Gynecological Disorders — MCQs

A 25-year-old female presents with a two-year history of trying to conceive. Her medical history includes cyclical pelvic pain, dysmenorrhea, dyspareunia, and infertility. Physical examination reveals diffuse abdominal or pelvic pain of variable location, nodular thickening and tenderness along the uterosacral ligaments, on the posterior surface of the uterus, and in the posterior cul-de-sac, scarring and narrowing of the posterior vaginal fornix, and adnexal enlargement and tenderness. What is your diagnosis?

Q760Medium

A 32-year-old woman consults her gynecologist for fever and progressively severe pain in her left lower abdominal quadrant. The pain began several days ago, shortly after the onset of her menses. Pelvic examination demonstrates bilateral adnexal tenderness, much more marked on the left than the right. Which of the following is the most likely pathogen?

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 751: Which of the following is NOT true about transverse vaginal septum?

A. Can develop at any level within the vagina.
B. Is associated with urologic abnormalities.
C. Has a high rate of endometriosis.
D. Is clinically easily distinguished from an imperforate hymen. (Correct Answer)

Explanation: **Explanation:** The correct answer is **D**. A transverse vaginal septum is often **clinically difficult to distinguish** from an imperforate hymen because both present with primary amenorrhea and cyclical pelvic pain due to hematocolpos. On physical examination, both conditions show a bulging membrane at the introitus; however, the key differentiator is that an imperforate hymen typically shows a **bluish discoloration** (due to blood behind a thin membrane) and moves with the Valsalva maneuver, whereas a septum is usually thicker, more proximal, and lacks the characteristic blue bulge. **Analysis of Options:** * **A is true:** A transverse vaginal septum results from the failure of canalization between the Müllerian ducts and the urogenital sinus. It can occur at the superior (46%), middle (40%), or inferior (14%) levels of the vagina. * **B is true:** Unlike isolated imperforate hymen, transverse vaginal septa are frequently associated with other Müllerian anomalies and **urologic malformations** (e.g., renal agenesis or ectopic ureters). * **C is true:** Because the septum causes outflow obstruction, it leads to retrograde menstruation, which significantly increases the risk of **endometriosis** and pelvic adhesions. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** MRI is the investigation of choice to determine the thickness and location of the septum before surgery. * **Management:** Surgical excision (Z-plasty) is required. * **Key Distinction:** If the question mentions a "bulging membrane with Valsalva" and "bluish hue," think **Imperforate Hymen**. If it mentions "obstruction with normal external genitalia but no blue bulge," think **Transverse Vaginal Septum**.

Question 752: Which of the following is FALSE about bacterial vaginosis?

A. Itching may be present
B. Clue cells are found on microscopy
C. Characterized by a gray, homogenous discharge (Correct Answer)
D. Associated with a fishy odor discharge

Explanation: This question is a classic "except" style question frequently seen in NEET-PG. However, there appears to be a technical error in the provided key: **Option C is actually a TRUE statement** regarding Bacterial Vaginosis (BV). In clinical practice and standard textbooks (Dutta/Williams), the hallmark of BV is indeed a thin, gray, homogenous discharge. If we must identify the **FALSE** statement among these, **Option A (Itching may be present)** is the most likely candidate. BV is characterized by a lack of inflammation (hence "vaginosis" rather than "vaginitis"); itching and soreness are typically absent, which helps differentiate it from *Candidiasis* or *Trichomoniasis*. ### Explanation of Options: * **A (Itching):** Usually **absent** in BV. Its presence suggests a co-infection or an alternative diagnosis like Vulvovaginal Candidiasis. * **B (Clue Cells):** These are vaginal epithelial cells coated with *Gardnerella vaginalis*, giving them a "stippled" or "shaggy" appearance. This is the most reliable microscopic finding (Amsel’s Criteria). * **C (Gray, homogenous discharge):** This is a **true** clinical feature. The discharge is non-viscous and coats the vaginal walls evenly. * **D (Fishy odor):** Caused by the release of volatile amines (cadaverine/putrescine) when KOH is added (Positive Whiff Test). ### High-Yield Clinical Pearls for NEET-PG: * **Amsel’s Criteria (3 out of 4 required):** 1. Homogenous, thin, white/gray discharge. 2. Vaginal pH > 4.5 (Most sensitive). 3. Positive Whiff test (10% KOH). 4. Clue cells on wet mount (>20% of cells). * **Nugent Scoring:** The "Gold Standard" for diagnosis (based on Gram stain morphotypes). * **Microbiology:** Shift from *Lactobacillus* (H2O2 producers) to anaerobes (*Gardnerella, Mobiluncus, Prevotella*). * **Treatment:** Drug of choice is **Metronidazole** (500mg BD for 7 days). Partner treatment is **not** recommended.

