Gynecological Disorders Practice Questions

Q: Which of the following is TRUE regarding bacterial vaginosis?

It is associated with increased risk of preterm labor. ***It is associated with increased risk of preterm labor*** - **Bacterial vaginosis (BV)** is a common cause of **increased risk of preterm labor** and premature rupture of membranes in pregnant women due to the inflammatory response it triggers. - The imbalance of vaginal flora and presence of certain bacteria can lead to the production of **amniotic fluid-degrading enzymes**, contributing to adverse pregnancy outcomes. *Clue cells are epithelial cells covered with Lactobacilli* - **Clue cells** are in fact **vaginal epithelial cells** covered in **coccobacillary bacteria**, primarily *Gardnerella vaginalis*, not *Lactobacilli*. - The normal flora, largely composed of **Lactobacilli**, is typically **depleted** in bacterial vaginosis. *It is characterized by decreased vaginal pH* - Bacterial vaginosis is characterized by an **increased vaginal pH (typically >4.5)**, not a decreased pH. - The **normal acidic vaginal pH** is maintained by *Lactobacilli* which produce lactic acid; their decrease leads to a higher pH. *Metronidazole treatment should always include male partners* - **Treatment of male partners** for bacterial vaginosis is generally **not recommended**, as BV is not considered a sexually transmitted infection in the same way as chlamydia or gonorrhea. - Recurrence of BV is common, but treatment of male partners has not been shown to significantly prevent recurrence in women.

Q: A 30-year-old woman presents with vaginal discharge and lower abdominal pain for 10 days. Examination reveals cervical motion tenderness and adnexal tenderness. Laboratory tests show elevated WBC count. What is the most appropriate initial antibiotic regimen?

Ceftriaxone plus doxycycline. ***Ceftriaxone plus doxycycline*** - This combination provides broad-spectrum coverage against common causative agents of **Pelvic Inflammatory Disease (PID)**, including *Neisseria gonorrhoeae* (covered by ceftriaxone) and *Chlamydia trachomatis* (covered by doxycycline). - The patient's symptoms of vaginal discharge, lower abdominal pain, cervical motion tenderness, adnexal tenderness, and elevated WBC count are highly suggestive of PID, necessitating empiric treatment for these infections. *Doxycycline plus metronidazole* - While doxycycline is effective against *Chlamydia trachomatis*, metronidazole primarily targets **anaerobic bacteria** and *Trichomonas vaginalis*. - This regimen lacks adequate coverage for **gonococcal infections**, which are a significant cause of PID and require a cephalosporin. *Azithromycin plus metronidazole* - Azithromycin can treat *Chlamydia trachomatis*, but it has **inferior efficacy against gonococcal infections** compared to ceftriaxone. - Metronidazole, as mentioned, addresses anaerobic bacteria but doesn't provide the necessary broad coverage for other common PID pathogens. *Ciprofloxacin plus clindamycin* - Ciprofloxacin has declining efficacy against **gonorrhea** due to increasing resistance and is generally not recommended as first-line therapy for PID without susceptibility testing. - Clindamycin primarily covers anaerobic bacteria and some gram-positive organisms but does not adequately target *Neisseria gonorrhoeae* or *Chlamydia trachomatis*.

Q: Why does Chlamydia trachomatis infection often remain asymptomatic in women?

Due to infection of columnar epithelium in endocervix. ***Due to infection of columnar epithelium in endocervix*** - Chlamydia trachomatis primarily infects the **columnar epithelial cells** of the endocervix. - These cells often do not elicit a significant **inflammatory response** or nerve stimulation, leading to a lack of noticeable symptoms. *Due to rapid clearance of organisms* - **Chlamydia infections** are not typically cleared rapidly; they can persist for months or even years if untreated. - The persistence of the organism, even in the absence of symptoms, is what makes it a common cause of **pelvic inflammatory disease (PID)** and infertility. *Due to inhibition of inflammatory response* - While Chlamydia does not always trigger a robust symptomatic inflammatory response in the early stages, it does not actively **inhibit** the immune system's general ability to respond. - Chronic or ascending infections eventually lead to **inflammation** and tissue damage, often resulting in silent but progressive pathology. *Due to hormonal influence on epithelial cells* - While **hormonal changes** can influence the susceptibility of epithelial cells to certain infections, they are not the primary reason for the asymptomatic nature of Chlamydia in women. - The main factor is the **type of cells** infected and the initial lack of a strong symptomatic host response.

Q: What is the preferred management of a uterine septum?

