Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 561: The investigation of choice for an ectopic pregnancy is:

A. CT scan
B. Transvaginal USG (Correct Answer)
C. Serum HCG levels
D. MRI

Explanation: **Explanation:** The diagnosis of ectopic pregnancy relies on the "Diagnostic Triad": amenorrhea, abdominal pain, and vaginal bleeding. **Why Transvaginal Ultrasound (TVS) is the Investigation of Choice:** TVS is the gold standard imaging modality because it offers superior resolution compared to transabdominal scans. It can detect an intrauterine gestational sac as early as 4.5 to 5 weeks of gestation (at a discriminatory zone of β-hCG levels between 1,500–2,000 mIU/mL). The definitive ultrasound sign of an ectopic pregnancy is the visualization of an extrauterine gestational sac with a yolk sac or embryo ("bagel sign" or "tubal ring sign"). **Analysis of Incorrect Options:** * **A & D (CT and MRI):** These are not first-line investigations. CT involves ionizing radiation (contraindicated in early pregnancy), and MRI, while highly sensitive, is time-consuming and expensive. They are reserved only for rare, complex cases like abdominal pregnancies. * **C (Serum β-hCG levels):** While essential for confirming pregnancy and interpreting ultrasound findings (via the discriminatory zone), a single β-hCG value cannot pinpoint the *location* of the pregnancy. It is a biochemical marker, not an imaging tool. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard for Diagnosis:** TVS + Serial Serum β-hCG. * **Most Common Site:** Ampulla of the Fallopian tube. * **Most Common Site for Rupture:** Isthmus (due to narrow lumen). * **Arias-Stella Reaction:** Endometrial changes (hypersecretory glands) seen in ectopic pregnancy, though not pathognomonic. * **Pseudosac:** A fluid collection in the endometrial cavity seen in 10% of ectopic cases; unlike a true gestational sac, it is centrally located and lacks a double decidual sign.

Question 562: What is the most common cause of cervical insufficiency?

A. Idiopathic (Correct Answer)
B. Previous dilatation and curettage
C. Exposure to diethylstilbestrol (DES)
D. Conization

Explanation: **Explanation:** Cervical insufficiency (formerly known as cervical incompetence) is characterized by the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of clinical contractions. **1. Why Idiopathic is correct:** While there are several known mechanical and congenital risk factors, the **most common cause of cervical insufficiency is idiopathic**. In many patients, no specific history of trauma or structural anomaly is identified. It is often attributed to a functional deficiency in the cervical collagen-to-elastin ratio or biochemical changes in the connective tissue that lead to premature ripening. **2. Analysis of Incorrect Options:** * **Previous Dilatation and Curettage (D&C):** This is a common **acquired** cause. Forceful mechanical dilatation of the internal os can lead to structural damage, but statistically, it occurs less frequently than idiopathic cases. * **Exposure to Diethylstilbestrol (DES):** This is a **congenital** cause. DES exposure in utero leads to structural uterine anomalies (e.g., T-shaped uterus) and cervical hypoplasia. However, DES is now rarely encountered in modern clinical practice. * **Conization:** Cold knife conization or LEEP (Loop Electrosurgical Excision Procedure) removes a significant portion of the cervical stroma, weakening its structural integrity. While a significant risk factor, it is not the most common cause. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Clinical history of recurrent painless second-trimester mid-trimester losses. * **USG Finding:** "Funneling" of the internal os and a cervical length **<25 mm** before 24 weeks. * **Treatment:** Cervical Cerclage (McDonald or Shirodkar technique), typically performed between **12–14 weeks** of gestation. * **Emergent Procedure:** "Rescue cerclage" is performed when the cervix is already dilated with bulging membranes.

Question 563: Which of the following is suggestive of ectopic pregnancy in a young woman with acute abdomen?

