Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 471: In a patient with pelvic inflammatory disease due to tuberculosis, which of the following statements is true?

A. Mycobacterium can be grown from menstrual blood
B. Associated with infertility
C. Ectopic pregnancy is common
D. All of these (Correct Answer)

Explanation: **Explanation:** Genital Tuberculosis (GTB) is a significant cause of chronic Pelvic Inflammatory Disease (PID) in developing countries, typically occurring secondary to a primary focus (usually pulmonary) via hematogenous spread. 1. **Mycobacterium in Menstrual Blood:** The endometrium is involved in 50-60% of GTB cases. Since the functional layer of the endometrium sheds during menstruation, *Mycobacterium tuberculosis* can be detected via culture (Löwenstein–Jensen medium) or PCR of the menstrual blood, particularly if collected within the first 48 hours of the cycle. 2. **Infertility:** This is the most common presenting symptom (found in 85-90% of patients). The infection causes chronic inflammation leading to cornual block, peritubular adhesions, and "lead pipe" rigid tubes, severely impairing conception. 3. **Ectopic Pregnancy:** GTB causes extensive damage to the fallopian tube mucosa and ciliary function. Even if the tubes remain patent, the distorted anatomy and impaired peristalsis significantly increase the risk of an embryo implanting outside the uterus. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Fallopian tubes (95-100%), followed by the Endometrium (50-60%). * **Gold Standard Diagnosis:** Endometrial biopsy for histopathology (showing caseating granulomas) and culture. * **Characteristic Signs:** "Beaded tube" appearance on HSG and "Tobacco pouch" appearance of the ovaries/tubes. * **Latent Infection:** GTB is often asymptomatic; a high index of suspicion is required in any young woman presenting with primary infertility and a history of constitutional symptoms (weight loss, low-grade fever).

Question 472: A 35-year-old female complains of clear, mucoid, non-offensive vaginal discharge without pruritus. She has a history of tubal damage. The cervix appears inflamed on per speculum examination. What is the most likely cause?

A. Bacterial vaginosis
B. Chlamydia (Correct Answer)
C. Gonorrhea
D. Trichomonas

Explanation: **Explanation:** The clinical presentation points toward **Chlamydia trachomatis** (Serotypes D-K), the most common bacterial sexually transmitted infection. **Why Chlamydia is the correct answer:** 1. **Nature of Discharge:** Chlamydia typically presents with a **clear, mucoid, or mucopurulent** discharge. Unlike vaginitis, it primarily causes **cervicitis**, explaining the inflamed appearance of the cervix on examination. 2. **Lack of Irritation:** It is often "silent" or presents without significant pruritus or odor, matching the patient's symptoms. 3. **Tubal Damage:** Chlamydia is the leading cause of **Pelvic Inflammatory Disease (PID)**. It has a predilection for the fallopian tubes, leading to scarring, tubal factor infertility, and ectopic pregnancies. The history of tubal damage is a classic "red flag" for prior Chlamydial infection. **Why other options are incorrect:** * **Bacterial Vaginosis:** Characterized by a thin, greyish-white, **fishy-smelling** discharge. It does not typically cause cervical inflammation or direct tubal damage. * **Gonorrhea:** Usually presents with a more **profuse, thick, yellow-green purulent** discharge and more acute inflammatory symptoms compared to the mucoid discharge of Chlamydia. * **Trichomonas:** Presents with a **frothy, greenish-yellow** discharge, intense pruritus, and the classic "strawberry cervix" (punctate hemorrhages), which is not described here. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Nucleic Acid Amplification Test (NAAT). * **Treatment:** Azithromycin (1g stat) or Doxycycline (100mg BID for 7 days). * **Fitz-Hugh-Curtis Syndrome:** Peri-hepatitis (violin-string adhesions) is a known complication of Chlamydial PID. * **Reiter’s Syndrome:** Can occur as a sequela (Urethritis, Conjunctivitis, Arthritis).

Question 473: What is the most common cause of vesicovaginal fistula?

