Gynecological Disorders Practice Questions

Q: During a routine examination, a gynecologist discovers a cystic mass in the ovary of a 30-year-old woman. What is the most common type of benign ovarian cyst?

Follicular cyst. ***Follicular cyst*** - **Follicular cysts** are the most common type of **benign functional ovarian cyst**, resulting from the non-rupture or inadequate absorption of a mature follicle. - They are typically asymptomatic, resolve spontaneously, and are common in women of reproductive age. *Dermoid cyst* - **Dermoid cysts**, also known as mature cystic teratomas, contain various tissues such as hair, teeth, or bone, originating from pluripotent germ cells. - While common, they are not as frequent as follicular cysts and arise from a different embryological origin. *Cystadenoma* - **Cystadenomas** are benign epithelial tumors of the ovary, often categorized as serous or mucinous based on their fluid content. - They are less common than functional cysts and represent a true neoplastic growth, differing from the physiological origin of follicular cysts. *Corpus luteum cyst* - A **corpus luteum cyst** forms when the corpus luteum, which develops after ovulation, fails to regress and instead fills with fluid or blood. - Although common, they are less frequent than follicular cysts and occur specifically after ovulation, while follicular cysts precede it.

Q: A 25-year-old woman presents with itching and white vaginal discharge. Microscopy reveals budding yeast cells. What is the most likely diagnosis?

Candidiasis. ***Candidiasis*** - The presence of **budding yeast cells on microscopy** is pathognomonic for vulvovaginal candidiasis, most commonly caused by *Candida albicans*. - Clinical features of **itching** and **white, thick, curd-like discharge** are classic findings. - This is one of the most common causes of vaginitis in reproductive-age women. *Bacterial vaginosis* - Presents with **thin, gray discharge** with a characteristic **fishy odor**, especially after intercourse. - Microscopy reveals **clue cells** (vaginal epithelial cells covered with bacteria), not budding yeast. - pH typically >4.5 and positive whiff test. *Trichomoniasis* - Caused by *Trichomonas vaginalis*, a flagellated protozoan. - Presents with **frothy, yellow-green discharge**, vulvovaginal irritation, and **strawberry cervix** (punctate hemorrhages). - Microscopy shows **motile trichomonads**, not budding yeast cells. *Gonorrhea* - Caused by *Neisseria gonorrhoeae*. - Often **asymptomatic** in women; when symptomatic, presents with **mucopurulent cervical discharge**, dysuria, or pelvic pain. - Diagnosed by identifying **Gram-negative intracellular diplococci** on Gram stain or through nucleic acid amplification testing (NAAT), not yeast cells.

Q: A 22-year-old woman presents with menorrhagia and a pelvic mass. An ultrasound reveals a well-circumscribed, homogeneous mass within the uterine wall. What is the most likely diagnosis?

Leiomyoma. ***Leiomyoma*** - **Leiomyomas** (fibroids) are common benign uterine tumors that typically present as **well-circumscribed, homogeneous masses within the uterine wall**, often causing **menorrhagia** and a palpable **pelvic mass**. - The patient's age (22) is consistent, as fibroids are more common in women of reproductive age. *Adenomyosis* - **Adenomyosis** involves endometrial tissue growing into the **myometrium**, typically causing a diffusely enlarged, globular uterus, rather than a discrete mass. - While it can cause **menorrhagia** and pelvic pain, the ultrasound finding of a **well-circumscribed mass** points away from adenomyosis. *Endometrial carcinoma* - **Endometrial carcinoma** is more common in **postmenopausal women** and presents with abnormal uterine bleeding, but it is typically associated with an **irregular endometrial stripe** or mass, not a well-circumscribed intramural mass. - Ultrasound findings are usually of **endometrial thickening** or an endometrial mass. *Ovarian cyst* - An **ovarian cyst** is located in the **ovary**, not within the uterine wall, and would typically present as an adnexal mass. - While some ovarian cysts can cause pelvic pain or mass sensation, they would not be described as a mass *within the uterine wall*.

