Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 181: A girl presents with primary amenorrhea, normal ovaries, absent internal genitalia, and normal external genitalia. What is the most probable diagnosis?

A. Mayer-Rokitansky-Kuster-Hauser syndrome (Correct Answer)
B. Turner's syndrome
C. Noonan syndrome
D. Androgen insensitivity syndrome

Explanation: ### Explanation **Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome** is the correct diagnosis based on the clinical triad of primary amenorrhea, absent internal genitalia (müllerian agenesis), and a female phenotype. **1. Why MRKH is Correct:** In MRKH syndrome, there is congenital aplasia of the Müllerian ducts. This results in the absence of the uterus, cervix, and upper two-thirds of the vagina. Because the ovaries develop from the primitive germ cells (not the Müllerian ducts), they are **normal and functional**, leading to normal secondary sexual characteristics (breast development/pubic hair) and a female 46,XX karyotype. **2. Why Other Options are Incorrect:** * **Turner’s Syndrome (45,XO):** Characterized by **streak ovaries** (gonadal dysgenesis). Patients have a uterus but lack secondary sexual characteristics due to estrogen deficiency. * **Noonan Syndrome:** Often called "male Turner’s," it presents with similar features to Turner’s (short stature, webbed neck) but usually involves fertile individuals with a 46,XX or 46,XY karyotype. Internal genitalia are typically present. * **Androgen Insensitivity Syndrome (46,XY):** While internal genitalia are absent (due to Anti-Müllerian Hormone from testes), the **ovaries are absent**. Instead, undescended testes are present, and there is usually scanty/absent pubic and axillary hair. **High-Yield Clinical Pearls for NEET-PG:** * **Karyotype:** MRKH is 46,XX; AIS is 46,XY. * **First Investigation:** Pelvic Ultrasound (to check for uterus/ovaries). * **Gold Standard Investigation:** MRI. * **Associated Anomalies:** 30–40% of MRKH patients have **Renal anomalies** (e.g., renal agenesis, ectopic kidney). Always screen with an ultrasound of the KUB region. * **Hormonal Profile:** In MRKH, FSH, LH, and Estrogen levels are **normal**.

Question 182: All of the following are causes of prolapse of the cervix EXCEPT:

A. Many MTP procedures (Correct Answer)
B. Chronic cough
C. Menopause
D. Delivery of a big baby

Explanation: **Explanation:** Pelvic organ prolapse (POP) occurs when the pelvic floor muscles and ligaments (specifically the cardinal and uterosacral ligaments) are weakened or damaged, failing to support the uterus and cervix. **Why "Many MTP procedures" is the correct answer:** Medical Termination of Pregnancy (MTP) procedures, whether medical or surgical (suction evacuation), involve the cervix and the uterine cavity but do not involve the stretching or tearing of the primary pelvic supports (endopelvic fascia). Therefore, multiple MTPs do not contribute to the mechanical failure of the pelvic floor and are not a risk factor for prolapse. **Analysis of incorrect options:** * **Chronic cough:** This causes a repetitive, long-term increase in **intra-abdominal pressure**. This pressure is transmitted to the pelvic floor, eventually leading to the attenuation and herniation of pelvic organs. * **Menopause:** Estrogen is vital for maintaining the collagen content and strength of the pelvic ligaments. The **hypoestrogenic state** in menopause leads to atrophy and weakening of the pelvic diaphragm and ligaments (Urogenital atrophy). * **Delivery of a big baby:** Vaginal delivery of a macrosomic baby causes significant overstretching, nerve damage (pudendal nerve), and direct trauma to the **Levator ani muscles** and the cardinal/uterosacral ligament complex. **High-Yield Clinical Pearls for NEET-PG:** * **Most important support of the uterus:** Cardinal (Mackenrodt’s) ligaments. * **Main muscular support:** Levator ani muscle (specifically the Pubococcygeus). * **Nulliparous prolapse:** Usually occurs due to congenital weakness of connective tissue (e.g., Ehlers-Danlos syndrome) or chronic increase in intra-abdominal pressure. * **POP-Q System:** The gold standard for staging pelvic organ prolapse in modern clinical practice.

