Gynecological Disorders — MCQs

A third gravida is admitted with a complaint of sudden onset right-sided lower abdominal pain after a period of 5 weeks of amenorrhea. Her pulse is 130 and blood pressure is 80/50 mmHg. Transvaginal sonography reveals a large amount of free fluid in the pelvis and an empty uterine cavity. What is the next step in management?

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 51: Which of the following is NOT a therapeutic indication of laparoscopy in gynecology?

A. Vault prolapse
B. Septate uterus
C. Gamete intrafallopian transfer
D. None of the above (Correct Answer)

Explanation: **Explanation:** The correct answer is **None of the above** because all the listed options (Vault prolapse, Septate uterus, and Gamete intrafallopian transfer) are valid therapeutic indications for laparoscopy in modern gynecological practice. **1. Why the Correct Answer is Right:** Laparoscopy has evolved from a diagnostic tool to a primary therapeutic modality. Since all three options represent conditions where laparoscopic intervention is a standard treatment option, none of them can be classified as a "non-indication." **2. Analysis of Options:** * **Vault Prolapse (Option A):** Laparoscopic **Sacrocolpopexy** is the gold standard for treating post-hysterectomy vault prolapse. It offers better visualization of the sacral promontory and faster recovery compared to open surgery. * **Septate Uterus (Option B):** While hysteroscopic septoplasty is the primary treatment, **laparoscopy is performed simultaneously** to differentiate a septate uterus from a bicornuate uterus and to monitor for potential uterine perforation during the hysteroscopic resection. * **Gamete Intrafallopian Transfer (GIFT) (Option C):** This is an assisted reproductive technique where eggs and sperm are placed directly into the fallopian tubes. This procedure is performed via **laparoscopy** to ensure accurate placement. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications for Laparoscopy:** Intestinal obstruction, generalized peritonitis, and large abdominal masses (relative). * **Gold Standard:** Laparoscopy is the gold standard for diagnosing **Endometriosis** and **Ectopic Pregnancy**. * **Pneumoperitoneum:** $CO_2$ is the gas of choice due to its high solubility and non-combustibility. The intra-abdominal pressure should be maintained between **12–15 mmHg**. * **Trendelenburg Position:** Used during laparoscopy to shift bowel loops cranially, improving pelvic visualization.

Question 52: A 30-year-old female presents with complaints of recurrent abortions and menorrhagia. Her USG showed two subserosal fibroids, 3 x 4 cm each, on the anterior wall and fundus of the uterus. What is the best line of management?

A. Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH with BSO)
B. Myolysis
C. Myomectomy (Correct Answer)
D. Uterine artery embolisation (UAE)

Explanation: **Explanation:** The patient is a 30-year-old female (reproductive age) presenting with **recurrent abortions** and **menorrhagia**, likely secondary to uterine fibroids. In a young patient who desires to preserve fertility or her uterus, **Myomectomy** is the gold standard treatment. It addresses the symptoms (menorrhagia) and potential obstetric complications (recurrent abortions) while maintaining reproductive potential. **Analysis of Options:** * **Myomectomy (Correct):** This is the treatment of choice for symptomatic fibroids in women who wish to retain fertility. Even though the fibroids are subserosal, their presence in a patient with recurrent pregnancy loss warrants surgical removal to optimize the uterine environment. * **TAH with BSO (Incorrect):** Hysterectomy is a definitive treatment but is contraindicated in a 30-year-old who desires fertility. BSO is further inappropriate as it would induce premature menopause. * **Myolysis (Incorrect):** This involves thermal or cryogenic destruction of the fibroid. It is rarely performed today because it can lead to significant uterine adhesions and carries a high risk of uterine rupture during subsequent pregnancies. * **Uterine Artery Embolisation (UAE) (Incorrect):** While effective for menorrhagia, UAE is generally **avoided** in women desiring future pregnancy. It may compromise ovarian reserve and is associated with increased risks of placental abnormalities and malpresentation. **Clinical Pearls for NEET-PG:** * **Indications for Myomectomy:** Infertility, recurrent pregnancy loss, pressure symptoms, or heavy menstrual bleeding in patients desiring fertility. * **Medical Management:** GnRH agonists can be used pre-operatively for 3 months to reduce fibroid size and vascularity, making surgery easier. * **Red Flag:** Rapid growth of a fibroid in a postmenopausal woman should raise suspicion of **Leiomyosarcoma**.

