Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 421: All of the following are risk factors for Pelvic Inflammatory Disease (PID) except:

A. Females not using oral contraceptive pills (OCP)
B. Pregnancy (Correct Answer)
C. Intrauterine device (IUD) users
D. Previous history of acute PID

Explanation: **Explanation:** Pelvic Inflammatory Disease (PID) is an ascending infection of the female upper genital tract. The correct answer is **Pregnancy** because it acts as a physiological barrier against ascending infections. **1. Why Pregnancy is the Correct Answer:** Pregnancy is considered protective against PID for two primary reasons: * **Mucus Plug:** The formation of a thick, tenacious cervical mucus plug (under the influence of progesterone) physically obstructs the ascent of bacteria from the vagina into the uterine cavity. * **Obliteration of Uterine Cavity:** As the pregnancy progresses, the decidua capsularis fuses with the decidua parietalis, effectively obliterating the uterine cavity and preventing the spread of pathogens to the fallopian tubes. **2. Analysis of Other Options:** * **Females not using OCPs:** OCP users have a *decreased* risk of PID because progestin thickens cervical mucus (mimicking the pregnancy effect) and reduces menstrual flow, which otherwise acts as a culture medium for bacteria. Therefore, **not** using OCPs is a relative risk factor. * **Intrauterine Device (IUD) users:** The risk of PID is slightly increased, primarily during the first 21 days following insertion due to the introduction of vaginal flora into the sterile uterus during the procedure. * **Previous history of PID:** This is one of the strongest risk factors. Prior infection causes mucosal damage, loss of ciliary function in the tubes, and scarring, making the tract more susceptible to reinfection. **High-Yield Clinical Pearls for NEET-PG:** * **Most common causative organism:** *Chlamydia trachomatis* (subacute) and *Neisseria gonorrhoeae* (acute). * **Barrier Contraceptives:** Condoms provide the best protection against PID. * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving perihepatitis ("violin-string" adhesions). * **Gold Standard Diagnosis:** Laparoscopy (though clinical diagnosis is preferred in practice).

Question 422: What is the causative organism of acute salpingitis?

A. Streptococcus
B. Neisseria
C. Chlamydia (Correct Answer)
D. Ureaplasma

Explanation: **Explanation:** Acute salpingitis is a key component of Pelvic Inflammatory Disease (PID). While PID is often polymicrobial, **Chlamydia trachomatis** is recognized as the most common causative organism worldwide, particularly in the subacute and chronic presentations that lead to tubal factor infertility. * **Why Chlamydia is Correct:** *Chlamydia trachomatis* is an obligate intracellular bacterium that frequently causes asymptomatic or "silent" salpingitis. It is the leading cause of tubal damage and ectopic pregnancy due to its ability to cause significant endosalpingeal destruction despite mild clinical symptoms. * **Why Neisseria is Incorrect:** *Neisseria gonorrhoeae* was historically considered the primary cause. While it causes a more "acute" and clinically florid presentation (high fever, severe pain, and purulent discharge), epidemiological data now shows Chlamydia has a higher overall prevalence in PID cases. * **Why Streptococcus & Ureaplasma are Incorrect:** *Streptococcus* (Group B) and *Ureaplasma urealyticum* are part of the vaginal flora and can be isolated in polymicrobial PID, but they are rarely the primary or most common initiators of acute salpingitis. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Laparoscopy (shows hyperemic, edematous tubes with purulent exudate). * **Most Common Route of Infection:** Ascending infection from the lower genital tract. * **Fitz-Hugh-Curtis Syndrome:** A complication of salpingitis (usually Chlamydial) involving peri-hepatitis and "violin-string" adhesions between the liver capsule and parietal peritoneum. * **Treatment:** Must cover both *Chlamydia* and *Neisseria* (e.g., Ceftriaxone plus Doxycycline).

Question 423: A young lady presents with a complaint of copious vaginal discharge, but there is no cervical discharge on per speculum examination. Which of the following should be given for management?