Question 183: A patient presents with primary amenorrhea. On examination, she has normal breast and pubic hair development but no visible vagina. Which of the following is the most probable diagnosis?

A. Turner's syndrome
B. Androgen insensitivity syndrome
C. Mullerian agenesis (Correct Answer)
D. Swyer syndrome

Explanation: **Explanation:** The patient presents with **primary amenorrhea** despite having **normal secondary sexual characteristics** (breast and pubic hair development). This indicates a functioning hypothalamic-pituitary-ovarian axis and normal peripheral response to hormones, but a structural defect in the outflow tract. **1. Why Mullerian Agenesis (MRKH Syndrome) is correct:** In Mullerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome), the 46,XX female has normal ovaries producing estrogen (leading to **normal breast development**) and normal adrenal/ovarian androgens (leading to **normal pubic hair**). However, the Mullerian ducts fail to develop, resulting in the absence of the uterus, cervix, and the upper two-thirds of the vagina. **2. Why the other options are incorrect:** * **Turner’s Syndrome (45,XO):** Characterized by "streak ovaries." The lack of estrogen results in **absent breast development** and primary amenorrhea. * **Androgen Insensitivity Syndrome (46,XY):** While these patients have breast development (due to peripheral conversion of testosterone to estrogen), they have **absent or scanty pubic and axillary hair** because of end-organ insensitivity to androgens. * **Swyer Syndrome (46,XY pure gonadal dysgenesis):** These patients have streak gonads and lack estrogen, leading to **absent breast development**. **High-Yield Clinical Pearls for NEET-PG:** * **First investigation:** Pelvic Ultrasound (to confirm the presence/absence of the uterus). * **Gold standard investigation:** MRI. * **Karyotype:** 46,XX (distinguishes it from AIS). * **Associated anomalies:** Renal (40% - e.g., renal agenesis, ectopic kidney) and Skeletal (12% - e.g., Klippel-Feil syndrome). Always screen the renal system in these patients.

Question 184: A 34-week pregnant female presented with intense itching over the vulvar area and a white, cheesy vaginal discharge. On examination, vulvar erythema is noted. Which among the following is the causative organism in this patient?

A. Epidermophyton
B. Aspergillus
C. Candida albicans (Correct Answer)
D. Tinea

Explanation: **Explanation:** The clinical presentation of **intense vulvar itching (pruritus)** and a **thick, white, "curdy" or "cheesy" vaginal discharge** is classic for **Vulvovaginal Candidiasis (VVC)**. In this case, the patient’s pregnancy (34 weeks) is a significant predisposing factor. High estrogen levels during pregnancy increase the glycogen content of the vaginal mucosa, providing an ideal environment for the overgrowth of *Candida*. **Why Candida albicans is correct:** * **Causative Agent:** *Candida albicans* is responsible for 80–90% of fungal vaginal infections. * **Clinical Features:** Characterized by "cottage-cheese" like discharge, vulvar erythema, edema, and intense itching. * **Diagnosis:** On microscopy (KOH mount), it shows pseudohyphae and budding yeast cells. The vaginal pH is typically **normal (<4.5)**, which helps distinguish it from Trichomoniasis or Bacterial Vaginosis. **Why other options are incorrect:** * **Epidermophyton & Tinea:** These are dermatophytes responsible for fungal infections of the skin (like Tinea cruris/jock itch). While they cause itching in the groin, they do not cause vaginal discharge. * **Aspergillus:** This is a filamentous fungus that typically causes respiratory infections or systemic opportunistic infections; it is not a standard cause of vaginitis. **NEET-PG High-Yield Pearls:** * **Risk Factors:** Pregnancy, Diabetes Mellitus, recent antibiotic use, and immunosuppression. * **Drug of Choice (Non-pregnant):** Oral Fluconazole (150 mg single dose). * **Drug of Choice (Pregnancy):** **Topical Azoles** (e.g., Clotrimazole) for 7 days are preferred; oral fluconazole is generally avoided in pregnancy. * **Gold Standard Diagnosis:** Culture on **Sabouraud’s Dextrose Agar (SDA)**.

