Gynecological Disorders — MCQs

A mother brings her 19-year-old daughter to your clinic with the complaint that she has not started menstruating. General examination reveals normally developed breasts and pubic hair. On pelvic examination, the vaginal ending is blind, and the uterus is not palpable. Which of the following do you suspect?

Q689Medium

What is the next line of management for a post-menopausal female with a biopsy report showing endometrial hyperplasia with atypia?

Q690Easy

What is the best investigation for endometriosis?

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 681: Endocervical polyps causing abnormal menstrual bleeding are seen most commonly in which group of women?

A. Nulliparous women
B. Pre-pubertal females
C. Multiparous women (Correct Answer)
D. Adolescents

Explanation: **Explanation:** **1. Why Multiparous Women is Correct:** Endocervical polyps are benign growths arising from the endocervical mucosa. They are most frequently encountered in **multiparous women** (women who have given birth multiple times), particularly between the ages of **40 and 60 years**. The exact etiology is not fully understood, but they are believed to result from a combination of chronic inflammation of the cervix and a localized congestion of cervical blood vessels, often influenced by high levels of circulating estrogen. The repeated physiological changes and trauma to the cervix during multiple deliveries may also contribute to their higher prevalence in this group. **2. Why Other Options are Incorrect:** * **Pre-pubertal females & Adolescents:** These groups have low estrogen levels and minimal cervical trauma. Endocervical polyps are extremely rare before menarche. * **Nulliparous women:** While polyps can occur in women who have never given birth, the statistical incidence is significantly lower compared to multiparous women, who represent the classic demographic for this condition. **3. Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Most polyps are asymptomatic and discovered during routine pelvic exams. When symptomatic, the most common symptom is **intermenstrual bleeding** or **post-coital bleeding**. * **Appearance:** They typically appear as cherry-red, pedunculated structures protruding from the external os. * **Management:** The treatment of choice is **polypectomy** (avulsion). * **Malignancy Risk:** The risk of malignant transformation is very low (<1%), but all removed polyps must be sent for **histopathological examination** to rule out malignancy. * **Differential Diagnosis:** Must be differentiated from a "fibroid polyp" (prolonged submucosal leiomyoma), which is usually firmer and paler.

Question 682: What is the definition of a unicornuate uterus?

A. Two uterine cavities with one cervix (Correct Answer)
B. Single vagina with a double uterus
C. An incomplete septum within the uterus
D. A double uterus with a double cervix

Explanation: ### Explanation The correct answer is **A: Two uterine cavities with one cervix**. A **Bicornuate Uterus** (specifically *Bicornuate Unicollis*) results from the partial failure of fusion of the Mullerian ducts at the level of the fundus. This leads to two separate uterine horns (cavities) that communicate at the level of the single cervix. #### Analysis of Options: * **Option B (Single vagina with a double uterus):** This describes **Uterus Didelphys** if there are also two cervices. If it refers to two horns with one cervix, it is a Bicornuate uterus, but "double uterus" is the classic terminology for Didelphys. * **Option C (Incomplete septum):** This defines a **Septate Uterus**, which occurs due to the failure of resorption of the midline septum after the Mullerian ducts have already fused. * **Option D (Double uterus with double cervix):** This is the classic definition of **Uterus Didelphys**, resulting from a complete failure of fusion of the two Mullerian ducts. #### High-Yield Clinical Pearls for NEET-PG: * **Mullerian Anomalies Classification:** Most commonly classified using the **AFS (American Fertility Society)** system. * **Bicornuate vs. Septate:** This is a frequent exam distinction. A **Bicornuate** uterus has a fundal cleft/indentation (>1 cm), whereas a **Septate** uterus has a flat or convex external fundal contour. * **Clinical Presentation:** Often associated with recurrent pregnancy loss (RPL), malpresentation (breech), and preterm labor. * **Gold Standard Diagnosis:** Combined **Laparoscopy and Hysteroscopy** (to visualize both the external contour and internal cavity). MRI is the best non-invasive modality. * **Treatment:** Bicornuate uteri usually do not require surgery unless there is obstetric failure (Strassman Metroplasty). In contrast, a Septate uterus is treated with Hysteroscopic Septal Resection.

