Gynecological Disorders Practice Questions

Q: Hysteroscopy is indicated in all of the following except:

Active pelvic infection. ***Active pelvic infection*** - An **active pelvic infection** is a **contraindication** to hysteroscopy due to the risk of exacerbating the infection and spreading it systemically. - Performing hysteroscopy in the presence of infection can lead to **sepsis** or worsening of pelvic inflammatory disease. *Asherman syndrome* - **Asherman syndrome**, characterized by **intrauterine adhesions**, is a common indication for hysteroscopy to diagnose and surgically resect the adhesions. - Hysteroscopy allows for direct visualization and **lysis of adhesions** to restore uterine cavity integrity. *Infertility* - **Infertility** is a frequent indication for hysteroscopy to evaluate the uterine cavity for **structural abnormalities** such as polyps, fibroids, or septa that might impede conception or implantation. - It helps in identifying and often correcting intrauterine pathologies that contribute to a woman's inability to conceive. *Misplaced intrauterine devices* - Hysteroscopy is indicated for the retrieval of **misplaced or embedded intrauterine devices (IUDs)**, especially if they cannot be removed by simpler methods. - It provides direct visualization of the uterine cavity to help locate and safely extract the IUD, preventing further complications.

Q: In which of the following scenarios is per rectal examination of the uterus most appropriate?

Virgins. ***Virgins*** - **Per rectal examination** has been traditionally taught as an option for assessing the uterus in **unmarried women or virgins** when concerns about hymenal integrity exist. - However, **modern medical practice** recognizes that: - The hymen is **not a reliable indicator of virginity** and "virginity testing" is considered **unethical** by WHO and medical organizations - If clinically necessary, a **per vaginal examination** with appropriate consent and a narrow speculum is the **preferred and more informative method** - PR examination is **less accurate** for uterine assessment compared to PV examination - PR examination may be considered when **PV examination is not feasible** due to anatomical abnormalities, severe vaginismus, or in **prepubertal girls** when pelvic pathology is suspected - In the context of **traditional medical teaching and examinations**, this remains a recognized indication, though clinical practice is evolving *Placenta previa (abnormal placental position)* - A **per vaginal examination** is strictly **contraindicated** in cases of suspected or confirmed **placenta previa** due to the high risk of severe hemorrhage - **Ultrasound** is the diagnostic modality of choice - PR examination offers **no benefit** and is not appropriate for placenta previa *Primigravida (first-time pregnant women)* - A **per vaginal examination** is the **standard and most appropriate method** for assessing the uterus and cervical changes in a **primigravida** during pregnancy and labor - PR examination is generally not performed unless a vaginal examination is impossible *Grand multiparas (women who have had many pregnancies)* - Similar to primigravida, a **per vaginal examination** is the **typical and appropriate method** for assessing uterine size, position, and cervical dilation - There is **no specific indication** for a per rectal examination in this group

Q: A 45-year-old woman with a diagnosis of atypical endometrial hyperplasia should be treated by:

Hysterectomy. ***Hysterectomy*** - **Atypical endometrial hyperplasia (AEH)**, also known as **endometrial intraepithelial neoplasia (EIN)**, carries a significant risk of progression to **endometrial cancer** (up to 25-40% when left untreated), making definitive surgical management with **hysterectomy** the most appropriate treatment, especially in women who have completed childbearing. - For a 45-year-old woman, **total hysterectomy** (often with bilateral salpingo-oophorectomy) ensures complete removal of the diseased endometrium and eliminates the risk of future **malignancy**. *Progesterone* - **Progestin therapy** (high-dose progestogens) might be considered for atypical endometrial hyperplasia in women who desire to preserve their fertility, as it can induce regression of hyperplasia. - However, it requires **close follow-up** with endometrial biopsies every 3-6 months to monitor for treatment success and rule out progression to cancer. - This is generally reserved for younger women with strong fertility desires, not the standard treatment for a 45-year-old. *Hysteroscopic resection* - While hysteroscopic resection can remove localized polyps or areas of hyperplasia, it is generally **not sufficient** for atypical endometrial hyperplasia due to the diffuse nature of the condition and the high risk of occult or future malignancy. - This method carries a risk of incomplete removal and may miss areas of undiagnosed **carcinoma**. *Danazol* - **Danazol** is a synthetic androgen used to treat conditions like **endometriosis** and **fibrocystic breast disease** due to its anti-estrogenic and immunosuppressive properties. - It does **not have a primary role** in the treatment of atypical endometrial hyperplasia, which specifically requires management targeting estrogen-driven proliferation with either surgery or progestin therapy.

Q: Most common site for extra-mammary Paget's disease is:

Vulva. ***Vulva*** - **Extramammary Paget's disease** most commonly occurs in the **vulvar region**, presenting as a red, eczematous lesion [1]. - It is often associated with underlying **adenocarcinoma** or other malignancies in the genital area [2]. *Ovary* - Paget's disease is **rarely** found in the ovary, which is primarily associated with **gonadal** tumors. - Symptoms and lesions are not typically localized to the **ovarian** area. *Vagina* - Extramammary Paget's disease does not commonly present in the vagina and is **not a typical site** for the lesions. - Vaginal cancers are usually **squamous cell carcinomas**, which differ from Paget's disease pathology. *Uterus* - The uterus is not a common site for **extramammary Paget's disease**, which primarily affects the external genitalia. - Uterine disorders more typically include **leiomyomas** or **endometrial carcinomas**, differing significantly from Paget's features. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, p. 1004. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 465-466.

