Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 1041: A 28-year-old female presents with vaginal discharge and cervical motion tenderness. Which finding best predicts upper genital tract infection?

A. Presence of clue cells
B. Elevated CRP (Correct Answer)
C. Elevated ESR
D. Microscopic hematuria

Explanation: ***Elevated CRP*** - **C-reactive protein (CRP)** is an acute-phase inflammatory marker that indicates systemic inflammation associated with **Pelvic Inflammatory Disease (PID)**, an upper genital tract infection. - While vaginal discharge and cervical motion tenderness suggest PID, an **elevated CRP confirms significant inflammatory response** and supports the diagnosis of upper tract involvement. - CRP rises rapidly in acute inflammation (within 6-8 hours) and is commonly used in PID diagnostic criteria alongside ESR. - In the context of this acute presentation, **CRP may be marginally preferred** as it responds faster to acute infection than ESR. *Presence of clue cells* - **Clue cells** are epithelial cells with adherent bacteria, characteristic of **bacterial vaginosis**, a lower genital tract condition. - Their presence indicates vaginal dysbiosis but does not predict upper genital tract infection. *Elevated ESR* - **Erythrocyte sedimentation rate (ESR)** >15 mm/hr is also an established marker in PID diagnostic criteria. - Both ESR and CRP have similar diagnostic utility for PID, with **comparable sensitivity (70-80%)** in detecting upper tract infection. - ESR rises more slowly than CRP in acute infection, making CRP slightly more useful in acute presentations. - In clinical practice, either marker can support the diagnosis of upper genital tract infection. *Microscopic hematuria* - **Microscopic hematuria** indicates blood in urine, typically associated with **urinary tract pathology** rather than genital tract infection. - It does not predict or correlate with upper genital tract infection.

Question 1042: Regarding vaginal candidiasis, which one of the following is false:

A. Most common in non-pregnant women (Correct Answer)
B. Intense pruritus
C. Wet mount with KOH is the preferred diagnostic method
D. Cottage cheese like secretions are seen

Explanation: ***Most common in non-pregnant women*** - This statement is **false** because **vaginal candidiasis** is more prevalent in **pregnant women** due to hormonal changes, particularly increased estrogen, which alters the vaginal environment. - **Elevated estrogen levels** during pregnancy increase glycogen content in vaginal epithelial cells, providing a nutrient source for *Candida* growth. - Other risk factors include diabetes, immunosuppression, and antibiotic use. *Intense pruritus* - **Intense pruritus** (itching) is a **hallmark symptom** of vaginal candidiasis, caused by the inflammatory response to fungal overgrowth. - This symptom is often accompanied by **vaginal irritation**, burning, and dyspareunia. *Wet mount with KOH is the preferred diagnostic method* - **Wet mount microscopy** with 10% potassium hydroxide (KOH) preparation is the **preferred rapid diagnostic method** for vaginal candidiasis. - KOH dissolves non-fungal cells, making **pseudohyphae and budding yeast cells** clearly visible under microscopy. - Culture on Sabouraud's agar is the gold standard for confirmation but takes longer. *Cottage cheese like secretions are seen* - The characteristic **thick, white, "cottage cheese-like" vaginal discharge** is a classic clinical sign of vaginal candidiasis. - This discharge is typically **odorless** and non-adherent, unlike the discharge in bacterial vaginosis or trichomoniasis.

Question 1043: Which is the least invasive and effective option for high-grade squamous intraepithelial lesion (HSIL) on Pap smear?

