Gynecological Disorders — MCQs
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What is the treatment of choice for perimenopausal adenomyosis?
A 32-year-old asymptomatic woman has a Pap's smear report of ASCUS. What are the possible management options, excluding one?
A 40-year-old primiparous woman with suspected endometriosis is undergoing diagnostic laparoscopy. Findings include a normal uterus, chocolate cysts in both ovaries, endometriotic deposits on the right round ligament, both fallopian tubes, and the pouch of Douglas, with moderately dense adhesions between the fallopian tubes and the pouch of Douglas. What is the treatment of choice in this case?
Cervical incompetence is when the cervix measures less than?
What is the first investigation to be done for postmenopausal bleeding?
What is the best way to treat a decubitus ulcer in a case of genital prolapse?
Which drug reduces the size of uterine myoma?
A woman diagnosed with Trichomoniasis should also be evaluated for which of the following?
Acute pyelonephritis in pregnancy most often complicates which trimester?
What is the best treatment for senile vaginitis?
Gynecological Disorders Indian Medical PG Practice Questions and MCQs
Question 191: What is the treatment of choice for perimenopausal adenomyosis?
- A. Oral contraceptive pills (OCP)
- B. Levonorgestrel-releasing intrauterine contraceptive device (LNG IUCD)
- C. Gonadotropin-releasing hormone (GnRH) agonists
- D. Hysterectomy (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Hysterectomy** **Why Hysterectomy is the Treatment of Choice:** Adenomyosis is a condition characterized by the presence of endometrial glands and stroma within the myometrium, leading to a diffusely enlarged "globular" uterus. While medical management can alleviate symptoms, **hysterectomy remains the only definitive (curative) treatment**. In a **perimenopausal** woman, the priority is often permanent relief from symptoms like menorrhagia and dysmenorrhea. Since she is nearing the end of her reproductive years and likely has completed her family, hysterectomy is preferred over long-term medical therapy or conservative surgery. **Analysis of Incorrect Options:** * **A. Oral Contraceptive Pills (OCP):** These provide symptomatic relief by suppressing the endometrium but do not treat the underlying myometrial pathology. They are considered first-line medical management for younger patients desiring contraception, not the "treatment of choice" for perimenopausal women. * **B. LNG IUCD (Mirena):** This is highly effective for reducing menstrual blood loss and is the **best medical/conservative management**. However, it is not curative, and high expulsion rates are noted in adenomyotic (enlarged) uteri. * **C. GnRH Agonists:** These induce a hypoestrogenic state and shrink the uterus. However, they are used only as a **short-term bridge** to surgery or to induce menopause, as prolonged use leads to bone mineral density loss. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Secondary dysmenorrhea, menorrhagia, and a symmetrically enlarged, "globular," soft/boggy uterus (usually not exceeding 12–14 weeks size). * **Investigation of Choice:** **MRI** is the gold standard (shows a thickened junctional zone >12 mm). TVS is the first-line investigation. * **Pathology:** "Halban’s sign" (tender uterus during premenstrual phase). * **Definitive Diagnosis:** Histopathological examination (HPE) after hysterectomy.
Question 192: A 32-year-old asymptomatic woman has a Pap's smear report of ASCUS. What are the possible management options, excluding one?
- A. High-risk HPV DNA testing
- B. Repeat cytology at 1 year
- C. Colposcopy
- D. Repeat cytology at 3 years (Correct Answer)
Explanation: **Explanation:** The management of **ASCUS (Atypical Squamous Cells of Undetermined Significance)** follows the ASCCP (American Society for Colposcopy and Cervical Pathology) guidelines. ASCUS is the most common abnormal Pap result, representing a borderline finding that requires further triage rather than immediate aggressive treatment or routine screening. **Why Option D is the Correct Answer (The Exception):** Routine screening (cytology every 3 years) is only appropriate for women with **normal** results. Once an abnormality like ASCUS is detected, the patient enters a "triage" or "surveillance" pathway. Extending the interval to 3 years is unsafe as it may miss a progressing CIN (Cervical Intraepithelial Neoplasia) lesion. **Analysis of Management Options (Incorrect Options):** * **A. High-risk HPV DNA testing:** This is the **preferred** management (Reflex HPV testing). If HPV is positive, the patient proceeds to colposcopy; if negative, she returns to routine screening. * **B. Repeat cytology at 1 year:** This is an acceptable alternative if HPV testing is unavailable. If the repeat Pap at 12 months is $\ge$ ASCUS, colposcopy is indicated. * **C. Colposcopy:** This is indicated if the reflex HPV test is positive or if the repeat cytology shows persistent abnormalities. **High-Yield Clinical Pearls for NEET-PG:** * **ASCUS Triage:** "Reflex HPV testing" is the most cost-effective and efficient strategy. * **Age Factor:** In women aged 21–24, the preferred management for ASCUS is **repeat cytology at 12 months** (not HPV testing), as HPV prevalence is high but often transient in this age group. * **Pregnancy:** Management of ASCUS in pregnancy is the same as in non-pregnant women, though endocervical curettage (ECC) is strictly contraindicated.