Question 53: Which of the following is NOT a typical Transvaginal Sonography (TVS) finding of adenomyosis?

A. Transition zone greater than 12 mm thick
B. Endometrial cyst (Correct Answer)
C. Heterogeneous myometrium
D. Subendometrial striations

Explanation: **Explanation:** **Adenomyosis** is a benign gynecological condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium, leading to reactive hypertrophy of the surrounding muscle. **Why "Endometrial Cyst" is the correct answer:** An **endometrial cyst (Endometrioma)** is a classic feature of **Endometriosis**, specifically ovarian involvement (the "chocolate cyst"). While adenomyosis and endometriosis often coexist, an endometrial cyst is an extra-uterine finding and is not a feature of the myometrial pathology that defines adenomyosis. **Analysis of Incorrect Options (Typical TVS findings of Adenomyosis):** * **Transition Zone (TZ) > 12 mm:** The TZ is the innermost layer of the myometrium. On imaging (especially MRI, but also TVS), a thickened TZ > 12 mm is highly suggestive of adenomyosis. * **Heterogeneous Myometrium:** This is the most common TVS finding. The ectopic tissue causes an "echo-poor" or "mottled" appearance, often described as a **"salt and pepper"** pattern. * **Subendometrial Striations:** These are linear shadows or "fan-shaped" echoes radiating from the endometrium into the myometrium, representing the invasion of endometrial tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Histopathology (post-hysterectomy). * **Best Non-invasive Investigation:** MRI (more specific than TVS). * **Classic Clinical Triad:** Secondary dysmenorrhea, menorrhagia, and a **globular, symmetrically enlarged, soft/boggy uterus.** * **Mnemonic for TVS findings:** "RAIN" (Rainfall shadows/Striations, Asymmetrical thickening, Internal myometrial cysts, Nodular/Heterogeneous echoes).

Question 54: What is the most common presenting complaint in a gynecology department?

A. Bleeding per vaginum
B. Leucorrhoea (Correct Answer)
C. Prolapse uterus
D. Mass abdomen

Explanation: **Explanation:** **Leucorrhoea (Option B)** is the most common presenting complaint in the gynecology outpatient department (OPD). It refers to a non-hemorrhagic vaginal discharge that may be physiological or pathological (e.g., Vulvovaginitis, Cervicitis). Its high prevalence is attributed to the frequency of reproductive tract infections (RTIs), pelvic inflammatory disease (PID), and normal physiological variations in the vaginal milieu. **Analysis of Incorrect Options:** * **Bleeding per vaginum (Option A):** While Abnormal Uterine Bleeding (AUB) is a very frequent reason for consultation and often the most alarming for patients, statistically, it ranks second to vaginal discharge in overall OPD volume. * **Prolapse uterus (Option C):** This is a common complaint among multiparous, elderly women in specific demographics, but it does not surpass the universal prevalence of leucorrhoea across all age groups. * **Mass abdomen (Option D):** This is a relatively less common presentation, usually associated with large leiomyomas or ovarian tumors. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Leucorrhoea:** Physiological (ovulatory phase, pregnancy) or Bacterial Vaginosis (pathological). * **Most common cause of AUB in reproductive age:** FIGO PALM-COEIN classification (Polyp, Adenomyosis, Leiomyoma, Malignancy & Hyperplasia; Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified). * **Gold Standard for Vaginal Discharge:** Gram stain and Whiff test (for Bacterial Vaginosis) or Wet mount (for Trichomoniasis/Candidiasis). * **Key Distinction:** Leucorrhoea is specifically a *non-bloody* discharge; if the discharge is blood-stained, it must be investigated for malignancy.

Question 55: What is the most common histological finding of the endometrium in dysfunctional uterine bleeding (DUB)?

