Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 321: Endometriosis is commonly associated with which of the following?

A. Bilateral chocolate cysts of the ovary (Correct Answer)
B. Adenomyosis
C. Fibroid
D. Luteal cyst

Explanation: **Explanation:** **Endometriosis** is defined as the presence of functioning endometrial tissue outside the uterine cavity. The ovary is the most common site of endometriosis. When blood accumulates within the ovary over multiple cycles, it forms an endometrioma, famously known as a **"Chocolate Cyst"** due to the thick, dark, tarry appearance of the old sequestered blood. 1. **Why Option A is correct:** In approximately **50% of cases**, ovarian involvement in endometriosis is **bilateral**. The presence of bilateral chocolate cysts is a classic hallmark of the disease and is frequently tested in NEET-PG as a diagnostic feature on ultrasound (showing characteristic "ground-glass" echoes). 2. **Why other options are incorrect:** * **Adenomyosis (Option B):** While often called "endometriosis interna," it is a distinct pathological entity where the endometrium invades the myometrium. Although they can coexist, they are separate conditions with different clinical presentations (e.g., a globally enlarged, globular uterus). * **Fibroid (Option C):** Leiomyomas are benign monoclonal tumors of smooth muscle cells. There is no direct pathophysiological link between fibroids and endometriosis, though both are estrogen-dependent. * **Luteal Cyst (Option D):** This is a functional physiological cyst formed after ovulation. It is not related to the ectopic endometrial tissue seen in endometriosis. **Clinical Pearls for NEET-PG:** * **Most common site:** Ovary (followed by the Pouch of Douglas). * **Gold Standard Diagnosis:** Laparoscopy ("Powder-burn" or "Gunshot" lesions). * **Classic Triad:** Dysmenorrhea (congestive), Dyspareunia, and Infertility. * **Tumor Marker:** CA-125 is often elevated but lacks specificity. * **Sampson’s Theory:** Retrograde menstruation is the most widely accepted theory for its pathogenesis.

Question 322: A 25-year-old nulliparous woman presents with third-degree uterine descent but no cystocele, rectocele, or enterocele. What is the best treatment option for her condition?

A. Fothergill's repair
B. Abdominal sling operation (Correct Answer)
C. Amputation of the cervix and reconstruction
D. Lefo's operation

Explanation: **Explanation:** The patient is a **young, nulliparous woman** with **third-degree uterine descent** but no associated vaginal wall prolapse (cystocele or rectocele). In such cases, the primary goal is to correct the uterine descent while **preserving fertility** and maintaining vaginal function. **Why Abdominal Sling Operation is correct:** The Abdominal Sling operation (e.g., Shirodkar’s or Khanna’s sling) is the treatment of choice for nulliparous or young women who wish to preserve their uterus and fertility. It involves using a synthetic mesh or fascia lata to anchor the cervix/isthmus to a bony landmark (like the sacral promontory) or the anterior superior iliac spine. It provides strong support without interfering with the cervix or vaginal anatomy. **Why other options are incorrect:** * **Fothergill’s Repair (Manchester Operation):** This involves amputation of the cervix and shortening of the Mackenrodt’s ligaments. It is contraindicated in young women desiring pregnancy because cervical amputation increases the risk of mid-trimester miscarriage, cervical incompetence, and dystocia. * **Amputation of the cervix:** This is a component of Fothergill’s repair. As a standalone procedure, it does not address the underlying ligamentous laxity causing third-degree descent and negatively impacts fertility. * **Le Fort’s Operation (Colpocleisis):** This is a "closing" procedure of the vagina. It is strictly reserved for elderly, sexually inactive women who are poor surgical candidates for major reconstructive surgery. **Clinical Pearls for NEET-PG:** * **Nulliparous Prolapse:** Usually occurs due to congenital weakness of pelvic supports or connective tissue disorders. * **Sling Operations:** Shirodkar (Sacropexy), Khanna (Rectus sheath), and Purandare (Rectus sheath) are common types. * **Ward-Mayo Operation:** This is a vaginal hysterectomy with repair, indicated for post-menopausal women with third-degree prolapse.