Hysteroscopic resection of septum. ***Hysteroscopic resection of septum*** - **Hysteroscopic resection of a uterine septum** is the preferred management due to its minimally invasive nature and high success rates in improving reproductive outcomes. - This procedure allows direct visualization and precise removal of the septal tissue, preserving the healthy uterine musculature. *Laparoscopic resection of septum* - While laparoscopic approaches are minimally invasive, directly resecting a uterine septum laparoscopically is generally **not the primary method**. - Laparoscopy is often used for diagnostics or in conjunction with hysteroscopy for guidance, but not typically for primary septal resection alone. *Uterine metroplasty* - **Uterine metroplasty** is a broader term for surgical reconstruction of the uterus, typically reserved for more complex uterine anomalies like a **bicornuate uterus**. - It involves more extensive surgical remodeling of the uterine cavity and is generally **more invasive** than hysteroscopic septal resection. *Laparotomy and resection* - **Laparotomy** involves a large abdominal incision and is a more invasive surgical approach with a longer recovery period. - It is generally **reserved for very complex uterine malformations** or cases where hysteroscopic or laparoscopic approaches are not feasible or have failed.

Q: The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?

USG. ***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.

Q: What are clue cells?

Vaginal epithelial cells lined by bacteria. ***Vaginal epithelial cells lined by bacteria*** - **Clue cells** are definitive diagnostic features of **bacterial vaginosis**, identified on microscopy. - They are specifically **vaginal epithelial cells** that appear "cluey" or stippled due to their surface being obscured by numerous adherent bacteria, primarily *Gardnerella vaginalis*. *Uterine endothelial cells lined by bacteria* - The **endometrium** (uterine lining) is composed of epithelial cells, not typically referred to as endothelial cells in this context, and is not where clue cells are found. - Presence of bacteria adherent to uterine cells would suggest an **endometritis** or other uterine infection, not bacterial vaginosis. *Cervical epithelial cells lined by bacteria* - While bacteria can adhere to **cervical epithelial cells**, especially in the presence of infection, these are not typically called **clue cells**. - **Clue cells** are characteristic of the vaginal environment and are specifically associated with bacterial vaginosis. *Abdominal cells lined by bacteria* - **Abdominal cells** are not relevant to the definition of clue cells, which are found in the vaginal canal. - The presence of bacteria on abdominal cells would indicate a completely different pathology, such as a **peritoneal infection**.

Q: A patient complained of whitish discharge from the vagina and yellow staining on their clothes. There is no itching, no redness, and pH is acidic. What is the likely cause?

Increased normal vaginal discharge. ***Increased normal vaginal discharge*** - The presence of a whitish discharge and yellow staining on clothes, without **itching** or **redness**, and with an **acidic pH**, is characteristic of a **normal physiological discharge**. - Normal vaginal discharge can vary in color and consistency, and its volume can increase due to hormonal changes (e.g., during ovulation or pregnancy) or sexual arousal. *Trichomoniasis* - This infection typically causes a **frothy, greenish-yellow discharge** with a **foul odor**, often accompanied by **itching**, redness, and a **pH greater than 4.5**. - The absence of itching and the acidic pH rule out trichomoniasis in this scenario. *Candidiasis* - **Candidiasis** (yeast infection) presents with a **thick, white, 'cottage cheese' like discharge**, accompanied by **intense itching**, burning, and redness, with a **normal to acidic pH (less than 4.5)**. - The lack of itching and redness, along with a simple whitish discharge, does not align with candidiasis. *Bacterial vaginosis* - **Bacterial vaginosis** is characterized by a **thin, grayish-white discharge** with a **"fishy" odor**, especially after intercourse, and a **vaginal pH greater than 4.5**. - The absence of a fishy odor and the acidic pH make bacterial vaginosis an unlikely diagnosis.

Q: A woman presents with painless ulcers on the vulva, she gives a history of having multiple sexual partners and has had a stillbirth at 28 weeks in the past. What is the next best step of investigation?

VDRL. ***VDRL*** - The presentation of **painless vulvar ulcers**, a history of **multiple sexual partners**, and a past **stillbirth at 28 weeks** are highly suggestive of **syphilis**. - A **VDRL (Venereal Disease Research Laboratory) test** is a non-treponemal serologic test used for screening and monitoring the treatment of syphilis. *PCR* - While **PCR** can be used to detect the genetic material of *Treponema pallidum*, it is not the primary diagnostic test for syphilis, especially given the classic clinical picture. - It is more commonly used for detecting other sexually transmitted infections (STIs) or for specific situations where direct detection of the organism from a lesion is preferred. *Vaginal swab and culture* - A **vaginal swab and culture** would be appropriate for diagnosing bacterial vaginosis, candidiasis, or certain bacterial STIs, but it is not suitable for diagnosing syphilis. - Syphilis is caused by a spirochete (*Treponema pallidum*) that cannot be cultured on standard media. *NAT* - **Nucleic Acid Amplification Tests (NATs)** are a broad category of tests that include PCR. - Like PCR, while potentially applicable for *Treponema pallidum* detection, they are not the standard or first-line diagnostic investigation for syphilis given the strong clinical indicators.

Q: The following set of instruments are used for which procedure?

