Gynecological Disorders Practice Questions

Q: A 32-year-old woman presents with menorrhagia and dysmenorrhea. An ultrasound reveals adenomyosis. What is the best initial treatment option for this condition?

NSAIDs. **NSAIDs** - **Nonsteroidal anti-inflammatory drugs (NSAIDs)** are often the first-line treatment for pain and heavy bleeding associated with adenomyosis, as they help reduce prostaglandin production and uterine contractions. - They are a conservative, **symptomatic treatment** suitable for women who desire future fertility or milder symptoms. *Hysterectomy* - **Hysterectomy** is a definitive cure for adenomyosis but is typically reserved for women with severe symptoms who have completed childbearing or when other treatments have failed, as it is a major surgical procedure. - It permanently removes the uterus, thus eliminating all symptoms, but it's not the **initial, least invasive** option. *Endometrial ablation* - **Endometrial ablation** involves destroying the uterine lining and is effective for heavy menstrual bleeding, but it does not treat the deep myometrial invasion characteristic of adenomyosis and may provide only temporary relief for pain in such cases. - It is generally less effective for adenomyosis compared to its efficacy in treating typical dysfunctional uterine bleeding because the **adenomyotic tissue** is often located deep within the myometrium, beyond the reach of standard ablation techniques. *Gonadotropin-releasing hormone agonists* - **Gonadotropin-releasing hormone (GnRH) agonists** induce a temporary, reversible menopause-like state by suppressing ovarian hormone production, which can reduce symptoms of adenomyosis. - However, they are typically used for **short-term treatment** due to potential side effects like bone loss and menopausal symptoms, and are often considered after NSAIDs or as a bridge to surgery, not as the primary initial treatment.

Q: A 30-year-old woman presents with abnormal uterine bleeding and an enlarged uterus. Which diagnostic test is the most appropriate?

Pelvic ultrasound. ***Pelvic ultrasound*** - A **pelvic ultrasound** is the most appropriate initial diagnostic test for evaluating abnormal uterine bleeding and an enlarged uterus, as it is non-invasive, widely available, and cost-effective. - It can visualize structural abnormalities such as **fibroids**, **adenomyosis**, or **endometrial polyps**, which are common causes of these symptoms. - Recommended by **ACOG guidelines** as the first-line imaging modality for these presentations. *Hysteroscopy* - While hysteroscopy allows for direct visualization of the uterine cavity and directed biopsies, it is typically performed *after* an initial imaging study like ultrasound has identified potential intrauterine pathology. - It is a more invasive procedure and not usually the first-line diagnostic test. *Endometrial biopsy* - An **endometrial biopsy** is crucial for ruling out **endometrial hyperplasia** or **carcinoma**, especially in women over 45 years or those with risk factors. - However, it primarily assesses the endometrial lining and may not fully explain an "enlarged uterus" if the cause is, for example, a large fibroid in the myometrium, so it often follows imaging. *MRI pelvis* - **MRI pelvis** provides excellent detailed anatomical information, particularly for characterizing complex uterine masses or for surgical planning. - It is generally reserved for cases where ultrasound findings are inconclusive or when more detailed tissue characterization is required, and it is more expensive and less accessible than ultrasound.

Q: What non-surgical intervention is primarily used to manage patients with symptomatic uterine fibroids who wish to retain their fertility?

Gonadotropin-releasing hormone agonists. ***Gonadotropin-releasing hormone agonists*** - GnRH agonists are the **primary medical therapy** for symptomatic fibroids in women desiring future fertility. - They effectively **shrink fibroid size** by 40-60% and reduce **menorrhagia** by inducing a temporary hypoestrogenic state. - Commonly used as **preoperative therapy** before myomectomy to reduce fibroid size, decrease vascularity, and improve surgical outcomes. - After discontinuation, **ovulation and fertility return** within 2-3 months, making them ideal as a bridge to definitive fertility-sparing surgery or pregnancy. - Used for 3-6 months to maximize benefit while minimizing bone density loss. *Progestin-releasing intrauterine device* - The LNG-IUS effectively reduces **menstrual bleeding** and provides symptomatic relief from fibroid-related menorrhagia. - However, it is a **contraceptive device** that prevents pregnancy, making it inappropriate for women actively trying to conceive. - Best suited for women who want to avoid hysterectomy and have **completed childbearing** or need temporary contraception. *Oral contraceptive pills* - OCPs can help manage **heavy menstrual bleeding** but do not significantly shrink fibroids. - They are **contraceptive** by nature, preventing ovulation and pregnancy. - Not suitable for women actively seeking fertility. *Nonsteroidal anti-inflammatory drugs (NSAIDs)* - NSAIDs provide **symptomatic relief** of pain and reduce menstrual bleeding by inhibiting prostaglandin synthesis. - They do not affect fibroid size or growth and offer no disease-modifying benefit. - Used as adjunctive therapy, not primary management.

