Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 261: Which surgical procedure is associated with the highest incidence of ureteric injury?

A. Abdominal hysterectomy
B. Vaginal hysterectomy
C. Wertheim's hysterectomy (Correct Answer)
D. Adnexectomy

Explanation: **Explanation:** The ureter is one of the most vulnerable structures in pelvic surgery due to its close anatomical proximity to the uterus and its blood supply. **Why Wertheim’s Hysterectomy is the Correct Answer:** Wertheim’s (Radical) Hysterectomy, performed for cervical cancer, carries the highest risk of ureteric injury (up to 2-5%). This is because the procedure requires extensive dissection of the **"Ureteric Tunnel"** (within the cardinal ligament) to mobilize the ureter away from the cervix and upper vagina. The risk is twofold: direct mechanical trauma (crushing or cutting) and **ischemic injury** caused by the stripping of the ureteric sheath, which compromises its delicate blood supply. **Analysis of Incorrect Options:** * **Abdominal Hysterectomy:** While this is the most common procedure associated with ureteric injury in absolute numbers (due to the high volume of surgeries performed), the *incidence rate* per procedure is lower than in radical surgery. * **Vaginal Hysterectomy:** The risk is generally lower as the ureters are displaced laterally during the descent of the uterus, though injury can occur during the clamping of the uterine arteries. * **Adnexectomy:** Injury typically occurs at the pelvic brim during the ligation of the **Infundibulopelvic ligament**, but the overall incidence is lower than in radical hysterectomy. **NEET-PG High-Yield Pearls:** * **Most common site of injury:** At the level of the **Ischial spine**, where the ureter passes under the uterine artery ("Water under the bridge"). * **Most common cause of ureteric fistula:** Ischemic necrosis following radical surgery (usually presents 7-14 days post-op). * **Gold standard for diagnosis:** Intravenous Pyelogram (IVP) or CT Urogram. * **Prevention:** Intraoperative identification and visualization of the ureter are the best ways to prevent injury.

Question 262: What is the most common cause of hematocolpos?

A. Cervical atresia
B. Vaginal atresia
C. Transverse vaginal septum
D. Imperforate hymen (Correct Answer)

Explanation: **Explanation:** **Hematocolpos** refers to the accumulation of menstrual blood within the vagina, typically occurring after menarche due to an anatomical obstruction in the female genital tract. **Why Imperforate Hymen is Correct:** The **imperforate hymen** is the most common obstructive anomaly of the female genital tract. It results from the failure of the central part of the hymen to canalize during fetal development. At puberty, menstrual blood cannot escape, leading to vaginal distension (hematocolpos). If left untreated, the backup of blood can extend to the uterus (hematometra) and fallopian tubes (hematosalpinx). **Analysis of Incorrect Options:** * **Cervical atresia:** This is a rare congenital anomaly where the cervix fails to develop. While it causes hematometra (blood in the uterus), it does not typically cause hematocolpos because the vagina remains empty. * **Vaginal atresia:** This involves the failure of the lower portion of the vagina to develop. While it can cause hematocolpos in the upper vaginal segment, it is significantly less common than an imperforate hymen. * **Transverse vaginal septum:** This occurs due to a failure of fusion or canalization between the urogenital sinus and Müllerian ducts. While it is a recognized cause of outflow obstruction, its incidence is lower than that of an imperforate hymen. **Clinical Pearls for NEET-PG:** * **Classic Presentation:** A pubertal girl presenting with **primary amenorrhea** and **cyclic pelvic pain**. * **Physical Exam:** A bulging, **bluish membrane** at the introitus (due to the underlying dark blood). * **Rectal Exam:** A palpable, tense cystic mass in the vagina. * **Treatment:** Cruciate incision or hymenotomy to drain the accumulated blood.

Question 263: What hormonal change is seen in dysfunctional uterine bleeding (DUB)?

A. Increased estrogen (Correct Answer)
B. Decreased progesterone receptors
C. Decreased estrogen receptors
D. Pituitary imbalance of hormones

