Evaluation of Menstrual Disorders — MCQs
The menstrual cycle can be best assessed by:
What is the primary hormonal cause of anovulatory dysfunctional uterine bleeding (DUB)?
A female patient presents with hirsutism, amenorrhea, and obesity. What is the most likely diagnosis?
35 yr old lady attends gynaec OPD with excessive bleeding since 6 months, not controlled with non hormonal drugs. USG and clinical examination reveals no abnormality. Next step is?
The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?
What is the average menstrual flow during normal menses?
A 33-year-old female presents with heavy menstrual bleeding for 6 months. On examination, no abnormalities were found, and an ultrasound also appeared normal. After failing non-hormonal treatment, what is the next appropriate management step?
An 18-year-old unmarried girl comes with complaints of heavy, prolonged bleeding during menses. Which among the following investigations is NOT usually advised?
Preferred treatment for menorrhagia in reproductive age group?
Which of the following statements is true regarding menorrhagia?
Evaluation of Menstrual Disorders Indian Medical PG Practice Questions and MCQs
Question 1: The menstrual cycle can be best assessed by:
- A. Fern test
- B. Spinnbarkeit phenomenon
- C. Sex steroid profile (Correct Answer)
- D. Cytology of endometrium
Explanation: ***Sex steroid profile*** - A **sex steroid profile** directly measures the levels of key hormones like **estrogen** and **progesterone** throughout the cycle, providing the most comprehensive and accurate assessment of ovarian function and phases [2]. - Changes in these hormones dictate the events of the menstrual cycle, including ovulation and endometrial preparation [2]. *Fern test* - The **fern test** assesses cervical mucus crystallization patterns, primarily indicating high estrogen levels, but it doesn't give a full picture of the entire cycle or progesterone influence [1]. - It's mainly used to confirm **rupture of membranes** in pregnancy or indicate the ovulatory phase [1]. *Spinnbarkeit phenomenon* - **Spinnbarkeit phenomenon** refers to the stretchiness of cervical mucus, which primarily indicates high estrogen levels around ovulation [1]. - While useful for ovulation detection, it does not provide a comprehensive assessment of the entire female sexual cycle or hormonal fluctuations [2]. *Cytology of endometrium* - **Endometrial cytology** involves examining cells from the uterine lining, which can show the effects of hormonal exposure but doesn't directly measure hormone levels or provide a dynamic assessment of the entire cycle [3]. - It is more commonly used to detect **abnormal cellular changes**, such as hyperplasia or malignancy.
Question 2: What is the primary hormonal cause of anovulatory dysfunctional uterine bleeding (DUB)?
- A. Insufficient progesterone due to anovulation (Correct Answer)
- B. Excess estrogen production from ovarian follicles
- C. Hypothalamic dysfunction affecting ovulation
- D. High levels of progesterone due to luteal phase defect
Explanation: ***Insufficient progesterone due to anovulation*** - Anovulation prevents the formation of a **corpus luteum**, which is responsible for producing progesterone. - The lack of progesterone leads to an **unstable, proliferative endometrium** that eventually sheds irregularly, causing abnormal uterine bleeding. - This is the **primary hormonal defect** in anovulatory DUB. *Excess estrogen production from ovarian follicles* - While **unopposed estrogen** is present in anovulatory cycles, the primary issue is the *absence of progesterone*, not necessarily excess estrogen production. - Estrogen levels may be normal or even low, but without progesterone to stabilize the endometrium, irregular shedding occurs. - Excess estrogen primarily leads to **endometrial hyperplasia** rather than irregular bleeding. *Hypothalamic dysfunction affecting ovulation* - Hypothalamic dysfunction (e.g., due to stress, extreme exercise) can be an *underlying cause* of anovulation. - However, the *primary hormonal mechanism* of the bleeding itself is the subsequent lack of progesterone, not the hypothalamic dysfunction directly. *High levels of progesterone due to luteal phase defect* - A **luteal phase defect** involves *insufficient* progesterone production or response, not high levels. - High progesterone levels would stabilize the endometrium and promote regular shedding, preventing DUB.
Question 3: A female patient presents with hirsutism, amenorrhea, and obesity. What is the most likely diagnosis?