A. Hypertrophic
B. Hyperplastic (Correct Answer)
C. Cystic glandular hyperplasia
D. Dysplastic

Explanation: **Explanation:** **Dysfunctional Uterine Bleeding (DUB)**, now more commonly referred to under the PALM-COEIN classification as AUB-O (Ovulatory dysfunction), is most frequently caused by **anovulation**. 1. **Why Hyperplastic is correct:** In anovulatory cycles, there is a failure of ovulation, meaning no corpus luteum is formed and no progesterone is produced. The endometrium is subjected to **unopposed estrogen** stimulation. Estrogen acts as a mitogen, causing the endometrial lining to proliferate continuously without the stabilizing effect of progesterone. This leads to an overgrowth of the tissue, termed **Hyperplastic endometrium**. When this thickened lining outgrows its blood supply, it sheds irregularly, resulting in DUB. 2. **Analysis of Incorrect Options:** * **Hypertrophic:** This refers to an increase in cell size rather than cell number. The endometrial response to estrogen is proliferative (increase in number), not hypertrophic. * **Cystic glandular hyperplasia:** While this is a *type* of hyperplasia (often called "Swiss-cheese" hyperplasia), it is a specific histological variant. "Hyperplastic" is the broader, more accurate general finding encompassing various degrees of proliferation seen in DUB. * **Dysplastic:** Dysplasia refers to atypical cellular changes that are pre-malignant. While long-term unopposed estrogen can lead to atypical hyperplasia, it is not the most common finding in routine DUB. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of DUB:** Anovulation (especially at extremes of reproductive age: puberty and perimenopause). * **Gold Standard Investigation:** Endometrial Biopsy (D&C) is essential in women >35 years to rule out endometrial carcinoma. * **Drug of Choice (Medical):** Combined Oral Contraceptive Pills (COCPs) or Progestogens (to provide the "missing" progesterone). * **Most common histological type of Endometrial Cancer:** Endometrioid adenocarcinoma (often preceded by atypical hyperplasia).

Question 56: All of the following are indications for hysterectomy, EXCEPT?

A. Prolapse
B. Dysfunctional uterine bleeding
C. Endometriosis
D. Red degeneration of fibroid (Correct Answer)

Explanation: **Explanation:** The correct answer is **Red degeneration of fibroid**. **Red degeneration (Carneous degeneration)** is an aseptic infarction of a uterine fibroid, most commonly occurring during the second half of pregnancy or the puerperium. It is caused by rapid growth of the fibroid leading to venous obstruction and hemorrhage within the tumor. * **Management:** It is a **medical emergency**, not a surgical one. The standard of care is **conservative management** with bed rest, hydration, and analgesics (NSAIDs). Surgery (hysterectomy or myomectomy) is contraindicated during the acute phase due to the high risk of hemorrhage and pregnancy loss. **Analysis of Incorrect Options:** * **Prolapse:** Uterine prolapse is a classic indication for hysterectomy (specifically Vaginal Hysterectomy), especially in post-menopausal women or those who have completed their family. * **Dysfunctional Uterine Bleeding (DUB):** Now classified under AUB (PALM-COEIN), hysterectomy is indicated when medical management (hormones, NSAIDs, LNG-IUS) fails or is contraindicated, and the patient has completed her family. * **Endometriosis:** While medical management is the first line, "Definitive Surgery" (Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy) is indicated for severe, symptomatic endometriosis in women who no longer desire fertility. **Clinical Pearls for NEET-PG:** * **Red Degeneration:** Characterized by "fish-flesh" appearance and a characteristic odor (due to fatty acids). On MRI, it shows a high-signal intensity rim on T1-weighted images. * **Most common degeneration of fibroid:** Hyaline degeneration. * **Most common degeneration in pregnancy:** Red degeneration. * **Calcific degeneration:** Most common in post-menopausal women ("Womb stone").

Question 57: Which of the following investigations is NOT useful for diagnosis in a 55-year-old female presenting with postmenopausal bleeding?

