Gynecological Disorders — MCQs
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Which of the following is NOT a feature of Mayer Rokitansky Kuster Hauser syndrome?
All of the following pelvic structures support the vagina, except:
Regarding vaginal candidiasis, which of the following statements is FALSE?
Vulval candidiasis is associated with:
A 25-year-old female presents to the casualty with a history of amenorrhea for two and a half months, and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from the os. On bimanual examination, the uterus is of 10 weeks size, soft, and the os admits one finger. What is the most likely diagnosis?
Toxic shock syndrome is due to what?
The squamocolumnar junction lies outside the external os in all of the following conditions EXCEPT:
Which of the following Mullerian duct anomalies is associated with the presence of two cervices?
A 65-year-old lady presents with a single episode of postmenopausal bleeding. What is the next step in management?
What uterine anomaly is characterized by a banana-shaped uterus?
Gynecological Disorders Indian Medical PG Practice Questions and MCQs
Question 741: Which of the following is NOT a feature of Mayer Rokitansky Kuster Hauser syndrome?
- A. Renal agenesis
- B. Menorrhagia (Correct Answer)
- C. Hemivertebrae
- D. Normal breasts
Explanation: **Explanation:** **Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome** is a congenital anomaly characterized by **Müllerian agenesis**, resulting from the failure of the Müllerian ducts to develop. **Why Menorrhagia is the Correct Answer:** Menorrhagia (heavy menstrual bleeding) is impossible in MRKH syndrome because there is **congenital absence of the uterus and the upper two-thirds of the vagina**. Since the functional endometrial lining is absent, patients present with **primary amenorrhea**. You cannot have menstrual bleeding without a uterus. **Analysis of Other Options:** * **Renal agenesis (Option A):** MRKH is frequently associated with renal anomalies (in ~30-40% of cases) because the development of the Müllerian ducts is closely linked to the Wolffian (mesonephric) system. Unilateral renal agenesis and ectopic kidneys are common. * **Hemivertebrae (Option C):** Skeletal abnormalities, particularly vertebral defects like hemivertebrae or Klippel-Feil syndrome, are known associations in Type II MRKH (also called MURCS association). * **Normal breasts (Option D):** In MRKH, the **ovaries are functional** and derived from the primitive germ cells (not the Müllerian ducts). Therefore, estrogen levels are normal, leading to **normal secondary sexual characteristics** (Tanner stage 5 breast development and pubic hair). **NEET-PG High-Yield Pearls:** * **Karyotype:** 46, XX (Normal female). * **Clinical Presentation:** A young girl with primary amenorrhea, normal secondary sexual characteristics, and a blind-ending vaginal pouch. * **Initial Investigation:** Ultrasonography (shows absent uterus). * **Gold Standard Investigation:** MRI (to visualize ovaries and renal/skeletal anomalies). * **Management:** Non-surgical (Frank’s dilators) or surgical (McIndoe vaginoplasty) to create a neovagina. Pregnancy is only possible via surrogacy (as ovaries are functional).
Question 742: All of the following pelvic structures support the vagina, except:
- A. Perineal body
- B. Pelvic diaphragm
- C. Levator ani muscle
- D. Infundibulopelvic ligament (Correct Answer)
Explanation: The vagina is supported by a complex network of muscles, fascia, and ligaments categorized into three levels (DeLancey’s levels of support). **Why the Infundibulopelvic Ligament is the Correct Answer:** The **Infundibulopelvic (IP) ligament**, also known as the suspensory ligament of the ovary, contains the ovarian artery, vein, and nerve plexus. Its primary function is to attach the **ovary** to the lateral pelvic wall. It plays no role in supporting the vaginal vault or walls. **Explanation of Incorrect Options:** * **Pelvic Diaphragm & Levator Ani Muscle:** These are essentially the same functional unit. The Levator ani (composed of pubococcygeus, puborectalis, and iliococcygeus) is the primary component of the pelvic diaphragm. It provides the "floor" upon which the pelvic organs rest and maintains the vaginal caliber through constant muscle tone. * **Perineal Body:** This is a fibromuscular pyramidal structure located between the vagina and the anus. It serves as the anchor for Level III support (distal third of the vagina). Damage to the perineal body (e.g., during childbirth) leads to rectocele and gaping of the introitus. **High-Yield Clinical Pearls for NEET-PG:** * **DeLancey Level I Support:** Suspends the upper vagina/cervix via **Paracolpium** (Cardinal and Uterosacral ligaments). Loss leads to Vault Prolapse. * **DeLancey Level II Support:** Attaches the mid-vagina to the **Arcus Tendineus Fascia Pelvis**. Loss leads to Cystocele. * **DeLancey Level III Support:** Attaches the lower vagina to the **Perineal Body**. * The **Uterosacral ligament** is the most important ligament for preventing apical prolapse.
