Gynecological Disorders Practice Questions

Q: What is the treatment of choice for a Bartholin cyst?

Marsupialization. ***Marsupialization*** - **Marsupialization** is the gold standard for Bartholin cysts because it creates a permanent opening for drainage, preventing recurrence. - This procedure involves incising the cyst, draining its contents, and then suturing the cyst walls to the surrounding skin, forming a **self-draining pouch**. *Aspiration* - **Aspiration** is generally not recommended as a primary treatment because it offers only temporary relief and has a high rate of recurrence. - The cyst will likely refill without a permanent drainage pathway, making it an ineffective long-term solution. *Observe* - **Observation** is only appropriate for very small, asymptomatic cysts that do not cause any discomfort or pain. - For symptomatic cysts, intervention is necessary to alleviate symptoms and prevent complications like infection. *Curettage and closure* - **Curettage and closure** is not a standard treatment for Bartholin cysts and would likely lead to immediate recurrence. - Simply excising the cyst without creating a new drainage duct for the Bartholin gland would result in the gland's continued blockage and cyst formation.

Q: What is the first-line investigation of choice for diagnosis of PID?

Ultrasonography. ***Ultrasonography*** - **Transvaginal ultrasonography (TVUS)** is the **first-line imaging investigation of choice** for diagnosing PID because it is **non-invasive**, readily available, cost-effective, and can visualize important diagnostic features such as adnexal masses, hydrosalpinx, free fluid, or tubo-ovarian abscesses. - While laparoscopy offers direct visualization, TVUS provides valuable diagnostic information with less risk and discomfort, making it the preferred initial investigation that guides further management. *Laparoscopy* - **Laparoscopy** is considered the **gold standard** for definitive diagnosis of PID as it allows direct visualization of the pelvic organs and can confirm inflammation, adhesions, or abscesses. - However, it is an **invasive surgical procedure** with associated risks and is therefore reserved for cases where the diagnosis is uncertain, when conservative management fails, or when complications are suspected. - It is not the first-line investigation due to its invasiveness and the need for anesthesia. *Colposcopy* - **Colposcopy** is a procedure used to **examine the cervix and vagina** with magnification; it is primarily used for screening and diagnosis of **cervical abnormalities** or cervical intraepithelial neoplasia. - It does not visualize the internal pelvic organs (uterus, fallopian tubes, ovaries) and therefore has no role in the diagnosis of PID. *Hysteroscopy* - **Hysteroscopy** involves inserting a scope into the **uterine cavity to visualize the endometrium** and inspect for intrauterine pathology such as polyps, fibroids, or adhesions. - While it can diagnose some uterine conditions, it does not allow for visualization of the fallopian tubes or adnexa, making it unsuitable for diagnosing PID which primarily affects these extrauterine structures.

Q: What factor is associated with decreased success in the medical management of ectopic pregnancy?

Beta HCG > 5000 IU/L. ***Beta HCG > 5000 IU/L*** - A **beta-hCG level greater than 5000 IU/L** is a well-established **relative contraindication** for medical management with methotrexate. - High beta-hCG levels indicate a **larger ectopic mass with higher metabolic activity**, which significantly increases the risk of **treatment failure** and need for surgical intervention. - Most protocols recommend **surgical management** when beta-hCG exceeds 5000 IU/L due to decreased success rates with methotrexate. *Gestational sac > 3cm* - While a **large ectopic mass** (typically > 3.5-4 cm) is associated with lower success rates, the cutoff varies across guidelines. - Ectopic mass size is a relative contraindication, but **beta-hCG level** is a more standardized and objectively measurable criterion used in clinical protocols. *Duration of gestation > 5 weeks* - The **duration of gestation alone** is not a primary determinant of medical management success. - Other factors like **beta-hCG levels, mass size, and cardiac activity** are more critical in determining suitability for medical management. *Cardiac activity absent* - **Absence of cardiac activity** is actually a **favorable prognostic factor** for medical management, indicating a non-viable pregnancy with lower metabolic activity. - Medical management is often **contraindicated** when **fetal cardiac activity is present**, as it indicates a more viable and metabolically active pregnancy with higher failure risk.

