Menstrual Disorders Practice Questions

Q: Asherman syndrome is secondary to which of the following?

Tuberculosis. **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.

Q: A female presents with primary amenorrhea and absent vagina. What is the next investigation to be done?

Laparoscopy. **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).

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

Asherman syndrome is secondary to which of the following?

Accepted Answer

Tuberculosis

Answer

Endometrial carcinoma

Answer

Endometriosis

Answer

Submucosal fibroid

Question 2

A female presents with primary amenorrhea and absent vagina. What is the next investigation to be done?

Accepted Answer

Laparoscopy

Answer

LH/FSH assay

Answer

Chromosomal analysis

Answer

Urinalysis

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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