Q: A 28-year-old woman is diagnosed with gonococcal cervicitis (NAAT positive for Neisseria gonorrhoeae) and presents with purulent cervical discharge. What is the most likely complication if left untreated?

Pelvic inflammatory disease (PID). ***Pelvic inflammatory disease (PID)*** - **Untreated gonococcal cervicitis** can ascend to the upper genital tract, leading to inflammation of the uterus, fallopian tubes, and ovaries, which is known as **Pelvic Inflammatory Disease (PID)** - This is the most common complication of untreated gonococcal infection, occurring in **10-20%** of cases - PID presents with **fever**, **lower abdominal pain**, **adnexal tenderness**, and may lead to serious sequelae including infertility, ectopic pregnancy, and chronic pelvic pain *Ovarian torsion* - **Ovarian torsion** involves the twisting of the ovary on its vascular pedicle, leading to acute, severe unilateral lower abdominal pain - It is typically associated with ovarian masses or cysts and is **not a complication of gonococcal cervicitis** *Bartholin's gland abscess* - A **Bartholin's gland abscess** presents as a painful, tender, swollen mass in the posterior labia majora - While *Neisseria gonorrhoeae* can cause Bartholin's gland infection, this is a **localized lower genital tract infection**, not an ascending complication - The most common ascending complication remains **PID** *Disseminated gonococcal infection* - **Disseminated gonococcal infection (DGI)** occurs when *N. gonorrhoeae* invades the bloodstream, causing **arthritis-dermatitis syndrome**, tenosynovitis, and rarely endocarditis or meningitis - DGI is relatively **rare (0.5-3% of cases)** compared to PID - PID is the **most likely** complication of untreated gonococcal cervicitis

Q: A 34-year-old woman presents with pelvic pain and a palpable adnexal mass. The CA-125 level is elevated. What is the next best step in management?

Transvaginal ultrasound. ***Transvaginal ultrasound*** - A **transvaginal ultrasound** is the initial and most appropriate imaging modality for evaluating a **palpable adnexal mass** and determining its characteristics. - It helps distinguish between benign and malignant features, guiding further diagnostic and management steps before more invasive procedures. *Immediate laparotomy* - **Immediate laparotomy** is an invasive surgical procedure and is typically reserved for cases with a high suspicion of malignancy or acute emergencies, such as **ruptured ectopic pregnancy** or **ovarian torsion**, after initial imaging and diagnostic workup. - Performing a laparotomy without prior imaging for characterization of the mass could lead to unnecessary surgery if the mass is benign or could be managed less invasively. *CT scan of the abdomen and pelvis* - While a **CT scan** provides detailed anatomical information, it is generally considered a secondary imaging study for ovarian masses and is performed after an initial ultrasound has characterized the mass. - CT scans expose the patient to **ionizing radiation** and are less effective than ultrasound for detailed characterization of ovarian mass morphology. *MRI of the pelvis* - An **MRI of the pelvis** offers excellent soft-tissue contrast and can further characterize indeterminate adnexal masses found on ultrasound, often used to differentiate between benign and malignant lesions. - However, it is a more expensive and time-consuming imaging modality and is typically performed after an initial **transvaginal ultrasound** if the findings are equivocal or require further clarification.

Q: A 30-year-old woman presents with vaginal discharge and pelvic pain. Examination reveals cervical motion tenderness. What is the next step?

Antibiotics. ***Antibiotics*** - The symptoms of **vaginal discharge**, **pelvic pain**, and **cervical motion tenderness** are highly suggestive of **Pelvic Inflammatory Disease (PID)**. - Initial management for PID is typically prompt empirical antibiotic therapy to prevent complications such as infertility or ectopic pregnancy *Laparoscopy* - This is a more invasive procedure generally used for definitive diagnosis or management of complications like **tubo-ovarian abscesses** or when the diagnosis is uncertain despite initial treatment. - It is not the **first-line intervention** for suspected PID without failed medical management or red flag symptoms. *Ultrasound* - While ultrasound can be helpful in identifying complications of PID, such as **tubo-ovarian abscesses** or ruling out other conditions. - It is not the **initial therapeutic step** for suspected PID, where timely antibiotic treatment is crucial. *Hysteroscopy* - This procedure involves inserting a thin scope into the uterus to visualize the uterine cavity. - It is primarily used for investigating causes of abnormal uterine bleeding, infertility, or recurrent miscarriage, and is **not indicated** for the initial management of PID.

