Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 511: A 46-year-old lady has abnormal uterine bleeding with simple hyperplasia of the endometrium. What is the treatment of choice?

A. Total hysterectomy (Correct Answer)
B. Progesterone
C. Estrogen + progestogen
D. Estrogen

Explanation: **Explanation:** The management of endometrial hyperplasia is primarily determined by two factors: the **presence of cytological atypia** and the **age/reproductive status** of the patient. **Why Total Hysterectomy is the Correct Choice:** In a 46-year-old woman (perimenopausal age group) presenting with abnormal uterine bleeding (AUB) and endometrial hyperplasia, the definitive treatment is **Total Hysterectomy**. At this age, the risk of progression to malignancy or the presence of a coexisting occult endometrial carcinoma is a significant concern. Since the patient has completed her family and is nearing menopause, surgical removal of the uterus provides a permanent cure and eliminates the risk of future neoplastic transformation. **Analysis of Incorrect Options:** * **B. Progesterone:** While progestogens (like Medroxyprogesterone acetate or Levonorgestrel-IUS) are the treatment of choice for simple hyperplasia **without atypia** in younger women who wish to preserve fertility, they are not the definitive "treatment of choice" for a 46-year-old where surgical management is safer and more conclusive. * **C & D. Estrogen/Combined Therapy:** Estrogen is contraindicated as it is the primary causative factor for endometrial hyperplasia (unopposed estrogen). Adding more estrogen would worsen the condition. **NEET-PG High-Yield Pearls:** * **Classification:** Endometrial hyperplasia is now classified by the WHO (2014) into: 1. Hyperplasia without atypia, and 2. Atypical hyperplasia (Endometrial Intraepithelial Neoplasia - EIN). * **Malignant Potential:** Simple hyperplasia without atypia has a <1% risk of progressing to cancer, whereas atypical hyperplasia has a ~29% risk. * **Gold Standard:** For any postmenopausal or perimenopausal woman with atypical hyperplasia, **Total Hysterectomy** is the gold standard. * **Investigation of Choice:** For AUB in women >40 years, the first-line investigation to rule out hyperplasia/malignancy is **Fractional Curettage or Endometrial Biopsy.**

Question 512: Cervical incompetence is characterized by:

A. Cerclage operation
B. Second trimester abortion
C. Premature rupture of membranes
D. All of the above (Correct Answer)

Explanation: **Explanation:** **Cervical Incompetence (Cervical Insufficiency)** is a clinical condition characterized by the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions, labor, or both. 1. **Why "All of the above" is correct:** * **Second Trimester Abortion (Option B):** This is the classic presentation. The cervix dilates painlessly under the weight of the growing fetus, leading to recurrent mid-trimester pregnancy losses (typically between 14–26 weeks). * **Premature Rupture of Membranes (Option C):** As the cervix dilates, the fetal membranes bulge into the vagina (funneling), making them vulnerable to infection and mechanical stress, which frequently leads to Preterm Premature Rupture of Membranes (PPROM). * **Cerclage Operation (Option A):** This is the definitive surgical management. Procedures like **McDonald’s** or **Shirodkar’s cerclage** involve placing a non-absorbable stitch around the cervix to provide mechanical support. 2. **Clinical Pearls for NEET-PG:** * **Diagnosis:** Primarily clinical (history of painless spontaneous mid-trimester losses). Ultrasonography (TVS) is used to measure **cervical length**; a length **<25 mm** or "funneling" of the internal os before 24 weeks is diagnostic. * **Timing of Cerclage:** Usually performed electively between **12–14 weeks** of gestation (after confirming fetal viability and screening for chromosomal anomalies). * **Removal:** The stitch is typically removed at **37 completed weeks** or earlier if labor begins, to avoid cervical laceration. * **Gold Standard:** While McDonald is common, Shirodkar is technically superior as the stitch is placed higher (at the level of the internal os).

Question 513: Retention of urine is most likely to be caused by which type of fibromyoma?

