Menstrual Disorders — MCQs
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Asherman syndrome is secondary to which of the following?
A female presents with primary amenorrhea and absent vagina. What is the next investigation to be done?
Which of the following is NOT a cause of unilateral dysmenorrhea?
A 16-year-old female presents with cryptomenorrhea and normal secondary sexual characters. What is the investigation of choice?
Which of the following is NOT true about the use of NSAIDs in abnormal uterine bleeding?
A 15-year-old girl presents with primary amenorrhea despite the orderly appearance of secondary sexual characteristics (breast and pubic hair). What is the next best step in her management?
Which of the following defines primary amenorrhea?
Which of the following drugs is not considered a first-line treatment for anovulatory abnormal uterine bleeding in a 13-year-old girl?
A woman is said to have menorrhagia if the menstrual blood loss is more than what quantity?
A 15-year-old female complains of heavy menstrual bleeding for the past two months. On examination, her weight is 40 kg and her blood pressure is 120/80 mmHg. Which of the following investigations is NOT indicated in this patient?
Menstrual Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Asherman syndrome is secondary to which of the following?
- A. Tuberculosis (Correct Answer)
- B. Endometrial carcinoma
- C. Endometriosis
- D. Submucosal fibroid
Explanation: **Explanation:** **Asherman Syndrome** refers to the formation of intrauterine adhesions (synechiae) that lead to the partial or complete obliteration of the uterine cavity. **Why Tuberculosis is correct:** In developing countries like India, **Genital Tuberculosis** is a leading cause of Asherman syndrome. The chronic inflammatory process of TB destroys the *basalis layer* of the endometrium, preventing normal regeneration. This results in dense fibrosis and scarring, often leading to irreversible secondary amenorrhea and infertility. While the most common cause globally is over-zealous curettage (post-abortion or postpartum), TB remains a high-yield infectious etiology for NEET-PG. **Analysis of Incorrect Options:** * **B. Endometrial Carcinoma:** This typically presents with postmenopausal bleeding and endometrial thickening, rather than the formation of intrauterine adhesions. * **C. Endometriosis:** This involves the presence of endometrial tissue *outside* the uterine cavity (e.g., ovaries, peritoneum). It causes pelvic pain and pelvic adhesions, but not intrauterine synechiae. * **D. Submucosal Fibroid:** These are benign tumors that distort the uterine cavity and usually cause heavy menstrual bleeding (menorrhagia), not the amenorrhea associated with Asherman syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Hysteroscopy (allows both diagnosis and treatment via adhesiolysis). * **HSG Finding:** Characterized by "filling defects" or a "honeycomb appearance." * **Treatment:** Hysteroscopic adhesiolysis followed by high-dose estrogen therapy to promote endometrial regrowth and the insertion of an IUCD or Foley catheter to prevent re-adhesion. * **Netter’s Syndrome:** A term sometimes used specifically for the end-stage destruction of the endometrium due to Tuberculosis.
Question 2: A female presents with primary amenorrhea and absent vagina. What is the next investigation to be done?
- A. LH/FSH assay
- B. Chromosomal analysis
- C. Urinalysis
- D. Laparoscopy (Correct Answer)
Explanation: **Explanation:** The clinical presentation of primary amenorrhea with an absent vagina primarily points towards two major differentials: **Müllerian Agenesis (MRKH Syndrome)** and **Androgen Insensitivity Syndrome (AIS)**. **Why Laparoscopy is the correct answer:** In the context of this specific question, **Laparoscopy** is considered the definitive investigation to visualize the internal pelvic anatomy. It allows for the direct confirmation of the presence or absence of the uterus, fallopian tubes, and ovaries. In Müllerian Agenesis, laparoscopy would typically reveal a rudimentary uterus (bicornuate bulbs) with normal ovaries, whereas in AIS, the uterus is absent and gonads are undescended testes. While MRI is a non-invasive alternative often used in modern practice, laparoscopy remains the "gold standard" for anatomical confirmation in surgical planning and diagnostic dilemmas in competitive exams. **Analysis of Incorrect Options:** * **A. LH/FSH assay:** These are useful for diagnosing hypogonadotropic hypogonadism or premature ovarian failure, but they do not help in evaluating anatomical defects like an absent vagina. * **B. Chromosomal analysis:** While essential to differentiate MRKH (46,XX) from AIS (46,XY), it is usually performed after anatomical confirmation or as a secondary step. * **C. Urinalysis:** This has no diagnostic value for primary amenorrhea or Müllerian anomalies. **High-Yield Clinical Pearls for NEET-PG:** * **Müllerian Agenesis (MRKH):** Most common cause of primary amenorrhea with absent vagina. Characterized by 46,XX karyotype, normal ovaries, and normal secondary sexual characters. * **Associated Anomalies:** Always check for **Renal anomalies** (most common, e.g., renal agenesis) and skeletal defects (VACTERL) in cases of MRKH. * **AIS:** Characterized by 46,XY karyotype, absent/scant pubic hair, and presence of testes (risk of gonadoblastoma).
