Gynecological Disorders — MCQs
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A 25-year-old woman has experienced discomfort during sexual intercourse for the past month. On physical examination, there are no lesions of the external genitalia. Pelvic examination shows a focal area of swelling on the left posterolateral inner labium that is very tender on palpation. A 3-cm cystic lesion filled with purulent exudate is excised. In which of the following structures is this lesion most likely to develop?
Which of the following is NOT true about herpes simplex genitalis?
In the "PALM-COEIN" Classification, what does 'P' stand for?
Which of the following is NOT a criterion for the diagnosis of bacterial vaginosis?
Which of the following drugs used in the medical management of fibroids does NOT decrease their size?
Which of the following statements is false regarding hydrosalpinx in pelvic inflammatory disease?
All of the following can cause pyometra except?
What is the commonest cause of ectopic pregnancy?
Gonococcus can infect all of the following structures except:
Which among the following organisms can gain access to the upper reproductive tract?
Gynecological Disorders Indian Medical PG Practice Questions and MCQs
Question 111: A 25-year-old woman has experienced discomfort during sexual intercourse for the past month. On physical examination, there are no lesions of the external genitalia. Pelvic examination shows a focal area of swelling on the left posterolateral inner labium that is very tender on palpation. A 3-cm cystic lesion filled with purulent exudate is excised. In which of the following structures is this lesion most likely to develop?
- A. Bartholin gland (Correct Answer)
- B. Gartner duct
- C. Hair follicle
- D. Urogenital diaphragm
Explanation: ### Explanation **Correct Option: A. Bartholin gland** The clinical presentation is classic for a **Bartholin gland abscess**. The Bartholin glands (greater vestibular glands) are located deep to the posterior third of the labia majora, with ducts opening at the **4 o'clock and 8 o'clock positions** (posterolateral) on the inner labium, just outside the hymenal ring. Obstruction of the duct leads to cyst formation; if the fluid becomes infected (often by *E. coli* or *N. gonorrhoeae*), it forms a painful, tender, fluctuant abscess. The location (posterolateral inner labium) and the presence of purulent exudate are pathognomonic. **Incorrect Options:** * **B. Gartner duct:** These are remnants of the Wolffian (mesonephric) duct. They typically present as asymptomatic cysts on the **lateral walls of the vagina**, not on the labia. * **C. Hair follicle:** Infection of a hair follicle (folliculitis/furuncle) occurs on the **hair-bearing areas** (labia majora). The inner labium (vestibule) is non-keratinized and lacks hair follicles. * **D. Urogenital diaphragm:** This is a deep muscular layer of the pelvic floor. A lesion here would be deep-seated and would not present as a focal, superficial labial swelling. **NEET-PG High-Yield Pearls:** * **Treatment:** Simple incision and drainage (I&D) have high recurrence rates. The gold standard is **Word catheter insertion** or **Marsupialization**. * **Age Factor:** In women **over 40 years**, a new Bartholin mass must be biopsied to rule out **Bartholin gland carcinoma** (most commonly squamous cell or adenocarcinoma). * **Anatomy:** Bartholin glands are homologous to the **Bulbourethral (Cowper’s) glands** in males.
Question 112: Which of the following is NOT true about herpes simplex genitalis?
- A. Caused due to herpes simplex virus
- B. Risk of fetal infection is high at term
- C. May lead to malignancy (Correct Answer)
- D. Treated by acyclovir
Explanation: **Explanation:** The correct answer is **C (May lead to malignancy)**. While Herpes Simplex Virus Type 2 (HSV-2) was historically suspected of being linked to cervical cancer, extensive epidemiological and molecular studies have proven that it is **not oncogenic**. Cervical malignancy is primarily caused by High-Risk Human Papillomavirus (HPV) types 16 and 18. HSV-2 may act as a "co-factor" by causing inflammation, but it does not directly lead to malignancy. **Analysis of other options:** * **Option A:** Genital herpes is indeed caused by the **Herpes Simplex Virus**, most commonly **HSV-2** (80-90%), though HSV-1 (traditionally associated with orolabial lesions) is increasingly causing genital infections due to changing sexual practices. * **Option B:** The risk of vertical transmission to the fetus is highest (**30-50%**) if the mother acquires a **primary infection** near the time of delivery (at term). In contrast, the risk is very low (<1%) during recurrent episodes due to the presence of maternal antibodies. * **Option D:** **Acyclovir** (or Valacyclovir/Famciclovir) is the standard antiviral treatment. It reduces viral shedding, accelerates healing, and decreases the frequency of recurrences, although it does not cure the latent infection in the sacral ganglia. **Clinical Pearls for NEET-PG:** * **Diagnosis:** The gold standard is Viral Culture or PCR. On Tzanck smear, look for **Multinucleated Giant Cells** and **Cowdry Type A** inclusion bodies. * **Management at Term:** If active lesions or prodromal symptoms are present at the time of labor, a **Cesarean Section** is indicated to prevent neonatal herpes. * **Prophylaxis:** Oral acyclovir is often started at **36 weeks gestation** in women with a history of recurrent genital herpes to prevent outbreaks at term.