Question 683: What is the DOC for candidiasis in pregnancy?

A. Metronidazole 500mg
B. Tinidazole 500mg
C. Fluconazole (Correct Answer)
D. Metronidazole 1 gm

Explanation: **Explanation:** **Correct Option: C. Fluconazole** Vulvovaginal Candidiasis (VVC) is common in pregnancy due to high estrogen levels and increased vaginal glycogen. While topical azoles (clotrimazole) are often used as first-line therapy, **Fluconazole** is considered the standard oral Drug of Choice (DOC) for candidiasis. In the context of NEET-PG questions, Fluconazole is the preferred answer for systemic management. However, it is crucial to note that for pregnant patients, a **single 150 mg oral dose** is generally considered safe, though many guidelines prefer topical therapy in the first trimester to minimize any theoretical risk. **Why Incorrect Options are Wrong:** * **A & D. Metronidazole:** This is the DOC for **Bacterial Vaginosis (BV)** and **Trichomoniasis**. It is an antiprotozoal/antibacterial agent and has no efficacy against fungal infections like Candida. * **B. Tinidazole:** Similar to Metronidazole, this is used for Trichomoniasis and BV. It is generally avoided in the first trimester of pregnancy due to limited safety data compared to Metronidazole. **Clinical Pearls for NEET-PG:** * **Diagnosis:** Characterized by "curdy white" or "cheese-like" discharge, intense pruritus, and a vaginal pH < 4.5. * **Microscopy:** Look for pseudohyphae and budding yeast on KOH mount. * **Recurrent VVC:** Defined as ≥4 episodes per year; requires induction followed by maintenance Fluconazole for 6 months. * **Pregnancy Caution:** While Fluconazole is the systemic DOC, the **USFDA** and **RCOG** suggest that topical Clotrimazole (7-day course) is the safest first-line approach during pregnancy to avoid high-dose oral exposure.

Question 684: Which of the following is NOT characteristic of bacterial vaginosis?

A. Profuse creamy discharge (Correct Answer)
B. Clue cells present
C. Positive whiff test
D. Absent leukocytes

Explanation: **Explanation:** Bacterial Vaginosis (BV) is a clinical syndrome resulting from a shift in the vaginal flora, where normal hydrogen peroxide-producing Lactobacilli are replaced by high concentrations of anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Mobiluncus*, and *Mycoplasma hominis*). **Why Option A is the correct answer:** The discharge in BV is characteristically **thin, homogenous, and greyish-white**. It is typically non-viscous and coats the vaginal walls evenly. A "profuse creamy discharge" is more characteristic of **Candidiasis** (thick, curd-like) or certain stages of physiological discharge, but it does not fit the diagnostic criteria for BV. **Analysis of other options:** * **Option B (Clue cells):** These are vaginal epithelial cells coated with coccobacilli, giving them a "stippled" or "shaggy" appearance. They are the most specific microscopic finding for BV. * **Option C (Positive Whiff test):** Adding 10% KOH to the discharge releases volatile amines (putrescine and cadaverine), resulting in a characteristic "fishy odor." * **Option D (Absent leukocytes):** BV is a **malodorant dysbiosis**, not a true inflammatory condition (hence "vaginosis" rather than "vaginitis"). The absence of pus cells (leukocytes) on microscopy is a hallmark that distinguishes it from Trichomoniasis or Cervicitis. **NEET-PG High-Yield Pearls:** * **Amsel’s Criteria (3 out of 4 required):** 1. Thin, homogenous discharge. 2. Vaginal pH > 4.5 (Most sensitive). 3. Positive Whiff test. 4. Presence of Clue cells (Most specific). * **Gold Standard Diagnosis:** Nugent Scoring (Gram stain of vaginal secretions). * **Treatment of Choice:** Oral or topical Metronidazole (500 mg BD for 7 days). Note: Treatment of the male partner is **not** recommended.

Question 685: What is the best endometrial reaction in ectopic pregnancy?

