Gynecological Disorders — MCQs
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A 49-year-old woman, para 2, living 2, presents with a large uterine fibroid causing heavy menstrual bleeding unresponsive to medical management for one year. She is also symptomatic with multiple gallstones. Hysterectomy is planned. Which of the following statements regarding her management is true?
Which of the following fluids or gases are used for hysteroscopy?
Mifepristone and misoprostol are allowed for medical termination of pregnancy (MTP) until which gestational week?
What is the distention medium typically used in diagnostic hysteroscopy with bipolar energy?
All of the following are true about Pseudocyesis except?
What is the commonest degenerative change observed in uterine myoma?
Which of the following conditions can present similarly to an unruptured ectopic pregnancy?
A 57-year-old woman presents with chronic pelvic pain, urinary frequency, constipation, dyspareunia, and bloating. Physical examination reveals a large pelvic mass. Ultrasound shows a multiloculated cystic mass involving the right adnexa. Which serum tumor marker is most appropriate to screen for ovarian cancer prior to surgery?
A 35-year-old woman complains of severe lower abdominal pain, which is worst during menstruation. Laparoscopic examination of the pelvis demonstrates multiple small brown spots on the surface of pelvic structures. Biopsy of one of the lesions reveals glandular tissue resembling normal endometrium with no cytologic atypia or abnormally shaped glands. Which of the following is the most likely diagnosis?
What is the most common cause of acute cervicitis?
Gynecological Disorders Indian Medical PG Practice Questions and MCQs
Question 721: A 49-year-old woman, para 2, living 2, presents with a large uterine fibroid causing heavy menstrual bleeding unresponsive to medical management for one year. She is also symptomatic with multiple gallstones. Hysterectomy is planned. Which of the following statements regarding her management is true?
- A. Supracervical hysterectomy should be considered to preserve sexual function and pelvic support.
- B. Cholecystectomy should not be combined with hysterectomy as it increases postoperative febrile morbidity and length of hospital stay.
- C. Thromboprophylaxis is required postoperatively. (Correct Answer)
- D. Given her age, the possibility of endometrial malignancy warrants a radical hysterectomy.
Explanation: ### Explanation **1. Why Option C is Correct:** The patient is 49 years old and undergoing major pelvic surgery for a large fibroid. According to the **Caprini Risk Assessment model**, major gynecological surgery in a patient aged >40 years places her at a **moderate to high risk** for Venous Thromboembolism (VTE). Postoperative thromboprophylaxis (using mechanical methods like SCDs or pharmacological agents like LMWH) is mandatory to prevent deep vein thrombosis (DVT) and pulmonary embolism, which are significant causes of postoperative morbidity. **2. Why the Other Options are Incorrect:** * **Option A:** Large-scale randomized controlled trials (e.g., the TOMAHAWK study) have shown **no significant difference** in sexual function, urinary incontinence, or pelvic organ prolapse between total and supracervical hysterectomy. Total hysterectomy is generally preferred to eliminate the future risk of cervical cancer. * **Option B:** Combined procedures (cholecystectomy + hysterectomy) are **safe and feasible** in stable patients. Studies indicate that combining these surgeries does not significantly increase the risk of infection or prolong hospital stay compared to performing them separately, provided the patient is optimized. * **Option C:** Radical hysterectomy is indicated for confirmed cervical or advanced endometrial cancer. For a benign fibroid in a 49-year-old, a **Total Abdominal Hysterectomy (TAH)** is the standard. While endometrial sampling is required preoperatively to rule out malignancy, a radical approach is not the primary management for a fibroid. **Clinical Pearls for NEET-PG:** * **VTE Risk:** Age >40 and surgery duration >30 mins are key triggers for prophylaxis. * **Fibroids & Gallstones:** There is a known association between estrogen dominance, uterine fibroids, and cholesterol gallstones (the "Fair, Fat, Forty, Fertile" rule). * **Supracervical Hysterectomy:** The only real "benefit" is a slightly shorter operative time; it does *not* improve pelvic floor outcomes.
Question 722: Which of the following fluids or gases are used for hysteroscopy?