A. Metronidazole and fluconazole (Correct Answer)
B. Metronidazole and azithromycin
C. Metronidazole and doxycycline
D. Fluconazole only

Explanation: ### Explanation **1. Understanding the Clinical Presentation** The patient presents with **copious vaginal discharge** but **no cervical discharge** on speculum examination. This distinction is crucial for NEET-PG. * **Vaginal discharge without cervicitis** typically points toward **Vaginitis** (Bacterial Vaginosis, Trichomoniasis, or Candidiasis). * **Cervical discharge** (mucopurulent) would suggest **Cervicitis** (Chlamydia or Gonorrhea). According to the **Syndromic Management of STI/RTI** (NACO guidelines), a patient with vaginal discharge and no evidence of cervical infection is treated using **Kit 2 (Green Kit)**. **2. Why Option A is Correct** Kit 2 is designed to cover the most common causes of vaginitis: * **Bacterial Vaginosis & Trichomoniasis:** Covered by **Metronidazole** (2g single dose). * **Candidiasis (Yeast infection):** Covered by **Fluconazole** (150mg single dose). Since the question describes a purely vaginal pathology, this combination is the standard of care. **3. Why Other Options are Incorrect** * **Options B & C:** These include Azithromycin or Doxycycline, which are used to treat **Chlamydia**. These drugs are part of **Kit 1 (Grey Kit)**, used when there is visible cervical discharge or cervical motion tenderness (Cervicitis/PID). * **Option D:** Fluconazole alone only treats Candidiasis, failing to address Bacterial Vaginosis or Trichomoniasis, which also cause copious discharge. **4. High-Yield Clinical Pearls for NEET-PG** * **Kit 1 (Grey):** Azithromycin + Cefixime (for Cervicitis/Urethritis). * **Kit 2 (Green):** Metronidazole + Fluconazole (for Vaginitis). * **Whiff Test:** Positive (fishy odor) in Bacterial Vaginosis (KOH mount). * **Strawberry Cervix:** Classic sign of *Trichomonas vaginalis*. * **Curdy White Discharge:** Classic for *Candida albicans*.

Question 424: What is the common mode of transmission in pyogenic TB salpingitis?

A. Hematogenous (Correct Answer)
B. Ascending infection
C. Direct invasion
D. Sexually transmitted

Explanation: **Explanation:** Genital tuberculosis is almost always a **secondary infection** resulting from a primary focus elsewhere in the body, most commonly the lungs. **1. Why Hematogenous is Correct:** The fallopian tubes are the most frequently affected organ in female genital TB (90-100% of cases). The primary mode of spread is **hematogenous (blood-borne)**. Mycobacteria travel from the primary pulmonary focus via the bloodstream and lodge in the subepithelial layers of the fallopian tubes. From the tubes, the infection typically spreads downwards to the endometrium (50-60%) and ovaries (20-30%). **2. Why Other Options are Incorrect:** * **Ascending Infection:** This is the common route for most Pelvic Inflammatory Diseases (PID) caused by *Chlamydia* or *Gonorrhea*, but it is extremely rare for TB. * **Direct Invasion:** This occurs only rarely via lymphatic spread from an infected adjacent organ, such as the intestines (tuberculous peritonitis) or mesenteric nodes. * **Sexually Transmitted:** While theoretically possible if a partner has active genitourinary TB, it is not the standard or common mode of transmission. **Clinical Pearls for NEET-PG:** * **Most common site:** Fallopian tubes (bilateral involvement is the rule). * **Infertility:** TB salpingitis is a major cause of tubal factor infertility in endemic regions. * **Hysterosalpingography (HSG) findings:** Look for "Lead pipe" tubes, "Beaded" appearance, or "Tobacco pouch" appearance. * **Gold Standard Diagnosis:** Endometrial biopsy/aspirate for Histopathology (showing granulomas) and Culture (Lowenstein-Jensen medium) or GeneXpert.

Question 425: What is red degeneration of a uterine fibroid?

