Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 801: Which of the following is the commonest site of fibroma?

A. Labia majora (Correct Answer)
B. Labia minora
C. Clitoris
D. Rudimentary hymen

Explanation: **Explanation:** Fibromas are the most common benign solid tumors of the vulva. They originate from the proliferation of fibroblasts within the connective tissue of the vulvar stroma. **Why Labia Majora is Correct:** The **labia majora** is the correct answer because it contains the highest concentration of subepithelial connective tissue and smooth muscle fibers in the vulvar region. Due to this abundance of stromal tissue, it serves as the most frequent site for the development of fibromas. These tumors typically present as firm, pedunculated, or sessile masses and are usually asymptomatic unless they grow large enough to cause mechanical discomfort or interfere with walking. **Why Other Options are Incorrect:** * **Labia minora:** While fibromas can occur here, the labia minora has significantly less connective tissue volume compared to the labia majora, making it a less common site. * **Clitoris:** This is an extremely rare site for fibromas. Tumors in this region are more likely to be neurofibromas or granular cell tumors. * **Rudimentary hymen:** This structure consists of thin mucosal folds with minimal stromal depth, making the development of a fibroma highly unlikely. **High-Yield Clinical Pearls for NEET-PG:** * **Most common benign solid tumor of vulva:** Fibroma (though some texts cite Lipoma, Fibroma is the classic examiner favorite). * **Most common benign cystic lesion of vulva:** Bartholin’s cyst. * **Treatment:** Simple surgical excision is the treatment of choice. * **Differential Diagnosis:** Must be distinguished from a **Fibromyoma** (which contains smooth muscle) and **Dermatofibroma**. Large vulvar masses should always be evaluated to rule out aggressive angiomyxoma.

Question 802: A 28-year-old female presents with a history of oligomenorrhea. On examination, she has hirsutism and virilization. Ultrasound shows an enlarged left ovary. Her testosterone level is 4 ng/ml, and LH levels are normal. What is the most probable diagnosis?

A. Polycystic Ovary Syndrome (PCOS)
B. Ovarian stromal hyperthecosis
C. Luteoma of pregnancy
D. Ovarian tumor (Correct Answer)

Explanation: ### Explanation The key to solving this clinical scenario lies in the **severity of androgen excess** and the **testosterone levels**. **1. Why "Ovarian Tumor" is correct:** In a female, the normal range for serum testosterone is approximately **0.2–0.8 ng/ml**. A testosterone level **>2 ng/ml** is a critical "red flag" that strongly suggests an androgen-secreting tumor (either ovarian or adrenal). Clinical signs of **virilization** (clitoromegaly, deepening of voice, male-pattern baldness) further differentiate a tumor from functional disorders like PCOS. The presence of an **enlarged left ovary** on ultrasound points specifically toward a Sertoli-Leydig cell tumor or a Hilus cell tumor. **2. Why other options are incorrect:** * **PCOS:** While PCOS causes oligomenorrhea and hirsutism, it rarely causes **virilization**. Testosterone levels in PCOS are typically mildly elevated (<2 ng/ml), and LH levels are often increased (LH:FSH ratio >2:1), which is not the case here. * **Ovarian Stromal Hyperthecosis:** This condition can cause virilization and high testosterone in postmenopausal women. However, it usually presents with bilateral ovarian involvement and is less common in a 28-year-old compared to a neoplastic process. * **Luteoma of Pregnancy:** This is a benign tumor-like condition that occurs only during pregnancy. There is no mention of pregnancy in the history. **3. NEET-PG High-Yield Pearls:** * **Testosterone >2 ng/ml:** Suspect Ovarian Tumor (e.g., Sertoli-Leydig cell tumor). * **DHEAS >7000 ng/ml:** Suspect Adrenal Tumor. * **Rapid onset** of symptoms + **Virilization** = Neoplastic etiology. * **Sertoli-Leydig Cell Tumor:** The most common virilizing ovarian tumor; often presents with Reinke crystals on histology (if it's a Hilus cell tumor).