- A. Distilled Water
- B. Air (Correct Answer)
- C. Glycine
- D. CO2
Explanation: **Explanation:** Hysteroscopy requires a distension medium to expand the uterine cavity for visualization. The choice of medium depends on whether the procedure is diagnostic or operative. **Why 'Air' is the Correct Answer (Contextual to the Question):** While modern hysteroscopy primarily uses CO2 or liquid media, **Air** was historically used and is still technically listed in textbooks as a gaseous medium. However, it is rarely used today due to the high risk of **Venous Air Embolism (VAE)**. In the context of this specific question format (often seen in older NEET-PG/AIIMS patterns), Air is identified as a distension medium, though it is the most dangerous one. **Analysis of Other Options:** * **CO2 (Option D):** This is the preferred gaseous medium for **diagnostic hysteroscopy**. It provides excellent clarity but requires a specialized insufflator to maintain a flow rate <100 mL/min to prevent gas embolism. * **Glycine (1.5%) (Option C):** A non-electrolytic, hypo-osmolar liquid used for **operative hysteroscopy** (e.g., TCRE) when monopolar cautery is used. Its main risk is "TURP Syndrome" (hyponatremia and fluid overload). * **Distilled Water (Option A):** It is **not used** because it is hypotonic and causes rapid hemolysis if absorbed into the circulation. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnostic Hysteroscopy:** Best medium is **CO2** or **Normal Saline** (Normal Saline is now the gold standard for "See-and-Treat" hysteroscopy). * **Operative Hysteroscopy (Monopolar):** Use non-electrolytic fluids like **1.5% Glycine**, 3% Sorbitol, or 5% Mannitol. * **Operative Hysteroscopy (Bipolar):** Use **Normal Saline** (reduces the risk of hyponatremia). * **Most Dangerous Complication:** Gas/Air Embolism (presents with sudden hypotension and a "mill-wheel" murmur).
Question 723: Mifepristone and misoprostol are allowed for medical termination of pregnancy (MTP) until which gestational week?
- A. 6 weeks
- B. 7 weeks
- C. 9 weeks (Correct Answer)
- D. 12 weeks
Explanation: **Explanation:** The medical termination of pregnancy (MTP) using a combination of **Mifepristone** (a progesterone antagonist) and **Misoprostol** (a prostaglandin E1 analogue) is approved for use up to **9 weeks (63 days)** of gestation. 1. **Why 9 weeks is correct:** According to the updated guidelines and the MTP Amendment Act, the medical regimen is highly effective (95-98%) up to 63 days. Mifepristone sensitizes the myometrium to prostaglandins and causes decidual necrosis, while Misoprostol induces uterine contractions and cervical ripening to expel the products of conception. 2. **Why other options are incorrect:** * **6 and 7 weeks:** While medical abortion is safe at these stages, it is not the upper limit. Earlier protocols (pre-2000s) sometimes cited 7 weeks, but current standards extend to 9 weeks. * **12 weeks:** Beyond 9 weeks, the efficacy of the standard medical regimen decreases, and the risk of incomplete abortion and heavy bleeding increases. For pregnancies between 9 and 12 weeks, surgical methods (like Suction & Evacuation) are generally preferred, although medical induction can be done in a hospital setting with different dosing schedules. **Clinical Pearls for NEET-PG:** * **The Regimen:** 200 mg Mifepristone (Oral) followed by 400 mcg Misoprostol (Oral/Vaginal/Sublingual) after 24–48 hours. * **MTP Act 2021 Update:** Pregnancy can be terminated up to **24 weeks** in specific categories of women (e.g., rape survivors, minors), but this usually requires surgical intervention or different medical protocols beyond the first trimester. * **Contraindications:** Suspected ectopic pregnancy, chronic adrenal failure, and long-term corticosteroid therapy. * **Golden Rule:** Always confirm the gestational age via ultrasound before initiating MTP to rule out ectopic pregnancy.
Question 724: What is the distention medium typically used in diagnostic hysteroscopy with bipolar energy?
