Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 661: Clue cells are seen in which of the following conditions?

A. Bacterial vaginosis (Correct Answer)
B. Moniliasis
C. Trichomoniasis
D. All of the above

Explanation: **Explanation:** **Bacterial Vaginosis (BV)** is the correct answer. It is a clinical syndrome resulting from the replacement of normal hydrogen peroxide-producing *Lactobacillus* species in the vagina with high concentrations of anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Mobiluncus*, and *Mycoplasma hominis*). **Clue Cells** are the pathognomonic microscopic finding for BV. These are vaginal epithelial cells that have a "stippled" or "shaggy" appearance because their borders are obscured by numerous coccobacilli adhering to them. Under a saline wet mount, these cells must comprise at least 20% of the total epithelial cells to be diagnostically significant. **Why other options are incorrect:** * **Moniliasis (Candidiasis):** Characterized by the presence of pseudohyphae and budding yeast cells on a KOH mount. * **Trichomoniasis:** Characterized by the presence of pear-shaped, flagellated, motile protozoa (*Trichomonas vaginalis*) on a wet mount. **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:** Fishy odor on adding 10% KOH. 4. **Clue cells** on microscopy (Most specific). * **Nugent Scoring:** The "Gold Standard" for diagnosis based on Gram stain morphotypes. * **Treatment:** Drug of choice is **Metronidazole** (500 mg BID for 7 days). Treatment of the male partner is NOT recommended. * **Complications:** Increased risk of Preterm Labor (PTL) and Pelvic Inflammatory Disease (PID).

Question 662: A 35-year-old female who has completed her family presents with an asymptomatic 10-week size fibroid. What is the most appropriate management?

A. Observation only (Correct Answer)
B. Hysterectomy with bilateral salpingo-oophorectomy
C. Hysteroscopic myomectomy
D. Myomectomy

Explanation: ### Explanation The management of uterine leiomyomas (fibroids) is primarily guided by the **presence of symptoms** and the **patient’s reproductive goals**, rather than the size of the fibroid alone (unless it is excessively large, typically >12–14 weeks). **Why "Observation only" is correct:** In this scenario, the patient is **asymptomatic**. Current clinical guidelines (ACOG) recommend expectant management (observation) for asymptomatic women with fibroids. Since the uterus is only 10-week size (well below the traditional threshold for surgery based on size alone) and she has no complaints of heavy menstrual bleeding or pressure symptoms, no surgical or medical intervention is required. Periodic follow-up with pelvic examinations or ultrasound is sufficient. **Why other options are incorrect:** * **Hysterectomy with BSO:** This is an over-treatment. While she has completed her family, major surgery is not indicated for an asymptomatic condition. Furthermore, BSO is generally avoided in a 35-year-old to prevent premature menopause unless there is specific adnexal pathology. * **Myomectomy / Hysteroscopic Myomectomy:** These are fertility-preserving surgeries. Since the patient is asymptomatic and has completed her family, the risks of surgery (hemorrhage, adhesion formation) outweigh any potential benefits. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom of fibroid:** Menorrhagia (Heavy Menstrual Bleeding). * **Most common site:** Intramural; **Most symptomatic:** Submucosal. * **Indications for surgery:** Severe pain, heavy bleeding causing anemia, rapid growth (suspicion of malignancy), or pressure symptoms (urinary frequency/hydronephrosis). * **Red Flag:** Rapid increase in size in a postmenopausal woman suggests **Leiomyosarcoma** (though rare, <0.5%). * **Medical Management:** GnRH agonists are used pre-operatively to reduce fibroid size and correct anemia, but they are not a definitive long-term cure.

Question 663: Which of the following is true about tubal pregnancy?

A. Intrauterine contraceptive device (IUCD) use predisposes to tubal pregnancy.
B. A prior tubal pregnancy is a predisposing factor.
C. A history of pelvic inflammatory disease (PID) or Chlamydia infection is a predisposing factor.
D. All of the above. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. All of the above.** Tubal pregnancy, the most common form of ectopic pregnancy, occurs when a fertilized ovum implants outside the uterine cavity, usually due to factors that delay or prevent its passage into the uterus. 1. **Prior Tubal Pregnancy (Option B):** This is the **strongest risk factor** for a recurrence. Once a patient has had one ectopic pregnancy, the risk of another increases by approximately 10-fold (roughly a 15% recurrence rate) due to underlying tubal damage or surgical scarring. 2. **History of PID/Chlamydia (Option C):** Pelvic Inflammatory Disease, particularly caused by *Chlamydia trachomatis*, leads to salpingitis. This results in the destruction of endosalpingeal cilia and the formation of intratubal adhesions (folds), which physically trap the embryo. 3. **IUCD Use (Option A):** While IUCDs are highly effective at preventing all pregnancies, if a woman *does* conceive with an IUCD in situ, the pregnancy is statistically more likely to be ectopic. This is because the IUCD prevents intrauterine implantation more effectively than it prevents tubal implantation. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ampulla (70%), followed by the Isthmus. * **Most common cause:** Chronic Salpingitis (PID). * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serial β-hCG levels (Discriminatory zone: 1500–2000 mIU/mL). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on curettage, indicating pregnancy but not necessarily its location.