Question 753: What is the commonest organism causing acute salpingitis?

A. Mycoplasma
B. Chlamydia
C. Gonococcus (Correct Answer)
D. Treponema

Explanation: **Explanation:** Acute salpingitis is a key component of Pelvic Inflammatory Disease (PID). The correct answer is **Gonococcus** (*Neisseria gonorrhoeae*), which is traditionally recognized as the most common cause of **acute** and **symptomatic** salpingitis. * **Why Gonococcus is correct:** *Neisseria gonorrhoeae* is highly virulent and causes a rapid, intense inflammatory response in the endosalpinx. It typically presents with high-grade fever, severe pelvic pain, and purulent discharge. In the context of "acute" presentations in standard textbooks (like Shaw’s or Jeffcoate’s), Gonococcus remains the primary pathogen cited for the initial acute episode. * **Why other options are incorrect:** * **Chlamydia (*C. trachomatis*):** While Chlamydia is the most common cause of PID overall in many developed regions, it often causes "silent" or subacute salpingitis. It leads to significant tubal damage and infertility but is less likely to present as a florid "acute" clinical episode compared to Gonococcus. * **Mycoplasma:** *Mycoplasma hominis* and *Ureaplasma* are often isolated in polymicrobial PID cases but are rarely the primary or most common cause of acute salpingitis. * **Treponema:** *Treponema pallidum* causes Syphilis, which is a systemic infection and does not typically cause acute salpingitis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of PID overall:** *Chlamydia trachomatis* (often asymptomatic). * **Most common cause of Acute/Symptomatic Salpingitis:** *Neisseria gonorrhoeae*. * **Gold Standard for Diagnosis:** Laparoscopy (shows hyperemic, edematous tubes with purulent exudate). * **Fitz-Hugh-Curtis Syndrome:** Peri-hepatitis (violin-string adhesions) associated with PID, most commonly caused by Chlamydia. * **Treatment:** Always covers both Gonococcus (Ceftriaxone) and Chlamydia (Doxycycline).

Question 754: Retention of urine is a feature in which of the following?

A. Subserosal leiomyoma
B. Interstitial leiomyoma
C. Submucosal leiomyoma
D. Anterior cervical leiomyoma (Correct Answer)

Explanation: **Explanation:** **1. Why Anterior Cervical Leiomyoma is Correct:** The primary mechanism for urinary retention in cases of uterine fibroids is **mechanical compression** of the urethra or the bladder neck. A leiomyoma (fibroid) arising from the **anterior wall of the cervix** is uniquely positioned to press directly against the urethra or the base of the bladder. As the tumor grows, it displaces the bladder upwards and compresses the urethra against the pubic symphysis, leading to acute or chronic urinary retention. **2. Why Other Options are Incorrect:** * **Subserosal Leiomyoma (A):** These grow toward the peritoneal cavity. While a large anterior subserosal fibroid might cause urinary frequency by reducing bladder capacity, it rarely causes complete retention unless it is very large and impacted in the pelvis. * **Interstitial/Intramural Leiomyoma (B):** These are located within the myometrium. They typically present with menorrhagia or dysmenorrhea rather than obstructive urinary symptoms. * **Submucosal Leiomyoma (C):** These distort the uterine cavity and primarily present with heavy menstrual bleeding (HMB) or infertility. They do not exert external pressure on the urinary tract. **3. Clinical Pearls for NEET-PG:** * **Retroverted Gravid Uterus:** Another classic cause of urinary retention (usually around 12–14 weeks of gestation) due to the cervix pressing against the urethra. * **Posterior Cervical Fibroid:** More likely to cause **constipation** or rectal pressure rather than urinary retention. * **Impacted Pelvic Mass:** Any mass (like a broad ligament fibroid) that becomes "impacted" in the Pouch of Douglas can displace the cervix anteriorly, leading to secondary urethral obstruction. * **Management:** Surgical intervention (Myomectomy or Hysterectomy) is usually required to relieve the mechanical obstruction.

