Adenomyosis — MCQs
Which of the following statements accurately describes adenomyosis?
All are true regarding adenomyosis except:
In a woman complaining of AUB following image was seen in endoscopic examination of uterus. What will be the diagnosis?
A 29 year old female presented with infertility. There is history of abdominal pain, dyspareunia, dysmenorrhea, menorrhagia. Most likely cause:
What is the definitive management for adenomyosis?
A 30-year-old female has severe dysmenorrhoea and dyspareunia. On examination, uterus is 8-week size, uniformly enlarged and there is tenderness in posterior fornix. What is the most probable diagnosis?
Day 20 of menstrual cycle falls under which phase?
Which of the following drugs is not commonly used for menorrhagia?
The "whiff test" is positive in which of the following conditions?
Which of the following instruments is used to obtain a cervical smear?
Adenomyosis Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following statements accurately describes adenomyosis?
- A. More common in parous women
- B. More common in middle-aged women
- C. Presents with menorrhagia, dysmenorrhea, and an enlarged uterus (Correct Answer)
- D. Typically resolves after menopause without treatment
Explanation: ***Presents with menorrhagia, dysmenorrhea, and an enlarged uterus*** - **Adenomyosis** is defined by the presence of **endometrial tissue within the myometrium**, leading to symptoms like **heavy menstrual bleeding (menorrhagia)** and **painful menstruation (dysmenorrhea)**. - The infiltration of endometrial glands and stroma into the uterine muscle causes the uterus to become **enlarged** and often **globular** or boggy on examination. *More common in parous women* - While adenomyosis is more common in women who have had children, this statement alone does not fully encompass the characteristic presentation of the condition. - The exact link between parity and adenomyosis is not completely understood, but it is often attributed to uterine trauma during childbirth allowing endometrial tissue to invade the myometrium. *More common in middle-aged women* - Adenomyosis is indeed more prevalent in **women aged 35 to 50**, but this statement only describes its epidemiology, not its clinical manifestation. - Hormonal fluctuations and prolonged estrogen exposure are thought to contribute to its development in this age group. *Typically resolves after menopause without treatment* - This statement is accurate regarding its resolution, but does not describe adenomyosis itself; rather, it describes its natural progression. - Since adenomyosis is **estrogen-dependent**, its symptoms usually regress or disappear after menopause due to the decline in estrogen levels.
Question 2: All are true regarding adenomyosis except:
- A. Enlarged uterus that rarely exceeds 12 weeks.
- B. Ectopic rests of endometrium located deep within the myometrium.
- C. Glands found within myometrium originate from stratum functionalis. (Correct Answer)
- D. Spongy surface trabeculated with focal areas of hemorrhage.
Explanation: ***Glands found within myometrium originate from stratum functionalis*** - The ectopic endometrial glands and stroma found in adenomyosis originate from the **stratum basalis** (basal layer) of the endometrium, not the stratum functionalis. - The stratum functionalis is the layer that sheds during menstruation, whereas the stratum basalis is responsible for regenerating the functionalis layer. *Enlarged uterus that rarely exceeds 12 weeks* - This statement is largely true for adenomyosis, as the uterus typically becomes **globularly enlarged** but usually does not reach the size of a 12-week pregnancy. - Significant uterine enlargement that exceeds this limit might suggest other pathologies like **fibroids**. *Ectopic rests of endometrium located deep within the myometrium* - This is the **defining characteristic** of adenomyosis, where endometrial tissue (glands and stroma) is found abnormally within the muscular wall of the uterus. - These ectopic endometrial implants cause the surrounding myometrial cells to undergo **hyperplasia and hypertrophy**. *Spongy surface trabeculated with focal areas of hemorrhage* - The cut surface of an adenomyotic uterus often appears **trabeculated or spongy** due to the hypertrophy of the myometrium surrounding the endometrial islands. - **Focal areas of hemorrhage** (small blood clots) may be seen where ectopic endometrial tissue has bled into the myometrium, especially during menstruation.
Question 3: In a woman complaining of AUB following image was seen in endoscopic examination of uterus. What will be the diagnosis?