Question 323: Which of the following statements regarding leukemia in pregnancy is false?

A. Leukemias may arise from bone marrow.
B. Remission is common during pregnancy.
C. Termination of pregnancy will improve prognosis. (Correct Answer)
D. Leukemias are more common in women above 40 years.

Explanation: **Explanation:** Leukemia is a rare but serious malignancy during pregnancy, occurring in approximately 1 in 75,000 to 100,000 pregnancies. **Why Option C is the Correct Answer (False Statement):** The prognosis of leukemia is determined by the cytogenetic profile and the subtype of the disease, not by the pregnancy itself. **Termination of pregnancy does not improve the maternal prognosis or alter the course of the disease.** Management is dictated by the gestational age; while immediate chemotherapy is required for acute leukemias (even in the first trimester), the pregnancy is usually only terminated if the mother requires urgent teratogenic treatment that cannot be delayed. **Analysis of Incorrect Options:** * **Option A:** Leukemias are by definition neoplastic proliferations of hematopoietic cells that **arise from the bone marrow** and involve the peripheral blood. * **Option B:** While the term "remission" usually refers to the response to chemotherapy, it is a known clinical observation that some patients may experience a temporary stabilization or **spontaneous (though rare) remission** during pregnancy due to hormonal changes, though this is not a reliable therapeutic effect. * **Option D:** The incidence of most leukemias (especially Chronic Myeloid Leukemia and Chronic Lymphocytic Leukemia) **increases with age**, making it more common in women approaching the end of their reproductive years (above 40). **High-Yield NEET-PG Pearls:** * **Most common type in pregnancy:** Acute Myeloid Leukemia (AML) is the most frequent acute leukemia diagnosed during pregnancy. * **Chemotherapy Timing:** Avoided in the 1st trimester (teratogenic risk); relatively safe in the 2nd and 3rd trimesters. * **Vaginal Delivery:** Always preferred over Cesarean section unless there are obstetric indications, to minimize the risk of infection and hemorrhage in an immunocompromised patient.

Question 324: Which of the following is a feature of a simple vesicovaginal fistula?

A. Supratrigonal location (Correct Answer)
B. Short vaginal length
C. Associated pelvic malignancy
D. Cause related to pelvic radiation

Explanation: ### Explanation Vesicovaginal fistulae (VVF) are classified into **simple** and **complex** based on their size, location, and the quality of the surrounding tissue. This classification is crucial for determining the surgical approach and prognosis. **1. Why "Supratrigonal location" is correct:** A **simple VVF** is defined by features that suggest a high likelihood of successful primary repair. A **supratrigonal location** (above the ureteric orifices) is a hallmark of a simple fistula. These are typically small (<2 cm), occur in healthy non-radiated tissue, and have a normal vaginal length, making them easier to access and repair surgically. **2. Why the other options are incorrect:** * **Short vaginal length:** This is a feature of a **complex VVF**. It often results from extensive scarring or previous failed surgical repairs, making the surgical field restricted and the repair more difficult. * **Associated pelvic malignancy:** Malignancy-associated fistulae are classified as **complex**. They involve diseased tissue, may have multiple tracts, and often require interposition flaps (like a Martius flap) for successful closure. * **Cause related to pelvic radiation:** Radiation-induced fistulae are **complex**. Radiation causes endarteritis obliterans, leading to poor blood supply and impaired healing. These fistulae often enlarge over time and have a high failure rate with simple primary closure. ### NEET-PG High-Yield Pearls * **Most common cause of VVF (Worldwide):** Obstructed labor (due to pressure necrosis). * **Most common cause of VVF (Developed countries/Gynae practice):** Iatrogenic (post-total abdominal hysterectomy). * **Gold Standard Investigation:** Cystoscopy (to locate the fistula relative to the ureteric orifices). * **Three-swab test (Moir’s test):** Used to differentiate VVF (top swab wet) from Ureterovaginal fistula (swab wet with clear urine, but dye in bladder doesn't stain it). * **Timing of repair:** Traditionally 3–6 months after the injury to allow inflammation to subside, though "early repair" is now increasingly practiced in non-radiated cases.

