Menstrual Disorders Practice Questions

Q: A 16-year-old girl presents with delayed and irregular menstrual cycles for the past year. On evaluation, ultrasound of the ovaries shows multiple small peripheral cysts giving a “string-of- pearls” appearance as shown below. What is the most likely diagnosis? Options

Polycystic ovary syndrome. ### ***Polycystic ovary syndrome*** - The combination of **irregular menstrual cycles** and the classic ultrasound finding of multiple small peripheral follicles, often described as a **"string-of-pearls" appearance**, is diagnostic for **Polycystic Ovary Syndrome (PCOS)** in the presence of hyperandrogenism or metabolic features. - This condition is the most common cause of **anovulatory infertility** and frequently manifests during adolescence with menstrual dysfunction and polycystic ovarian morphology. ### *Premature ovarian failure* - This condition is characterized by **primary or secondary amenorrhea** due to ovarian depletion before age 40, typically presenting with **high FSH levels** and low estrogen. - Ultrasound in this condition typically shows **atrophic ovaries** rather than the multicystic appearance seen in PCOS. ### *Ovarian hyperstimulation syndrome* - This is an **iatrogenic complication** occurring as a result of **ovulation induction** therapies (like IVF), causing massive ovarian enlargement and fluid shift. - It is not a primary diagnosis for chronic menstrual irregularity and would present in a patient currently undergoing **assisted reproductive technology**. ### *Endometriosis* - Endometriosis typically presents with **cyclic pelvic pain** and dysmenorrhea rather than primarily isolated menstrual irregularity. - Ultrasound findings in endometriosis are typically characterized by **endometriomas** ("chocolate cysts"), which appear as ground-glass opacities, not the peripheral small follicles typical of PCOS.

Q: A 14-year-old girl presents with primary amenorrhea. On examination, the uterus is absent and ovaries are absent. Pubic hair is scanty. What is the most likely diagnosis?

Androgen insensitivity syndrome. ***Androgen insensitivity syndrome*** - Patients with **complete androgen insensitivity syndrome (CAIS)** have a 46,XY karyotype but fail to respond to androgens due to defective androgen receptors, resulting in an **absent uterus** (due to Anti-Müllerian hormone production by testes) and **absent ovaries**. - The testes remain intra-abdominal or inguinal, and **scanty or absent pubic hair** is a hallmark sign due to the absence of androgen-mediated hair growth. *Turner syndrome* - Involves a 45,X karyotype and typically presents with **short stature**, a **webbed neck**, and **streak ovaries**. - The uterus is usually present, albeit infantile, because there is no production of Anti-Müllerian hormone. *Gonadal dysgenesis* - Refers to a failure of gonadal development, often leading to **streak gonads** and variable development of Müllerian structures depending on whether Anti-Müllerian hormone is produced. - Pubic hair is generally present in these conditions, and it does not typically present with the specific constellation of a completely absent uterus with absent ovaries and sparse/absent hair seen in AIS. *Müllerian agenesis* - Specifically known as **Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome**, it presents with an **absent uterus** and upper vagina, but with **normal ovarian function** and normal secondary sexual characteristics. - Patients have 46,XX karyotype, normal testosterone levels, and **normal pubic hair development**.

Q: A woman is said to have menorrhagia if the menstrual blood loss is more than what quantity?

80 ml. **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)**.

Q: 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?

Estradiol levels. 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.

Question 1

A 16-year-old girl presents with delayed and irregular menstrual cycles for the past year. On evaluation, ultrasound of the ovaries shows multiple small peripheral cysts giving a “string-of- pearls” appearance as shown below. What is the most likely diagnosis? Options

Accepted Answer

Polycystic ovary syndrome

Answer

Premature ovarian failure

Answer

Ovarian hyperstimulation syndrome

Answer

Endometriosis

Question 2

A 14-year-old girl presents with primary amenorrhea. On examination, the uterus is absent and ovaries are absent. Pubic hair is scanty. What is the most likely diagnosis?

Accepted Answer

Androgen insensitivity syndrome

Answer

Turner syndrome

Answer

Gonadal dysgenesis

Answer

Müllerian agenesis

Question 3

Which of the following is NOT a cause of unilateral dysmenorrhea?

Accepted Answer

Large fundal fibroid

Answer

Rudimentary uterine horn

Answer

Right ovarian vein syndrome

Answer

Unicornuate uterus

Question 4

A 16-year-old female presents with cryptomenorrhea and normal secondary sexual characters. What is the investigation of choice?

Accepted Answer

Genital examination for outflow obstruction

Answer

MRI brain

Answer

Prolactin estimation

Answer

None of the above

Question 5

Which of the following is NOT true about the use of NSAIDs in abnormal uterine bleeding?

Accepted Answer

NSAIDs should be commenced just prior to the start of menses and continued up to day 14 of the cycle.

Answer

Prostaglandins play a role in the pathogenesis of endometrial dysfunction.

Answer

NSAIDs are used just prior to the onset of menses as women lose 90% of menstrual blood volume in the first 3 days.

Answer

NSAIDs can reduce menstrual blood loss by approximately 25%.

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?

Accepted Answer

Ultrasound (USG)

Answer

Reassurance

Answer

Hysterosalpingography (HSG)

Answer

Hormonal studies

Question 7

Which of the following defines primary amenorrhea?

Accepted Answer

Absence of menarche by 16 years with secondary sexual characters

Answer

Absence of menarche by 14 years without secondary sexual characters

Answer

Absence of secondary sexual characters by 13 years

Answer

Endometriosis

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?

Accepted Answer

Mefenamic acid

Answer

Tranexemic acid

Answer

Progesterone

Answer

Estrogen plus progesterone

Question 9

A woman is said to have menorrhagia if the menstrual blood loss is more than what quantity?

Accepted Answer

80 ml

Answer

20 ml

Answer

40 ml

Answer

60 ml

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?

Accepted Answer

Estradiol levels

Answer

Serum TSH

Answer

Platelet count

Answer

Bleeding and clotting time

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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