Question 755: Marsupialization is the procedure done for:

A. Bartholin's cyst (Correct Answer)
B. Carcinoma cervix
C. Chronic cervicitis
D. Endometriosis

Explanation: **Explanation:** **Bartholin’s cyst** is the correct answer. The Bartholin’s glands are located at the 4 and 8 o’clock positions of the vaginal introitus. When the duct becomes obstructed, a cyst forms. **Marsupialization** is the surgical treatment of choice for recurrent or symptomatic cysts. The procedure involves incising the cyst wall and suturing the edges to the surrounding skin, creating a permanent "pouch" or opening. This allows for continuous drainage and prevents the re-accumulation of fluid, thereby reducing the risk of recurrence compared to simple incision and drainage. **Why other options are incorrect:** * **Carcinoma Cervix:** Treatment depends on the FIGO stage but typically involves radical hysterectomy (e.g., Wertheim’s) or radiotherapy/chemoradiotherapy. Marsupialization has no role in oncological management. * **Chronic Cervicitis:** This is usually managed with antibiotics or local destructive methods like cryosurgery or electrocautery (cauterization) to destroy the abnormal epithelium. * **Endometriosis:** Management involves medical therapy (OCPs, GnRH agonists) or surgical excision/ablation of endometriotic implants and adhesiolysis. **NEET-PG High-Yield Pearls:** * **Gold Standard:** Marsupialization is the preferred treatment for recurrent Bartholin’s cysts. * **Word Catheter:** An alternative conservative management where a small balloon catheter is inserted into the cyst for 4–6 weeks to create a permanent epithelialized tract. * **Biopsy Rule:** In postmenopausal women, any Bartholin’s mass must be biopsied or excised to rule out **Bartholin’s gland carcinoma**, although it is rare. * **Primary Symptom:** Most cysts are asymptomatic unless they become infected, forming a **Bartholin’s abscess** (most commonly caused by *E. coli* or *N. gonorrhoeae*).

Question 756: Mifepristone can be effectively used to induce therapeutic abortion until which gestational week?

A. 6 weeks
B. 7 weeks
C. 8 weeks
D. 9 weeks (Correct Answer)

Explanation: **Explanation:** **Mifepristone** is a potent synthetic anti-progestational agent. It acts by competitively binding to progesterone receptors, leading to decidual necrosis, cervical softening, and increased uterine sensitivity to prostaglandins. **Why 9 weeks is correct:** According to standard clinical protocols (including WHO and ACOG guidelines) and the updated Medical Termination of Pregnancy (MTP) guidelines, medical abortion using a combination of **Mifepristone (200 mg)** followed by a prostaglandin analogue like **Misoprostol (800 mcg)** is highly effective and FDA-approved for use up to **63 days (9 weeks)** of gestation. Beyond this period, the efficacy of medical induction decreases, and the risk of incomplete abortion increases significantly. **Analysis of Incorrect Options:** * **A, B, & C (6, 7, and 8 weeks):** While Mifepristone is certainly effective at these earlier gestational ages, these options do not represent the *upper limit* of its standard clinical efficacy for medical abortion. Choosing these would prematurely restrict the window for medical management. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Mifepristone is a **competitive progesterone antagonist**. It also has anti-glucocorticoid and anti-androgenic activity. * **MTP Act (India) Update:** Medical abortion is legal in India up to **9 weeks (63 days)**. For gestations between 9–12 weeks, surgical methods (Manual Vacuum Aspiration) are preferred. * **The Regimen:** The most common regimen is 200 mg Mifepristone orally, followed 24–48 hours later by 800 mcg Misoprostol (vaginal, buccal, or sublingual). * **Contraindications:** Suspected ectopic pregnancy, chronic adrenal failure, long-term corticosteroid therapy, and known allergy to prostaglandins. * **Side Effects:** Heavy bleeding and cramping are expected; however, excessive bleeding may require surgical intervention (D&C).

Question 757: All of the following statements are true about Bacterial vaginosis EXCEPT?