Q: A 38-year-old female with a history of multiple sexual partners presents with lower abdominal pain, fever, and purulent cervical discharge. Despite initial treatment for pelvic inflammatory disease, her symptoms persist. What is the most appropriate next step?

Pelvic ultrasound. ***Pelvic ultrasound*** - A persistent **lower abdominal pain**, **fever**, and **purulent cervical discharge** despite initial treatment for PID suggests a possible **pelvic abscess** or **tubo-ovarian abscess (TOA)**. - A pelvic ultrasound is the most appropriate initial imaging study to **visualize pelvic structures** and identify abscess formation, which would necessitate a change in management. *Laparoscopy* - Laparoscopy is an **invasive surgical procedure** that is not typically the first step when a patient fails initial medical management for PID, especially without prior imaging. - It would be considered if imaging confirms an abscess or if the diagnosis remains uncertain and conservative measures have failed. *Repeat antibiotics* - While adjusting antibiotic regimens may be necessary, simply repeating antibiotics **without further investigation** into the persistent symptoms may delay the diagnosis and treatment of a possible pelvic abscess. - It is crucial to determine if there's a **collection of pus** that requires drainage. *Endometrial biopsy* - An endometrial biopsy is primarily used to investigate abnormal uterine bleeding, infertility, or suspected endometrial pathology (e.g., endometrial cancer or hyperplasia). - It would not be the initial step for persistent symptoms of pelvic inflammatory disease, nor would it help to diagnose a pelvic abscess.

Q: A 29-year-old woman presents with dyspareunia and nodularity in the posterior fornix. What is the most likely diagnosis?

Endometriosis. ***Endometriosis*** - **Dyspareunia** (painful intercourse) and **nodularity in the posterior fornix** are classic signs of endometriosis, especially when endometrial tissue implants on the uterosacral ligaments or rectovaginal septum. - The presence of **ectopic endometrial tissue** can cause chronic pelvic pain, dysmenorrhea, and painful defecation, in addition to dyspareunia. *Adenomyosis* - Characterized by the presence of **endometrial tissue within the myometrium** (muscular wall of the uterus), leading to a bulky, tender uterus. - While it can cause dysmenorrhea and menorrhagia, **dyspareunia and posterior fornix nodularity are not typical presentations**; these findings are more specific to peritoneal implants of endometriosis. *Pelvic inflammatory disease* - PID is an infection of the upper female reproductive tract, often causing **pelvic pain, fever, vaginal discharge**, and sometimes cervical motion tenderness. - It does not typically present with **nodularity in the posterior fornix**, which suggests solid tissue involvement rather than infection. *Ovarian cyst* - Ovarian cysts are fluid-filled sacs on the ovary, which can cause **pelvic pain or pressure**, especially if large or ruptured. - They do not typically cause **nodularity in the posterior fornix** and dyspareunia specifically related to this finding.

Q: A 30-year-old woman presents with severe menorrhagia and is found to have a 5 cm submucosal fibroid. What is the most appropriate treatment?

Myomectomy. ***Myomectomy*** - **Myomectomy** is the most appropriate treatment as it removes the fibroid while preserving the uterus, which is crucial for a 30-year-old woman who may desire future fertility. - This procedure directly addresses the cause of the **menorrhagia** by removing the submucosal fibroid. *Hysterectomy* - **Hysterectomy** involves the removal of the uterus and is a definitive cure for fibroids, but it is not appropriate for a 30-year-old woman who may wish to preserve her fertility. - It is a more invasive procedure with a longer recovery time and is typically reserved for women who have completed childbearing or have more extensive uterine pathology. *Endometrial ablation* - **Endometrial ablation** destroys the uterine lining to reduce bleeding, but it is less effective for large or submucosal fibroids. - While it can reduce menorrhagia, it does not remove the fibroid itself and is generally unsuitable for women who desire future pregnancies. *Uterine artery embolization* - **Uterine artery embolization (UAE)** blocks blood supply to the fibroid, causing it to shrink, but its long-term effects on fertility are still under investigation. - UAE may be considered, but **myomectomy** is often preferred for a 5 cm submucosal fibroid in a woman desiring fertility due to more predictable outcomes and less concern about future pregnancy complications.

