Gynecological Disorders — MCQs

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 841: Which drug is commonly used in the treatment of endometriosis?

A. LH
B. GnRH analogues (Correct Answer)
C. MPA
D. FSH

Explanation: **Explanation:** Endometriosis is an estrogen-dependent condition characterized by the presence of endometrial tissue outside the uterine cavity. The primary goal of medical management is to induce a hypoestrogenic state, which leads to the atrophy of ectopic endometrial implants. **Why GnRH Analogues are correct:** GnRH analogues (e.g., Leuprolide, Goserelin) are a mainstay of treatment. When administered continuously, they cause **downregulation and desensitization of GnRH receptors** in the pituitary gland. This results in a "medical oophorectomy" by suppressing the secretion of LH and FSH, leading to profound hypoestrogenism. This starves the endometriotic lesions of the estrogen required for their growth and inflammation. **Analysis of Incorrect Options:** * **LH (Luteinizing Hormone):** Administering LH would stimulate the ovaries to produce more estrogen and progesterone, potentially worsening the disease. * **MPA (Medroxyprogesterone Acetate):** While progestins like MPA can be used to treat endometriosis by causing decidualization and atrophy of the endometrium, **GnRH analogues** are more frequently cited as the "classic" or potent pharmacological choice in competitive exams due to their definitive mechanism of action. * **FSH (Follicle Stimulating Hormone):** FSH stimulates follicular development and estrogen production, which would exacerbate endometriosis symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Add-back Therapy:** To prevent bone mineral density loss and vasomotor symptoms (hot flashes) caused by GnRH analogues, low-dose estrogen/progestin "add-back therapy" is started if treatment exceeds 6 months. * **First-line Treatment:** Combined Oral Contraceptive Pills (COCPs) or NSAIDs are often the first-line for pain, but GnRH analogues are the gold standard for refractory cases. * **Danazol:** An older drug (weak androgen) also used for endometriosis; it creates a "pseudo-menopause" but is less preferred now due to androgenic side effects (acne, hirsutism).

Question 842: Endometriosis is common in:

A. Multiple parity
B. Perimenopausal age
C. Nulliparity (Correct Answer)
D. Virgins

Explanation: **Explanation:** Endometriosis is a chronic, estrogen-dependent condition characterized by the presence of endometrial-like tissue outside the uterine cavity. **Why Nulliparity is correct:** The most widely accepted theory for endometriosis is **Sampson’s Theory of Retrograde Menstruation**. Risk factors for endometriosis are generally linked to increased exposure to menstrual blood and estrogen. **Nulliparity** (never having given birth) is a classic risk factor because these women experience "uninterrupted" menstrual cycles. Pregnancy and lactation provide a physiological break from menstruation (amenorrhea) and create a high-progesterone environment, which causes decidualization and atrophy of endometriotic implants. Therefore, women who have not had children are at a higher risk due to continuous cyclic exposure. **Analysis of Incorrect Options:** * **A. Multiple parity:** This is a protective factor. Pregnancy reduces the risk of endometriosis by interrupting the menstrual cycle and lowering cumulative estrogen exposure. * **B. Perimenopausal age:** Endometriosis is a disease of the **reproductive age group** (typically 25–35 years). As a woman approaches menopause, estrogen levels decline, leading to the regression of endometriotic lesions. * **C. Virgins:** While endometriosis can occur in virgins (especially if there are obstructive Mullerian anomalies), it is statistically more common in women of reproductive age who are nulliparous. Sexual activity itself is not the primary risk determinant; rather, it is the hormonal and menstrual history. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Dysmenorrhea (congestive/secondary), Dyspareunia, and Infertility. * **Most common site:** The **Ovary** (often presenting as a "Chocolate Cyst" or Endometrioma). * **Most common site for distant metastasis:** The Lungs. * **Risk Factors:** Early menarche, late menopause, short menstrual cycles (<27 days), and heavy flow (menorrhagia). * **Gold Standard Diagnosis:** Laparoscopy (visual confirmation with biopsy).

Question 843: What is the chromosomal complement of a normal female?