Q: A 30-year-old woman presents with secondary amenorrhea and a history of curettage. What is the diagnosis?

Asherman syndrome. ***Asherman syndrome*** - **Asherman syndrome** is characterized by the formation of **intrauterine adhesions** (scar tissue), typically as a complication of uterine surgeries like **curettage**. - These adhesions can lead to **secondary amenorrhea** by preventing normal endometrial growth and shedding, despite normal ovarian function. *Polycystic ovary syndrome* - **PCOS** presents with **oligomenorrhea** or amenorrhea, but it's usually primary or secondary amenorrhea without a clear history of uterine instrumentation. - Key features include **hyperandrogenism** (hirsutism, acne) and **polycystic ovaries** on ultrasound, which are not mentioned. *Hypothyroidism* - **Hypothyroidism** can cause menstrual irregularities, including **amenorrhea**, due to its impact on the hypothalamic-pituitary-gonadal axis. - However, it typically presents with other systemic symptoms like **fatigue**, **weight gain**, and **cold intolerance**, and the history of curettage directly points to a uterine cause. *Premature ovarian failure* - **Premature ovarian failure (POF)** involves the cessation of ovarian function before age 40, leading to **amenorrhea** and menopausal symptoms like hot flashes and vaginal dryness. - It would be associated with **elevated FSH** and **low estrogen**, but the history of curettage makes Asherman syndrome a more direct explanation for secondary amenorrhea.

Q: 60 yr female with a history of intermittent bleeding. What is the diagnosis based on the ultrasound image?

Endometrial polyp. ***Endometrial polyp*** - An **endometrial polyp** often presents as a **well-defined, homogeneous mass** within the endometrial cavity on ultrasound, which aligns with the description of the provided image. - Intermittent bleeding, especially in a 60-year-old female, is a common symptom of endometrial polyps, due to their fragile nature and potential for surface ulceration. *Endometrial carcinoma* - **Endometrial carcinoma** typically appears as an **irregularly thickened endometrium** or a heterogeneous mass with ill-defined borders and increased vascularity, which is not clearly illustrated in the provided image. - While postmenopausal bleeding is a hallmark symptom, the characteristic ultrasound appearance of a homogeneous, well-circumscribed lesion makes carcinoma less likely based on the image alone. *Submucosal fibroid* - A **submucosal fibroid** would typically appear as a **hypoechoic, well-circumscribed mass** originating from the myometrium and distorting the endometrial cavity, often with posterior shadowing. - The image suggests a lesion arising from the endometrium itself rather than the myometrial wall, differentiating it from a fibroid. *Uterine sarcoma* - **Uterine sarcoma** is a very aggressive and rare tumor, often presenting as a **rapidly growing, heterogeneous mass** with areas of necrosis and hemorrhage. - Its ultrasound features are usually more complex and irregular compared to the homogeneous appearance of the lesion in the image.

Q: Identify the X-ray HSG image shown below:

Unicornuate uterus. ***Unicornuate uterus*** - The image distinctly shows a **single, banana-shaped uterine horn** with only one fallopian tube visible, characteristic of a unicornuate uterus resulting from the unilateral arrest of Mullerian duct development. - The contrast material preferentially fills this single cavity, and there is no evidence of a second, rudimentary horn or a bilobed appearance. *Septate uterus* - A septate uterus would show a **normal uterine contour externally** but an **internal septum** dividing the uterine cavity into two cornua. - The image does not show a bilobed uterine cavity with a dividing septum; instead, it demonstrates a single, elongated horn. *Uterus didelphys* - Uterus didelphys involves **two completely separate uteri**, each with its own cervix and vagina, resulting from a complete failure of Mullerian duct fusion. - The image displays a single uterine cavity, not two distinct uterine bodies. *Bicornuate uterus* - A bicornuate uterus is characterized by a **heart-shaped external contour** with a deep fundal indentation and two divergent uterine horns, though often sharing a single cervix and vagina. - The image does not present a prominent fundal indentation or two distinct uterine horns, but rather a single, slender horn.

