Gynecological Disorders — MCQs

A 31-year-old, sexually active woman has had a mucopurulent vaginal discharge for 1 week. On pelvic examination, the cervix appears reddened around the os, but no erosions or mass lesions are present. A Pap smear shows numerous neutrophils, but no dysplastic cells. A cervical biopsy specimen shows marked follicular cervicitis. Which of the following infectious agents is most likely to produce these findings?

Q88Easy

In Fothergill's operation, which of the following procedures is NOT undertaken?

Q89Easy

What are the contraindications to hysteroscopy?

Q90Medium

A 30-year-old female presents with a fishy vaginal discharge. On examination, the vagina is not erythematous and the cervix appears normal. Which of the following criteria is NOT required for the diagnosis of bacterial vaginosis?

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 81: All of the following protect against endometriosis except?

A. Pregnancy
B. Nulliparity (Correct Answer)
C. Exercise
D. Smoking

Explanation: **Explanation:** Endometriosis is an estrogen-dependent condition characterized by the presence of endometrial tissue outside the uterine cavity. The primary pathophysiology involves **retrograde menstruation** (Sampson’s theory); therefore, factors that increase the number of menstrual cycles or estrogen exposure increase the risk, while factors that decrease them are protective. * **Why Nulliparity is the correct answer:** Nulliparity (never having given birth) is a **risk factor**, not a protective factor. It implies uninterrupted menstrual cycles and prolonged exposure to endogenous estrogen, providing more opportunities for retrograde menstruation and implantation of ectopic tissue. * **Why the other options are protective:** * **Pregnancy:** This is a state of physiological amenorrhea and high progesterone levels. Progesterone causes decidualization and atrophy of endometrial tissue, effectively "halting" the disease. * **Exercise:** Regular vigorous exercise (especially >4 hours/week) is associated with lower estrogen levels and increased SHBG (Sex Hormone Binding Globulin), which reduces the bioavailability of estrogen. * **Smoking:** Although harmful to general health, smoking has an anti-estrogenic effect (by inducing hepatic metabolism of estrogen and inhibiting aromatase). Statistically, smokers have a decreased risk of endometriosis, though this is never clinically recommended as a preventive measure. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Early menarche, late menopause, short menstrual cycles (<27 days), and mullerian anomalies (causing outflow obstruction). * **Protective Factors:** Multiparity, extended breastfeeding, and oral contraceptive pills (OCPs). * **Gold Standard Diagnosis:** Laparoscopy with biopsy (visualizing "powder-burn" or "gunshot" lesions). * **Classic Triad:** Dysmenorrhea, Dyspareunia, and Dyschezia.

Question 82: What is the most common cause of death in ectopic pregnancy?

A. Bowel obstruction
B. Hemorrhage (Correct Answer)
C. Infection
D. None of the above

Explanation: **Explanation:** **Why Hemorrhage is the Correct Answer:** Ectopic pregnancy occurs when a fertilized ovum implants outside the uterine cavity, most commonly in the **ampulla of the fallopian tube (70%)**. Unlike the uterus, the fallopian tube is not designed to accommodate a growing embryo. As the pregnancy progresses, the trophoblastic invasion erodes maternal blood vessels, and the limited distensibility of the tube eventually leads to **tubal rupture**. This results in massive intraperitoneal hemorrhage and hypovolemic shock. Hemorrhage remains the leading cause of pregnancy-related mortality in the first trimester worldwide. **Analysis of Incorrect Options:** * **A. Bowel obstruction:** While pelvic adhesions from a chronic ectopic pregnancy or previous surgeries could theoretically cause obstruction, it is an extremely rare complication and not a cause of acute mortality. * **C. Infection:** While pelvic inflammatory disease (PID) is a major *risk factor* for developing an ectopic pregnancy, infection/sepsis is rarely the primary cause of death in the acute presentation of a ruptured ectopic. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Fallopian tube (95%), specifically the **Ampulla**. * **Most dangerous site:** **Interstitium (Cornual)**. Rupture here occurs later (12–16 weeks) and causes the most profuse bleeding because of the proximity to the uterine artery. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serial β-hCG levels (Discriminatory zone: 1500–2000 mIU/mL). * **Management:** Hemodynamically unstable patients require immediate **Laparotomy**. Stable patients may be candidates for Laparoscopy or medical management with Methotrexate.