A. Laser ablation
B. Cone biopsy
C. Cryotherapy
D. LEEP (Correct Answer)

Explanation: ***LEEP*** - **LEEP (Loop Electrosurgical Excision Procedure)** is a highly effective treatment for HSIL, offering both diagnostic and therapeutic benefits. - It involves using a thin, electrified wire loop to remove the abnormal tissue, and it is considered less invasive than a cold knife cone biopsy while maintaining high efficacy. *Laser ablation* - **Laser ablation** destroys abnormal tissue but does not provide a specimen for histological examination, which is crucial for confirming the diagnosis and ensuring clear margins in HSIL. - While minimally invasive, its effectiveness for HSIL treatment is generally considered lower than LEEP due to the lack of a histological specimen and potential for incomplete eradication. *Cone biopsy* - **Cold knife cone biopsy** is highly effective but more invasive than LEEP, carrying a higher risk of complications such as bleeding, infection, and cervical incompetence. - It involves surgical removal of a larger cone-shaped piece of tissue, often requiring general anesthesia. *Cryotherapy* - **Cryotherapy** involves freezing and destroying abnormal cells; however, it is primarily recommended for **low-grade squamous intraepithelial lesions (LSIL)**. - It is generally considered less effective for HSIL compared to excisional procedures like LEEP, as it also does not provide a specimen for histological evaluation.

Question 1044: What is the drug of choice for Bacterial vaginosis in pregnancy?

A. Erythromycin
B. Rovamycin
C. Metronidazole (Correct Answer)
D. Clindamycin

Explanation: ***Metronidazole*** - **Metronidazole** is the drug of choice for **bacterial vaginosis** in pregnancy due to its excellent efficacy against **anaerobic bacteria**, which are causative organisms, and its established safety profile during gestation. - It effectively restores the normal vaginal flora by targeting the overgrowth of **Gardnerella vaginalis** and other **anaerobic bacteria**, reducing symptoms and preventing potential pregnancy complications. *Erythromycin* - **Erythromycin** is a macrolide antibiotic primarily used for **atypical pneumonia**, **pertussis**, and certain **skin infections**, but it is generally not considered the first-line treatment for bacterial vaginosis due to lower efficacy against the specific anaerobic flora involved. - While generally safe in pregnancy, its spectrum of activity is less optimal for bacterial vaginosis compared to metronidazole, and it is reserved for specific situations or allergies. *Rovamycin* - **Rovamycin** is **spiramycin**, another macrolide antibiotic, often used for **toxoplasmosis** in pregnancy to prevent vertical transmission. - It is not typically recommended for the treatment of **bacterial vaginosis** as its efficacy against the causative anaerobic bacteria is not as well-established as that of metronidazole or clindamycin. *Clindamycin* - **Clindamycin** is an alternative treatment for **bacterial vaginosis** in pregnancy, particularly for patients who cannot tolerate metronidazole or have resistant infections. - It is effective against anaerobic bacteria and can be administered orally or as a vaginal cream, but **metronidazole** is usually preferred as the initial treatment.

Question 1045: Most commonly associated organism in bacterial vaginosis?

A. Gardnerella vaginalis (Correct Answer)
B. Candida albicans
C. E. coli
D. Trichomonas vaginalis

Explanation: ***Gardnerella vaginalis*** - **Gardnerella vaginalis** is the predominant bacterium associated with the polymicrobial condition known as **bacterial vaginosis (BV)**. - While BV involves a shift in the vaginal microbiome with an increase in various anaerobic bacteria, **Gardnerella vaginalis** is consistently implicated in its pathogenesis and is often present in high concentrations. *Candida albicans* - **Candida albicans** is the most common cause of **vulvovaginal candidiasis** (yeast infection), not bacterial vaginosis. - Symptoms of candidiasis typically include intense itching, burning, and thick, white, "cottage cheese-like" discharge, distinct from BV. *E. coli* - **E. coli** is a common bacterium found in the gastrointestinal tract and is a frequent cause of **urinary tract infections (UTIs)**. - It is not a primary cause of bacterial vaginosis in the vagina. *Trichomonas vaginalis* - **Trichomonas vaginalis** is a **protozoan parasite** that causes **trichomoniasis**, a sexually transmitted infection. - While it causes vaginitis, its presentation often includes frothy, greenish-yellow discharge and a "strawberry cervix," differentiating it from BV.