- A. Leiomyoma (Correct Answer)
- B. Adenomyosis
- C. Ovarian neoplasm
- D. Carcinoma of uterus
Explanation: ***Leiomyoma*** - The image shows **well-circumscribed, smooth, rounded masses protruding into the uterine cavity**, which are characteristic of **submucous (intracavitary) leiomyomas (fibroids)** seen on hysteroscopy. - Submucous leiomyomas are benign smooth muscle tumors that project into the endometrial cavity and commonly cause **abnormal uterine bleeding (AUB)** due to increased endometrial surface area, distortion of the endometrial cavity, ulceration of overlying endometrium, and interference with normal uterine contractility. - On **hysteroscopic examination**, they appear as firm, pale, smooth-surfaced masses with overlying endometrium. *Adenomyosis* - Adenomyosis involves the presence of **endometrial tissue within the myometrium**, leading to diffuse uterine enlargement. - On hysteroscopy, it may show a **globally irregular endometrial surface** with small endometrial openings or cystic spaces, but not the discrete, well-circumscribed protruding masses seen in the image. - While it can cause AUB and dysmenorrhea, the appearance is distinctly different from submucous leiomyomas. *Ovarian neoplasm* - Ovarian neoplasms originate in the **ovaries**, which are separate from the uterus. - **Hysteroscopic examination** visualizes only the **endometrial cavity** and cannot directly visualize ovarian pathology. - Ovarian masses do not protrude into the uterine cavity. *Carcinoma of uterus* - Endometrial carcinoma typically presents on hysteroscopy as **irregular, friable, ulcerative, or fungating lesions** with abnormal vascularity and易出血 (easy bleeding). - The **smooth, well-defined, and rounded appearance** with intact overlying mucosa in the image is characteristic of benign leiomyomas, not malignant growths. - Uterine sarcomas are rare and would show more irregular, infiltrative features rather than well-circumscribed masses.
Question 4: A 29 year old female presented with infertility. There is history of abdominal pain, dyspareunia, dysmenorrhea, menorrhagia. Most likely cause:
- A. Adenomyosis
- B. Endometriosis (Correct Answer)
- C. Cervicitis
- D. Myomas
Explanation: ***Endometriosis*** - The classic triad of symptoms in this 29-year-old female—**dysmenorrhea**, **dyspareunia**, and **infertility**—is highly suggestive of endometriosis. - **Ectopic endometrial tissue** can cause chronic abdominal pain, menorrhagia, and inflammation, contributing to infertility. *Adenomyosis* - This condition involves the presence of **endometrial tissue within the myometrium**, leading to a thickened uterine wall. - While it can cause dysmenorrhea and menorrhagia, **infertility** is not its primary presentation, and it is less commonly associated with severe dyspareunia compared to endometriosis. *Cervicitis* - **Inflammation of the cervix** typically presents with vaginal discharge, post-coital bleeding, or pelvic pain. - It is not a common cause of primary infertility, severe dysmenorrhea, or dyspareunia as described. *Myomas* - Uterine **fibroids (leiomyomas)** are benign tumors that can cause heavy menstrual bleeding (menorrhagia), pelvic pressure, and sometimes infertility. - However, they are less commonly associated with the triad of severe dysmenorrhea and dyspareunia as prominently as seen in endometriosis.
Question 5: What is the definitive management for adenomyosis?
- A. Endometrial ablation.
- B. Hysterectomy (surgical removal of the uterus). (Correct Answer)
- C. Hormonal therapy (e.g., Danazol) for temporary symptom relief.
- D. Hormonal therapy (e.g., GnRH analogue) for temporary symptom relief.
Explanation: ***Hysterectomy (surgical removal of the uterus)*** - This is considered the **definitive management** for adenomyosis because it completely removes the uterine tissue where the ectopic endometrial glands are found. - Hysterectomy effectively eliminates the source of symptoms such as **heavy menstrual bleeding** and **pelvic pain** by removing the uterus entirely. *Endometrial ablation* - Endometrial ablation involves destroying the **lining of the uterus** and is primarily used for heavy menstrual bleeding. - It is **ineffective for adenomyosis** since the endometrial tissue is embedded deep within the myometrium and is not fully reached by ablation. *Hormonal therapy (e.g., Danazol) for temporary symptom relief* - **Danazol** (an androgen derivative) can suppress ovarian function and reduce symptoms of adenomyosis by shrinking endometrial tissue. - However, its effects are **temporary**, and symptoms typically return upon cessation of treatment, making it not a definitive solution. *Hormonal therapy (e.g., GNRH analogue) for temporary symptom relief* - **GnRH analogues** induce a temporary menopausal state, which can significantly reduce symptoms by inhibiting estrogen production, leading to atrophy of the adenomyotic tissue. - This treatment is also **temporary**, and symptoms often recur once the medication is stopped; it's often used as a bridge to surgery or for women nearing menopause.
