Gynecological Disorders — MCQs

A patient with a long-standing intrauterine contraceptive device (IUCD) develops chronic pelvic pain. The device is removed, and a biopsy of the endometrium is performed. The biopsy specimen shows a prominent infiltrate composed of lymphocytes, plasma cells, and histiocytes. Which of the following is the most likely diagnosis?

Q678Medium

Which of the following is true regarding pain in endometriosis?

Q679Medium

A young lady presents with a complaint of copious vaginal discharge. On per speculum examination, a 'strawberry vagina' is noted, with no cervical discharge. Which of the following should be given for management?

Q680Medium

All are true regarding endometriosis, except?

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 671: Leiomyomatosis is:

A. A malignant tumor
B. A non-infiltrative tumor
C. An extrauterine tumor (Correct Answer)
D. A uterine fibroid

Explanation: **Explanation:** **Leiomyomatosis** refers to a group of rare conditions characterized by the growth of benign smooth muscle tumors in locations **outside the uterine cavity**. While histologically identical to common uterine fibroids (leiomyomas), these tumors exhibit unusual growth patterns, spreading to extrauterine sites such as the pelvic peritoneum, lungs, or even within the vascular system. * **Why Option C is Correct:** The defining feature of leiomyomatosis is its **extrauterine** presence. Examples include *Intravenous Leiomyomatosis* (growth into venous channels) and *Leiomyomatosis Peritonealis Disseminata* (multiple nodules on the peritoneal surfaces), both of which occur outside the confines of the uterus. * **Why Option A is Incorrect:** Despite their aggressive-sounding name and ability to spread, these tumors are **benign**. They lack the cellular atypia, high mitotic index, and coagulative necrosis characteristic of Leiomyosarcoma (malignant). * **Why Option B is Incorrect:** Certain forms, like Intravenous Leiomyomatosis, are highly **infiltrative**, extending into the internal iliac veins, vena cava, and sometimes reaching the right chambers of the heart. * **Why Option D is Incorrect:** A standard "uterine fibroid" is a localized, intramural, subserosal, or submucosal tumor. Leiomyomatosis represents a systemic or disseminated variant rather than a simple localized fibroid. **High-Yield NEET-PG Pearls:** * **Leiomyomatosis Peritonealis Disseminata (LPD):** Often associated with high estrogen states (pregnancy or OCP use) and can mimic peritoneal carcinomatosis laparoscopically. * **Benign Metastasizing Leiomyoma:** A variant where histologically benign uterine fibroids "metastasize" most commonly to the **lungs**. * **Management:** Treatment usually involves surgical excision and hormonal suppression (GnRH agonists), as these tumors are often estrogen-dependent.

Question 672: Following an ectopic pregnancy, what is the approximate recurrence rate?

A. 5%
B. 10%
C. 15% (Correct Answer)
D. 20%

Explanation: **Explanation:** The risk of a repeat ectopic pregnancy is significantly higher in women who have already experienced one, primarily due to underlying tubal damage or dysfunction (e.g., chronic salpingitis or scarring from surgery). **1. Why 15% is correct:** Statistically, after one ectopic pregnancy, the recurrence rate is approximately **15%**. This risk increases dramatically after two or more ectopic pregnancies, rising to about **25-30%**. The underlying medical concept is that the factors which predisposed the patient to the first ectopic (such as Pelvic Inflammatory Disease, smoking, or previous tubal surgery) often persist or are exacerbated by the initial event, leading to a higher likelihood of future implantation outside the uterine cavity. **2. Analysis of Incorrect Options:** * **A (5%):** This is too low. The risk in the general population is approximately 1-2%; a previous ectopic increases this baseline risk by nearly tenfold. * **B (10%):** While some older texts cite 10%, standard contemporary textbooks (like Williams Obstetrics and Dutta) generally point toward the 15% mark as the most accurate representative figure for a single prior event. * **D (20%):** This figure is slightly higher than the average for a single recurrence, though it may be seen in specific high-risk cohorts (e.g., those with bilateral tubal disease). **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Ampulla of the Fallopian tube (70%). * **Most common site for rupture:** Isthmus (due to narrow lumen). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Discriminatory zone: 1500–2000 mIU/mL). * **Management:** Methotrexate is the medical treatment of choice in hemodynamically stable patients with a small sac (<3.5-4 cm) and no fetal cardiac activity. Salpingectomy is preferred over salpingostomy if the contralateral tube is healthy.