A. Tender cervix
B. Amenorrhea
C. Positive urinary HCG
D. All of the above (Correct Answer)

Explanation: **Explanation:** Ectopic pregnancy is a life-threatening emergency and a leading cause of maternal mortality in the first trimester. The diagnosis is based on a high index of clinical suspicion in any woman of reproductive age presenting with abdominal pain. **Why "All of the Above" is correct:** The classic clinical triad of ectopic pregnancy consists of **amenorrhea**, **abdominal pain**, and **vaginal bleeding**. * **Amenorrhea (Option B):** Reflects the underlying pregnancy. In ectopic cases, the decidual breakdown due to fluctuating hormones leads to the characteristic spotting. * **Positive Urinary HCG (Option C):** This is the most sensitive initial screening tool. A positive test confirms pregnancy, which, when combined with acute pain, necessitates ruling out an ectopic location via ultrasound. * **Tender Cervix (Option A):** Also known as **Cervical Motion Tenderness (Chandelier Sign)**, this occurs due to peritoneal irritation caused by blood (hemoperitoneum) in the Pouch of Douglas. It is a hallmark finding of a ruptured or leaking ectopic pregnancy. **Clinical Pearls for NEET-PG:** * **Most common site:** Ampulla of the Fallopian tube. * **Most common site for rupture:** Isthmus (due to its narrow lumen). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serial Serum β-hCG. * **Discriminatory Zone:** The level of β-hCG (usually 1500–2000 mIU/mL) at which an intrauterine gestational sac should be visible on TVUS. If the sac is absent at this level, ectopic pregnancy is highly suspected. * **Arias-Stella Reaction:** Hypersecretory endometrium seen on histology, which is suggestive but not diagnostic of ectopic pregnancy.

Question 564: Arias-Stella reaction is not seen in which of the following conditions?

A. Ovarian pregnancy
B. Molar pregnancy
C. Interstitial pregnancy
D. Salpingitis isthmica nodosa (Correct Answer)

Explanation: **Explanation:** The **Arias-Stella reaction** is a benign, physiological change in the endometrial glands characterized by nuclear hypertrophy, hyperchromasia, and cytoplasmic vacuolation. It occurs due to the **prolonged hormonal stimulation** (primarily progesterone) associated with the presence of viable or non-viable **trophoblastic tissue** anywhere in the body. **Why Salpingitis Isthmica Nodosa (SIN) is the correct answer:** SIN is a condition characterized by nodular thickening of the isthmic portion of the fallopian tube due to the diverticula of the tubal epithelium into the muscularis layer. It is associated with infertility and an increased risk of ectopic pregnancy, but it is **not** a pregnancy-related condition itself. Since there is no trophoblastic tissue or pregnancy-associated hormonal surge in SIN, the Arias-Stella reaction is not seen. **Analysis of Incorrect Options:** * **Ovarian and Interstitial Pregnancy:** Both are forms of ectopic pregnancy. The presence of trophoblastic tissue in these conditions triggers the endometrial response, leading to the Arias-Stella reaction. * **Molar Pregnancy:** This is a gestational trophoblastic disease. The high levels of HCG and progesterone associated with molar tissue frequently induce these endometrial changes. **NEET-PG High-Yield Pearls:** * **Key Feature:** It can be mistaken for **clear cell carcinoma** of the endometrium due to its cellular atypia; however, the absence of mitosis helps differentiate it. * **Clinical Significance:** It is most commonly associated with **Ectopic Pregnancy** (found in ~50-70% of cases) but can also be seen in intrauterine pregnancy, molar pregnancy, and even after Clomiphene Citrate therapy. * **Location:** While typically seen in the endometrium, it can rarely occur in the fallopian tube or cervix.

Question 565: Which of the following statements about female genital tuberculosis is true?

A. Genital tract involvement results only from lymphatic spread.
B. Postmenstrual histopathological examination is diagnostic.
C. Polymerase chain reaction (PCR) techniques have higher sensitivity in detection. (Correct Answer)
D. Reproductive outcome following antituberculous chemotherapy is satisfactory.