A. Transvaginal USG
B. Postcoital test (Correct Answer)
C. Pap smear
D. Endometrial biopsy

Explanation: **Explanation:** The primary objective in evaluating a 55-year-old female with postmenopausal bleeding (PMB) is to rule out **endometrial carcinoma**, which is the most serious cause of this presentation. **Why Postcoital Test is the Correct Answer:** The **Postcoital Test (Huhner test)** is an outdated investigation used in the evaluation of **infertility** to assess the interaction between cervical mucus and sperm. Since a 55-year-old postmenopausal woman is no longer in her reproductive years and the clinical concern is malignancy rather than fertility, this test has no diagnostic value in this scenario. **Analysis of Other Options:** * **Transvaginal USG (TVUSG):** This is the initial screening tool of choice. A high-yield fact for NEET-PG is the **endometrial thickness (ET) cut-off**: an ET of **≤ 4 mm** has a high negative predictive value for endometrial cancer. * **Pap Smear:** While primarily a screening tool for cervical cancer, it is essential in PMB to rule out cervical causes of bleeding. Occasionally, glandular cells from an endometrial primary may also be detected on a Pap smear. * **Endometrial Biopsy:** This is the **gold standard** for definitive diagnosis. It is mandatory if the ET is > 4 mm or if bleeding is persistent/recurrent, regardless of USG findings. **Clinical Pearls for NEET-PG:** * **Most common cause of PMB:** Senile/Atrophic vaginitis or Atrophic endometritis. * **Most concerning cause of PMB:** Endometrial carcinoma (found in ~10% of cases). * **First-line investigation:** Transvaginal USG. * **Gold standard investigation:** Fractional Curettage or Hysteroscopy-guided biopsy.

Question 58: In uterine prolapse, a decubitus ulcer in the cervix is caused by:

A. Friction
B. Malignant change
C. Venous congestion (Correct Answer)
D. Trophic changes

Explanation: **Explanation:** In cases of uterine prolapse (specifically 2nd and 3rd degree), a **decubitus ulcer** is a common complication. The primary pathophysiology behind its formation is **venous congestion**. **1. Why Venous Congestion is Correct:** When the uterus descends, the uterine veins (which have thinner walls and lower pressure than arteries) are stretched and compressed against the pelvic floor or the edges of the genital hiatus. This leads to impaired venous return, resulting in passive congestion and edema of the dependent part of the cervix. The persistent edema compromises the local blood supply and tissue nutrition, leading to ischemic necrosis of the surface epithelium and the formation of an ulcer. **2. Why Other Options are Incorrect:** * **Friction:** While friction against clothing or thighs can aggravate the condition, it is not the primary cause. The ulcer is often found even when the prolapse is contained within the introitus. * **Malignant change:** A decubitus ulcer is a benign inflammatory lesion. While chronic irritation can theoretically predispose to malignancy, the ulcer itself is not a malignant process. * **Trophic changes:** This is a vague term. While tissue nutrition is affected, the specific underlying mechanism in prolapse is vascular (venous) rather than neurogenic or primary trophic failure. **Clinical Pearls for NEET-PG:** * **Location:** It is typically found on the dependent part of the cervix (usually the anterior lip). * **Characteristics:** It is a "clean" ulcer with regular margins and a red, granulating base. It is usually painless unless infected. * **Management:** The first step in management is **repositioning the uterus** (reducing the prolapse) and packing the vagina with gauze soaked in **glycerine and acriflavine**. Glycerine acts as a hygroscopic agent to reduce edema, while acriflavine acts as an antiseptic. * **Surgical Note:** A decubitus ulcer is not a contraindication to surgery; however, it should be healed with local packing before performing a Vaginal Hysterectomy or Fothergill’s operation to reduce the risk of post-operative infection.

Question 59: Frozen pelvis is usually associated with which of the following conditions?