Q: Greenish vaginal discharge with severe itching is suggestive of:

Trichomoniasis. ***Trichomoniasis*** - **Trichomoniasis** is characterized by a **greenish-yellow, frothy vaginal discharge** and severe **vaginal itching**, often accompanied by discomfort during urination and intercourse. - The causative agent is *Trichomonas vaginalis*, a **flagellated protozoan**, which can lead to inflammation and irritation of the vaginal mucosa. *Candidiasis* - **Candidiasis** (yeast infection) typically presents with a **thick, white, cottage cheese-like discharge** and intense itching, but the discharge is rarely greenish. - The primary cause is an overgrowth of *Candida albicans*, and the classic appearance of the discharge is distinct from the greenish discharge mentioned. *Senile vaginitis* - **Senile vaginitis**, also known as **atrophic vaginitis**, is caused by **estrogen deficiency** after menopause, leading to thinning and inflammation of the vaginal walls. - Symptoms include vaginal dryness, itching, and dyspareunia, but the discharge is usually minimal, watery, or blood-tinged, not greenish. *Pyogenic vaginitis* - **Pyogenic vaginitis** is a general term for bacterial infections causing inflammation of the vagina, which can produce various types of discharge. - While it can cause itching and discharge, it is less specific for a greenish discharge than trichomoniasis, and other symptoms like foul odor or pain might be more prominent depending on the specific bacteria involved.

Q: What is the recommended duration for GnRH agonist therapy for leiomyoma?

3 to 6 months. ***3 to 6 months*** - **GnRH agonists** are typically used for a short duration, usually **3 to 6 months**, to shrink **leiomyomas** and reduce bleeding. - Prolonged use is generally avoided due to the risk of **bone mineral density loss** and other hypoestrogenic side effects. *4 to 8 months* - While falling within a similar range, **8 months** is often considered at the longer end of the recommended duration due to potential side effects. - Most patients achieve maximal benefit within the 3-6 month window, making longer durations less common. *5 to 10 months* - This duration is generally considered **too long** for routine GnRH agonist therapy for leiomyomas. - Risks of **osteoporosis** and other menopausal symptoms significantly increase with therapy extending beyond 6 months. *2 to 4 months* - While some benefit may be seen within **2 months**, the full therapeutic effect of maximal shrinkage and symptom improvement often requires a slightly longer duration. - **4 months** falls within the acceptable range, but 3 to 6 months is more commonly cited for optimal outcomes.

Q: What type of ovarian neoplasm is most likely to occur in a 14-year-old girl?

Germ cell tumour. ***Germ cell tumour*** - **Germ cell tumors** are the **most common type of ovarian neoplasm** in females under the age of 20, including adolescent girls [1]. - These tumors arise from the primordial germ cells of the ovary and include types such as **dysgerminoma**, **teratoma**, and **yolk sac tumor** [2], [3]. *Epithelial tumour* - **Epithelial ovarian tumors** are far more common in **older women**, typically those over 40 years of age. - They are rare in adolescents and young women. *Sertoli-Leydig cell tumour* - **Sertoli-Leydig cell tumors** are a type of **sex cord-stromal tumor** that can occur at any age but are relatively rare overall. - While they can affect young women, they are not the most common type of ovarian neoplasm in a 14-year-old. *Granulosa cell tumour* - **Granulosa cell tumors** are another type of **sex cord-stromal tumor** and are the most common malignant sex cord-stromal tumor. - They tend to occur predominantly in **adult women**, with a mean age of presentation around 50-55 years, making them less likely in an adolescent.

Question 1

Hysteroscopy is indicated in all of the following except:

Accepted Answer

Active pelvic infection

Answer

Asherman syndrome

Answer

Infertility

Answer

Misplaced intrauterine devices

Question 2

Which of the following statements about outpatient hysteroscopy is false?

Accepted Answer

Hysteroscopy is less accurate than saline infusion sonography (SIS) for uterine cavity assessment

Answer

Normal saline as distension medium can be used

Answer

It is not reliable to exclude endometrial carcinoma

Answer

Abnormal uterine bleeding is an indication

Question 3

In which of the following scenarios is per rectal examination of the uterus most appropriate?

Accepted Answer

Virgins

Answer

Placenta previa (abnormal placental position)

Answer

Primigravida (first-time pregnant women)

Answer

Grand multiparas (women who have had many pregnancies)

Question 4

A 45-year-old woman with a diagnosis of atypical endometrial hyperplasia should be treated by:

Accepted Answer

Hysterectomy

Answer

Progesterone

Answer

Hysteroscopic resection

Answer

Danazol

Question 5

Most common site for extra-mammary Paget's disease is:

Accepted Answer

Vulva

Answer

Uterus

Answer

Vagina

Answer

Ovary

Question 6

Greenish vaginal discharge with severe itching is suggestive of:

Accepted Answer

Trichomoniasis

Answer

Candidiasis

Answer

Senile vaginitis

Answer

Pyogenic vaginitis

Question 7

Which of the following statements accurately describes adenomyosis?

Accepted Answer

Presents with menorrhagia, dysmenorrhea, and an enlarged uterus

Answer

More common in parous women

Answer

More common in middle-aged women

Answer

Typically resolves after menopause without treatment

Question 8

Investigation of choice in postcoital bleeding in a 60-year-old woman is:

Accepted Answer

Colposcopy and biopsy

Answer

Pap smear

Answer

Pelvic ultrasound

Answer

Cone excision of cervix

Question 9

What is the recommended duration for GnRH agonist therapy for leiomyoma?

Accepted Answer

3 to 6 months

Answer

4 to 8 months

Answer

5 to 10 months

Answer

2 to 4 months

Question 10

What type of ovarian neoplasm is most likely to occur in a 14-year-old girl?

Accepted Answer

Germ cell tumour

Answer

Epithelial tumour

Answer

Granulosa cell tumour

Answer

Sertoli-Leydig cell tumour

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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