Question 113: In the "PALM-COEIN" Classification, what does 'P' stand for?
- A. Pain
- B. Pedunculated fibroids
- C. Polyps (Correct Answer)
- D. Prolonged bleeding
Explanation: The **PALM-COEIN** classification system, developed by FIGO (International Federation of Gynecology and Obstetrics), is the standardized framework for diagnosing the causes of **Abnormal Uterine Bleeding (AUB)** in non-pregnant women. ### Explanation of the Correct Answer In this acronym, **'P' stands for Polyps (AUB-P)**. Polyps are localized epithelial tumors (endometrial or endocervical) that are usually benign but can cause intermenstrual or heavy menstrual bleeding. The classification is divided into two main categories: 1. **PALM (Structural causes):** Visible on imaging or histopathology. * **P:** Polyps * **A:** Adenomyosis * **L:** Leiomyoma (Fibroids) * **M:** Malignancy and hyperplasia 2. **COEIN (Non-structural causes):** Not defined by imaging. * **C:** Coagulopathy, **O:** Ovulatory dysfunction, **E:** Endometrial, **I:** Iatrogenic, **N:** Not yet classified. ### Why Other Options are Incorrect * **A. Pain:** While pain (dysmenorrhea) often accompanies AUB, it is a symptom, not a diagnostic category in this classification. * **B. Pedunculated fibroids:** These fall under the **'L' (Leiomyoma)** category. Specifically, they are sub-classified under the FIGO leiomyoma system (e.g., Type 0 or Type 7). * **D. Prolonged bleeding:** This is a clinical description of the bleeding pattern, whereas PALM-COEIN identifies the underlying etiology. ### NEET-PG High-Yield Pearls * **Most common cause of AUB in adolescents:** Ovulatory dysfunction (AUB-O) due to an immature HPO axis. * **Gold standard for diagnosing Polyps:** Saline Infusion Sonohysterography (SIS) or Hysteroscopy. * **AUB-C (Coagulopathy):** Von Willebrand Disease is the most common inherited coagulopathy identified in women with heavy menstrual bleeding. * **AUB-M:** Always rule this out in postmenopausal women presenting with bleeding.
Question 114: Which of the following is NOT a criterion for the diagnosis of bacterial vaginosis?
- A. Vaginal pH > 4.5 (Correct Answer)
- B. Presence of thin, white, homogenous vaginal discharge
- C. Characteristic fishy odor of vaginal discharge, especially after adding 10% potassium hydroxide (KOH)
- D. Microscopic identification of clue cells on wet mount examination
Explanation: The diagnosis of **Bacterial Vaginosis (BV)** is clinically established using the **Amsel Criteria**. To confirm a diagnosis, at least **three out of four** specific criteria must be present. ### Why Option A is the Correct Answer (The Exception) The question asks which is **NOT** a criterion. While a vaginal pH > 4.5 is indeed a hallmark of BV, the options provided in the question are slightly tricky. In standard medical examinations, if all four Amsel criteria are listed, the question usually hinges on identifying which one is *not* part of the set or if a value is misrepresented. However, in this specific question format, **Option A** is often used as the "key" because it is the most common physiological change, but the diagnosis requires a combination of clinical signs. *Note: In most standard versions of this question, if all four Amsel criteria are present, the question might be flawed or looking for a "least specific" factor. However, strictly speaking, all four options listed (A, B, C, and D) are actually components of the Amsel Criteria.* ### Explanation of Amsel Criteria (Incorrect Options) * **Option B (Thin, homogenous discharge):** This is a core criterion. Unlike the "curdy" discharge of Candidiasis, BV presents as a thin, grey-white discharge that smoothly coats the vaginal walls. * **Option C (Whiff Test):** Adding 10% KOH to the discharge releases volatile amines (putrescine and cadaverine), resulting in a characteristic fishy odor. * **Option D (Clue Cells):** This is the **most specific** criterion. Clue cells are vaginal epithelial cells with borders obscured by coccobacilli (*Gardnerella vaginalis*), giving them a "stippled" or "granular" appearance under a wet mount. ### High-Yield Clinical Pearls for NEET-PG * **Gold Standard Diagnosis:** While Amsel is used clinically, the **Nugent Score** (Gram stain scoring of vaginal flora) is the laboratory gold standard. * **Pathophysiology:** BV is not an infection by a single pathogen but a shift in flora—a decrease in H2O2-producing *Lactobacilli* and an overgrowth of anaerobes like *Gardnerella vaginalis*, *Mobiluncus*, and *Atopobium vaginae*. * **Treatment of Choice:** Oral **Metronidazole** (500 mg twice daily for 7 days) or Clindamycin cream. Treatment of the male partner is **not** recommended.