Question 3: Which of the following is NOT a cause of unilateral dysmenorrhea?
- A. Rudimentary uterine horn
- B. Right ovarian vein syndrome
- C. Unicornuate uterus
- D. Large fundal fibroid (Correct Answer)
Explanation: **Explanation:** The core concept in this question is distinguishing between **generalized pelvic pain** and **lateralized (unilateral) pain**. Dysmenorrhea is typically midline; however, structural or vascular anomalies that are strictly one-sided will result in unilateral symptoms. **Why "Large Fundal Fibroid" is the Correct Answer:** A large fundal fibroid is located in the midline or the central upper portion of the uterine body. When it causes dysmenorrhea (usually due to increased prostaglandin production or uterine contractions trying to expel the mass), the pain is typically **central and generalized** across the lower abdomen. It does not anatomically favor one side. **Analysis of Incorrect Options (Causes of Unilateral Dysmenorrhea):** * **Rudimentary Uterine Horn:** If a patient has a functional but non-communicating rudimentary horn, menstrual blood traps within it (hematometra). This causes intense, cyclic, unilateral pain on the side of the horn. * **Right Ovarian Vein Syndrome:** This involves compression of the ureter by an enlarged right ovarian vein. It typically causes right-sided pelvic pain and can exacerbate during menstruation due to pelvic congestion. * **Unicornuate Uterus:** While a simple unicornuate uterus might be asymptomatic, it is frequently associated with a rudimentary horn (as mentioned above). Furthermore, asymmetric pelvic anatomy or associated adnexal issues on the hypoplastic side can lead to lateralized pain. **NEET-PG High-Yield Pearls:** * **Primary Dysmenorrhea:** Always starts with the onset of ovulatory cycles (6–12 months after menarche); pain is midline and spasmodic. * **Secondary Dysmenorrhea:** Usually starts years after menarche; pain is often constant and associated with pathology like endometriosis or adenomyosis. * **Unilateral Pain Rule:** Always rule out **obstructive Mullerian anomalies** (like OHVIRA syndrome or rudimentary horns) when a young girl presents with severe unilateral dysmenorrhea from menarche.
Question 4: A 16-year-old female presents with cryptomenorrhea and normal secondary sexual characters. What is the investigation of choice?
- A. MRI brain
- B. Prolactin estimation
- C. Genital examination for outflow obstruction (Correct Answer)
- D. None of the above
Explanation: ### Explanation **Core Medical Concept: Cryptomenorrhea** Cryptomenorrhea refers to a condition where menstruation occurs but the menstrual blood is unable to exit the body due to an anatomical obstruction in the genital tract. In a 16-year-old with **normal secondary sexual characteristics**, the Hypothalamic-Pituitary-Ovarian (HPO) axis is functioning correctly, and estrogen production is adequate. The primary clinical suspicion in such cases is an **outflow tract obstruction**, most commonly an **imperforate hymen** or a **transverse vaginal septum**. **Why Option C is Correct:** A thorough **genital examination** (inspection of the vulva and vagina) is the first and most crucial step. It can immediately identify a bulging, bluish membrane (imperforate hymen) or a blind-ending vagina. This bedside clinical assessment confirms the diagnosis of outflow obstruction without the need for expensive imaging or hormonal assays. **Why Other Options are Incorrect:** * **Option A (MRI Brain):** This is indicated in cases of hypogonadotropic hypogonadism or suspected pituitary lesions. Since the patient has normal secondary sexual characters, a central/brain pathology is highly unlikely. * **Option B (Prolactin estimation):** Hyperprolactinemia typically presents with secondary amenorrhea or galactorrhea. It does not cause cryptomenorrhea (where blood is produced but trapped). **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Cryptomenorrhea:** Imperforate hymen. * **Classic Presentation:** Cyclic pelvic pain in a pubertal girl who has not yet achieved menarche, often associated with a palpable midline mass (hematocolpos/hematometra). * **Physical Finding:** A "bluish bulging membrane" at the introitus is pathognomonic for imperforate hymen. * **Initial Imaging (if needed):** USG Pelvis is the initial imaging of choice to visualize hematocolpos, but it follows the clinical examination. * **Treatment:** Surgical incision (e.g., cruciate incision for imperforate hymen).
