Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 91: In a case of ectopic pregnancy, medical treatment is contraindicated if:

A. Sac size is 3.0 cm
B. Serum HCG levels > 1500 miu / ml
C. Significant hemoperitoneum is present (Correct Answer)
D. Absent fetal activity

Explanation: **Explanation:** The medical management of ectopic pregnancy (typically using Methotrexate) is reserved for patients who are **hemodynamically stable**. The presence of **significant hemoperitoneum** (Option C) indicates a ruptured ectopic pregnancy or active internal bleeding. This is a surgical emergency requiring immediate laparoscopy or laparotomy; attempting medical management in this scenario is life-threatening and strictly contraindicated. **Analysis of Incorrect Options:** * **Option A (Sac size 3.0 cm):** Medical management is generally considered favorable if the gestational sac diameter is **< 3.5 cm or 4 cm**. A 3.0 cm sac is an indication *for* medical therapy, not a contraindication. * **Option B (Serum hCG > 1500 mIU/ml):** While success rates are higher when hCG is low, the absolute contraindication threshold is typically **> 5000 mIU/ml**. A level of 1500 mIU/ml is well within the acceptable range for Methotrexate. * **Option D (Absent fetal activity):** The *presence* of embryonic cardiac activity is a relative contraindication (as it predicts medical failure). Therefore, the **absence** of fetal activity makes the patient a better candidate for medical treatment. **NEET-PG High-Yield Pearls:** * **Absolute Contraindications to Methotrexate:** Hemodynamic instability, signs of rupture (hemoperitoneum), breastfeeding, immunodeficiency, and hepatic/renal/hematologic dysfunction. * **Ideal Candidate:** Hemodynamically stable, hCG < 5000 mIU/ml, sac size < 3.5 cm, and no fetal cardiac activity. * **Dosing:** Most commonly the **Single-dose regimen** (50 mg/m² IM). * **Monitoring:** hCG levels are measured on Day 4 and Day 7. A decline of **< 15%** between Day 4 and 7 necessitates a second dose or surgical intervention.

Question 92: Which of the following factors causes endometrial hyperplasia?

A. Estrogen (Correct Answer)
B. Danazol
C. Perimenopausal age
D. None of the above

Explanation: **Explanation:** **Endometrial Hyperplasia** is a condition characterized by the proliferation of endometrial glands, resulting in an increased gland-to-stroma ratio. **1. Why Estrogen is Correct:** The fundamental pathophysiology of endometrial hyperplasia is **unopposed estrogen stimulation**. Estrogen acts as a potent mitogen for the endometrium, causing cellular proliferation. Under normal physiological conditions, progesterone (produced after ovulation) counteracts this by inducing secretory changes and limiting growth. When estrogen levels are high or progesterone is absent (unopposed), the endometrium continues to thicken pathologically, which can eventually lead to atypia and malignancy (Endometrial Carcinoma). **2. Analysis of Incorrect Options:** * **Danazol:** This is a synthetic androgen used to treat endometriosis and fibrocystic breast disease. It creates a high-androgen, low-estrogen environment, which actually leads to **atrophy** of the endometrium rather than hyperplasia. * **Perimenopausal Age:** While endometrial hyperplasia often *presents* during the perimenopausal period due to anovulatory cycles, the age itself is not the "factor" or cause. The underlying cause remains the hormonal imbalance (estrogen without sufficient progesterone). Note: If the option were "Anovulation," it would be a significant contributing factor. **3. NEET-PG High-Yield Pearls:** * **Risk Factors:** Obesity (peripheral conversion of androstenedione to estrone), PCOS (chronic anovulation), Estrogen-secreting tumors (Granulosa cell tumor), and Tamoxifen use. * **Classification (WHO):** Divided into "Hyperplasia without atypia" and "Atypical hyperplasia" (the latter has a ~25-30% risk of progressing to cancer). * **Investigation of Choice:** Transvaginal Ultrasound (TVUS) is the initial screening tool (Endometrial thickness >4mm in postmenopausal women is significant), but **Endometrial Biopsy** is the gold standard for diagnosis. * **Treatment:** Progestogens (like LNG-IUS or Medroxyprogesterone) are used for hyperplasia without atypia; Hysterectomy is preferred for atypical hyperplasia.