Question 1046: Treatment of endometrial hyperplasia with atypia in a 45-year-old female:

A. Progestin
B. Mirena
C. Hysterectomy (Correct Answer)
D. Endometrial ablation

Explanation: ***Hysterectomy*** - **Endometrial hyperplasia with atypia** carries a significant risk of progression to **endometrial cancer**, ranging from 20% to 50% over several years, making hysterectomy a definitive treatment option. - For a 45-year-old female, especially if she has completed childbearing or is nearing menopause, a **hysterectomy** eliminates the uterine pathology and prevents future recurrence or malignant transformation. *Progestin* - While progestin therapy can be used for endometrial hyperplasia without atypia or for atypical hyperplasia in women who desire to preserve fertility, its effectiveness for **simple atypical hyperplasia** is 70-80%. - The risk of residual or coexisting carcinoma, and the potential for recurrence if fertility is not a concern, makes progestin a less definitive treatment than hysterectomy in this age group. *Mirena* - The **Mirena IUD** (levonorgestrel-releasing intrauterine system) delivers local progestin, which is effective for **endometrial hyperplasia without atypia** and is sometimes used for atypical hyperplasia when fertility preservation is desired. - However, for **atypical hyperplasia**, which has a notable risk of malignancy, a more definitive treatment like hysterectomy is generally preferred, especially as Mirena's systemic effects are limited and regular follow-up biopsies are needed. *Endometrial ablation* - **Endometrial ablation** destroys the endometrial lining and is typically used for managing **heavy menstrual bleeding (menorrhagia)** when fertility is not desired. - It is **contraindicated in cases of endometrial hyperplasia with atypia** due to the risk of obscuring underlying or developing malignancy and making future surveillance difficult.

Question 1047: A patient presents with frothy green vaginal discharge. What is the most likely diagnosis?

A. Trichomoniasis (Correct Answer)
B. Candidiasis
C. Bacterial vaginosis
D. Chlamydia

Explanation: ***Trichomoniasis*** - The classic presentation of **frothy, greenish-yellow vaginal discharge** is highly characteristic of *Trichomonas vaginalis* infection. - This discharge is often associated with a **foul smell**, **itching**, and **dysuria**. *Candidiasis* - Typically presents with **thick, white, curd-like discharge** and intense vaginal itching, often described as cottage cheese-like. - It is not associated with a frothy or green appearance. *Bacterial vaginosis* - Characterized by a **thin, grayish-white discharge** with a **fishy odor**, especially after intercourse, due to amines. - This discharge is generally not frothy or green. *Chlamydia* - Often **asymptomatic**, but when symptoms occur, they may include **mucopurulent cervical discharge**, intermenstrual bleeding, or dysuria. - The discharge is usually not frothy or green, and instead tends to be yellowish and watery.

Question 1048: A 14-year-old female presented with acute retention of urine. She complains of cyclical pain in the abdomen. On examination, a tense blue swelling is seen on local examination. On PR examination - suprapubic bulge present. Her condition is most likely due to?

A. Imperforate hymen (Correct Answer)
B. Transverse vaginal septum
C. Cervical agenesis
D. Longitudinal vaginal septum

Explanation: ***Imperforate hymen*** - This condition is characterized by a **complete obstruction** of the vaginal opening, leading to the accumulation of menstrual blood (hematocolpos) behind the hymen. - The classic presentation includes **cyclical abdominal pain** (due to trapped menstrual bleeding), **amenorrhea**, and a visible **tense, blue bulging mass** at the introitus, which can cause urinary retention due to pressure on the urethra. *Transverse vaginal septum* - A **transverse vaginal septum** is a congenital anomaly where a band of tissue completely or partially blocks the vaginal canal, typically higher up than the hymen. - While it can also cause **hematocolpos** and cyclical pain, the physical examination would reveal the obstruction deeper within the vagina rather than a bulging blue mass at the introitus. *Cervical agenesis* - **Cervical agenesis** refers to the congenital absence of the cervix. This condition would lead to obstruction of menstrual flow, causing hematometra (blood in the uterus) and hematocolpos. - However, unlike imperforate hymen, it would not present with a **tense blue swelling at the introitus**, as the obstruction is higher up at the level of the cervix. *Longitudinal vaginal septum* - A **longitudinal vaginal septum** divides the vagina into two separate canals, often associated with a uterine anomaly like uterus didelphys. - This condition does **not typically cause obstruction** of menstrual flow or urinary retention, as menstrual blood can still exit through one of the vaginal canals.