Question 5: Which of the following is NOT true about the use of NSAIDs in abnormal uterine bleeding?
- A. Prostaglandins play a role in the pathogenesis of endometrial dysfunction.
- B. NSAIDs are used just prior to the onset of menses as women lose 90% of menstrual blood volume in the first 3 days.
- C. NSAIDs can reduce menstrual blood loss by approximately 25%.
- D. NSAIDs should be commenced just prior to the start of menses and continued up to day 14 of the cycle. (Correct Answer)
Explanation: **Explanation:** **1. Why Option D is the Correct Answer (The "Not True" Statement):** NSAIDs are used for the management of **ovulatory** Abnormal Uterine Bleeding (AUB) due to their effect on prostaglandin synthesis. However, they are only effective during the period of active bleeding. The standard protocol is to start NSAIDs **just prior to or on the first day of menses** and continue them for the **duration of the flow (usually 3–5 days)**. Continuing them until day 14 of the cycle is clinically unnecessary, provides no additional benefit for blood loss, and increases the risk of gastric side effects. **2. Analysis of Other Options:** * **Option A:** True. Women with heavy menstrual bleeding (HMB) often have higher levels of vasodilatory prostaglandins (PGE2 and PGI2) relative to vasoconstrictors (PGF2α) in the endometrium. * **Option B:** True. Approximately 90% of total menstrual blood loss occurs within the first 3 days of the cycle. Therefore, timing the medication to coincide with this window is most effective. * **Option C:** True. Clinical studies show that NSAIDs (like Mefenamic acid or Naproxen) reduce menstrual blood loss by an average of **20–30%**. While less effective than Tranexamic acid (40–50%) or the LNG-IUS (70–90%), they are a first-line non-hormonal option. **3. NEET-PG High-Yield Pearls:** * **Drug of Choice (NSAID):** Mefenamic acid is the most commonly used NSAID for AUB/Dysmenorrhea. * **Mechanism:** They inhibit the enzyme cyclooxygenase (COX), shifting the balance toward vasoconstrictive prostaglandins (PGF2α), which aids in endometrial hemostasis. * **Dual Benefit:** NSAIDs are the preferred first-line treatment for patients who have **both** heavy menstrual bleeding and dysmenorrhea. * **Contraindication:** Avoid in patients with peptic ulcer disease or aspirin-sensitive asthma.
Question 6: A 15-year-old girl presents with primary amenorrhea despite the orderly appearance of secondary sexual characteristics (breast and pubic hair). What is the next best step in her management?
- A. Reassurance
- B. Ultrasound (USG) (Correct Answer)
- C. Hysterosalpingography (HSG)
- D. Hormonal studies
Explanation: **Explanation:** The presence of secondary sexual characteristics (breast development) indicates a functional **Hypothalamic-Pituitary-Ovarian (HPO) axis** and adequate estrogen production. In a 15-year-old with primary amenorrhea and normal secondary sexual characteristics, the primary clinical suspicion is an **anatomical/outflow tract obstruction** or **Müllerian agenesis**. **Why Ultrasound (USG) is the Correct Step:** The immediate priority is to determine the presence or absence of the **uterus**. USG is a non-invasive, cost-effective, and highly reliable first-line imaging modality to visualize pelvic anatomy. It helps differentiate between: 1. **Müllerian Agenesis (MRKH Syndrome):** Uterus is absent. 2. **Outflow Tract Obstruction (e.g., Imperforate Hymen/Transverse Vaginal Septum):** Uterus is present, often with hematometra/hematocolpos. 3. **Androgen Insensitivity Syndrome (AIS):** Uterus is absent (though these patients typically have scant pubic hair). **Why Other Options are Incorrect:** * **Reassurance:** While puberty can be late, primary amenorrhea at age 15 with secondary sexual characteristics warrants investigation (cutoff is 15 years if characteristics are present, or 13 years if absent). * **Hysterosalpingography (HSG):** This is used to check tubal patency in infertility cases. It cannot be performed if there is an outflow tract obstruction or vaginal agenesis. * **Hormonal Studies:** Since breast development is present, the HPO axis is functional. FSH/LH levels are secondary to anatomical evaluation in this specific presentation. **NEET-PG High-Yield Pearls:** * **Definition of Primary Amenorrhea:** No menses by age 13 (no secondary sexual characteristics) OR by age 15 (with secondary sexual characteristics). * **MRKH Syndrome:** Most common cause of primary amenorrhea with normal breast development and absent uterus (46, XX). * **AIS:** Normal breast development, absent uterus, but **scant/absent** pubic hair (46, XY). * **Initial Investigation:** Always start with a physical exam (check for imperforate hymen) followed by **USG Pelvis**.
