Endometriosis — MCQs
Gold standard technique for diagnosis of endometriosis?
The typical histological finding in endometriotic lesions is:
What is the preferred treatment option for a 21-year-old college girl with mild endometriosis?
What is the definitive management for adenomyosis?
One of the risks of the endometrial biopsy that was performed on this patient is perforation of the uterus. The endometrial biopsy device is placed through the cervix and into the endometrial cavity. If complete perforation occurs, what is the sequence of layers that the biopsy device would penetrate prior to entering the peritoneal cavity?
True about endometriosis:
A 29 year old female presented with infertility. There is history of abdominal pain, dyspareunia, dysmenorrhea, menorrhagia. Most likely cause:
Causes of postmenopausal bleeding include all of the following EXCEPT:
The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?
For a woman who has been operated for chocolate cyst with normal menstrual cycle, any of the following may be prescribed except:
Endometriosis Indian Medical PG Practice Questions and MCQs
Question 1: Gold standard technique for diagnosis of endometriosis?
- A. Ca 125 level
- B. Ultrasound
- C. MRI
- D. Laparoscopy (Correct Answer)
Explanation: ***Laparoscopy*** - **Laparoscopy** allows for direct visualization of endometrial implants and enables **biopsy confirmation**, making it the gold standard. - This minimally invasive surgical procedure is crucial for diagnosing, staging, and often treating endometriosis simultaneously. *Ca 125 level* - **CA-125** is a serum marker that can be elevated in endometriosis, but it is **not specific** and can be raised in other conditions like ovarian cancer or physiologic states. - It is primarily used for monitoring treatment response or recurrence, rather than as a primary diagnostic tool. *Ultrasound* - **Transvaginal ultrasound (TVS)** can identify endometriomas (chocolate cysts) and deep infiltrating endometriosis, but it cannot reliably visualize small peritoneal implants. - While it's a good initial imaging modality, its sensitivity for diagnosing all forms of endometriosis is **limited**. *MRI* - **MRI** offers better soft tissue contrast than ultrasound and can identify deep infiltrating endometriosis and some peritoneal implants, especially those involving the bowel or bladder. - However, MRI is **more expensive** and less accessible, and it still cannot definitively rule out all small, superficial endometrial lesions without direct visualization.
Question 2: The typical histological finding in endometriotic lesions is:
- A. Smooth muscle bundles with calcification
- B. Endometrial glands and stroma (Correct Answer)
- C. Squamous epithelium with keratin pearls
- D. Granulomatous inflammation with giant cells
Explanation: ***Endometrial glands and stroma*** - Endometriosis is defined by the presence of **ectopic endometrial tissue**, which histologically includes both **endometrial glands** and **stroma** outside the uterine cavity. - These aberrant tissues respond to **hormonal fluctuations** just like normal endometrium, leading to cyclical bleeding and inflammation in the ectopic sites. *Squamous epithelium with keratin pearls* - This histological pattern is characteristic of **squamous cell carcinoma**, particularly well-differentiated types, and is not found in endometriotic lesions. - Endometriotic lesions are derived from uterine lining cells, which are **columnar glandular epithelium**, not squamous epithelium. *Smooth muscle bundles with calcification* - This description is more consistent with findings in **uterine leiomyomas** (fibroids), which are benign smooth muscle tumors, sometimes undergoing degenerative changes like calcification. - Endometriosis is primarily glandular and stromal tissue, not smooth muscle. *Granulomatous inflammation with giant cells* - This histological picture indicates a **granulomatous process**, often seen in conditions like **tuberculosis**, sarcoidosis, or foreign body reactions. - While inflammation occurs in endometriosis, it is typically chronic, non-specific inflammation caused by cyclical bleeding, not a granulomatous response with giant cells.
Question 3: What is the preferred treatment option for a 21-year-old college girl with mild endometriosis?