Q: What non-surgical intervention is primarily used to manage patients with symptomatic uterine fibroids who wish to retain their fertility?

Gonadotropin-releasing hormone agonists. ***Gonadotropin-releasing hormone agonists*** - GnRH agonists are the **primary medical therapy** for symptomatic fibroids in women desiring future fertility. - They effectively **shrink fibroid size** by 40-60% and reduce **menorrhagia** by inducing a temporary hypoestrogenic state. - Commonly used as **preoperative therapy** before myomectomy to reduce fibroid size, decrease vascularity, and improve surgical outcomes. - After discontinuation, **ovulation and fertility return** within 2-3 months, making them ideal as a bridge to definitive fertility-sparing surgery or pregnancy. - Used for 3-6 months to maximize benefit while minimizing bone density loss. *Progestin-releasing intrauterine device* - The LNG-IUS effectively reduces **menstrual bleeding** and provides symptomatic relief from fibroid-related menorrhagia. - However, it is a **contraceptive device** that prevents pregnancy, making it inappropriate for women actively trying to conceive. - Best suited for women who want to avoid hysterectomy and have **completed childbearing** or need temporary contraception. *Oral contraceptive pills* - OCPs can help manage **heavy menstrual bleeding** but do not significantly shrink fibroids. - They are **contraceptive** by nature, preventing ovulation and pregnancy. - Not suitable for women actively seeking fertility. *Nonsteroidal anti-inflammatory drugs (NSAIDs)* - NSAIDs provide **symptomatic relief** of pain and reduce menstrual bleeding by inhibiting prostaglandin synthesis. - They do not affect fibroid size or growth and offer no disease-modifying benefit. - Used as adjunctive therapy, not primary management.

Q: A 30-year-old woman presents with abnormal uterine bleeding and an enlarged uterus. Which diagnostic test is the most appropriate?

Pelvic ultrasound. ***Pelvic ultrasound*** - A **pelvic ultrasound** is the most appropriate initial diagnostic test for evaluating abnormal uterine bleeding and an enlarged uterus, as it is non-invasive, widely available, and cost-effective. - It can visualize structural abnormalities such as **fibroids**, **adenomyosis**, or **endometrial polyps**, which are common causes of these symptoms. - Recommended by **ACOG guidelines** as the first-line imaging modality for these presentations. *Hysteroscopy* - While hysteroscopy allows for direct visualization of the uterine cavity and directed biopsies, it is typically performed *after* an initial imaging study like ultrasound has identified potential intrauterine pathology. - It is a more invasive procedure and not usually the first-line diagnostic test. *Endometrial biopsy* - An **endometrial biopsy** is crucial for ruling out **endometrial hyperplasia** or **carcinoma**, especially in women over 45 years or those with risk factors. - However, it primarily assesses the endometrial lining and may not fully explain an "enlarged uterus" if the cause is, for example, a large fibroid in the myometrium, so it often follows imaging. *MRI pelvis* - **MRI pelvis** provides excellent detailed anatomical information, particularly for characterizing complex uterine masses or for surgical planning. - It is generally reserved for cases where ultrasound findings are inconclusive or when more detailed tissue characterization is required, and it is more expensive and less accessible than ultrasound.

Q: A 28-year-old woman is diagnosed with gonococcal cervicitis (NAAT positive for Neisseria gonorrhoeae) and presents with purulent cervical discharge. What is the most likely complication if left untreated?