A. Laparoscopy
B. Abdominal hysterectomy
C. Obstructed labour (Correct Answer)
D. Cystoscopy

Explanation: **Explanation:** A **Vesicovaginal Fistula (VVF)** is an abnormal epithelialized communication between the urinary bladder and the vagina, resulting in continuous involuntary leakage of urine. **Why Obstructed Labour is the Correct Answer:** In developing countries like India, **obstructed labour** remains the most common cause of VVF. During prolonged obstructed labour, the fetal head compresses the maternal soft tissues (bladder and vagina) against the pubic symphysis. This leads to **pressure necrosis** and ischemia of the tissues. The necrotic tissue sloughs off 3–10 days postpartum, creating a fistulous track. **Analysis of Incorrect Options:** * **Abdominal Hysterectomy (Option B):** While this is the **most common cause of VVF in developed nations** (iatrogenic injury), it ranks second to obstetric causes in developing countries. Injury typically occurs during the dissection of the bladder flap or accidental ligation. * **Laparoscopy (Option A) & Cystoscopy (Option D):** These are rare causes of VVF. While laparoscopic hysterectomy carries a risk of thermal or sharp injury to the bladder, it is statistically less frequent than open surgery or obstructed labour. Cystoscopy is a diagnostic procedure and rarely results in fistula formation unless associated with severe bladder wall trauma. **Clinical Pearls for NEET-PG:** * **Most common cause (Global/Developing nations):** Obstructed labour. * **Most common cause (Developed nations/Iatrogenic):** Total Abdominal Hysterectomy. * **Characteristic Sign:** Continuous "dribbling" of urine despite normal voiding (if the fistula is small). * **Diagnostic Test:** **Three-swab test** (Methylene blue dye is instilled into the bladder; if the top swab is soaked in blue dye, it confirms VVF). * **Management:** Small fistulae may heal with continuous catheterization; larger ones require surgical repair (e.g., Ward-Mayo’s or Latzko’s procedure), typically performed 3–6 months after the initial injury to allow inflammation to subside.

Question 474: Colposcopy is used to visualize which of the following structures?

A. Upper 2/3rd of the endocervix (Correct Answer)
B. Lower 1/3rd of the endocervix
C. Lateral fornix
D. Vault of the vagina

Explanation: **Explanation:** Colposcopy is a diagnostic procedure used to examine the cervix, vagina, and vulva under magnification. The primary goal of colposcopy in cervical cancer screening is to visualize the **Transformation Zone (TZ)**—the area where the squamous epithelium of the ectocervix meets the columnar epithelium of the endocervix. **Why Option A is Correct:** The colposcope provides a magnified view of the **ectocervix** and the **distal portion of the endocervical canal**. In a "satisfactory" colposcopy, the entire squamocolumnar junction (SCJ) must be visible. While the colposcope cannot see deep into the internal os, it effectively visualizes the **upper 2/3rd of the endocervix** (the visible portion of the canal) to rule out pre-malignant lesions like CIN (Cervical Intraepithelial Neoplasia). **Why Other Options are Incorrect:** * **Option B:** The "lower 1/3rd" is an anatomical misnomer in this clinical context; the focus is on the SCJ, which usually lies at the external os or slightly within the canal. * **Options C & D:** While the lateral fornices and the vaginal vault (post-hysterectomy) can be inspected using a colposcope (Vaginoscopy), they are not the primary structures for which colposcopy is indicated or standardized. Colposcopy is specifically designed to evaluate the cervical transformation zone. **High-Yield Clinical Pearls for NEET-PG:** * **Acetic Acid (3-5%):** Used to identify "acetowhite" areas (high nuclear-to-cytoplasmic ratio). * **Schiller’s Test (Lugol’s Iodine):** Normal squamous epithelium stains **mahogany brown** (contains glycogen); cancerous cells remain **unstained (yellow/pale)**. * **Green Filter:** Used to highlight abnormal vascular patterns like **punctations** and **mosaicism**. * **Satisfactory Colposcopy:** Defined as the ability to visualize the entire 360° of the Squamocolumnar Junction.

