Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 141: A 45-year-old lady presented with a Pap smear result showing atypical squamous cells of undetermined significance. What is the next line of management?

A. Repeat cervical cytology (Correct Answer)
B. Cervical biopsy
C. HPV DNA testing
D. Loop Electrosurgical Excision Procedure (LEEP)

Explanation: ### Explanation **1. Why Repeat Cervical Cytology is Correct:** According to the **Bethesda System** and standard management guidelines (like ASCCP), **Atypical Squamous Cells of Undetermined Significance (ASC-US)** is the most common abnormal Pap smear result. In a 45-year-old patient, there are two primary acceptable management pathways: * **HPV DNA Testing (Reflex HPV):** This is the preferred approach if available. * **Repeat Cytology:** If HPV testing is not performed or unavailable, the standard recommendation is to **repeat the Pap smear in 6–12 months**. If the repeat smear is negative, the patient returns to routine screening; if ASC-US or higher is found again, colposcopy is indicated. **2. Why Other Options are Incorrect:** * **B. Cervical Biopsy:** This is an invasive procedure. It is only performed after a colposcopy identifies a specific lesion. It is never the immediate next step for a low-grade result like ASC-US. * **C. HPV DNA Testing:** While this is a preferred "reflex" test, in the context of many standardized exams (including some NEET-PG patterns), if the question asks for the "next line" and assumes a resource-limited or traditional algorithm, repeat cytology is a classic correct answer. However, if both are present, HPV testing is often superior; but here, repeat cytology remains a definitive management pillar. * **D. LEEP:** This is a therapeutic procedure used for confirmed high-grade dysplasia (CIN II/III). It is contraindicated as an initial step for ASC-US. **3. Clinical Pearls for NEET-PG:** * **ASC-US Management:** If HPV positive → Colposcopy. If HPV negative → Repeat Pap in 3 years. * **LSIL/HSIL:** Generally require more immediate investigation (Colposcopy) compared to ASC-US. * **Age Factor:** In women <25 years with ASC-US, repeat cytology at 12 months is the preferred strategy to avoid over-treating transient HPV infections. * **Triaging:** ASC-US is the only category where "Reflex HPV testing" is used to decide who needs a colposcopy.

Question 142: A young lady presents with acute abdominal pain and a history of 1 1/2 months of amenorrhea. On ultrasound examination, there is a collection of fluid in the pouch of Douglas and an empty gestational sac. What is the most likely diagnosis?

A. Ectopic pregnancy (Correct Answer)
B. Pelvic hematocele
C. Threatened abortion
D. Twisted ovarian cyst

Explanation: ### Explanation **Correct Answer: A. Ectopic Pregnancy** The clinical triad of **amenorrhea, acute abdominal pain, and vaginal bleeding** (though bleeding isn't mentioned here, the first two are classic) in a woman of reproductive age should always raise a high suspicion of ectopic pregnancy. * **Why it is correct:** The presence of an **empty gestational sac** (pseudogestational sac) within the uterus, combined with **fluid in the Pouch of Douglas (POD)**, is a hallmark sign. In a ruptured or leaking ectopic pregnancy, blood collects in the POD (hemoperitoneum). The "empty sac" seen on ultrasound is often a decidual reaction or a pseudogestational sac, which can be mistaken for an early intrauterine pregnancy but lacks a yolk sac or embryo. **Analysis of Incorrect Options:** * **B. Pelvic Hematocele:** This is a *sequela* of a ruptured ectopic pregnancy (organized blood collection), not the primary diagnosis itself. While present, "Ectopic Pregnancy" is the more definitive clinical diagnosis. * **C. Threatened Abortion:** In this condition, the gestational sac is located **inside** the uterus and is usually not empty; it contains a viable embryo. Furthermore, it typically presents with painless vaginal bleeding rather than acute abdominal pain with fluid in the POD. * **D. Twisted Ovarian Cyst:** While it causes acute pain, it is usually not associated with amenorrhea or an intrauterine "empty sac" unless there is a coexisting pregnancy. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) + Serum β-hCG. * **Discriminatory Zone:** The level of β-hCG (usually 1500–2000 mIU/ml) at which a normal intrauterine pregnancy should be visible on TVS. If the uterus is empty above this level, suspect ectopic pregnancy. * **Arias-Stella Reaction:** A characteristic hypertrophic change in the endometrial lining seen in ectopic pregnancy (and sometimes normal pregnancy). * **Most common site:** Ampulla of the Fallopian tube.