Explanation: **Explanation:** **Why Option C is Correct:** Polymerase Chain Reaction (PCR) is a molecular technique that detects the DNA of *Mycobacterium tuberculosis*. In female genital tuberculosis (FGTB), the bacterial load is often very low (paucibacillary), making traditional methods like smear microscopy or culture frequently negative. PCR offers **higher sensitivity** because it can amplify even minute amounts of genetic material, allowing for detection in cases where conventional methods fail. **Analysis of Incorrect Options:** * **Option A:** The most common route of spread to the genital tract is **hematogenous** (blood-borne), usually from a primary focus in the lungs. Lymphatic spread and direct extension (e.g., from tuberculous peritonitis) are less common. * **Option B:** For histopathological diagnosis, the biopsy should ideally be taken in the **premenstrual phase** (late secretory phase). This is because the tubercles have had the maximum time to develop in the endometrium before it is shed during menstruation. * **Option D:** Unfortunately, the reproductive outcome remains **poor** even after successful antituberculous therapy (ATT). This is due to irreversible damage to the fallopian tube mucosa (causing tubal factor infertility) and endometrial scarring (Asherman-like syndrome). **Clinical Pearls for NEET-PG:** * **Most common site:** Fallopian tubes (90-100%), followed by the Endometrium (50-60%). * **Gold Standard Diagnosis:** Culture of *M. tuberculosis* on Lowenstein-Jensen (LJ) medium or BACTEC (though PCR is more sensitive). * **Classic Sign:** "Lead pipe" or "Beaded" appearance of tubes on Hysterosalpingography (HSG). * **Clinical Presentation:** Infertility is the most common presenting symptom, followed by pelvic pain and menstrual irregularities (amenorrhea or oligomenorrhea).

Question 566: Watery nature of the cervical mucus at the time of ovulation may be caused by:

A. Estrogen (Correct Answer)
B. Progesterone
C. Infection
D. All of the above

Explanation: **Explanation:** The characteristics of cervical mucus are primarily regulated by the fluctuating levels of ovarian steroids during the menstrual cycle. **1. Why Estrogen is Correct:** During the follicular phase, rising levels of **Estrogen** (peaking just before ovulation) act on the endocervical glands to produce **Type E (Estrogenic) mucus**. This mucus is characterized by being **watery, profuse, clear, and alkaline**. Its low viscosity and high water content facilitate the penetration and transport of sperm. Under the influence of estrogen, the mucus also exhibits high **spinnbarkeit** (elasticity) and a characteristic **ferning pattern** on microscopy due to increased sodium chloride concentration. **2. Why Other Options are Incorrect:** * **Progesterone:** Dominant during the luteal phase, progesterone antagonizes estrogen's effects. It produces **Type G (Gestogenic) mucus**, which is thick, opaque, viscid, and cellular. This forms a "mucus plug" that is impenetrable to sperm. * **Infection:** Inflammatory conditions (like cervicitis) typically result in purulent, thick, or malodorous discharge containing leukocytes, which is the opposite of the clear, watery mucus seen at ovulation. **NEET-PG High-Yield Pearls:** * **Spinnbarkeit Test:** Measures the elasticity of cervical mucus. At ovulation, it can be stretched 8–12 cm. * **Ferning (Arborization):** A result of crystallization of NaCl. It is maximal at ovulation and disappears after progesterone takes over (around day 21). * **Insler Score:** A clinical scoring system used to assess cervical mucus (volume, spinnbarkeit, ferning, and cervical os opening) to predict the timing of ovulation.

Question 567: A 24-year-old female presented with vaginal discharge which is thin and white with a fishy odor. A positive whiff test indicates infection with which of the following organisms?