A. 46XY
B. 46XX (Correct Answer)
C. 45XY
D. 45XX

Explanation: **Explanation:** The human somatic cell contains **46 chromosomes**, organized into 23 pairs. Of these, 22 pairs are autosomes, and one pair consists of sex chromosomes (gonosomes) which determine the biological sex of the individual. * **Why 46,XX is correct:** In a normal female, the sex chromosome pair consists of two X chromosomes. Therefore, the standard karyotype is represented as **46,XX**. During embryonic development, the absence of the Y chromosome (and specifically the SRY gene) allows the bipotential gonad to develop into an ovary, leading to female phenotypic differentiation. **Analysis of Incorrect Options:** * **46,XY (Option A):** This is the chromosomal complement of a normal **male**. The presence of the Y chromosome triggers testis determination. * **45,XY and 45,XX (Options C & D):** These represent **monosomy**, which is a numerical chromosomal abnormality. A 45,X karyotype (missing one sex chromosome) results in **Turner Syndrome**, the most common cause of primary amenorrhea. A 45,Y complement is non-viable and results in early spontaneous abortion. **NEET-PG Clinical Pearls:** * **Barr Body:** In females, one X chromosome undergoes inactivation (Lyonization) to balance gene dosage. This inactivated X chromosome is visible as a **Barr body** in the nucleus of somatic cells (e.g., buccal smear). The number of Barr bodies = (Total X chromosomes - 1). * **Swyer Syndrome:** A high-yield condition where an individual has a **46,XY** karyotype but presents as a phenotypic female due to a mutation in the SRY gene. * **Mullerian Agenesis (MRKH Syndrome):** These patients have a normal female karyotype (**46,XX**) and normal ovaries but are born without a uterus and upper vagina.

Question 844: Which of the following criteria is used for the diagnosis of abdominal pregnancy?

A. Studiford criteria (Correct Answer)
B. Speigelberg criteria
C. Rubins criteria
D. Rotterdam criteria

Explanation: **Explanation:** **1. Why Studiford Criteria is Correct:** Abdominal pregnancy is a rare form of ectopic pregnancy where the fetus develops within the peritoneal cavity. To diagnose a **Primary Abdominal Pregnancy**, the **Studiford Criteria** must be met: * Both fallopian tubes and ovaries must be normal (no evidence of recent or remote injury). * There is no evidence of a uteroperitoneal fistula. * The pregnancy is related exclusively to the peritoneal surface and is early enough to eliminate the possibility of secondary implantation after primary tubal rupture. **2. Analysis of Incorrect Options:** * **Speigelberg Criteria:** These are used for the diagnosis of **Ovarian Pregnancy**. They require the tube on the affected side to be intact, the fetal sac to occupy the position of the ovary, and ovarian tissue to be present in the sac wall. * **Rubins Criteria:** These are used for the diagnosis of **Cervical Pregnancy**. Criteria include the presence of cervical glands opposite the placental attachment and the placenta being below the level of the internal os. * **Rotterdam Criteria:** These are used for the diagnosis of **Polycystic Ovary Syndrome (PCOS)**, requiring two out of three: oligo/anovulation, hyperandrogenism, and polycystic ovaries on ultrasound. **3. Clinical Pearls for NEET-PG:** * **Secondary Abdominal Pregnancy** is more common than primary, usually occurring after tubal abortion or rupture. * **Management:** Surgical intervention is usually required. A high-yield point is **not to remove the placenta** if it is attached to vital organs (like the bowel or major vessels) to avoid massive hemorrhage; instead, leave it in situ and treat with Methotrexate. * **Arias-Stella Reaction:** Can be seen in the endometrium of any ectopic pregnancy (decidual change without chorionic villi).

Question 845: What is the drug of choice in bacterial vaginosis?