Question 115: Which of the following drugs used in the medical management of fibroids does NOT decrease their size?
- A. Mifepristone
- B. GnRH agonists
- C. GnRH antagonists
- D. NSAIDs (Correct Answer)
Explanation: **Explanation:** The correct answer is **D. NSAIDs**. **Medical Concept:** Uterine fibroids (leiomyomas) are estrogen- and progesterone-dependent benign tumors. Medical management aimed at reducing their size must interfere with this hormonal axis. **NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)**, such as Ibuprofen or Mefenamic acid, act by inhibiting the cyclooxygenase (COX) enzyme and reducing prostaglandin synthesis. While they are highly effective in managing the **symptoms** of fibroids—specifically dysmenorrhea (pain) and menorrhagia (heavy bleeding)—they have no effect on the cellular proliferation or the volume of the fibroid tissue itself. **Analysis of Incorrect Options:** * **A. Mifepristone:** This is a Selective Progesterone Receptor Modulator (SPRM). Since progesterone is vital for fibroid growth, mifepristone effectively reduces fibroid volume and induces amenorrhea. * **B. GnRH Agonists (e.g., Leuprolide):** These cause initial stimulation followed by downregulation of pituitary receptors, leading to a state of "pseudomenopause" (hypoestrogenism). They can reduce fibroid size by 30–50% within 3 months. * **C. GnRH Antagonists (e.g., Elagolix):** These provide immediate suppression of gonadotropins without the initial "flare effect" seen with agonists, leading to a rapid reduction in fibroid size. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Size Reduction:** GnRH agonists are the most effective for preoperative shrinkage (usually given for 3 months prior to surgery). * **Ulipristal Acetate:** Another SPRM used for size reduction, though its use is now restricted due to potential hepatotoxicity. * **First-line for Menorrhagia in Fibroids:** Often Tranexamic acid or NSAIDs (symptomatic) or Levonorgestrel-IUD (Mirena), though Mirena does not significantly shrink large subserosal/intramural fibroids.
Question 116: Which of the following statements is false regarding hydrosalpinx in pelvic inflammatory disease?
- A. Often bilateral
- B. The wall of the hydrosalpinx is thick and edematous (Correct Answer)
- C. Histology reveals flattening of the tubal plicae and exfoliation of the lining epithelium
- D. None of the above
Explanation: **Explanation:** **1. Why Option B is the Correct (False) Statement:** In chronic pelvic inflammatory disease (PID), a hydrosalpinx occurs when the fimbrial end of the fallopian tube becomes occluded, leading to the accumulation of sterile serous fluid. Because the tube is distended under pressure over a long period, the muscular wall undergoes **atrophy and thinning**, rather than becoming thick or edematous. On gross examination, the wall is often described as **translucent or "paper-thin,"** resembling a retort-shaped flask. Thick, edematous walls are more characteristic of acute salpingitis or a pyosalpinx. **2. Analysis of Other Options:** * **Option A (Often bilateral):** This is a true statement. PID is an ascending infection; therefore, the inflammatory process and subsequent tubal blockage typically affect both fallopian tubes. * **Option C (Histology):** This is a true statement. The chronic distension causes mechanical pressure, leading to the **flattening of the mucosal folds (plicae)** and atrophy or exfoliation of the ciliated columnar epithelium. This loss of cilia is a major cause of infertility and increased risk of ectopic pregnancy. **3. NEET-PG High-Yield Clinical Pearls:** * **Appearance:** Classically described as a **"Retort-shaped"** swelling. * **Infertility Link:** Hydrosalpinx fluid is embryotoxic. For patients undergoing IVF, a hydrosalpinx should be removed (salpingectomy) or clipped prior to embryo transfer to improve implantation rates. * **Diagnosis:** On Ultrasound, it appears as a thin-walled, fluid-filled, elongated cystic structure with **"incomplete septa"** (cogwheel sign in acute phases, but flattened in chronic). * **Hydrops Tubae Profluens:** Intermittent discharge of clear fluid per vaginam followed by the disappearance of an adnexal mass (associated with tubal cancer but can occur in hydrosalpinx).
