Gynecological Disorders Practice Questions

Q: What is the next best step when a postmenopausal lady presents with complaints of irregular bleeding with endometrial thickness of 8mm?

Endometrial sampling. ***Endometrial sampling*** - In postmenopausal bleeding, any **endometrial thickness > 4-5 mm** warrants tissue diagnosis to rule out **endometrial carcinoma**. - Office-based **endometrial biopsy (pipelle)** is the gold standard initial investigation due to its accuracy, cost-effectiveness, and minimally invasive nature. *MRI pelvis* - MRI is not recommended as a first-line investigation for initial assessment of **postmenopausal bleeding** or abnormal **endometrial thickness**. - It is mainly reserved for **staging endometrial cancer** once a histologic diagnosis has been confirmed. *Diagnostic hysteroscopy* - While useful for visualizing the uterine cavity, it is generally considered a second-line procedure if **office-based biopsy** is non-diagnostic or technically difficult. - It is not the most suitable

Q: A girl was brought to the clinic for primary evaluation. Physical examination: Tanner stage -4 breast. USG: blind vagina, no uterus, no ovaries. Lab: High testosterone levels. What is the most probable diagnosis?

Complete AIS. ***Complete androgen insensitivity syndrome (Complete AIS)*** - In this condition, individuals with a **46,XY karyotype** have testes that produce **high levels of testosterone**, but peripheral tissues are insensitive to androgens due to a defective androgen receptor. - Breast development (Tanner stage 4) occurs because the high levels of circulating testosterone are **aromatized into estrogen**, and there is an **absence of a uterus and ovaries** (Müllerian agenesis) due to the presence of Anti-Müllerian Hormone (AMH) produced by the testes. *17 Alpha hydroxylase deficiency* - This condition typically presents with **hypertension and hypokalemia** due to excess mineralocorticoid production (precursors upstream of the block). - Patients would have **low testosterone levels**, unlike the high testosterone seen in this patient. *Swyer syndrome* - Individuals with Swyer syndrome have **46,XY pure gonadal dysgenesis**, which results in streak gonads (not functioning testes) and **low/absent testosterone**. - Because they lack functional testes to produce AMH and testosterone, they have a **uterus present**, which is absent in this case. *MRKH (Müllerian agenesis)* - MRKH patients have a **46,XX karyotype** with functional ovaries, resulting in **normal female-range testosterone levels**. - While they present with an absent uterus and blind vagina, they typically have normal secondary sexual characteristics like pubic hair, which is sparse or absent in Complete AIS.

Q: What investigation should be done when a patient is presented with leiomyoma in the uterine wall?

MRI pelvis. ***MRI pelvis*** - **MRI** is the gold standard imaging modality for uterine leiomyomas as it provides superior **soft-tissue contrast** to accurately map the number, size, and location of fibroids. - It is particularly useful for **surgical planning** (e.g., myomectomy) to distinguish between intramural, submucosal, and subserosal fibroids, and to differentiate fibroids from **adenomyosis**. *CT pelvis* - **CT scans** have limited utility in evaluating uterine pathology due to poor soft-tissue resolution compared to ultrasound or MRI. - It is generally reserved for identifying **extrapelvic masses** or evaluating for metastatic disease, not for routine characterization of benign **uterine leiomyomas**. *Hysterosalphingography* - **HSG** is primarily designed to assess **tubal patency** and uterine cavity contour, often in the workup of **infertility**. - It is not the modality of choice for characterizing an intramural mass, as it offers limited visualization of the **myometrium**. *Plain Roentgenogram - pelvis* - **Plain X-rays** lack the sensitivity and specificity to evaluate soft-tissue uterine structures. - While they might show large calcified fibroids (popcorn calcification), this is a non-specific incidental finding and not a diagnostic tool for **leiomyoma evaluation**.

Q: A woman with white and foul smelling vaginal discharge was subjected to PAP smear examination, which revealed clue cells. What is the appropriate treatment?

Metronidazole. ***Metronidazole*** - This is the **first-line treatment** for **bacterial vaginosis**, which is diagnosed here by the presence of **clue cells** (vaginal epithelial cells covered with bacteria). - Metronidazole acts by inhibiting **nucleic acid synthesis** in anaerobic bacteria like *Gardnerella vaginalis*, which are overrepresented in this condition. *Oral Itraconazole* - This is an **antifungal medication** used primarily for conditions like **vulvovaginal candidiasis**. - It is ineffective against the bacterial cause of bacterial vaginosis and is not indicated for this presentation. *Clotrimazole pessaries* - This is also an **antifungal agent** commonly used to treat **yeast infections** (candidiasis). - It would not address the **polymicrobial shift** involving anaerobes that characterizes bacterial vaginosis. *Selenium sulphide* - This is typically used as a **topical treatment** for conditions like **tinea versicolor** or **seborrheic dermatitis**. - It has no role in the management of gynecological infections or bacterial vaginosis.

Q: A patient with pain, heavy menstrual bleeding and symmetrically enlarged uterus of size corresponding to 10 -14 weeks. Diagnosis?