Q: A 16-year-old girl presents with cyclical pelvic pain every month. She has not achieved menarche yet. On examination, a suprapubic bulge can be seen in the lower abdomen. PR examination reveals a bulging swelling in the anterior aspect. What is the most likely diagnosis?

Imperforate hymen. ***Imperforate hymen*** - The combination of **cyclical pelvic pain** without menarche (primary amenorrhea) and a **suprapubic bulge** with **bulging swelling on PR examination** strongly suggests an imperforate hymen. - This condition leads to the **accumulation of menstrual blood (hematocolpos)**, causing the observed swelling and pain. - Imperforate hymen is the **most distal obstruction** of the female genital tract, presenting with a characteristic **bulging membrane at the vaginal opening**. *Transverse vaginal septum* - This condition also causes **primary amenorrhea** and **hematocolpos** leading to cyclical pain. - However, a transverse vaginal septum is located **higher in the vagina** (not at the introitus) and would not typically present with such an obvious **bulging swelling on examination** at the vaginal opening. *Vaginal atresia* - **Vaginal atresia** involves the complete or partial absence of the vagina, which would prevent menarche and cause cyclical pain. - While it results in hematocolpos (if the uterus is present), the presentation differs from the classic **bulging membrane** seen with imperforate hymen. *Cervical agenesis* - **Cervical agenesis** is the congenital absence or incomplete formation of the cervix, leading to **primary amenorrhea** and severe cyclical pain due to retained menstrual blood in the uterus (**hematometra**). - This condition would not present with a **bulging mass on PR examination** at the vaginal level, but rather with an enlarged uterus above, as the obstruction is at the cervical level, not at the vaginal outlet.

Q: A woman comes with complaints of pain and swelling in the perineal area. She also has complaints of difficulty in walking and sitting. She gives a history of multiple sexual partners. On examination, a tender swelling is seen with redness on the labia. What is the most likely diagnosis?

Bartholin abscess. ***Bartholin abscess*** - The presentation of **painful, tender swelling with redness** on the labia, especially causing difficulty in walking and sitting, is classic for a **Bartholin gland abscess**. - **Multiple sexual partners** can increase the risk of infection leading to abscess formation due to bacterial contamination. *Chlamydial infection* - While Chlamydia is a sexually transmitted infection, it typically manifests as **cervicitis**, **urethritis**, or pelvic inflammatory disease, often with a discharge. - It does not directly cause an acute, localized labial abscess as described. *Genital Tuberculosis* - Genital tuberculosis is a **chronic condition** that usually presents with menstrual irregularities, infertility, or chronic pelvic pain. - It rarely causes an acute, tender labial swelling or abscess. *Herpes infection* - Genital herpes presents with **painful vesicles or ulcers** on the genitalia, often associated with a prodrome of itching or tingling. - It does not typically cause a single, large, tender, and red fluctuant swelling indicative of an abscess.

Q: Which distension medium is used for hysteroscopy with bipolar cautery?

NS. ***NS*** - **Normal Saline (NS)** is an **electrolyte-containing solution** (0.9% NaCl) and is thus safe to use with **bipolar electrosurgery** because it does not conduct current across the tissue but only between the two poles of the instrument. - Its isotonicity minimizes fluid shifts and its clear nature allows for good visualization. *Glycine* - **Glycine** is a **non-electrolyte solution** that is used with **monopolar electrosurgery**, as it does not conduct electrical current to the patient but only through the active electrode. - Using it with bipolar devices is unnecessary and can lead to complications such as **dilutional hyponatremia** and **hyperammonemia** if significant intravascular absorption occurs. *Carbon Dioxide* - **Carbon dioxide** is used as a distension medium for **diagnostic hysteroscopy** because of its lack of risk for fluid overload and clear visualization. - It is **contraindicated with electrosurgery** because of the risk of **gas embolism** and its potential for impaired visualization with significant bleeding. *Dextran 70* - **Dextran 70** is a **high-viscosity, non-electrolyte solution** primarily used for diagnostic hysteroscopy when blood or mucus obscures the view. - It is **contraindicated for electrosurgery** due to its non-conductive nature and the risk of **anaphylactic reactions** and **pulmonary edema** from volume expansion.