Question 83: A woman presents with amenorrhea of 6 weeks duration and a lump in the right iliac fossa. What is the investigation of choice?

A. Ultrasound (USG) abdomen (Correct Answer)
B. Laparoscopy
C. CT scan
D. Shielded X-ray

Explanation: **Explanation:** The clinical presentation of **amenorrhea** followed by a **palpable mass in the iliac fossa** is a classic "red flag" for an **Ectopic Pregnancy** until proven otherwise. Other differentials include a corpus luteum cyst or a tubo-ovarian mass. **1. Why Ultrasound (USG) is the Investigation of Choice:** USG (specifically Transvaginal Sonography/TVS) is the gold standard initial investigation for any woman of reproductive age presenting with early pregnancy complications. It is non-invasive, cost-effective, and highly sensitive in identifying an intrauterine vs. extrauterine gestational sac. In this case, USG can confirm the location of the pregnancy, assess the nature of the iliac mass, and check for free fluid (hemoperitoneum) in the Pouch of Douglas. **2. Why other options are incorrect:** * **Laparoscopy:** While it is the *gold standard for diagnosis* and allows for simultaneous treatment, it is an invasive surgical procedure. It is reserved for cases where USG is inconclusive or the patient is hemodynamically unstable. * **CT Scan:** CT is contraindicated in early pregnancy due to high ionizing radiation (teratogenic risk) and provides inferior soft-tissue detail of the pelvis compared to USG. * **Shielded X-ray:** X-rays have no role in diagnosing early pregnancy or adnexal masses and expose the fetus to unnecessary radiation. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of Ectopic Pregnancy:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Discriminatory Zone:** The level of serum β-hCG (usually 1500–2000 mIU/ml) at which an intrauterine gestational sac should be visible on TVS. * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy in ectopic pregnancy (due to hormonal stimulation without an intrauterine sac).

Question 84: What is the most common site of a tubal pregnancy?

A. Ampulla (Correct Answer)
B. Isthmus
C. Fimbria
D. Interstitial

Explanation: **Explanation:** Ectopic pregnancy occurs when a fertilized ovum implants outside the normal uterine cavity. The **Fallopian tube** is the most common site for ectopic pregnancy (95–97%). **1. Why Ampulla is Correct:** The **Ampulla** is the most common site of tubal pregnancy, accounting for approximately **70–80%** of cases. This is primarily because the ampulla is the widest and longest part of the fallopian tube, and it is the physiological site where fertilization typically occurs. If the transport of the zygote is delayed, it is most likely to implant here. **2. Analysis of Incorrect Options:** * **Isthmus (12%):** This is the second most common site. Due to the narrow lumen, pregnancies here tend to rupture earlier (6–8 weeks) than those in the ampulla. * **Fimbria (5%):** Implantation occurs at the distal end of the tube. These often result in "tubal abortions" rather than ruptures. * **Interstitial/Intramural (2%):** This is the least common tubal site. However, it is the most dangerous because the area is highly vascular (supplied by both uterine and ovarian arteries). Rupture here occurs late (12–16 weeks) and can lead to catastrophic, life-threatening hemorrhage. **Clinical Pearls for NEET-PG:** * **Most common site of Ectopic Pregnancy:** Fallopian Tube (Ampulla). * **Most common site of Ovarian Pregnancy:** Corpus Luteum. * **Classic Triad:** Amenorrhea, abdominal pain, and vaginal bleeding (present in only 50% of cases). * **Arias-Stella Reaction:** Hypersecretory endometrium seen on biopsy; it is suggestive but not diagnostic of ectopic pregnancy. * **Gold Standard Diagnosis:** Transvaginal Ultrasound (TVUS) + Serum β-hCG (Discriminatory zone: 1500–2000 mIU/mL).

Question 85: Paradoxical incontinence of urine in a primigravida is seen with which of the following conditions?