A. Subserous fibromyoma
B. Interstitial fibromyoma
C. Submucous fibromyoma
D. Posterior cervical fibromyoma (Correct Answer)

Explanation: **Explanation:** **1. Why Posterior Cervical Fibromyoma is Correct:** Retention of urine in cases of fibroids is primarily a mechanical complication. A **posterior cervical fibromyoma** (or a fibroid in the posterior wall of the lower uterine segment) is the most common culprit. As the fibroid grows, it fills the pouch of Douglas and displaces the cervix anteriorly. This displacement pushes the cervix against the **symphysis pubis**, which in turn compresses the **urethra** and the bladder neck. This mechanical obstruction leads to acute or chronic urinary retention, typically occurring just before menstruation when the fibroid becomes more congested. **2. Analysis of Incorrect Options:** * **Subserous Fibromyoma (A):** These grow toward the peritoneal cavity. While a very large anterior subserous fibroid might cause pressure symptoms (frequency), it rarely causes acute retention unless it is pedunculated and becomes impacted. * **Interstitial (Intramural) Fibromyoma (B):** These are located within the muscular wall. While they cause heavy bleeding and bulk symptoms, they do not typically cause the specific anatomical displacement required to compress the urethra unless they are exceptionally large or located in the cervix. * **Submucous Fibromyoma (C):** These project into the uterine cavity. Their primary clinical presentation is heavy menstrual bleeding (menorrhagia) or infertility, not urinary obstruction. **3. Clinical Pearls for NEET-PG:** * **Most common symptom of fibroids:** Menorrhagia (especially in submucous and intramural types). * **Most common fibroid to undergo red degeneration:** Large fibroids during pregnancy. * **Impaction:** A retroverted gravid uterus (at 12–14 weeks) and a posterior cervical fibroid are the two classic causes of urinary retention due to urethral compression against the pubic bone. * **Broad Ligament Fibroids:** These are more likely to cause **ureteric displacement** or hydronephrosis rather than bladder neck obstruction.

Question 514: Hematosalpinx is seen in:

A. Haematocolpos
B. Torsion of hydrosalpinx
C. Tubal pregnancy
D. All of the above (Correct Answer)

Explanation: **Explanation:** Hematosalpinx refers to the accumulation of blood within the fallopian tubes. It is a clinical finding associated with various gynecological conditions where blood either originates in the tube or refluxes into it. **Why "All of the above" is correct:** 1. **Tubal Pregnancy (Option C):** This is the **most common cause** of hematosalpinx. As the ectopic pregnancy grows, it causes erosion of the tubal wall and vessels, leading to intratubal hemorrhage. 2. **Haematocolpos (Option A):** In cases of an imperforate hymen or vaginal atresia, menstrual blood accumulates in the vagina (hematocolpos), then the uterus (hematometra), and eventually refluxes into the fallopian tubes (hematosalpinx). 3. **Torsion of Hydrosalpinx (Option B):** When a pre-existing hydrosalpinx (fluid-filled tube) undergoes torsion, the venous return is obstructed first. This leads to intense congestion, rupture of small vessels, and subsequent hemorrhage into the lumen, converting a hydrosalpinx into a hematosalpinx. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause overall:** Ectopic pregnancy. * **Non-gestational causes:** Endometriosis (tubal endometriosis), pelvic inflammatory disease (PID), and cervical/vaginal stenosis. * **Triad of Ectopic Pregnancy:** Amenorrhea, abdominal pain, and vaginal bleeding (though hematosalpinx is a pathological finding, not a clinical symptom). * **Ultrasound Appearance:** A complex adnexal mass with low-level internal echoes (ground-glass appearance) if blood is old, or an "anechoic" tubular structure if acute. **Conclusion:** Since all three conditions can pathologically result in blood accumulation within the fallopian tubes, "All of the above" is the correct choice.

Question 515: A 30-year-old woman is examined for infertility. Hysterosalpingography reveals 'bead-like' fallopian tubes and clubbing of the ampulla. What is the most likely cause?