Question 93: Regarding the use of lasers in gynecology, all are true EXCEPT:

A. Management of CIN, VIN, VAIN
B. Laser laparoscopy for ectopic pregnancy
C. Laser hysteroscopy for presacral neurectomy (Correct Answer)
D. It acts by tissue cutting, vaporization, or coagulation

Explanation: ### Explanation The correct answer is **C. Laser hysteroscopy for presacral neurectomy.** **1. Why Option C is the Correct Answer (The "Except"):** Presacral neurectomy (PSN) is a surgical procedure used to treat chronic pelvic pain by interrupting the sympathetic nerve fibers at the level of the superior hypogastric plexus. This procedure is performed in the **retroperitoneal space** (presacral space) via **laparotomy or laparoscopy**, not hysteroscopy. Hysteroscopy is an endoscopic procedure used to visualize and treat pathologies *inside* the uterine cavity (e.g., polyps, septa, or fibroids). Therefore, "Laser hysteroscopy" for a nerve procedure located outside the uterus is anatomically and surgically incorrect. **2. Analysis of Other Options:** * **Option A:** Lasers (specifically CO2 lasers) are a standard treatment modality for **Cervical, Vaginal, and Vulvar Intraepithelial Neoplasia (CIN, VAIN, VIN)**. They allow for precise tissue ablation or excisional conization with minimal damage to surrounding healthy tissue. * **Option B:** Laser laparoscopy can be used for the surgical management of **ectopic pregnancy** (e.g., linear salpingostomy) to achieve precise incisions and hemostasis. * **Option D:** The mechanism of action for medical lasers involves the conversion of light energy into thermal energy, which results in **tissue cutting (incising), vaporization (ablation), or coagulation (hemostasis)** depending on the power density and wavelength. **3. High-Yield Clinical Pearls for NEET-PG:** * **CO2 Laser:** The most common laser in gynecology; it is highly absorbed by water, making it excellent for superficial vaporization (CIN/VIN). * **Nd:YAG Laser:** Has deeper tissue penetration; often used for endometrial ablation or hysteroscopic myomectomy. * **Presacral Neurectomy:** Indicated primarily for **midline** pelvic pain (e.g., primary dysmenorrhea) that is refractory to medical management. * **Key Complication of PSN:** Risk of injury to the **Middle Sacral Artery**, which lies directly beneath the nerve plexus.

Question 94: Which of the following is NOT true regarding adenomyosis?

A. Presents with menorrhagia, dysmenorrhea, and an enlarged uterus.
B. More common in multiparous women.
C. Progestins are the treatment of choice. (Correct Answer)
D. 'Lakes' of endometrial collection are seen in the myometrium on ultrasound.

Explanation: **Explanation** Adenomyosis is a condition characterized by the presence of endometrial glands and stroma within the myometrium, leading to reactive hypertrophy of the surrounding muscle. **Why Option C is the correct answer (The "Not True" statement):** While progestins (like the LNG-IUS) can help alleviate symptoms, they are **not the treatment of choice**. The definitive treatment for adenomyosis is **hysterectomy**. Unlike endometriosis, adenomyosis is often diffuse and deep within the myometrium, making medical management or conservative surgery (like adenomyomectomy) less effective. **Analysis of Incorrect Options:** * **Option A:** This is the classic clinical triad. Menorrhagia occurs due to increased endometrial surface area and impaired uterine contractility; dysmenorrhea is typically "secondary" and congestive; the uterus is characteristically **globular and symmetrically enlarged** (rarely exceeding 12–14 weeks size). * **Option B:** Adenomyosis is classically seen in **multiparous women** in their 40s and 50s. It is hypothesized that pregnancy and labor facilitate the invagination of the basal endometrium into the myometrium. * **Option D:** On Transvaginal Ultrasound (TVS), "lakes" or anechoic lacunae represent small areas of hemorrhage or glandular secretions within the myometrium. Other findings include an asymmetrical myometrial wall and "venetian blind" shadowing. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Histopathology (after hysterectomy). * **MRI Findings:** Thickening of the **Junctional Zone (JZ) >12 mm** is diagnostic. * **Physical Exam:** The uterus is often described as "soft" or "boggy" and tender during menstruation (Halban’s sign). * **Distinction:** Unlike fibroids, adenomyosis has ill-defined margins and no true capsule.