Question 475: A 24-year-old woman presents with primary infertility and acute abdominal pain. Her vital signs are: blood pressure 90/60 mm Hg, pulse rate 102 bpm. Her hematocrit is 28%. Which of the following is a feature of ectopic pregnancy?

A. Elevated blood pressure on assuming an erect position
B. Pulsus paradoxus
C. Tenderness below the right subcostal margin (Murphy's sign)
D. Pain referred to the supraclavicular region (Correct Answer)

Explanation: ### Explanation The clinical presentation of acute abdominal pain, hypotension (90/60 mm Hg), tachycardia (102 bpm), and a low hematocrit (28%) in a woman of reproductive age strongly suggests a **ruptured ectopic pregnancy** with resulting hemoperitoneum and hypovolemic shock. **Why Option D is Correct:** The correct answer is **pain referred to the supraclavicular region (Laffon’s sign)**. When an ectopic pregnancy ruptures, blood accumulates in the peritoneal cavity. As the patient lies down, this blood tracks up to the subdiaphragmatic space, irritating the **phrenic nerve (C3-C5)**. Since the supraclavicular nerves share the same spinal origin (C3-C4), the brain perceives this irritation as pain in the shoulder/neck area. This is a classic example of **referred pain**. **Analysis of Incorrect Options:** * **Option A:** In hypovolemic shock, blood pressure **decreases** (orthostatic hypotension) rather than elevates when assuming an erect position. * **Option B:** **Pulsus paradoxus** (an exaggerated drop in systolic BP >10 mmHg during inspiration) is characteristic of cardiac tamponade or severe asthma, not ectopic pregnancy. * **Option C:** **Murphy’s sign** is indicative of acute cholecystitis. While right upper quadrant pain can occur in Fitz-Hugh-Curtis syndrome (PID), it is not a classic feature of ruptured ectopic pregnancy. **NEET-PG High-Yield Pearls:** * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Correlation with the "Discriminatory Zone" of 1500–2000 mIU/mL). * **Cullen’s Sign:** Periumbilical bluish discoloration indicating hemoperitoneum (rare but high-yield). * **Management:** Hemodynamically unstable patients (like the one in this vignette) require **immediate laparotomy**, not laparoscopy or medical management.

Question 476: The staging for pelvic inflammatory disease is described by which system?

A. Jonathan
B. Florence
C. Gainesville (Correct Answer)
D. Sartonini

Explanation: The staging of Pelvic Inflammatory Disease (PID) is clinically categorized using the **Gainesville Staging System** (also known as Monif’s Staging). This system is essential for determining the severity of the infection and guiding management (medical vs. surgical). ### Explanation of Options: * **C. Gainesville (Correct):** Developed by Monif at the University of Florida (Gainesville), this system stages PID based on clinical and laparoscopic findings: * **Stage I:** Acute salpingitis without peritonitis. * **Stage II:** Salpingitis with peritonitis. * **Stage III:** Salpingitis with inflammatory mass or Tubo-ovarian abscess (TOA). * **Stage IV:** Ruptured TOA (surgical emergency). * **A, B, and D:** These are distractors. There are no recognized medical staging systems for PID named Jonathan, Florence, or Sartonini. ### High-Yield Clinical Pearls for NEET-PG: * **Gold Standard Diagnosis:** Laparoscopy is the gold standard for diagnosing PID (visualizing "violin-string" adhesions or hyperemic tubes). * **Most Common Organisms:** *Chlamydia trachomatis* (most common overall) and *Neisseria gonorrhoeae*. * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving peri-hepatitis, characterized by "violin-string" adhesions between the liver capsule and the diaphragm. * **Treatment:** CDC guidelines recommend Ceftriaxone (500mg IM) + Doxycycline (100mg BID for 14 days) + Metronidazole (500mg BID for 14 days). * **Chandler’s Sign:** Cervical Motion Tenderness (CMT), a classic physical exam finding in PID.

