Gynecological Disorders — MCQs

A 35-year-old woman complains of vaginal discomfort for 2 weeks. Physical examination reveals a scanty vaginal discharge. The fluid develops a "fishy" odor after treatment with 10% potassium hydroxide. A Pap smear taken during the pelvic examination shows squamous cells covered by coccobacilli ("clue" cells). Which of the following is the most likely etiology of vaginal discomfort in this patient?

Q179Medium

A 21-year-old woman with 8 weeks of amenorrhea presents in shock. What is the likely diagnosis?

Q180Easy

A patient presented with intense vulvar pruritus, a white curd-like, cheesy vaginal discharge and vulvar erythema. Candidiasis was diagnosed. Which among the following is NOT a risk factor for vaginal candidiasis?

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 171: Which of the following drugs is not used for pain management in endometriosis?

A. Oral contraceptive pills (OCPs)
B. Gonadotropin-releasing hormone (GnRH) agonists
C. Mifepristone
D. Methotrexate (Correct Answer)

Explanation: **Explanation:** The primary goal of pain management in endometriosis is to induce a hypoestrogenic state or cause decidualization of the ectopic endometrial tissue, as the disease is estrogen-dependent. **Why Methotrexate is the Correct Answer:** **Methotrexate** is a folic acid antagonist that inhibits DNA synthesis. It is primarily used in the management of **ectopic pregnancy** (to destroy rapidly dividing trophoblastic tissue) and in certain autoimmune conditions or malignancies. It has no role in the hormonal modulation required to treat endometriosis and is not used for its pain management. **Analysis of Incorrect Options:** * **Oral Contraceptive Pills (OCPs):** These are considered **first-line** therapy. They work by inducing a pseudopregnancy state, leading to decidualization and eventual atrophy of the endometrial implants. * **GnRH Agonists (e.g., Leuprolide):** These create a state of **pseudomenopause**. Continuous administration causes downregulation of pituitary GnRH receptors, leading to low FSH/LH and profound hypoestrogenism, which shrinks the lesions. * **Mifepristone:** This is a selective progesterone receptor modulator (SPRM). It inhibits ovulation and causes direct endometrial atrophy, effectively reducing endometriosis-associated pain in refractory cases. **High-Yield Clinical Pearls for NEET-PG:** * **First-line medical treatment:** NSAIDs and OCPs. * **Gold Standard for Diagnosis:** Laparoscopy (visualizing "powder-burn" or "mulberry" lesions). * **Add-back therapy:** When using GnRH agonists for >6 months, low-dose estrogen/progesterone must be added to prevent bone mineral density loss and vasomotor symptoms. * **Danazol:** An older treatment that creates a "pseudomenopause" state but is rarely used now due to androgenic side effects (hirsutism, acne).

Question 172: Which one of the following drugs is not used in endometriosis?

A. Danazol
B. Progestins
C. GnRH agonists
D. Misoprostol (Correct Answer)

Explanation: **Explanation:** The primary goal in the medical management of endometriosis is to induce a state of **"pseudopregnancy"** or **"pseudomenopause,"** thereby causing atrophy of the ectopic endometrial tissue. This is achieved by suppressing the hypothalamic-pituitary-ovarian axis and lowering estrogen levels. **Why Misoprostol is the correct answer:** **Misoprostol** is a synthetic **Prostaglandin E1 (PGE1) analog**. Its primary actions include inducing uterine contractions and cervical ripening. It is used for medical abortion, induction of labor, and management of postpartum hemorrhage. It has no role in suppressing estrogen or treating endometriosis; in fact, prostaglandins are often elevated in endometriotic lesions and contribute to the associated pain (dysmenorrhea). **Why the other options are used:** * **Danazol (Option A):** An androgenic steroid that inhibits gonadotropin secretion and creates a high-androgen, low-estrogen environment, leading to atrophy of endometriotic implants. * **Progestins (Option B):** These agents (e.g., Medroxyprogesterone acetate, Dienogest) antagonize the proliferative effects of estrogen on the endometrium, leading to decidualization and eventual atrophy. * **GnRH Agonists (Option C):** Drugs like Leuprolide or Goserelin cause pituitary desensitization, leading to a state of "medical oophorectomy" or profound hypoestrogenism. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Laparoscopy (visual confirmation with/without biopsy). * **First-line Medical Management:** Combined Oral Contraceptive Pills (COCPs) or NSAIDs for pain. * **Dienogest:** A specific progestin now widely considered a preferred long-term medical treatment due to its efficacy and safety profile. * **Add-back Therapy:** Used with GnRH agonists to prevent bone mineral density loss and vasomotor symptoms if treatment exceeds 6 months.