A. Tuberculous endosalpingitis
B. Tuberculous salpingitis (Correct Answer)
C. Interstitial tuberculous salpingitis
D. Subserous myoma

Explanation: **Explanation:** The term **"Frozen Pelvis"** refers to a clinical condition where the pelvic organs (uterus, tubes, and ovaries) become densely adherent to each other and to the surrounding structures like the bladder, rectum, and pelvic walls. This results in a complete loss of mobility of the pelvic organs during a bimanual examination. **Why Tuberculous Salpingitis is correct:** Genital Tuberculosis (TB) most commonly affects the Fallopian tubes (90-100% of cases). **Tuberculous salpingitis** leads to chronic inflammation, causing extensive "plastic" adhesions and the formation of a tubo-ovarian mass. This intense inflammatory process results in the characteristic "frozen pelvis." While other conditions like Stage IV endometriosis or advanced pelvic inflammatory disease (PID) can also cause this, in the context of TB, salpingitis is the primary driver. **Analysis of Incorrect Options:** * **Tuberculous endosalpingitis:** This refers specifically to the infection of the inner lining of the tube. While it is the initial stage of the infection, a frozen pelvis requires transmural involvement and perisalpingitis to create external adhesions. * **Interstitial tuberculous salpingitis:** This involves the muscular layer of the tube. While part of the pathology, it is a localized description and not the standard clinical term associated with the global pelvic fixity seen in TB. * **Subserous myoma:** These are usually mobile unless they are very large or pedunculated and twisted. They do not typically cause the dense, inflammatory adhesions required to "freeze" the pelvis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site for Genital TB:** Fallopian Tubes (1st), followed by Endometrium (2nd). * **Hysterosalpingography (HSG) findings in TB:** Tobacco pouch appearance, Lead pipe appearance, or Bead-on-a-string appearance. * **Differential Diagnosis for Frozen Pelvis:** Genital TB, Endometriosis, Advanced Pelvic Malignancy, and Chronic PID. * **Key Symptom:** Infertility is the most common presenting complaint in Genital TB.

Question 60: A third gravida is admitted with a complaint of sudden onset right-sided lower abdominal pain after a period of 5 weeks of amenorrhea. Her pulse is 130 and blood pressure is 80/50 mmHg. Transvaginal sonography reveals a large amount of free fluid in the pelvis and an empty uterine cavity. What is the next step in management?

A. Perform laparoscopy
B. Treat with intramuscular methotrexate
C. Perform urgent laparotomy (Correct Answer)
D. Do serum beta-hCG to confirm diagnosis

Explanation: ### Explanation The clinical presentation of sudden onset abdominal pain, amenorrhea (5 weeks), and signs of hemodynamic instability (Tachycardia: 130 bpm; Hypotension: 80/50 mmHg) in a woman of reproductive age is a classic triad for a **Ruptured Ectopic Pregnancy**. The TVS findings of an empty uterus and significant free fluid (hemoperitoneum) confirm the diagnosis of a surgical emergency. **Why Urgent Laparotomy is the Correct Choice:** In a hemodynamically unstable patient with a suspected ruptured ectopic pregnancy, the priority is **resuscitation and immediate surgical intervention**. Laparotomy is the gold standard in an unstable patient because it allows for faster access to the bleeding site and quicker control of hemorrhage compared to laparoscopy. **Analysis of Incorrect Options:** * **A. Perform laparoscopy:** While laparoscopy is the preferred approach for stable patients, it is contraindicated in patients with severe shock/hemodynamic instability due to the time required for pneumoperitoneum and the potential for CO2 insufflation to further compromise venous return. * **B. Treat with intramuscular methotrexate:** Medical management is strictly reserved for hemodynamically stable patients with low beta-hCG levels and no evidence of rupture. * **D. Do serum beta-hCG:** While beta-hCG is used for diagnosis in stable cases, waiting for lab results in a patient with a BP of 80/50 mmHg is a fatal delay. Diagnosis here is clinical. **Clinical Pearls for NEET-PG:** * **Golden Rule:** If a patient with suspected ectopic pregnancy is **unstable**, the answer is always **Laparotomy**. If **stable**, the answer is **Laparoscopy**. * **Arias-Stella Reaction:** A high-yield histological finding in the endometrium associated with ectopic pregnancy (hypersecretory glands with enlarged nuclei). * **Pouch of Douglas (POD) fluid:** On TVS, the presence of echogenic fluid in the POD in this context is highly suggestive of hemoperitoneum.

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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