Gynecological Disorders — MCQs

A 31-year-old woman presents to the emergency department because of two days of abdominal pain without vaginal bleeding. Pelvic examination reveals a closed cervical os and right adnexal pain. The serum beta hCG level is 9,000 mIU/mL. An endovaginal ultrasound demonstrates no intrauterine gestational sac. Which of the following is the most likely diagnosis?

Q580Easy

What is the procedure of choice for diagnosing uterus didelphys?

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 571: Endometrial hyperplasia is caused by:

A. Estrogen (Correct Answer)
B. Smoking
C. Ovulation-inducing drugs
D. Asherman's syndrome

Explanation: **Explanation:** **Endometrial hyperplasia** is a condition characterized by the proliferation of endometrial glands, resulting in an increased gland-to-stroma ratio. The fundamental pathophysiology is **unopposed estrogen stimulation**. Estrogen acts as a potent mitogen for the endometrium; when its proliferative effects are not countered by the differentiating effects of **progesterone** (which normally occurs after ovulation), the endometrium continues to thicken abnormally, increasing the risk of progression to endometrial carcinoma. **Analysis of Options:** * **A. Estrogen (Correct):** Chronic exposure to endogenous (e.g., PCOS, obesity, estrogen-secreting tumors like Granulosa cell tumors) or exogenous estrogen (e.g., HRT without progesterone) is the primary cause. * **B. Smoking:** Smoking is actually associated with *decreased* estrogen levels (anti-estrogenic effect) and is considered a protective factor against endometrial cancer, though it increases other health risks. * **C. Ovulation-inducing drugs:** Drugs like Clomiphene citrate induce ovulation, which leads to the formation of the corpus luteum and the production of **progesterone**. Progesterone protects the endometrium by inducing secretory changes and shedding. * **D. Asherman’s syndrome:** This involves the formation of intrauterine adhesions (synechiae) usually following trauma or infection, leading to a *denuded* or absent endometrium and amenorrhea, rather than hyperplasia. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Obesity (peripheral conversion of androstenedione to estrone in adipose tissue), Nulliparity, Early menarche/Late menopause, and **Tamoxifen** use (which acts as an agonist on the endometrium). * **WHO Classification (2014):** Simplified into two categories: 1. Hyperplasia without atypia, 2. Atypical hyperplasia (Endometrial Intraepithelial Neoplasia - EIN). * **Management:** Progestogens (like Mirena/LNG-IUS) are the treatment of choice for hyperplasia without atypia, while Hysterectomy is preferred for atypical hyperplasia due to high malignancy risk.

Question 572: What is the definitive treatment of choice for adenomyosis?

A. Hormone therapy
B. Cryotherapy
C. Curettage
D. Hysterectomy (Correct Answer)

Explanation: **Explanation:** **Adenomyosis** is a condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium, leading to a diffusely enlarged, "globular" uterus. **Why Hysterectomy is the Correct Answer:** Hysterectomy is the **definitive treatment** because it is the only curative intervention. Since the endometrial tissue is deeply embedded within the muscular wall of the uterus, it cannot be completely removed or reached by superficial procedures. For women who have completed their family or have severe, refractory symptoms (menorrhagia and dysmenorrhea), total hysterectomy (with or without ovarian preservation) remains the gold standard. **Analysis of Incorrect Options:** * **A. Hormone Therapy:** While Levonorgestrel-releasing intrauterine systems (LNG-IUS), GnRH agonists, or OCPs can provide symptomatic relief by suppressing the endometrium, they are considered medical management and not a permanent cure. Symptoms often recur once treatment stops. * **B. Cryotherapy:** This is used for cervical lesions (like CIN) or occasionally for endometrial ablation, but it cannot penetrate the deep myometrial layers involved in adenomyosis. * **C. Curettage:** Dilation and Curettage (D&C) only removes the superficial functional layer of the endometrium. It has no effect on the ectopic tissue located deep within the myometrium and is therefore ineffective for treating adenomyosis. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Secondary dysmenorrhea, menorrhagia, and a symmetrically enlarged, soft, "boggy" uterus. * **MRI Findings:** The most accurate non-invasive diagnostic tool; look for a **Junctional Zone (JZ) thickness >12 mm**. * **Histopathology:** The definitive diagnosis is made post-operatively by finding endometrial tissue >2.5 mm below the endo-myometrial junction. * **Medical Management of Choice:** LNG-IUS (Mirena) is the most effective medical option for those wishing to avoid surgery.