Question 173: All of the following are used in the treatment of endometriosis except:

A. Medroxyprogesterone acetate
B. Tibolone (Correct Answer)
C. OCP
D. Danazol

Explanation: The goal of medical management in endometriosis is to induce a **"pseudopregnancy"** or **"pseudomenopause"** state to cause atrophy of the ectopic endometrial tissue. This is achieved by suppressing the hypothalamic-pituitary-ovarian axis and creating a hypoestrogenic environment. ### Why Tibolone is the Correct Answer **Tibolone** is a synthetic steroid with estrogenic, progestogenic, and androgenic properties. It is primarily used as **Hormone Replacement Therapy (HRT)** in postmenopausal women to treat vasomotor symptoms and prevent osteoporosis. Because it has estrogenic activity, it would theoretically stimulate endometrial implants rather than suppress them. Therefore, it is not used as a primary treatment for endometriosis (though it may be used as "add-back therapy" alongside GnRH agonists to mitigate side effects). ### Explanation of Incorrect Options * **Medroxyprogesterone acetate (Progestins):** These cause decidualization and eventual atrophy of the endometrial tissue. They are a mainstay of treatment. * **OCPs (Combined Oral Contraceptive Pills):** These induce a "pseudopregnancy" state. They inhibit ovulation and thin the endometrial lining, reducing dysmenorrhea and pelvic pain. * **Danazol:** An attenuated androgen that inhibits the mid-cycle LH surge and creates a high-androgen, low-estrogen environment ("pseudomenopause"), leading to atrophy of the implants. ### NEET-PG High-Yield Pearls * **Gold Standard Diagnosis:** Laparoscopy (visualizing "powder-burn" or "mulberry" lesions). * **First-line Medical Management:** NSAIDs and Combined OCPs. * **Drug of Choice for Recurrence:** GnRH agonists (e.g., Leuprolide). * **Add-back Therapy:** When using GnRH agonists for >6 months, small doses of estrogen/progesterone or **Tibolone** are added to prevent bone mineral density loss and vasomotor symptoms.

Question 174: Which of the following is known to decrease the recurrence rate of bacterial vaginosis?

A. Treatment of the male sexual partner
B. Introduction of lactobacilli
C. Acidifying vaginal gels
D. None of the above (Correct Answer)

Explanation: ### Explanation Bacterial Vaginosis (BV) is a clinical syndrome resulting from the replacement of normal hydrogen peroxide-producing **Lactobacilli** with high concentrations of anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Prevotella*, and *Mobiluncus*). Despite effective initial treatment with Metronidazole or Clindamycin, recurrence rates are notoriously high (up to 50% within 6–12 months). **Why "None of the above" is correct:** Current evidence-based guidelines (CDC and ACOG) indicate that none of the listed interventions have been proven to significantly reduce the long-term recurrence rate of BV. * **Treatment of the male sexual partner (Option A):** Multiple randomized controlled trials have demonstrated that treating the male partner does not prevent recurrence in the woman or improve her clinical outcome. BV is considered a "sexually associated" condition rather than a traditional STI. * **Introduction of lactobacilli (Option B):** While the loss of Lactobacilli is the hallmark of BV, clinical trials using oral or vaginal probiotics (Lactobacillus preparations) have shown inconsistent results and are currently not recommended as a standard strategy to prevent recurrence. * **Acidifying vaginal gels (Option C):** Although BV is associated with an alkaline pH (>4.5), the use of lactic acid or other acidifying gels has not been proven superior to placebo in preventing long-term relapse. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Gram stain with **Nugent Scoring** (most reliable). * **Clinical Diagnosis:** **Amsel’s Criteria** (requires 3 out of 4: Thin white discharge, pH >4.5, +ve Whiff test/Amine test, and **Clue cells** on microscopy). * **Management of Recurrence:** The recommended strategy for recurrent BV (≥3 episodes/year) is **suppressive therapy** with twice-weekly vaginal Metronidazole gel for 4–6 months. * **Pregnancy:** BV is associated with preterm labor and PPROM; symptomatic pregnant women must be treated.

