** can effectively measure **endometrial thickness** and is valuable for evaluating postmenopausal bleeding. - While not used for population-based screening of asymptomatic women, it aids in **risk stratification** and guiding further investigation like biopsy in symptomatic patients. - When used appropriately in symptomatic women, TVUS is a useful diagnostic adjunct. *Pap smear for cervical cancer* - The **Pap smear** is a highly effective and widely adopted screening method for **cervical cancer**, detecting precancerous and cancerous changes in cervical cells. - Its widespread use has **significantly reduced the incidence and mortality rates** of cervical cancer due to its ability to identify abnormalities early, allowing for timely intervention. - This is the gold standard for cancer screening with proven mortality benefit.
Question 2: Which of the following hormones will be affected most after the change in sex hormone binding globulin?
- A. Testosterone (Correct Answer)
- B. Progesterone
- C. DHEA
- D. Estrogen
Explanation: ***Testosterone*** - **Sex hormone-binding globulin (SHBG)** binds primarily to **testosterone** (and dihydrotestosterone) with **high affinity**. - SHBG has approximately **5 times greater affinity** for testosterone compared to estradiol. - A change in SHBG levels will significantly impact the proportion of **free (biologically active) testosterone** available in the circulation, thus affecting its overall function and measurement. - This makes testosterone the hormone **most affected** by changes in SHBG levels. *Progesterone* - **Progesterone** is primarily bound to **albumin** and **corticosteroid-binding globulin (CBG)**, not SHBG. - Therefore, changes in SHBG would have minimal direct impact on progesterone levels or its bioavailability. *DHEA* - **Dehydroepiandrosterone (DHEA)** is mostly bound to **albumin** in the blood. - Its binding to SHBG is negligible, making changes in SHBG irrelevant to its overall circulating levels or activity. *Estrogen* - **Estrogen (estradiol)** also binds to SHBG, but with **significantly lower affinity** than testosterone (approximately 5-fold less). - While affected by SHBG changes, the impact is less pronounced than on testosterone due to the lower binding affinity and its additional binding to albumin.
Question 3: HRT is helpful in all of the following except:
- A. Vaginal atrophy
- B. Flushing
- C. Osteoporosis
- D. Coronary heart disease (Correct Answer)
Explanation: ***Coronary heart disease*** - Hormone Replacement Therapy (HRT) does not provide cardiovascular protection and may even increase the risk of **coronary heart disease (CHD)**, particularly in older women or those starting HRT many years after menopause. - The Women's Health Initiative (WHI) study demonstrated that HRT, specifically combined estrogen-progestin, increased the risk of **cardiovascular events** including myocardial infarction and stroke in postmenopausal women. - HRT is therefore **not recommended** for the prevention or treatment of coronary heart disease. *Vaginal atrophy* - HRT, particularly estrogen therapy (topical or systemic), is highly effective in treating **vaginal atrophy** by restoring vaginal tissue health. - Symptoms like **vaginal dryness**, itching, and dyspareunia are significantly improved with HRT. *Flushing* - HRT, especially estrogen, is very effective for reducing the frequency and severity of **hot flashes** and **flushing**, which are common vasomotor symptoms of menopause. - Estrogen stabilizes the thermoregulatory control center in the hypothalamus, alleviating these symptoms. *Osteoporosis* - HRT is approved for the prevention of **osteoporosis** in postmenopausal women because estrogen helps maintain bone mineral density and reduces the risk of fractures. - It helps to arrest bone loss and is a viable option for women at high risk who cannot take non-estrogen therapies.
Question 4: Continuous GnRH therapy is used in All EXCEPT.
- A. Precocious puberty
- B. Prostate cancer
- C. Male infertility (Correct Answer)
- D. Endometriosis
Explanation: ***Male infertility*** - **Pulsatile GnRH therapy** is used to stimulate gonadotropin secretion and subsequent testosterone production in hypogonadotropic hypogonadism, which can cause male infertility. - **Continuous GnRH therapy** causes downregulation of GnRH receptors leading to suppression of gonadotropin release, which would worsen male infertility. *Precocious puberty* - Continuous GnRH therapy (GnRH agonists) is used to suppress the **pituitary-gonadal axis**, effectively stopping the progression of precocious puberty. - By continuously stimulating GnRH receptors, it leads to their **desensitization and downregulation**, preventing the pulsatile release of LH and FSH. *Prostate cancer* - Continuous GnRH therapy (GnRH agonists) is used for **androgen deprivation therapy**, suppressing testosterone production, which fuels prostate cancer growth. - This effectively creates a chemical castration effect by **downregulating GnRH receptors** on pituitary gonadotrophs. *Endometriosis* - Continuous GnRH therapy (GnRH agonists) is used to induce a **hypoestrogenic state**, which helps shrink endometrial implants. - By continuously stimulating GnRH receptors, it leads to their **desensitization and downregulation**, reducing estrogen production from the ovaries.