A. Anteflexion of the uterus
B. Retroflexion of the uterus (Correct Answer)
C. Sacculation
D. Uterine prolapse

Explanation: **Explanation:** **Paradoxical incontinence** (also known as overflow incontinence) in early pregnancy is a classic clinical sign associated with a **retroverted/retroflexed gravid uterus**. 1. **Mechanism of the Correct Answer (B):** As a retroflexed uterus enlarges during the first trimester (typically between **12–14 weeks**), the fundus may become trapped below the sacral promontory (incarceration). As the uterus grows, the cervix is pushed upward and forward against the symphysis pubis. This displacement stretches and elongates the urethra and compresses the bladder neck. The resulting urinary retention causes the bladder to overfill until the intravesical pressure exceeds urethral resistance, leading to the involuntary dribbling of urine—hence, "paradoxical" incontinence. 2. **Analysis of Incorrect Options:** * **A. Anteflexion:** This is the normal anatomical position. While it may cause increased frequency due to pressure on the bladder, it does not cause incarceration or overflow incontinence. * **C. Sacculation:** This is a rare compensatory mechanism where the anterior wall of an incarcerated uterus thins and expands to accommodate the fetus. While related to retroflexion, the primary cause of the initial incontinence is the retroflexion itself. * **D. Uterine Prolapse:** In pregnancy, prolapse usually improves as the uterus rises into the abdomen. While it can cause stress incontinence, it does not typically present with paradoxical incontinence due to incarceration. **Clinical Pearls for NEET-PG:** * **The "12-week" Rule:** Symptoms of incarceration typically manifest when the uterus fills the pelvic cavity (12–14 weeks). * **Clinical Presentation:** Patients present with lower abdominal pain, inability to void, and paradoxical dribbling. * **Management:** Immediate catheterization to decompress the bladder, followed by manual correction of the uterine position (Sims position or knee-chest position). * **Distinguishing Feature:** On per-vaginal exam, the cervix is felt high up behind the pubic symphysis, and a soft mass (the fundus) fills the Pouch of Douglas.

Question 86: In which of the following gynecological conditions is intravenous urography advisable to perform?

A. Endometriosis
B. Bicornuate uterus (Correct Answer)
C. Adenomyosis
D. Uterine polyp

Explanation: **Explanation:** **Correct Answer: B. Bicornuate uterus** The correct answer is **Bicornuate uterus** because of the shared embryological origin of the genital and urinary systems. Both systems develop from the intermediate mesoderm. The **Müllerian ducts** (paramesonephric ducts), which form the uterus, fallopian tubes, and upper vagina, develop in close proximity to the **Wolffian ducts** (mesonephric ducts), which are essential for the development of the kidneys and ureters. When there is a failure in the fusion or development of the Müllerian ducts (resulting in anomalies like a bicornuate, septate, or unicornuate uterus), there is a high incidence (**up to 30-40%**) of associated **congenital renal anomalies**. These include renal agenesis, ectopic kidney, or horseshoe kidney. Therefore, an Intravenous Urography (IVU) or Ultrasound of the renal tract is mandatory to screen for these silent but significant urinary tract malformations. **Why other options are incorrect:** * **A. Endometriosis:** This is a functional disorder where endometrial tissue grows outside the uterus. While severe deep infiltrating endometriosis can involve the ureters, it is not a congenital structural anomaly requiring routine IVU. * **C. Adenomyosis:** This is a benign condition where the endometrial stroma and glands invade the myometrium. It is an acquired condition and is not associated with congenital renal defects. * **D. Uterine polyp:** These are localized overgrowths of the endometrial lining. They are purely intrauterine and have no association with the urinary system. **High-Yield Clinical Pearls for NEET-PG:** * **Müllerian Anomalies:** Always screen the renal system (USG/IVU). * **Most common renal anomaly** associated with Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) is **Unilateral Renal Agenesis**. * **Wunderlich Syndrome:** A triad of uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis.

Question 87: A 31-year-old, sexually active woman has had a mucopurulent vaginal discharge for 1 week. On pelvic examination, the cervix appears reddened around the os, but no erosions or mass lesions are present. A Pap smear shows numerous neutrophils, but no dysplastic cells. A cervical biopsy specimen shows marked follicular cervicitis. Which of the following infectious agents is most likely to produce these findings?