Question 7: Which of the following defines primary amenorrhea?
- A. Absence of menarche by 14 years without secondary sexual characters
- B. Absence of menarche by 16 years with secondary sexual characters (Correct Answer)
- C. Absence of secondary sexual characters by 13 years
- D. Endometriosis
Explanation: **Explanation:** Primary amenorrhea is defined by the failure of menarche to occur within a specific age range, categorized by the presence or absence of secondary sexual characteristics (thelarche/pubarche). **1. Why Option B is Correct:** According to standard gynecological criteria, primary amenorrhea is diagnosed if a girl has not started her periods by **age 16**, provided she has **normal development of secondary sexual characteristics**. This indicates that the Hypothalamic-Pituitary-Ovarian (HPO) axis is functional enough to produce estrogen, but there is a likely outflow tract obstruction (e.g., imperforate hymen) or anatomical anomaly (e.g., MRKH syndrome). **2. Analysis of Incorrect Options:** * **Option A:** This is partially correct but incomplete. Primary amenorrhea is also defined as the absence of menarche by **age 14 in the absence** of secondary sexual characteristics. Option A mentions 14 years but is not the "best" definition compared to the standard 16-year rule for those with development. * **Option C:** This describes **delayed puberty**, not necessarily primary amenorrhea. While related, the clinical definition of amenorrhea specifically focuses on the absence of the menstrual bleed. * **Option D:** Endometriosis is a condition where endometrial tissue grows outside the uterus; it typically causes dysmenorrhea (painful periods), not the absence of menarche. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "14/16 Rule":** No periods by **14** (no breasts) OR no periods by **16** (with breasts). * **Most Common Cause:** Chromosomal abnormalities (e.g., **Turner Syndrome 45,XO**) are the most common cause of primary amenorrhea with streak ovaries. * **Second Most Common Cause:** **Müllerian Agenesis (MRKH Syndrome)**, where the uterus is absent but ovaries are functional (46,XX). * **Initial Investigation:** The first step in evaluation is usually a physical exam followed by a **Pelvic Ultrasound** to check for the presence of a uterus.
Question 8: Which of the following drugs is not considered a first-line treatment for anovulatory abnormal uterine bleeding in a 13-year-old girl?
- A. Tranexemic acid
- B. Mefenamic acid (Correct Answer)
- C. Progesterone
- D. Estrogen plus progesterone
Explanation: **Explanation:** In a 13-year-old girl, Abnormal Uterine Bleeding (AUB) is most commonly caused by an **immature hypothalamic-pituitary-ovarian (HPO) axis**, leading to **anovulation**. Without ovulation, there is no corpus luteum formation and no progesterone production. This results in "unopposed estrogen" action, causing the endometrium to proliferate excessively until it becomes unstable and sheds irregularly and heavily. **Why Mefenamic Acid is the correct answer:** Mefenamic acid is an NSAID that works by inhibiting prostaglandin synthesis. While it is highly effective for **ovulatory** AUB (menorrhagia) and primary dysmenorrhea, it does not address the underlying hormonal deficiency (lack of progesterone) in **anovulatory** AUB. Therefore, it is not considered a first-line treatment for anovulatory cycles in adolescents. **Analysis of Incorrect Options:** * **Progesterone (C):** This is a first-line treatment. It stabilizes the estrogen-primed endometrium and allows for a controlled "medical curettage" upon withdrawal. * **Estrogen plus Progesterone (D):** Combined Oral Contraceptive Pills (OCPs) are first-line agents. They regulate the cycle, thin the endometrial lining, and provide predictable withdrawal bleeds. * **Tranexamic Acid (A):** This antifibrinolytic is considered a first-line non-hormonal option for managing acute heavy bleeding episodes in adolescents by stabilizing clot formation in the uterine vasculature. **Clinical Pearls for NEET-PG:** * **Most common cause of AUB in adolescents:** Anovulation (due to HPO axis immaturity). * **Drug of choice for acute heavy AUB in adolescents:** High-dose Estrogen (to rapidly regrow denuded endometrium) or OCPs. * **Investigation of choice:** Pelvic Ultrasound (to rule out structural causes, though rare in this age group). * **Note:** Always rule out pregnancy and bleeding disorders (like von Willebrand disease) in adolescents presenting with heavy menstrual bleeding from menarche.
