Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 291: A 27-year-old sexually active woman presents with copious vaginal discharge of 2 days duration. According to the syndromal management of vaginal discharge, which of the following would be given to her?

A. Azithromycin + Metronidazole + Fluconazole
B. Azithromycin
C. Metronidazole + Fluconazole (Correct Answer)
D. Fluconazole

Explanation: ### Explanation **1. Why Option C is Correct:** Under the **Syndromal Management of Sexually Transmitted Infections (STIs)** guidelines provided by NACO (National AIDS Control Organisation), a patient presenting with **vaginal discharge** is treated using **Kit 2 (Green Kit)**. The most common causes of vaginal discharge are **Bacterial Vaginosis (BV)**, **Trichomoniasis**, and **Candidiasis**. * **Metronidazole (2g single dose)** is used to cover both Bacterial Vaginosis and Trichomoniasis. * **Fluconazole (150mg single dose)** is used to treat Candidiasis (yeast infection). Therefore, the combination of Metronidazole and Fluconazole addresses the most likely pathogens in this syndrome. **2. Why Other Options are Incorrect:** * **Option A:** This combination (Kit 1/Grey Kit) includes Azithromycin, which is used for **Urethral/Cervical discharge** to cover *Chlamydia trachomatis* and *Neisseria gonorrhoeae*. While this patient is sexually active, the primary complaint is vaginal discharge, not cervicitis. * **Option B:** Azithromycin alone is insufficient as it does not cover the anaerobic bacteria or fungi responsible for vaginal discharge. * **Option D:** Fluconazole alone only treats Candidiasis, leaving Bacterial Vaginosis and Trichomoniasis (the most common causes) untreated. **3. Clinical Pearls for NEET-PG:** * **Kit 1 (Grey):** Urethral/Cervical discharge (Azithromycin 1g + Cefixime 400mg). * **Kit 2 (Green):** Vaginal discharge (Metronidazole 2g + Fluconazole 150mg). * **Kit 3 (White):** Non-herpetic Genital Ulcer (Benzathine Penicillin + Azithromycin). * **Kit 6 (Yellow):** Lower Abdominal Pain/PID (Cefixime + Metronidazole + Doxycycline). * **Whiff Test:** Positive (fishy odor) in Bacterial Vaginosis. * **Strawberry Cervix:** Characteristic of *Trichomonas vaginalis*.

Question 292: A 30-year-old female presents with chronic cyclical abdominal pain, which is increased during the 5 days of her menstrual cycle. The patient has been married for 2 years and has not conceived. What is the most appropriate next step in management?

A. Ultrasonography (Correct Answer)
B. Test for male infertility
C. CT Scan of abdomen with contrast
D. Test for urine infection

Explanation: **Explanation:** The clinical presentation of **chronic cyclical abdominal pain** (dysmenorrhea) associated with **primary infertility** in a 30-year-old female strongly suggests a diagnosis of **Endometriosis** or **Adenomyosis**. **1. Why Ultrasonography (USG) is the correct answer:** Ultrasonography (specifically Transvaginal Sonography - TVS) is the **first-line imaging modality** for evaluating pelvic pain and infertility. It is highly effective in detecting "chocolate cysts" (endometriomas), uterine fibroids, and features of adenomyosis. It is non-invasive, cost-effective, and provides immediate information regarding the pelvic anatomy, making it the most appropriate next step after a clinical history and physical examination. **2. Why other options are incorrect:** * **Test for male infertility (B):** While male factor infertility must be evaluated in any infertile couple, the patient's primary complaint is cyclical pain. The diagnostic priority is to address the symptomatic pathology in the female first. * **CT Scan (C):** CT is not the preferred modality for pelvic pathology in gynecology due to poor soft-tissue resolution of the uterus and ovaries compared to USG or MRI. It also involves unnecessary radiation exposure. * **Test for urine infection (D):** While UTIs can cause abdominal pain, they typically present with acute dysuria and frequency, not chronic cyclical pain synchronized with the menstrual cycle. **Clinical Pearls for NEET-PG:** * **Gold Standard** for diagnosing Endometriosis: **Laparoscopy** (visual confirmation + biopsy). * **First-line investigation** for pelvic masses/pain: **Ultrasonography**. * **Classic Triad of Endometriosis:** Dysmenorrhea, Dyspareunia, and Infertility. * **CA-125** may be elevated in endometriosis but is non-specific; it is used more for monitoring than primary diagnosis.