- A. Cyclical OC pill
- B. Continuous OC pill (Correct Answer)
- C. Progesterone only pill
- D. Danazole
Explanation: ***Continuous OC pill*** - For **mild endometriosis** in a young woman, **continuous oral contraceptive pills (OCP)** are the **first-line medical treatment** according to current evidence-based guidelines (ACOG, ESHRE). - Continuous OCP use provides better suppression of endometriosis by creating a **stable hormonal environment** that prevents cyclic menstrual bleeding and retrograde menstruation, which can worsen endometriosis. - This approach effectively manages symptoms like **dysmenorrhea** and **pelvic pain** while preserving future fertility, and is well-tolerated in young women with the added benefit of menstrual suppression. *Cyclical OC pill* - While cyclical OCPs can help manage endometriosis symptoms, they are **less effective** than continuous OCPs because they allow withdrawal bleeding, which may perpetuate retrograde menstruation and endometrial implant stimulation. - Cyclical OCPs may still provide symptom relief but are considered a **second-line option** when continuous use is not acceptable to the patient. *Progesterone only pill* - **Progesterone-only pills (POP)** can suppress endometriosis by inducing amenorrhea and decidualization of endometrial implants, but they may cause **irregular bleeding patterns**, especially in the first few months. - While effective, they are generally considered when combined OCPs are contraindicated (e.g., migraine with aura, thrombotic risk) rather than as first-line for uncomplicated mild endometriosis. *Danazole* - **Danazol** is an androgenic agent that creates a hypoestrogenic environment, leading to atrophy of endometrial tissue, but it is **rarely used today** due to significant androgenic side effects. - Common side effects include **acne**, **hirsutism**, **weight gain**, and **voice deepening**, which are often unacceptable for a 21-year-old woman, making it an obsolete option for first-line management of mild endometriosis.
Question 4: 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 5: One of the risks of the endometrial biopsy that was performed on this patient is perforation of the uterus. The endometrial biopsy device is placed through the cervix and into the endometrial cavity. If complete perforation occurs, what is the sequence of layers that the biopsy device would penetrate prior to entering the peritoneal cavity?
- A. Ovary, fallopian tube, broad ligament
- B. Endometrium, myometrium, serosa (Correct Answer)
- C. Round ligament, cardinal ligament, uterosacral ligament
- D. Serosa, myometrium, endometrium
Explanation: ***Endometrium, myometrium, serosa*** - The **endometrium** is the innermost lining layer of the uterus and is the first layer encountered by the biopsy device within the uterine cavity [1]. - The **myometrium** is the thick muscular middle layer of the uterine wall, which lies superficial to the endometrium and deep to the serosa [1]. - The **peritoneum** (also known as the serosa or perimetrium when referring to the uterus) is the outermost layer of the uterus that covers the myometrium, and once perforated, the device enters the peritoneal cavity [4]. *Ovary, fallopian tube, broad ligament* - The **ovaries** and **fallopian tubes** are located lateral to the uterus, and the **broad ligament** is a fold of peritoneum that supports the uterus, ovaries, and fallopian tubes [3]. - These structures are not directly superior or immediately adjacent to the uterine wall in such a way that they would be sequentially penetrated during a direct anterior-posterior perforation from the uterine cavity. *Round ligament, cardinal ligament, uterosacral ligament* - The **round, cardinal, and uterosacral ligaments** are supportive structures of the uterus located externally to the uterine wall. - They would not be encountered in a direct transmural penetration from within the uterine cavity into the peritoneal cavity. *Serosa, myometrium, endometrium* - This sequence describes penetration in the reverse direction, from the **peritoneal cavity** inward towards the uterine lumen. - An endometrial biopsy device starts within the **endometrial cavity**, so it would penetrate from inside out [2].
Question 6: True about endometriosis:
- A. Presence of endometrial gland in deep myometrium
- B. Presence of endometrium at ectopic locations (Correct Answer)
- C. Treated preferably with hysterectomy
- D. Seen in multiparous women
Explanation: ***Presence of endometrium at ectopic locations*** - **Endometriosis** is defined as the presence of endometrial glands and stroma outside of the uterine cavity. - These ectopic endometrial implants respond to hormonal changes, leading to cyclical pain and inflammation. *Presence of endometrial gland in deep myometrium* - This describes **adenomyosis**, a condition where endometrial tissue invades the muscular wall of the uterus (myometrium). - While both can cause pelvic pain, endometriosis specifically refers to endometrial tissue *outside* the uterus. *Treated preferably with hysterectomy* - Hysterectomy is a definitive treatment option, especially for severe cases or when fertility is not desired, but it is not the *preferred* initial treatment for all patients. - Initial management often includes **pain relievers**, **hormonal therapy**, or **laparoscopic excision** of endometriotic implants. *Seen in multiparous women* - Endometriosis is more commonly diagnosed in **nulliparous (never given birth)** or women who delay childbearing. - While it can occur in multiparous women, it is not a characteristic association.