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

Endometrial polyp. ***Endometrial polyp*** - The ultrasound image shows a well-defined, **echogenic focal lesion within the endometrial cavity**, which is characteristic of an endometrial polyp. - In a 60-year-old female with intermittent bleeding, a polyp is a common cause of **postmenopausal bleeding** and is often identified as an intracavitary mass on ultrasound. - Endometrial polyps appear as **focal, hyperechoic or isoechoic masses** with a smooth contour projecting into the endometrial cavity. *Ca endometrium* - **Endometrial carcinoma** typically appears as diffuse endometrial thickening (>4-5 mm in postmenopausal women), irregular endometrial-myometrial interface, or heterogeneous endometrial echoes, often with evidence of myometrial invasion. - While bleeding is a cardinal symptom of endometrial carcinoma, the distinct **focal, well-circumscribed nature** of the lesion on ultrasound is less typical for carcinoma, which tends to be more diffuse and irregular. *Submucosal fibroid* - A **submucosal fibroid** (leiomyoma) is a benign smooth muscle tumor originating from the myometrium that protrudes into the endometrial cavity. - While it can appear as an intracavitary mass and cause abnormal bleeding, fibroids often have a more **heterogeneous or hypoechoic appearance** with posterior acoustic shadowing, compared to the isoechoic to hyperechoic appearance of a polyp. - The feeding vessel sign (blood flow at the base) is more characteristic of polyps than fibroids. *Endometrial hyperplasia* - **Endometrial hyperplasia** presents as **diffuse, uniform endometrial thickening** rather than a focal intracavitary mass. - It typically shows homogeneous increased echogenicity of the entire endometrium without a discrete, well-defined lesion as seen with a polyp. - While it can cause postmenopausal bleeding, the focal nature of the lesion in this case makes hyperplasia less likely.

Q: A sexually active female presenting with profuse frothy foul-smelling discharge with intense itching. Strawberry cervix revealed on examination. What will be the diagnosis?

Trichomonas vaginalis. **Trichomonas vaginalis** - The classic presentation of **profuse, frothy, foul-smelling vaginal discharge** with **intense itching** and the presence of a **strawberry cervix** are highly characteristic of a *Trichomonas vaginalis* infection. - *Trichomonas vaginalis* is a **motile protozoan** and a common sexually transmitted infection. *Bacterial vaginosis* - While bacterial vaginosis (BV) causes a **foul-smelling discharge** (often described as "fishy"), it is typically **thin and grayish-white**, not frothy, and does not cause a strawberry cervix. - BV is caused by an **overgrowth of anaerobic bacteria** and a decrease in lactobacilli, leading to an elevated vaginal pH. *Candidiasis* - Candidiasis (yeast infection) presents with a **thick, white, "cottage cheese-like" discharge** and intense itching, but the discharge is usually odorless and it does not cause a frothy discharge or strawberry cervix. - It is caused by an **overgrowth of *Candida* species**, primarily *Candida albicans*, and is not typically sexually transmitted. *None of the options* - Given the classic constellation of symptoms and definitive signs, a specific diagnosis can be made, making this option incorrect.

Q: 45 years female with 3 months of menorrhagia. USG showing 2 cm submucosal fibroid. What is the most appropriate management option?