Question 293: Pyometra commonly occurs following:

A. Carcinoma endometrium (Correct Answer)
B. Carcinoma cervix
C. Carcinoma urethra
D. Senile endometritis

Explanation: ### Explanation **Pyometra** refers to the accumulation of pus within the uterine cavity. It occurs due to an **obstruction of the cervical canal**, which prevents the natural drainage of uterine secretions, leading to secondary infection and suppuration. **1. Why Carcinoma Endometrium is the correct answer:** While pyometra can occur in various conditions, **Carcinoma Endometrium** is a classic and common cause. The malignant growth often infiltrates the cervical canal or originates near the internal os, leading to mechanical obstruction. Furthermore, necrotic tumor tissue serves as an ideal nidus for infection. In postmenopausal women, the combination of pyometra and postmenopausal bleeding is highly suspicious of underlying endometrial malignancy. **2. Analysis of Incorrect Options:** * **Carcinoma Cervix:** While it can cause pyometra by obstructing the endocervical canal, it is statistically less common as a primary cause compared to endometrial pathology in the context of this specific question's hierarchy. * **Carcinoma Urethra:** This involves the urinary tract. While advanced stages may involve the vagina, it does not typically cause cervical obstruction or uterine suppuration. * **Senile Endometritis:** This is an inflammatory condition of the atrophic endometrium in elderly women. While it can lead to pyometra if the cervix is stenosed, it is often a *result* of the same obstructive process rather than the most common primary trigger compared to malignancy. **3. High-Yield Clinical Pearls for NEET-PG:** * **Triad of Pyometra:** Postmenopausal age, vaginal discharge (often foul-smelling), and an enlarged, tender uterus. * **Management:** The primary step is **cervical dilatation and drainage** of pus. However, the most crucial step is **fractional curettage** after the infection subsides to rule out underlying malignancy (Carcinoma Endometrium). * **Spontaneous Perforation:** Though rare, pyometra can rupture, leading to generalized peritonitis (Pneumoperitoneum without a ruptured viscus).

Question 294: A foul-smelling, fishy vaginal odor is characteristic of which condition?

A. Trichomoniasis
B. Bacterial vaginosis (Gardnerella) (Correct Answer)
C. Chlamydia infection
D. Candidiasis

Explanation: **Explanation:** **Bacterial Vaginosis (BV)** is the most common cause of vaginal discharge in women of reproductive age. It is not a true infection but a **dysbiosis** where the normal hydrogen peroxide-producing *Lactobacilli* are replaced by anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Mobiluncus*). The characteristic **foul-smelling, fishy odor** is due to the release of **amines** (putrescine and cadaverine) when the vaginal discharge reacts with alkaline substances, such as semen or KOH (Whiff test). **Analysis of Incorrect Options:** * **A. Trichomoniasis:** Caused by *Trichomonas vaginalis*. It typically presents with a **profuse, frothy, greenish-yellow discharge** and a "strawberry cervix" (punctate hemorrhages). While it can be malodorous, it lacks the classic fishy amine scent of BV. * **C. Chlamydia infection:** Often asymptomatic or presents as mucopurulent cervicitis. It does not typically cause a fishy vaginal odor. * **D. Candidiasis:** Caused by *Candida albicans*. It presents with intense pruritus and a thick, **curdy, white "cottage-cheese" discharge**. Crucially, it is **odorless** and associated with a normal vaginal pH (<4.5). **High-Yield Clinical Pearls for NEET-PG:** * **Amsel’s Criteria (3 out of 4 required for BV diagnosis):** 1. Homogeneous, thin, white-grey discharge. 2. Vaginal pH **> 4.5**. 3. **Positive Whiff Test** (fishy odor on adding 10% KOH). 4. **Clue Cells** on saline microscopy (most specific finding). * **Treatment of Choice:** Oral or topical **Metronidazole** (500 mg twice daily for 7 days). * **Note:** Partner treatment is **not** recommended for BV, unlike Trichomoniasis.