Question 573: Pelvic inflammatory disease is caused by all except?

A. Schistosomiasis
B. Crohn's disease
C. Syphilis
D. Leprosy (Correct Answer)

Explanation: **Explanation:** Pelvic Inflammatory Disease (PID) is an infection-induced inflammation of the upper female reproductive tract. While most cases are caused by sexually transmitted pathogens (like *N. gonorrhoeae* and *C. trachomatis*), certain non-venereal and systemic conditions can also involve the pelvic organs. **Why Leprosy is the Correct Answer:** **Leprosy (*Mycobacterium leprae*)** primarily affects the skin, peripheral nerves, and upper respiratory tract mucosa. It does **not** involve the female internal genital tract or cause PID. Therefore, it is the "except" in this list. **Analysis of Other Options:** * **Schistosomiasis:** *Schistosoma haematobium* can cause "Female Genital Schistosomiasis." The parasite can lodge in the cervix, fallopian tubes, and ovaries, leading to chronic inflammation, granuloma formation, and clinical features indistinguishable from PID. * **Crohn’s Disease:** This is a common cause of **secondary PID**. Due to the proximity of the bowel to the adnexa, transmural inflammation or fistulous tracts from the intestines can spread directly to the fallopian tubes and ovaries. * **Syphilis:** While primarily known for chancres and systemic spread, *Treponema pallidum* can involve the pelvic organs during secondary or tertiary stages, and it is traditionally categorized among the infectious causes of pelvic inflammatory changes. **NEET-PG High-Yield Pearls:** * **Most common cause of PID:** *Chlamydia trachomatis* (often subclinical/silent) followed by *Neisseria gonorrhoeae* (more acute presentation). * **Actinomycosis:** Frequently associated with long-term **IUD use**. * **Tuberculous PID:** A major cause of infertility in developing countries; usually spreads via the **hematogenous route**. * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving peri-hepatitis ("violin-string" adhesions).

Question 574: A patient in shock is diagnosed with ectopic pregnancy in the right fallopian tube. What is the postulated cause of fetal death in ectopic pregnancy?

A. Vascular accident (Correct Answer)
B. Nutritional adequacy
C. Endocrine insufficiency
D. Immune response of mother

Explanation: In an ectopic pregnancy, the gestational sac implants outside the uterine cavity, most commonly in the ampulla of the fallopian tube. Unlike the uterus, the fallopian tube lacks a thick, decidualized endometrium and a robust muscular wall capable of expanding to accommodate a growing fetus. **Explanation of the Correct Answer:** **A. Vascular accident:** This is the primary cause of fetal death. As the trophoblast invades the thin, inelastic wall of the fallopian tube, it erodes through small maternal blood vessels. This leads to **intratubal hemorrhage** or the formation of a **peritubal hematocele**. The resulting hemorrhage causes a sudden separation of the placenta from the tubal wall, leading to a "vascular accident" that abruptly cuts off the oxygen and nutrient supply to the fetus, resulting in its death. **Explanation of Incorrect Options:** * **B. Nutritional adequacy:** While the tube is less nutrient-rich than the uterus, fetal death usually occurs due to acute mechanical or vascular failure long before generalized "malnutrition" becomes the limiting factor. * **C. Endocrine insufficiency:** Although low progesterone levels are often associated with ectopic pregnancies, this is typically a *result* of a failing pregnancy rather than the primary cause of fetal death in an acute rupture or tubal abortion. * **D. Immune response of mother:** The maternal immune system does not specifically target an ectopic fetus more than an intrauterine one; the pathology is anatomical and vascular, not immunological. **NEET-PG High-Yield Pearls:** * **Most common site:** Ampulla (70%); **Most common site for rupture:** Isthmus (due to narrow lumen). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy, indicating pregnancy (but not specific to ectopic). * **Management in Shock:** Immediate laparotomy (salpingectomy) is the gold standard for a ruptured ectopic pregnancy with hemodynamic instability.

