Gynecological Disorders Practice Questions

Q: 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?

Bartholin gland. ### 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.

Q: Which of the following is NOT true about herpes simplex genitalis?

May lead to malignancy. **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.

Q: In the "PALM-COEIN" Classification, what does 'P' stand for?

Polyps. 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.

Q: Which of the following drugs used in the medical management of fibroids does NOT decrease their size?

NSAIDs. **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.

Q: Which of the following statements is false regarding hydrosalpinx in pelvic inflammatory disease?

The wall of the hydrosalpinx is thick and edematous. **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).

Q: What is the commonest cause of ectopic pregnancy?

Previous salpingitis. **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).

Q: Gonococcus can infect all of the following structures except:

Vagina. **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 1

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?

Accepted Answer

Bartholin gland

Answer

Gartner duct

Answer

Hair follicle

Answer

Urogenital diaphragm

Question 2

Which of the following is NOT true about herpes simplex genitalis?

Accepted Answer

May lead to malignancy

Answer

Caused due to herpes simplex virus

Answer

Risk of fetal infection is high at term

Answer

Treated by acyclovir

Question 3

In the "PALM-COEIN" Classification, what does 'P' stand for?

Accepted Answer

Polyps

Answer

Pain

Answer

Pedunculated fibroids

Answer

Prolonged bleeding

Question 4

Which of the following is NOT a criterion for the diagnosis of bacterial vaginosis?

Accepted Answer

Vaginal pH > 4.5

Answer

Presence of thin, white, homogenous vaginal discharge

Answer

Characteristic fishy odor of vaginal discharge, especially after adding 10% potassium hydroxide (KOH)

Answer

Microscopic identification of clue cells on wet mount examination

Question 5

Which of the following drugs used in the medical management of fibroids does NOT decrease their size?

Accepted Answer

NSAIDs

Answer

Mifepristone

Answer

GnRH agonists

Answer

GnRH antagonists

Question 6

Which of the following statements is false regarding hydrosalpinx in pelvic inflammatory disease?

Accepted Answer

The wall of the hydrosalpinx is thick and edematous

Answer

Often bilateral

Answer

Histology reveals flattening of the tubal plicae and exfoliation of the lining epithelium

Answer

None of the above

Question 7

All of the following can cause pyometra except?

Accepted Answer

Septate uterus

Answer

Cervical cancer

Answer

Uterine cancer

Answer

Genital TB

Question 8

What is the commonest cause of ectopic pregnancy?

Accepted Answer

Previous salpingitis

Answer

Endometriosis

Answer

Anemia

Answer

Cervicitis

Question 9

Gonococcus can infect all of the following structures except:

Accepted Answer

Vagina

Answer

Cervix

Answer

Bartholin gland

Answer

Fallopian tube

Question 10

Which among the following organisms can gain access to the upper reproductive tract?

Accepted Answer

Neisseria gonorrhoeae

Answer

Lactobacillus

Answer

Bacteroides

Answer

Peptostreptococci

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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