Question 673: A 50-year-old diabetic female presents with intense pruritus and discharge from the vagina. A smear of the discharge shows budding yeast cells. What is the most likely causative agent?

A. Candida albicans (Correct Answer)
B. Trichomonas vaginalis
C. Mobiluncus
D. Chlamydia trachomatis

Explanation: ### Explanation The correct answer is **Candida albicans**. **1. Why Candida albicans is correct:** The clinical presentation of intense pruritus, vaginal discharge, and the presence of **budding yeast cells** (and/or pseudohyphae) on a smear is pathognomonic for **Vulvovaginal Candidiasis (VVC)**. * **Risk Factors:** Diabetes mellitus is a major predisposing factor because hyperglycemia increases glycogen levels in vaginal secretions, promoting fungal growth. * **Microscopy:** Budding yeast cells and pseudohyphae are typically seen on a KOH mount or Gram stain. **2. Why the other options are incorrect:** * **Trichomonas vaginalis:** Presents with a profuse, frothy, greenish-yellow discharge and a "strawberry cervix." Microscopy would show motile, flagellated pear-shaped organisms, not yeast. * **Mobiluncus:** This is an anaerobic organism associated with **Bacterial Vaginosis (BV)**. BV is characterized by a "fishy" odor and "clue cells" on microscopy, not budding yeast. * **Chlamydia trachomatis:** Typically causes cervicitis or Pelvic Inflammatory Disease (PID). It is an obligate intracellular bacterium and would not appear as budding yeast on a smear. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Culture on **Sabouraud’s Dextrose Agar (SDA)**. * **Clinical Sign:** "Curdy white" or "cottage cheese" like discharge. * **pH Factor:** Unlike Trichomonas and BV (where pH > 4.5), the vaginal pH in Candidiasis is usually **normal (< 4.5)**. * **Treatment:** Fluconazole (oral) or Clotrimazole (topical). In pregnancy, only topical azoles are recommended.

Question 674: Intermenstrual bleeding (metrorrhagia) arises typically when the fibroid tumour is:

A. Submucous (Correct Answer)
B. Subserous
C. Interstitial
D. Broad ligament myoma

Explanation: ### Explanation **Correct Option: A (Submucous)** The primary reason for abnormal uterine bleeding in fibroids is the distortion and increased surface area of the endometrial lining. **Submucous fibroids** (Type 0, 1, and 2 according to FIGO classification) are located directly beneath the endometrium. They cause **metrorrhagia (intermenstrual bleeding)** because they lead to: 1. **Ulceration and necrosis** of the overlying thinned-out endometrium. 2. **Venous congestion** and stasis within the endometrial plexuses. 3. Interference with normal uterine contractility, preventing effective hemostasis. **Incorrect Options:** * **B. Subserous:** These fibroids grow toward the peritoneal cavity. They are usually asymptomatic regarding menstruation but may cause pressure symptoms (e.g., frequency of micturition) or torsion. * **C. Interstitial (Intramural):** These are the most common type and typically present with **menorrhagia** (heavy cyclic bleeding) due to increased uterine surface area and vascularity, rather than irregular intermenstrual bleeding. * **D. Broad ligament myoma:** These are a type of subserous fibroid that grows between the layers of the broad ligament. They do not involve the endometrium and thus do not cause metrorrhagia. **NEET-PG High-Yield Pearls:** * **Most common symptom of fibroid:** Menorrhagia (Heavy Menstrual Bleeding). * **Most common type of fibroid:** Intramural (Interstitial). * **Fibroid most likely to cause infertility/abortion:** Submucous. * **Degeneration most common in pregnancy:** Red degeneration (due to rapid growth and venous thrombosis). * **Investigation of choice:** Transvaginal Ultrasound (TVS). Saline Infusion Sonohysterography (SIS) is superior for diagnosing submucous fibroids.

Question 675: Which is not a feature of pseudocyesis?