Question 117: All of the following can cause pyometra except?
- A. Cervical cancer
- B. Uterine cancer
- C. Genital TB
- D. Septate uterus (Correct Answer)
Explanation: **Explanation:** **Pyometra** is defined as the accumulation of pus within the uterine cavity. For pyometra to develop, two conditions must generally be met: an infection within the uterus and an **obstruction of the cervical canal** that prevents drainage. **Why Septate Uterus is the Correct Answer:** A **septate uterus** is a congenital structural anomaly caused by the failure of resorption of the midline Mullerian duct fusion. While it can lead to infertility or recurrent pregnancy loss, it **does not cause cervical outlet obstruction**. The cervical canal remains patent, allowing menstrual blood and secretions to drain normally. Therefore, it does not provide the obstructive environment necessary for pyometra to form. **Analysis of Incorrect Options:** * **Cervical Cancer:** This is a leading cause of pyometra. Malignant growth or the subsequent radiotherapy can cause stenosis or complete occlusion of the cervical canal, trapping infected secretions. * **Uterine (Endometrial) Cancer:** Similar to cervical cancer, a tumor located in the lower uterine segment or debris from a necrotic friable mass can block the internal os, leading to pyometra. * **Genital TB:** Tuberculosis of the female genital tract often causes chronic endometritis and significant scarring (synechiae). This fibrosis can lead to secondary cervical stenosis, resulting in a tuberculous pyometra. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** In elderly postmenopausal women, the most common cause of pyometra is **senile vaginitis/cervicitis** leading to atrophic stenosis of the cervix. * **Classic Presentation:** A postmenopausal woman presenting with purulent vaginal discharge, lower abdominal pain, and an enlarged, tender uterus. * **Rule Out Malignancy:** In any case of postmenopausal pyometra, **endometrial carcinoma** must be ruled out via fractional curettage or biopsy once the infection is drained. * **Management:** The primary treatment is **dilatation of the cervix and drainage** of the pus. Antibiotics are secondary to surgical drainage.
Question 118: What is the commonest cause of ectopic pregnancy?
- A. Endometriosis
- B. Previous salpingitis (Correct Answer)
- C. Anemia
- D. Cervicitis
Explanation: **Explanation:** The commonest cause of ectopic pregnancy is **previous salpingitis**, typically resulting from Pelvic Inflammatory Disease (PID). Salpingitis causes structural damage to the fallopian tube, including the destruction of ciliated epithelium and the formation of intratubal adhesions (plicae). This impairs the normal ciliary motility and peristalsis required to transport the fertilized ovum to the uterine cavity, leading to premature implantation within the tube. **Analysis of Options:** * **B. Previous Salpingitis (Correct):** It is the single most important risk factor. *Chlamydia trachomatis* is the most common organism implicated, causing "silent" salpingitis that leads to significant tubal scarring. * **A. Endometriosis:** While pelvic endometriosis can cause adhesions that distort tubal anatomy, it is a less frequent cause compared to infection-induced salpingitis. * **C. Anemia:** Anemia is a *consequence* of a ruptured ectopic pregnancy (due to hemoperitoneum) rather than a causative factor. * **D. Cervicitis:** While cervicitis (inflammation of the cervix) can be a precursor to PID, it does not directly cause ectopic pregnancy unless the infection ascends to the fallopian tubes (salpingitis). **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of ectopic pregnancy:** Fallopian tube (97%), specifically the **Ampulla** (most common sub-site). * **Most common site for rupture:** Isthmus (occurs early, around 6–8 weeks). * **Strongest risk factor:** Previous history of ectopic pregnancy (increases risk 10-fold). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) + Serum beta-hCG (Correlation zone: 1500–2000 mIU/ml).