A. Candida albicans
B. Chlamydia trachomatis (Correct Answer)
C. Gardnerella vaginalis
D. Herpes simplex virus

Explanation: ### Explanation **Correct Answer: B. Chlamydia trachomatis** The clinical presentation and histopathological findings are classic for **Chlamydia trachomatis** infection. The key diagnostic clue in this question is **"Follicular Cervicitis."** * **Underlying Concept:** *Chlamydia trachomatis* (serotypes D-K) is an obligate intracellular bacterium that infects the columnar epithelium of the endocervix. Chronic or subacute infection leads to the formation of lymphoid follicles with germinal centers in the subepithelial stroma, a pathognomonic finding known as follicular cervicitis. * **Clinical Presentation:** Patients typically present with mucopurulent discharge and a "friable" cervix (bleeds easily on contact) that appears reddened (ectopy/cervicitis). The presence of numerous neutrophils on a Pap smear indicates an acute inflammatory response, while the absence of dysplasia rules out malignancy. **Why other options are incorrect:** * **A. Candida albicans:** Typically presents with a thick, "curd-like" or "cottage cheese" vaginal discharge and intense pruritus. On microscopy, it shows pseudohyphae and spores, not lymphoid follicles. * **C. Gardnerella vaginalis:** The causative agent of Bacterial Vaginosis. It presents with a thin, grayish-white, fishy-smelling discharge. Diagnosis is based on Amsel’s criteria (Clue cells, positive Whiff test), not follicular changes in the cervix. * **D. Herpes simplex virus (HSV):** Usually presents with painful vesicles or shallow, "punched-out" ulcers. Histology would show multinucleated giant cells with Cowdry type A intranuclear inclusions (Tzanck smear), not lymphoid follicles. **NEET-PG High-Yield Pearls:** * **Follicular Cervicitis** = Highly suggestive of *Chlamydia trachomatis*. * **Strawberry Cervix** (punctate hemorrhages) = *Trichomonas vaginalis*. * **Clue Cells** = *Gardnerella vaginalis*. * **Treatment of choice for Chlamydia:** Azithromycin (1g single dose) or Doxycycline (100mg BID for 7 days). Always treat the partner to prevent reinfection.

Question 88: In Fothergill's operation, which of the following procedures is NOT undertaken?

A. Amputation of cervix
B. Anterior colporrhaphy
C. Colpoperineorrhaphy
D. Plication of round ligament (Correct Answer)

Explanation: **Explanation:** **Fothergill’s Operation** (also known as the Manchester Operation) is a conservative surgical procedure designed for the management of **uterine prolapse**, typically in women who wish to preserve their uterus. The core principle of the surgery is to shorten the cardinal ligaments to provide better apical support. **Why "Plication of round ligament" is the correct answer:** Plication of the round ligament is a procedure used for uterine retroversion (e.g., Gilliam’s suspension) but is **not** a component of Fothergill’s operation. Fothergill’s focuses on the **Mackenrodt’s (cardinal) ligaments**, which are the primary supports of the uterus, rather than the round ligaments. **Analysis of other options:** * **Amputation of cervix (A):** This is a key step. The elongated cervix is removed, and the cardinal ligaments are then sutured to the anterior aspect of the remaining cervical stump (Fothergill’s stitch) to pull the uterus upward and backward. * **Anterior colporrhaphy (B):** This is performed to correct the associated cystocele, which is almost always present with uterine prolapse. * **Colpoperineorrhaphy (C):** This is the final step, performed to repair a deficient perineum or rectocele, ensuring pelvic floor integrity. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Best suited for young women with uterine prolapse who desire to retain menstrual function or avoid a hysterectomy. * **Prerequisite:** The surgeon must first rule out any endometrial pathology (via D&C) and ensure the cervix is not malignant. * **Key Complication:** Cervical stenosis or "leukorrhea" post-surgery. It may also lead to mid-trimester abortions or cervical dystocia in future pregnancies due to the cervical amputation. * **The "Fothergill Stitch":** Specifically refers to the suturing of the cut ends of the cardinal ligaments in front of the cervical stump.