Question 803: To start, all fibroids are:

A. Interstitial (Correct Answer)
B. Submucous
C. Subserous
D. Ovarian

Explanation: **Explanation:** The correct answer is **Interstitial (Intramural)**. **Why it is correct:** Uterine fibroids (leiomyomas) originate from the proliferation of a single smooth muscle cell (monoclonal) within the **myometrium**. Because the myometrium is the middle muscular layer of the uterus, every fibroid begins its life surrounded by this muscle tissue. Therefore, all fibroids are initially **interstitial** (intramural) in location. As the tumor grows, it may remain within the wall or be pushed toward the uterine cavity or the peritoneal surface, changing its classification. **Analysis of Incorrect Options:** * **Submucous:** These are fibroids that have migrated toward and distorted the endometrium. While they are the most symptomatic (causing heavy menstrual bleeding), they only become submucous after originating in the interstitium. * **Subserous:** These are fibroids that have grown toward the outer serosal surface of the uterus. Like submucous types, this is a secondary location resulting from the outward growth of an interstitial fibroid. * **Ovarian:** Fibroids are primary tumors of the uterine smooth muscle. While rare "extrauterine" fibroids exist, they do not originate in the ovary; primary ovarian smooth muscle tumors are extremely rare and not a standard classification for leiomyomas. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Interstitial (Intramural) fibroids are the most common overall. * **Most symptomatic type:** Submucous fibroids (even if small, they cause significant menorrhagia). * **Degenerations:** Red degeneration is most common during **pregnancy** (due to rapid growth and venous thrombosis), while Hyaline degeneration is the most common overall. * **FIGO Classification:** Uses a 0–8 system; Type 0 is completely intracavitary (submucous), while Type 4 is purely intramural.

Question 804: A 40-year-old woman presented with complaints of profuse vaginal discharge. On speculum examination, there was no discharge from the cervix. The diagnosis of bacterial vaginosis was made based upon all of the following findings on microscopy except?

A. Abundance of gram-variable coccobacilli
B. Absence of Lactobacilli
C. Abundance of polymorphs (Correct Answer)
D. Presence of clue cells

Explanation: **Explanation:** Bacterial Vaginosis (BV) is a clinical syndrome resulting from the replacement of normal hydrogen peroxide-producing **Lactobacilli** with high concentrations of anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Prevotella* spp., and *Mobiluncus*). The hallmark of BV is that it is a **non-inflammatory condition**. Because it is a "vaginosis" rather than a "vaginitis," there is a characteristic **absence or paucity of polymorphonuclear leukocytes (polymorphs)**. If an abundance of polymorphs is seen on microscopy, a clinician should suspect co-infection with Trichomoniasis or Cervicitis. **Analysis of Options:** * **Option C (Correct):** BV is characterized by a lack of inflammation; therefore, an abundance of polymorphs is **not** a feature. * **Option A:** BV involves a massive overgrowth of anaerobic bacteria, which appear as gram-variable coccobacilli on Gram stain. * **Option B:** The primary pathophysiology of BV is the depletion of the protective *Lactobacillus* species, leading to an increase in vaginal pH. * **Option D:** **Clue cells** (vaginal epithelial cells coated with bacteria giving them a "stippled" or "shaggy" appearance) are the most specific diagnostic finding on microscopy. **Clinical Pearls for NEET-PG:** * **Amsel’s Criteria (3 out of 4 required):** 1. Thin, homogenous, grey-white discharge. 2. Vaginal pH > 4.5. 3. Positive **Whiff test** (fishy odor with 10% KOH). 4. Presence of **Clue cells** on wet mount (>20%). * **Nugent Scoring:** The "Gold Standard" for diagnosis, based on Gram stain morphotypes. * **Treatment:** Drug of choice is **Metronidazole** (500 mg BID for 7 days). Treatment of the male partner is not recommended.