Question 143: What is the investigation of choice in a 55-year-old postmenopausal woman who has presented with postmenopausal bleeding?

A. Pap smear
B. Fractional curettage (Correct Answer)
C. Transvaginal ultrasound (TVS)
D. Ca-125 estimation

Explanation: **Explanation:** In a postmenopausal woman presenting with vaginal bleeding, the primary clinical objective is to rule out **Endometrial Carcinoma**, which is present in approximately 10% of such cases. **Why Fractional Curettage is the Correct Answer:** Fractional curettage remains the traditional "gold standard" investigation of choice for definitive diagnosis. It involves separate sampling of the endocervical canal and the endometrial cavity. This process is crucial because it not only provides a tissue diagnosis (histopathology) but also helps in determining the extent of the disease (staging), specifically whether the malignancy involves the cervix. While Pipelle biopsy is often the first-line office procedure today, fractional curettage is the definitive diagnostic choice in the context of NEET-PG examinations. **Analysis of Incorrect Options:** * **A. Pap smear:** This is a screening tool for cervical cancer, not a diagnostic tool for endometrial pathology. It has very low sensitivity for detecting endometrial cancer. * **C. Transvaginal ultrasound (TVS):** TVS is the best **initial screening** modality. An endometrial thickness (ET) of $\leq$ 4 mm has a high negative predictive value for cancer. However, it cannot provide a tissue diagnosis, which is mandatory for confirmation. * **D. Ca-125 estimation:** This is a tumor marker primarily used for monitoring epithelial ovarian cancer. It is neither sensitive nor specific for diagnosing postmenopausal bleeding. **Clinical Pearls for NEET-PG:** * **Most common cause** of postmenopausal bleeding: Senile/Atrophic vaginitis. * **Most common malignancy** associated: Endometrial carcinoma. * **Endometrial Thickness (ET) Cut-off:** If ET is $>4$ mm in a postmenopausal woman, tissue biopsy is mandatory. * **Gold Standard:** Fractional curettage (or Hysteroscopy-guided biopsy for focal lesions).

Question 144: Sarcomatous change should be suspected in a uterine fibroid when there occurs:

A. Increase in the size
B. Pain
C. Bleeding
D. All of the above (Correct Answer)

Explanation: **Explanation:** Uterine leiomyosarcoma (LMS) is a rare but aggressive malignant transformation of a uterine fibroid (leiomyoma), occurring in approximately 0.1–0.3% of cases. While most fibroids are benign, certain clinical "red flags" necessitate the suspicion of sarcomatous change. 1. **Why "All of the Above" is correct:** * **Increase in size (Rapid Growth):** A sudden, rapid increase in the size of a uterine mass, especially in **postmenopausal women**, is the most classic sign of malignancy. While "rapid growth" in premenopausal women is often still benign, any significant enlargement after menopause is highly suspicious. * **Pain:** Unlike typical fibroids which are often asymptomatic, sarcomas frequently cause pelvic pain due to rapid expansion, tissue necrosis, or hemorrhage within the tumor. * **Bleeding:** Abnormal uterine bleeding (AUB) or postmenopausal bleeding is a common presenting symptom of LMS as the tumor disrupts the endometrial cavity or outgrows its blood supply. 2. **Clinical Context of Options:** While pain and bleeding can occur in benign fibroids (e.g., red degeneration or submucosal types), their **new onset or worsening**, particularly when coupled with rapid growth, shifts the clinical suspicion toward leiomyosarcoma. Therefore, all three clinical features are recognized indicators for further investigation. **High-Yield Clinical Pearls for NEET-PG:** * **The "Postmenopausal Rule":** A fibroid should ideally shrink after menopause due to estrogen withdrawal. Any growth during this period is a major warning sign for sarcoma. * **Diagnosis:** Definitive diagnosis is only possible via **histopathology** (look for high mitotic index, cellular atypia, and coagulative tumor cell necrosis). * **MRI Findings:** High signal intensity on T2-weighted images with irregular borders may suggest malignancy, but it is not definitive. * **Risk Factor:** Prior pelvic radiation is a known risk factor for developing uterine sarcomas.