A. TORCH
B. HIV
C. Bacterial vaginosis (Correct Answer)
D. Candida albicans

Explanation: ### Explanation The clinical presentation of thin, white vaginal discharge with a characteristic "fishy odor" and a positive whiff test is pathognomonic for **Bacterial Vaginosis (BV)**. **1. Why Bacterial Vaginosis is Correct:** Bacterial Vaginosis is a clinical syndrome resulting from a shift in the vaginal flora, where normal hydrogen peroxide-producing *Lactobacilli* are replaced by anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Mobiluncus*, and *Prevotella*). The "fishy odor" is caused by the release of volatile amines (putrescine and cadaverine) when the discharge is mixed with 10% KOH—this is known as a **positive Whiff test**. **2. Why the Other Options are Incorrect:** * **TORCH:** This refers to a group of congenital infections (Toxoplasmosis, Rubella, CMV, Herpes) that affect the fetus during pregnancy; they do not present as malodorous vaginal discharge. * **HIV:** While HIV is a sexually transmitted infection, it does not cause a specific type of vaginal discharge. However, BV can increase the risk of acquiring HIV. * **Candida albicans:** This causes Vulvovaginal Candidiasis, characterized by thick, white, "curd-like" or "cottage cheese" discharge. The whiff test is negative, and the pH is typically normal (<4.5). **3. High-Yield Clinical Pearls for NEET-PG:** * **Amsel’s Criteria (3 out of 4 required for diagnosis):** 1. Homogeneous, thin, white-grey discharge. 2. Vaginal pH > 4.5 (most sensitive). 3. Positive Whiff test (amine odor with 10% KOH). 4. Presence of **Clue cells** on saline microscopy (most specific). * **Nugent Scoring:** The "Gold Standard" for diagnosis (based on Gram stain). * **Treatment of Choice:** Oral or topical **Metronidazole** (500 mg twice daily for 7 days). Note: Treatment of the male partner is NOT recommended.

Question 568: A patient presents with signs of an abortus in the uterus and a dilated, open cervical os. This clinical presentation is suggestive of which of the following conditions?

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

Explanation: ### Explanation The clinical presentation of products of conception (abortus) still within the uterus accompanied by a **dilated/open cervical os** is the hallmark of an **Inevitable Abortion**. In this stage, the process of miscarriage has progressed to a point where it cannot be stopped or reversed. #### Analysis of Options: * **Inevitable Abortion (Correct):** Defined by vaginal bleeding, uterine cramps, and an **open internal os**. The products of conception are still inside the uterus but are destined to be expelled. * **Missed Abortion:** Characterized by fetal demise where the products of conception are retained in the uterus for a prolonged period. Crucially, the **cervical os remains closed**, and there is often a disappearance of pregnancy symptoms. * **Threatened Abortion:** Presents with vaginal bleeding, but the **cervical os is closed**, and the fetus is alive (cardiac activity present). It is the only stage of spontaneous abortion that is potentially reversible. * **Complete Abortion:** Occurs when all products of conception have been expelled. On examination, the **cervical os has usually closed**, and the uterus is contracted and empty on ultrasound. #### NEET-PG High-Yield Pearls: 1. **Cervical Os Status:** This is the most critical physical finding to differentiate types of abortion. If the os is **open**, it is either Inevitable or Incomplete. If the os is **closed**, it is either Threatened, Missed, or Complete. 2. **Management:** For Inevitable abortion, the management is typically **suction evacuation** (if <12 weeks) or medical induction to prevent infection and heavy hemorrhage. 3. **Incomplete Abortion:** Similar to inevitable (open os), but some products have already been expelled, often described as "fleshy masses" per vaginum.

Question 569: A 25-year-old woman complains of abdominal pain of rapid onset in the right lower quadrant. She subsequently undergoes surgery for suspected acute appendicitis. At surgery, however, a tubal pregnancy is discovered. What is the most frequent predisposing factor for this condition?