Question 477: According to Shaw's classification, what defines an Grade III tear?

A. Cervical laceration above the introitus
B. Cervical laceration at the level of the introitus
C. Cervical laceration outside the introitus (Correct Answer)
D. Procidentia

Explanation: **Explanation:** Shaw’s classification is a clinical grading system used to categorize the severity of **cervical tears (lacerations)**, which often occur as a complication of instrumental vaginal delivery or precipitate labor. **Why Option C is correct:** According to Shaw’s classification, a **Grade III tear** is defined as a cervical laceration that extends **outside the introitus**. This indicates a significant injury where the tear is visible externally, often involving the vaginal vault or extending towards the lateral fornices. **Analysis of Incorrect Options:** * **Option A & B:** These describe lesser degrees of injury. Grade I involves a tear limited to the cervix itself, while Grade II involves a tear reaching up to the level of the introitus but not protruding beyond it. * **Option D (Procidentia):** This refers to a third-degree uterine prolapse where the entire uterus lies outside the vulva. While it involves anatomical displacement, it is a feature of Pelvic Organ Prolapse (POP) and is not a classification for acute cervical lacerations. **NEET-PG High-Yield Pearls:** * **Most common site:** Cervical tears most frequently occur at the **3 o’clock and 9 o’clock** positions (lateral walls). * **Clinical Presentation:** Suspect a cervical tear if there is profuse vaginal bleeding immediately after delivery despite a **firm, contracted uterus** (ruling out atonic PPH). * **Management:** Always examine the cervix under good light and anesthesia. Repair is done using interrupted or continuous catgut/vicryl sutures, starting slightly above the apex to ensure hemostasis of the retracted vessels.

Question 478: Which one of the following is the most common extrauterine site to be affected by endometriosis?

A. Vagina
B. Rectovaginal septum
C. Sigmoid colon
D. Broad ligament (except tubes and ovaries) (Correct Answer)

Explanation: **Explanation:** Endometriosis is defined as the presence of functioning endometrial tissue outside the uterine cavity. While the **ovary** is the most common site overall for endometriosis, the question specifically asks for the most common **extrauterine** site (excluding the ovaries and tubes). **1. Why the Broad Ligament is Correct:** According to standard textbooks like Shaw’s and Williams Gynecology, the **broad ligament** (specifically the posterior leaf) and the **uterosacral ligaments** are the most frequent sites for pelvic peritoneal endometriosis. These areas are anatomically dependent in the pelvis, making them prone to the implantation of endometrial cells via retrograde menstruation (Sampson’s Theory). **2. Analysis of Incorrect Options:** * **Vagina (A):** This is a rare site, usually occurring secondary to direct extension from the pouch of Douglas or following episiotomy scars. * **Rectovaginal Septum (B):** While a common site for *deep infiltrating endometriosis* (DIE), it is less frequent than superficial peritoneal implants on the broad ligament. * **Sigmoid Colon (C):** The sigmoid colon is the most common site for **bowel** endometriosis, but it is less common than primary pelvic peritoneal involvement. **3. NEET-PG High-Yield Pearls:** * **Most common site overall:** Ovary (often presenting as a "Chocolate Cyst" or Endometrioma). * **Most common site for distant/extrapelvic endometriosis:** Lungs and pleura (can cause catamenial pneumothorax). * **Classic Triad:** Dysmenorrhea (congestive/secondary), Dyspareunia, and Infertility. * **Gold Standard Diagnosis:** Laparoscopy with biopsy ("Gunpowder" or "Flame-shaped" lesions). * **Powder-burn lesions:** Represent old, inactive implants.