Question 89: What are the contraindications to hysteroscopy?

A. Cervical cancer
B. Vaginal bleeding
C. Pelvic inflammatory disease
D. All the above (Correct Answer)

Explanation: Hysteroscopy is the gold standard for evaluating the uterine cavity, but it involves distending the uterus with fluid or gas, which can disseminate infection or malignant cells into the peritoneal cavity. **Explanation of the Correct Answer:** The correct answer is **All the above** because each condition presents a specific risk during the procedure: 1. **Cervical Cancer:** Hysteroscopy is contraindicated in known cervical or endometrial malignancy. The high pressure used to distend the uterus can cause **transtubal retrograde seeding** of malignant cells into the peritoneal cavity, potentially upstaging the disease. 2. **Pelvic Inflammatory Disease (PID):** This is an **absolute contraindication**. Performing hysteroscopy during an active infection can cause the mechanical spread of pathogens from the lower genital tract to the pelvic cavity, leading to life-threatening peritonitis or pelvic abscess. 3. **Vaginal Bleeding:** While "heavy" bleeding is a relative contraindication, active profuse bleeding obscures the visual field (the "red-out" effect), making the procedure technically impossible and increasing the risk of uterine perforation. Note: Pregnancy is also a major absolute contraindication. **Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Pregnancy, Acute PID, and known Cervical/Endometrial Malignancy. * **Best Time for Procedure:** In premenopausal women, the **early follicular phase** (Day 4 to Day 7) is ideal as the endometrium is thin, providing the best visualization. * **Distension Media:** For diagnostic hysteroscopy, **Normal Saline** is preferred. For operative hysteroscopy using monopolar cautery, non-electrolytic solutions like **Glycine (1.5%)** are used, though they carry a risk of hyponatremia (TURP syndrome).

Question 90: A 30-year-old female presents with a fishy vaginal discharge. On examination, the vagina is not erythematous and the cervix appears normal. Which of the following criteria is NOT required for the diagnosis of bacterial vaginosis?

A. Abundant lactobacilli (Correct Answer)
B. Vaginal pH greater than 4.5
C. Positive Whiff's test
D. Presence of clue cells

Explanation: The diagnosis of **Bacterial Vaginosis (BV)** is clinically established using the **Amsel Criteria**. BV is not an infection in the traditional sense, but a dysbiosis characterized by a shift in vaginal flora from acid-producing Lactobacilli to anaerobic bacteria (e.g., *Gardnerella vaginalis*, *Mobiluncus*). ### Why "Abundant lactobacilli" is the Correct Answer: In a healthy vaginal ecosystem, *Lactobacillus* species are the dominant organisms; they maintain an acidic pH by producing lactic acid. In BV, there is a **marked reduction or absence of Lactobacilli**. Therefore, the presence of abundant lactobacilli contradicts a diagnosis of BV. ### Explanation of Incorrect Options (Amsel Criteria): To diagnose BV, at least **3 out of the following 4** criteria must be present: * **Vaginal pH > 4.5:** The loss of Lactobacilli leads to a rise in pH, making the environment more alkaline. * **Positive Whiff’s Test:** Adding 10% KOH to the discharge releases volatile amines (putrescine/cadaverine), resulting in a characteristic "fishy odor." * **Presence of Clue Cells:** These are vaginal epithelial cells coated with coccobacilli, giving them a "stippled" or "shaggy" appearance under microscopy. This is the **most specific** finding. * **Homogeneous Discharge:** A thin, grayish-white, non-inflammatory discharge that smoothly coats the vaginal walls. ### NEET-PG High-Yield Pearls: * **Nugent Scoring:** The "Gold Standard" for BV diagnosis (based on Gram stain morphotypes). A score of 7–10 is diagnostic. * **Treatment of Choice:** Oral or topical **Metronidazole** (500 mg BID for 7 days). * **Key Distinction:** Unlike Trichomoniasis or Candidiasis, BV is **not** associated with vaginal inflammation (no redness or itching). * **Pregnancy Risk:** BV is associated with preterm labor and PPROM.

Practice by Chapter

Abnormal Uterine Bleeding

Practice Questions

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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