A. Gonococcus
B. Mycoplasma
C. Chlamydia
D. Mycobacterium tuberculosis (Correct Answer)

Explanation: **Explanation:** The clinical presentation and hysterosalpingography (HSG) findings are classic for **Genital Tuberculosis**, caused by *Mycobacterium tuberculosis*. **1. Why Mycobacterium tuberculosis is correct:** Genital TB is a significant cause of tubal factor infertility in developing countries. It typically spreads hematogenously to the fallopian tubes (affected in 90-100% of cases). The chronic granulomatous inflammation leads to scarring and strictures. On HSG, these alternating areas of constriction and dilatation create the characteristic **"beaded" appearance**. As the disease progresses, the fimbrial end closes, and the ampulla becomes distended and blunt, known as **"clubbing."** Other HSG signs include a "lead pipe" appearance (rigid tubes) and "tobacco pouch" appearance. **2. Why other options are incorrect:** * **Gonococcus and Chlamydia:** These are the most common causes of Pelvic Inflammatory Disease (PID). While they cause tubal damage and infertility, they typically present with **hydrosalpinx** (thin-walled, fluid-filled tubes) or complete tubal occlusion with a "retort-shaped" appearance, rather than the specific beaded/calcified pattern seen in TB. * **Mycoplasma:** While associated with bacterial vaginosis and sometimes PID, it does not produce the specific chronic granulomatous changes or the "beaded" radiological morphology associated with tuberculosis. **Clinical Pearls for NEET-PG:** * **Most common site** of Genital TB: Fallopian tubes (1st), followed by Endometrium (2nd). * **Gold Standard Diagnosis:** Endometrial biopsy for histopathology (showing giant cells/tubercles) and TB culture (BACTEC). * **Schier's Sign:** A specific HSG finding in TB where there is calcification of the pelvic lymph nodes or the tubes themselves. * **Asherman’s Syndrome:** Genital TB is a leading cause of secondary amenorrhea due to extensive intrauterine synechiae.

Question 516: Clitoromegaly is defined if the clitoris is:

A. >=5 mm
B. >=7 mm
C. >10 mm (Correct Answer)
D. 15 mm

Explanation: **Explanation:** Clitoromegaly (macroclitoris) is an abnormal enlargement of the clitoris, often serving as a clinical marker for hyperandrogenism or disorders of sexual development (DSD). **Why Option C is correct:** In clinical practice, the clitoris is measured by its **Clitoral Index**, which is the product of the longitudinal and transverse diameters. However, for a quick bedside assessment, the longitudinal diameter (length) is used. A clitoral length **>10 mm (1 cm)** in a newborn or an adult is considered the standard threshold for defining clitoromegaly. In newborns, a clitoral index >35 $mm^2$ is also diagnostic. **Analysis of Incorrect Options:** * **Option A (5 mm) & B (7 mm):** These values fall within the physiological range. The average clitoral length in a newborn is approximately 3–4 mm, and in an adult, it typically ranges from 4–7 mm. * **Option D (15 mm):** While 15 mm is certainly clitoromegaly, it is not the *defining* threshold. The definition starts at the point where the measurement exceeds the 97th percentile for the population, which is >10 mm. **High-Yield Clinical Pearls for NEET-PG:** 1. **Prader Staging:** Used to describe the degree of virilization of female genitalia; clitoromegaly is a key feature of Prader Stage 1 and above. 2. **Most Common Cause:** In newborns, the most common cause of clitoromegaly is **Congenital Adrenal Hyperplasia (CAH)** due to 21-hydroxylase deficiency. 3. **Adult Onset:** If clitoromegaly develops in an adult, clinicians must rule out **Androgen-secreting tumors** (e.g., Sertoli-Leydig cell tumors) or PCOS (though PCOS rarely causes significant clitoromegaly). 4. **Measurement:** It is measured using a sliding caliper, ensuring the glans is fully exposed.

Question 517: All of the following are characteristic features of genitourinary tuberculosis on imaging, EXCEPT?

A. Rigid, lead pipe appearance of fallopian tubes with nodulation.
B. Tobacco pouch appearance of the fallopian tube.
C. Bilateral cornual blockage.
D. Multiple nodular diverticula. (Correct Answer)

Explanation: **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).

Question 518: 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?

A. Laparotomy and cystectomy
B. Laparotomy and unilateral salpingo-oophorectomy
C. Laparoscopic aspiration of the cyst
D. Observation to see if it disappears by itself in three months (Correct Answer)