Question 743: Regarding vaginal candidiasis, which of the following statements is FALSE?
- A. Cottage cheese-like secretions are seen.
- B. Intense pruritus is a common symptom.
- C. Vaginal candidiasis occurring during pregnancy is classified as uncomplicated candidiasis. (Correct Answer)
- D. Budding yeast cells and pseudohyphae are seen in KOH preparation.
Explanation: **Explanation:** The correct answer is **C**, as vaginal candidiasis occurring during pregnancy is classified as **complicated candidiasis**, not uncomplicated. **1. Why Option C is the correct (False) statement:** According to the CDC classification, Vulvovaginal Candidiasis (VVC) is categorized into Uncomplicated and Complicated. **Complicated VVC** includes cases that are recurrent (≥4 episodes/year), severe, caused by non-albicans species, or occurring in **compromised hosts** (such as those with uncontrolled diabetes, immunosuppression, or **pregnancy**). Pregnancy creates a high-estrogen environment that increases glycogen content in the vaginal mucosa, providing a rich medium for *Candida* growth and making it harder to eradicate, thus requiring longer treatment courses (usually 7 days of topical azoles). **2. Why other options are incorrect (True statements):** * **Option A:** The classic clinical sign is a thick, white, "curd-like" or **cottage cheese-like** discharge that adheres to the vaginal walls. * **Option B:** **Intense pruritus** (itching) is the hallmark and most distressing symptom of fungal vaginitis. * **Option D:** Diagnosis is confirmed by a **10% KOH mount**, which dissolves host cells to reveal characteristic **budding yeast and pseudohyphae** (except in *C. glabrata*, which only shows spores). **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Pregnancy, Diabetes Mellitus, recent antibiotic use, and OCP use. * **Vaginal pH:** In candidiasis, the pH is typically **normal (<4.5)**, unlike Trichomoniasis or Bacterial Vaginosis where pH is >4.5. * **Treatment:** Oral Fluconazole (150mg single dose) is the drug of choice for uncomplicated cases but is **contraindicated in pregnancy** (use topical Clotrimazole instead). * **Whiff Test:** Negative (no fishy odor).
Question 744: Vulval candidiasis is associated with:
- A. Addison disease
- B. Cushing disease
- C. Diabetes mellitus (Correct Answer)
- D. Acromegaly
Explanation: **Explanation:** **Vulval candidiasis** (caused primarily by *Candida albicans*) is a common opportunistic fungal infection. The correct answer is **Diabetes Mellitus** because hyperglycemia creates an ideal environment for fungal overgrowth. Elevated glucose levels in vaginal secretions and urine (glycosuria) provide a rich substrate for *Candida*. Furthermore, poorly controlled diabetes impairs neutrophil function and local immunity, facilitating the transition of *Candida* from a commensal to a pathogenic state. **Analysis of Options:** * **Diabetes Mellitus (Correct):** It is the most significant metabolic risk factor for recurrent vulvovaginal candidiasis (RVVC). High glycogen content in vaginal epithelial cells and a lowered pH favor yeast proliferation. * **Addison Disease (Incorrect):** This involves adrenocortical insufficiency. While it can be part of Autoimmune Polyglandular Syndrome Type 1 (which includes mucocutaneous candidiasis), Addison’s itself is not a classic primary risk factor for vulval candidiasis. * **Cushing Disease (Incorrect):** While excess cortisol causes immunosuppression, it is not as classically or frequently associated with specific vulval candidiasis as the direct glucose-rich environment of Diabetes. * **Acromegaly (Incorrect):** Excess growth hormone does not have a direct pathophysiological link to fungal vulvovaginitis. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors for Candidiasis:** Pregnancy (high estrogen), Diabetes, Broad-spectrum antibiotics, and Immunosuppression (HIV/Steroids). * **Clinical Presentation:** Characterized by intense pruritus (most common symptom) and **thick, white, "curdy" or "cottage-cheese" discharge**. * **Diagnosis:** pH is typically **normal (<4.5)**. On KOH mount, look for **pseudohyphae** and spores. * **Treatment:** Topical or oral azoles (e.g., Fluconazole). Note: Fluconazole is contraindicated in pregnancy; use topical Clotrimazole instead.