Question 5: What is the recommended treatment for children with mild to moderate symptoms of COVID-19?
- A. Antiviral therapy
- B. Supportive care (Correct Answer)
- C. Corticosteroids
- D. Antibiotics
Explanation: ***Supportive care*** - For children with **mild to moderate COVID-19 symptoms**, **supportive care** is the cornerstone of treatment, focusing on symptom relief. - This includes **rest**, **hydration**, and **fever-reducing medications** (e.g., acetaminophen or ibuprofen) as needed. *Antiviral therapy* - **Antiviral medications** like Paxlovid are generally reserved for older children and adolescents with **severe COVID-19** or those at **high risk for progression to severe disease**. - They are not typically recommended for mild to moderate cases in children due to potential side effects and the usually self-limiting nature of the illness. *Corticosteroids* - **Corticosteroids** (e.g., dexamethasone) are primarily used in children with **severe COVID-19** who require **oxygen support** or have significant inflammation. - They are not indicated for mild to moderate cases, as their benefits are outweighed by potential adverse effects in this population. *Antibiotics* - **Antibiotics** are effective against **bacterial infections** and have no role in treating **viral illnesses** like COVID-19. - They should only be used if a **secondary bacterial infection** is suspected or confirmed.
Question 6: A 4-year-old girl weighing 12 kg, with diarrhea, skin pinch that goes back very slowly, and who is unable to drink, is most likely to:
- A. Start IV fluids per Plan C (Correct Answer)
- B. Discharge home with oral fluids
- C. Monitor for worsening dehydration
- D. Attempt oral rehydration with ORS
Explanation: ***Start IV fluids per Plan C*** - The child presents with **severe dehydration** based on WHO criteria: **skin pinch goes back very slowly** (>2 seconds) and **unable to drink**. - These two signs mandate immediate **Plan C management** which involves rapid IV fluid resuscitation using **Ringer's Lactate or Normal Saline**. - WHO Plan C protocol: Give **100 ml/kg** IV fluids divided as 30 ml/kg in first hour (if <12 months) or first 30 minutes (if ≥12 months), then 70 ml/kg over next 2.5-5 hours. - Plan C is specifically designed for **severe dehydration** requiring immediate intravenous rehydration, not Plan B which is for moderate dehydration with oral rehydration. *Discharge home with oral fluids* - Discharging a child with **severe dehydration** is inappropriate and potentially life-threatening. - The child **cannot drink** effectively, making home management with oral fluids impossible and dangerous. - This would lead to worsening dehydration, shock, and potentially fatal complications. *Monitor for worsening dehydration* - While monitoring is important, this child requires **immediate active intervention**, not observation alone. - Delaying IV rehydration in a child with **severe dehydration** (unable to drink, very slow skin pinch) could lead to hypovolemic shock, acute kidney injury, and death. *Attempt oral rehydration with ORS* - This child is **unable to drink**, making ORS ineffective and contraindicated. - Oral rehydration (Plan B) is appropriate only for **moderate dehydration** in children who are conscious, alert, and able to drink. - Attempting ORS in a child unable to drink delays appropriate IV therapy and worsens outcomes.
Question 7: A woman with postmenopausal bleeding has thickened endometrium. Which approach is most suitable for evaluating malignancy risk?
- A. Endometrial biopsy (Correct Answer)
- B. Transvaginal ultrasound
- C. Pap smear
- D. Hysteroscopy
Explanation: ***Endometrial biopsy*** - An **endometrial biopsy** directly obtains tissue samples from the endometrial lining, allowing for histological examination to definitively diagnose or rule out **endometrial hyperplasia** or **carcinoma**. - This is the **most suitable first-line approach** when postmenopausal bleeding is coupled with a thickened endometrium, as it directly assesses for **malignancy at a cellular level**. - It is **cost-effective, minimally invasive, and can be performed in an office setting** without anesthesia. *Transvaginal ultrasound* - While a **transvaginal ultrasound** can measure endometrial thickness and identify structural abnormalities, it cannot definitively differentiate between benign and malignant changes. - It serves as an initial screening tool but requires further investigation like a **biopsy** for definitive diagnosis in cases of thickened endometrium and postmenopausal bleeding. - An endometrial thickness >4-5 mm in postmenopausal women warrants tissue diagnosis. *Pap smear* - A **Pap smear** (Papanicolaou test) is used to screen for **cervical cancer** by collecting cells from the cervix. - It is not effective for detecting **endometrial pathologies** or cancer of the uterine lining. *Hysteroscopy* - **Hysteroscopy** allows for direct visualization of the uterine cavity and directed biopsies under direct vision, which is highly accurate for identifying focal lesions such as polyps or fibroids. - While it provides excellent diagnostic accuracy, it is **more invasive, expensive, and typically requires anesthesia**. - For initial evaluation of postmenopausal bleeding with diffuse endometrial thickening, **endometrial biopsy is preferred** as the first-line approach due to its accessibility, lower cost, and adequate sensitivity (>90% for detecting endometrial cancer).