A. Amenorrhoea
B. Abdominal distension
C. Fetal heart sounds are audible (Correct Answer)
D. None of the above

Explanation: **Explanation:** **Pseudocyesis** (False Pregnancy) is a rare psychosomatic disorder where a non-pregnant woman exhibits classic signs and symptoms of pregnancy. It is often driven by an intense desire to conceive or a fear of pregnancy, leading to a complex neuroendocrine feedback loop. **Why Option C is the correct answer:** The hallmark of pseudocyesis is that despite the physical manifestations, there is **no actual fetus**. Therefore, objective signs of pregnancy such as **fetal heart sounds (FHS)**, fetal movements (palpated by a clinician), or fetal parts on imaging are **always absent**. The presence of audible fetal heart sounds would indicate a true pregnancy, making it incompatible with a diagnosis of pseudocyesis. **Analysis of incorrect options:** * **Option A (Amenorrhoea):** This is a common feature. Stress and psychological factors can disrupt the hypothalamic-pituitary-ovarian axis, leading to hormonal changes (like elevated prolactin or persistent luteal phase) that result in the cessation of menses. * **Option B (Abdominal distension):** This is frequently observed and is usually caused by aerophagia (swallowing air), abdominal muscle contraction (lordosis), or excess omental fat. Interestingly, the distension often disappears under general anesthesia. **High-Yield Clinical Pearls for NEET-PG:** * **Hormonal Profile:** Patients may show elevated levels of prolactin and LH, but **hCG levels are always negative**. * **Differential Diagnosis:** Must be distinguished from **Delusion of Pregnancy**, which is a fixed false belief without the physical symptoms, and **Malingering**, where the patient is consciously faking symptoms. * **Management:** The primary treatment is psychological counseling and ultrasound demonstration of an empty uterus to the patient.

Question 676: A woman with a history of recurrent abortions presents with an isolated increase in aPTT. What is the most likely cause?

A. Lupus anticoagulant (Correct Answer)
B. Factor VII deficiency
C. Von Willebrand's disease
D. Hemophilia A

Explanation: ### Explanation **Correct Answer: A. Lupus anticoagulant** The clinical presentation of **recurrent abortions** combined with an **isolated increase in activated Partial Thromboplastin Time (aPTT)** is a classic hallmark of **Antiphospholipid Antibody Syndrome (APS)**. **Why it is correct:** Lupus anticoagulant (LA) is an antibody that binds to phospholipids involved in the coagulation cascade. In *vitro* (in the lab test), LA interferes with the phospholipids required for the aPTT test, causing a paradoxical **prolongation of aPTT**. However, in *vivo* (in the body), it creates a **hypercoagulable state**, leading to arterial/venous thrombosis and placental infarction, which results in recurrent pregnancy loss. Notably, the prolonged aPTT does not correct with a 1:1 mixing study (mixing patient plasma with normal plasma), confirming the presence of an inhibitor. **Why incorrect options are wrong:** * **Factor VII deficiency:** Factor VII is part of the extrinsic pathway. Its deficiency leads to a prolonged **PT (Prothrombin Time)**, while the aPTT remains normal. * **Von Willebrand's disease (vWD):** While vWD can sometimes mildly elevate aPTT (due to low Factor VIII levels), it typically presents with **mucocutaneous bleeding** (epistaxis, menorrhagia) rather than recurrent abortions or thrombosis. * **Hemophilia A:** This is an X-linked recessive disorder (rare in females) characterized by Factor VIII deficiency. While it prolongs aPTT, it presents with **bleeding diathesis** (hemarthrosis, muscle hematomas), not pregnancy loss. **High-Yield Clinical Pearls for NEET-PG:** * **The Paradox:** Lupus anticoagulant causes "clotting in the patient, but bleeding in the test tube." * **Diagnostic Criteria for APS:** Requires at least one clinical criteria (thrombosis or specific pregnancy morbidity) and one laboratory criteria (Lupus anticoagulant, Anti-cardiolipin antibody, or Anti-β2 glycoprotein I antibody) positive on two occasions 12 weeks apart. * **Treatment in Pregnancy:** Low-dose Aspirin (LDA) and Low Molecular Weight Heparin (LMWH) are the mainstays to improve live birth rates.