Question 145: Ectopic pregnancy is associated with all of the following conditions EXCEPT:

A. Salpingitis
B. Intrauterine contraceptive device (IUCD)
C. Plastic procedure on the fallopian tube
D. None of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **D (None of the above)** because all the conditions listed (Salpingitis, IUCD use, and tubal surgeries) are well-established risk factors for ectopic pregnancy. 1. **Salpingitis (Option A):** This is the most common risk factor. Pelvic Inflammatory Disease (PID), specifically salpingitis, causes endosalpingeal damage, loss of ciliary action, and structural adhesions. This hinders the transport of the fertilized ovum, leading to implantation within the fallopian tube. 2. **Intrauterine Contraceptive Device (Option B):** While IUCDs are highly effective at preventing pregnancy, if a pregnancy *does* occur with an IUCD in situ, the likelihood of it being ectopic is significantly higher. This is because the IUCD prevents intrauterine implantation more effectively than it prevents tubal implantation. 3. **Plastic procedure on the fallopian tube (Option C):** Any tubal surgery (reconstructive "plastic" procedures, tubal ligation, or salpingostomy) creates scarring or anatomical distortions. These alterations can trap the embryo or delay its passage to the uterus. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ampulla of the fallopian tube (70%). * **Highest risk factor:** Previous history of ectopic pregnancy (increases risk by 10-fold). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy; it is suggestive of pregnancy but not specific to ectopic pregnancy. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (seen in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) combined with serial β-hCG levels (Discriminatory zone: 1500–2000 mIU/mL).

Question 146: Which of the following statements is NOT true regarding Endometriosis?

A. Sampson proposed the implantation theory.
B. Endometriosis can cause infertility.
C. Laparoscopy is considered the gold standard for diagnosing endometriosis.
D. Endometriosis is common in low socio-economic groups. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D**. Endometriosis is traditionally known as a "disease of the modern woman" or a "career woman's disease." It is more frequently diagnosed in **high socio-economic groups**, likely due to factors such as delayed childbearing, lower parity, and better access to diagnostic facilities. **Analysis of Options:** * **Option A (Sampson’s Theory):** This is a true statement. John Sampson proposed the **Implantation Theory**, which suggests that endometriosis results from **retrograde menstruation**, where endometrial tissue flows through the fallopian tubes and implants on pelvic organs. * **Option B (Infertility):** This is true. Endometriosis is found in approximately 30–50% of women with infertility. It causes subfertility through pelvic adhesions, distorted anatomy, and an altered peritoneal microenvironment that affects oocyte quality and sperm motility. * **Option C (Laparoscopy):** This is true. **Diagnostic Laparoscopy with biopsy** is the "Gold Standard" for diagnosis. It allows for direct visualization of lesions (e.g., "powder-burn" or "gunshot" appearances) and histological confirmation. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Dysmenorrhea (congestive/secondary), Dyspareunia, and Infertility. * **Commonest Site:** The **Ovary** is the most common site of endometriosis. * **Chocolate Cyst:** An endometrioma of the ovary, filled with thick, dark, old blood. * **CA-125:** Often elevated in endometriosis but lacks specificity; used primarily for monitoring recurrence. * **Management:** Combined Oral Contraceptive Pills (OCPs) are first-line for pain; GnRH agonists create a "pseudomenopause" state.

Question 147: What is the investigation of choice for recurrent abortion in the first trimester?