Question 9: A woman is said to have menorrhagia if the menstrual blood loss is more than what quantity?
- A. 20 ml
- B. 40 ml
- C. 60 ml
- D. 80 ml (Correct Answer)
Explanation: **Explanation:** **Menorrhagia** (now clinically referred to under the umbrella of Heavy Menstrual Bleeding or HMB) is defined as cyclic bleeding at normal intervals that is excessive in amount or duration. **1. Why 80 ml is the Correct Answer:** The classic objective definition of menorrhagia is a total menstrual blood loss exceeding **80 ml per cycle** or a period lasting longer than **7 days**. This threshold is clinically significant because blood loss greater than 80 ml consistently leads to a negative iron balance, eventually resulting in iron-deficiency anemia in most women. **2. Analysis of Incorrect Options:** * **A (20 ml) & B (40 ml):** These are within the range of normal menstrual blood loss. The average blood loss in a healthy eumenorrheic woman is approximately **30–40 ml**. * **C (60 ml):** While this is on the higher side of normal, it does not meet the diagnostic criteria for menorrhagia. Most women can maintain iron stores at this level of loss. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Measurement:** The **Alkaline Hematin Method** is the most accurate objective way to measure blood loss, though it is rarely used in clinical practice. * **Clinical Assessment:** In practice, the **PBAC (Pictorial Blood Loss Assessment Chart)** score is used; a score **>100** suggests blood loss >80 ml. * **Terminology Update:** According to the **FIGO (PALM-COEIN)** classification, the term "Menorrhagia" is being replaced by **Heavy Menstrual Bleeding (HMB)**. * **Most Common Cause:** In reproductive-age women, the most common organic cause of HMB is **Uterine Fibroids (Leiomyoma)**.
Question 10: A 15-year-old female complains of heavy menstrual bleeding for the past two months. On examination, her weight is 40 kg and her blood pressure is 120/80 mmHg. Which of the following investigations is NOT indicated in this patient?
- A. Serum TSH
- B. Platelet count
- C. Bleeding and clotting time
- D. Estradiol levels (Correct Answer)
Explanation: In an adolescent female presenting with heavy menstrual bleeding (HMB), the primary goal is to rule out systemic causes and common hematological disorders. **Why Estradiol levels are NOT indicated:** In a 15-year-old, the most common cause of HMB is **Anovulatory DUB (Dysfunctional Uterine Bleeding)** due to an immature Hypothalamic-Pituitary-Ovarian (HPO) axis. During anovulatory cycles, there is "unopposed estrogen" causing the endometrium to overgrow and shed irregularly. Measuring serum **Estradiol levels** is clinically irrelevant because levels fluctuate significantly throughout the cycle and do not change the management plan or help in diagnosing the underlying cause of HMB in this age group. **Explanation of other options:** * **Platelet count:** Essential to rule out **Idiopathic Thrombocytopenic Purpura (ITP)**, which often manifests as HMB in adolescents. * **Bleeding and clotting time:** These are screening tests for **von Willebrand Disease (vWD)**, the most common inherited bleeding disorder. Up to 20% of adolescents presenting with HMB have an underlying coagulopathy. * **Serum TSH:** Thyroid dysfunction (both hypo- and hyperthyroidism) is a frequent systemic cause of menstrual irregularities and must be ruled out. **Clinical Pearls for NEET-PG:** * **Most common cause of HMB in adolescents:** Immature HPO axis (Anovulatory cycles). * **Most common bleeding disorder in adolescents with HMB:** von Willebrand Disease. * **Initial Investigation of choice:** Complete Blood Count (to check Hb and Platelets). * **First-line management (Medical):** Combined Oral Contraceptive Pills (COCPs) or Tranexamic acid. Progestins are used for cycle stabilization.
Practice by Chapter
Normal Menstrual Physiology
Practice Questions
Primary Dysmenorrhea
Practice Questions
Secondary Dysmenorrhea
Practice Questions
Premenstrual Syndrome and PMDD
Practice Questions
Primary Amenorrhea
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Secondary Amenorrhea
Practice Questions
Polycystic Ovary Syndrome
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Abnormal Uterine Bleeding: Classification
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Evaluation of Menstrual Disorders
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Management Approaches to Menstrual Disorders
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