Adenomyosis. ***Adenomyosis*** - Characterized by the presence of **endometrial tissue** within the **myometrium**, clinically manifesting as **menorrhagia** (heavy menstrual bleeding) and **dysmenorrhea** (pain). - On physical examination, it typically presents with a **symmetrically enlarged**, **globular**, and **tender** (boggy) uterus, usually corresponding to a size of 10-14 weeks. *Endometrial cancer* - Common presentation in **postmenopausal women** with **postmenopausal bleeding** rather than cyclic menorrhagia. - Uterine enlargement is typically **irregular** if present, and the diagnosis is confirmed via **endometrial biopsy** which would show adenocarcinoma. *Endometrial polyp* - Usually presents with **intermenstrual bleeding** or spotting and is often asymptomatic. - It does not typically cause **diffuse, symmetrical uterine enlargement**; ultrasound would show a focal intracavitary lesion. *Endometrosis* - Refers to **endometriosis**, which involves endometrial tissues outside the uterus, typically causing **cyclic pelvic pain** and **dyspareunia**. - It does not cause symmetrical uterine enlargement; the uterus is often normal in size unless accompanied by coexisting conditions.

Q: A woman’s Pap smear shows atypical glandular cells. What is the next appropriate investigation?

Colposcopy + Endocervical curettage. ***Colposcopy + Endocervical curettage*** - Atypical glandular cells (AGC) on cytology indicate a risk of both cervical and endometrial pathology, necessitating a thorough evaluation of the endocervical canal and transformation zone. - ASCCP guidelines recommend performing a colposcopy with endocervical curettage (ECC) and, depending on age and clinical factors, sampling of the endometrium to rule out pre-invasive or invasive lesions. *Biopsy* - While tissue sampling is crucial, a blind biopsy is insufficient without prior colposcopic evaluation to identify the abnormal lesion. - The term 'biopsy' is too non-specific; the gold standard for investigation here includes targeted examination and ancillary procedures like ECC. *Colposcopy* - Although colposcopy is part of the workup, it is incomplete on its own because the origin of glandular cells may be high in the endocervical canal, which may not be visible. - Endocervical curettage is essential to sample the glandular cells of the endocervical canal that cannot be visualized directly. *Hysterectomy* - Hysterectomy is a definitive treatment for certain conditions (like invasive cancer or severe hyperplasia) but is never a diagnostic test for abnormal cytology. - Performing a hysterectomy without a definitive diagnosis gained through appropriate cervical and endometrial sampling is both inappropriate and unethical.

Q: 30 year old female with cyclical rectal bleeding & pelvic pain. Pain increased with menses. Diagnosis ?

Endometriosis. ***Endometriosis*** - **Cyclical rectal bleeding** combined with pelvic pain that worsens during **menses** is a classic presentation of **bowel endometriosis**. - The ectopic endometrial tissue responds to hormonal fluctuations, leading to inflammation and bleeding at the site of involvement (e.g., the rectum or rectosigmoid). *Hemorrhoids* - While hemorrhoids cause rectal bleeding, the pain is typically related to **defecation** or irritation rather than the menstrual cycle. - **Cyclical symptoms** are not a feature of hemorrhoidal disease. *Endometrial cancer* - This condition typically presents with **postmenopausal bleeding** or intermenstrual bleeding, not strictly cyclical, menstrual-associated rectal bleeding. - The peak incidence is in **postmenopausal women**, whereas this patient is 30 years old. *Fibroids* - Uterine fibroids (leiomyomas) primarily cause **menorrhagia** (heavy menstrual bleeding) or pressure symptoms if large enough to affect adjacent organs. - Fibroids do not typically cause **cyclical rectal bleeding** unless there is direct invasion or significant extrinsic compression, which is rare.

Q: A woman presents with curdy white vaginal discharge with vaginal itching and burning. What Is this the most likely diagnosis?

Vulvovaginal candidiasis. ***Vulvovaginal candidiasis*** - The hallmark of this condition is a **thick, curdy white (cottage cheese-like)** vaginal discharge that is typically **odorless**. - Intense **vulvovaginal pruritus (itching)** and **burning** are classic presenting complaints, often exacerbated by sexual intercourse or urination. *Bacterial vaginosis* - Characterized by a **thin, grayish-white** discharge with a distinct **

Q: A 50-year-old postmenopausal woman presents with postmenopausal bleeding. Ultrasound shows a “feeding vessel” sign, suggestive of an endometrial polyp. What is the most appropriate management?