- A. Androgen-secreting ovarian tumor
- B. Congenital adrenal hyperplasia
- C. Cushing's syndrome
- D. Polycystic Ovary Syndrome (PCOS) (Correct Answer)
Explanation: ***Polycystic Ovary Syndrome (PCOS)*** - **Hirsutism**, **amenorrhea** (or oligomenorrhea), and **obesity** are classic clinical features of PCOS, reflecting hyperandrogenism and insulin resistance [2]. - PCOS is a diagnosis of exclusion and involves chronic anovulation and polycystic ovaries on ultrasound [3], though these are not explicitly mentioned, the constellation of symptoms strongly points to it. *Androgen-secreting ovarian tumor* - While it can cause **hirsutism** and **amenorrhea**, the onset is typically **rapid** and severe, with very high androgen levels, and obesity is not a primary feature. - Ovarian tumors are generally less common than PCOS and may present with a palpable mass or specific imaging findings. *Congenital adrenal hyperplasia* - This genetic condition often presents in childhood or adolescence with varying degrees of **virilization** and menstrual irregularities due to enzyme deficiencies in cortisol synthesis [1]. - While it causes **hirsutism** and potentially **amenorrhea**, obesity is not a direct consequence, and the patient's age of presentation and specific symptom pattern are less typical for adult-onset CAH in this context. *Cushing's syndrome* - Characterized by **central obesity**, **moon facies**, **buffalo hump**, **striae**, and proximal muscle weakness due to chronic glucocorticoid excess. - Although it can cause **menstrual irregularities** and mild **hirsutism** [2], the overall clinical picture including the absence of other specific Cushingoid features makes it less likely than PCOS.
Question 4: 35 yr old lady attends gynaec OPD with excessive bleeding since 6 months, not controlled with non hormonal drugs. USG and clinical examination reveals no abnormality. Next step is?
- A. Hysterectomy
- B. Endometrial sampling (Correct Answer)
- C. Endometrial ablation
- D. Hormonal therapy
Explanation: ***Endometrial sampling*** - In a 35-year-old with **excessive uterine bleeding** not controlled by non-hormonal drugs and with normal imaging/clinical exam, endometrial sampling is crucial to **rule out endometrial hyperplasia or malignancy**. - This diagnostic step is essential before considering definitive treatments, as it provides a **histological diagnosis** of the endometrial lining. *Hysterectomy* - Hysterectomy is a **definitive surgical treatment** for excessive bleeding, but it is typically reserved for cases where conservative or less invasive treatments have failed, or if there's a serious underlying pathology like malignancy. - It involves removing the uterus and is a **major surgery** with potential complications, thus not usually the first step given an otherwise normal examination and imaging. *Endometrial ablation* - Endometrial ablation is a procedure to destroy the lining of the uterus, aiming to **reduce or stop menstrual bleeding**. - It is a treatment option for **abnormal uterine bleeding (AUB)**, but it's typically performed after other diagnostic steps (like endometrial sampling) have ruled out malignancy or high-risk hyperplasia, and when conservative medical management has failed. *Hormonal therapy* - Hormonal therapy (e.g., combined oral contraceptives, progestin-only pills, levonorgestrel-releasing intrauterine device) is often a **first-line medical treatment** for excessive uterine bleeding. - However, the question states that non-hormonal drugs have already failed, and without a clear diagnosis, initiating new hormonal therapy without **evaluating the endometrium** is not the next best step for persistent bleeding.
Question 5: The patient presented with a retroverted uterus, dysmenorrhea, and dyspareunia. What is the next step of the investigation?
