Gynecological Disorders Practice Questions

Q: Which of the following symptoms are seen in endometriosis? 1. Infertility 2. Dysmenorrhea 3. Vaginal discharge 4. Vaginal bleeding

1,2. ***Correct: 1,2 (Infertility and Dysmenorrhea)*** - **Infertility** is present in 30-50% of women with endometriosis, making it one of the most common presentations. Caused by inflammation, adhesions, altered pelvic anatomy, and inflammatory mediators that impair reproductive function. - **Dysmenorrhea (painful menstruation)** is the hallmark symptom of endometriosis. The pain is typically severe, progressive, and occurs due to cyclic bleeding from ectopic endometrial tissue, causing inflammation and irritation of surrounding structures. - These are the two most characteristic and consistent symptoms of endometriosis. *Incorrect: 2,3* - While dysmenorrhea is correct, **vaginal discharge is NOT a characteristic symptom of endometriosis**. Vaginal discharge is typically associated with infections (vaginitis, cervicitis) or other gynecological conditions, not endometriosis. *Incorrect: 1,2,4* - While infertility and dysmenorrhea are correct, including "vaginal bleeding" makes this option less accurate. Although some women with endometriosis may experience menorrhagia or irregular bleeding (particularly with adenomyosis or ovarian endometriomas), **abnormal vaginal bleeding is not a primary or pathognomonic symptom** of endometriosis. *Incorrect: 3,4* - **Vaginal discharge** is not associated with endometriosis. - **Vaginal bleeding** as a standalone symptom is not a primary feature of endometriosis, though menstrual abnormalities can occasionally occur. **Note:** Other classic symptoms of endometriosis include dyspareunia (painful intercourse), dyschezia (painful defecation), and chronic pelvic pain.

Q: Arrange the following in sequential order with regards to the steps of collection of samples for pap smear testing: Use posterior vaginal wall retractor Take the sample Make smear on a slide Fix the smear

1,2,3,4. ***1,2,3,4*** - The correct sequence for collecting a Pap smear involves first **visualizing the cervix** using a posterior vaginal wall retractor, then **taking the sample** (e.g., using a broom or spatula and brush), followed by **making a smear on a slide** and finally **fixing the smear** to preserve the cells. - This sequential order ensures proper cell collection and preservation for accurate cytological examination. *1,2,4,3* - This option incorrectly places **fixing the smear** before **making the smear on the slide**. Cells must first be spread onto the slide before they can be fixed. - Fixing an un-smeared sample or attempting to smear after fixing would lead to an inadequate or damaged specimen. *3,1,2,4* - This sequence incorrectly starts with **making a smear on a slide** before any sample has been collected or the cervix visualized. - One cannot make a smear without first taking a sample and accessing the cervix via a retractor. *2,1,3,4* - This option incorrectly states that **taking the sample** occurs before **using a posterior vaginal wall retractor**. The retractor is essential for proper visualization and access to the cervix to obtain a quality sample. - Attempting to take a sample without proper visualization would lead to an inadequate or incorrect specimen collection.

Q: A 24-year-old woman presents with abnormal vaginal discharge. Wet mount shows motile trichomonads. Her male partner is asymptomatic. Which of the following is the most appropriate management for her partner?

Treat regardless of symptoms. ***Treat regardless of symptoms*** - **Trichomoniasis** is a sexually transmitted infection, and partners of infected individuals should be treated even if they are asymptomatic to prevent **reinfection** and further transmission. - **Male partners** often carry the infection asymptomatically, acting as a reservoir for transmission. *No treatment unless symptoms develop* - This approach would lead to **persistent infection** in the male partner and an increased risk of **reinfection** for the female patient. - Asymptomatic carriers can still transmit the infection, undermining the treatment of the symptomatic partner. *Test before treating* - While testing is possible, current guidelines recommend **presumptive treatment** for male partners of women diagnosed with trichomoniasis to ensure effective eradication and prevent recurrence. - The **sensitivity** of diagnostic tests for trichomoniasis in men can be lower than in women, potentially leading to false negatives. *Monitor without intervention* - Monitoring without intervention is inadequate as it allows the male partner to remain an **infectious source** and risks **recurrent infection** for the female patient. - The goal is to break the chain of transmission and fully cure both partners.