Question 325: All of the following are causes of primary amenorrhea with eugonadism, EXCEPT:

A. GnRH deficiency (Correct Answer)
B. PCOS
C. Mullerian agenesis
D. Congenital adrenal hyperplasia

Explanation: **Explanation:** The term **Eugonadism** in the context of primary amenorrhea refers to the presence of normal secondary sexual characteristics (breast development), indicating a functional Hypothalamic-Pituitary-Ovarian (HPO) axis and adequate estrogen production. **1. Why GnRH Deficiency is the Correct Answer:** GnRH deficiency (e.g., Kallmann Syndrome) leads to **Hypogonadotropic Hypogonadism**. Without GnRH, there is no stimulation of FSH/LH, resulting in failed follicular development and low estrogen. This leads to a lack of secondary sexual characteristics (infantile breasts). Therefore, it is a cause of primary amenorrhea with **hypogonadism**, not eugonadism. **2. Analysis of Incorrect Options (Causes of Eugonadism):** * **Mullerian Agenesis (MRKH Syndrome):** The HPO axis is intact (normal hormones/ovaries), but the uterus and upper vagina are absent. Patients have normal breast development but primary amenorrhea. * **PCOS:** While more common in secondary amenorrhea, it can present as primary. The HPO axis is functional (often with high LH), and estrogen levels are normal or elevated, leading to normal breast development. * **Congenital Adrenal Hyperplasia (CAH):** In non-salt wasting or late-onset forms, peripheral conversion of androgens to estrogens can maintain breast development despite virilization and amenorrhea. **Clinical Pearls for NEET-PG:** * **Primary Amenorrhea + No Breasts:** Think Hypogonadism (Turner Syndrome - Hypergonadotropic; Kallmann - Hypogonadotropic). * **Primary Amenorrhea + Normal Breasts:** Think Outflow tract obstruction (MRKH, Imperforate hymen) or Endocrine dysfunction (PCOS, CAH, AIS). * **Androgen Insensitivity Syndrome (AIS):** These patients have breasts (due to peripheral aromatization) but are genetically 46,XY and lack a uterus.

Question 326: Which of the following is LEAST likely to cause post-menopausal bleeding in a woman with uterine prolapse?

A. Bleeding disorder (Correct Answer)
B. Vaginal atrophy
C. Cervical cancer
D. Decubitus ulcer on the prolapse

Explanation: **Explanation:** In the context of uterine prolapse and post-menopausal bleeding (PMB), the focus is on identifying local anatomical causes versus systemic issues. **Why "Bleeding Disorder" is the correct answer:** While systemic bleeding disorders (like von Willebrand disease or thrombocytopenia) can cause abnormal uterine bleeding in reproductive-aged women, they are the **least likely** cause of PMB in a patient with uterine prolapse. PMB in an elderly woman is almost always due to local pathology (atrophy, malignancy, or trauma). Systemic coagulopathies rarely manifest for the first time as isolated post-menopausal bleeding without other systemic signs (petechiae, mucosal bleeds). **Analysis of other options:** * **Decubitus Ulcer:** This is a classic complication of Grade III or IV uterine prolapse (Procidentia). It occurs due to venous congestion and friction against the clothing/thighs, leading to trophic changes and bleeding. * **Vaginal Atrophy:** The most common cause of PMB overall. In menopause, low estrogen leads to thinning of the vaginal and endometrial epithelium, making the tissue fragile and prone to micro-trauma and spotting. * **Cervical Cancer:** Any post-menopausal woman with a protruding mass or bleeding must be screened for malignancy. Prolapse does not protect against cervical or endometrial cancer; in fact, chronic irritation of a prolapsed cervix can occasionally mask or coexist with neoplastic changes. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of PMB:** Senile Vaginitis/Atrophic Endometritis. * **Most important cause to rule out in PMB:** Endometrial Carcinoma. * **Decubitus Ulcer Management:** The primary treatment is **Glycerine and Acriflavine** packing (reduces edema and infection) followed by definitive surgery (e.g., Ward-Mayo’s operation) once the ulcer heals. * **Biopsy Rule:** Always biopsy the edge of a decubitus ulcer if it doesn't heal with conservative management to rule out malignancy.

