Gynecological Disorders Practice Questions

Q: A 29-year-old nulliparous woman complains of severe menorrhagia and lower abdominal pain for 3 months. On examination, there was a 14 weeks size uterus with a fundal fibroid. What is the treatment of choice?

Myomectomy. **Explanation:** The patient is a **29-year-old nulliparous woman** presenting with symptomatic uterine fibroids (menorrhagia and pain) and a significant uterine size (14 weeks). **1. Why Myomectomy is the Correct Answer:** In women of reproductive age who desire to **preserve fertility** or their uterus, **myomectomy** is the surgical treatment of choice for symptomatic fibroids. Since the patient is nulliparous and young, maintaining reproductive potential is a priority. Surgery is indicated here because the fibroid is symptomatic (menorrhagia/pain) and large (exceeding 12–14 weeks' size). **2. Why the Other Options are Incorrect:** * **GnRH Analogs:** These are typically used as **pre-operative adjuncts** to shrink the fibroid and correct anemia. They are not a definitive "treatment of choice" because the fibroids often regrow once the medication is stopped. * **Hysterectomy:** This is the definitive treatment for fibroids but is reserved for women who have **completed their family** or are post-menopausal. It is contraindicated as a first-line choice in a young nulliparous woman. * **Wait and Watch:** This is only appropriate for **asymptomatic** fibroids. This patient is symptomatic (severe menorrhagia and pain), requiring active intervention. **Clinical Pearls for NEET-PG:** * **Indications for Surgery in Fibroids:** Heavy menstrual bleeding (most common), pelvic pain, size >12–14 weeks, rapid growth, or infertility/recurrent pregnancy loss. * **Medical Management:** Tranexamic acid or NSAIDs are first-line for bleeding; GnRH agonists are used for 3–6 months pre-operatively. * **ULM (Uterine Artery Embolization):** An alternative for those who wish to avoid surgery but may negatively impact future pregnancy outcomes compared to myomectomy.

Q: All of the following are characteristic features of genitourinary tuberculosis on imaging, EXCEPT?

Multiple nodular diverticula.. **Explanation:** Genitourinary Tuberculosis (GUTB) is a major cause of infertility in developing countries. The infection typically spreads hematogenously to the fallopian tubes, which are affected in nearly 90-100% of cases. **Why "Multiple nodular diverticula" is the correct answer:** Multiple nodular diverticula (Salpingitis Isthmica Nodosa) is a condition characterized by nodular thickening of the isthmic portion of the fallopian tube with diverticula of the endosalpinx into the muscularis layer. While it causes infertility, it is primarily associated with **chronic inflammation or endometriosis**, rather than being a classic imaging hallmark of tuberculosis. **Analysis of Incorrect Options (Characteristic Features of TB):** * **Rigid, lead pipe appearance:** Chronic TB causes fibrosis and scarring of the fallopian tubes, making them lose their peristaltic ability and appear straight and rigid on Hysterosalpingography (HSG). * **Tobacco pouch appearance:** This occurs when the fimbrial end of the tube is everted and phimotic (partially occluded) due to chronic inflammation, resembling a drawstring pouch. * **Bilateral cornual blockage:** TB often causes proximal tubal occlusion due to granulomatous lesions and fibrosis at the cornual end. **Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** Endometrial biopsy/aspirate for Histopathology (showing granulomas) and GeneXpert/TB-PCR. * **HSG Findings:** Look for "Beaded tube" appearance (early stage) and "Golf hole" ureteric orifices on cystoscopy (urinary TB). * **Most common site of Female Genital TB:** Fallopian tubes (100%) > Endometrium (50%) > Ovaries (20%). * **Asherman’s Syndrome:** TB is a leading cause of secondary amenorrhea due to extensive intrauterine synechiae (Netter’s Syndrome).

Q: All of the following are associated with polycystic ovarian syndrome except?