A. Metronidazole (Correct Answer)
B. Doxycycline
C. Clindamycin
D. Ciprofloxacin

Explanation: **Explanation:** **Bacterial Vaginosis (BV)** is a clinical syndrome resulting from the replacement of normal hydrogen peroxide-producing *Lactobacillus* species with high concentrations of anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Prevotella* spp., and *Mobiluncus* spp.). **1. Why Metronidazole is the Correct Answer:** Metronidazole is the **drug of choice (DOC)** because of its superior efficacy against anaerobic bacteria while relatively sparing the protective vaginal lactobacilli. According to CDC and ACOG guidelines, the standard regimen is **Metronidazole 500 mg orally twice daily for 7 days**. Alternatively, Metronidazole 0.75% gel intravaginally can be used. **2. Why Incorrect Options are Wrong:** * **Doxycycline:** This is a tetracycline primarily used for *Chlamydia trachomatis* or Mycoplasma infections. It is ineffective against the polymicrobial anaerobic flora of BV. * **Clindamycin:** While Clindamycin (oral or cream) is a recommended **alternative** treatment for BV, it is not the first-line drug of choice. It is often reserved for patients allergic to Metronidazole. * **Ciprofloxacin:** This fluoroquinolone has poor activity against anaerobes and is generally used for urinary tract infections or pelvic inflammatory disease (in combination therapy), but not for BV. **3. High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis:** Based on **Amsel’s Criteria** (3 out of 4 required): 1. Thin, homogenous discharge; 2. Vaginal pH > 4.5; 3. Positive Whiff test (fishy odor with 10% KOH); 4. **Clue cells** on wet mount (Gold Standard). * **Nugent Scoring:** The "Gold Standard" for research diagnosis based on Gram stain morphotypes. * **Treatment in Pregnancy:** Symptomatic pregnant women should be treated with Metronidazole to reduce the risk of preterm labor and PPROM. * **Partner Treatment:** Routine treatment of the male sexual partner is **not recommended** as it does not prevent recurrence. * **Counseling:** Advise patients to avoid alcohol during Metronidazole therapy due to the **disulfiram-like reaction**.

Question 846: All are the criteria for medical management of ectopic pregnancy except?

A. Asymptomatic patient.
B. Serum β-hCG level <2000 IU/L.
C. Gestational sac diameter <5 cm. (Correct Answer)
D. Unruptured tube.

Explanation: **Explanation:** The medical management of ectopic pregnancy (primarily using **Methotrexate**) is reserved for hemodynamically stable patients who meet specific criteria to ensure a high success rate and minimize the risk of tubal rupture. **Why Option C is the correct answer (The Exception):** The standard criterion for the size of the gestational sac in medical management is **<3.5 cm or <4 cm** (depending on the guideline, e.g., RCOG/ACOG). A diameter of **<5 cm is too large**; as the sac size increases, the risk of treatment failure and tubal rupture rises significantly. Therefore, "Gestational sac <5 cm" is not a standard criterion. **Analysis of Incorrect Options:** * **A. Asymptomatic patient:** Medical management is only indicated in hemodynamically stable patients with minimal or no symptoms (no signs of hemoperitoneum or acute abdomen). * **B. Serum β-hCG level <2000 IU/L:** While some guidelines allow up to 5000 IU/L, a level <2000 IU/L is a classic criterion associated with the highest success rates (up to 95%). Higher levels are relative contraindications. * **D. Unruptured tube:** This is an absolute prerequisite. If the tube has ruptured, the patient requires emergency surgical intervention (Laparoscopy/Laparotomy). **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice:** Methotrexate (Folic acid antagonist). * **Dose:** 50 mg/m² (Single-dose regimen is most common). * **Absolute Contraindications:** Ruptured ectopic, hemodynamic instability, breastfeeding, and presence of **fetal cardiac activity** (relative/absolute depending on size). * **Monitoring:** β-hCG levels are measured on Day 4 and Day 7. A drop of **>15%** between Day 4 and 7 indicates successful treatment.

Question 847: Which of the following drugs is NOT used in the treatment of a pregnant woman with SLE who is at >35 weeks gestation?