Question 193: A 40-year-old primiparous woman with suspected endometriosis is undergoing diagnostic laparoscopy. Findings include a normal uterus, chocolate cysts in both ovaries, endometriotic deposits on the right round ligament, both fallopian tubes, and the pouch of Douglas, with moderately dense adhesions between the fallopian tubes and the pouch of Douglas. What is the treatment of choice in this case?
- A. Total hysterectomy with bilateral salpingo-oophorectomy
- B. Danazol therapy
- C. Progesterone therapy
- D. Fulguration of endometriotic deposits (Correct Answer)
Explanation: ### Explanation **Correct Answer: D. Fulguration of endometriotic deposits** **Underlying Medical Concept:** The management of endometriosis is individualized based on the patient's age, symptoms, and desire for future fertility. In this 40-year-old primiparous woman, the findings (chocolate cysts, deposits, and adhesions) indicate **Stage III (Moderate) to Stage IV (Severe) endometriosis** according to the rASRM classification. For symptomatic patients undergoing diagnostic laparoscopy, the "see and treat" approach is the gold standard. **Laparoscopic conservative surgery**—which includes fulguration (cauterization) of deposits, cystectomy for endometriomas, and adhesiolysis—is the treatment of choice. It aims to restore pelvic anatomy and remove ectopic endometrial tissue while preserving ovarian function and the uterus. **Why Incorrect Options are Wrong:** * **A. Total hysterectomy with bilateral salpingo-oophorectomy:** This is "definitive surgery." It is reserved for women who have completed their family, have severe debilitating symptoms, and have failed conservative medical or surgical therapies. At 40, preserving the uterus and ovaries is preferred unless symptoms are refractory. * **B & C. Danazol and Progesterone therapy:** These are medical management options. While they suppress symptoms by inducing a pseudomenopausal or pseudopregnant state, they **cannot** resolve anatomical distortions like "moderately dense adhesions" or large chocolate cysts. Surgery is superior for treating existing structural pathology found during laparoscopy. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Laparoscopy with biopsy (visualizing "powder-burn" or "gunshot" lesions). * **Staging:** Based on the **rASRM (Revised American Society for Reproductive Medicine)** score, which considers the size of deposits and the severity of adhesions. * **Drug of Choice (Medical):** Combined Oral Contraceptive Pills (COCPs) or Progestins (e.g., Dienogest) are first-line; GnRH agonists are highly effective but limited by side effects. * **Infertility:** In endometriosis-associated infertility, surgical ablation/excision is more effective than medical management.
Question 194: Cervical incompetence is when the cervix measures less than?
- A. 1 cm
- B. 1.5 cm
- C. 2 cm
- D. 2.5 cm (Correct Answer)
Explanation: **Explanation:** Cervical incompetence (or cervical insufficiency) is the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions. The diagnosis is primarily based on a history of painless second-trimester miscarriages or via Transvaginal Ultrasound (TVS). **Why 2.5 cm is the correct answer:** In clinical practice and according to standard guidelines (ACOG/RCOG), a cervical length of **less than 2.5 cm (25 mm)** before 24 weeks of gestation is the established threshold for diagnosing a "short cervix." This measurement is a significant predictor of preterm birth, as a shorter cervix lacks the structural integrity to support the growing fetus and increasing intrauterine pressure. **Analysis of Incorrect Options:** * **A (1 cm) and B (1.5 cm):** While these measurements definitely indicate cervical shortening, they represent extreme cases. Waiting for the cervix to reach 1 cm or 1.5 cm before diagnosing incompetence would delay critical interventions like cerclage, increasing the risk of imminent pregnancy loss. * **C (2 cm):** Although 2 cm is clinically concerning, the standardized diagnostic cutoff for intervention and risk assessment in asymptomatic high-risk women is 2.5 cm. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) is superior to transabdominal ultrasound for measuring cervical length. * **The "Funneling" Sign:** This refers to the protrusion of amniotic membranes into the internal os, often taking a 'T, Y, V, or U' shape (Mnemonic: **TRUST** - **T**hinning, **R**eaching **U** **S**haped **T**erminal). * **Treatment:** The definitive management is **Cervical Cerclage** (e.g., McDonald’s or Shirodkar’s technique), typically performed between 14–18 weeks of gestation. * **Best Time for Screening:** In women with a history of preterm birth, cervical length is monitored between 16 and 24 weeks.