Question 479: Presence of a decubitus ulcer in a prolapse indicates:

A. Infection
B. Malignancy
C. Circulatory disturbances (Correct Answer)
D. Mechanical trauma

Explanation: ### Explanation **Correct Option: C. Circulatory disturbances** A **decubitus ulcer** in cases of pelvic organ prolapse (POP) is a pressure sore that typically occurs on the dependent part of the cervix or vaginal walls. The primary pathophysiology involves **venous congestion and stasis**. When the uterus prolapses, the blood vessels (especially the thin-walled veins) are stretched and kinked. This leads to impaired venous return, resulting in local edema and tissue hypoxia. The compromised circulation makes the epithelium fragile and prone to breakdown, leading to ulceration. **Why other options are incorrect:** * **Infection (A):** While a decubitus ulcer can become secondarily infected, infection is a *consequence* of the ulcer, not the primary cause of its formation. * **Malignancy (B):** Decubitus ulcers are benign. However, long-standing chronic irritation can rarely lead to squamous cell carcinoma. Clinically, a biopsy is indicated only if the ulcer fails to heal after the prolapse is reduced. * **Mechanical Trauma (D):** While friction against clothing or thighs can exacerbate the condition, the fundamental cause is the underlying circulatory compromise and tissue ischemia. **High-Yield Clinical Pearls for NEET-PG:** * **Common Site:** Usually found on the **anterior lip** of the cervix. * **Management:** The first step in management is **reduction of the prolapse** (repositioning the uterus inside) and packing with **Glycerin-Acriflavine** or estrogen cream. Glycerin acts as a hygroscopic agent to reduce edema, while Acriflavine acts as an antiseptic. * **Surgical Significance:** A decubitus ulcer is not a contraindication to surgery. In fact, preoperative bed rest and packing are used to heal the ulcer before performing a Vaginal Hysterectomy. * **Rule of Thumb:** If the ulcer does not heal within 7–10 days of local treatment and reduction, a biopsy must be performed to rule out malignancy.

Question 480: Tuberculosis of the fallopian tube occurs mainly by which route of spread?

A. Direct spread from the uterine cavity
B. Lymphatic spread
C. Hematogenous spread (Correct Answer)
D. Iatrogenic

Explanation: **Explanation:** Genital Tuberculosis (GTB) is almost always a secondary infection, originating from a primary focus elsewhere in the body—most commonly the lungs. **1. Why Hematogenous Spread is Correct:** The fallopian tubes are the most frequently affected site in female genital TB (90–100% of cases). The primary mode of infection is **hematogenous spread** (blood-borne). Tubercle bacilli reach the highly vascular endosalpinx from a primary pulmonary or abdominal focus. Once established, the infection typically spreads from the tubes downward to the uterus (endometrium) and ovaries. **2. Why Other Options are Incorrect:** * **Direct spread from the uterine cavity:** This is incorrect because the spread is usually **descending** (tubes to uterus). Primary infection of the cervix or vagina spreading upward is extremely rare. * **Lymphatic spread:** While this can occur (especially from an abdominal/mesenteric focus to the tubes), it is much less common than the hematogenous route. * **Iatrogenic:** This refers to infection introduced during medical procedures. While possible in other infections, it is not the standard mechanism for TB. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Fallopian tubes (90-100%), followed by the Endometrium (50-60%). * **Classic Sign:** "Lead pipe" or "Tobacco pouch" appearance of the tubes on imaging/laparoscopy. * **Infertility:** GTB is a major cause of tubal factor infertility in developing countries. * **Diagnosis:** Gold standard is a culture (Lowenstein-Jensen medium) or PCR of endometrial biopsy/menstrual blood, though laparoscopy is the most reliable for visual diagnosis (beaded tubes). * **Menstrual Pattern:** The most common presentation is **amenorrhea or oligomenorrhea** due to endometrial destruction (Asherman-like syndrome).

Practice by Chapter

Abnormal Uterine Bleeding

Practice Questions

Endometriosis

Practice Questions

Adenomyosis

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Uterine Fibroids

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Ovarian Cysts

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Pelvic Inflammatory Disease

Practice Questions

Vulvovaginitis

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Pelvic Organ Prolapse

Practice Questions

Vulvar Disorders

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Benign Breast Diseases

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