Q: A 26-year-old woman presents with vaginal discharge and dyspareunia. Wet mount microscopy shows clue cells. Which of the following additional findings would confirm the diagnosis?

Positive whiff test and vaginal pH > 4.5. ***Positive whiff test and vaginal pH > 4.5*** - The combination of **clue cells**, a **positive whiff test** (amine odor after adding KOH), and a **vaginal pH > 4.5** are diagnostic criteria for **bacterial vaginosis (BV)**. - This classic triad, along with thin, homogeneous discharge, forms part of the **Amsel criteria** for diagnosing BV. *Pseudohyphae on microscopy* - **Pseudohyphae** are characteristic findings in **vulvovaginal candidiasis (yeast infection)**, not bacterial vaginosis. - Candidiasis typically presents with thick, white, "cottage cheese-like" discharge and intense pruritus, which differs from the described symptoms. *WBCs > 10 per high power field* - An increased number of **white blood cells (WBCs)**, specifically polymorphonuclear leukocytes, suggests **inflammation** or infection but is typically *absent* or minimal in uncomplicated bacterial vaginosis. - High WBC counts are more indicative of **trichomoniasis** or **cervicitis**. *Motile trichomonads* - The presence of **motile trichomonads** on wet mount microscopy is diagnostic for **trichomoniasis**, a sexually transmitted infection. - While trichomoniasis can cause vaginal discharge and dyspareunia, its microscopic features are distinct from clue cells.

Q: Which of the following is NOT a criterion in Amsel's criteria for diagnosing bacterial vaginosis?

Positive culture for G. vaginalis. ***Positive culture for G. vaginalis*** - A positive culture for **Gardnerella vaginalis** is not part of Amsel's criteria, as this bacterium is also found in the normal vaginal flora of many healthy women. - The diagnosis of bacterial vaginosis (BV) relies on clinical and microscopic findings, not on bacterial culture. *Presence of clue cells* - **Clue cells** (vaginal epithelial cells covered with bacteria, obscuring the cell borders) are a key diagnostic criterion in Amsel's, indicating the presence of abundant bacteria. - Their presence under microscopy is a strong indicator of bacterial overgrowth. *Vaginal pH > 4.5* - An elevated **vaginal pH above 4.5** is a crucial criterion, reflecting the shift from a healthy acidic environment to a more alkaline one in BV. - This change in pH is due to the reduction of lactobacilli and overgrowth of anaerobic bacteria. *Positive whiff test* - A **positive whiff test**, characterized by a fishy odor after adding potassium hydroxide (KOH) to vaginal secretions, is a diagnostic criterion. - This odor is caused by the production of volatile amines by anaerobic bacteria.

Q: A 25-year-old woman presents with thin, gray-white vaginal discharge and mild itching. Microscopy shows clue cells and pH is 5.5. What is the most appropriate treatment?

Metronidazole 500mg BD for 7 days. ***Metronidazole 500mg BD for 7 days*** - The patient's symptoms (thin, gray-white discharge, mild itching), microscopic findings (**clue cells**), and **vaginal pH of 5.5** are classic for **bacterial vaginosis (BV)**. - **Oral metronidazole 500mg twice daily for 7 days** is a highly effective and commonly recommended first-line treatment for BV, targeting anaerobic bacteria responsible for the condition. *Metronidazole gel 0.75% for 5 days* - Metronidazole gel is an alternative treatment for BV, but it is typically prescribed for **5 days**, not 7 days, and is a **vaginal application**, not oral. - While effective, oral metronidazole is often preferred for more severe or recurrent cases, or if patient preference dictates. *Fluconazole 150mg single dose* - **Fluconazole** is an **antifungal medication** used to treat **vulvovaginal candidiasis (yeast infection)**, which typically presents with thick, white, "cottage cheese-like" discharge and severe itching, and is not associated with clue cells. - The presented symptoms and findings are inconsistent with a yeast infection. *Clindamycin cream 2% for 7 days* - **Clindamycin cream** is another effective topical treatment for **bacterial vaginosis**; however, it is typically applied **intravaginally** for 7 days. - While clindamycin is an appropriate antibiotic for BV, oral metronidazole is often favored for its systemic effect and patient convenience in many cases.