Question 185: Trans-Cervical Endometrial Resection (TCER) is used in which of the following conditions?

A. Endometriosis
B. Dysfunctional Uterine Bleeding (DUB) (Correct Answer)
C. Endometrial carcinoma
D. Submucous fibroid

Explanation: ### Explanation **Trans-Cervical Endometrial Resection (TCER)** is a second-generation hysteroscopic surgical procedure designed to treat heavy menstrual bleeding by removing the full thickness of the endometrium along with 2–3 mm of the underlying myometrium. **Why Option B is Correct:** TCER is primarily indicated for **Dysfunctional Uterine Bleeding (DUB)**—now clinically referred to under the PALM-COEIN classification as AUB-E (Endometrial) or AUB-O (Ovulatory)—in women who have completed their family and wish to avoid a hysterectomy. It serves as a conservative surgical alternative when medical management (like hormonal therapy or NSAIDs) fails. By resecting the basal layer of the endometrium, it induces amenorrhea or significantly reduces menstrual flow. **Why Other Options are Incorrect:** * **A. Endometriosis:** This involves endometrial-like tissue *outside* the uterus (e.g., ovaries, peritoneum). TCER only treats the uterine lining and has no role in managing ectopic implants. * **C. Endometrial Carcinoma:** Malignancy is a strict **contraindication** for TCER. Cancer requires definitive staging and treatment, usually via total hysterectomy and bilateral salpingo-oophorectomy. * **D. Submucous Fibroid:** While hysteroscopy is used to treat fibroids, the specific procedure is called **Transcervical Resection of Myoma (TCRM)** or hysteroscopic myomectomy, not TCER. **Clinical Pearls for NEET-PG:** * **Pre-requisite:** A preoperative endometrial biopsy is mandatory to rule out malignancy. * **Pre-treatment:** GnRH analogs or Danazol are often given 4 weeks prior to thin the endometrium, improving surgical visualization and outcomes. * **Complication:** The most specific risk is **TURP syndrome** (fluid overload/hyponatremia) if non-electrolytic distension media like Glycine are used. * **Gold Standard:** While TCER is effective, Hysterectomy remains the definitive treatment for AUB, but TCER has a faster recovery time.

Question 186: What is the definition of a satisfactory colposcopy?

A. Visualization of the entire transformation zone (Correct Answer)
B. Visualization of the endocervix
C. Visualization of the ectocervix
D. Visualization of the os (opening of the cervix)

Explanation: ### Explanation **Why Option A is Correct:** A colposcopy is considered **satisfactory** (or "adequate") only when the **entire transformation zone (TZ)** and the full extent of any lesion are clearly visible. The transformation zone is the area between the original squamocolumnar junction (SCJ) and the new SCJ. This is the most critical region because over 90% of cervical neoplasias (CIN) and cancers originate here. If the upper limit of the TZ or the SCJ recedes into the endocervical canal and cannot be seen, the exam is "unsatisfactory," as a high-grade lesion could be hidden from view. **Why Other Options are Incorrect:** * **Option B & C:** Visualizing the endocervix or ectocervix alone is insufficient. While both are inspected during the procedure, the definition of adequacy specifically hinges on the visibility of the junction where these two epithelial types meet (the TZ). * **Option D:** The cervical os is a landmark, but seeing it does not guarantee that the SCJ is visible, especially in postmenopausal women where the SCJ often migrates deep into the canal. **High-Yield Clinical Pearls for NEET-PG:** * **Unsatisfactory Colposcopy:** If the TZ is not fully visualized, the next step is often an **Endocervical Curettage (ECC)** or a diagnostic excisional procedure (like LEEP or Cold Knife Conization). * **Green Filter:** Used during colposcopy to highlight **vascular patterns** (punctations, mosaicism, and atypical vessels), which are markers of high-grade lesions. * **Acetic Acid (3-5%):** Causes reversible dehydration of cells; areas with high nuclear density (cancer/dysplasia) appear **Acetowhite**. * **Schiller’s Test:** Uses Lugol’s Iodine. Normal squamous cells (rich in glycogen) turn mahogany brown. **Iodine-negative** (pale) areas are suspicious.