A. Karyotyping (Correct Answer)
B. Systemic Lupus Erythematosus (SLE) antibodies
C. Human Immunodeficiency Virus (HIV) testing
D. TORCH infection screening

Explanation: **Explanation:** Recurrent pregnancy loss (RPL) is defined as two or more consecutive spontaneous abortions. In the **first trimester**, the most common cause of sporadic miscarriage is chromosomal abnormalities. When these losses become recurrent, parental chromosomal anomalies (most commonly **balanced reciprocal translocations**) are a significant underlying factor. **1. Why Karyotyping is the Investigation of Choice:** Parental **Karyotyping** is the gold standard investigation to identify structural chromosomal rearrangements. If one parent carries a balanced translocation, they are phenotypically normal but produce unbalanced gametes, leading to recurrent embryonic aneuploidy and subsequent first-trimester loss. **2. Analysis of Incorrect Options:** * **SLE antibodies (Antiphospholipid Antibodies):** While Antiphospholipid Syndrome (APLAs) is a major cause of RPL, it is more classically associated with second-trimester losses or specific late-term complications (though it can cause early loss). Karyotyping remains the primary genetic screen for early-first-trimester recurrence. * **HIV testing:** HIV is not a recognized cause of recurrent pregnancy loss. * **TORCH infection screening:** This is a common misconception. TORCH infections (Toxoplasmosis, Rubella, CMV, Herpes) cause **sporadic** fetal loss or malformations, but they do **not** cause recurrent abortions because the mother develops immunity after the initial infection. **Clinical Pearls for NEET-PG:** * **Most common cause of 1st-trimester abortion:** Fetal chromosomal anomaly (Autosomal trisomy is the most common; specifically Trisomy 16). * **Most common parental anomaly in RPL:** Balanced reciprocal translocation. * **Uterine causes:** Septate uterus is the most common uterine anomaly associated with RPL. * **Investigation Timing:** Karyotyping should be performed on both parents and, if possible, the products of conception (POC).

Question 148: Which of the following is NOT typically seen in uterine fibroids?

A. Amenorrhea (Correct Answer)
B. Pelvic mass
C. Infertility
D. Menstrual irregularity

Explanation: **Explanation:** Uterine fibroids (leiomyomas) are benign monoclonal tumors of the myometrium. The hallmark of fibroids is **increased** uterine bleeding, not its absence. **Why Amenorrhea is the Correct Answer:** Amenorrhea (absence of menstruation) is **not** a feature of fibroids. In fact, fibroids typically cause the opposite: **Heavy Menstrual Bleeding (HMB/Menorrhagia)**. This occurs due to an increased endometrial surface area, increased vascularity of the uterus, and interference with normal myometrial contractions. If a patient with known fibroids presents with amenorrhea, the most likely cause is a coexisting pregnancy or menopause. **Analysis of Incorrect Options:** * **Pelvic Mass:** Large intramural or subserosal fibroids often present as a firm, non-tender, irregular mass felt on abdominal or bimanual examination. * **Infertility:** Fibroids can cause infertility by distorting the uterine cavity (submucosal type), obstructing the fallopian tube ostia, or causing chronic endometritis that prevents implantation. * **Menstrual Irregularity:** While HMB is most common, fibroids can lead to intermenstrual bleeding or metrorrhagia, especially if they are submucosal or pedunculated intracavitary types. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Heavy Menstrual Bleeding (Menorrhagia). * **Most common degeneration:** Hyaline degeneration. * **Degeneration during pregnancy:** Red degeneration (due to rapid growth and venous thrombosis). * **Most common type to cause infertility/miscarriage:** Submucosal fibroid (FIGO Type 0, 1, 2). * **Medical Management:** GnRH agonists are used pre-operatively to shrink fibroid volume and correct anemia.

Question 149: Which of the following distension media used in hysteroscopy causes fluid overload and electrolyte disturbances?