Q: A 32-year-old HIV-positive woman with CD4 count 180/µL presents with extensive genital warts resistant to conventional therapy. Recent Pap smear shows HSIL. Which management approach is most appropriate?

Immediate colposcopy and surgical excision. ***Immediate colposcopy and surgical excision*** - Given the patient's **HIV-positive status**, **low CD4 count**, extensive and resistant **genital warts**, and **HSIL on Pap smear**, there is a high likelihood of advanced or rapidly progressing cervical intraepithelial neoplasia or early invasive carcinoma. - **Colposcopy** allows for direct visualization and targeted biopsies, while **surgical excision** (e.g., LEEP or cold knife conization) can effectively remove both the HSIL and resistant warts, which is crucial in immunocompromised patients. *Observation and repeat Pap in 6 months* - This approach is inappropriate due to the patient's **immunocompromised state** (low CD4 count), which predisposes her to more aggressive and rapidly progressive **HPV-related disease**. - **HSIL** in an HIV-positive patient warrants immediate investigation and intervention, not delayed follow-up, as the risk of progression to **invasive cancer** is significantly higher. *Topical imiquimod alone* - **Imiquimod** is an immune-response modifier used for external genital warts, but it is unlikely to be sufficient for extensive, resistant warts, especially in an **immunocompromised host**. - It does not directly address the underlying **HSIL**, which requires histological evaluation and potential excisional treatment to prevent progression to cancer. *Podophyllin application weekly* - **Podophyllin** is a cytotoxic agent used for external genital warts, but it is generally reserved for smaller lesions and requires careful application due to its potential toxicity. - It is **contraindicated in pregnancy** and not recommended for internal lesions or for treating or preventing the progression of **HSIL**, which requires a more definitive management.

Q: A 25 year old lady presented with curdy white discharge from the vagina is likely to be suffering from:-

Candida vaginitis. ***Candida vaginitis*** - **Candida vaginitis** is characterized by a **curdy white vaginal discharge**, often described as cottage cheese-like. - This condition is caused by an overgrowth of *Candida* species, typically *Candida albicans*, and is associated with **vaginal itching, burning**, and **dyspareunia**. *Trichomoniasis* - **Trichomoniasis** typically presents with a **frothy, greenish-yellow discharge** and a **foul odor**. - It often causes **severe itching, redness, and irritation**, which differ from the curdy discharge described. *Gonococcal vulvovaginitis* - **Gonococcal vulvovaginitis** in women can cause a **purulent or mucopurulent discharge**, often yellowish. - While it can lead to vaginal irritation, a **curdy white discharge** is not its classic presentation. *Chlamydia trachomatis* - **Chlamydia trachomatis** often causes an **asymptomatic infection**; when symptoms occur, they may include a **mucopurulent discharge**. - A **curdy white discharge** is not a typical symptom of *Chlamydia* infection.

Q: Amsel's criteria are used for?

Bacterial vaginosis. ***Bacterial vaginosis*** - **Amsel's criteria** are a set of four clinical signs used to diagnose **bacterial vaginosis**, a common vaginal infection. - At least three of the four criteria must be present for a positive diagnosis: **thin, white, homogeneous discharge**, **clue cells** on microscopy, vaginal pH >4.5, and a **fishy odor** before or after adding 10% KOH (whiff test). *Candidiasis* - Diagnosed based on clinical symptoms such as **pruritus** and thick, white, **"cottage cheese-like" discharge**, along with identification of yeast (hyphae/pseudohyphae) on microscopy. - **Amsel's criteria** are not used for its diagnosis. *Trichomoniasis* - Typically diagnosed by microscopic observation of **motile trichomonads** in a wet mount, or by nucleic acid amplification tests (NAATs). - It presents with a **foamy, yellow-green discharge** and sometimes a **"strawberry cervix"**, none of which are part of Amsel's criteria. *Chlamydia infection* - Primarily diagnosed using **nucleic acid amplification tests (NAATs)** from urine or swab samples. - It is often **asymptomatic** or presents with non-specific symptoms like discharge or dysuria, and **Amsel's criteria** are not applicable.