Question 745: A 25-year-old female presents to the casualty with a history of amenorrhea for two and a half months, and abdominal pain and bleeding per vaginum for one day. On examination, vital parameters and other systems are normal. On speculum examination, bleeding is found to come from the os. On bimanual examination, the uterus is of 10 weeks size, soft, and the os admits one finger. What is the most likely diagnosis?
- A. Threatened abortion
- B. Missed abortion
- C. Inevitable abortion (Correct Answer)
- D. Incomplete abortion
Explanation: ### Explanation The clinical presentation points toward a diagnosis of **Inevitable Abortion**. The key diagnostic feature in this case is the combination of vaginal bleeding and an **open cervical os** (os admits one finger) in the presence of a viable-sized uterus, where the products of conception have not yet been expelled. #### Why Inevitable Abortion is Correct: In **Inevitable Abortion**, the clinical process has progressed to a state where termination of pregnancy is certain. The diagnostic hallmarks are: 1. **History:** Amenorrhea, abdominal pain (colicky), and bleeding. 2. **Examination:** The internal os is **dilated (open)**, but the products of conception are still inside the uterus (indicated by the uterus being 10 weeks size, corresponding to her period of amenorrhea). #### Why Other Options are Incorrect: * **Threatened Abortion:** While bleeding occurs, the **cervical os remains closed**, and the pain is usually minimal or absent. The pregnancy may still continue. * **Missed Abortion:** The fetus has died in utero but is retained. The **cervical os is closed**, and there is often a regression of pregnancy symptoms; the uterine size is typically smaller than the period of gestation. * **Incomplete Abortion:** Some products of conception have already been expelled. While the os is open, the **uterine size would be smaller** than the expected period of gestation. #### NEET-PG High-Yield Pearls: * **Os Status is Key:** If the Os is **Closed**, consider Threatened or Missed abortion. If the Os is **Open**, consider Inevitable or Incomplete abortion. * **Uterine Size:** In Inevitable abortion, Uterine Size = Period of Amenorrhea (POA). In Incomplete abortion, Uterine Size < POA. * **Management:** For inevitable abortion, the management is usually hospitalization and evacuation of the uterus (Suction & Evacuation) if the gestation is <12 weeks.
Question 746: Toxic shock syndrome is due to what?
- A. Septic abortion
- B. Forgotten tampons (Correct Answer)
- C. Intrauterine contraceptive device (IUCD)
- D. Pelvic examination
Explanation: **Toxic Shock Syndrome (TSS)** is a life-threatening multisystem illness caused by the exotoxin **TSST-1** (Toxic Shock Syndrome Toxin-1) produced by *Staphylococcus aureus*. ### Why "Forgotten Tampons" is Correct The classic association of TSS is with the use of **high-absorbency tampons** left in place for prolonged periods. The tampon acts as a synthetic nidus that promotes the rapid multiplication of *S. aureus* and provides an aerobic environment conducive to toxin production. The toxin acts as a **superantigen**, causing massive, non-specific T-cell activation and a "cytokine storm," leading to fever, hypotension, and multi-organ failure. ### Analysis of Incorrect Options * **A. Septic Abortion:** While septic abortion can lead to septic shock (often due to *E. coli* or *Clostridium perfringens*), it is not the primary clinical association for the specific entity known as Toxic Shock Syndrome. * **C. IUCD:** Although IUCDs are associated with Pelvic Inflammatory Disease (PID) and Actinomycosis, they are rarely implicated in the pathogenesis of TSS. * **D. Pelvic Examination:** This is a transient clinical procedure and does not provide the prolonged, stagnant environment required for *S. aureus* colonization and toxin release. ### NEET-PG High-Yield Pearls * **Causative Agent:** *Staphylococcus aureus* (TSST-1 toxin). A similar syndrome can be caused by *Streptococcus pyogenes* (Exotoxin A). * **Clinical Triad:** High fever (>38.9°C), hypotension, and a diffuse macular **erythroderma (sunburn-like rash)** that later desquamates (especially on palms and soles). * **Non-menstrual TSS:** Can occur post-operatively, in wound infections, or with vaginal diaphragms/contraceptive sponges. * **Management:** Aggressive fluid resuscitation, removal of the foreign body (tampon), and antibiotics (Clindamycin is often added to decrease toxin production).