- A. HSG
- B. USG (Correct Answer)
- C. Laparotomy
- D. Diagnostic Laparoscopy
Explanation: ***USG*** - **Transvaginal ultrasound (TVS)** is the initial imaging modality of choice for evaluating uterine position, assessing for causes of dysmenorrhea and dyspareunia (e.g., **endometriosis**, adenomyosis, fibroids), and can visualize the retroverted uterus. - It is **non-invasive**, readily available, and provides good resolution of pelvic organs, making it suitable for first-line investigation. *HSG* - **Hysterosalpingography (HSG)** is primarily used to assess **fallopian tube patency** in cases of infertility. - It will **not provide detailed information** about the uterine position or other pelvic pathologies contributing to pain. *Laparotomy* - **Laparotomy** is a major surgical procedure involving a large abdominal incision, typically reserved for **definitive diagnosis and treatment** of significant pelvic pathology when less invasive methods are insufficient. - It is **not an initial investigatory step** for symptoms like dysmenorrhea and dyspareunia. *Diagnostic Laparoscopy* - **Diagnostic laparoscopy** is a minimally invasive surgical procedure that allows direct visualization of pelvic organs, often used to **confirm endometriosis** or other pathologies. - While it offers definitive diagnosis, it is an **invasive procedure** and usually performed **after initial non-invasive imaging** (like USG) has been completed.
Question 6: What is the average menstrual flow during normal menses?
- A. 80ml
- B. 15ml
- C. 30ml (Correct Answer)
- D. 50ml
Explanation: ***30ml*** - The average menstrual blood loss during a normal period is approximately **30 mL**. - While there is a range, 30 mL is often cited as the mean for defining **normal menses**. *50ml* - Although it falls within the broader definition of normal, 50ml is slightly higher than the statistically observed **average menstrual flow**. - Blood loss exceeding **80 mL** is generally considered **menorrhagia**. *15ml* - A menstrual flow of **15 mL** is on the lower end of the normal range and could sometimes be indicative of **hypomenorrhea**. - While not necessarily abnormal, it is less common as an average compared to 30 mL. *80ml* - A menstrual flow of **80 mL** is consistently considered **menorrhagia** or heavy menstrual bleeding. - This level of blood loss can lead to **anemia** and often requires investigation and treatment.
Question 7: A 33-year-old female presents with heavy menstrual bleeding for 6 months. On examination, no abnormalities were found, and an ultrasound also appeared normal. After failing non-hormonal treatment, what is the next appropriate management step?
- A. Perform endometrial sampling.
- B. Initiate hormonal therapy. (Correct Answer)
- C. Consider hysterectomy.
- D. Perform dilation and curettage (D&C).
Explanation: ***Initiate hormonal therapy.*** - For unexplained **heavy menstrual bleeding (HMB)** in a young woman with a normal workup, hormonal therapy (e.g., combined oral contraceptives, progestin-only pills, or a progestin-releasing IUD) is the first-line medical treatment after non-hormonal options fail. - These treatments stabilize the **endometrial lining** and reduce blood flow, effectively managing symptoms. *Perform endometrial sampling.* - **Endometrial sampling** is typically reserved for women at higher risk of endometrial hyperplasia or cancer, such as those over 45 with HMB, or younger women with persistent irregular bleeding, risk factors for endometrial cancer (e.g., obesity, PCOS), or unresponsive to initial medical therapy. - In this 33-year-old with normal ultrasound and no other identified risk factors, the likelihood of endometrial pathology is low, making sampling less urgent as a *next* step. *Consider hysterectomy.* - **Hysterectomy** is a definitive surgical procedure usually reserved for severe, persistent HMB that has failed all less invasive medical and surgical treatments, or for cases where there is significant uterine pathology (e.g., large fibroids, adenomyosis) not present here. - It is an irreversible procedure and generally not considered early in the management of heavy menstrual bleeding in a 33-year-old without uterine abnormalities. *Perform dilation and curettage (D&C).* - A **D&C** is a procedure to remove tissue from the uterus, often used for diagnostic purposes (like endometrial sampling) or to remove retained products of conception. - While it can temporarily reduce bleeding by removing some endometrial lining, it is not a long-term solution for treating abnormal uterine bleeding and is typically not indicated as a primary therapeutic step for chronic HMB in the absence of acute severe bleeding or suspected pathology requiring tissue removal.
Question 8: An 18-year-old unmarried girl comes with complaints of heavy, prolonged bleeding during menses. Which among the following investigations is NOT usually advised?