Question 805: Ball's operation is performed for which condition?

A. Carcinoma of the cervix
B. Carcinoma of the ovary
C. Carcinoma of the fallopian tube
D. Pruritus vulvae (Correct Answer)

Explanation: **Explanation:** **Ball’s Operation** is a surgical procedure historically used for the treatment of intractable **Pruritus Vulvae** (Option D). The procedure involves making an incision to undercut the skin of the vulva or perianal area to sever the sensory nerve endings (cutaneous nerves). By denervating the affected area, the sensation of itching is abolished, providing relief to patients who have failed medical management. **Analysis of Incorrect Options:** * **Carcinoma of the Cervix (Option A):** The standard surgical treatment for early-stage cervical cancer is **Wertheim’s Radical Hysterectomy**. Advanced stages are primarily managed with radiotherapy and chemotherapy. * **Carcinoma of the Ovary (Option B):** Management typically involves **Staging Laparotomy** with cytoreductive surgery (debulking), which includes total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. * **Carcinoma of the Fallopian Tube (Option C):** This rare malignancy is managed similarly to ovarian cancer, focusing on surgical staging and cytoreduction. **High-Yield Clinical Pearls for NEET-PG:** * **Pruritus Vulvae:** It is a symptom, not a diagnosis. Common causes include infections (Candidiasis), dermatoses (Lichen sclerosus), or malignancy (VIN). * **Mering’s Procedure:** Another surgical technique similar to Ball’s operation used for intractable vulvar pruritus involving skin undercutting. * **Modern Management:** Today, Ball’s operation is rarely performed due to the efficacy of potent topical corticosteroids and the risk of skin necrosis or sensory loss. * **Key Association:** Always rule out **Diabetes Mellitus** in any patient presenting with persistent pruritus vulvae.

Question 806: A fibroid uterus may present with all of the following except?

A. Pelvic mass
B. Infertility
C. Amenorrhoea (Correct Answer)
D. Polymenorrhoea

Explanation: **Explanation:** Uterine leiomyomas (fibroids) are benign monoclonal tumors of smooth muscle cells. The hallmark of fibroids is **increased menstrual bleeding**, not the absence of it. **Why Amenorrhoea is the Correct Answer:** Amenorrhoea (absence of menstruation) is **not** a clinical feature of fibroids. In fact, fibroids typically cause the opposite—heavy or prolonged bleeding. If a patient with a known fibroid presents with amenorrhoea, the most likely cause is a co-existing **pregnancy** (as fibroids often enlarge during pregnancy due to high estrogen levels) or the onset of menopause. **Analysis of Other Options:** * **Pelvic Mass:** Large intramural or subserosal fibroids often present as a firm, non-tender, irregular mass felt per abdomen or on bimanual examination. * **Infertility:** Fibroids can cause infertility by distorting the uterine cavity (submucosal), obstructing the fallopian tubes (cornual), or causing dysfunctional uterine contractions that interfere with sperm transport or implantation. * **Polymenorrhoea:** Fibroids increase the total surface area of the endometrium and cause congestion of the perimyometrial veins, leading to frequent (polymenorrhoea) or heavy (menorrhagia) cycles. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Menorrhagia (Heavy Menstrual Bleeding). * **Most common type of fibroid:** Intramural. * **Most symptomatic type:** Submucosal (causes maximum bleeding and infertility). * **Degenerations:** **Red degeneration** is most common during pregnancy (presents with acute pain); **Hyaline degeneration** is the most common overall. * **Treatment of choice:** Myomectomy (if fertility is desired) or Hysterectomy (if family is complete). Medical management includes GnRH agonists to shrink the tumor pre-operatively.

Question 807: A fibroid uterus may present with all of the following except?