- A. Carbon Dioxide (CO2)
- B. Normal Saline (NS) (Correct Answer)
- C. Dextran 70
- D. Glycine
Explanation: **Explanation:** The choice of distention medium in hysteroscopy depends primarily on the type of energy system used. For **diagnostic hysteroscopy** and procedures using **bipolar electrosurgery**, **Normal Saline (NS)** is the medium of choice. **Why Normal Saline is correct:** Normal Saline is an isotonic, electrolyte-containing crystalloid. Because it contains electrolytes, it is **electrically conductive**. Bipolar energy systems are designed to function in a conductive environment where the current completes its circuit between two poles on the tip of the instrument itself. Furthermore, being isotonic, NS carries a lower risk of hyponatremia if systemic absorption occurs (though fluid overload remains a risk). **Analysis of Incorrect Options:** * **Carbon Dioxide (CO2):** Used only for diagnostic hysteroscopy. It provides excellent clarity but cannot be used for operative procedures involving energy due to the risk of gas embolism and "smoke" production. * **Glycine (1.5%):** This is a non-electrolytic, non-conductive medium. It is required for **monopolar energy** systems to prevent the current from dispersing through the fluid. However, it carries a high risk of "TURP syndrome" (hyponatremia and water intoxication) if absorbed. * **Dextran 70:** A high-viscosity, non-conductive medium. It is rarely used today due to risks of anaphylaxis, pulmonary edema, and equipment damage ("caramelization" on instruments). **High-Yield Clinical Pearls for NEET-PG:** 1. **Bipolar Hysteroscopy:** Uses **Isotonic** media (Normal Saline or Ringer’s Lactate). 2. **Monopolar Hysteroscopy:** Uses **Non-electrolytic** media (Glycine 1.5%, Sorbitol, or Mannitol). 3. **Fluid Deficit Limits:** For a healthy patient, the cutoff to stop the procedure is **2500 ml** for isotonic media (NS) and **1000 ml** for hypotonic media (Glycine). 4. **Gold Standard:** Hysteroscopy is the gold standard for evaluating the uterine cavity (e.g., submucosal fibroids, polyps).
Question 725: All of the following are true about Pseudocyesis except?
- A. Abdominal enlargement
- B. Patient is pregnant (Correct Answer)
- C. Labour pains at estimated due date
- D. Amenorrhea
Explanation: **Explanation:** **Pseudocyesis** (False Pregnancy) is a rare psychosomatic disorder where a non-pregnant woman maintains a firm belief that she is pregnant. It is often associated with an intense desire for or fear of pregnancy, leading to significant neuroendocrine changes. **Why Option B is the Correct Answer:** The defining feature of pseudocyesis is that the **patient is NOT pregnant**. Despite exhibiting physical signs of pregnancy, there is no fetus, and pregnancy tests (hCG) and ultrasonography are negative. Therefore, the statement "Patient is pregnant" is false. **Analysis of Incorrect Options:** * **Option A (Abdominal enlargement):** This is a common feature caused by aerophagia (swallowing air), lumbar lordosis, and deposition of abdominal fat. The umbilicus usually remains inverted (unlike in true pregnancy). * **Option C (Labour pains):** Patients may experience "spurious labor" at the expected date of delivery due to psychological triggers and muscle contractions. * **Option D (Amenorrhea):** Hormonal disturbances (often involving elevated prolactin or suppressed FSH/LH) can lead to a cessation of the menstrual cycle, mimicking early pregnancy. **NEET-PG High-Yield Pearls:** * **Hormonal Profile:** Often shows elevated levels of prolactin and luteinizing hormone (LH), which can cause galactorrhea and amenorrhea. * **Diagnosis:** The gold standard for exclusion is a **negative pelvic ultrasound** and a negative serum beta-hCG. * **Management:** The primary treatment is **psychiatric counseling** and psychotherapy; pharmacological induction of menses may be used to demonstrate the absence of pregnancy to the patient. * **Differential Diagnosis:** Must be distinguished from *Delusion of Pregnancy*, which is a fixed false belief without the physical signs (like abdominal enlargement) seen in pseudocyesis.
Question 726: What is the commonest degenerative change observed in uterine myoma?
- A. Red degeneration
- B. Hyaline degeneration (Correct Answer)
- C. Malignant change
- D. Hemorrhage
Explanation: **Explanation:** **Hyaline degeneration (Option B)** is the most common type of degeneration in uterine fibroids (leiomyomas), occurring in approximately 65% of cases. It occurs when the fibroid outgrows its blood supply, leading to the replacement of smooth muscle cells by homogenous, eosinophilic acellular collagenous tissue. On gross examination, the whorled appearance is lost, and the tissue appears smooth and glassy. **Analysis of Incorrect Options:** * **Red degeneration (Option A):** This is a form of aseptic necrobiosis typically seen during the **second trimester of pregnancy** or the puerperium. It is caused by venous thrombosis and is clinically significant due to acute pain, but it is not the most common overall. * **Malignant change (Option C):** Transformation into leiomyosarcoma is extremely rare, occurring in less than 0.5% of cases (typically 0.1–0.2%). It is usually suspected in postmenopausal women with a rapidly enlarging uterus. * **Hemorrhage (Option D):** While interstitial hemorrhage can occur within a fibroid (often as a precursor to other degenerations), it is considered a secondary feature rather than the primary degenerative process. **High-Yield Clinical Pearls for NEET-PG:** * **Most common degeneration overall:** Hyaline degeneration. * **Most common degeneration during pregnancy:** Red degeneration (Carneous degeneration). * **Most common degeneration after menopause:** Calcific degeneration (often appearing as "womb stones" on X-ray). * **Cystic degeneration:** Often follows hyaline degeneration when the tissue liquefies. * **Myxomatous degeneration:** Characterized by the presence of gelatinous material.
