Management Approaches to Menstrual Disorders — MCQs
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 67-year-old female with hypertension and diabetes presents with heavy vaginal bleeding. What is the next step in management?
Preferred treatment for menorrhagia in reproductive age group?
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 newly married couple, the woman is having irregular menstruation. What is the contraceptive of choice?
In a woman complaining of AUB following image was seen in endoscopic examination of uterus. What will be the diagnosis?
An 18-year-old unmarried girl comes with complaints of heavy, prolonged bleeding during menses. Which among the following investigations is NOT usually advised?
Which of the following statements is true regarding menorrhagia?
Which one of the following is true regarding normal menstrual physiology?
Oligomenorrhoea means ?
Management Approaches to Menstrual Disorders Indian Medical PG Practice Questions and MCQs
Question 1: 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 2: A 67-year-old female with hypertension and diabetes presents with heavy vaginal bleeding. What is the next step in management?
- A. Endometrial biopsy (Correct Answer)
- B. Pelvic ultrasound
- C. Detailed history and physical examination
- D. Complete blood count and coagulation studies
Explanation: ***Endometrial biopsy*** - **Postmenopausal bleeding is endometrial cancer until proven otherwise** - this is a fundamental principle in gynecology requiring immediate tissue diagnosis. - **Endometrial biopsy is the first-line investigation** for any postmenopausal woman presenting with vaginal bleeding, as per **ACOG, RCOG, and WHO guidelines**. - An office endometrial biopsy (using **Pipelle sampler**) can be performed quickly and has **90-97% sensitivity** for detecting endometrial cancer and hyperplasia. - In this 67-year-old patient with risk factors (hypertension, diabetes), direct tissue sampling is mandatory to rule out **endometrial carcinoma**, which is the most concerning etiology. - If office biopsy is inadequate or negative but bleeding persists, proceed to **hysteroscopy with directed biopsy** or **dilatation and curettage (D&C)**. *Pelvic ultrasound* - While transvaginal ultrasound can assess **endometrial thickness** (cancer unlikely if <4-5mm in postmenopausal women), it **cannot replace histological diagnosis**. - Ultrasound may be used as an **adjunct** or for **triage in resource-limited settings**, but in established postmenopausal bleeding, **tissue diagnosis takes priority**. - Some protocols use ultrasound first, but the definitive diagnostic step remains biopsy, and many guidelines recommend proceeding directly to biopsy in postmenopausal bleeding. *Detailed history and physical examination* - History and examination are **always performed initially** when a patient presents, but the question asks for the "next step in management" after the presentation is established. - These would have already been completed to confirm postmenopausal status, exclude obvious causes (trauma, atrophic vaginitis), and assess hemodynamic stability. - The "next step" implies the specific diagnostic or therapeutic intervention to identify the cause. *Complete blood count and coagulation studies* - **CBC** helps assess the degree of anemia from blood loss and guides need for transfusion. - **Coagulation studies** may identify bleeding disorders but are not routinely indicated unless clinical suspicion exists. - These investigations are **supportive** but do not identify the **anatomical source** or **histological cause** of bleeding, which is essential for management of postmenopausal bleeding.
Question 3: 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 4: 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 5: A newly married couple, the woman is having irregular menstruation. What is the contraceptive of choice?
- A. Barrier method
- B. Calendar method
- C. OCP (Correct Answer)
- D. Progesterone only pills
Explanation: ***OCP*** - **Oral Contraceptive Pills (OCPs)** are a highly effective method that also help regulate **menstrual cycles** due to their hormonal content. - They provide effective contraception while simultaneously addressing the symptom of **irregular menstruation** in a newly married woman. *Barrier method* - **Barrier methods** like condoms are effective for contraception but do not address or regulate irregular menstrual cycles. - Their effectiveness depends heavily on consistent and correct use with each act of intercourse. *Calendar method* - The **calendar method** relies on tracking the menstrual cycle to predict fertile windows and is unreliable with **irregular menstruation**. - It would be ineffective as a contraceptive for a woman with unpredictable cycle lengths, leading to a high risk of unintended pregnancy. *Progesterone only pills* - **Progesterone-only pills** (POPs) can be used for contraception, but they may cause or exacerbate **menstrual irregularities**. - While effective in preventing pregnancy, they do not offer the cycle-regulating benefits that combination OCPs do for women with irregular periods.
Question 6: In a woman complaining of AUB following image was seen in endoscopic examination of uterus. What will be the diagnosis?