Question 7: 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 8: Causes of postmenopausal bleeding include all of the following EXCEPT:
- A. Carcinoma ovary
- B. Endometriosis (Correct Answer)
- C. Carcinoma cervix
- D. Endometrial carcinoma
Explanation: ***Endometriosis*** - Endometriosis is characterized by the presence of **endometrial-like tissue outside the uterus** and is primarily a disease of **reproductive-aged women**, driven by estrogen. - While it can cause pelvic pain and irregular bleeding in premenopausal women, it is generally **rare and inactive after menopause** due to the decline in estrogen levels. - Among the given options, endometriosis is the **least likely cause** of postmenopausal bleeding, making it the correct answer to this EXCEPT question. *Carcinoma ovary* - **Ovarian cancer** can present with postmenopausal bleeding, especially **hormone-producing tumors** such as granulosa cell tumors that secrete estrogen. - These tumors can stimulate endometrial proliferation, leading to abnormal bleeding. - Other symptoms may include **abdominal discomfort, bloating, or changes in bowel/bladder habits**. *Carcinoma cervix* - **Cervical cancer** is a significant cause of postmenopausal bleeding, often due to **tumor friability** and ulceration. - Bleeding can be **intermittent, postcoital, or heavy**, and may be accompanied by foul-smelling vaginal discharge. - Regular screening helps detect cervical pathology early. *Endometrial carcinoma* - **Endometrial carcinoma** is the **most important malignant cause** of postmenopausal bleeding and accounts for approximately **10-15% of cases**. - While atrophic changes are more common overall, **any postmenopausal bleeding requires investigation** to rule out endometrial malignancy. - Risk factors include obesity, diabetes, unopposed estrogen therapy, and nulliparity.
Question 9: The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?
- A. HSG
- B. USG (Correct Answer)
- C. Laparotomy
- D. Diagnostic Laparoscopy
Explanation: ***USG*** - **Transvaginal ultrasound (TVS)** is the initial imaging modality of choice for evaluating uterine position, assessing for causes of dysmenorrhea and dyspareunia (e.g., **endometriosis**, adenomyosis, fibroids), and can visualize the retroverted uterus. - It is **non-invasive**, readily available, and provides good resolution of pelvic organs, making it suitable for first-line investigation. *HSG* - **Hysterosalpingography (HSG)** is primarily used to assess **fallopian tube patency** in cases of infertility. - It will **not provide detailed information** about the uterine position or other pelvic pathologies contributing to pain. *Laparotomy* - **Laparotomy** is a major surgical procedure involving a large abdominal incision, typically reserved for **definitive diagnosis and treatment** of significant pelvic pathology when less invasive methods are insufficient. - It is **not an initial investigatory step** for symptoms like dysmenorrhea and dyspareunia. *Diagnostic Laparoscopy* - **Diagnostic laparoscopy** is a minimally invasive surgical procedure that allows direct visualization of pelvic organs, often used to **confirm endometriosis** or other pathologies. - While it offers definitive diagnosis, it is an **invasive procedure** and usually performed **after initial non-invasive imaging** (like USG) has been completed.
Question 10: For a woman who has been operated for chocolate cyst with normal menstrual cycle, any of the following may be prescribed except:
- A. Oral progestogens
- B. Injection leuprolide
- C. Tablet dienogest
- D. Tranexamic acid (Correct Answer)
Explanation: ***Tranexamic acid*** - **Tranexamic acid** is an antifibrinolytic agent used to reduce **heavy menstrual bleeding** by inhibiting plasminogen activation. - In a woman with a **normal menstrual cycle** who has undergone surgery for a chocolate cyst, heavy bleeding is not an issue, so tranexamic acid would be **unnecessary** and not indicated for endometriosis management. *Oral progestogens* - **Oral progestogens** are commonly prescribed for endometriosis to **suppress ovarian activity** and induce decidualization and atrophy of endometrial implants. - They help manage symptoms like **pain** and prevent recurrence of chocolate cysts by creating a **progestin-dominant environment**. *Injection leuprolide* - **Leuprolide** is a **GnRH agonist** that creates a **hypoestrogenic state** by downregulating pituitary GnRH receptors, thereby suppressing ovarian hormone production. - This effectively reduces the growth of **endometrial implants** and manages endometriosis symptoms, often used post-operatively to prevent recurrence. *Tablet dienogest* - **Dienogest** is a **fourth-generation progestin** specifically approved for the treatment of endometriosis. - It works by suppressing ovarian estrogen production and inhibiting the growth of **endometrial lesions**, making it a suitable long-term post-operative therapy.
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