Question 295: A patient presents with greenish discharge and a "strawberry cervix." This clinical presentation is most commonly associated with which infection?

A. Trichomonas vaginalis (Correct Answer)
B. Gardnerella vaginalis
C. Candida albicans
D. Herpes simplex virus

Explanation: ### Explanation The clinical presentation of **greenish, frothy vaginal discharge** accompanied by a **"strawberry cervix"** is a classic hallmark of **Trichomoniasis**, caused by the protozoan *Trichomonas vaginalis*. **1. Why Trichomonas vaginalis is correct:** * **Strawberry Cervix (Colpitis Macularis):** This occurs due to punctate hemorrhages on the cervical epithelium caused by the parasite. While highly specific for Trichomoniasis, it is clinically visible in only about 2-5% of cases (more commonly seen via colposcopy). * **Discharge Characteristics:** The discharge is typically profuse, malodorous, thin, and yellowish-green or grey. It is often "frothy" due to the gas produced by the organism. * **Vaginal pH:** The pH is usually elevated (>4.5). **2. Why other options are incorrect:** * **Gardnerella vaginalis (Bacterial Vaginosis):** Presents with a thin, homogenous, **milky-white** discharge with a "fishy odor" (positive Whiff test). The cervix appears normal, and microscopy shows **Clue cells**. * **Candida albicans (Candidiasis):** Characterized by intense pruritus and a thick, **curdy, "cottage-cheese"** like discharge. The vaginal mucosa is often erythematous, but the "strawberry" appearance is absent. Microscopy shows pseudohyphae. * **Herpes simplex virus (HSV):** Presents with painful, fluid-filled **vesicles or shallow ulcers**, fever, and lymphadenopathy, rather than a specific discharge or strawberry cervix. **3. High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** The gold standard is **NAAT**, but the most common initial test is **Wet Mount microscopy**, which shows **pear-shaped, motile flagellates**. * **Treatment:** The drug of choice is **Metronidazole** (2g single dose or 500mg BD for 7 days). * **Key Point:** Trichomoniasis is a **Sexually Transmitted Infection (STI)**; therefore, **treating the partner** is mandatory to prevent reinfection.

Question 296: Hidradenoma of the vulva arises from which structure?

A. Apocrine glands (Correct Answer)
B. Sebaceous glands
C. Subcutaneous tissue
D. Hair follicle

Explanation: **Explanation:** **Hidradenoma papilliferum** is a benign, slow-growing tumor of the vulva that typically presents as a firm, mobile, non-tender nodule in the interlabial grooves. **1. Why Apocrine Glands are Correct:** Hidradenoma papilliferum originates from the **apocrine sweat glands** (specifically the modified apocrine glands of the vulva). Histologically, it is characterized by complex papillary projections lined by a double layer of epithelium: an inner secretory columnar layer (showing decapitation secretion, a hallmark of apocrine glands) and an outer myoepithelial layer. It is considered the vulvar counterpart of intraductal papilloma of the breast. **2. Why Other Options are Incorrect:** * **Sebaceous glands:** These give rise to sebaceous cysts or Fordyce spots. While common on the vulva, they do not form the papillary structures seen in hidradenomas. * **Subcutaneous tissue:** Tumors arising here are typically mesenchymal, such as lipomas, fibromas, or aggressive angiomyxomas. * **Hair follicle:** These give rise to conditions like folliculitis, trichilemmal cysts, or trichoepitheliomas, which have distinct keratinizing histological features. **3. NEET-PG High-Yield Pearls:** * **Location:** Most commonly found on the **labia majora** or the interlabial folds. * **Clinical Presentation:** Often asymptomatic but can occasionally ulcerate, mimicking a malignancy (vulvar carcinoma). * **Management:** Simple surgical excision is curative; recurrence is rare. * **Key Histology:** Look for "decapitation secretion" and a "frond-like" papillary pattern. It is strictly benign.