Question 195: What is the first investigation to be done for postmenopausal bleeding?
- A. Endometrial biopsy (Correct Answer)
- B. Dilatation and curettage
- C. Fractional curettage
- D. Hysterosalpingography
Explanation: **Explanation:** Postmenopausal bleeding (PMB) is defined as vaginal bleeding occurring 12 months or more after the cessation of menstruation. In any case of PMB, the primary clinical objective is to **rule out endometrial carcinoma**, which is present in approximately 10% of these patients. **Why Endometrial Biopsy is the Correct Answer:** The **Endometrial Biopsy (Pipelle biopsy)** is the gold standard **first-line investigation** because it is a simple, cost-effective, office-based procedure that does not require anesthesia. It has a high sensitivity (over 90%) for detecting endometrial cancer. If the biopsy confirms malignancy, the patient proceeds directly to staging laparotomy. If the biopsy is "inadequate" or symptoms persist despite a negative biopsy, further evaluation via Transvaginal Ultrasound (TVS) or Hysteroscopy is indicated. **Analysis of Incorrect Options:** * **B. Dilatation and Curettage (D&C):** While accurate, D&C is an invasive procedure requiring general anesthesia. It is now considered a second-line investigation if an office biopsy cannot be performed or provides inconclusive results. * **C. Fractional Curettage:** This involves separate scraping of the endocervix and endometrium. While historically used to stage endometrial cancer (distinguishing Stage I from Stage II), it is not the initial diagnostic step. * **D. Hysterosalpingography:** This is used to evaluate tubal patency in infertility and has no role in the diagnostic workup of postmenopausal bleeding. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of PMB:** Senile/Atrophic vaginitis (followed by endometrial atrophy). * **Most common precursor to cancer:** Endometrial hyperplasia with atypia. * **TVS Cut-off:** In a postmenopausal woman, an **endometrial thickness (ET) ≤ 4 mm** has a high negative predictive value for malignancy. If ET > 4 mm, a biopsy is mandatory. * **Gold Standard for focal lesions:** Hysteroscopy-guided biopsy is superior to blind D&C for detecting polyps or focal growths.
Question 196: What is the best way to treat a decubitus ulcer in a case of genital prolapse?
- A. Bed rest
- B. Antibiotics
- C. Antiseptic dressing
- D. Reduction with tampon (Correct Answer)
Explanation: **Explanation:** A **decubitus ulcer** in genital prolapse is a pressure necrosis caused by venous congestion. When the uterus remains outside the introitus, the dependent position leads to impaired venous drainage and edema. The everted vaginal mucosa rubs against the thighs or clothing, resulting in ischemic ulceration. **Why "Reduction with tampon" is the correct answer:** The primary goal of treatment is to **relieve venous congestion**. By reducing the prolapse (pushing it back into the pelvic cavity) and holding it in place with a **glycerine-soaked gauze tampon**, the gravitational obstruction to venous return is removed. Glycerine, being hygroscopic, reduces local edema, while the reduction allows the ulcer to heal rapidly by restoring normal circulation. This is a mandatory preoperative step to ensure the vaginal tissue is healthy enough to hold sutures. **Analysis of Incorrect Options:** * **A. Bed rest:** While it reduces gravity's effect, it is insufficient to keep the prolapsed mass reduced and does not provide the necessary local decongestant effect. * **B. Antibiotics:** Decubitus ulcers are primarily **trophic/ischemic**, not infectious. Antibiotics are only required if there is secondary cellulitis. * **C. Antiseptic dressing:** Topical antiseptics do not address the underlying cause (venous congestion). Healing will not occur as long as the tissue remains prolapsed and edematous. **Clinical Pearls for NEET-PG:** * **Site:** Usually occurs on the dependent part of the prolapse (cervix or vaginal wall). * **Nature:** It is a **trophic ulcer**, not malignant. However, if it doesn't heal after reduction, a biopsy is mandatory to rule out malignancy. * **Pre-op management:** Surgery (e.g., Ward-Mayo’s) is contraindicated in the presence of an active ulcer. Reduction with glycerine tampons for 7–10 days is the standard pre-operative protocol.