Question 327: Mifepristone causes which of the following effects on uterine fibroids?

A. Hyperplasia of the fibroid
B. Atrophy of the fibroid (Correct Answer)
C. No effect on the fibroid
D. Effect varies with the age of the patient

Explanation: **Explanation:** **Mifepristone** is a Selective Progesterone Receptor Modulator (SPRM). Since uterine fibroids (leiomyomas) are highly dependent on both estrogen and progesterone for growth, mifepristone acts as a competitive antagonist at the progesterone receptor level. 1. **Why Option B is Correct:** Mifepristone inhibits the action of progesterone, which is essential for the proliferation of leiomyoma cells. By blocking these receptors, it induces **atrophy** of the fibroid tissue, leading to a significant reduction in tumor volume (approximately 25–50%) and a decrease in associated symptoms like heavy menstrual bleeding (menorrhagia). 2. **Why Other Options are Incorrect:** * **Option A:** Hyperplasia implies growth or increase in cell number. Mifepristone inhibits growth; it does not promote it. * **Option C:** Mifepristone has a well-documented clinical effect on reducing fibroid size, making "no effect" incorrect. * **Option D:** While the baseline size of fibroids may vary with age (due to hormonal status), the pharmacological mechanism of mifepristone (receptor blockade) remains consistent regardless of the patient's age. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism in Fibroids:** It reduces the volume of the fibroid and induces amenorrhea in a high percentage of patients. * **PAEC:** A specific side effect of long-term SPRM use (like Mifepristone or Ulipristal) is **Progesterone Receptor Modulator Associated Endometrial Changes (PAEC)**, which is a benign form of endometrial thickening, not to be confused with typical hyperplasia. * **Other Uses:** Medical abortion (with Misoprostol), induction of labor (IUFD), and management of Cushing’s syndrome. * **Ulipristal Acetate:** Another SPRM used for fibroids, often considered more potent than Mifepristone for this specific indication.

Question 328: What is the most common site of obstetric injury leading to uretero-vaginal fistula?

A. Infundibulopelvic ligament
B. Vaginal vault
C. Ureteric tunnel
D. Below the cardinal ligament where the uterine artery crosses (Correct Answer)

Explanation: **Explanation:** The ureter is most vulnerable to injury at specific anatomical "danger zones" during gynecological and obstetric surgeries. The **most common site** of injury leading to a uretero-vaginal fistula is where the ureter passes **below the cardinal ligament**, approximately 1.5–2 cm lateral to the cervix. At this point, the **uterine artery crosses over the ureter** ("water under the bridge"). During procedures like a total abdominal hysterectomy or a difficult cesarean section, the ureter can be inadvertently clamped, ligated, or kinked while attempting to control bleeding or ligate the uterine vessels. **Analysis of Options:** * **Option A (Infundibulopelvic ligament):** This is the second most common site of injury, occurring during the ligation of the ovarian vessels. However, it is less frequent than injuries near the uterine artery. * **Option B (Vaginal vault):** While the ureter is close to the lateral vaginal angles, injuries here usually occur during the closure of the vaginal cuff, which is statistically less common than injuries at the uterine artery crossing. * **Option C (Ureteric tunnel):** The ureteric tunnel (Waldeyer’s sheath) is located in the vesicouterine ligament. While injuries can occur here during bladder dissection, it is not the primary site for obstetric-related fistulae. **Clinical Pearls for NEET-PG:** * **Most common cause of Ureterovaginal Fistula:** Gynecological surgery (Hysterectomy). * **Most common site of Ureteral Injury:** At the level of the uterine artery (under the cardinal ligament). * **Classic Presentation:** Constant dribbling of urine (via the fistula) along with normal periodic voiding (from the unaffected ureter). * **Diagnostic Test:** Methylene blue test (negative in vagina) + Indigo carmine IV (positive in vagina) confirms the ureteral origin.