A. It is aseptic infarction. (Correct Answer)
B. It occurs only during pregnancy.
C. It causes leucopenia with lymphocytosis.
D. It is due to emboli occluding the major blood vessels supplying the myoma.

Explanation: **Explanation:** **Red Degeneration (Carneous Degeneration)** is a form of **aseptic infarction** of a uterine fibroid. It occurs when a rapidly growing fibroid outstrips its blood supply, leading to venous obstruction, congestion, and subsequent interstitial hemorrhage. The characteristic "red" appearance is due to the diffusion of hemoglobin into the infarcted tissue. * **Why Option A is correct:** It is a necrobiotic process caused by acute ischemia. Unlike an infection, it is "aseptic," meaning no bacteria are involved; the inflammation is purely a response to tissue necrosis. * **Why Option B is incorrect:** While most common during the **second half of pregnancy** (due to rapid growth), it can also occur in non-pregnant women, particularly those using oral contraceptive pills. * **Why Option C is incorrect:** Clinically, red degeneration presents with acute abdominal pain, low-grade fever, and **leukocytosis** (increased WBC count), not leucopenia. * **Why Option D is incorrect:** The pathology is due to **venous thrombosis** and congestion at the periphery of the tumor, not arterial emboli. **High-Yield Clinical Pearls for NEET-PG:** * **Most common degeneration during pregnancy:** Red degeneration. * **Most common degeneration overall:** Hyaline degeneration. * **Clinical Presentation:** Acute onset of localized pain, tenderness over the fibroid, and vomiting. * **Management:** It is a **medical emergency, not a surgical one.** Management is strictly **conservative** (bed rest, analgesics like NSAIDs). Surgery (myomectomy) is contraindicated during pregnancy due to the risk of massive hemorrhage.

Question 426: What is the most common symptom of uterine retroversion?

A. Backache
B. Dyspareunia (Correct Answer)
C. Infertility
D. Diarrhea

Explanation: **Explanation:** Uterine retroversion refers to the posterior tilting of the uterus toward the rectum. While it is often an asymptomatic anatomical variant (found in approximately 20% of healthy women), when symptoms do occur, **deep dyspareunia** is the most common and characteristic presentation. **1. Why Dyspareunia is Correct:** In a retroverted uterus, the cervix is displaced anteriorly, and the uterine body, along with the ovaries (which often prolapse into the Pouch of Douglas), lies in a dependent posterior position. During sexual intercourse, mechanical thrusting causes direct pressure or impact on the retroverted fundus and the prolapsed ovaries, leading to deep pelvic pain. **2. Analysis of Incorrect Options:** * **Backache:** Historically, retroversion was blamed for chronic backache. However, modern evidence shows that simple retroversion rarely causes back pain unless it is fixed due to underlying pathology like endometriosis or Pelvic Inflammatory Disease (PID). * **Infertility:** Retroversion itself does not cause infertility. While the anterior displacement of the cervix might theoretically affect sperm deposition, clinical studies show no significant difference in conception rates compared to anteverted uteri. * **Diarrhea:** There is no direct physiological link between uterine position and bowel motility. While a retroverted uterus may press against the rectum, it typically causes constipation or tenesmus rather than diarrhea. **NEET-PG High-Yield Pearls:** * **Most common cause of "Fixed" Retroversion:** Endometriosis and PID (due to adhesions). * **Pessary Test (Hodge Test):** Used to determine if symptoms (like backache) are truly due to retroversion. If symptoms disappear after correcting the position with a pessary, the test is positive. * **Management:** Asymptomatic cases require no treatment. Symptomatic cases may require pelvic floor exercises or, rarely, surgical ventrosuspension.

Question 427: A patient presents to the gynecology outpatient department with complaints of foul-smelling frothy vaginal discharge and intense itching. On examination, a 'strawberry cervix' is noted. Which of the following statements is false regarding the causative organism?

A. It is a flagellated protozoan. (Correct Answer)
B. It is transmitted sexually.
C. Metronidazole is the drug of choice for treatment.
D. It is associated with bacterial vaginosis.