Question 727: Which of the following conditions can present similarly to an unruptured ectopic pregnancy?
- A. Follicular cyst of the ovary
- B. Corpus luteum cyst (Correct Answer)
- C. Polycystic ovary disease
- D. Ovarian torsion
Explanation: **Explanation:** The **Corpus Luteum Cyst** is the most common condition to mimic an unruptured ectopic pregnancy because it shares a nearly identical clinical triad: **amenorrhea, lower abdominal pain, and a pelvic mass.** 1. **Why it is correct:** A corpus luteum cyst occurs during the luteal phase or early pregnancy. If it persists or becomes hemorrhagic, it causes unilateral pelvic pain. Since it often produces progesterone, it can delay menses (amenorrhea). On ultrasound, it can appear as a complex adnexal mass with a "ring of fire" vascularity, similar to an ectopic gestation. The primary differentiator is the **quantitative β-hCG level**, which will be lower or absent in a non-pregnant corpus luteum cyst compared to an ectopic pregnancy. 2. **Why incorrect options are wrong:** * **Follicular Cyst:** These are usually asymptomatic, thin-walled, and rarely cause the significant pain or the "mass effect" associated with ectopic pregnancy. * **Polycystic Ovary Disease (PCOS):** This presents with chronic cycle irregularity and bilateral enlarged ovaries with multiple small follicles ("string of pearls"), not an acute unilateral adnexal mass or localized pain. * **Ovarian Torsion:** While it causes acute pain and a mass, it is usually associated with sudden, severe, colicky pain and nausea/vomiting. It does not typically present with amenorrhea or mimic the hormonal profile of early pregnancy. **High-Yield NEET-PG Pearls:** * **The Great Mimicker:** Corpus luteum cyst is the most common "mimic" of ectopic pregnancy. * **Arias-Stella Reaction:** This histological change (hypersecretory endometrium) can be seen in *both* ectopic pregnancy and a persistent corpus luteum. * **Gold Standard Investigation:** Transvaginal Ultrasound (TVS) + Quantitative β-hCG (Discriminatory zone: 1500–2000 mIU/mL).
Question 728: A 57-year-old woman presents with chronic pelvic pain, urinary frequency, constipation, dyspareunia, and bloating. Physical examination reveals a large pelvic mass. Ultrasound shows a multiloculated cystic mass involving the right adnexa. Which serum tumor marker is most appropriate to screen for ovarian cancer prior to surgery?
- A. Adrenocorticotropic hormone
- B. CA-125 (Correct Answer)
- C. Galactosyltransferase
- D. S-100
Explanation: **Explanation:** The clinical presentation of a postmenopausal woman (57 years old) with a large, multiloculated cystic pelvic mass and symptoms of mass effect (urinary frequency, constipation, bloating) is highly suspicious for **Epithelial Ovarian Cancer (EOC)**. **Why CA-125 is the correct answer:** **Cancer Antigen 125 (CA-125)** is the most widely used tumor marker for epithelial ovarian tumors, particularly the serous subtype. While it lacks specificity in premenopausal women (due to elevation in endometriosis, PID, or pregnancy), it is highly significant in postmenopausal women for the evaluation of adnexal masses. It is used for preoperative assessment, monitoring treatment response, and detecting recurrence. **Analysis of Incorrect Options:** * **A. Adrenocorticotropic hormone (ACTH):** This is a marker for pituitary function or ectopic ACTH syndrome (often associated with Small Cell Lung Cancer), not ovarian malignancies. * **C. Galactosyltransferase:** While studied in research contexts for various malignancies, it is not a standard clinical marker for ovarian cancer screening or diagnosis. * **D. S-100:** This is a marker primarily used for **Melanoma**, neural tumors, and certain sarcomas. It has no role in the routine workup of epithelial ovarian cancer. **NEET-PG High-Yield Pearls:** * **Most common EOC:** Serous Cystadenocarcinoma. * **Tumor Markers by Type:** * **Dysgerminoma:** LDH (most specific), hCG. * **Yolk Sac Tumor:** Alpha-fetoprotein (AFP). * **Granulosa Cell Tumor:** Inhibin B. * **Choriocarcinoma:** beta-hCG. * **RMI (Risk of Malignancy Index):** Uses CA-125 levels, Ultrasound features, and Menopausal status to predict the likelihood of malignancy.