Question 677: A patient with a long-standing intrauterine contraceptive device (IUCD) develops chronic pelvic pain. The device is removed, and a biopsy of the endometrium is performed. The biopsy specimen shows a prominent infiltrate composed of lymphocytes, plasma cells, and histiocytes. Which of the following is the most likely diagnosis?

A. Acute endometritis
B. Adenomyosis
C. Chronic endometritis (Correct Answer)
D. Endometriosis

Explanation: **Explanation:** **1. Why Chronic Endometritis is Correct:** Chronic endometritis is defined by the presence of a persistent inflammatory infiltrate in the endometrial stroma. The hallmark histological finding is the presence of **plasma cells**, often accompanied by lymphocytes and histiocytes. In this clinical scenario, the long-standing **Intrauterine Contraceptive Device (IUCD)** acts as a foreign body and a potential nidus for low-grade infection, which is a classic cause of chronic endometritis. Other common causes include Pelvic Inflammatory Disease (PID), retained products of conception, and tuberculosis. **2. Why the Other Options are Incorrect:** * **Acute Endometritis:** This is characterized histologically by a **neutrophilic infiltrate** within the endometrial glands and stroma. It typically presents with acute fever, purulent discharge, and pelvic tenderness following childbirth or miscarriage. * **Adenomyosis:** This condition involves the presence of endometrial glands and stroma **within the myometrium**. While it causes chronic pelvic pain and menorrhagia, the biopsy would show myometrial hypertrophy rather than a specific plasma cell infiltrate in the endometrium. * **Endometriosis:** This is defined as the presence of endometrial tissue **outside the uterine cavity** (e.g., ovaries, ligaments). A biopsy of the *endometrium* itself would not diagnose endometriosis; diagnosis requires visualization or biopsy of ectopic lesions. **Clinical Pearls for NEET-PG:** * **Pathognomonic Cell:** The presence of **plasma cells** is essential for the diagnosis of chronic endometritis (look for "clock-face" nuclei). * **Staining:** If plasma cells are difficult to see on H&E stain, **CD138 (syndecan-1)** immunohistochemical staining is used to identify them. * **Microbiology:** *Actinomyces israelii* is specifically associated with long-term IUCD use and can cause pelvic abscesses. * **Treatment:** The first-line treatment for non-tuberculous chronic endometritis is typically Doxycycline.

Question 678: Which of the following is true regarding pain in endometriosis?

A. Dysmenorrhea usually starts from day 2 of periods and subsides with the end of menstrual flow.
B. Dysmenorrhea is more common in ovarian endometriomas than peritoneal lesions.
C. Dyspareunia is more common with peritoneal lesions in the pouch of Douglas. (Correct Answer)
D. Pelvic pain is usually unilateral.

Explanation: **Explanation:** Endometriosis is characterized by the presence of endometrial glands and stroma outside the uterine cavity. The pain associated with this condition is multifaceted and depends on the location and depth of the lesions. **Why Option C is Correct:** Deeply infiltrating endometriosis (DIE) frequently involves the **Pouch of Douglas (POD)** and the **uterosacral ligaments**. During sexual intercourse, mechanical pressure and stretching of these fibrotic, inflamed areas—especially when the POD is obliterated or contains nodules—trigger sharp, deep-seated pain known as **deep dyspareunia**. **Analysis of Incorrect Options:** * **Option A:** Dysmenorrhea in endometriosis is typically **congestive and secondary**. It usually begins **2–3 days before** the onset of menses (premenstrual) and often continues throughout the period, sometimes even persisting after the flow stops. * **Option B:** Paradoxically, pain severity does not always correlate with the size of the lesion. Small, active **peritoneal lesions** (especially red, vascular ones) secrete more prostaglandins and inflammatory cytokines than large, stagnant ovarian endometriomas (chocolate cysts), making them more likely to cause significant dysmenorrhea. * **Option D:** Pelvic pain in endometriosis is typically **bilateral and diffuse**, though it may be more pronounced on one side if a large endometrioma is present. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Dysmenorrhea, Dyspareunia, and Infertility. * **Character of Pain:** "Secondary Congestive Dysmenorrhea." * **Gold Standard Diagnosis:** Laparoscopy (visual confirmation with biopsy). * **Physical Exam:** Fixed retroverted uterus and tender nodules in the posterior fornix are classic signs of POD involvement.