Explanation: **Explanation:** **Dysfunctional Uterine Bleeding (DUB)**, now more commonly classified under the **PALM-COEIN** criteria as AUB-O (Ovulatory Dysfunction), is most frequently caused by **anovulation**. **Why Option A is Correct:** In an anovulatory cycle, a corpus luteum is not formed, leading to a **deficiency of progesterone**. In the absence of progesterone to counteract it, there is **unopposed estrogen** action on the endometrium. This leads to continuous endometrial proliferation. Eventually, the endometrium outgrows its blood supply or lacks structural support, leading to asynchronous breakdown and heavy, irregular bleeding (estrogen breakthrough bleeding). Therefore, a relative or absolute **increase in estrogen** (unopposed) is the hallmark. **Why Other Options are Incorrect:** * **B & C:** DUB is primarily a hormonal signaling issue rather than a primary pathology of receptor density. While receptors fluctuate during the cycle, the clinical manifestation of DUB is driven by the hormonal milieu (estrogen/progesterone ratio) rather than a decrease in receptors. * **D:** While the HPO (Hypothalamic-Pituitary-Ovarian) axis is involved, "Pituitary imbalance" is too vague. The specific pathophysiology is the failure of the LH surge and subsequent lack of progesterone, not a generalized pituitary disorder. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of DUB:** Anovulation (90% of cases). * **Age Distribution:** Most common at extremes of reproductive life (Adolescence and Perimenopause). * **Histology:** The classic finding in DUB is **Endometrial Hyperplasia** or a proliferative endometrium during the secretory phase of the cycle. * **Treatment of Choice:** For acute heavy bleeding, high-dose estrogen or OCPs; for long-term management, **Levonorgestrel-releasing Intrauterine System (LNG-IUS)** is the gold standard.

Question 264: What is the least common complication of uterine fibroids?

A. Menstrual disorder
B. Malignancy (Correct Answer)
C. Urinary retention
D. Degeneration

Explanation: **Explanation:** Uterine fibroids (leiomyomas) are the most common benign tumors of the female reproductive tract. While they are associated with several complications, **malignant transformation** (leiomyosarcoma) is the **least common**, occurring in less than **0.1% to 0.5%** of cases. Most leiomyosarcomas are thought to arise *de novo* rather than from pre-existing benign fibroids. **Analysis of Options:** * **A. Menstrual Disorders:** This is the **most common** presentation. Intramural and submucosal fibroids increase the uterine surface area and vascularity, leading to menorrhagia (heavy menstrual bleeding). * **C. Urinary Retention:** Large anterior or fundal fibroids can exert pressure on the bladder or urethra, causing frequency, urgency, or acute urinary retention (especially if the fibroid is cervical or impacted in the pouch of Douglas). * **D. Degeneration:** Fibroids frequently outgrow their blood supply, leading to various types of degeneration. **Hyaline degeneration** is the most common overall, while **Red degeneration** is a classic high-yield complication occurring during pregnancy. **Clinical Pearls for NEET-PG:** * **Most common degeneration:** Hyaline degeneration. * **Most common degeneration during pregnancy:** Red (carneous) degeneration (due to venous thrombosis). * **Degeneration after menopause:** Calcific degeneration. * **Sarcomatous change:** Suspect if there is rapid increase in size, especially in postmenopausal women. * **Most common site for fibroids:** Intramural (within the myometrium).

Question 265: During laparoscopy, what is the preferred site for obtaining cultures in a patient with acute pelvic inflammatory disease (PID)?

A. Endocervix
B. Endometrium
C. Pouch of Douglas
D. Fallopian tubes (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Fallopian tubes** **1. Why Fallopian Tubes are the Preferred Site:** Acute Pelvic Inflammatory Disease (PID) is an ascending infection that progresses from the lower genital tract to the upper genital tract. While the initial infection often begins in the cervix, the definitive site of active infection and tissue damage in PID is the **fallopian tubes (salpingitis)**. During laparoscopy—which is the **gold standard** for the diagnosis of PID—obtaining exudate or fimbrial biopsies directly from the fallopian tubes provides the most accurate microbiological profile. Cultures from this site have the highest correlation with the actual causative pathogens (such as *Neisseria gonorrhoeae* and *Chlamydia trachomatis*) and avoid contamination from the normal vaginal flora. **2. Analysis of Incorrect Options:** * **A. Endocervix:** While cervical swabs are the most common *initial* screening tool, they often do not reflect the true pathogens present in the upper tract. Up to 30-40% of patients with PID have different organisms in the tubes compared to the cervix. * **B. Endometrium:** Endometrial cultures (obtained via biopsy) are more specific than cervical swabs but are still prone to contamination from vaginal flora during the procedure. * **C. Pouch of Douglas (POD):** While fluid may collect here, it is often reactive or contains a mix of organisms. The fallopian tube remains the primary focus of the disease process. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Laparoscopy (visualizing tubal erythema, edema, and purulent exudate). * **Most Common Organisms:** *Chlamydia trachomatis* (most common overall) and *Neisseria gonorrhoeae*. * **Chandler’s Sign:** Adnexal tenderness and Cervical Motion Tenderness (CMT) on bimanual examination. * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving peri-hepatitis ("violin-string" adhesions). * **Treatment:** Must cover anaerobes, Gram-negatives, and Chlamydia (e.g., Ceftriaxone + Doxycycline + Metronidazole).

Question 266: A pregnant female at 16 weeks of gestation presents with bleeding. Ultrasound reveals a fibroid. What is the most appropriate management?