Question 664: Ectopic pregnancy is most commonly associated with:

A. Endometriosis
B. Congenital tubal anomalies
C. Tuberculosis
D. Tubal inflammatory diseases (Correct Answer)

Explanation: **Explanation:** The most common site for ectopic pregnancy is the fallopian tube (95%), and the primary risk factor is any condition that causes **structural or functional damage** to the tubal cilia and mucosa. **1. Why Tubal Inflammatory Diseases (TID/PID) is correct:** Pelvic Inflammatory Disease (PID), often caused by *Chlamydia trachomatis* or *Neisseria gonorrhoeae*, leads to endosalpingitis. This results in the loss of ciliary action and the formation of intratubal adhesions (plicae). These changes physically obstruct or delay the transport of the fertilized ovum to the uterine cavity, leading to implantation within the tube. It is the single most common identifiable risk factor. **2. Why other options are incorrect:** * **Endometriosis:** While it can cause pelvic adhesions and distort anatomy, it is a much less frequent cause of ectopic pregnancy compared to infection. * **Congenital tubal anomalies:** Conditions like accessory ostia or tubal hypoplasia are rare occurrences in the general population. * **Tuberculosis:** Genital TB is a significant cause of infertility in developing countries because it often leads to complete tubal occlusion (e.g., "lead pipe" tubes). While it can cause ectopic pregnancy, the incidence of PID-related ectopic cases is statistically much higher. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ampulla of the fallopian tube (70%). * **Most common site for rupture:** Isthmus (due to its narrow lumen). * **Strongest risk factor:** Previous history of ectopic pregnancy (increases risk by 10-fold). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Discriminatory zone: 1500–2000 mIU/mL). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on curettage, characteristic of (but not diagnostic for) ectopic pregnancy.

Question 665: Corpus luteum cyst occurs due to:

A. HCG (Correct Answer)
B. HPL
C. Estrogen
D. Progesterone

Explanation: **Explanation:** The **Corpus Luteum (CL)** is a temporary endocrine structure formed from the ovarian follicle after ovulation. Its primary role is to secrete progesterone to support a potential pregnancy. **Why HCG is the correct answer:** The maintenance and growth of the corpus luteum are directly dependent on **Human Chorionic Gonadotropin (HCG)**. In a normal menstrual cycle, the CL regresses (becomes corpus albicans) due to the lack of LH/HCG. However, if fertilization occurs, the syncytiotrophoblast secretes HCG, which acts on the LH receptors of the CL. This "rescues" the corpus luteum, causing it to enlarge and continue producing progesterone. When this stimulation is excessive or prolonged, it can lead to the formation of a **Corpus Luteum Cyst** (often seen in early pregnancy or gestational trophoblastic disease). **Analysis of Incorrect Options:** * **B. HPL (Human Placental Lactogen):** This hormone is involved in maternal metabolism and insulin resistance; it has no luteotrophic effect on the ovary. * **C. Estrogen:** While the CL secretes some estrogen, estrogen itself does not stimulate the formation or maintenance of the cyst; it actually provides negative feedback to the pituitary. * **D. Progesterone:** This is the *product* of the corpus luteum, not the cause of its formation. High levels of progesterone actually inhibit the gonadotropins required for follicular development. **NEET-PG High-Yield Pearls:** * **Theca Lutein Cysts:** These are bilateral cysts caused by **hypersensitivity to HCG**, commonly associated with Molar Pregnancy, Multiple Gestation, or Ovulation Induction. * **Luteoma of Pregnancy:** A rare, non-neoplastic virilizing tumor of the ovary that regresses spontaneously postpartum. * **Corpus Luteum of Pregnancy:** It is most active during the first **7–10 weeks** of gestation, after which the "Luteo-placental shift" occurs, and the placenta takes over progesterone production.

Question 666: Which of the following treatments is not indicated in ectopic pregnancy?