Question 175: Adenomyosis is defined as:

A. Endometriosis interna (Correct Answer)
B. Endometriosis externa
C. Uterine sarcoma
D. Leiomyoma

Explanation: ### Explanation **Correct Answer: A. Endometriosis interna** **Understanding the Concept:** Adenomyosis is a benign uterine condition characterized by the **ectopic presence of endometrial glands and stroma within the myometrium**, accompanied by compensatory hypertrophy and hyperplasia of the surrounding smooth muscle. Historically and conceptually, it is referred to as **Endometriosis interna** because the endometrial tissue is growing "inside" the muscular wall of the uterus itself. **Analysis of Options:** * **B. Endometriosis externa:** This refers to classic **Endometriosis**, where endometrial-like tissue is found outside the uterus (e.g., ovaries, uterosacral ligaments, or peritoneum). * **C. Uterine sarcoma:** This is a rare, malignant tumor of the uterine muscle or connective tissue. While adenomyosis causes uterine enlargement, it is a benign process. * **D. Leiomyoma (Fibroids):** These are benign monoclonal tumors of smooth muscle cells. While both cause an enlarged uterus, leiomyomas are usually well-circumscribed "balls" of muscle, whereas adenomyosis is a diffuse infiltration. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Secondary dysmenorrhea, menorrhagia (heavy menstrual bleeding), and a symmetrically enlarged, "globular," and tender uterus. * **Physical Exam:** The uterus is typically **soft and "boggy"** (unlike the firm, irregular feel of fibroids). * **Diagnosis:** Transvaginal Ultrasound (TVUS) shows "myometrial cysts" or a "venetian blind" appearance. **MRI** is the gold standard for diagnosis (look for a Junctional Zone thickness >12 mm). * **Definitive Treatment:** Total Hysterectomy. * **Pathology:** On gross section, it shows a "honeycomb" appearance with small chocolate-colored spots in the myometrium.

Question 176: Which of the following is a minimum criterion to diagnose Pelvic Inflammatory Disease (PID)?

A. Lower abdominal pain (Correct Answer)
B. Fever
C. Cervical motion tenderness
D. Leukocytosis

Explanation: **Explanation:** Pelvic Inflammatory Disease (PID) is a clinical diagnosis. Because the consequences of untreated PID (infertility, ectopic pregnancy) are severe, the **CDC (Centers for Disease Control and Prevention)** has established specific criteria to ensure a low threshold for starting empirical treatment. **1. Why "Lower Abdominal Pain" is the Correct Answer:** According to the CDC guidelines, the diagnosis of PID is based on the presence of **minimum clinical criteria** in a sexually active young woman or a woman at risk for STIs. The primary minimum criterion is **lower abdominal or pelvic pain** with no other apparent cause. In addition to this, at least one of the following **physical exam findings** must be present: * Cervical motion tenderness (CMT) * Uterine tenderness * Adnexal tenderness **2. Why the Other Options are Incorrect:** * **Cervical Motion Tenderness (Option C):** While CMT is a hallmark sign of PID, it is considered a physical examination finding that supports the diagnosis in a patient already presenting with the minimum symptom of lower abdominal pain. * **Fever (Option B) and Leukocytosis (Option D):** These are classified as **additional (supportive) criteria**. They increase the specificity of the diagnosis but are not required for a minimum diagnosis, as many patients with PID are afebrile and have a normal white cell count. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** *Chlamydia trachomatis* (most common overall) and *Neisseria gonorrhoeae*. * **Gold Standard Diagnosis:** Laparoscopy (shows tubal edema and erythema). * **Definitive Criteria:** Histopathologic evidence of endometritis, imaging (TVUS/MRI) showing thickened fluid-filled tubes, or laparoscopic abnormalities. * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving perihepatitis ("violin-string" adhesions).

Question 177: Cryptomenorrhea is seen in which of the following conditions?