Question 6: A 30-year-old female has severe dysmenorrhoea and dyspareunia. On examination, uterus is 8-week size, uniformly enlarged and there is tenderness in posterior fornix. What is the most probable diagnosis?
- A. Fibroid uterus
- B. Endometrial carcinoma
- C. Dysfunctional uterine bleeding
- D. Adenomyosis (Correct Answer)
Explanation: ***Adenomyosis*** - **Adenomyosis** is characterized by the presence of **endometrial glands and stroma within the myometrium**, leading to a diffusely enlarged uterus and often presenting with **severe dysmenorrhoea** and **dyspareunia**. - A **uniformly enlarged, tender uterus** (described as 8 weeks size) in a patient with these symptoms is highly suggestive of adenomyosis, as the ectopic endometrial tissue causes pain and uterine enlargement. *Fibroid uterus* - **Fibroids (leiomyomas)** typically cause an **irregularly enlarged uterus** and can lead to heavy menstrual bleeding (menorrhagia) and pelvic pressure, but severe dyspareunia is less common. - While fibroids can cause an enlarged uterus and dysmenorrhoea, the **uniform enlargement** and prominent **tenderness of the posterior fornix** (suggesting broad involvement) are more aligned with adenomyosis. *Endometrial carcinoma* - **Endometrial carcinoma** typically presents with **postmenopausal bleeding** or abnormal uterine bleeding, often in older women, and usually does not cause a uniformly enlarged and tender uterus. - While it can cause pelvic pain, the specific presentation of **severe dysmenorrhoea and dyspareunia** with a diffusely enlarged and tender uterus is not characteristic of endometrial cancer. *Dysfunctional uterine bleeding* - **Dysfunctional uterine bleeding (DUB)** refers to abnormal bleeding that is not due to structural or systemic causes, often associated with **anovulation** and hormonal imbalances, primarily characterized by irregular or heavy periods. - DUB usually does not cause a **uniformly enlarged or tender uterus** and is less directly associated with the severe dysmenorrhoea and dyspareunia seen in this case.
Question 7: Day 20 of menstrual cycle falls under which phase?
- A. Menstrual phase
- B. Follicular phase
- C. Ovulation phase
- D. Luteal phase (Correct Answer)
Explanation: ***Luteal phase*** - The **luteal phase** typically starts after ovulation, around day 14, and lasts until menstruation begins, usually day 28 of a 28-day cycle. Therefore, **day 20 falls squarely within this phase**. - During this phase, the **corpus luteum** forms and produces **progesterone**, preparing the uterus for potential pregnancy. *Menstrual phase* - The **menstrual phase** is the period of shedding of the uterine lining, typically occurring from **day 1 to day 5** of the menstrual cycle. - Day 20 is well past this phase, during which bleeding and low hormone levels are characteristic. *Follicular phase* - The **follicular phase** starts on day 1 of menstruation and lasts until ovulation, usually around **day 13-14** in a 28-day cycle. - During this phase, follicles mature under the influence of **FSH** and **estrogen** levels rise. Day 20 is beyond this period. *Ovulation phase* - The **ovulation phase** is a short period, typically around **day 14** of a 28-day cycle, when the mature egg is released from the ovary. - This phase is brief and marks the transition from the follicular to the luteal phase, so day 20 is considerably after ovulation.
Question 8: Which of the following drugs is not commonly used for menorrhagia?
- A. GnRH
- B. NSAIDS
- C. Methergin
- D. Clomiphene (Correct Answer)
Explanation: ***Clomiphene*** - **Clomiphene citrate** is a selective estrogen receptor modulator used primarily to **induce ovulation** in women with infertility, not to treat menorrhagia. - Its mechanism involves blocking estrogen receptors in the hypothalamus, leading to increased release of **gonadotropins (FSH and LH)**. - It has no role in the management of heavy menstrual bleeding. *Methergin* - **Methergine (methylergonovine)** is an ergot alkaloid that causes sustained uterine contractions. - It is primarily used for **postpartum hemorrhage** and control of bleeding after abortions (acute obstetric bleeding). - While it can control acute uterine bleeding, it is **not used for chronic menorrhagia management** due to its side effects and availability of better alternatives. - It is an acute intervention, not a treatment for cyclic heavy menstrual bleeding. *GnRH* - **GnRH agonists** (e.g., leuprolide) are used to treat menorrhagia by inducing a **hypoestrogenic state**, which leads to endometrial atrophy and reduced menstrual bleeding. - They are often used as a temporary measure before surgery or for short-term management due to potential side effects like **hot flashes and bone loss**. *NSAIDS* - **Nonsteroidal anti-inflammatory drugs (NSAIDs)**, such as ibuprofen or naproxen, reduce prostaglandin production, which can decrease **menstrual blood loss** by affecting uterine contractility and vasoconstriction. - They are a common first-line treatment for menorrhagia, especially when associated with **painful periods (dysmenorrhea)**.