Question 95: All of the following are advantages of laparoscope assisted vaginal hysterectomy (LAVH) over abdominal hysterectomy except?

A. Less peritoneal adhesions postoperatively
B. Shorter hospital stay
C. Less postoperative pain
D. Scope for wide exploration of the abdominal and pelvic organs (Correct Answer)

Explanation: **Explanation:** The core concept here is comparing **Minimally Invasive Surgery (MIS)** with **Open Surgery (Laparotomy)**. While Laparoscopically Assisted Vaginal Hysterectomy (LAVH) offers the benefits of laparoscopy, it has specific limitations regarding surgical field visualization compared to an open abdominal approach. **Why Option D is the Correct Answer:** In an **Abdominal Hysterectomy**, the surgeon has a direct, wide-field view and physical access to the entire abdominal cavity, allowing for extensive manual palpation and exploration of upper abdominal organs (like the liver, diaphragm, and omentum). In contrast, LAVH is primarily focused on the pelvic cavity. While the laparoscope provides magnification, the "scope for exploration" is technically more restricted and less tactile than a large midline incision used in abdominal hysterectomy. **Analysis of Incorrect Options:** * **A. Less peritoneal adhesions:** Laparoscopy involves less tissue handling, less drying of serosal surfaces, and smaller incisions, which significantly reduces the formation of postoperative adhesions compared to open surgery. * **B. Shorter hospital stay:** Due to smaller incisions and faster return of bowel function (peristalsis), patients undergoing LAVH are typically discharged much earlier than those undergoing abdominal hysterectomy. * **C. Less postoperative pain:** Reduced abdominal wall trauma and absence of a large muscle-cutting incision lead to significantly lower pain scores and decreased requirement for opioid analgesics in LAVH. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** For benign pathology where the uterus is mobile and of appropriate size, **Vaginal Hysterectomy (VH)** remains the first choice (least invasive). * **LAVH Indication:** It is preferred when a vaginal hysterectomy is desired but the surgeon needs to treat concomitant pelvic pathology (e.g., endometriosis, adnexal masses) or to facilitate the division of upper pedicles. * **Contraindication:** Large uteri (usually >12–14 weeks size) or suspected malignancy requiring extensive staging are better suited for abdominal hysterectomy.

Question 96: A 45-year-old multipara presents with dysmenorrhea and menorrhagia. The uterus is symmetrically enlarged to 14 weeks. What is the probable diagnosis?

A. Intramural fibroid
B. Adenomyosis (Correct Answer)
C. Endometrial hyperplasia
D. Pelvic inflammatory disease

Explanation: ### Explanation The clinical presentation of a **45-year-old multipara** with **dysmenorrhea, menorrhagia**, and a **symmetrically enlarged uterus** is a classic description of **Adenomyosis**. #### Why Adenomyosis is Correct: Adenomyosis is defined as the presence of endometrial glands and stroma within the myometrium. It typically affects multiparous women in their 40s and 50s. * **Symmetrical Enlargement:** Unlike fibroids, which are usually focal and cause irregular contours, adenomyosis causes diffuse global hypertrophy of the myometrium, leading to a **globular, symmetrically enlarged uterus** (rarely exceeding 12–14 weeks in size). * **Clinical Triad:** Menorrhagia (due to increased surface area), progressive secondary dysmenorrhea, and a soft, boggy uterus. #### Why Other Options are Incorrect: * **Intramural Fibroid:** While fibroids cause menorrhagia and dysmenorrhea, they typically result in an **asymmetrically enlarged, firm, and irregular** uterus. * **Endometrial Hyperplasia:** This presents with abnormal uterine bleeding (AUB), but the uterus is usually **normal in size** or only minimally enlarged. It does not typically cause significant dysmenorrhea. * **Pelvic Inflammatory Disease (PID):** PID presents with pelvic pain, vaginal discharge, and fever. While it can cause dysmenorrhea, it does not cause significant uterine enlargement. #### High-Yield Clinical Pearls for NEET-PG: * **Uterine Consistency:** The adenomyomatous uterus is often described as **"soft and boggy"** on bimanual examination. * **MRI Findings:** The gold standard for diagnosis is MRI, showing a **Junctional Zone (JZ) thickness >12 mm**. * **USG Sign:** Look for the **"Venetian blind"** appearance (posterior shadowing) or "Rain-in-the-forest" appearance on Doppler. * **Definitive Management:** Hysterectomy remains the treatment of choice for symptomatic women who have completed their family.