A. Salpingectomy
B. Salpingo-oophorectomy (Correct Answer)
C. Salpingostomy
D. Resection of involved segment

Explanation: ### Explanation The primary goal in the surgical management of ectopic pregnancy is to remove the conceptus while preserving as much healthy tissue as possible, particularly the ovary, to maintain the patient’s future fertility and hormonal balance. **Why Salpingo-oophorectomy is the correct answer:** In a tubal ectopic pregnancy, the pathology is confined to the fallopian tube. The ovary is rarely involved and has its own independent blood supply (ovarian artery). Therefore, removing the ovary (**Salpingo-oophorectomy**) along with the tube is unnecessary and considered over-treatment. It is **not indicated** unless there is a specific reason like a concomitant ovarian torsion, malignancy, or a rare tubo-ovarian abscess. **Analysis of Incorrect Options:** * **Salpingectomy:** This is the standard **radical** surgical treatment. It is indicated when the tube is ruptured, there is severe hemorrhage, or the tube is extensively damaged. * **Salpingostomy:** This is a **conservative** surgical procedure where a longitudinal incision is made on the tube to remove the products of conception, leaving the tube intact. It is preferred in hemodynamically stable patients who desire future fertility. * **Resection of involved segment:** This is specifically indicated for **isthmic pregnancies**. Since the isthmus has a narrow lumen, a salpingostomy often leads to scarring and occlusion; therefore, segmental resection followed by delayed re-anastomosis is preferred. **NEET-PG High-Yield Pearls:** * **Most common site of Ectopic Pregnancy:** Ampulla (Fallopian tube). * **Most common site of Rupture:** Isthmus (due to narrow lumen). * **Gold Standard Investigation:** Transvaginal Ultrasound (TVUS) + Serial β-hCG (Discriminatory zone: 1500–2000 mIU/mL). * **Medical Management:** Methotrexate (50 mg/m²) is the drug of choice in hemodynamically stable patients with a small sac (<3.5–4 cm) and no fetal heart activity.

Question 667: A 55-year-old woman presents with post-menopausal bleeding. Pelvic examination reveals a normal cervix, and a Pap smear performed one month prior was normal. Her ultrasound shows an endometrial thickness of 1 mm and atrophic ovaries. What is the most probable diagnosis?

A. Cervical cancer
B. Endometrial cancer
C. Senile endometritis (Correct Answer)
D. Ovarian cancer

Explanation: **Explanation:** The patient presents with post-menopausal bleeding (PMB), which is a "red flag" symptom requiring immediate evaluation. However, the diagnostic findings point towards a benign, atrophic etiology rather than malignancy. **Why Senile Endometritis is correct:** In post-menopausal women, the lack of estrogen leads to thinning (atrophy) of the endometrial lining and the vaginal mucosa. **Senile endometritis** occurs when this thin, friable lining becomes inflamed or infected, leading to spotting or bleeding. The key diagnostic clue here is the **endometrial thickness (ET) of 1 mm**. In PMB, an ET of **≤ 4 mm** has a high negative predictive value for endometrial cancer, making atrophy or senile endometritis the most likely cause. **Why the other options are incorrect:** * **Cervical Cancer:** Ruled out by the normal pelvic examination of the cervix and the recent normal Pap smear. * **Endometrial Cancer:** While PMB is the classic presentation, an ET of 1 mm is extremely unlikely for malignancy. Endometrial cancer typically presents with a thickened, irregular endometrium (usually >5 mm in post-menopausal women). * **Ovarian Cancer:** Usually presents with vague abdominal symptoms, adnexal masses, or ascites. Atrophic ovaries on ultrasound are a normal physiological finding in a 55-year-old and argue against ovarian malignancy. **NEET-PG High-Yield Pearls:** * **Most common cause of PMB:** Atrophic vaginitis/endometritis (Senile endometritis). * **Most common "malignant" cause of PMB:** Endometrial carcinoma. * **Cut-off for ET in PMB:** If ET is **≤ 4 mm**, the risk of malignancy is <1%, and a biopsy is generally not required unless bleeding persists. * **Gold Standard Investigation for PMB:** Fractional Curettage or Hysteroscopy-guided biopsy (if ET > 4 mm).

Question 668: In gynecologic surgery, what is the most common procedure associated with ureter injury and where is the typical site of injury?

A. Vaginal hysterectomy, tunnel of Weheim
B. Bladder neck suspension, tunnel of Weheim
C. Laparoscopic oophorectomy, pelvic brim near the infundibulopelvic ligament
D. Simple abdominal hysterectomy, pelvic brim near the infundibulopelvic ligament (Correct Answer)