Question 9: The "whiff test" is positive in which of the following conditions?
- A. Candidiasis
- B. Chlamydial infection
- C. Trichomonas vaginitis (Correct Answer)
- D. Herpes simplex virus (HSV) infection
Explanation: **Explanation:** The **Whiff test** (amine test) is a diagnostic maneuver used to identify vaginal infections characterized by the production of volatile amines. It involves adding a drop of 10% Potassium Hydroxide (KOH) to a sample of vaginal discharge. A "positive" result is the immediate release of a pungent, fishy odor. **Why Trichomonas vaginitis is correct:** In **Trichomoniasis**, the anaerobic environment and the presence of the parasite lead to the production of amines (like putrescine and cadaverine). When KOH is added, these amines are volatilized, resulting in a positive whiff test. While the whiff test is most classically associated with **Bacterial Vaginosis (BV)**—where it is a component of the Amsel criteria—it is also frequently positive in Trichomoniasis due to the similar alkaline pH and anaerobic overgrowth. Among the given options, Trichomonas is the only condition that typically yields this result. **Why the other options are incorrect:** * **Candidiasis:** Characterized by a thick, curd-like discharge with a normal (acidic) pH. The whiff test is negative. KOH is used here instead to visualize pseudohyphae and spores. * **Chlamydial infection:** This is primarily a cervicitis. It does not typically alter the vaginal flora or produce volatile amines. * **HSV infection:** Presents with painful vesicles or ulcers; it is a viral infection and does not produce a fishy odor upon addition of KOH. **High-Yield Clinical Pearls for NEET-PG:** * **Amsel Criteria for BV:** (1) Thin, homogenous discharge, (2) pH >4.5, (3) **Positive Whiff test**, (4) Presence of **Clue cells** (most specific). * **Trichomoniasis:** Look for "Strawberry cervix" (colpitis macularis) and motile flagellates on wet mount. * **Vaginal pH:** Normal is 3.8–4.5. pH is elevated (>4.5) in both BV and Trichomoniasis, but remains normal in Candidiasis.
Question 10: Which of the following instruments is used to obtain a cervical smear?
- A. Pipelle spatula
- B. Sims spatula
- C. Ayre's spatula (Correct Answer)
- D. Colposcope
Explanation: **Explanation:** The correct answer is **Ayre’s spatula**. This instrument is specifically designed for obtaining a cervical smear during a Pap test to screen for cervical cancer. **1. Why Ayre’s Spatula is Correct:** Ayre’s spatula is a wooden or plastic device with a bifid (contoured) end and a flat end. The bifid end is designed to fit the anatomy of the cervix; the longer projection is inserted into the external os, while the shorter arm rests on the ectocervix. By rotating the spatula 360 degrees, the clinician collects exfoliated cells from the **Squamocolumnar Junction (Transformation Zone)**, which is the primary site for cervical intraepithelial neoplasia (CIN). **2. Analysis of Incorrect Options:** * **Pipelle:** This is a flexible, thin plastic suction cannula used for **Endometrial Biopsy**. It is not used for cervical cytology. * **Sims Spatula:** This is a distractor. While "Sims" is associated with the Sims Vaginal Speculum (used to retract the posterior vaginal wall), there is no standard "Sims spatula" used for smears. * **Colposcope:** This is an optical magnifying instrument used to visualize the cervix under magnification (usually 6x to 40x) after an abnormal Pap smear. It is a diagnostic tool, not a sampling instrument. **3. High-Yield Clinical Pearls for NEET-PG:** * **Triple Smear (VCE):** Traditionally includes samples from the **V**agina (posterior fornix), **C**ervix (ectocervix), and **E**ndocervix. * **Cytobrush:** Often used in conjunction with Ayre’s spatula to sample the **endocervical canal** more effectively. * **Liquid-Based Cytology (LBC):** The modern gold standard where the sample (collected via a Cervex-brush) is rinsed into a preservative vial rather than smeared directly onto a slide. * **Fixative:** If using a conventional smear, 95% ethyl alcohol is the standard fixative.
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