Question 575: Simple hyperplasia of the endometrium is treated with progesterone for how many days?

A. 14
B. 21 (Correct Answer)
C. 5
D. 10

Explanation: **Explanation:** Endometrial hyperplasia without atypia (Simple Hyperplasia) is primarily caused by **unopposed estrogen** stimulation. The goal of treatment is to counteract this effect using progestogens, which induce secretory changes in the endometrium, leading to its thinning and eventual shedding. **Why 21 days is correct:** For the medical management of simple hyperplasia, the standard protocol involves cyclic progestogen therapy (e.g., Medroxyprogesterone acetate 10mg). It is typically administered for **21 days per month** (usually from Day 5 to Day 25 of the cycle) for a duration of 3 to 6 months. This extended duration is necessary to ensure adequate transformation of the proliferative endometrium and to prevent progression to atypia or malignancy. **Analysis of incorrect options:** * **10 & 14 days:** While a 10–14 day course of progesterone is often used to induce a withdrawal bleed in cases of secondary amenorrhea or PCOS, it is considered **insufficient** for the therapeutic reversal of established endometrial hyperplasia. * **5 days:** This duration is too short to achieve any significant histological change in the endometrial lining and is clinically ineffective for hyperplasia. **High-Yield NEET-PG Pearls:** * **Gold Standard Treatment:** For hyperplasia *without* atypia, the **Levonorgestrel Intrauterine System (LNG-IUS)** is now considered the first-line treatment due to higher regression rates compared to oral progestogens. * **Atypical Hyperplasia:** This is a premalignant condition. In postmenopausal women or those who have completed their family, the treatment of choice is **Total Abdominal Hysterectomy**. * **Follow-up:** Patients on medical management require a repeat endometrial biopsy every 3–6 months until two consecutive negative results are obtained.

Question 576: In which stage of Pelvic Inflammatory Disease (PID) is acute salpingitis with peritonitis considered?

A. Stage 2 (Correct Answer)
B. Stage 3
C. Stage 4
D. Stage 5

Explanation: The classification of Pelvic Inflammatory Disease (PID) is based on the **Monif Staging System**, which categorizes the severity and anatomical extent of the infection. ### **Explanation of the Correct Answer** * **Stage 2 (Acute Salpingitis with Peritonitis):** In this stage, the infection has progressed beyond the fallopian tubes (salpingitis) to involve the pelvic peritoneum. The presence of pelvic peritonitis indicates that inflammatory exudate has leaked from the fimbrial ends of the tubes, causing localized irritation of the peritoneal lining. ### **Analysis of Incorrect Options** * **Stage 1 (Acute Salpingitis without Peritonitis):** The infection is limited to the fallopian tubes. There is no spread to the pelvic peritoneum or surrounding structures. * **Stage 3 (Acute Salpingitis with Tubo-ovarian Abscess):** This stage is characterized by the formation of a palpable inflammatory mass involving the tube and ovary (Tubo-ovarian Abscess or TOA). * **Stage 4 (Ruptured Tubo-ovarian Abscess):** This is a surgical emergency where the abscess ruptures, leading to generalized peritonitis and potential septic shock. * **Stage 5:** There is no Stage 5 in the standard Monif classification for PID. ### **NEET-PG High-Yield Pearls** * **Gold Standard Diagnosis:** Laparoscopy (shows tubal edema and purulent exudate). * **Most Common Organisms:** *Chlamydia trachomatis* (most common overall) and *Neisseria gonorrhoeae*. * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving peri-hepatitis ("violin-string" adhesions between the liver capsule and parietal peritoneum). * **Treatment:** CDC guidelines recommend Ceftriaxone (IM) + Doxycycline (Oral) + Metronidazole (Oral) for outpatient management.

Question 577: What is the most important structure preventing uterine prolapse?