Question 747: The squamocolumnar junction lies outside the external os in all of the following conditions EXCEPT:
- A. Pregnancy
- B. Oral contraceptive pills (OCPs)
- C. Menopause (Correct Answer)
- D. Puberty
Explanation: The position of the **Squamocolumnar Junction (SCJ)** is dynamic and primarily influenced by **estrogen levels** and the pH of the vagina. ### **Explanation of the Correct Answer** **C. Menopause:** During menopause, estrogen levels significantly decline. This leads to the atrophy of the cervical tissue and the migration of the SCJ **upward into the endocervical canal** (internal to the external os). This makes the SCJ often invisible during a routine colposcopy in postmenopausal women, requiring an endocervical speculum for visualization. ### **Why Other Options are Incorrect** The SCJ moves **outward (Ectopy/Ectropion)** onto the ectocervix (outside the external os) under high-estrogen states or physiological changes: * **A. Pregnancy:** High levels of estrogen and increased vascularity cause the endocervical mucosa to bulge outwards (eversion). * **B. Oral Contraceptive Pills (OCPs):** The exogenous estrogen in OCPs stimulates the eversion of the columnar epithelium onto the ectocervix. * **D. Puberty:** The physiological rise in estrogen during puberty causes the cervix to enlarge and the endocervical lining to evert. ### **High-Yield NEET-PG Pearls** * **Transformation Zone (TZ):** The area between the original SCJ and the new SCJ. This is the most common site for **Cervical Intraepithelial Neoplasia (CIN)** and squamous cell carcinoma. * **Metaplasia:** The process where the fragile columnar epithelium is replaced by tougher squamous epithelium due to the acidic vaginal environment. * **Nabothian Cysts:** These form when squamous metaplasia blocks the openings of endocervical crypts; they are a hallmark of a normal, physiological transformation zone. * **Clinical Note:** If the SCJ is not fully visible (common in menopause), the colposcopy is labeled **"Unsatisfactory."**
Question 748: Which of the following Mullerian duct anomalies is associated with the presence of two cervices?
- A. Uterus didelphys (Correct Answer)
- B. Uterus bicornis unicollis
- C. Uterus subseptus
- D. Uterus unicornis with a rudimentary horn
Explanation: **Explanation:** The correct answer is **Uterus didelphys**. Mullerian duct anomalies result from the failure of development, fusion, or canalization of the paramesonephric (Mullerian) ducts. **Uterus didelphys** occurs due to a complete failure of fusion of the two Mullerian ducts. This results in two entirely separate uterine horns, two distinct cervices (**bicollis**), and often a longitudinal vaginal septum. **Analysis of Options:** * **Uterus bicornis unicollis:** This results from partial fusion of the Mullerian ducts at the level of the fundus. While there are two uterine horns, they share a single common cervix (*unicollis*). * **Uterus subseptus:** This is a failure of resorption of the midline septum after fusion. The external uterine contour is normal, and there is only one cervix. * **Uterus unicornis:** This results from the failure of one Mullerian duct to develop. Even if a rudimentary horn is present, there is only one functional cervix derived from the developed duct. **High-Yield Clinical Pearls for NEET-PG:** * **Uterus Didelphys:** Associated with the highest rate of successful pregnancy among Mullerian anomalies but carries a risk of preterm labor. * **Septate Uterus:** The most common Mullerian anomaly and the one most frequently associated with recurrent pregnancy loss (miscarriage) due to poor vascularization of the septum. * **Renal Anomalies:** Always screen the renal system (e.g., renal agenesis) in patients with Mullerian duct anomalies, as both systems develop from the intermediate mesoderm. * **HSG vs. MRI:** While Hysterosalpingography (HSG) can show the internal cavity, **MRI** is the gold standard for diagnosing the specific type of anomaly as it visualizes the external uterine contour.