A. Arias-Stella reaction
B. Secretory phase
C. Decidual reaction without chorionic villi (Correct Answer)
D. Decidual reaction with chorionic villi

Explanation: In an ectopic pregnancy, the body produces high levels of progesterone from the corpus luteum, which stimulates the endometrium to undergo **decidualization** (thickening and vascularization) in preparation for implantation. However, because the pregnancy is located outside the uterus, the uterine cavity remains empty. **1. Why "Decidual reaction without chorionic villi" is correct:** The presence of a **decidua without chorionic villi** is the hallmark histological finding in the endometrium of an ectopic pregnancy. Since the trophoblastic tissue is extrauterine, no villi (fetal tissue) will be found within the uterine curettage. This is clinically significant: if a patient with a positive pregnancy test undergoes a D&C and the pathology report shows "decidua but no villi," an ectopic pregnancy must be strongly suspected. **2. Why the other options are incorrect:** * **Arias-Stella reaction:** While this is a high-yield association with ectopic pregnancy (characterized by hypertrophic, hyperchromatic nuclei), it is only seen in about **30-40%** of cases. A simple decidual reaction is more common. * **Secretory phase:** This occurs during the normal luteal phase of the menstrual cycle. Once pregnancy is established (ectopic or intrauterine), the endometrium progresses beyond the secretory phase into a decidual reaction. * **Decidual reaction with chorionic villi:** This is the definitive sign of an **intrauterine pregnancy** (IUP). The presence of villi (fetal tissue) inside the uterus effectively rules out a primary ectopic pregnancy. **Clinical Pearls for NEET-PG:** * **ASR (Arias-Stella Reaction):** It is a non-specific finding and can also be seen in intrauterine pregnancies or with trophoblastic disease. * **The "Decidual Cast":** Occasionally, the entire decidual lining is shed intact through the vagina, mimicking a miscarriage. * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) showing an adnexal mass + empty uterus.

Question 686: Pseudomyxoma peritonei is seen with which of the following conditions?

A. Fibroids
B. Adenomyosis
C. Ovarian tumors (Correct Answer)
D. Endometriosis

Explanation: **Explanation:** **Pseudomyxoma Peritonei (PMP)** is a clinical syndrome characterized by the accumulation of large amounts of gelatinous, mucinous ascites within the peritoneal cavity. This condition is most commonly associated with **mucinous tumors**. 1. **Why Ovarian Tumors is Correct:** While the most common primary site for PMP is the appendix (low-grade appendiceal mucinous neoplasm), it is frequently associated with **Mucinous Ovarian Tumors** (specifically borderline or malignant types). The "jelly-belly" appearance occurs when mucin-secreting cells implant on the peritoneal surfaces and continue to produce mucus. In many cases, PMP found in the ovary is actually a metastasis from a primary appendiceal tumor. 2. **Why Other Options are Incorrect:** * **Fibroids (Leiomyomas):** These are benign smooth muscle tumors of the uterus. They may cause pressure symptoms or bleeding but do not produce mucin or lead to peritoneal seeding. * **Adenomyosis:** This involves the presence of endometrial glands within the myometrium. It causes uterine enlargement and heavy menses but remains confined to the uterine wall. * **Endometriosis:** While endometriosis involves peritoneal implants, these are ectopic endometrial tissues that lead to "chocolate cysts" (hemosiderin-laden fluid), not mucinous ascites. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Presentation:** Progressive abdominal distension ("Jelly Belly") and "Starry Sky" appearance on ultrasound. * **Primary Source:** Always rule out the **Appendix** first; it is the primary source in >90% of PMP cases. * **Treatment:** The gold standard is **Cytoreductive Surgery (CRS)** combined with **Hyperthermic Intraperitoneal Chemotherapy (HIPEC)**. * **Tumor Marker:** **CEA** and **CA-125** may be elevated, but they are non-specific.

Question 687: Which of the following is true about a complete hydatidiform mole?