A. Pelvic mass
B. Infertility
C. Amenorrhoea (Correct Answer)
D. Polymenorrhoea

Explanation: **Explanation:** **Why Amenorrhoea is the Correct Answer:** Amenorrhoea (absence of menstruation) is **not** a clinical feature of uterine fibroids (leiomyomas). In fact, fibroids are typically associated with an *increase* in menstrual flow. The primary mechanism involves an increased endometrial surface area, congestion of perimyometrial veins, and interference with uterine contractility. Therefore, if a patient with a known fibroid presents with amenorrhoea, the most likely cause is a coexisting pregnancy or secondary pathology, rather than the fibroid itself. **Analysis of Incorrect Options:** * **Pelvic Mass:** Large intramural or subserosal fibroids often present as a firm, non-tender, irregular mass arising from the pelvis. This is a classic presentation in asymptomatic or large-volume cases. * **Infertility:** Fibroids can cause infertility by distorting the uterine cavity (submucosal), obstructing the fallopian tubes (cornual), or causing dysfunctional uterine contractions that prevent implantation. * **Polymenorrhoea:** Fibroids frequently cause various patterns of Abnormal Uterine Bleeding (AUB). While **Menorrhagia** (heavy cyclic bleeding) is the most common symptom, **Polymenorrhoea** (frequent cycles) and Metrorrhagia (irregular bleeding) can occur due to endometrial hyperplasia or venous stasis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom:** Menorrhagia (Heavy Menstrual Bleeding). * **Most common site:** Intramural (within the muscle wall). * **Most symptomatic type:** Submucosal (even small ones cause significant bleeding/infertility). * **Degeneration during pregnancy:** Red degeneration (due to rapid growth and ischemia). * **Most common degeneration:** Hyaline degeneration. * **Medical Management:** GnRH agonists (to shrink size pre-operatively) or Ulipristal acetate.

Question 808: What is the investigation of choice for Asherman syndrome?

A. Ultrasound (USG)
B. Hysterosalpingography (HSG)
C. Hysteroscopy (Correct Answer)
D. Laparoscopy

Explanation: **Explanation:** **Asherman Syndrome** is characterized by the presence of intrauterine adhesions (synechiae), most commonly occurring after over-vigorous curettage following a miscarriage or postpartum hemorrhage. **Why Hysteroscopy is the Correct Answer:** Hysteroscopy is the **Gold Standard** and the investigation of choice for Asherman syndrome. It allows for direct visualization of the uterine cavity, enabling the clinician to assess the location, extent, and severity of the adhesions. Crucially, it serves both a **diagnostic and therapeutic** purpose, as adhesiolysis (resection of the scars) can be performed during the same procedure. **Why Other Options are Incorrect:** * **Hysterosalpingography (HSG):** While HSG is often the *initial* screening test, it is not the investigation of choice. It shows "filling defects" but cannot distinguish between adhesions, polyps, or fibroids, and carries a risk of false positives due to air bubbles or mucus. * **Ultrasound (USG):** Routine USG is insensitive for detecting fine adhesions. While Saline Infusion Sonography (SIS) is better than a standard USG, it still lacks the diagnostic precision and therapeutic capability of hysteroscopy. * **Laparoscopy:** This visualizes the exterior of the uterus and the pelvic cavity. It cannot see inside the uterine lumen where Asherman syndrome occurs. However, it may be used concurrently with hysteroscopy to prevent uterine perforation during difficult adhesiolysis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Post-traumatic (D&C) following pregnancy. * **Clinical Presentation:** Secondary amenorrhea or hypomenorrhea and infertility. * **HSG Finding:** Characteristic "honeycomb appearance" or irregular filling defects. * **Classification:** Often graded using the **March classification** or the **American Fertility Society (AFS)** score based on hysteroscopic findings.

Question 809: What is the first-line therapy in women with adenomyosis who wish to preserve fertility?