Osteoporosis. **Explanation:** Polycystic Ovarian Syndrome (PCOS) is a multisystem endocrinopathy characterized by hyperandrogenism, ovulatory dysfunction, and metabolic disturbances. **Why Osteoporosis is the correct answer:** PCOS is characterized by a state of **hyperestrogenism** (due to peripheral conversion of androgens to estrone) and hyperinsulinemia. Estrogen is bone-protective as it inhibits osteoclast activity. Therefore, patients with PCOS typically have **normal or increased bone mineral density**, making osteoporosis an unlikely association. In contrast, osteoporosis is associated with hypoestrogenic states like menopause or Turner syndrome. **Analysis of incorrect options:** * **Endometrial Carcinoma:** Chronic anovulation leads to "unopposed estrogen" action on the endometrium without the stabilizing effect of progesterone. This causes endometrial hyperplasia, significantly increasing the risk of endometrial adenocarcinoma. * **Insulin Resistance:** This is a hallmark of PCOS (found in both obese and lean phenotypes). It leads to compensatory hyperinsulinemia, which stimulates the ovarian theca cells to produce more androgens and decreases Sex Hormone Binding Globulin (SHBG). * **Ovarian Carcinoma:** While the link is less direct than endometrial cancer, epidemiological studies show a moderately increased risk of certain types of ovarian cancer in PCOS patients, likely due to chronic low-grade inflammation and hormonal imbalances. **High-Yield Clinical Pearls for NEET-PG:** * **Rotterdam Criteria (2 of 3):** 1. Clinical/biochemical hyperandrogenism; 2. Oligo/anovulation; 3. Polycystic ovaries on USG (≥12 follicles or volume >10ml). * **LH:FSH Ratio:** Classically >2:1 or 3:1 (though no longer a diagnostic criterion). * **Metabolic Syndrome:** PCOS increases the risk of Type 2 Diabetes, Dyslipidemia, and Hypertension. * **First-line for ovulation induction:** Letrozole (Aromatase inhibitor).

Q: What is the primary mode of spread in tuberculous Pelvic Inflammatory Disease?

Spread through the bloodstream. **Explanation:** Genital tuberculosis is almost always a secondary infection, originating from a primary focus elsewhere in the body—most commonly the lungs. **1. Why the Correct Answer is Right:** The primary mode of spread for tuberculous Pelvic Inflammatory Disease (PID) is **hematogenous (bloodstream)**. Mycobacterium tuberculosis bacilli travel from the primary pulmonary focus via the blood to the fallopian tubes. The fallopian tubes are the initial site of infection in 90-100% of cases because of their high vascularity. Once established in the tubes, the infection can then spread to the endometrium (50-60%) and ovaries (20-30%). **2. Why the Other Options are Wrong:** * **Spread through continuity/adjacent organs:** While TB can spread from the peritoneum to the tubes (descending infection), this is less common than hematogenous spread. In most cases, the peritoneum is actually involved secondary to the infected tubes. * **Spread through lymphatics:** Lymphatic spread is rare and typically occurs only if there is a primary lesion in the intestinal tract (mesenteric nodes) or very rarely from an ascending infection from the vulva/vagina. **3. NEET-PG High-Yield Clinical Pearls:** * **Most common site:** Fallopian tubes (bilateral involvement is the rule). * **Most common symptom:** Infertility (due to tubal block or "Lead pipe" appearance). * **Menstrual pattern:** Most common is oligomenorrhea or amenorrhea (due to endometrial destruction/Asherman’s syndrome), though menorrhagia can occur in early stages. * **Hysterosalpingography (HSG) findings:** "Beaded tube," "Lead pipe tube," "Tobacco pouch" appearance, and "Golf hole" ostia. * **Gold Standard Diagnosis:** Endometrial biopsy/aspirate for TB-PCR or Culture (Lowenstein-Jensen medium), preferably taken in the pre-menstrual phase.

Q: Medical treatment of unruptured ectopic pregnancy is contraindicated in which of the following situations?

Fetal heart activity present. The medical management of ectopic pregnancy primarily involves the use of **Methotrexate (MTX)**, a folic acid antagonist. The success of this treatment depends on the viability and size of the trophoblastic tissue. ### **Explanation of the Correct Answer** **Option C (Fetal heart activity present)** is an absolute contraindication for medical management. The presence of cardiac activity indicates a highly viable and advanced pregnancy that is unlikely to respond to MTX. Such cases have a significantly higher risk of treatment failure and subsequent tubal rupture, necessitating surgical intervention (Laparoscopy). ### **Analysis of Incorrect Options** * **Option A (Sac size 3 cm):** Medical management is generally considered safe and effective if the gestational sac diameter is **< 3.5 cm or 4 cm**. A 3 cm sac falls within the inclusion criteria. * **Option B (HCG level 3000 IU):** While lower levels are preferred, MTX is typically indicated when the baseline serum β-hCG is **< 5000 mIU/mL**. A level of 3000 IU is acceptable for medical therapy. * **Option D (70 ml blood collection):** A small amount of free fluid in the pouch of Douglas (typically **< 100 ml**) is common and does not necessarily imply rupture. It is only a contraindication if there are signs of hemoperitoneum or hemodynamic instability. ### **NEET-PG High-Yield Pearls** * **Drug of Choice:** Methotrexate (inhibits Dihydrofolate Reductase). * **Absolute Contraindications:** Ruptured ectopic, hemodynamic instability, fetal cardiac activity, breastfeeding, and renal/hepatic/hematological dysfunction. * **Relative Contraindications:** β-hCG > 5000 mIU/mL, sac size > 3.5 cm, and refusal of blood transfusion. * **Monitoring:** Following MTX administration, β-hCG levels are monitored on **Day 4 and Day 7**. A drop of **≥ 15%** between Day 4 and Day 7 indicates successful treatment.