Question 297: Which of the following is true of endometriosis?

A. Always associated with tubal blood
B. Painful (Correct Answer)
C. Amenorrhea
D. Surgery is curative

Explanation: **Explanation:** **Endometriosis** is defined as the presence of functional endometrial glands and stroma outside the uterine cavity. 1. **Why "Painful" is correct:** Pain is the hallmark symptom of endometriosis. It typically presents as the "Classic Triad": **Dysmenorrhea** (congestive, starting before menses), **Dyspareunia** (deep), and **Chronic Pelvic Pain**. The pain is caused by cyclical bleeding into the ectopic implants, leading to inflammation, fibrosis, and the release of prostaglandins. 2. **Why other options are incorrect:** * **A. Always associated with tubal blood:** While endometriosis can involve the fallopian tubes, it does not "always" cause tubal blood. Tubal blood (hematosalpinx) is more characteristic of an ectopic pregnancy. * **C. Amenorrhea:** Endometriosis is associated with **menorrhagia** (heavy bleeding) or polymenorrhea, not the absence of menses. In fact, "retrograde menstruation" is a primary theory (Sampson’s Theory) for its pathogenesis. * **D. Surgery is curative:** Surgery (laparoscopic excision/ablation) is the gold standard for diagnosis and treatment, but it is **not always curative**. Recurrence rates are high (up to 40-50%) because microscopic implants may remain, and the underlying hormonal environment persists until menopause. **High-Yield NEET-PG Pearls:** * **Gold Standard Investigation:** Diagnostic Laparoscopy ("See and Treat"). * **Commonest Site:** Ovary (often presenting as a "Chocolate Cyst" or Endometrioma). * **Powder-burn/Gunshot lesions:** Characteristic appearance on laparoscopy. * **CA-125:** May be elevated but is non-specific; used for monitoring recurrence. * **First-line Medical Management:** Combined Oral Contraceptive Pills (COCPs) or NSAIDs.

Question 298: A positive whiff test is seen in which of the following conditions?

A. Bacterial vaginosis (Correct Answer)
B. Candidiasis
C. Chlamydiasis
D. Trichomoniasis

Explanation: The **Whiff test** (also known as the Amisel’s amine test) is a diagnostic tool used to identify **Bacterial Vaginosis (BV)**. It involves adding 10% Potassium Hydroxide (KOH) to a sample of vaginal discharge. In BV, the alkaline KOH causes the release of volatile amines (specifically cadaverine and putrescine) produced by anaerobic bacteria, resulting in a characteristic **fishy odor**. ### Why the other options are incorrect: * **Candidiasis:** Caused by *Candida albicans*, it typically presents with a thick, "curdy-white" discharge and an acidic pH (<4.5). The KOH mount is used here to visualize pseudohyphae/spores, but it does not produce a fishy odor. * **Chlamydiasis:** This is primarily a cervicitis rather than a vaginitis. It presents with mucopurulent cervical discharge and does not involve the amine production seen in BV. * **Trichomoniasis:** While *Trichomonas vaginalis* can sometimes produce a mild odor and an elevated pH, the Whiff test is not a standard diagnostic criterion for it. Diagnosis is confirmed by seeing motile pear-shaped trophozoites on a wet mount. ### NEET-PG High-Yield Pearls: * **Amsel’s Criteria for BV (3 out of 4 required):** 1. Homogeneous, thin, white-grey discharge. 2. Vaginal pH > 4.5. 3. **Positive Whiff test.** 4. Presence of **Clue cells** on microscopy (most specific finding). * **Treatment of Choice:** Metronidazole (Oral or Gel). * **Nugent Scoring:** The "Gold Standard" for diagnosing BV based on Gram stain morphotypes.