A. Chromosome pattern is XX (Correct Answer)
B. It is of maternal origin
C. Enlarged ovarian cyst occurs
D. It is common in developed countries

Explanation: **Explanation:** **1. Why Option A is Correct:** A complete hydatidiform mole (CHM) is characterized by the fertilization of an "empty" egg (lacking maternal chromosomes) by a sperm. The most common mechanism (90%) is **androgenesis**, where a single sperm (23,X) fertilizes the empty ovum and subsequently duplicates its DNA. This results in a **46,XX** diploid karyotype that is entirely paternal in origin. Less commonly (10%), it occurs via dispermy (46,XX or 46,XY). **2. Why Other Options are Incorrect:** * **Option B:** It is of **paternal origin**, not maternal. The maternal nuclear DNA is absent or inactivated. * **Option C:** While **Theca Lutein cysts** (bilateral ovarian enlargement) occur in about 25-30% of cases due to high hCG levels, the question asks for a definitive "true" statement. The chromosomal pattern (XX) is a defining genetic hallmark, whereas ovarian cysts are a clinical complication that does not occur in every case. * **Option D:** Hydatidiform moles are significantly **more common in developing countries** (especially Southeast Asia and Africa) compared to developed nations. **Clinical Pearls for NEET-PG:** * **Pathology:** "Bunch of grapes" appearance; histologically shows diffuse trophoblastic proliferation and hydropic villi with **no fetal parts**. * **Diagnosis:** "Snowstorm appearance" on USG; serum hCG levels are typically >100,000 mIU/ml. * **Marker:** **p57** is a paternally imprinted gene. Since CHM lacks maternal DNA, it is **p57 negative** (immunostaining), whereas partial moles are p57 positive. * **Risk:** CHM has a higher risk (15-20%) of progressing to Gestational Trophoblastic Neoplasia (Choriocarcinoma) compared to partial moles (1-5%).

Question 688: A mother brings her 19-year-old daughter to your clinic with the complaint that she has not started menstruating. General examination reveals normally developed breasts and pubic hair. On pelvic examination, the vaginal ending is blind, and the uterus is not palpable. Which of the following do you suspect?

A. Mullerian agenesis (Correct Answer)
B. Asherman syndrome
C. Gonadal dysgenesis
D. Turner syndrome

Explanation: ### Explanation The patient presents with **Primary Amenorrhea** and normal secondary sexual characteristics (breasts and pubic hair), but an absent uterus and a blind vaginal pouch. This classic presentation points directly to **Mullerian Agenesis (Mayer-Rokitansky-Küster-Hauser syndrome)**. **1. Why Mullerian Agenesis is correct:** In MRKH syndrome, the Mullerian ducts fail to develop. Since the ovaries are derived from germ cells (not Mullerian ducts), they function normally, producing estrogen and progesterone. This leads to **normal breast development** (Tanner Stage 5) and normal female hormone levels. However, the structures derived from the Mullerian ducts—the fallopian tubes, uterus, and upper two-thirds of the vagina—are absent or rudimentary. **2. Why the other options are incorrect:** * **Asherman Syndrome:** This is a cause of *secondary* amenorrhea due to intrauterine adhesions (usually post-curettage). The uterus is present, and the patient would have had a prior history of menstruation. * **Gonadal Dysgenesis / Turner Syndrome (45,XO):** These conditions involve streak ovaries. Because the ovaries fail to produce estrogen, these patients typically present with **delayed puberty** and **absent breast development**. In Turner syndrome, the uterus is present but infantile. **3. High-Yield Clinical Pearls for NEET-PG:** * **Karyotype:** In Mullerian Agenesis, the karyotype is **46,XX** (Normal Female). * **Associated Anomalies:** 30–40% of cases have **Renal anomalies** (e.g., renal agenesis, pelvic kidney). Always order a Renal Ultrasound. Skeletal anomalies (Scoliosis) are also common. * **Differential Diagnosis:** **Androgen Insensitivity Syndrome (AIS)** also presents with a blind vagina and absent uterus, but the karyotype is **46,XY**, and there is **scant/absent pubic hair** due to androgen resistance. * **Management:** Non-surgical vaginal dilation (Frank’s method) is the first-line treatment to create a functional vagina.