Hysteroscopic polypectomy. ***Hysteroscopic polypectomy*** - **Hysteroscopic removal** is the treatment of choice for symptomatic endometrial polyps, particularly in postmenopausal women with **postmenopausal bleeding**, to provide definitive diagnosis and rule out malignancy. - It allows for **direct visualization** and complete resection of the base, which is superior to blind techniques, ensuring a lower rate of recurrence and higher accuracy in pathology. *Watchful waiting* - In postmenopausal women with **symptomatic** bleeding, the risk of **endometrial cancer** or hyperplasia must be excluded, making simple observation inappropriate. - While some asymptomatic polyps in premenopausal women may resolve spontaneously, the presence of bleeding in a postmenopausal patient mandates a **tissue diagnosis**. *Medical therapy with progestins* - **Progestins** are not effective for the removal of existing endometrial polyps; they are generally used for conditions like **endometrial hyperplasia** without atypia. - Medical management does not confirm the diagnosis histologically, which is crucial for excluding **malignancy** in the setting of postmenopausal bleeding. *Dilation and curettage* - **Dilation and curettage (D&C)** is a blind procedure often associated with a high rate of **missed polyps** due to the focal nature of these lesions within the cavity. - **Hysteroscopy** is the gold standard because it allows the surgeon to identify and selectively remove the polyp while minimizing trauma to the surrounding **endometrium**.

Q: What is the most likely diagnosis?

Complete mole. ***Complete mole*** - A complete mole typically presents with ultrasound findings of a **snowstorm appearance** (multiple cystic spaces), absent fetal parts, and **markedly elevated hCG levels**. - Pathologically, it results from fertilization of an **empty egg** by one or two sperm, resulting in a **46,XX** (mostly) or 46,XY karyotype with no fetal tissue. *Partial mole* - Usually contains **fetal parts** or embryonic tissue identifiable by ultrasound, unlike the complete mole which is strictly placental tissue. - The karyotype is typically **triploid (69,XXX or 69,XXY)**, resulting from fertilization of a normal egg by two sperm or reduplication of one sperm. *Ectopic pregnancy* - Presents with a **positive pregnancy test** but an empty uterus on ultrasound, alongside an adnexal mass and lower abdominal pain. - hCG levels typically rise more slowly compared to a molar pregnancy, and it is identified by the presence of an **extrauterine gestational sac**. *Hydropic degeneration* - Refers to benign changes where villi appear swollen due to fluid accumulation, often seen in a **miscarriage or non-molar pregnancy**. - Unlike a molar pregnancy, this does not show the characteristic **trophoblastic proliferation** that leads to high hCG levels and potential progression to gestational trophoblastic neoplasia.

Question 1

What is the next best step when a postmenopausal lady presents with complaints of irregular bleeding with endometrial thickness of 8mm?

Accepted Answer

Endometrial sampling

Answer

MRI pelvis

Answer

Diagnostic hysteroscopy

Answer

Dilatation and Curettage

Question 2

A girl was brought to the clinic for primary evaluation. Physical examination: Tanner stage -4 breast. USG: blind vagina, no uterus, no ovaries. Lab: High testosterone levels. What is the most probable diagnosis?

Accepted Answer

Complete AIS

Answer

17 Alpha hydroxylase deficiency

Answer

Swyer syndrome

Answer

MRKH

Question 3

What investigation should be done when a patient is presented with leiomyoma in the uterine wall?

Accepted Answer

MRI pelvis

Answer

CT pelvis

Answer

Hysterosalphingography

Answer

Plain Roentgenogram -pelvis

Question 4

A woman with white and foul smelling vaginal discharge was subjected to PAP smear examination, which revealed clue cells. What is the appropriate treatment?

Accepted Answer

Metronidazole

Answer

Oral Itraconazole

Answer

Clotrimazole pessaries

Answer

Selenium sulphide

Question 5

A patient with pain, heavy menstrual bleeding and symmetrically enlarged uterus of size corresponding to 10 -14 weeks. Diagnosis?

Accepted Answer

Adenomyosis

Answer

Endometrial cancer

Answer

Endometrial polyp

Answer

Endometrosis

Question 6

A woman’s Pap smear shows atypical glandular cells. What is the next appropriate investigation?

Accepted Answer

Colposcopy + Endocervical curettage

Answer

Biopsy

Answer

Colposcopy

Answer

Hysterectomy

Question 7

30 year old female with cyclical rectal bleeding & pelvic pain. Pain increased with menses. Diagnosis ?

Accepted Answer

Endometriosis

Answer

Hemorrhoids

Answer

Endometrial cancer

Answer

Fibroids

Question 8

A woman presents with curdy white vaginal discharge with vaginal itching and burning. What Is this the most likely diagnosis?

Accepted Answer

Vulvovaginal candidiasis

Answer

Bacterial vaginosis

Answer

Trichomoniasis

Answer

Atrophic vaginitis

Question 9

A 50-year-old postmenopausal woman presents with postmenopausal bleeding. Ultrasound shows a “feeding vessel” sign, suggestive of an endometrial polyp. What is the most appropriate management?

Accepted Answer

Hysteroscopic polypectomy

Answer

Watchful waiting

Answer

Medical therapy with progestins

Answer

Dilation and curettage

Question 10

What is the most likely diagnosis?

Accepted Answer

Complete mole

Answer

Partial mole

Answer

Ectopic pregnancy

Answer

Hydropic degeneration

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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