Question 1

Which of the following symptoms are seen in endometriosis?

1. Infertility
2. Dysmenorrhea
3. Vaginal discharge
4. Vaginal bleeding

Accepted Answer

1,2

Answer

2,3

Answer

1,2,4

Answer

3,4

Question 2

Arrange the following in sequential order with regards to the steps of collection of samples for pap smear testing:
Use posterior vaginal wall retractor
Take the sample
Make smear on a slide
Fix the smear

Accepted Answer

1,2,3,4

Answer

1,2,4,3

Answer

3,1,2,4

Answer

2,1,3,4

Question 3

A 24-year-old woman presents with abnormal vaginal discharge. Wet mount shows motile trichomonads. Her male partner is asymptomatic. Which of the following is the most appropriate management for her partner?

Accepted Answer

Treat regardless of symptoms

Answer

No treatment unless symptoms develop

Answer

Test before treating

Answer

Monitor without intervention

Question 4

A 26-year-old woman presents with vaginal discharge and dyspareunia. Wet mount microscopy shows clue cells. Which of the following additional findings would confirm the diagnosis?

Accepted Answer

Positive whiff test and vaginal pH > 4.5

Answer

Pseudohyphae on microscopy

Answer

WBCs > 10 per high power field

Answer

Motile trichomonads

Question 5

Which of the following is NOT a criterion in Amsel's criteria for diagnosing bacterial vaginosis?

Accepted Answer

Positive culture for G. vaginalis

Answer

Presence of clue cells

Answer

Vaginal pH > 4.5

Answer

Positive whiff test

Question 6

A 25-year-old woman presents with thin, gray-white vaginal discharge and mild itching. Microscopy shows clue cells and pH is 5.5. What is the most appropriate treatment?

Accepted Answer

Metronidazole 500mg BD for 7 days

Answer

Metronidazole gel 0.75% for 5 days

Answer

Fluconazole 150mg single dose

Answer

Clindamycin cream 2% for 7 days

Question 7

A 32-year-old HIV-positive woman with CD4 count 180/µL presents with extensive genital warts resistant to conventional therapy. Recent Pap smear shows HSIL. Which management approach is most appropriate?

Accepted Answer

Immediate colposcopy and surgical excision

Answer

Observation and repeat Pap in 6 months

Answer

Topical imiquimod alone

Answer

Podophyllin application weekly

Question 8

A 56-year-old woman makes an appointment with her physician to discuss the results of her cervical cancer screening. She has been menopausal for  2 years and does not take hormone replacement therapy. Her previous Pap smear showed low-grade squamous intraepithelial lesion (LSIL); no HPV testing was performed. Her gynecologic examination is unremarkable. The results of her current Pap smear is as follows:
Specimen adequacy satisfactory for evaluation
Interpretation low-grade squamous intraepithelial lesion
Notes atrophic pattern
Which option is the next best step in the management of this patient?

Accepted Answer

Colposcopy

Answer

Reflex HPV testing

Answer

Repeat HPV testing in 6 months

Answer

Immediate loop excision

Answer

Intravaginal estrogen therapy followed by repeat Pap smear in 1 week

Question 9

A 25 year old lady presented with curdy white discharge from the vagina is likely to be suffering from:-

Accepted Answer

Candida vaginitis

Answer

Trichomoniasis

Answer

Gonococcal vulvovaginitis

Answer

Chlamydia trachomatis

Question 10

Amsel's criteria are used for?

Accepted Answer

Bacterial vaginosis

Answer

Candidiasis

Answer

Trichomoniasis

Answer

Chlamydia infection

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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