Q: A levonorgestrel-releasing intrauterine device is advised in fibroid management if the uterine size is less than which of the following?

12 weeks. **Explanation:** The **Levonorgestrel-releasing Intrauterine System (LNG-IUS)** is a highly effective medical management option for heavy menstrual bleeding (HMB) associated with uterine fibroids. However, its efficacy and retention depend significantly on the size and contour of the uterine cavity. **Why 12 weeks is the correct answer:** For an LNG-IUS to function effectively and remain in situ, the uterine cavity must not be significantly distorted. Clinical guidelines (including NICE and FIGO) specify that the uterine size should not exceed **12 weeks of gestation** (approximately the size of a large grapefruit). Beyond this size, the risk of **spontaneous expulsion** increases dramatically, and the hormonal distribution may be insufficient to control the enlarged endometrial surface area. Additionally, the device is primarily indicated for intramural fibroids; it is generally contraindicated if submucosal fibroids distort the cavity, regardless of uterine size. **Analysis of Incorrect Options:** * **B, C, and D (14, 16, and 20 weeks):** These sizes represent a significantly enlarged uterus that typically extends well beyond the pelvic brim. At these volumes, the uterine cavity is usually distorted or elongated beyond the reach of a standard 32mm x 32mm LNG-IUS frame, leading to high failure rates, displacement, or inability to control bleeding. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Action:** Primarily causes endometrial atrophy and thickening of cervical mucus. It reduces menstrual blood loss by ~90%. * **Ideal Candidate:** Small intramural fibroids ( 12 weeks, GnRH agonists or Selective Progesterone Receptor Modulators (SPRMs) like Ulipristal are preferred to shrink the volume before surgery.

Question 1

A 29-year-old nulliparous woman complains of severe menorrhagia and lower abdominal pain for 3 months. On examination, there was a 14 weeks size uterus with a fundal fibroid. What is the treatment of choice?

Accepted Answer

Myomectomy

Answer

GnRH analogs

Answer

Hysterectomy

Answer

Wait and watch

Question 2

A 46-year-old lady has abnormal uterine bleeding with simple hyperplasia of the endometrium. What is the treatment of choice?

Accepted Answer

Total hysterectomy

Answer

Progesterone

Answer

Estrogen + progestogen

Answer

Estrogen

Question 3

All of the following are characteristic features of genitourinary tuberculosis on imaging, EXCEPT?

Accepted Answer

Multiple nodular diverticula.

Answer

Rigid, lead pipe appearance of fallopian tubes with nodulation.

Answer

Tobacco pouch appearance of the fallopian tube.

Answer

Bilateral cornual blockage.

Question 4

A 30-year-old multiparous woman is found to have a 5 to 6 cm cyst in one ovary. What is the most appropriate line of management?

Accepted Answer

Observation to see if it disappears by itself in three months

Answer

Laparotomy and cystectomy

Answer

Laparotomy and unilateral salpingo-oophorectomy

Answer

Laparoscopic aspiration of the cyst

Question 5

All of the following are associated with polycystic ovarian syndrome except?

Accepted Answer

Osteoporosis

Answer

Ovarian carcinoma

Answer

Endometrial carcinoma

Answer

Insulin resistance

Question 6

What is the primary mode of spread in tuberculous Pelvic Inflammatory Disease?

Accepted Answer

Spread through the bloodstream

Answer

Spread through continuity

Answer

Spread to adjacent organs

Answer

Spread through lymphatics

Question 7

Medical treatment of unruptured ectopic pregnancy is contraindicated in which of the following situations?

Accepted Answer

Fetal heart activity present

Answer

Sac size 3 cm

Answer

HCG level 3000 IU

Answer

70 ml blood collection in pelvis

Question 8

Which of the following statements about the role of laparoscopy in the diagnosis and treatment of endometriosis is FALSE?

Accepted Answer

Differentiating chocolate cyst from hemorrhagic corpus luteal cyst

Answer

Diagnosis of peritoneal endometriosis

Answer

Management of ovarian endometrioma

Answer

Staging of endometriosis

Question 9

A levonorgestrel-releasing intrauterine device is advised in fibroid management if the uterine size is less than which of the following?

Accepted Answer

12 weeks

Answer

14 weeks

Answer

16 weeks

Answer

20 weeks

Question 10

Miladevi is a diagnosed case of ectopic gestation, which of the following will be the most reliable indicator?

Accepted Answer

No gestational sac in USG

Answer

Arias Stella reaction

Answer

Culdocentesis showing blood in the posterior cul-de-sac

Answer

Absence of the normal doubling of HCG levels

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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