Question 729: A 35-year-old woman complains of severe lower abdominal pain, which is worst during menstruation. Laparoscopic examination of the pelvis demonstrates multiple small brown spots on the surface of pelvic structures. Biopsy of one of the lesions reveals glandular tissue resembling normal endometrium with no cytologic atypia or abnormally shaped glands. Which of the following is the most likely diagnosis?
- A. Acute endometritis
- B. Adenomyosis
- C. Chronic endometritis
- D. Endometriosis (Correct Answer)
Explanation: **Explanation:** **1. Why Endometriosis is the Correct Answer:** The clinical presentation of severe dysmenorrhea (pain during menstruation) combined with the laparoscopic finding of **"powder-burn" or "mulberry" lesions** (small brown spots) is classic for endometriosis. Pathologically, endometriosis is defined as the presence of functional endometrial glands and stroma outside the uterine cavity. The biopsy confirms this by showing normal-appearing glandular tissue (no atypia) in an ectopic location (pelvic surface). The brown color is due to hemosiderin deposition from cyclical bleeding within these ectopic implants. **2. Why Other Options are Incorrect:** * **Acute/Chronic Endometritis:** These are inflammatory conditions of the inner lining of the uterus, usually presenting with fever, pelvic pain, and vaginal discharge. They do not present as discrete pelvic surface lesions or cyclical pain. * **Adenomyosis:** While it also involves ectopic endometrial tissue, it is specifically located **within the myometrium** (uterine wall). It typically presents with a symmetrically enlarged "globular" uterus and menorrhagia, rather than superficial pelvic spots. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Laparoscopy with biopsy is the definitive diagnostic tool. * **Common Sites:** The **ovary** is the most common site (often forming "Chocolate Cysts" or Endometriomas). The **Pouch of Douglas** is the most common site for peritoneal implants. * **Classic Triad:** Dysmenorrhea, Dyspareunia, and Dyschezia (painful defecation). * **Microscopic Hallmarks:** Presence of endometrial glands, stroma, and hemosiderin-laden macrophages (Siderophages). * **Theories of Origin:** Sampson’s theory (Retrograde menstruation) is the most widely accepted.
Question 730: What is the most common cause of acute cervicitis?
- A. Escherichia coli
- B. Chlamydia
- C. Pseudomonas
- D. Neisseria gonorrhoeae (Correct Answer)
Explanation: **Explanation:** Acute cervicitis is characterized by inflammation of the columnar and subepithelial layers of the endocervix. It typically presents with purulent or mucopurulent endocervical exudate and sustained endocervical bleeding induced by gentle touch (friability). **Why Neisseria gonorrhoeae is correct:** The most common infectious etiologies of acute cervicitis are sexually transmitted infections (STIs). **Neisseria gonorrhoeae** and **Chlamydia trachomatis** are the two primary pathogens. While Chlamydia is often more prevalent in general screening populations, in the context of acute, symptomatic, and purulent cervicitis, *Neisseria gonorrhoeae* is traditionally cited as the most common cause of acute inflammatory changes in the endocervix. **Why the other options are incorrect:** * **Chlamydia trachomatis (Option B):** While a very common cause of cervicitis, it is often asymptomatic or subacute. In many clinical examinations, if both are listed, *N. gonorrhoeae* is favored for "acute" presentations due to the higher degree of inflammatory response. * **Escherichia coli (Option A) & Pseudomonas (Option C):** These are common causes of Urinary Tract Infections (UTIs) or pelvic inflammatory disease (PID) following instrumentation, but they are not primary pathogens for acute cervicitis in sexually active women. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Nucleic Acid Amplification Test (NAAT) is the most sensitive test for both Chlamydia and Gonorrhea. * **Treatment:** Due to high rates of co-infection, patients are often treated empirically for both (e.g., Ceftriaxone for Gonorrhea and Azithromycin/Doxycycline for Chlamydia). * **Strawberry Cervix:** This is a classic sign of *Trichomonas vaginalis* (vaginitis/ectocervicitis), not acute endocervicitis. * **Chronic Cervicitis:** Usually non-infectious, often due to chemical or mechanical irritation (e.g., tampons, diaphragms).
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
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