Hysteroscopic myomectomy. **Hysteroscopic myomectomy** - A **2 cm submucosal fibroid** causing **menorrhagia** is best treated with hysteroscopic myomectomy to directly remove the fibroid and resolve the bleeding. - This approach is definitive for symptomatic submucosal fibroids and allows for immediate relief of heavy bleeding. *Oral contraceptive pills for symptom management* - While OCPs can reduce menstrual bleeding, they primarily manage symptoms and do not address the underlying cause, which is the **submucosal fibroid**. - For a **symptomatic submucosal fibroid**, a more definitive treatment is usually preferred over long-term symptom suppression. *Progesterone therapy for conservative management* - Progesterone therapy can help reduce bleeding but also does not remove the **submucosal fibroid** itself. - It is often used for dysfunctional uterine bleeding or smaller fibroids with less severe symptoms, not typically for a 2 cm submucosal fibroid causing significant menorrhagia. *Endometrial biopsy to rule out malignancy* - While ruling out malignancy is important in cases of abnormal uterine bleeding, an **endometrial biopsy** is not the primary treatment for a **submucosal fibroid** identified on USG. - The most appropriate next step given the clear diagnosis is to address the known cause of menorrhagia, which is the fibroid.

Question 1

What is the treatment of choice for a Bartholin cyst?

Accepted Answer

Marsupialization

Answer

Aspiration

Answer

Observe

Answer

Curettage and closure

Question 2

What is the first-line investigation of choice for diagnosis of PID?

Accepted Answer

Ultrasonography

Answer

Colposcopy

Answer

Hysteroscopy

Answer

Laparoscopy

Question 3

What factor is associated with decreased success in the medical management of ectopic pregnancy?

Accepted Answer

Beta HCG > 5000 IU/L

Answer

Gestational sac > 3cm

Answer

Duration of gestation > 5 weeks

Answer

Cardiac activity absent

Question 4

A 16-year-old girl presents with cyclical pelvic pain every month. She has not achieved menarche yet. On examination, a suprapubic bulge can be seen in the lower abdomen. PR examination reveals a bulging swelling in the anterior aspect. What is the most likely diagnosis?

Accepted Answer

Imperforate hymen

Answer

Transverse vaginal septum

Answer

Vaginal atresia

Answer

Cervical agenesis

Question 5

A woman comes with complaints of pain and swelling in the perineal area. She also has complaints of difficulty in walking and sitting. She gives a history of multiple sexual partners. On examination, a tender swelling is seen with redness on the labia. What is the most likely diagnosis?

Accepted Answer

Bartholin abscess

Answer

Chlamydial infection

Answer

Genital Tuberculosis

Answer

Herpes infection

Question 6

During a hysteroscopic removal of a submucosal fibroid, a fluid deficit of 2000 mL is estimated    in a patient. What is the immediate complication of this?

Answer

Acute tubular necrosis

Answer

DIC

Answer

Thromboembolism

Answer

Hypotension due to fluid deficit

Question 7

Which distension medium is used for hysteroscopy with bipolar cautery?

Accepted Answer

NS

Answer

Glycine

Answer

Carbon Dioxide

Answer

Dextran 70

Question 8

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

Accepted Answer

Endometrial polyp

Answer

Ca endometrium

Answer

Submucosal fibroid

Answer

Endometrial hyperplasia

Question 9

A sexually active female presenting with profuse frothy foul-smelling discharge with intense itching. Strawberry cervix revealed on examination. What will be the diagnosis?

Accepted Answer

Trichomonas vaginalis

Answer

Bacterial vaginosis

Answer

Candidiasis

Answer

None of the options

Question 10

45 years female with 3 months of menorrhagia. USG showing 2 cm submucosal fibroid. What is the most appropriate management option?

Accepted Answer

Hysteroscopic myomectomy

Answer

Oral contraceptive pills for symptom management

Answer

Progesterone therapy for conservative management

Answer

Endometrial biopsy to rule out malignancy

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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