Question 197: Which drug reduces the size of uterine myoma?
- A. Danazol
- B. Progesterone
- C. GnRH agonist (Correct Answer)
- D. Mifepristone
Explanation: ### Explanation **Correct Option: C. GnRH agonist** Uterine myomas (fibroids) are estrogen-dependent tumors. **GnRH agonists** (e.g., Leuprolide, Goserelin) are the most effective medical therapy for reducing fibroid volume. They work by causing initial stimulation followed by **downregulation and desensitization** of the pituitary GnRH receptors. This leads to a state of profound **hypoestrogenism** (pseudomenopause), which induces atrophy of the myometrium and fibroid tissue. Typically, they can reduce fibroid volume by 30–50% within 3 months and are primarily used preoperatively to facilitate surgery and correct anemia. **Analysis of Incorrect Options:** * **A. Danazol:** While it creates a hypoestrogenic environment, it is rarely used for fibroids due to significant androgenic side effects (weight gain, hirsutism, acne) and inferior efficacy compared to GnRH agonists. * **B. Progesterone:** Progesterone actually plays a dual role; while it can inhibit some growth, it is often considered a **mitogen** for fibroids. Progestins are used to control the associated heavy menstrual bleeding but do not reliably reduce the size of the myoma itself. * **D. Mifepristone:** This is a Selective Progesterone Receptor Modulator (SPRM). While studies show it can reduce size and symptoms, it is not the conventional "gold standard" or first-line drug for volume reduction in the context of standard PG-level exams compared to GnRH agonists. **High-Yield Clinical Pearls for NEET-PG:** * **The "Flare Effect":** GnRH agonists cause an initial surge in LH/FSH for the first 7–10 days before downregulation occurs. * **Add-back Therapy:** To prevent bone mineral density loss and vasomotor symptoms, low-dose estrogen/progesterone is added if GnRH agonist therapy exceeds 6 months. * **Regrowth:** Fibroids typically return to their original size within 4–6 months after discontinuing GnRH agonists. * **Drug of Choice for Bleeding Control:** Levonorgestrel-IUS (Mirena) is excellent for symptom control but does not significantly reduce the size of large myomas.
Question 198: A woman diagnosed with Trichomoniasis should also be evaluated for which of the following?
- A. Functional bowel dysfunction
- B. Hypertension
- C. Other venereal disease (Correct Answer)
- D. Ovarian malfunction
Explanation: **Explanation:** **Trichomoniasis**, caused by the flagellated protozoan *Trichomonas vaginalis*, is a classic **Sexually Transmitted Infection (STI)**. The fundamental medical principle here is that STIs rarely occur in isolation. Because the risk factors for acquiring one STI (unprotected intercourse, multiple partners) are identical for others, the presence of *T. vaginalis* serves as a clinical marker for high-risk sexual behavior. 1. **Why "Other venereal disease" is correct:** Patients diagnosed with Trichomoniasis have a significantly higher prevalence of co-infections. Standard clinical protocol dictates that any patient with a confirmed STI must be screened for other "venereal" (sexually transmitted) diseases, specifically **HIV, Syphilis, Gonorrhea, and Chlamydia**. Furthermore, Trichomoniasis causes local inflammation and "strawberry spots" (petechiae) on the cervix, which can increase the risk of HIV transmission and acquisition. 2. **Why other options are incorrect:** * **Functional bowel dysfunction:** There is no physiological link between a protozoal vaginal infection and IBS or other bowel motility disorders. * **Hypertension:** Trichomoniasis is a localized genitourinary infection and does not have a systemic vascular etiology. * **Ovarian malfunction:** The infection primarily affects the squamous epithelium of the vagina, cervix, and urethra; it does not impact endocrine ovarian function or ovulation. **NEET-PG High-Yield Pearls:** * **Clinical Feature:** Profuse, malodorous, **frothy yellowish-green discharge** and "Strawberry Cervix" (Colpitis Macularis). * **Diagnosis:** **Whiff test** may be positive; **Wet mount** shows motile pear-shaped flagellates; **Gold Standard** is NAAT (Nucleic Acid Amplification Test). * **Treatment:** **Metronidazole** 2g single dose (oral). **Crucial:** Always treat the partner simultaneously to prevent "ping-pong" reinfection.