A. Endometriosis
B. An intrauterine device
C. Leiomyomas of the uterus
D. Pelvic inflammatory disease (Correct Answer)

Explanation: **Explanation:** The clinical presentation describes an **Ectopic Pregnancy**, which often mimics acute appendicitis when it occurs in the right fallopian tube. **1. Why Pelvic Inflammatory Disease (PID) is Correct:** PID is the **most common risk factor** for ectopic pregnancy. Infections (primarily *Chlamydia trachomatis* or *Neisseria gonorrhoeae*) lead to salpingitis, causing structural damage to the tubal mucosa, loss of ciliary action, and the formation of intratubal adhesions (endosalpingeal folds). This mechanical and functional impairment hinders the transport of the fertilized ovum, leading to implantation within the tube. **2. Analysis of Incorrect Options:** * **Endometriosis (A):** While pelvic endometriosis can cause adhesions that distort tubal anatomy, it is a much less frequent cause compared to PID. * **Intrauterine Device (B):** IUDs do not *cause* ectopic pregnancy; they are highly effective at preventing all pregnancies. However, if a woman becomes pregnant with an IUD in situ, the *proportion* of those pregnancies being ectopic is higher, but the absolute risk is lower than in non-contraceptive users. * **Leiomyomas (C):** Uterine fibroids may cause infertility or miscarriage by distorting the uterine cavity, but they are rarely implicated in the pathogenesis of tubal pregnancies. **3. NEET-PG High-Yield Pearls:** * **Most common site of Ectopic Pregnancy:** Ampulla of the Fallopian tube (70%). * **Most common site for Tubal Rupture:** Isthmus (occurs early, around 6–8 weeks). * **Strongest Risk Factor:** Prior history of ectopic pregnancy (highest odds ratio). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on histology, characteristic of (but not pathognomonic for) ectopic pregnancy.

Question 570: A 18-year-old, sexually active female has no family history of cancer or cardiac disease, and her physical examination is unremarkable. Which of the following screening tests would most benefit this patient?

A. Colonoscopy
B. Mammography
C. Pap smear (Correct Answer)
D. Pelvic scan

Explanation: **Explanation:** The correct answer is **Pap smear**. **Why it is correct:** The primary goal of screening in a young, sexually active female is the early detection of cervical dysplasia. According to standard guidelines (ACOG/FOGSI), cervical cancer screening via a **Pap smear** should generally begin at age 21. However, in the context of this question, the patient is **sexually active**. Since Human Papillomavirus (HPV) infection—the primary driver of cervical cancer—is a sexually transmitted infection, this patient is at risk. Among the options provided, the Pap smear is the only evidence-based screening tool that significantly reduces morbidity and mortality in this demographic by identifying pre-malignant lesions. **Why the other options are incorrect:** * **A. Colonoscopy:** Routine screening for colorectal cancer typically begins at age 45 (or 40 if there is a family history). It is not indicated for an asymptomatic 18-year-old. * **B. Mammography:** Routine screening for breast cancer starts at age 40–50. In an 18-year-old with no family history or palpable mass, mammography is inappropriate due to high breast tissue density and low risk. * **D. Pelvic scan:** Routine pelvic ultrasound is not a recommended screening tool for asymptomatic women. It lacks the sensitivity and specificity to serve as a screening test for ovarian or uterine cancers. **Clinical Pearls for NEET-PG:** * **Cervical Cancer Screening:** In India, the WHO/FOGSI recommends screening from age 30, but for exams, follow the standard rule: Start at **21 years** regardless of the age of onset of sexual activity (though some boards emphasize sexual activity as the trigger). * **Frequency:** Age 21–29: Pap smear every 3 years. Age 30–65: Co-testing (Pap + HPV DNA) every 5 years is preferred. * **HPV Vaccine:** Ideally administered between ages 9–14 (2 doses) or 15–45 (3 doses). It is the most effective primary prevention.

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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