Pap smear. ***Pap smear*** - The image displays a complete set of instruments used for a **Pap smear**, including **glass slides** for sample collection, a **cervical brush**, a **spatula** (cytobrush and Ayre spatula), and a **speculum** to visualize the cervix. - These tools are specifically designed for collecting cervical cells to screen for **cervical cancer** and **precancerous changes**. *Biopsy* - A biopsy typically involves specialized instruments like **punch biopsy tools**, **forceps**, or needles to extract tissue samples, which are not depicted here. - While glass slides might be used for processing biopsy samples, the primary collection tools are absent. *Dilatation and curettage* - This procedure requires instruments such as **dilators** to open the cervix and **curetters** to scrape the uterine lining, which are not shown in the image. - The instruments shown are for surface cell collection, not for uterine cavity procedures. *Hysteroscopy* - Hysteroscopy uses a **hysteroscope**—a thin, lighted tube with a camera—to visualize the inside of the uterus. - The instruments in the image are for external examination and cervical cell collection, not for direct visualization of the uterine cavity.

Q: A female patient having frothy vaginal discharge was found to have a strawberry cervix. Which of the following is the drug of choice?

Metronidazole. ***Correct Option: Metronidazole*** - The combination of **frothy vaginal discharge** and a **strawberry cervix** (colpitis macularis) is highly indicative of **trichomoniasis**, caused by *Trichomonas vaginalis*. - **Metronidazole** is the drug of choice for treating trichomoniasis, effectively eradicating the protozoan parasite. - Alternative: **Tinidazole** is also highly effective for trichomoniasis treatment. *Incorrect Option: Cefixime* - **Cefixime** is a third-generation cephalosporin antibiotic primarily used to treat bacterial infections, particularly **gonorrhea** (*Neisseria gonorrhoeae*). - It is not effective against parasitic infections like **trichomoniasis**. *Incorrect Option: Tetracycline* - **Tetracycline** is a broad-spectrum antibiotic commonly used for bacterial infections like **chlamydia** and certain atypical organisms. - It is not indicated for the treatment of **trichomoniasis**, which requires antiprotozoal therapy. *Incorrect Option: Fluconazole* - **Fluconazole** is an antifungal medication specifically used to treat **yeast infections** (vulvovaginal candidiasis caused by *Candida* species). - It has no activity against the protozoan parasite *Trichomonas vaginalis*.

Question 1

Which of the following is TRUE regarding bacterial vaginosis?

Accepted Answer

It is associated with increased risk of preterm labor

Answer

Clue cells are epithelial cells covered with Lactobacilli

Answer

It is characterized by decreased vaginal pH

Answer

Metronidazole treatment should always include male partners

Question 2

A 30-year-old woman presents with vaginal discharge and lower abdominal pain for 10 days. Examination reveals cervical motion tenderness and adnexal tenderness. Laboratory tests show elevated WBC count. What is the most appropriate initial antibiotic regimen?

Accepted Answer

Ceftriaxone plus doxycycline

Answer

Doxycycline plus metronidazole

Answer

Azithromycin plus metronidazole

Answer

Ciprofloxacin plus clindamycin

Question 3

Why does Chlamydia trachomatis infection often remain asymptomatic in women?

Accepted Answer

Due to infection of columnar epithelium in endocervix

Answer

Due to rapid clearance of organisms

Answer

Due to inhibition of inflammatory response

Answer

Due to hormonal influence on epithelial cells

Question 4

What is the preferred management of a uterine septum?

Accepted Answer

Hysteroscopic resection of septum

Answer

Laparoscopic resection of septum

Answer

Uterine metroplasty

Answer

Laparotomy and resection

Question 5

The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?

Accepted Answer

USG

Answer

HSG

Answer

Laparotomy

Answer

Diagnostic Laparoscopy

Question 6

What are clue cells?

Accepted Answer

Vaginal epithelial cells lined by bacteria

Answer

Uterine epithelial cells lined by bacteria

Answer

Cervical epithelial cells lined by bacteria

Answer

Abdominal cells lined by bacteria

Question 7

A patient complained of whitish discharge from the vagina and yellow staining on their clothes. There is no itching, no redness, and pH is acidic. What is the likely cause?

Accepted Answer

Increased normal vaginal discharge

Answer

Trichomoniasis

Answer

Candidiasis

Answer

Bacterial vaginosis

Question 8

A woman presents with painless ulcers on the vulva, she gives a history of having multiple sexual partners and has had a stillbirth at 28 weeks in the past. What is the next best step of investigation?

Accepted Answer

VDRL

Answer

PCR

Answer

Vaginal swab and culture

Answer

NAT

Question 9

The following set of instruments are used for which procedure?

Accepted Answer

Pap smear

Answer

Biopsy

Answer

Dilatation and curettage

Answer

Hysteroscopy

Question 10

A female patient having frothy vaginal discharge was found to have a strawberry cervix. Which of the following is the drug of choice?

Accepted Answer

Metronidazole

Answer

Cefixime

Answer

Tetracycline

Answer

Fluconazole

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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