Explanation: **Explanation:** The clinical presentation of **foul-smelling frothy vaginal discharge**, intense pruritus, and the pathognomonic **"strawberry cervix"** (punctate hemorrhages on the ectocervix) is diagnostic of **Trichomoniasis**, caused by *Trichomonas vaginalis*. **Why Option A is the "False" Statement (Correct Answer):** The question asks for the **false** statement. Option A states it is a flagellated protozoan. This is a **true** biological fact about *Trichomonas vaginalis*. In the context of a "Which is false" question, a true statement is the incorrect choice unless there is a typo in the question's framing or the provided key. *Note: If the key indicates A is the answer to "Which is false," it implies the statement is incorrect, but biologically, Trichomonas IS a flagellated protozoan. In standard NEET-PG patterns, if all options A, B, and C are true, D is often the intended false statement as the association with BV is common but they are distinct entities.* **Analysis of Other Options:** * **Option B (True):** Trichomoniasis is a classic **Sexually Transmitted Infection (STI)**. Simultaneous treatment of the partner is mandatory to prevent "ping-pong" reinfection. * **Option C (True):** **Metronidazole** (2g single dose or 500mg BD for 7 days) is the gold standard treatment. Tinidazole is an alternative. * **Option D (True/Associated):** While distinct, Trichomoniasis frequently co-exists with **Bacterial Vaginosis (BV)** because both thrive in an alkaline vaginal pH (>4.5). **High-Yield Clinical Pearls for NEET-PG:** * **Organism:** Pear-shaped, jerky motility on wet mount (saline microscopy). * **pH:** Vaginal pH is typically **>4.5** (unlike Candidiasis where pH is <4.5). * **Whiff Test:** May be positive (amine odor). * **Gold Standard Diagnosis:** NAAT (Nucleic Acid Amplification Test) or Culture (Diamond’s medium). * **Pregnancy:** Associated with preterm labor and PROM (Premature Rupture of Membranes).

Question 428: What is the least common site of ectopic pregnancy?

A. Interstitial part (Correct Answer)
B. Isthmus
C. Ampulla
D. Fimbrial end

Explanation: **Explanation:** The site of an ectopic pregnancy is determined by where the blastocyst implants outside the uterine cavity. Over 95% of ectopic pregnancies occur in the Fallopian tube. **1. Why the Interstitial part is the correct answer:** The **interstitial (intramural) part** is the segment of the Fallopian tube that traverses the muscular wall of the uterus. It is the **least common tubal site**, accounting for only about **2–3%** of cases. Because this area is surrounded by thick myometrium, it can accommodate a larger gestational sac before rupturing (usually between 12–16 weeks), often leading to life-threatening hemorrhage due to its proximity to the uterine and ovarian vessels. **2. Why the other options are incorrect:** * **Ampulla (Option C):** This is the **most common** site of ectopic pregnancy (approx. 70–80%). It is the widest part of the tube where fertilization typically occurs. * **Isthmus (Option B):** This is the second most common site (approx. 12%). Rupture occurs early here (6–8 weeks) because the lumen is narrow and non-distensible. * **Fimbrial end (Option D):** This accounts for about 5% of cases. It is more common than the interstitial part but less common than the ampulla or isthmus. **Clinical Pearls for NEET-PG:** * **Most common overall site:** Ampulla (70-80%). * **Least common tubal site:** Interstitial (2-3%). * **Most common non-tubal site:** Ovary (followed by abdominal and cervical). * **Highest risk of mortality:** Interstitial pregnancy (due to delayed rupture and massive bleeding). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Question 429: Media commonly used for distension in hysteroscopy is:

A. Oxygen
B. Carbon dioxide (Correct Answer)
C. Nitrous oxide
D. Hydrogen

Explanation: **Explanation:** Hysteroscopy requires a distension medium to expand the potential space of the uterine cavity for visualization. These media are broadly classified into gaseous and liquid types. **Why Carbon Dioxide (CO₂) is Correct:** CO₂ is the most commonly used **gaseous** medium for diagnostic hysteroscopy. It is preferred because it has a high refractive index (providing excellent image clarity) and is highly soluble in blood. Its high solubility reduces the risk of a fatal gas embolism compared to other gases, as it dissolves quickly if it enters the venous circulation. It is typically delivered via an electronic insufflator at a controlled flow rate (usually <100 mL/min) and pressure (<100 mmHg). **Why Other Options are Incorrect:** * **Oxygen (A) and Hydrogen (D):** These are never used for distension. Oxygen supports combustion (risk with electrosurgery) and Hydrogen is highly flammable. Neither is sufficiently soluble in blood, posing a massive risk of air embolism. * **Nitrous Oxide (C):** While used in laparoscopy occasionally, it is not the standard for hysteroscopy. It is less soluble in blood than CO₂ and carries a higher risk of embolism if it enters the uterine sinuses. **High-Yield Clinical Pearls for NEET-PG:** * **Liquid Media:** For operative hysteroscopy (where bleeding or electrosurgery occurs), liquids are used. * **Normal Saline/Ringer’s Lactate:** Used with **bipolar** cautery (prevents hyponatremia). * **Glycine (1.5%):** Used with **monopolar** cautery. *Complication:* "TURP syndrome" or water intoxication/hyponatremia. * **Pressure Limit:** Intrauterine pressure should be kept **below the Mean Arterial Pressure (MAP)**, typically <100 mmHg, to minimize intravasation of the medium into the bloodstream. * **CO₂ Side Effect:** Can cause shoulder pain due to diaphragmatic irritation (similar to laparoscopy).

Question 430: Which among the following is used as criteria to diagnose Pelvic Inflammatory Disease (PID)?

A. Oral temperature >38.3 C (101.6 F)
B. Cervical motion tenderness or cervical/adnexal tenderness
C. Abundant white blood cells on saline microscopy of cervical secretions
D. All of the above (Correct Answer)

Explanation: The diagnosis of **Pelvic Inflammatory Disease (PID)** is primarily clinical, based on the **CDC Diagnostic Criteria**. Because the clinical presentation can be vague and the consequences of missing the diagnosis (infertility, ectopic pregnancy) are severe, a low threshold for diagnosis is maintained. ### **Explanation of the Correct Answer** The CDC classifies criteria into "Minimum" and "Additional" criteria. To diagnose PID, one or more of the **Minimum Criteria** must be present on pelvic examination: 1. **Cervical motion tenderness (Chandelier sign)** 2. **Uterine tenderness** 3. **Adnexal tenderness** (Option B) To increase the specificity of the diagnosis, **Additional Criteria** are used, which include: * **Oral temperature >38.3°C (101°F)** (Option A) * **Abnormal cervical/vaginal mucopurulent discharge** or **Abundant WBCs on saline microscopy** (Option C) * Elevated ESR or C-reactive protein. * Laboratory documentation of cervical infection with *N. gonorrhoeae* or *C. trachomatis*. Since Options A, B, and C are all recognized components of the diagnostic framework, **Option D (All of the above)** is the correct answer. ### **Clinical Pearls for NEET-PG** * **Most Common Organism:** *Chlamydia trachomatis* (most common overall); *Neisseria gonorrhoeae* (more acute presentation). * **Gold Standard Investigation:** **Laparoscopy** (shows tubal erythema and edema), though not routinely done for diagnosis. * **Definitive Diagnosis:** Endometrial biopsy (endometritis), Imaging (Tubo-ovarian abscess), or Laparoscopic findings. * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving peri-hepatitis, characterized by "violin-string" adhesions between the liver capsule and the parietal peritoneum.

Practice by Chapter

Abnormal Uterine Bleeding

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Endometriosis

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Adenomyosis

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Uterine Fibroids

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Ovarian Cysts

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Pelvic Inflammatory Disease

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Vulvovaginitis

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Pelvic Organ Prolapse

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Vulvar Disorders

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Benign Breast Diseases

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