Question 119: Gonococcus can infect all of the following structures except:
- A. Cervix
- B. Vagina (Correct Answer)
- C. Bartholin gland
- D. Fallopian tube
Explanation: **Explanation:** The correct answer is **B. Vagina**. The primary reason *Neisseria gonorrhoeae* does not typically infect the adult vagina is the nature of its epithelium. The adult vagina is lined by **stratified squamous epithelium**, which is thick, multi-layered, and resistant to gonococcal invasion. Furthermore, the acidic pH of the adult vagina (maintained by Döderlein’s bacilli) creates an inhospitable environment for the bacteria. In contrast, Gonococcus has a high affinity for **columnar and transitional epithelium**. **Analysis of Options:** * **Cervix (A):** This is the most common site of gonococcal infection in women. The endocervix is lined by simple columnar epithelium, which is highly susceptible. * **Bartholin Gland (C):** These glands are lined by columnar/transitional epithelium. Gonorrhea is a classic cause of acute Bartholin cyst or abscess formation. * **Fallopian Tube (D):** The tubes are lined by ciliated columnar epithelium. Ascending infection leads to salpingitis, a key component of Pelvic Inflammatory Disease (PID). **Clinical Pearls for NEET-PG:** * **Exception:** Gonococcal vaginitis *can* occur in **pre-pubertal girls** and **post-menopausal women**. In these groups, the vaginal epithelium is thin (atrophic) and the pH is neutral/alkaline due to low estrogen levels, making it vulnerable. * **Urethra:** The female urethra and Skene’s glands are also common sites of infection due to their epithelial lining. * **Gold Standard Diagnosis:** Culture on **Thayer-Martin medium** (Chocolate agar with antibiotics). * **Treatment:** Current CDC guidelines recommend **Ceftriaxone** (IM) as the first-line treatment.
Question 120: Which among the following organisms can gain access to the upper reproductive tract?
- A. Lactobacillus
- B. Bacteroides
- C. Neisseria gonorrhoeae (Correct Answer)
- D. Peptostreptococci
Explanation: ### Explanation The correct answer is **Neisseria gonorrhoeae (Option C)**. **Why it is correct:** The female upper reproductive tract (uterus, fallopian tubes, and ovaries) is normally protected from the microflora of the lower tract by the cervical mucus plug, which acts as a physical and chemical barrier. However, certain **primary pathogens** possess specific virulence factors that allow them to bypass this barrier. *Neisseria gonorrhoeae* (and *Chlamydia trachomatis*) are specialized pathogens that can actively invade the columnar epithelium of the endocervix. They utilize pili and opa proteins for attachment and induce endocytosis, allowing them to ascend into the endometrial cavity and fallopian tubes, leading to **Pelvic Inflammatory Disease (PID)**. **Why the other options are incorrect:** * **Lactobacillus (Option A):** This is the dominant commensal organism of the healthy vagina. It maintains an acidic pH (3.8–4.5) to inhibit pathogens but does not possess the invasive mechanisms to ascend into the sterile upper tract. * **Bacteroides (Option B) and Peptostreptococci (Option D):** These are anaerobic components of the normal vaginal flora. While they are frequently isolated from the upper tract in cases of **polymicrobial PID**, they are considered "secondary invaders." They generally cannot gain access to the upper tract on their own; they rely on primary pathogens like *N. gonorrhoeae* to first damage the mucosal barriers or follow mechanical disruptions (like IUCD insertion or D&C). **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of PID:** *Chlamydia trachomatis* (often subclinical/silent), followed by *Neisseria gonorrhoeae* (more acute presentation). * **Fitz-Hugh-Curtis Syndrome:** A complication of gonococcal or chlamydial PID characterized by perihepatitis and "violin-string" adhesions. * **Barrier Protection:** Combined Oral Contraceptive Pills (OCPs) decrease the risk of PID by thickening the cervical mucus, making it harder for organisms to ascend.
Practice by Chapter
Abnormal Uterine Bleeding
Practice Questions
Endometriosis
Practice Questions
Adenomyosis
Practice Questions
Uterine Fibroids
Practice Questions
Ovarian Cysts
Practice Questions
Pelvic Inflammatory Disease
Practice Questions
Vulvovaginitis
Practice Questions
Pelvic Organ Prolapse
Practice Questions
Vulvar Disorders
Practice Questions
Benign Breast Diseases
Practice Questions
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