A. Caused by Gardnerella vaginalis
B. Fishy odor upon whiff test
C. Infection seen when vaginal pH is < 4.5 (Correct Answer)
D. It is not an STD

Explanation: **Explanation:** Bacterial Vaginosis (BV) is a clinical syndrome characterized by a shift in the vaginal flora from the dominant *Lactobacillus* species to an overgrowth of anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Mobiluncus*, and *Atopobium vaginae*). **Why Option C is the Correct Answer (The False Statement):** The hallmark of Bacterial Vaginosis is a **rise in vaginal pH to > 4.5**. In a healthy vagina, *Lactobacilli* produce lactic acid to maintain an acidic environment (pH 3.8–4.5), which inhibits the growth of pathogens. In BV, the loss of these acid-producing bacteria leads to an alkaline environment. Therefore, an infection seen when pH is < 4.5 is incorrect. **Analysis of Other Options:** * **Option A:** While BV is polymicrobial, ***Gardnerella vaginalis*** is the most common organism associated with the condition. * **Option B:** The **Whiff test** (adding 10% KOH to vaginal discharge) releases volatile amines (putrescine and cadaverine), producing a characteristic **fishy odor**. * **Option D:** BV is considered a dysbiosis (imbalance of flora) rather than a traditional **Sexually Transmitted Disease (STD)**, although it is associated with sexual activity and having multiple partners. **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. 3. Positive Whiff test. 4. Presence of **Clue cells** on wet mount (Stippled epithelial cells)—**Most specific finding.** * **Nugent Scoring:** The "Gold Standard" for diagnosis based on Gram stain. * **Treatment:** Drug of choice is **Metronidazole** (500 mg BID for 7 days). Treatment of the male partner is **not** recommended.

Question 758: In Purandare's sling procedure, the cervix is suspended by attaching it to which anatomical structure?

A. Sacrum
B. Anterosuperior iliac spine
C. Pubis
D. Anterior abdominal wall (Correct Answer)

Explanation: **Explanation:** **Purandare’s Cervico-pexy** is a surgical procedure used for the management of **nulliparous prolapse** (prolapse in young women who wish to preserve their uterus and fertility). 1. **Why the Correct Answer is Right:** In this procedure, the cervix is suspended from the **anterior abdominal wall** (specifically the rectus sheath). A strip of the rectus sheath is fashioned and passed through the broad ligament to be attached to the anterior surface of the cervix at the level of the internal os. This provides a dynamic support that elevates the uterus when the abdominal muscles contract. 2. **Analysis of Incorrect Options:** * **A. Sacrum:** This refers to **Shirodkar’s Sling** or **Sacrocolpopexy/Sacrohysteropexy**, where the cervix or vaginal vault is attached to the promontory of the sacrum using synthetic mesh or fascia lata. * **B. Anterosuperior iliac spine:** This is the landmark for **Khanna’s Sling** procedure, where the cervix is attached to the ASIS using a non-absorbable suture or tape. * **C. Pubis:** While some procedures involve the pubic bone (like the Marshall-Marchetti-Krantz for stress incontinence), it is not the anchor point for Purandare’s sling. 3. **Clinical Pearls for NEET-PG:** * **Indication:** Best for young women with second or third-degree uterovaginal prolapse who desire future childbearing. * **Sling Procedures Summary:** * **Purandare’s:** Rectus sheath (Anterior abdominal wall). * **Shirodkar’s:** Sacral promontory. * **Khanna’s:** Anterosuperior iliac spine. * **Soonawala’s:** Uses the round ligament to anchor the cervix to the abdominal wall. * **Key Advantage:** It avoids the use of foreign material (mesh) by using the patient's own rectus sheath.

Question 759: A 25-year-old female presents with a two-year history of trying to conceive. Her medical history includes cyclical pelvic pain, dysmenorrhea, dyspareunia, and infertility. Physical examination reveals diffuse abdominal or pelvic pain of variable location, nodular thickening and tenderness along the uterosacral ligaments, on the posterior surface of the uterus, and in the posterior cul-de-sac, scarring and narrowing of the posterior vaginal fornix, and adnexal enlargement and tenderness. What is your diagnosis?