A. Asherman's syndrome
B. Testicular feminizing syndrome
C. Imperforate hymen (Correct Answer)
D. Uterine agenesis

Explanation: **Explanation:** **Cryptomenorrhea** (hidden menstruation) refers to a condition where menstruation occurs physiologically, but the menstrual blood fails to exit the genital tract due to an anatomical obstruction in the outflow tract. **1. Why Imperforate Hymen is Correct:** In patients with an **imperforate hymen**, the ovaries and uterus function normally, leading to regular endometrial shedding. However, the blood is trapped behind the intact hymen, leading to **hematocolpos** (blood in the vagina) and eventually **hematometra** (blood in the uterus). This typically presents in adolescent girls as primary amenorrhea with cyclical lower abdominal pain and a bulging, bluish membrane at the introitus. **2. Why the Other Options are Incorrect:** * **Asherman’s Syndrome:** This involves intrauterine adhesions that obliterate the uterine cavity. There is no menstruation occurring because the endometrium is replaced by scar tissue; hence, it is a cause of true amenorrhea, not hidden menstruation. * **Testicular Feminizing Syndrome (AIS):** These individuals have a 46,XY karyotype. They lack a uterus and ovaries; therefore, no menstruation occurs at all. * **Uterine Agenesis (Müllerian Agenesis):** In this condition (Mayer-Rokitansky-Küster-Hauser syndrome), the uterus is absent. Without a uterus, there is no endometrial shedding, making cryptomenorrhea impossible. **Clinical Pearls for NEET-PG:** * **Most common cause** of cryptomenorrhea: Imperforate hymen. * **Second most common cause:** Transverse vaginal septum. * **Clinical Sign:** A palpable suprapubic mass (hematometra) may be present. * **Management:** Cruciate incision on the hymen to allow the old blood (which appears like "chocolate" or "tar") to drain. Avoid packing the vagina post-procedure to prevent infection.

Question 178: A 35-year-old woman complains of vaginal discomfort for 2 weeks. Physical examination reveals a scanty vaginal discharge. The fluid develops a "fishy" odor after treatment with 10% potassium hydroxide. A Pap smear taken during the pelvic examination shows squamous cells covered by coccobacilli ("clue" cells). Which of the following is the most likely etiology of vaginal discomfort in this patient?

A. Chlamydia trachomatis
B. Gardnerella vaginalis (Correct Answer)
C. Herpes simplex virus
D. Human papillomavirus

Explanation: ### Explanation The clinical presentation is a classic case of **Bacterial Vaginosis (BV)**, characterized by a shift in vaginal flora where protective *Lactobacilli* are replaced by anaerobic bacteria, most notably **Gardnerella vaginalis**. **Why Gardnerella vaginalis is correct:** The diagnosis is confirmed using **Amsel’s Criteria** (requires 3 out of 4): 1. **Thin, homogenous, grayish-white discharge:** Described here as "scanty." 2. **Positive Whiff Test:** The "fishy odor" upon adding 10% KOH is due to the release of volatile amines (putrescine and cadaverine). 3. **Clue Cells:** These are vaginal epithelial cells studded with coccobacilli, giving them a "stippled" or "shaggy" border. This is the most specific finding on microscopy/Pap smear. 4. **Vaginal pH > 4.5** (not mentioned, but implied). **Why the other options are incorrect:** * **Chlamydia trachomatis:** Typically causes mucopurulent cervicitis or pelvic inflammatory disease (PID). It is an obligate intracellular organism and does not produce clue cells or a positive whiff test. * **Herpes simplex virus (HSV):** Presents with painful, fluid-filled vesicles or shallow ulcers, often accompanied by systemic symptoms like fever. * **Human papillomavirus (HPV):** Associated with genital warts (Condyloma acuminata) or cervical dysplasia. Cytology would show **koilocytes** (cells with perinuclear halos and nuclear wrinkling), not clue cells. **NEET-PG High-Yield Pearls:** * **Treatment of Choice:** Oral Metronidazole (500 mg twice daily for 7 days). * **Pregnancy:** BV is associated with preterm labor and premature rupture of membranes (PROM). * **Nugent Scoring:** The "Gold Standard" for diagnosis (based on Gram stain morphotypes), though Amsel’s is used clinically. * **Key Distinguisher:** Unlike Trichomoniasis or Candidiasis, BV is generally **not** associated with significant vaginal inflammation (no redness or itching).

Question 179: A 21-year-old woman with 8 weeks of amenorrhea presents in shock. What is the likely diagnosis?