Question 199: Acute pyelonephritis in pregnancy most often complicates which trimester?
- A. 1st trimester
- B. 2nd trimester (Correct Answer)
- C. 3rd trimester
- D. Puerperium
Explanation: **Explanation:** Acute pyelonephritis is the most common non-obstetric medical complication requiring hospitalization during pregnancy, occurring in approximately 1–2% of all pregnancies. **Why the 2nd Trimester is Correct:** The incidence of pyelonephritis peaks in the **second trimester** (and early third trimester). This is due to the cumulative effect of physiological changes that reach their clinical significance during this period: 1. **Progesterone effect:** High levels cause smooth muscle relaxation, leading to decreased ureteral peristalsis and "physiologic hydroureter." 2. **Mechanical Compression:** The enlarging uterus begins to compress the ureters at the pelvic brim (more common on the right side due to dextrorotation of the uterus). 3. **Stasis:** These factors lead to urinary stasis, which facilitates the ascent of bacteria (most commonly *E. coli*) from the bladder to the renal parenchyma. **Analysis of Incorrect Options:** * **1st Trimester:** While asymptomatic bacteriuria (ASB) is often established here, the mechanical obstructive factors of the uterus are not yet significant enough to cause frequent ascending infections. * **3rd Trimester:** Though the risk remains high, many cases are identified and treated earlier in the second trimester. However, if left untreated, ASB progresses to pyelonephritis in up to 30% of cases by this stage. * **Puerperium:** The risk decreases significantly after delivery as the mechanical obstruction is removed and progesterone levels plummet, though postpartum diuresis and bladder trauma can occasionally lead to UTIs. **NEET-PG High-Yield Pearls:** * **Most common organism:** *Escherichia coli* (70–80%). * **Laterality:** More common on the **Right side** (due to dextrorotation of the uterus and the protective cushioning of the left ureter by the sigmoid colon). * **Complication:** It is a leading cause of **preterm labor** and ARDS in pregnancy. * **Management:** Requires hospitalization, IV fluids, and IV antibiotics (usually Cephalosporins).
Question 200: What is the best treatment for senile vaginitis?
- A. Hormone Replacement Therapy (HRT)
- B. Local estrogen cream
- C. Hormone Replacement Therapy (HRT) + Local estrogen cream (Correct Answer)
- D. Surgery
Explanation: **Explanation:** **Senile Vaginitis** (also known as Atrophic Vaginitis) is a condition characterized by the inflammation of the vaginal epithelium due to a deficiency in estrogen, typically occurring in postmenopausal women. **Why Option C is correct:** The underlying pathophysiology is the loss of estrogenic stimulation, which leads to thinning of the vaginal mucosa, loss of glycogen, and an increase in vaginal pH (making it more alkaline). * **Local Estrogen Cream:** This is the most effective treatment for reversing local urogenital atrophy. It restores the vaginal epithelium, lowers pH, and repopulates the vagina with *Lactobacilli*. * **Systemic HRT:** While local therapy addresses the vagina, systemic HRT is often indicated to manage concurrent vasomotor symptoms (hot flashes) and to provide long-term protection against osteoporosis, which frequently coexists in this age group. The combination (Option C) ensures both immediate local relief and systemic hormonal stabilization. **Why other options are incorrect:** * **Option A (HRT alone):** While systemic HRT helps, it may take longer to achieve the same concentration of estrogen in the vaginal tissue compared to direct local application. * **Option B (Local cream alone):** This is excellent for isolated vaginal symptoms, but in the context of "best treatment" for a postmenopausal patient, it ignores systemic needs like bone health and vasomotor control. * **Option D (Surgery):** Senile vaginitis is a hormonal/medical condition; surgery has no role and may worsen symptoms due to scarring of fragile tissues. **NEET-PG High-Yield Pearls:** * **Cytology:** A vaginal smear in senile vaginitis shows a high **Maturation Index** shift to the left (predominance of **parabasal cells** and absence of superficial cells). * **pH Change:** Normal vaginal pH is 3.8–4.5; in senile vaginitis, it rises to **>5.0**. * **Clinical Sign:** Look for "petechial hemorrhages" or "strawberry spots" on a pale, friable vaginal wall. * **First-line for local symptoms:** Low-dose topical estrogen is preferred if systemic symptoms are absent.
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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