Question 1049: As per Indian guidelines, what is the recommended age for a woman to begin screening for cervical cancer?

A. 25 years
B. 21 years
C. 30 years (Correct Answer)
D. 18 years

Explanation: ***30 years*** - **Indian guidelines** from the **Ministry of Health & Family Welfare (MoHFW)** and the **Indian Council of Medical Research (ICMR)** recommend initiating cervical cancer screening at **age 30 years** or within 3 years of first sexual contact. - The recommended screening methods in India include **VIA (Visual Inspection with Acetic Acid)**, **HPV DNA testing**, or **Pap smear**, performed every 5 years until age 65. - This approach is tailored to the **Indian healthcare setting** and resource availability. *21 years* - This is the recommended screening age according to **US guidelines (ACOG/USPSTF)**, not Indian guidelines. - While appropriate for the US context, Indian guidelines start screening later at age 30, considering **epidemiological data**, **disease prevalence**, and **healthcare infrastructure** specific to India. *25 years* - Some **European countries** and the **UK** recommend starting screening at age 25. - This is **not the recommended age** for cervical cancer screening according to Indian national guidelines. - In India, screening typically begins at age 30 years. *18 years* - Initiating cervical cancer screening at age 18 is **not recommended** by any major international or Indian guidelines. - Screening before age 21 (in US guidelines) or 30 (in Indian guidelines) often leads to **unnecessary procedures and anxiety**, as **HPV infections** and mild dysplasias in adolescents usually resolve spontaneously.

Question 1050: A 36-year-old woman with a history of endometriosis presents with chronic pelvic pain and infertility. What is the best initial management?

A. GnRH agonists
B. IVF
C. NSAIDs
D. Surgical resection (Correct Answer)

Explanation: ***Surgical resection*** - For women with **moderate-to-severe endometriosis** (Stage III-IV) presenting with infertility and chronic pelvic pain, surgical resection of endometriotic implants is often the **best initial management**. - Surgery aims to **reduce disease burden**, restore normal pelvic anatomy, and remove endometriomas, which can **improve spontaneous conception rates** and alleviate pain. - **Laparoscopic excision** is preferred, as it provides both diagnostic confirmation and therapeutic benefit, with studies showing improved pregnancy rates post-operatively in appropriately selected patients. - This approach is particularly beneficial when there are **visible lesions, adhesions, or ovarian endometriomas** affecting fertility. *NSAIDs* - **NSAIDs** provide **symptomatic pain relief** but do not address the underlying endometriosis or improve fertility outcomes. - While useful as adjunctive therapy, they are insufficient as sole initial management for patients seeking conception. *GnRH agonists* - **GnRH agonists** induce a **hypoestrogenic state** that reduces endometriotic lesions and pain by suppressing ovarian function. - However, they cause **temporary anovulation**, making them unsuitable for women actively trying to conceive. - They may be used preoperatively to reduce lesion size or postoperatively to prevent recurrence, but not as initial management for infertility. *IVF* - **In vitro fertilization (IVF)** is an effective option for endometriosis-related infertility, particularly in **minimal-to-mild disease** or after failed surgical management. - While IVF bypasses tubal and peritoneal factors, it does **not treat the underlying endometriosis** or alleviate chronic pelvic pain. - In cases with significant anatomical distortion or endometriomas, **surgical management is typically preferred initially** to optimize pelvic environment before considering assisted reproductive technology.

Practice by Chapter

Abnormal Uterine Bleeding

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Endometriosis

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Adenomyosis

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Uterine Fibroids

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Ovarian Cysts

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Pelvic Inflammatory Disease

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Vulvovaginitis

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Pelvic Organ Prolapse

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Vulvar Disorders

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Benign Breast Diseases

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