A. Ruptured ectopic pregnancy (Correct Answer)
B. Incarcerated amnion
C. Torsion of ovarian cyst
D. Threatened abortion

Explanation: **Explanation:** The clinical presentation of a young woman with **amenorrhea (8 weeks)** and sudden **hypovolemic shock** is a classic "spotter" for a **Ruptured Ectopic Pregnancy**. In this condition, the gestational sac implants outside the uterine cavity (most commonly in the ampulla of the fallopian tube). As the embryo grows, it outstrips the distensibility of the tube, leading to rupture and massive intraperitoneal hemorrhage, which manifests as shock. **Analysis of Options:** * **Ruptured Ectopic Pregnancy (Correct):** This is the most common cause of life-threatening hemoperitoneum in the first trimester. The 8-week mark is a typical time for tubal rupture. * **Incarcerated Uterus:** This usually occurs between 12–16 weeks of gestation when a retroverted gravid uterus becomes trapped in the pelvic cavity. It presents with urinary retention, not sudden shock. * **Torsion of Ovarian Cyst:** While it causes acute pelvic pain, it rarely leads to hemodynamic collapse (shock) unless accompanied by rupture of a large hemorrhagic cyst or infarction leading to secondary sepsis. * **Threatened Abortion:** This presents with vaginal bleeding and mild cramping with a closed cervical os. It does not cause shock unless it progresses to an Incomplete Abortion with massive external hemorrhage. **NEET-PG High-Yield Pearls:** * **Most common site of Ectopic Pregnancy:** Fallopian tube (95%), specifically the **Ampulla**. * **Most common site for rupture:** Isthmus (6–8 weeks) due to its narrow lumen; Ampulla ruptures later (8–12 weeks). * **Gold Standard Diagnosis:** Laparoscopy. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Management of Shock:** Immediate aggressive fluid resuscitation and **emergency laparotomy** (salpingectomy) to control bleeding.

Question 180: A patient presented with intense vulvar pruritus, a white curd-like, cheesy vaginal discharge and vulvar erythema. Candidiasis was diagnosed. Which among the following is NOT a risk factor for vaginal candidiasis?

A. Diabetes mellitus
B. Hypertension (Correct Answer)
C. Human Immunodeficiency Virus (HIV) infection
D. Pregnancy

Explanation: **Explanation:** Vaginal Candidiasis (Vulvovaginal Candidiasis) is a fungal infection primarily caused by *Candida albicans*. It thrives in environments where there is an alteration in the vaginal flora or a change in the host's metabolic/immune status. **Why Hypertension is the Correct Answer:** Hypertension is a vascular/hemodynamic disorder and does not alter the vaginal pH, glycogen content, or the local immune environment. There is no established pathophysiological link between high blood pressure and the overgrowth of fungal pathogens. Therefore, it is **not** a risk factor. **Analysis of Incorrect Options (Risk Factors):** * **Diabetes Mellitus:** Hyperglycemia leads to increased glycogen levels in vaginal epithelial cells. This provides an abundant food source for *Candida* and promotes its adherence to the vaginal mucosa. * **Pregnancy:** High estrogen levels during pregnancy increase vaginal glycogen content and lower the vaginal pH. Estrogen also enhances the expression of receptors for *Candida* on vaginal epithelial cells, making pregnant women highly susceptible. * **HIV Infection:** Candidiasis is an opportunistic infection. Immunosuppression (low CD4 counts) impairs the body’s ability to limit fungal colonization, leading to frequent or persistent infections. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Characterized by "curd-like" or "cottage cheese" discharge, intense pruritus, and a vaginal pH that usually remains **normal (<4.5)**. * **Diagnosis:** Confirmed by seeing pseudohyphae and spores on a **KOH mount** (Wet smear). * **Other Risk Factors:** Broad-spectrum antibiotics (which kill protective Lactobacilli), high-dose Oral Contraceptive Pills (OCPs), and corticosteroid use. * **Drug of Choice:** Fluconazole (150 mg single dose) is the standard oral treatment; Topical Clotrimazole is preferred in pregnancy.

Practice by Chapter

Abnormal Uterine Bleeding

Practice Questions

Endometriosis

Practice Questions

Adenomyosis

Practice Questions

Uterine Fibroids

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Ovarian Cysts

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Pelvic Inflammatory Disease

Practice Questions

Vulvovaginitis

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Pelvic Organ Prolapse

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Vulvar Disorders

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Benign Breast Diseases

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