Question 187: Metroplasty is a plastic/reconstructive surgery on which of the following organs?

A. Fallopian tube
B. Vagina
C. Uterus (Correct Answer)
D. Ovary

Explanation: **Explanation:** **Metroplasty** is a reconstructive surgical procedure performed on the **uterus** (Option C). The term is derived from the Greek words *"metra"* (uterus) and *"plassein"* (to shape). It is primarily indicated for correcting congenital structural anomalies, such as a septate uterus or a bicornuate uterus, to improve reproductive outcomes in women experiencing recurrent pregnancy loss or infertility. **Analysis of Options:** * **Fallopian tube (Option A):** Surgery to repair or reconstruct the fallopian tubes is called **Tuboplasty** or Salpingoplasty (e.g., Fimbrioplasty). * **Vagina (Option B):** Plastic surgery of the vagina is termed **Vaginoplasty** (often part of pelvic floor repair or gender affirmation surgery). * **Ovary (Option D):** Surgical procedures on the ovary include Oophorectomy (removal) or Ovarian Cystectomy. There is no standard "metroplasty" equivalent for the ovary. **Clinical Pearls for NEET-PG:** * **Strassman Operation:** A classic metroplasty technique used specifically for **bicornuate uteri** (unification of two horns). * **Jones and Tompkins Metroplasty:** Historically used for **septate uteri**, though these have largely been replaced by **Hysteroscopic Septal Resection**, which is now the gold standard due to its minimally invasive nature. * **Indication:** Metroplasty is generally not indicated for arcuate or unicornuate uteri; it is most beneficial for the **septate uterus** to reduce the risk of second-trimester miscarriages.

Question 188: Which of the following can cause urinary retention in obstetrics and gynecology?

A. Impacted ovarian tumor
B. Retroversion
C. Hematocolpos
D. All of the above (Correct Answer)

Explanation: **Explanation:** Urinary retention in gynecology and obstetrics is primarily caused by **mechanical compression** or **displacement of the urethra and bladder neck**. This occurs when a pelvic mass fills the Pouch of Douglas (POD) and pushes the cervix anteriorly against the pubic symphysis, thereby elongating and compressing the urethra. * **Impacted Ovarian Tumor:** A large or dermoid cyst incarcerated in the Pouch of Douglas can exert direct pressure on the bladder neck or displace the cervix forward, leading to acute urinary retention. * **Retroversion (Incarcerated Gravid Uterus):** This is a classic high-yield cause. Between 12–16 weeks of gestation, a retroverted uterus may fail to rise into the abdominal cavity. As it enlarges, the cervix moves anteriorly, compressing the urethra against the back of the pubic bone. * **Hematocolpos:** In cases of imperforate hymen, the accumulation of menstrual blood (hematocolpos) causes the vagina to distend significantly. This distended vaginal wall exerts extrinsic pressure on the urethra, leading to retention (often the presenting symptom in adolescent girls). **Clinical Pearls for NEET-PG:** * **Most common cause of retention in pregnancy:** Incarcerated gravid uterus (typically occurs at 14 weeks). * **Red-flag symptom:** "Paradoxical incontinence" or "Overflow incontinence" where the patient leaks small amounts of urine despite a full bladder. * **Other causes to remember:** Fibroids (especially cervical or posterior wall), pelvic abscess, and postoperative pain/nerve injury (e.g., after radical hysterectomy).

Question 189: A 30-year-old woman, para two, with two live children, has experienced menorrhagia for 2 years. She underwent tubal ligation 4 years ago. Investigations reveal a 2cm x 2cm submucous myoma. What is the best management option for her?