- A. Urine pregnancy test
- B. Coagulation profile
- C. Dilatation and curettage (Correct Answer)
- D. Ultrasound uterus and adnexa
Explanation: ***Dilatation and curettage*** - This is an **invasive surgical procedure** used diagnostically and therapeutically for heavy uterine bleeding, but it is generally *not* the initial or routinely advised investigation for an 18-year-old unmarried girl with heavy menstrual bleeding. - In a young, unmarried patient, less invasive methods are preferred unless other investigations point to a structural abnormality requiring tissue diagnosis or therapeutic intervention. *Urine pregnancy test* - A urine pregnancy test is **essential** to rule out pregnancy-related complications (e.g., ectopic pregnancy, miscarriage) as a cause of heavy vaginal bleeding, even in unmarried individuals. - **Abnormal uterine bleeding** can be the presenting symptom of an early pregnancy loss. *Coagulation profile* - Heavy and prolonged bleeding, especially from a young age (as suggested by "18-year-old girl"), raises suspicion for an **underlying coagulopathy** (e.g., Von Willebrand disease). - A coagulation profile (including PT, aPTT, platelet count, and sometimes specific factor assays) is crucial to **assess bleeding risk** and guide management. *Ultrasound uterus and adnexa* - An ultrasound is a **non-invasive imaging technique** that can identify structural causes of abnormal uterine bleeding, such as **fibroids, polyps, adenomyosis**, or ovarian pathologies. - It helps in assessing the **uterine lining and ovarian morphology**, which is important in evaluating the cause of heavy menstrual bleeding.
Question 9: Preferred treatment for menorrhagia in reproductive age group?
- A. Cu IUD
- B. Hysterectomy
- C. NOVA T
- D. OCPs (Correct Answer)
Explanation: ***OCPs*** - **Combined oral contraceptives (OCPs)** are a common and effective first-line treatment for menorrhagia in reproductive-aged women, particularly when contraception is also desired. - They work by stabilizing the **endometrial lining**, reducing menstrual blood loss and regulating cycles. *NOVA T* - NOVA T is a type of **copper IUD (intrauterine device)**, which is known to potentially *increase* menstrual bleeding and dysmenorrhea, making it unsuitable for menorrhagia. - Its primary function is contraception, not the management of heavy menstrual bleeding. *Cu IUD* - The **copper intrauterine device (Cu IUD)** is generally contraindicated in women with menorrhagia because it can exacerbate heavy menstrual bleeding. - While an effective contraceptive, it does not offer therapeutic benefits for managing heavy periods. *Hysterectomy* - **Hysterectomy** is a surgical procedure for removing the uterus and is considered a definitive treatment for menorrhagia. - However, it is an **invasive procedure** with irreversible loss of fertility, typically reserved for severe cases where conservative treatments have failed or when other uterine pathology is present.
Question 10: Which of the following statements is true regarding menorrhagia?
- A. Bleeding volume greater than 80 ml per cycle
- B. Heavy and irregularly timed episodes of bleeding
- C. Heavy and regularly timed episodes of bleeding (Correct Answer)
- D. Menstrual bleeding lasting more than 7 days
Explanation: ***Heavy and regularly timed episodes of bleeding*** - **Menorrhagia** is defined as **excessive menstrual blood loss** occurring at **regular intervals** (cyclical pattern). - This is the classic definition distinguishing it from other abnormal uterine bleeding patterns. - The key features are: **heavy flow** + **regular timing** (maintains normal cycle length). *Heavy and irregularly timed episodes of bleeding* - This describes **irregular heavy bleeding**, which would fall under abnormal uterine bleeding with irregular timing. - The **irregular timing** is the key differentiator that excludes this from being simple menorrhagia. *Bleeding volume greater than 80 ml per cycle* - While **>80 ml blood loss** is the objective measurement for menorrhagia, this alone doesn't capture the complete definition. - Menorrhagia specifically requires this heavy bleeding to occur at **regular intervals**. - In clinical practice, subjective assessment (soaking through pads/tampons, clots, impact on quality of life) is often more practical than measuring volume. *Menstrual bleeding lasting more than 7 days* - Duration **>7 days** describes **prolonged menstrual bleeding**. - This can occur with menorrhagia but is not the defining feature. - A patient can have menorrhagia with normal duration (3-7 days) if the volume is excessive during that period. - The definition of menorrhagia focuses on **amount** (heavy), not duration (prolonged).
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