A. Conservative management (Correct Answer)
B. Laparoscopic myomectomy
C. Curettage
D. Hysterectomy

Explanation: **Explanation:** The correct management for a fibroid diagnosed during pregnancy is **Conservative Management (Option A)**. **Why it is correct:** Most fibroids are asymptomatic during pregnancy and do not require intervention. Surgical removal of a fibroid (myomectomy) during pregnancy is strictly contraindicated due to the high risk of profuse hemorrhage from the increased pelvic vascularity and the significant risk of miscarriage or preterm labor. If a patient experiences pain (often due to **Red Degeneration**), the standard of care is bed rest, hydration, and analgesics (NSAIDs like Ibuprofen, though avoided near term). **Why other options are incorrect:** * **Laparoscopic myomectomy (Option B):** Myomectomy is generally deferred until 3–6 months postpartum. Surgery during pregnancy is only considered in extreme, rare cases of pedunculated fibroid torsion that fails to respond to conservative treatment. * **Curettage (Option C):** This is a procedure to remove the uterine lining or products of conception; it has no role in the management of a fibroid and would lead to pregnancy loss. * **Hysterectomy (Option D):** This is an invasive, definitive surgery that results in the loss of the fetus and future fertility. It is only a last resort for life-threatening postpartum hemorrhage. **NEET-PG High-Yield Pearls:** * **Most common change** in fibroid during pregnancy: No change in size (though 20-30% may increase). * **Most common complication:** Red Degeneration (Necrobiosis), typically occurring in the 2nd trimester. * **Red Degeneration Diagnosis:** Clinical (pain, fever, tenderness); MRI shows a characteristic peripheral rim of high signal intensity on T1-weighted images. * **Mode of delivery:** Fibroids are not an absolute indication for C-section unless they are large, lower-segment fibroids obstructing the birth canal (Previa fibroid).

Question 267: Repeated curettage is most likely to lead to which of the following conditions?

A. Fibroids
B. Sheehan's syndrome
C. Endometrial cancer
D. Asherman's syndrome (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Asherman's syndrome** **Why it is correct:** Asherman’s syndrome refers to the formation of intrauterine adhesions (synechiae). The endometrium consists of two layers: the *stratum functionalis* (which sheds during menses) and the *stratum basalis* (the regenerative layer). **Repeated or over-vigorous curettage** (especially post-abortion or postpartum) causes trauma to the **stratum basalis**. When this regenerative layer is destroyed, the opposing raw surfaces of the uterine walls heal by forming fibrous bridges. This leads to partial or complete obliteration of the uterine cavity, manifesting as secondary amenorrhea, hypomenorrhea, or infertility. **Why the other options are incorrect:** * **A. Fibroids:** These are benign monoclonal tumors of the uterine smooth muscle (myometrium). Their etiology is linked to genetics and estrogen/progesterone levels, not mechanical trauma from curettage. * **B. Sheehan's syndrome:** This is postpartum pituitary necrosis caused by severe obstetric hemorrhage and hypotension. It is a vascular/endocrine complication, not a result of local uterine trauma. * **C. Endometrial cancer:** This is primarily associated with prolonged unopposed estrogen exposure, obesity, and nulliparity. Curettage is actually a diagnostic tool for this condition, not a causative factor. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation:** Hysteroscopy (allows for both diagnosis and grading of adhesions). * **Hysterosalpingography (HSG) finding:** Characterized by "filling defects" within the uterine cavity. * **Most common cause:** Post-traumatic (D&C for missed abortion or secondary PPH). In developing countries, **Genital Tuberculosis** is another significant cause of intrauterine adhesions. * **Treatment:** Hysteroscopic adhesiolysis followed by the placement of an IUCD or Foley’s catheter and estrogen therapy to promote endometrial regrowth.

Question 268: What is the commonest cause of pelvic inflammatory disease?

A. Tuberculosis
B. Urinary tract infection
C. Fungal infection
D. Copper-T (Intrauterine device) (Correct Answer)

Explanation: **Explanation:** Pelvic Inflammatory Disease (PID) is an ascending infection of the upper female genital tract. While the majority of PID cases are sexually transmitted (caused by *Chlamydia trachomatis* and *Neisseria gonorrhoeae*), among the options provided, the **Copper-T (Intrauterine Device)** is the most significant risk factor and common cause associated with the introduction of pathogens into the uterine cavity. **Why Copper-T is the correct answer:** The insertion of an IUD (like Copper-T) carries a transiently increased risk of PID, particularly within the first **20 days post-insertion**. The process of insertion can carry vaginal or cervical bacteria into the sterile endometrial cavity. Additionally, the "wicking" effect of the IUD strings can facilitate the ascent of bacteria, making it a high-yield clinical cause in exam scenarios. **Analysis of Incorrect Options:** * **A. Tuberculosis:** While Genital TB is a common cause of chronic PID and infertility in developing countries like India, it is not the *most* common cause overall. It usually presents as a secondary infection from a primary pulmonary focus. * **B. Urinary Tract Infection (UTI):** UTIs involve the renal system (bladder/urethra). While anatomically close, they do not typically cause PID unless there is a rare fistulous communication. * **C. Fungal Infection:** Vaginal candidiasis is common but is usually limited to the lower genital tract (vagina/vulva) and rarely ascends to cause systemic PID. **High-Yield Clinical Pearls for NEET-PG:** * **Most common organism overall:** *Chlamydia trachomatis* (followed by *N. gonorrhoeae*). * **Most common symptom:** Lower abdominal pain (Dull aching). * **Gold Standard Investigation:** Laparoscopy (shows "violin-string" adhesions in Fitz-Hugh-Curtis Syndrome). * **IUD and PID:** If PID occurs with an IUD in situ, the IUD does not necessarily need removal unless symptoms fail to improve after 48–72 hours of antibiotics.