Pelvic inflammatory disease (PID). ***Pelvic inflammatory disease (PID)*** - **Untreated gonococcal cervicitis** can ascend to the upper genital tract, leading to inflammation of the uterus, fallopian tubes, and ovaries, which is known as **Pelvic Inflammatory Disease (PID)** - This is the most common complication of untreated gonococcal infection, occurring in **10-20%** of cases - PID presents with **fever**, **lower abdominal pain**, **adnexal tenderness**, and may lead to serious sequelae including infertility, ectopic pregnancy, and chronic pelvic pain *Ovarian torsion* - **Ovarian torsion** involves the twisting of the ovary on its vascular pedicle, leading to acute, severe unilateral lower abdominal pain - It is typically associated with ovarian masses or cysts and is **not a complication of gonococcal cervicitis** *Bartholin's gland abscess* - A **Bartholin's gland abscess** presents as a painful, tender, swollen mass in the posterior labia majora - While *Neisseria gonorrhoeae* can cause Bartholin's gland infection, this is a **localized lower genital tract infection**, not an ascending complication - The most common ascending complication remains **PID** *Disseminated gonococcal infection* - **Disseminated gonococcal infection (DGI)** occurs when *N. gonorrhoeae* invades the bloodstream, causing **arthritis-dermatitis syndrome**, tenosynovitis, and rarely endocarditis or meningitis - DGI is relatively **rare (0.5-3% of cases)** compared to PID - PID is the **most likely** complication of untreated gonococcal cervicitis

Question 1

During a routine examination, a gynecologist discovers a cystic mass in the ovary of a 30-year-old woman. What is the most common type of benign ovarian cyst?

Accepted Answer

Follicular cyst

Answer

Dermoid cyst

Answer

Cystadenoma

Answer

Corpus luteum cyst

Question 2

A 22-year-old woman presents for a routine check-up. The Pap smear shows LSIL. What is the appropriate follow-up?

Accepted Answer

Repeat Pap smear in 6 months

Answer

Immediate colposcopy

Answer

HPV testing

Answer

Cone biopsy

Question 3

A 25-year-old woman presents with itching and white vaginal discharge. Microscopy reveals budding yeast cells. What is the most likely diagnosis?

Accepted Answer

Candidiasis

Answer

Bacterial vaginosis

Answer

Trichomoniasis

Answer

Gonorrhea

Question 4

A 22-year-old woman presents with menorrhagia and a pelvic mass. An ultrasound reveals a well-circumscribed, homogeneous mass within the uterine wall. What is the most likely diagnosis?

Accepted Answer

Leiomyoma

Answer

Adenomyosis

Answer

Endometrial carcinoma

Answer

Ovarian cyst

Question 5

A 38-year-old female with a history of multiple sexual partners presents with lower abdominal pain, fever, and purulent cervical discharge. Despite initial treatment for pelvic inflammatory disease, her symptoms persist. What is the most appropriate next step?

Accepted Answer

Pelvic ultrasound

Answer

Repeat antibiotics

Answer

Endometrial biopsy

Answer

Laparoscopy

Question 6

A 29-year-old woman presents with dyspareunia and nodularity in the posterior fornix. What is the most likely diagnosis?

Accepted Answer

Endometriosis

Answer

Adenomyosis

Answer

Pelvic inflammatory disease

Answer

Ovarian cyst

Question 7

A 30-year-old woman presents with severe menorrhagia and is found to have a 5 cm submucosal fibroid. What is the most appropriate treatment?

Accepted Answer

Myomectomy

Answer

Hysterectomy

Answer

Endometrial ablation

Answer

Uterine artery embolization

Question 8

What non-surgical intervention is primarily used to manage patients with symptomatic uterine fibroids who wish to retain their fertility?

Accepted Answer

Gonadotropin-releasing hormone agonists

Answer

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Answer

Progestin-releasing intrauterine device

Answer

Oral contraceptive pills

Question 9

A 30-year-old woman presents with abnormal uterine bleeding and an enlarged uterus. Which diagnostic test is the most appropriate?

Accepted Answer

Pelvic ultrasound

Answer

Hysteroscopy

Answer

Endometrial biopsy

Answer

MRI pelvis

Question 10

A 28-year-old woman is diagnosed with gonococcal cervicitis (NAAT positive for Neisseria gonorrhoeae) and presents with purulent cervical discharge. What is the most likely complication if left untreated?

Accepted Answer

Pelvic inflammatory disease (PID)

Answer

Ovarian torsion

Answer

Bartholin's gland abscess

Answer

Disseminated gonococcal infection

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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