Question 749: A 65-year-old lady presents with a single episode of postmenopausal bleeding. What is the next step in management?
- A. Fractional curettage (Correct Answer)
- B. Pap smear
- C. Hysterectomy immediately
- D. Endometrial biopsy
Explanation: **Explanation:** The primary objective in managing postmenopausal bleeding (PMB) is to **exclude endometrial carcinoma**, which is present in approximately 10% of these cases. **Why Fractional Curettage is the Correct Answer:** Fractional curettage remains the traditional "gold standard" for evaluating PMB in many clinical scenarios. It involves separate scraping of the endocervical canal and the endometrial cavity. This technique is crucial because it not only provides tissue for histopathology but also helps in **staging** by determining if a malignancy is confined to the corpus or has extended to the cervix. While Transvaginal Ultrasound (TVS) is often the first screening tool (with an endometrial thickness >4mm requiring further action), fractional curettage provides the definitive tissue diagnosis required for management. **Analysis of Incorrect Options:** * **B. Pap smear:** This is a screening tool for cervical cancer, not a diagnostic tool for endometrial pathology. While it may occasionally show glandular cells, it lacks the sensitivity to rule out endometrial cancer. * **C. Hysterectomy immediately:** Surgery is the treatment, not the diagnostic step. Performing a hysterectomy without a tissue diagnosis is contraindicated as it prevents proper surgical staging and planning. * **D. Endometrial biopsy (Pipelle):** While often used as a first-line office procedure due to its high sensitivity, it is a "blind" procedure. If the biopsy is negative but symptoms persist, a more formal evaluation like fractional curettage or hysteroscopy-guided biopsy is mandatory. **Clinical Pearls for NEET-PG:** * **Most common cause of PMB:** Senile/Atrophic vaginitis. * **Most common cause of PMB (among malignancies):** Endometrial carcinoma. * **Investigation of choice (Modern):** TVS followed by Hysteroscopy-guided biopsy (more accurate than blind curettage). * **Cut-off for TVS:** Endometrial thickness **<4 mm** has a high negative predictive value for malignancy.
Question 750: What uterine anomaly is characterized by a banana-shaped uterus?
- A. Uterus didelphys
- B. Arcuate uterus
- C. Unicornuate uterus (Correct Answer)
- D. None of the above
Explanation: **Explanation:** The correct answer is **Unicornuate uterus (Option C)**. This anomaly results from the **partial or complete failure of one Müllerian duct to develop**, while the other develops normally. Because only one half of the uterus is present, it appears elongated, narrow, and curved, resembling a **"banana shape"** on imaging. It typically has a single fallopian tube and a single uterine horn. **Analysis of Incorrect Options:** * **Uterus Didelphys (Option A):** This occurs due to the complete failure of fusion of the two Müllerian ducts. It results in two entirely separate uteri, two cervices, and often a longitudinal vaginal septum. It is characterized by a "double" appearance rather than a banana shape. * **Arcuate Uterus (Option B):** This is a mild variation where the uterine fundus has a slight midline indentation into the cavity. The external contour of the uterus remains normal (convex or flat), and it does not result in a banana-shaped configuration. **NEET-PG High-Yield Pearls:** * **Imaging Gold Standard:** MRI is the best non-invasive modality for diagnosing Müllerian duct anomalies (MDAs). * **Renal Association:** Unicornuate uterus is highly associated with **ipsilateral renal agenesis** (up to 40% of cases). Always screen the kidneys in these patients. * **Obstetric Risks:** Associated with increased risks of malpresentation, preterm labor, and **ectopic pregnancy in a rudimentary horn** (which can lead to life-threatening rupture). * **Classification:** According to the AFS classification, Unicornuate uterus is **Class II**.
Practice by Chapter
Abnormal Uterine Bleeding
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Endometriosis
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Adenomyosis
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Uterine Fibroids
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Ovarian Cysts
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Pelvic Inflammatory Disease
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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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