A. Round ligament
B. Broad ligaments
C. Cardinal ligament (Correct Answer)
D. Uterosacral ligament

Explanation: **Explanation:** The pelvic organs are supported by a complex network of ligaments and the pelvic floor musculature. The primary support of the uterus is divided into three tiers, with the **Cardinal ligament (Mackenrodt’s ligament)** being the most critical. **1. Why Cardinal Ligament is Correct:** The Cardinal ligaments are thick bands of connective tissue located at the base of the broad ligament, extending from the supravaginal portion of the cervix and lateral vaginal fornices to the pelvic side walls. They provide the **primary lateral support** to the uterus, keeping the cervix in a central position and preventing downward protrusion (prolapse). **2. Analysis of Incorrect Options:** * **Round Ligament:** Its primary function is to maintain the uterus in an **anteverted (AV)** and **anteflexed (AF)** position. It does not provide significant vertical support; hence, its laxity leads to retroversion, not prolapse. * **Broad Ligament:** This is a double fold of peritoneum. It is a weak structure that primarily acts as a "cloak" for the adnexa and does not contribute significantly to uterine support. * **Uterosacral Ligament:** While these provide important **posterior support** and pull the cervix backward to maintain anteversion, they are considered secondary to the cardinal ligaments in preventing descent. **NEET-PG High-Yield Pearls:** * **Primary Support (Level 1):** Cardinal and Uterosacral ligaments. * **Secondary Support (Level 2):** Levator ani muscle (specifically the Pubococcygeus part) and pelvic fascia. * **Most important muscular support:** Levator ani. * **Most important ligamentous support:** Cardinal ligament. * **Uterine Position:** Maintained by the Round ligament (AV/AF).

Question 578: In a newborn, the vagina is lined by which epithelium?

A. Squamous
B. Transitional (Correct Answer)
C. Columnar
D. Stratified

Explanation: **Explanation:** The vaginal epithelium undergoes significant morphological changes throughout life, primarily driven by the presence or absence of maternal or endogenous estrogen. **Why "Transitional" is Correct:** In a **newborn**, the vaginal lining is described as **transitional**. This is because the vagina has been under the influence of high levels of maternal estrogen *in utero*. This hormonal stimulation causes the epithelium to be thick and multi-layered. However, immediately after birth, the sudden withdrawal of maternal estrogen causes the epithelium to thin out and transition. During this neonatal period, it is neither the fully mature stratified squamous epithelium of an adult nor the simple columnar epithelium of the endocervix; hence, it is histologically characterized as transitional. **Analysis of Incorrect Options:** * **A. Squamous:** While the adult vagina is lined by non-keratinized stratified squamous epithelium, in a newborn, the withdrawal of hormones makes "transitional" the more specific embryological/histological description. * **C. Columnar:** The vagina is derived from the urogenital sinus (lower 4/5ths) and Müllerian ducts (upper 1/5th). While the Müllerian ducts are initially lined by columnar epithelium, this is replaced by squamous/transitional cells during fetal development. * **D. Stratified:** This is a broad category. While the epithelium is multi-layered (stratified), "Transitional" is the specific term used in standard gynecological textbooks (like Shaw’s) to describe the newborn's vaginal state. **High-Yield Clinical Pearls for NEET-PG:** * **Neonatal Period:** The vagina is acidic (pH 4–5) due to maternal estrogen and the presence of Doderlein’s bacilli. * **Childhood:** As maternal estrogen fades, the epithelium becomes thin and the pH becomes **neutral or alkaline**, making children more prone to vulvovaginitis. * **Puberty:** Endogenous estrogen returns, the epithelium becomes **stratified squamous**, and glycogen deposition leads to an acidic pH. * **Newborn Bleeding:** "Pseudomenstruation" in a newborn is a normal physiological response to maternal estrogen withdrawal.

Question 579: A 31-year-old woman presents to the emergency department because of two days of abdominal pain without vaginal bleeding. Pelvic examination reveals a closed cervical os and right adnexal pain. The serum beta hCG level is 9,000 mIU/mL. An endovaginal ultrasound demonstrates no intrauterine gestational sac. Which of the following is the most likely diagnosis?