Question 679: A young lady presents with a complaint of copious vaginal discharge. On per speculum examination, a 'strawberry vagina' is noted, with no cervical discharge. Which of the following should be given for management?

A. Metronidazole (Correct Answer)
B. Metronidazole and azithromycin
C. Metronidazole and doxycycline
D. Fluconazole only

Explanation: **Explanation:** The clinical presentation of **copious vaginal discharge** and a characteristic **'strawberry vagina'** (punctate hemorrhages on the vaginal and cervical mucosa) is pathognomonic for **Trichomoniasis**, caused by the protozoan *Trichomonas vaginalis*. **1. Why Metronidazole is correct:** Metronidazole is the drug of choice for Trichomoniasis. It is a nitroimidazole that targets anaerobic bacteria and protozoa. According to current guidelines, both the patient and their sexual partner(s) must be treated simultaneously to prevent reinfection, as Trichomoniasis is a sexually transmitted infection (STI). **2. Analysis of Incorrect Options:** * **Metronidazole and Azithromycin/Doxycycline (Options B & C):** These combinations are used for Syndromic Management of Pelvic Inflammatory Disease (PID) or Cervicitis (targeting *N. gonorrhoeae* and *C. trachomatis*). Since the question specifies "no cervical discharge," the focus remains on the vaginal infection alone. * **Fluconazole (Option D):** This is an antifungal used for Vulvovaginal Candidiasis, which typically presents with a thick, "curdy-white" discharge and an inflamed (but not strawberry) vagina. **Clinical Pearls for NEET-PG:** * **Whiff Test:** Often positive (amine odor) in Trichomoniasis, similar to Bacterial Vaginosis. * **Microscopy:** Look for "pear-shaped, flagellated motile trophozoites" on a wet mount. * **pH:** The vaginal pH in Trichomoniasis is typically **>4.5**. * **Gold Standard Diagnosis:** Culture (Diamond’s Medium), though NAAT is now preferred for its high sensitivity. * **Pregnancy:** Metronidazole is safe to use in all trimesters of pregnancy for symptomatic Trichomoniasis.

Question 680: All are true regarding endometriosis, except?

A. It is a hormone-dependent condition.
B. It can involve the lung and pleura.
C. Endometriotic cysts typically contain clear fluid. (Correct Answer)
D. The ovary is the most common site for endometriosis.

Explanation: **Explanation:** **Why Option C is the correct answer:** Endometriotic cysts, commonly known as **Chocolate Cysts**, do not contain clear fluid. Instead, they are filled with thick, dark, chocolate-colored material. This characteristic appearance is due to repeated cyclical bleeding into the cyst cavity; over time, the blood undergoes hemolysis and degradation, resulting in a viscous, brownish fluid. Clear fluid is more characteristic of simple follicular or serous cysts. **Analysis of other options:** * **Option A (Hormone-dependent):** This is true. Endometriosis is an **estrogen-dependent** inflammatory condition. It primarily affects women of reproductive age and typically regresses after menopause or during pregnancy when estrogen levels are low or counteracted. * **Option B (Lung and pleura involvement):** This is true. While most common in the pelvis, "extra-pelvic endometriosis" can occur. The **thoracic cavity** is the most common site outside the abdomen, leading to conditions like catamenial pneumothorax (collapsed lung during menstruation). * **Option D (Ovary as the most common site):** This is true. The **ovary** is statistically the most frequent site of endometriotic implants, followed by the Pouch of Douglas (POD) and the broad ligaments. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Laparoscopy with biopsy (visual confirmation of "powder-burn" or "gunshot" lesions). * **Classic Triad:** Dysmenorrhea (congestive), Dyspareunia, and Infertility. * **CA-125:** Often elevated in endometriosis, but it is non-specific and used more for monitoring than diagnosis. * **Sampson’s Theory:** Retrograde menstruation is the most widely accepted theory for its pathogenesis.

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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