A. Endometriosis (Correct Answer)
B. Ectopic pregnancy
C. Adnexal mass
D. Pelvic relaxation

Explanation: ### Explanation **1. Why Endometriosis is Correct:** The clinical presentation is a classic "textbook" case of endometriosis. The patient exhibits the **"3 Ds"**: Dysmenorrhea, Dyspareunia, and Dyschezia (implied by pelvic pain), alongside primary infertility. * **Pathophysiology:** Endometrial glands and stroma grow outside the uterine cavity. * **Physical Findings:** The **nodular thickening and tenderness of the uterosacral ligaments** and the posterior cul-de-sac (Pouch of Douglas) are pathognomonic signs of deeply infiltrating endometriosis. Adnexal enlargement suggests the presence of an **endometrioma** (chocolate cyst). The cyclical nature of the pain coincides with the menstrual cycle, reflecting the hormonal responsiveness of the ectopic tissue. **2. Why Other Options are Incorrect:** * **B. Ectopic Pregnancy:** This typically presents acutely with amenorrhea, vaginal bleeding, and sharp unilateral pain. A two-year history of cyclical pain and infertility is inconsistent with an acute ectopic event. * **C. Adnexal Mass:** While an adnexal mass (like an endometrioma) is present here, "Adnexal mass" is a clinical finding, not a definitive diagnosis. It does not account for the uterosacral nodularity or the systemic nature of the symptoms. * **D. Pelvic Relaxation:** This refers to pelvic organ prolapse (cystocele, rectocele, or uterine prolapse). It presents with a "bearing down" sensation or a palpable bulge, not cyclical pain, nodularity, or infertility. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Laparoscopy with biopsy (visualization of "powder-burn" or "mulberry" lesions). * **Most Common Site:** The ovary. * **CA-125:** Often elevated in endometriosis but lacks specificity; used for monitoring, not primary diagnosis. * **First-line Medical Management:** Combined Oral Contraceptive Pills (COCPs) or NSAIDs. * **Definitive Treatment:** Total Laparoscopic Hysterectomy with Bilateral Salpingo-oophorectomy (TLH with BSO).

Question 760: A 32-year-old woman consults her gynecologist for fever and progressively severe pain in her left lower abdominal quadrant. The pain began several days ago, shortly after the onset of her menses. Pelvic examination demonstrates bilateral adnexal tenderness, much more marked on the left than the right. Which of the following is the most likely pathogen?

A. Escherichia
B. Neisseria (Correct Answer)
C. Staphylococcus
D. Streptococcus

Explanation: **Explanation:** The clinical presentation of fever, lower abdominal pain, and bilateral adnexal tenderness following the onset of menses is classic for **Pelvic Inflammatory Disease (PID)**. **Why Neisseria is the Correct Answer:** *Neisseria gonorrhoeae* and *Chlamydia trachomatis* are the most common causative agents of acute PID. A key high-yield feature in this vignette is the **timing of symptoms**. Gonococcal PID typically manifests **shortly after the onset of menses**. During menstruation, the protective cervical mucus plug is lost, and the alkaline pH of menstrual blood facilitates the upward migration of *N. gonorrhoeae* from the lower genital tract to the endometrium and fallopian tubes. **Analysis of Incorrect Options:** * **Escherichia coli (A):** While *E. coli* can be part of the polymicrobial flora in chronic or severe PID (especially in older women or post-procedural infections), it is not the primary initiator of acute PID in a young, menstruating woman. * **Staphylococcus (C) and Streptococcus (D):** These are common skin or respiratory flora. While *Streptococcus agalactiae* (Group B) can colonize the vagina, these organisms are rarely the primary cause of acute, sexually transmitted PID. **NEET-PG High-Yield Pearls:** 1. **Most common cause of PID:** *Chlamydia trachomatis* (often subacute/asymptomatic). 2. **Most common cause of acute/symptomatic PID:** *Neisseria gonorrhoeae*. 3. **Fitz-Hugh-Curtis Syndrome:** Perihepatitis (violin-string adhesions) associated with PID. 4. **Diagnosis:** Primarily clinical (Cervical Motion Tenderness/Adnexal tenderness). 5. **Treatment:** Must cover both *Neisseria* (Ceftriaxone) and *Chlamydia* (Doxycycline), plus anaerobes (Metronidazole) if a tubo-ovarian abscess is suspected.

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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