Explanation: **Explanation:** Ureteral injury is a significant complication of gynecological surgery due to the close anatomical proximity of the ureter to the female reproductive organs. **1. Why Option D is Correct:** Statistically, **Simple Abdominal Hysterectomy** is the most common procedure associated with ureteric injury, simply because it is one of the most frequently performed major gynecological surgeries. The most common site of injury during this procedure is at the **pelvic brim**, specifically during the ligation of the **infundibulopelvic (IP) ligament**. At this point, the ureter crosses the external iliac artery and lies immediately medial and posterior to the ovarian vessels within the IP ligament, making it highly vulnerable to clamping or accidental ligation. **2. Analysis of Incorrect Options:** * **Option A & B:** While injuries can occur at the **Tunnel of Wertheim** (where the ureter passes under the uterine artery—"water under the bridge"), this site is more commonly associated with *Radical Hysterectomies* rather than simple ones. * **Option C:** Laparoscopic procedures have a rising incidence of injury, but abdominal hysterectomy remains the leading cause in total volume. Furthermore, the injury in oophorectomy is specific to that step, whereas hysterectomy involves multiple danger zones. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common site of injury overall:** Distal 1/3rd of the ureter (near the uterine artery ligation or the vesicoureteric junction). * **Most common site during IP ligament ligation:** Pelvic brim. * **Gold Standard for Diagnosis:** Intravenous Pyelogram (IVP) or CT Urogram. * **Intraoperative Detection:** Intravenous indigo carmine dye can be used to check for leaks. * **Prevention:** Always identify the ureter by its characteristic **peristalsis** and its "snapping" sensation when flicked (the "Luschka" sign).

Question 669: Mayer-Rokitansky-Kuster-Hauser syndrome is characterized by which of the following findings?

A. Presence of ovaries, uterus, and fallopian tubes
B. Absence of the uterus, but presence of fallopian tubes and ovaries (Correct Answer)
C. Absence of all reproductive organs
D. Presence of the uterus, but absence of tubes and ovaries

Explanation: **Explanation:** **Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome**, also known as Müllerian Agenesis, is a congenital anomaly characterized by the failure of the Müllerian ducts (paramesonephric ducts) to develop. **1. Why the Correct Answer is Right:** The Müllerian ducts are responsible for forming the **uterus, fallopian tubes, and the upper two-thirds of the vagina**. In MRKH, these structures are either absent or rudimentary. However, the **ovaries** develop from the primitive germ cells and the genital ridge, not the Müllerian ducts. Therefore, patients with MRKH have a normal female karyotype (46, XX), normal ovarian function, and normal secondary sexual characteristics, but lack a uterus and the upper vaginal canal. **2. Analysis of Incorrect Options:** * **Option A:** Incorrect because the hallmark of MRKH is the absence of the uterus. * **Option C:** Incorrect because the ovaries (gonads) are present and functional. Only the Müllerian-derived structures are missing. * **Option D:** Incorrect because it describes the opposite of the pathology; in MRKH, the uterus is absent while the ovaries are preserved. **3. NEET-PG High-Yield Clinical Pearls:** * **Presentation:** Typically presents as **primary amenorrhea** in a young girl with normal breast development (Tanner stage 5) and normal pubic hair. * **Karyotype:** 46, XX (Distinguishes it from Androgen Insensitivity Syndrome, which is 46, XY). * **Associated Anomalies:** Up to 40% of cases have **renal anomalies** (e.g., renal agenesis, ectopic kidney) and 10-15% have skeletal anomalies (e.g., spinal malformations like Klippel-Feil syndrome). * **First-line Investigation:** Pelvic Ultrasound; however, **MRI** is the gold standard for characterizing the anatomy. * **Treatment:** Non-surgical vaginal dilation (Frank’s dilators) is the first-line management for creating a functional vagina.

Question 670: Which drug is used for the management of ectopic pregnancy?

A. Methotrexate (Correct Answer)
B. Mifepristone
C. Procarbazine
D. Cytosine arabinoside

Explanation: **Explanation:** **Methotrexate (Option A)** is the drug of choice for the medical management of unruptured ectopic pregnancy. It is a folic acid antagonist that inhibits the enzyme **dihydrofolate reductase**, thereby preventing the synthesis of DNA, RNA, and proteins. Since trophoblastic tissue is rapidly dividing, it is highly sensitive to methotrexate, which effectively halts the growth of the ectopic pregnancy and allows for gradual resorption. **Why other options are incorrect:** * **Mifepristone (Option B):** While it is an anti-progestogen used for medical abortion (in combination with Misoprostol), it is not the primary treatment for ectopic pregnancy. It acts on the decidua but is insufficient to reliably terminate a tubal pregnancy. * **Procarbazine (Option C):** This is an alkylating agent primarily used in the treatment of Hodgkin’s lymphoma, not in obstetric practice. * **Cytosine arabinoside (Option D):** Also known as Cytarabine, this is a chemotherapy agent used for leukemias and has no role in managing ectopic pregnancies. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for Methotrexate:** Hemodynamically stable patient, unruptured mass <3.5–4 cm, no fetal cardiac activity, and baseline serum β-hCG <5000 mIU/mL. * **Contraindications:** Breastfeeding, immunodeficiency, ruptured ectopic pregnancy, or hepatic/renal dysfunction. * **Dosing:** Most commonly administered as a single intramuscular dose (50 mg/m²). * **Monitoring:** Success is defined by a ≥15% drop in β-hCG levels between Day 4 and Day 7 after administration.

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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