Question 8: A Post-Menopausal woman complains of spotting per vaginum after 5 years of menopause. USG reveals endometrial thickness of 7 mm and an intramural fibroid of size 3cm. Next step in management is?
- A. CA 125 levels
- B. Paps smear and follow up
- C. Myomectomy
- D. Endometrial biopsy (Correct Answer)
Explanation: ***Endometrial biopsy*** - Post-menopausal **vaginal bleeding** or spotting, especially with an **endometrial thickness of ≥ 4-5 mm** on ultrasound, is highly suspicious for endometrial hyperplasia or carcinoma and warrants an endometrial biopsy for definitive diagnosis. - An endometrial biopsy is crucial to rule out endometrial malignancy, as this is the primary concern in such presentations. *CA 125 levels* - **CA 125** is primarily used as a tumor marker for **ovarian cancer** surveillance and response to treatment, not for initial diagnosis of post-menopausal bleeding or endometrial pathology. - Elevated CA 125 can be found in various benign conditions as well and is not specific enough to guide the initial management of post-menopausal bleeding without tissue sampling. *Paps smear and follow up* - A **Pap smear** screens for **cervical abnormalities** and **cervical cancer**, not endometrial pathology. - While it's part of routine gynecological care, it will not address the investigation of post-menopausal bleeding originating from the uterus. *Myomectomy* - **Myomectomy** is a surgical procedure to remove **uterine fibroids**, typically when they are causing symptoms like heavy menstrual bleeding or pressure. - In a post-menopausal woman with spotting, the intramural fibroid may or may not be directly responsible, and the priority is to exclude **endometrial cancer** before considering fibroid-specific interventions.
Question 9: Treatment of endometrial hyperplasia with atypia in a 45-year-old female:
- A. Progestin
- B. Mirena
- C. Hysterectomy (Correct Answer)
- D. Endometrial ablation
Explanation: ***Hysterectomy*** - **Endometrial hyperplasia with atypia** carries a significant risk of progression to **endometrial cancer**, ranging from 20% to 50% over several years, making hysterectomy a definitive treatment option. - For a 45-year-old female, especially if she has completed childbearing or is nearing menopause, a **hysterectomy** eliminates the uterine pathology and prevents future recurrence or malignant transformation. *Progestin* - While progestin therapy can be used for endometrial hyperplasia without atypia or for atypical hyperplasia in women who desire to preserve fertility, its effectiveness for **simple atypical hyperplasia** is 70-80%. - The risk of residual or coexisting carcinoma, and the potential for recurrence if fertility is not a concern, makes progestin a less definitive treatment than hysterectomy in this age group. *Mirena* - The **Mirena IUD** (levonorgestrel-releasing intrauterine system) delivers local progestin, which is effective for **endometrial hyperplasia without atypia** and is sometimes used for atypical hyperplasia when fertility preservation is desired. - However, for **atypical hyperplasia**, which has a notable risk of malignancy, a more definitive treatment like hysterectomy is generally preferred, especially as Mirena's systemic effects are limited and regular follow-up biopsies are needed. *Endometrial ablation* - **Endometrial ablation** destroys the endometrial lining and is typically used for managing **heavy menstrual bleeding (menorrhagia)** when fertility is not desired. - It is **contraindicated in cases of endometrial hyperplasia with atypia** due to the risk of obscuring underlying or developing malignancy and making future surveillance difficult.
Question 10: The most appropriate management of a 32 weeks pregnant lady with carcinoma cervix stage IIb is.
- A. Observation and follow-up
- B. Chemo-radiation followed by labour induction and vaginal delivery
- C. Labour induction, vaginal delivery followed by radio-therapy
- D. Cesarean delivery followed by chemoradiation (Correct Answer)
Explanation: ***Cesarean delivery followed by chemoradiation*** - For **stage IIb carcinoma cervix** at 32 weeks gestation, **cesarean delivery** is the safest option to deliver the baby while avoiding trauma to the tumor and potential dissemination. - Subsequently, **chemoradiation** is the standard treatment for stage IIb cervical cancer, ensuring optimal maternal oncologic outcome. *Observation and follow-up* - This approach is **inappropriate** for stage IIb cervical cancer in pregnancy, as it delays definitive treatment and allows for disease progression. - Such an aggressive cancer requires **prompt intervention** for the best maternal prognosis. *Chemo-radiation followed by labour induction and vaginal delivery* - **Chemoradiation during pregnancy** is harmful to the fetus, especially beyond the first trimester. - A **vaginal delivery** in the presence of cervical cancer carries a high risk of hemorrhage and tumor dissemination, making it contraindicated. *Labour induction, vaginal delivery followed by radio-therapy* - **Labour induction and vaginal delivery** are contraindicated due to risks of hemorrhage, tumor spread, and potential obstruction from the tumor. - While radiotherapy would follow, the mode of delivery poses significant risks to the mother.
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