- A. Leiomyoma (Correct Answer)
- B. Adenomyosis
- C. Ovarian neoplasm
- D. Carcinoma of uterus
Explanation: ***Leiomyoma*** - The image shows **well-circumscribed, smooth, rounded masses protruding into the uterine cavity**, which are characteristic of **submucous (intracavitary) leiomyomas (fibroids)** seen on hysteroscopy. - Submucous leiomyomas are benign smooth muscle tumors that project into the endometrial cavity and commonly cause **abnormal uterine bleeding (AUB)** due to increased endometrial surface area, distortion of the endometrial cavity, ulceration of overlying endometrium, and interference with normal uterine contractility. - On **hysteroscopic examination**, they appear as firm, pale, smooth-surfaced masses with overlying endometrium. *Adenomyosis* - Adenomyosis involves the presence of **endometrial tissue within the myometrium**, leading to diffuse uterine enlargement. - On hysteroscopy, it may show a **globally irregular endometrial surface** with small endometrial openings or cystic spaces, but not the discrete, well-circumscribed protruding masses seen in the image. - While it can cause AUB and dysmenorrhea, the appearance is distinctly different from submucous leiomyomas. *Ovarian neoplasm* - Ovarian neoplasms originate in the **ovaries**, which are separate from the uterus. - **Hysteroscopic examination** visualizes only the **endometrial cavity** and cannot directly visualize ovarian pathology. - Ovarian masses do not protrude into the uterine cavity. *Carcinoma of uterus* - Endometrial carcinoma typically presents on hysteroscopy as **irregular, friable, ulcerative, or fungating lesions** with abnormal vascularity and易出血 (easy bleeding). - The **smooth, well-defined, and rounded appearance** with intact overlying mucosa in the image is characteristic of benign leiomyomas, not malignant growths. - Uterine sarcomas are rare and would show more irregular, infiltrative features rather than well-circumscribed masses.
Question 7: 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 8: 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).
Question 9: Which one of the following is true regarding normal menstrual physiology?
- A. Ovulation occurs after 12 hours of LH peak (Correct Answer)
- B. Ovulation occurs after 48 hours of LH surge
- C. Oestradiol levels peak at 48 hours prior to ovulation
- D. LH surge duration is typically 12-24 hours
Explanation: ***Ovulation occurs after 12 hours of LH peak*** - Ovulation typically occurs approximately **10-12 hours after the luteinizing hormone (LH) peak** and about 34-36 hours after the initial rise in LH. This delay allows for the final maturation of the oocyte. - The **LH surge** is the crucial hormonal signal that triggers the ovulation process in the mature follicle. *Ovulation occurs after 48 hours of LH surge* - This statement is incorrect as **ovulation occurs much sooner** after the LH surge, typically within 34-36 hours from the onset of the surge, and 10-12 hours after its peak. - A 48-hour delay would mean the oocyte would likely be past its optimal viability for fertilization. *Oestradiol levels peak at 48 hours prior to ovulation* - **Estradiol levels peak approximately 24-36 hours before ovulation**, not 48 hours. This peak in estradiol is what triggers the surge in LH. - The timing of the estradiol peak is crucial in initiating the positive feedback loop that leads to the LH surge. *LH surge duration is typically 12-24 hours* - The **LH surge typically lasts for about 48 hours**, not 12-24 hours. A surge of this duration ensures sufficient time for the final maturation of the oocyte and the process of follicular rupture. - The prolonged nature of the LH surge is essential for the completion of meiosis I in the oocyte and the weakening of the follicular wall.
Question 10: Oligomenorrhoea means ?
- A. Cycle < 20 days
- B. Cycle more than 45 days
- C. Cycle more than 28 days
- D. Cycle longer than 35 days (Correct Answer)
Explanation: ***Cycle longer than 35 days*** - **Oligomenorrhea** is defined by menstrual cycles that are **infrequently occurring**, specifically lasting longer than 35 days. - This condition is distinct from **amenorrhea**, which is the complete absence of menstruation. *Cycle < 20 days* - A menstrual cycle lasting less than 20 days is considered **polymenorrhea**, indicating abnormally frequent menstruation. - This is the opposite of oligomenorrhea, which refers to infrequent menstruation. *Cycle more than 45 days* - While a cycle longer than 45 days would technically fall under **oligomenorrhea**, the general definition begins at an interval longer than **35 days**. - Cycles significantly longer than 45 days might also point to **amenorrhea**, depending on the exact duration and pattern. *Cycle more than 28 days* - A cycle lasting more than 28 days is within the **normal range** for many individuals, as the average cycle length is 21-35 days. - Therefore, this duration alone does **not define oligomenorrhea**.
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