Question 689: What is the next line of management for a post-menopausal female with a biopsy report showing endometrial hyperplasia with atypia?

A. Type 1 hysterectomy (Correct Answer)
B. Oral progestins
C. Mirena
D. Dilatation and curettage

Explanation: **Explanation:** The management of endometrial hyperplasia depends on two critical factors: the presence of **atypia** and the patient’s **menopausal status**. **1. Why Type 1 Hysterectomy is correct:** Endometrial hyperplasia with atypia (Atypical Hyperplasia/Endometrioid Intraepithelial Neoplasia) is a **premalignant condition**. In post-menopausal women, the risk of progression to endometrial carcinoma is approximately 30%, and there is a high co-existence rate (up to 40%) of an occult invasive malignancy already present at the time of diagnosis. Therefore, the definitive treatment of choice is a **Total Laparoscopic or Abdominal Hysterectomy (Type 1)** with bilateral salpingo-oophorectomy. **2. Why the other options are incorrect:** * **Oral Progestins (B) & Mirena (C):** Medical management with progestins is reserved for patients with hyperplasia *without* atypia or for those with atypia who are pre-menopausal and strongly desire fertility preservation. In a post-menopausal female, the risk of malignancy outweighs the benefits of medical therapy. * **Dilatation and Curettage (D):** D&C is a diagnostic tool used to obtain a sample. Once the biopsy report has already confirmed atypia, D&C is no longer the "next line of management" as the diagnosis is established. **High-Yield Clinical Pearls for NEET-PG:** * **Risk of Progression (WHO Classification):** * Simple Hyperplasia without atypia: 1% * Complex Hyperplasia without atypia: 3% * Simple Hyperplasia with atypia: 8% * **Complex Hyperplasia with atypia: 29%** * **Gold Standard Diagnosis:** Endometrial biopsy (Pipelle) or D&C. * **Drug of choice for fertility preservation:** Megestrol acetate or Levonorgestrel Intrauterine System (Mirena).

Question 690: What is the best investigation for endometriosis?

A. Laparoscopy (Correct Answer)
B. Ultrasound (USG)
C. X-ray pelvis
D. CT Scan

Explanation: **Explanation:** **Laparoscopy (Option A)** is the **Gold Standard** investigation for the diagnosis of endometriosis. This is because it allows for direct visualization of characteristic lesions (such as "powder-burn" or "mulberry" spots) on the pelvic peritoneum and ovaries. Furthermore, it provides the opportunity for **histopathological confirmation** via biopsy, which is the definitive diagnostic requirement. **Why other options are incorrect:** * **Ultrasound (USG) (Option B):** While Transvaginal Sonography (TVS) is the first-line screening tool and excellent for detecting **Endometriomas** ("chocolate cysts" with ground-glass echogenicity), it often fails to detect small peritoneal implants or deep infiltrating endometriosis. * **X-ray Pelvis (Option C):** This has no role in the diagnosis of endometriosis as soft tissue implants and adhesions are not radiopaque. * **CT Scan (Option D):** CT has poor soft-tissue resolution for the pelvis compared to MRI or USG and is not used for routine diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard:** Laparoscopy + Biopsy. * **First-line Investigation:** Transvaginal Ultrasound (TVS). * **Investigation of choice for Deep Infiltrating Endometriosis (DIE):** MRI. * **Serum Marker:** **CA-125** may be elevated (usually >35 U/ml) but lacks specificity; it is primarily used for monitoring recurrence rather than primary diagnosis. * **Classic Triad:** Dysmenorrhea (congestive/secondary), Dyspareunia, and Infertility.

Practice by Chapter

Abnormal Uterine Bleeding

Practice Questions

Endometriosis

Practice Questions

Adenomyosis

Practice Questions

Uterine Fibroids

Practice Questions

Ovarian Cysts

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Pelvic Inflammatory Disease

Practice Questions

Vulvovaginitis

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Pelvic Organ Prolapse

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Vulvar Disorders

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Benign Breast Diseases

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