Question 97: What is the commonest manifestation of endometriosis?

A. Infertility
B. Pain (Correct Answer)
C. Bleeding
D. Leukorrhea

Explanation: **Explanation:** Endometriosis is defined as the presence of functional endometrial tissue (stroma and glands) outside the uterine cavity. **Why Pain is the Correct Answer:** Pain is the **most common clinical manifestation** of endometriosis, affecting approximately 70–80% of symptomatic patients. The pain is typically chronic and cyclic, mediated by the inflammatory response of ectopic tissue to hormonal fluctuations. It classically presents as a "triad" of symptoms: 1. **Dysmenorrhea:** Specifically secondary, congestive dysmenorrhea (starts before menses). 2. **Dyspareunia:** Deep-seated pain during intercourse, often due to involvement of the pouch of Douglas or uterosacral ligaments. 3. **Chronic Pelvic Pain:** Non-cyclic pain lasting >6 months. **Analysis of Incorrect Options:** * **Infertility (A):** While endometriosis is a leading cause of infertility (found in 30–50% of infertile women), it is not as frequent a presenting complaint as pain. * **Bleeding (C):** Abnormal uterine bleeding (AUB) or menorrhagia occurs in about 15–20% of cases, often due to associated adenomyosis or ovarian dysfunction, but it is not the hallmark symptom. * **Leukorrhea (D):** This refers to excessive white vaginal discharge, which is typically associated with infections (vaginitis) or physiological changes, not endometriosis. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Diagnostic Laparoscopy (Visual confirmation + Biopsy). * **Commonest Site:** Ovary (often presenting as a "Chocolate Cyst" or Endometrioma). * **Classic Sign:** Fixed retroverted uterus and tender nodules in the Pouch of Douglas (POD). * **Serum Marker:** CA-125 (used for monitoring recurrence, not for primary diagnosis).

Question 98: Halban's sign is seen in which of the following conditions?

A. Endometriosis
B. Adenomyosis (Correct Answer)
C. Cervical cancer
D. Endometrial cancer

Explanation: **Explanation:** **Halban’s Sign** is a classic clinical finding associated with **Adenomyosis**. It refers to a **tender, symmetrically enlarged (globular) uterus** found during a bimanual examination, particularly during the premenstrual or menstrual phase. In adenomyosis, the ectopic endometrial glands and stroma within the myometrium cause reactive hypertrophy and hyperplasia, leading to a "boggy" consistency and increased sensitivity to palpation. **Why other options are incorrect:** * **Endometriosis:** While related to adenomyosis, endometriosis typically presents with a fixed, retroverted uterus, tender nodules in the Pouch of Douglas, or adnexal masses (chocolate cysts), rather than a symmetrically enlarged uterus. * **Cervical Cancer:** This usually presents with a hard, friable growth on the cervix or a barrel-shaped cervix in advanced stages, not generalized uterine enlargement. * **Endometrial Cancer:** This typically presents with postmenopausal bleeding. While the uterus may be enlarged, it is not specifically associated with Halban’s sign, which is characterized by cyclic tenderness. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of Adenomyosis:** Secondary dysmenorrhea, Menorrhagia (heavy menstrual bleeding), and a Symmetrically enlarged, boggy uterus. * **MRI:** The gold standard for non-invasive diagnosis; look for a **Junctional Zone (JZ) thickness >12 mm**. * **Histopathology:** The definitive diagnosis is made by identifying endometrial glands and stroma >2.5 mm below the endo-myometrial junction on a hysterectomy specimen. * **Management:** Levonorgestrel-releasing intrauterine system (LNG-IUS) is the medical treatment of choice; Hysterectomy is the definitive treatment.

Question 99: What is the most common route of transmission of endometrial tuberculosis?