Explanation: **Explanation:** The management of an ovarian cyst in a reproductive-age woman depends primarily on the size of the cyst and its ultrasonographic features. **Why Option D is Correct:** In a 30-year-old woman, the most common cause of a 5–6 cm ovarian cyst is a **functional cyst** (such as a follicular or corpus luteum cyst). These are physiological, benign, and usually resolve spontaneously. The standard clinical protocol for a simple, unilocular cyst measuring **less than 7–8 cm** in a premenopausal woman is **expectant management**. Observation for 2–3 menstrual cycles (roughly 3 months) allows time for these functional cysts to regress. **Why Other Options are Incorrect:** * **Options A & B (Laparotomy):** Surgical intervention via laparotomy is overly invasive for a small, likely physiological cyst. Surgery is generally reserved for cysts >8 cm, those that persist beyond 3 months, or those showing suspicious features on ultrasound (solid components, septations, increased vascularity). * **Option C (Laparoscopic Aspiration):** Aspiration is not recommended because it has a high recurrence rate and carries the risk of spilling malignant cells into the peritoneal cavity if the cyst is actually a malignancy (pseudomyxoma peritonei). **High-Yield Clinical Pearls for NEET-PG:** * **Size Threshold:** Cysts **<5 cm** usually require no follow-up; **5–7 cm** require yearly follow-up or observation; **>7 cm** often require MRI or surgical intervention. * **Postmenopausal Women:** Any palpable ovary or cyst in a postmenopausal woman is considered pathological until proven otherwise (RMI - Risk of Malignancy Index is used here). * **OCPs:** Combined Oral Contraceptive Pills do not make existing cysts disappear faster, but they do prevent the formation of new functional cysts.

Question 519: Which of the following statements regarding ectopic pregnancy is true?

A. Pregnancy test is positive. (Correct Answer)
B. hCG levels should be >1000 mlU/ml for the earliest detection of the gestational sac by TVS.
C. hCG levels should be <1000 mlU/ml for the earliest detection of the gestational sac by TVS.
D. Methotrexate is used in its management.

Explanation: **Explanation:** **1. Why Option A is Correct:** In an ectopic pregnancy, trophoblastic tissue is present and functional, which produces **human chorionic gonadotropin (hCG)**. Since the urine pregnancy test (UPT) detects the presence of the beta-subunit of hCG, it will be **positive** in almost all cases of ectopic pregnancy. While hCG levels may be lower than in a normal intrauterine pregnancy (IUP) of the same gestational age, they are still high enough to trigger a positive result. **2. Why the Other Options are Incorrect:** * **Options B & C:** These refer to the **"Discriminatory Zone."** For a Transvaginal Sonography (TVS), the standard discriminatory zone to visualize an intrauterine gestational sac is an hCG level between **1500–2000 mIU/ml**. If the level is above this threshold and no sac is seen in the uterus, an ectopic pregnancy is highly suspected. Levels of 1000 mIU/ml are generally too low for reliable detection. * **Option D:** While Methotrexate is indeed used in the medical management of ectopic pregnancy, it is **not a universal statement** for all cases. Its use is restricted to hemodynamically stable patients meeting specific criteria (e.g., hCG <5000 mIU/ml, no fetal heart activity, sac size <3.5–4 cm). In a multiple-choice format where one answer is "more" fundamentally true, the physiological fact that the pregnancy test is positive takes precedence over a conditional management strategy. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ampulla of the Fallopian tube (70%). * **Most common site for rupture:** Isthmus (due to its narrow lumen). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy, indicating a pregnancy response without chorionic villi in the uterus. * **Gold Standard Diagnosis:** Laparoscopy. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases).

Question 520: What is the percentage change of cystic glandular hyperplasia turning to malignancy?

A. 0.10%
B. 0.2%
C. 1% (Correct Answer)
D. 10%

Explanation: **Explanation:** The progression of endometrial hyperplasia to malignancy depends significantly on the presence of **cellular atypia**. **Cystic Glandular Hyperplasia (CGH)**, also known as Simple Hyperplasia without atypia, is characterized by an increase in the number of glands which may be dilated (cystic), but the cells lining them do not show nuclear abnormalities. 1. **Why 1% is correct:** According to the classic **Kurman’s classification**, simple hyperplasia without atypia (CGH) has a very low malignant potential, with only about **1%** of cases progressing to endometrial carcinoma over a period of 10–20 years. 2. **Why other options are incorrect:** * **0.1% and 0.2%:** These values are too low; while the risk is minimal, it is clinically documented at approximately 1%. * **10%:** This value is more characteristic of **Complex Hyperplasia without atypia** (approximately 3–5%) or is an underestimate for cases with atypia. **High-Yield Clinical Pearls for NEET-PG:** * **The Kurman Classification Risk Profile:** * Simple Hyperplasia (CGH): **1%** * Complex Hyperplasia: **3%** * Simple Atypical Hyperplasia: **8%** * Complex Atypical Hyperplasia: **29% (approx. 30%)** * **Key Concept:** The presence of **atypia** is the single most important prognostic factor for progression to cancer. * **Management:** CGH is usually treated with progestogens (to oppose estrogen) and periodic follow-up biopsies, rather than immediate hysterectomy.

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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