A. Methotrexate (Correct Answer)
B. Sulfasalazine
C. Prednisolone
D. Chloroquine

Explanation: **Explanation:** The management of Systemic Lupus Erythematosus (SLE) during pregnancy requires a careful balance between controlling maternal disease activity and ensuring fetal safety. **Why Methotrexate is the Correct Answer:** **Methotrexate** is strictly **contraindicated** throughout pregnancy (FDA Category X). It is a folic acid antagonist that interferes with DNA synthesis. If used in the first trimester, it is a potent teratogen (causing "Methotrexate-aminopterin syndrome"). Even at **>35 weeks gestation**, it is avoided because it is an antimetabolite that can cause fetal myelosuppression and growth restriction. Furthermore, it is not used for acute flares in late pregnancy when safer alternatives exist. **Why the other options are incorrect:** * **Prednisolone:** This is the mainstay for treating SLE flares in pregnancy. It is metabolized by the placental enzyme **11β-hydroxysteroid dehydrogenase 2**, which converts it into inactive prednisone, ensuring minimal fetal exposure. * **Chloroquine/Hydroxychloroquine:** These are considered safe and are often continued throughout pregnancy to prevent maternal flares and reduce the risk of neonatal congenital heart block. * **Sulfasalazine:** This is considered safe in pregnancy. It does not increase the risk of congenital anomalies, though supplemental folic acid (5mg) is recommended for the mother. **NEET-PG High-Yield Pearls:** * **Safe SLE Drugs in Pregnancy:** Hydroxychloroquine (HCQ), Prednisolone, Azathioprine, and Sulfasalazine. * **Contraindicated SLE Drugs:** Methotrexate, Cyclophosphamide, and Mycophenolate Mofetil (MMF). * **Neonatal Lupus:** Associated with **Anti-Ro (SS-A)** and **Anti-La (SS-B)** antibodies; the most serious complication is irreversible **congenital complete heart block**. * **Flare vs. Preeclampsia:** Low complement levels (C3, C4) suggest an SLE flare, whereas normal complement levels with high uric acid suggest preeclampsia.

Question 848: What is the drug of choice for bacterial vaginosis?

A. Metronidazole (Correct Answer)
B. Ampicillin
C. Ciprofloxacin
D. Fluconazole

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* spp.). **Why Metronidazole is the Correct Answer:** Metronidazole is the **Drug of Choice (DOC)** because it is highly effective against anaerobic bacteria while sparing the protective *Lactobacilli*. It works by inhibiting nucleic acid synthesis. According to CDC and ACOG guidelines, the standard regimen is **500 mg orally twice daily for 7 days**. Alternatively, 0.75% Metronidazole gel or 2% Clindamycin cream can be used intravaginally. **Analysis of Incorrect Options:** * **B. Ampicillin:** While it has some activity against *G. vaginalis*, it is significantly less effective than Metronidazole and is not recommended for treatment. * **C. Ciprofloxacin:** This is a fluoroquinolone used for urinary tract infections and some aerobic infections; it lacks the necessary anaerobic coverage for BV. * **D. Fluconazole:** This is an antifungal agent used to treat **Vulvovaginal Candidiasis**, not bacterial infections. **High-Yield Clinical Pearls for NEET-PG:** 1. **Amsel’s Criteria (3 out of 4 required):** Homogeneous white discharge, pH > 4.5, Positive "Whiff test" (KOH 10%), and presence of **Clue Cells** on microscopy. 2. **Nugent Score:** The "Gold Standard" for diagnosis based on Gram stain of vaginal discharge. 3. **Treatment in Pregnancy:** Symptomatic pregnant women should be treated with oral Metronidazole to reduce the risk of preterm labor and PPROM. 4. **Partner Treatment:** Routine treatment of the male partner is **not recommended** as it does not prevent recurrence. 5. **Counseling:** Advise patients to avoid alcohol during Metronidazole therapy due to the **Disulfiram-like reaction**.

Question 849: A 36-year-old female presents with heavy menstrual bleeding. She has one child of 7 years. USG shows a single 3x3 cm submucosal fibroid. Hemoglobin is 10.5 gm/dl. What is the best treatment option for her?