A. Total abdominal hysterectomy (Correct Answer)
B. Danazol 400mg twice daily for 3 months
C. GnRH analogues
D. Hysteroscopic myomectomy

Explanation: ### Explanation The patient is a 30-year-old multiparous woman (P2L2) who has completed her family, as evidenced by her previous tubal ligation. She presents with symptomatic menorrhagia caused by a **submucous myoma**. **1. Why Total Abdominal Hysterectomy (TAH) is the correct answer:** In clinical practice and NEET-PG scenarios, the management of leiomyoma depends on the patient's age, parity, and desire for future fertility. While a 2cm submucous myoma is technically amenable to hysteroscopic resection, this patient has **completed her family** and is suffering from chronic symptoms (2 years). In a multiparous woman with no desire for further children, **Hysterectomy** is considered the **definitive treatment**. It eliminates the risk of recurrence and provides a permanent cure for her menorrhagia. **2. Why the other options are incorrect:** * **Hysteroscopic Myomectomy (Option D):** This is the gold standard for women wishing to **preserve fertility** or the uterus. However, in a multiparous woman who has already undergone tubal ligation, a definitive procedure like hysterectomy is often preferred to avoid the risk of new fibroids developing later. * **Danazol (Option B) & GnRH analogues (Option C):** These are medical therapies used primarily to shrink fibroids pre-operatively or to manage symptoms temporarily. They are not definitive treatments; once the medication is stopped, the fibroid often regrows, and symptoms return. **Clinical Pearls for NEET-PG:** * **Submucous Myoma:** The most common type of fibroid to cause heavy menstrual bleeding (menorrhagia) due to increased endometrial surface area and interference with uterine contractions. * **FIGO Classification:** Submucous myomas are classified as Type 0 (pedunculated), Type 1 (<50% intramural), and Type 2 (≥50% intramural). * **Management Rule:** * Desires pregnancy $\rightarrow$ Myomectomy. * Completed family/Near menopause $\rightarrow$ Hysterectomy. * **Medical Management:** Primarily used as a bridge to surgery to correct anemia or reduce tumor volume.

Question 190: A 17-year-old unmarried girl presents with fever, nausea, vomiting, pallor, and pain abdomen. She is having foul-smelling, blood-stained discharge per vaginum. What is your most likely diagnosis?

A. Twisted ovarian cyst
B. Typhoid with enteric perforation
C. Pelvic abscess with septic peritonitis (Correct Answer)
D. Ruptured ectopic pregnancy

Explanation: ### Explanation The clinical presentation of fever, nausea, vomiting, and abdominal pain indicates an acute inflammatory or infectious process. The pathognomonic finding in this case is the **foul-smelling, blood-stained vaginal discharge**, which strongly suggests a pelvic infection (likely Pelvic Inflammatory Disease or a septic abortion/instrumentation) that has progressed to a **Pelvic abscess with septic peritonitis**. The presence of pallor and systemic symptoms suggests sepsis or severe inflammation. #### Why the other options are incorrect: * **Twisted ovarian cyst:** While this causes acute abdominal pain and vomiting, it is typically an aseptic process. Fever and foul-smelling vaginal discharge are not characteristic features unless secondary infection occurs (rare). * **Typhoid with enteric perforation:** This presents with fever and abdominal pain, but it would not explain the gynecological symptom of foul-smelling vaginal discharge. * **Ruptured ectopic pregnancy:** This is a major differential for acute abdomen and pallor (due to hemoperitoneum). However, it usually presents with amenorrhea and a positive pregnancy test. While it causes vaginal bleeding, the discharge is not typically foul-smelling or associated with high-grade fever unless secondarily infected. #### Clinical Pearls for NEET-PG: * **Triad of Pelvic Abscess:** Fever, pelvic pain, and a palpable, tender adnexal mass. * **Vaginal Discharge Clues:** Foul-smelling discharge in an acute abdomen context almost always points toward an infectious gynecological etiology (PID/Sepsis). * **Management:** The gold standard for diagnosing a pelvic abscess is a Transvaginal Ultrasound (TVS). Treatment involves broad-spectrum antibiotics and, if necessary, surgical or ultrasound-guided drainage. * **Septic Peritonitis:** Suspect this when a patient with localized pelvic symptoms develops generalized abdominal rigidity, rebound tenderness, and systemic signs of sepsis (tachycardia, hypotension).

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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