Question 299: What happens to ovarian function after a hysterectomy?

A. Increases
B. Decreases within 2-3 years
C. Remains the same
D. Decreases after 5 years (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Decreases after 5 years.** **Medical Concept:** While a simple hysterectomy involves the removal of the uterus and not the ovaries, it significantly impacts ovarian longevity. The ovaries receive a dual blood supply: the **ovarian artery** (direct branch of the abdominal aorta) and the **ovarian branch of the uterine artery**. During a hysterectomy, the uterine artery is ligated. This reduces the total collateral blood flow to the ovaries, leading to chronic relative ischemia. Over time, this accelerated follicular depletion results in "Secondary Ovarian Failure," typically manifesting as menopause approximately **3–5 years earlier** than the natural age of menopause. **Analysis of Options:** * **A. Increases:** Ovarian function never increases after the removal of the uterus; the loss of blood supply and disruption of the utero-ovarian axis leads to decline. * **B. Decreases within 2-3 years:** While some decline begins early, significant clinical decrease and hormonal shifts leading to failure are generally documented closer to the 5-year mark in longitudinal studies. * **C. Remains the same:** This is a common misconception. Although the ovaries are preserved, the surgical disruption of the vascular bed ensures that function does not remain identical to a non-surgical state. **High-Yield Facts for NEET-PG:** * **Residual Ovary Syndrome:** Pelvic pain or a mass developing in an ovary left behind after hysterectomy. * **Hormonal Impact:** Post-hysterectomy patients often show higher levels of FSH and lower Inhibin-B levels compared to age-matched controls. * **Surgical Note:** To preserve maximal function, surgeons attempt to preserve the infundibulopelvic ligament and its associated ovarian artery.

Question 300: In a nulliparous woman, what is the treatment of choice for a ruptured ectopic pregnancy?

A. Salpingectomy with end-to-end anastomosis (Correct Answer)
B. Salpingo-oophorectomy
C. Expectant management (wait and watch)
D. Linear salpingostomy

Explanation: **Explanation** In the management of a **ruptured ectopic pregnancy**, the primary clinical concern is life-threatening intraperitoneal hemorrhage. The standard of care for a ruptured tube, regardless of parity, is **Salpingectomy**. **Why Option A is Correct:** In a ruptured ectopic pregnancy, the fallopian tube is structurally damaged and actively bleeding. **Salpingectomy** (removal of the affected tube) is the definitive treatment to achieve surgical hemostasis. While the option mentions "end-to-end anastomosis," in the context of NEET-PG questions regarding ruptured cases, the focus is on the necessity of removing the damaged segment/tube to save the patient's life. Note: In modern practice, simple salpingectomy is standard; however, if the question implies reconstructive intent in a nulliparous woman, it emphasizes preserving future fertility potential via the contralateral tube. **Why Other Options are Incorrect:** * **B. Salpingo-oophorectomy:** This involves removing the ovary along with the tube. This is unnecessary and contraindicated as it prematurely reduces the patient's ovarian reserve, which is critical for a nulliparous woman. * **C. Expectant management:** This is only reserved for hemodynamically stable patients with declining β-hCG levels (<200 mIU/mL). It is absolutely contraindicated in a ruptured ectopic pregnancy due to the risk of hemorrhagic shock. * **D. Linear salpingostomy:** This is a "tube-conserving" surgery used only in **unruptured** ectopic pregnancies. In a ruptured state, the tissue is too friable and damaged for this technique to be safe or effective. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVS) + Serum β-hCG. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (seen in only 50% of cases). * **Medical Management:** Methotrexate is used if the sac is <3.5 cm, β-hCG <5000 mIU/mL, and the patient is hemodynamically stable with no fetal heart rate. * **Surgical Choice:** Laparoscopy is preferred over laparotomy unless the patient is hemodynamically unstable.

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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