Q: In a woman complaining of AUB, the following image was seen in endoscopic examination of uterus. What will be the diagnosis?

Leiomyoma. ***Leiomyoma*** - The question describes an **endoscopic image** within the uterus showing a specific finding, which, given AUB, is most consistent with the appearance of a **uterine leiomyoma** (fibroid). - **Submucosal leiomyomas**, in particular, can protrude into the uterine cavity, making them visible on hysteroscopy and are a common cause of **abnormal uterine bleeding (AUB)**. *Adenomyosis* - **Adenomyosis** involves endometrial tissue growing into the myometrium, which is typically diagnosed by **MRI** or **transvaginal ultrasound** showing a thickened, heterogeneous myometrium. - It is generally not directly visualized as a distinct mass within the uterine cavity during a hysteroscopy in the manner a leiomyoma might be. *Ovarian neoplasm* - An **ovarian neoplasm** is a growth on the ovary and would not be visible during an **endoscopic examination of the uterus** (hysteroscopy). - While ovarian tumors can cause hormonal imbalances affecting uterine bleeding, they are physically located outside the uterus. *Carcinoma of uterus* - **Uterine carcinoma** (endometrial cancer) often appears as an **irregular, friable, or exophytic mass** on hysteroscopy due to abnormal endometrial growth. - While it can cause AUB and be seen endoscopically, the typical appearance described for a leiomyoma (e.g., a smooth, well-defined mass) is different from the more irregular and often infiltrative nature of cancer.

Question 1

A 32-year-old woman presents with menorrhagia and dysmenorrhea. An ultrasound reveals adenomyosis. What is the best initial treatment option for this condition?

Accepted Answer

NSAIDs

Answer

Hysterectomy

Answer

Endometrial ablation

Answer

Gonadotropin-releasing hormone agonists

Question 2

A 30-year-old woman presents with abnormal uterine bleeding and an enlarged uterus. Which diagnostic test is the most appropriate?

Accepted Answer

Pelvic ultrasound

Answer

Hysteroscopy

Answer

Endometrial biopsy

Answer

MRI pelvis

Question 3

What non-surgical intervention is primarily used to manage patients with symptomatic uterine fibroids who wish to retain their fertility?

Accepted Answer

Gonadotropin-releasing hormone agonists

Answer

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Answer

Progestin-releasing intrauterine device

Answer

Oral contraceptive pills

Question 4

A 28-year-old woman is diagnosed with gonococcal cervicitis (NAAT positive for Neisseria gonorrhoeae) and presents with purulent cervical discharge. What is the most likely complication if left untreated?

Accepted Answer

Pelvic inflammatory disease (PID)

Answer

Ovarian torsion

Answer

Bartholin's gland abscess

Answer

Disseminated gonococcal infection

Question 5

A 34-year-old woman presents with pelvic pain and a palpable adnexal mass. The CA-125 level is elevated. What is the next best step in management?

Accepted Answer

Transvaginal ultrasound

Answer

Immediate laparotomy

Answer

CT scan of the abdomen and pelvis

Answer

MRI of the pelvis

Question 6

A 30-year-old woman presents with vaginal discharge and pelvic pain. Examination reveals cervical motion tenderness. What is the next step?

Accepted Answer

Antibiotics

Answer

Laparoscopy

Answer

Ultrasound

Answer

Hysteroscopy

Question 7

A 30-year-old woman presents with secondary amenorrhea and a history of curettage. What is the diagnosis?

Accepted Answer

Asherman syndrome

Answer

Polycystic ovary syndrome

Answer

Hypothyroidism

Answer

Premature ovarian failure

Question 8

60 yr female with a history of intermittent bleeding. What is the diagnosis based on the ultrasound image?

Accepted Answer

Endometrial polyp

Answer

Endometrial carcinoma

Answer

Submucosal fibroid

Answer

Uterine sarcoma

Question 9

Identify the X-ray HSG image shown below:

Accepted Answer

Unicornuate uterus

Answer

Septate uterus

Answer

Uterus didelphys

Answer

Bicornuate uterus

Question 10

In a woman complaining of AUB, the following image was seen in endoscopic examination of uterus. What will be the diagnosis?

Accepted Answer

Leiomyoma

Answer

Adenomyosis

Answer

Ovarian neoplasm

Answer

Carcinoma of uterus

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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