Question 329: Which organism contributes to the vaginal defense mechanism?

A. Doderlein's bacillus (Correct Answer)
B. Staphylococcus
C. Streptococcus
D. Treponema pallidum

Explanation: **Explanation:** The vaginal ecosystem is a delicate balance of flora, where **Doderlein’s bacilli** (a species of *Lactobacillus*) play the most critical role in the defense mechanism. These Gram-positive bacilli convert glycogen, stored in the vaginal squamous epithelium under the influence of estrogen, into **lactic acid**. This process maintains a healthy, acidic vaginal pH (typically **3.8 to 4.5**), which inhibits the growth of pathogenic bacteria and prevents infections like Bacterial Vaginosis. **Analysis of Options:** * **A. Doderlein’s bacillus (Correct):** As the dominant commensal, it produces lactic acid and hydrogen peroxide ($H_2O_2$), creating an environment hostile to most pathogens. * **B & C. Staphylococcus and Streptococcus:** While these may exist in small quantities as transient flora, they are not primary defense organisms. If they overgrow, they can become pathogenic, leading to conditions like aerobic vaginitis or Toxic Shock Syndrome (in the case of *S. aureus*). * **D. Treponema pallidum:** This is the causative agent of **Syphilis**. It is a pathogen, not a commensal, and its presence indicates a sexually transmitted infection. **High-Yield Clinical Pearls for NEET-PG:** 1. **Estrogen Dependency:** Doderlein’s bacilli are absent before puberty and after menopause due to low estrogen levels (and thus low glycogen), making the vaginal pH more alkaline (neutral) in these age groups. 2. **Vaginal pH:** A pH >4.5 in a reproductive-age woman is a diagnostic criterion (Amsel’s criteria) for **Bacterial Vaginosis**, signifying a loss of Lactobacilli. 3. **Protective Factors:** Besides lactic acid, Lactobacilli produce **biosurfactants** and **bacteriocins** that prevent the adhesion of harmful microbes.

Question 330: In which type of abortion does the gestational age correspond to the uterine size?

A. Threatened (Correct Answer)
B. Inevitable
C. Complete
D. Missed

Explanation: In clinical practice, comparing uterine size to the period of amenorrhea (POA) is a high-yield diagnostic tool for differentiating types of abortion. **Explanation of the Correct Answer:** In **Threatened Abortion**, the pregnancy is still viable and the products of conception (POC) are entirely intact within the uterus. The cervical os remains closed. Because the gestational sac and fetus continue to develop normally despite the vaginal bleeding, the **uterine size corresponds to the gestational age.** **Analysis of Incorrect Options:** * **Inevitable Abortion:** While the POC are still inside, the cervical os is dilated and heavy bleeding/rupture of membranes often occurs. While the size may initially correspond, it is often slightly **less than or equal to** gestational age due to the impending expulsion and loss of liquor. * **Complete Abortion:** All products of conception have been expelled. Consequently, the uterus is empty and contracted, making the **uterine size significantly smaller** than the gestational age. * **Missed Abortion:** The fetus has died in utero but is retained. Over time, the amniotic fluid is absorbed and the POC macerate, leading to a **uterine size that is less than** the period of amenorrhea. **High-Yield Clinical Pearls for NEET-PG:** * **Uterine Size > POA:** Think of Molar Pregnancy, Multiple Gestation, or Polyhydramnios. * **Uterine Size < POA:** Think of Missed Abortion, Complete Abortion, or IUGR. * **Internal Os Status:** It is **Closed** in Threatened and Missed abortions; it is **Open** in Inevitable and Incomplete abortions. * **Management:** Threatened abortion is managed conservatively (bed rest and progesterone), whereas Inevitable/Missed abortions require medical or surgical evacuation.

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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