A. Carbon dioxide
B. Glycine (Correct Answer)
C. Hyskon
D. Ringer Lactate

Explanation: **Explanation:** Hysteroscopy requires a distension medium to expand the uterine cavity for visualization. These media are categorized into gaseous (CO₂) and liquid (electrolytic or non-electrolytic). **Why Glycine is the Correct Answer:** Glycine (1.5%) is a **non-electrolytic, hypotonic** liquid medium. It is commonly used during operative hysteroscopy (like TCRE) because it is non-conductive, allowing the use of monopolar electrosurgery. However, if absorbed systemically through opened uterine sinuses (intravasation), it leads to **dilutional hyponatremia** and **hypoosmolality**. Furthermore, glycine is metabolized into ammonia, which can cause neurotoxicity and encephalopathy. This constellation of fluid overload and electrolyte imbalance is often referred to as "Hysteroscopic Syndrome" (similar to TURP syndrome). **Analysis of Incorrect Options:** * **Carbon Dioxide (A):** Used only for diagnostic hysteroscopy. The main risks are gas embolism and "shoulder tip pain," but it does not cause fluid/electrolyte disturbances. * **Hyskon (C):** A high-molecular-weight dextran (32%). While it can cause fluid overload due to its high osmotic pressure (pulling interstitial fluid into vessels), its classic complications are **anaphylaxis** and "sticky" equipment; it does not typically cause the electrolyte disturbances seen with glycine. * **Ringer Lactate (D):** An **isotonic, electrolytic** solution. While it can cause fluid overload (pulmonary edema), it does **not** cause electrolyte disturbances (hyponatremia) because its sodium concentration matches plasma. It cannot be used with monopolar cautery. **High-Yield NEET-PG Pearls:** * **Monopolar Cautery:** Requires non-electrolytic media (Glycine, Sorbitol, Mannitol). * **Bipolar Cautery:** Can be used with isotonic media (Normal Saline, Ringer Lactate), which are safer regarding electrolytes. * **Fluid Deficit Limit:** For Glycine, the procedure should be stopped if the fluid deficit exceeds **1000 ml** (or 750 ml in patients with comorbidities). For isotonic saline, the limit is **2500 ml**.

Question 150: Ectopic pregnancy occurs in all of the following situations EXCEPT?

A. Pelvic inflammatory disease (PID)
B. Intrauterine device (IUD) use
C. History of previous ectopic pregnancy
D. Dysfunctional uterine bleeding (DUB) (Correct Answer)

Explanation: **Explanation:** The core concept behind ectopic pregnancy is any factor that interferes with the normal transport of the fertilized ovum through the fallopian tube or causes premature implantation. **Why D is the correct answer:** **Dysfunctional Uterine Bleeding (DUB)**, now more commonly referred to under the umbrella of Abnormal Uterine Bleeding (AUB-E/O), is primarily a hormonal pathology involving the hypothalamic-pituitary-ovarian axis. It results in irregular shedding of the endometrium but does not anatomically or physiologically predispose the embryo to implant outside the uterine cavity. Therefore, it is not a risk factor for ectopic pregnancy. **Why the other options are incorrect (Risk Factors):** * **Pelvic Inflammatory Disease (PID):** This is the **most common risk factor**. It causes endosalpingitis, leading to the loss of ciliary action and the formation of tubal adhesions/strictures, which trap the ovum. * **Intrauterine Device (IUD) use:** While IUDs are highly effective at preventing all pregnancies, if a woman *does* conceive with an IUD in situ, the risk of that pregnancy being ectopic is significantly higher because the device prevents intrauterine implantation more effectively than tubal implantation. * **History of previous ectopic pregnancy:** This is a major risk factor (10-15% recurrence rate) due to underlying tubal damage or shared risk factors that caused the first event. **NEET-PG High-Yield Pearls:** * **Most common site:** Ampulla of the Fallopian tube (70%). * **Most common site for rupture:** Isthmus (due to its narrow lumen). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serial β-hCG (Discriminatory zone: 1500–2000 mIU/mL). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on curettage, which is suggestive of pregnancy but not specific to ectopic.

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

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