A. Ectopic pregnancy (Correct Answer)
B. Incomplete abortion
C. Ovarian torsion
D. Ruptured ovarian cyst

Explanation: **Explanation:** The diagnosis of **Ectopic Pregnancy** is established based on the concept of the **Discriminatory Zone**. This is the serum $\beta$-hCG level above which a gestational sac should be visible on ultrasound in a normal intrauterine pregnancy (IUP). 1. **Why it is correct:** For transvaginal sonography (TVS), the discriminatory zone is typically **1,500–2,000 mIU/mL**. In this patient, the $\beta$-hCG is significantly elevated at **9,000 mIU/mL**, yet the ultrasound shows an empty uterus. The combination of a positive pregnancy test, abdominal pain, adnexal tenderness, and the absence of an intrauterine sac despite high $\beta$-hCG levels is pathognomonic for an ectopic pregnancy. 2. **Why other options are incorrect:** * **Incomplete Abortion:** This would typically present with vaginal bleeding and an **open cervical os** on examination. Ultrasound would show retained products of conception within the uterus. * **Ovarian Torsion:** While it causes acute pelvic pain and adnexal tenderness, it does not explain the elevated $\beta$-hCG level. * **Ruptured Ovarian Cyst:** This can cause sudden pain and peritoneal irritation, but like torsion, it is unrelated to a positive pregnancy test unless it is a ruptured corpus luteum of pregnancy (which would usually still show an IUP). **NEET-PG High-Yield Pearls:** * **Most common site:** Ampulla of the Fallopian tube. * **Most common site for rupture:** Isthmus (due to narrow lumen). * **Gold Standard Diagnosis:** Laparoscopy. * **Medical Management (Methotrexate) Criteria:** Hemodynamically stable, $\beta$-hCG < 5,000 mIU/mL, mass < 3.5–4 cm, and no fetal heart activity.

Question 580: What is the procedure of choice for diagnosing uterus didelphys?

A. Laparoscopy
B. Intravenous pyelography (IVP)
C. Hysterosalpingography (HSG)
D. Ultrasonography (USG) (Correct Answer)

Explanation: **Explanation:** **Uterus didelphys** is a Mullerian duct anomaly resulting from the complete failure of fusion of the two Mullerian ducts. This leads to two separate hemi-uteri, two separate cervices, and often a longitudinal vaginal septum. **Why Ultrasonography (USG) is the correct answer:** USG, particularly **3D-Ultrasonography**, is considered the gold standard and the initial procedure of choice for diagnosing Mullerian duct anomalies. It allows for the visualization of two widely divergent uterine horns and, crucially, the assessment of the **external fundal contour**. In uterus didelphys, USG reveals a deep fundal cleft, distinguishing it from a septate uterus (where the external contour is normal/convex). While MRI is the most accurate non-invasive imaging modality, USG is the preferred practical diagnostic tool in clinical practice and exam scenarios. **Why the other options are incorrect:** * **Laparoscopy (A):** While it can visualize the external contour of the uterus, it is an invasive surgical procedure. It is no longer the first-line diagnostic choice when non-invasive imaging like 3D-USG is available. * **Intravenous Pyelography (B):** IVP is used to detect associated renal anomalies (e.g., renal agenesis), which occur in up to 30-50% of these patients, but it cannot diagnose the uterine anomaly itself. * **Hysterosalpingography (C):** HSG can visualize the internal uterine cavities but **cannot** see the external fundal contour. Therefore, it cannot reliably differentiate between a bicornuate uterus and a septate uterus. **High-Yield Clinical Pearls for NEET-PG:** * **Uterus Didelphys:** Look for the "double-barrel" appearance (two cervices, two uteri). * **Renal Anomalies:** Always screen the kidneys (USG/IVP) in any patient with Mullerian anomalies. * **Pregnancy:** Uterus didelphys is associated with the highest rate of successful pregnancy among Mullerian anomalies, though it carries risks of malpresentation and preterm labor. * **Gold Standard:** 3D-USG is the procedure of choice; MRI is the most accurate.

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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