A. GnRH injection
B. Uterine Artery Embolization (UAE)
C. Hysteroscopic myomectomy (Correct Answer)
D. Laparoscopic myomectomy

Explanation: ### Explanation **1. Why Hysteroscopic Myomectomy is the Correct Answer:** The patient presents with symptomatic heavy menstrual bleeding (HMB) caused by a **submucosal fibroid**. According to FIGO classification, submucosal fibroids (Type 0, 1, and 2) are best managed via the **hysteroscopic route** if they are less than 5 cm in size. * **Medical Concept:** Submucosal fibroids distort the endometrial cavity, leading to increased surface area for bleeding and interference with uterine contractions. Hysteroscopic myomectomy is the **gold standard** treatment as it is minimally invasive, preserves fertility, and directly addresses the pathology within the cavity without requiring an abdominal incision. **2. Why Other Options are Incorrect:** * **GnRH Injection (A):** These are typically used as a preoperative adjunct to shrink the fibroid or correct anemia (by inducing amenorrhea). They are not a definitive treatment as the fibroid regrows once the drug is discontinued. * **Uterine Artery Embolization (B):** While effective for intramural fibroids, UAE is generally avoided in women desiring future pregnancy (due to potential placental complications) and is less preferred than resection for pedunculated submucosal fibroids. * **Laparoscopic Myomectomy (D):** This is the preferred route for **intramural or subserosal** fibroids. It is not ideal for submucosal fibroids because it requires cutting through the entire thickness of the myometrium to reach the cavity, increasing the risk of uterine rupture in future pregnancies. **3. Clinical Pearls for NEET-PG:** * **FIGO Type 0:** Pedunculated intracavitary (easiest to resect hysteroscopically). * **FIGO Type 1:** <50% intramural extension. * **FIGO Type 2:** >50% intramural extension (most challenging for hysteroscopy). * **Investigation of Choice:** Saline Infusion Sonography (SIS) is superior to standard USG for diagnosing the degree of protrusion of submucosal fibroids. * **Medical Management:** Levonorgestrel Intrauterine System (LNG-IUS) is the first-line medical management for HMB, but it is often contraindicated or less effective if the fibroid significantly distorts the cavity.

Question 850: Which of the following is the most common site of bladder injury during abdominal hysterectomy?

A. Anterior wall
B. Posterior wall (Correct Answer)
C. Medial wall
D. Lateral wall

Explanation: **Explanation:** The bladder is the most frequently injured organ during a hysterectomy, occurring in approximately 1–2% of cases. **Why the Posterior Wall is the Correct Answer:** During an abdominal hysterectomy, the bladder must be separated from the lower uterine segment and cervix. This is achieved by incising the vesicouterine peritoneum and developing the **vesicovaginal space**. The **posterior wall (base)** of the bladder is anatomically adjacent to the anterior surface of the uterus and cervix. Injury most commonly occurs during the **dissection of the bladder flap** or while reflecting the bladder inferiorly, especially if there are adhesions from previous surgeries (like a C-section) or endometriosis. **Analysis of Incorrect Options:** * **Anterior Wall:** This surface faces the pubic symphysis and is generally away from the primary surgical field of a hysterectomy. * **Medial Wall:** The bladder is a midline structure; it does not have a distinct "medial" wall in the context of surgical anatomy. * **Lateral Walls:** While the ureters enter the bladder at the posterolateral angles (trigone), the lateral walls themselves are not the primary site of dissection during the mobilization of the uterus. **NEET-PG High-Yield Pearls:** * **Most common site of injury:** Posterior wall (base). * **Most common timing of injury:** During the dissection of the bladder flap or during the clamping of the vaginal vault. * **Diagnosis:** Intraoperatively, injury is identified by the appearance of urine in the field or by filling the bladder with **methylene blue** or sterile milk. * **Management:** Small injuries (<1 cm) may heal with catheterization; larger injuries require a two-layer closure with absorbable sutures. * **Ureteric Injury:** The most common site for ureteric injury is at the level of the **infundibulopelvic ligament** or where the ureter passes under the **uterine artery** ("water under the bridge").

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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