Question 269: Characteristic features of Rokitanski-Kuster Hauser syndrome are all of the following except?

A. Absent uterus
B. Absent vagina
C. Anovulation (Correct Answer)
D. 46-XX karyotype

Explanation: **Explanation:** **Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome** is a congenital anomaly characterized by the failure of the Müllerian ducts to develop. **Why "Anovulation" is the correct answer (the exception):** In MRKH syndrome, the defect is purely anatomical (Müllerian agenesis). The **ovaries** develop from the primitive germ cells and are not derived from the Müllerian ducts. Therefore, ovarian function remains completely intact. Patients have normal follicular development, regular ovulation, and normal female levels of estrogen and progesterone. Hence, "Anovulation" is incorrect as these patients ovulate normally. **Analysis of incorrect options:** * **Absent uterus & Absent vagina:** Since the Müllerian ducts normally form the fallopian tubes, uterus, cervix, and the upper two-thirds of the vagina, their agenesis leads to an absent or rudimentary uterus and a blind-ending or absent vaginal pouch. * **46-XX karyotype:** These patients are genetically female with a normal 46-XX constitution. They exhibit normal secondary sexual characteristics (breast development and pubic hair) because their ovaries function normally. **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** Most common cause of primary amenorrhea after Turner Syndrome. Typically presents as primary amenorrhea in a young girl with normal secondary sexual characteristics. * **Associated Anomalies:** 30–40% have **Renal anomalies** (e.g., renal agenesis, ectopic kidney) and 10–15% have **Skeletal anomalies** (e.g., Klippel-Feil syndrome). * **Diagnosis:** Gold standard is MRI to visualize pelvic structures; Ultrasound is the initial screening tool. * **Treatment:** Non-surgical (Frank’s dilators) or surgical (McIndoe vaginoplasty) creation of a neovagina. Reproductive options include surrogacy (as they have functional ovaries).

Question 270: The rise in the incidence of ectopic pregnancy is related to all, except?

A. Increase in STD
B. ART techniques
C. Combined oral contraceptive pills (Correct Answer)
D. Tubal reconstructive surgery

Explanation: **Explanation:** The incidence of ectopic pregnancy has risen globally due to factors that cause tubal damage or involve artificial manipulation of the reproductive tract. **Why Combined Oral Contraceptive Pills (COCPs) are the correct answer:** COCPs work primarily by inhibiting ovulation, thickening cervical mucus, and altering the endometrium. They are highly effective contraceptives. Because they prevent ovulation, they **reduce the absolute risk** of both intrauterine and ectopic pregnancies. If a woman conceives while taking COCPs, the pregnancy is more likely to be intrauterine. In contrast, Progesterone-Only Pills (POPs) and Levonorgestrel-IUCDs, if they fail, carry a higher relative risk of the pregnancy being ectopic due to slowed tubal motility. **Analysis of Incorrect Options:** * **Increase in STDs:** Pelvic Inflammatory Disease (PID), often caused by *Chlamydia trachomatis* or *Neisseria gonorrhoeae*, leads to tubal scarring, loss of ciliary function, and adhesions, which are the leading causes of ectopic pregnancy. * **ART Techniques:** Assisted Reproductive Technologies (e.g., IVF) increase the risk due to multiple embryo transfers, high hormonal levels affecting tubal motility, and the retrograde migration of embryos into the tubes. * **Tubal Reconstructive Surgery:** Any surgery on the fallopian tubes (e.g., tuboplasty or reversal of tubal ligation) creates anatomical distortions or luminal narrowing that predisposes to ectopic implantation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ampulla (70%). * **Most common risk factor:** Previous history of PID. * **Highest relative risk:** Previous history of ectopic pregnancy. * **Contraceptive paradox:** While IUCDs provide excellent protection against pregnancy, if a failure occurs, the *proportion* of ectopic pregnancies is higher compared to non-users. However, COCPs remain protective against both.

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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