A. Combined oral contraceptive pills
B. Levonorgestrel-containing intrauterine device (Correct Answer)
C. Ulipristal acetate
D. Hysterectomy

Explanation: **Explanation:** **Adenomyosis** is characterized by the presence of endometrial glands and stroma within the myometrium, leading to a diffusely enlarged uterus, heavy menstrual bleeding (HMB), and dysmenorrhea. **Why Option B is Correct:** The **Levonorgestrel-releasing Intrauterine System (LNG-IUS)** is considered the first-line medical management for adenomyosis in women desiring to preserve their uterus/fertility. It works by releasing progestogen directly into the uterine cavity, causing profound decidualization and atrophy of the endometrial lining. This significantly reduces menstrual blood loss and alleviates pain by suppressing the inflammatory response within the adenomyotic foci. **Why Other Options are Incorrect:** * **Option A (COCPs):** While COCPs can help manage symptoms by inducing endometrial atrophy, they are generally less effective than the LNG-IUS in reducing the uterine volume and pain associated specifically with adenomyosis. * **Option C (Ulipristal acetate):** This Selective Progesterone Receptor Modulator (SPRM) is primarily used for uterine fibroids. While it may reduce bleeding, it is not the first-line choice for adenomyosis and has concerns regarding liver toxicity. * **Option D (Hysterectomy):** This is the **definitive treatment** for adenomyosis. However, it is contraindicated in this scenario as the patient wishes to **preserve fertility**. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Secondary dysmenorrhea, Menorrhagia, and a symmetrically enlarged "globular," soft, and tender uterus (often described as "boggy"). * **Investigation of Choice:** Transvaginal Ultrasound (TVUS) is the initial investigation (look for "Venetian blind" shadowing); **MRI** is the gold standard for diagnosis. * **Definitive Treatment:** Hysterectomy (for those who have completed their family). * **Key Distinction:** Unlike fibroids (which are firm and asymmetrical), adenomyosis typically presents as a soft, symmetrical enlargement.

Question 810: A girl presents with a cystic swelling at the junction of the lower one-third and upper two-thirds of the anterior vaginal wall at the 10 o'clock position. What is the most likely diagnosis?

A. Bartholin's cyst
B. Gartner's duct cyst (Correct Answer)
C. Adenocarcinoma
D. Vaginal inclusion cyst

Explanation: ### Explanation **Correct Answer: B. Gartner’s duct cyst** **Reasoning:** Gartner’s duct cysts are embryological remnants of the **Wolffian (mesonephric) duct**. In females, these ducts normally regress; however, if a portion persists, it can become cystic. These cysts are characteristically located in the **anterolateral wall** of the vagina, typically in the **upper two-thirds**. The description of a swelling at the 10 o'clock (or 2 o'clock) position on the anterior vaginal wall is a classic clinical presentation for a Gartner’s duct cyst. **Why other options are incorrect:** * **A. Bartholin’s cyst:** These occur due to obstruction of the Bartholin gland duct. They are located in the **posterior third** of the labia majora (vulva), near the 4 or 8 o'clock position, not the anterior vaginal wall. * **C. Adenocarcinoma:** While clear cell adenocarcinoma can occur in the vagina (often linked to DES exposure), it typically presents as a solid, friable mass with bleeding in older patients, rather than a simple cystic swelling in a young girl. * **D. Vaginal inclusion cyst:** These are the most common vaginal cysts, but they usually occur in the **posterior or lateral wall of the lower vagina** and are typically secondary to birth trauma or episiotomy scars. **High-Yield Clinical Pearls for NEET-PG:** * **Origin:** Gartner’s duct = Mesonephric/Wolffian remnant; Paramesonephric duct = Müllerian duct. * **Association:** Gartner’s duct cysts are sometimes associated with **congenital renal anomalies** (e.g., renal agenesis or ectopic ureter) because the ureteric bud develops from the Wolffian duct. * **Differential Diagnosis:** Always differentiate from a **Urethral Diverticulum**, which is also anterior but usually associated with the "3 Ds": Dysuria, Dribbling, and Dyspareunia. * **Treatment:** Usually asymptomatic and requires no treatment; surgical excision is reserved for symptomatic cases.

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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