A. Direct local spread
B. Lymphatic spread
C. Retrograde spread (Correct Answer)
D. Hematogenous spread

Explanation: **Explanation:** Genital tuberculosis (TB) is almost always secondary to a primary focus elsewhere in the body (usually the lungs). Understanding the sequence of spread is crucial for NEET-PG: 1. **The Correct Answer (C):** While the initial spread from the lungs to the pelvic organs (specifically the fallopian tubes) occurs via the **hematogenous route**, the transmission to the **endometrium** specifically occurs via **retrograde spread** (descending spread) from the fallopian tubes. In 90-100% of cases, the fallopian tubes are affected first. The infection then tracks down the mucosa to involve the endometrium in about 50-60% of cases. 2. **Why other options are incorrect:** * **Hematogenous spread (D):** This is the most common route for the *initial* infection of the genital tract (seeding the fallopian tubes from the lungs), but not the specific route for endometrial involvement. * **Lymphatic spread (B):** This is less common and usually occurs from abdominal nodes or the primary intestinal complex. * **Direct local spread (A):** This occurs rarely from adjacent infected organs like the bladder or bowel (e.g., tuberculous peritonitis). **High-Yield Clinical Pearls for NEET-PG:** * **Most common site** of Genital TB: Fallopian Tubes (90-100%), followed by Endometrium (50-60%), and Ovaries (20-30%). * **Classic Presentation:** Infertility (most common symptom) and menstrual irregularities (amenorrhea or oligomenorrhea due to endometrial synechiae/Asherman’s syndrome). * **Hysterosalpingography (HSG) findings:** "Beaded tube," "Lead pipe appearance," or "Tobacco pouch" appearance. * **Gold Standard Diagnosis:** Endometrial biopsy/histopathology showing caseating granulomas or TB-PCR/Culture.

Question 100: Strawberry cervix is seen in which condition?

A. Trichomoniasis (Correct Answer)
B. Chlamydial infection
C. Gonococcal infection
D. Candidiasis

Explanation: **Explanation:** **Strawberry Cervix (Colpitis Macularis)** is a classic clinical sign pathognomonic for **Trichomoniasis**, a common sexually transmitted infection caused by the flagellated protozoan *Trichomonas vaginalis*. 1. **Why Trichomoniasis is correct:** The "strawberry" appearance is caused by multiple small, punctate hemorrhages (petechiae) on the ectocervix and vaginal walls. These occur due to the intense inflammatory response and capillary dilation triggered by the parasite. While highly specific, this sign is only visible to the naked eye in about 2–5% of cases (more frequently seen via colposcopy). 2. **Why other options are incorrect:** * **Chlamydial infection:** Typically presents with a "friable" cervix (bleeds easily on contact) and mucopurulent endocervical discharge, but not punctate hemorrhages. * **Gonococcal infection:** Primarily causes endocervicitis with thick, purulent discharge. It does not produce the characteristic petechial spots of a strawberry cervix. * **Candidiasis:** Characteristically presents with a "cottage-cheese" like, thick white discharge and an erythematous (red) vaginal vault, but without the specific punctate pattern. **High-Yield Clinical Pearls for NEET-PG:** * **Discharge:** Trichomoniasis features a **foul-smelling, thin, frothy, greenish-yellow** discharge. * **pH:** The vaginal pH in Trichomoniasis is typically **>4.5** (elevated). * **Diagnosis:** The gold standard is **NAAT**, but the most common bedside test is **Wet Mount microscopy**, showing "jerky" motility of the pear-shaped protozoa. * **Treatment:** The drug of choice is **Metronidazole** (2g single dose or 500mg BD for 7 days). **Simultaneous treatment of the partner** is mandatory to prevent reinfection.

Practice by Chapter

Abnormal Uterine Bleeding

Practice Questions

Endometriosis

Practice Questions

Adenomyosis

Practice Questions

Uterine Fibroids

Practice Questions

Ovarian Cysts

Practice Questions

Pelvic Inflammatory Disease

Practice Questions

Vulvovaginitis

Practice Questions

Pelvic Organ Prolapse

Practice Questions

Vulvar Disorders

Practice Questions

Benign Breast Diseases

Practice Questions

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