Menstrual Disorders Practice Questions

Q: Causes of AUB are subdivided by the acronym PALM-COEIN. What are the characteristics of PALM causes? I. Structural lesions II. Diagnosed by ultrasound III. Confirmed by histopathology Select the correct answer using the code given below :

I, II and III. ***I, II and III*** - The PALM group of AUB causes refers to **structural abnormalities** of the uterus, including polyps (P), adenomyosis (A), leiomyomas (L), and malignancy/hyperplasia (M). - These conditions are typically identified through **imaging techniques** like ultrasound, saline infusion sonography, or hysteroscopy, and often confirmed with **histopathological examination** (e.g., biopsy) to provide a definitive diagnosis or characterize the lesion. *I and III only* - This option is incomplete as **ultrasound (II)** is a primary diagnostic tool for identifying PALM causes. - While structural lesions (I) are involved and histopathology (III) is often confirmatory, imaging remains crucial for initial detection and characterization. *I and II only* - This option is incomplete because **histopathology (III)** is frequently necessary for a definitive diagnosis or to rule out malignancy, especially for conditions like endometrial hyperplasia or malignancy. - While structural lesions (I) are detectable by ultrasound (II), microscopic examination provides crucial details. *II and III only* - This option is incomplete because the PALM causes are fundamentally **structural lesions (I)**. - Imaging and histopathology are methods of diagnosing and confirming these underlying structural changes, not the primary characteristic themselves.

Q: Which one of the following is a prerequisite for Endometrial Ablation ?

Completed childbearing. ***Correct: Completed childbearing*** **Completed childbearing** is the key **prerequisite** for **endometrial ablation (EA)**. This is a fundamental requirement because: - **EA significantly impairs or destroys fertility** by ablating the endometrial lining essential for implantation - Pregnancy after EA is **rare and high-risk**, with increased chances of **miscarriage, ectopic pregnancy, preterm birth, and placental abnormalities** (placenta accreta, previa) - Patients must be **thoroughly counseled** that EA is intended as a permanent solution and future pregnancy is contraindicated - Most guidelines and consent protocols require documentation that the patient has completed childbearing or accepts permanent loss of fertility - While not an absolute contraindication if a patient insists, the strong recommendation is that childbearing should be complete *Incorrect: Presence of large submucous fibroids* - Large submucous fibroids are a **CONTRAINDICATION**, not a prerequisite - Fibroids distort the uterine cavity, making safe and effective ablation **difficult or impossible** - They may require **hysteroscopic myomectomy** first, or EA may not be appropriate at all - This is the opposite of a prerequisite *Incorrect: Desire to maintain fertility* - This is a strong **CONTRAINDICATION** for EA - EA destroys the endometrium needed for pregnancy - Patients desiring future fertility should pursue other treatments for abnormal uterine bleeding - This directly contradicts the purpose and effects of the procedure *Incorrect: Uterine size >16 weeks* - A uterus larger than **12 weeks' gestation** is a **relative contraindication** or limitation - Increased risk of **incomplete ablation, perforation**, and treatment failure - Large uteri often indicate underlying pathology needing alternative management - This is a contraindication, not a prerequisite

Q: A 16-year-old girl with primary amenorrhoea presents to the gynaecology OPD for evaluation. She has normal secondary sexual characters. Her karyotype is 46,XX and ultrasound reveals normal ovaries and tubes but absent uterus. What is her clinical diagnosis?

Mayer-Rokitansky-Küster-Hauser syndrome. ***Mayer-Rokitansky-Küster-Hauser syndrome (MRKH)*** - This syndrome is characterized by **agenesis of the uterus and upper vagina** in a genotypically and phenotypically normal female (46,XX karyotype, normal ovaries, and normal secondary sexual characteristics). - The presence of **normal secondary sexual characteristics** indicates normal ovarian function and estrogen production, ruling out ovarian failure as the primary cause of amenorrhea. *Primary ovarian failure* - This condition would typically lead to **absent or delayed development of secondary sexual characteristics** due to insufficient estrogen production by the ovaries. - The patient's **normal secondary sexual characteristics** contradict primary ovarian failure. *Androgen insensitivity syndrome* - Individuals with CAIS are **genetically male (46,XY)** but phenotypically female, with **absent or rudimentary uterus** and internal female reproductive organs. - While they have absent menses and normal secondary sexual characteristics (due to peripheral conversion of androgens to estrogens), their **karyotype is 46,XY**, not 46,XX as in this patient. *Turner syndrome* - This syndrome is characterized by a **45,X karyotype**, leading to **gonadal dysgenesis** (streak gonads) and thus absent or delayed secondary sexual characteristics. - The patient's **normal secondary sexual characteristics** and **46,XX karyotype** rule out Turner syndrome.

Q: A 25-year-old female comes to the gynaecology OPD for evaluation of secondary amenorrhoea. She gives history of previous dilatation and curettage, and her FSH levels are 8 IU/L. The probable cause of amenorrhoea is

Asherman syndrome. ***Asherman syndrome*** - This syndrome is characterized by the formation of **intrauterine adhesions** or scarring, often following uterine procedures such as **dilatation and curettage (D&C)**. - The **normal FSH level** (8 IU/L) indicates intact ovarian function, ruling out primary ovarian issues and pointing towards a structural uterine problem as the cause of secondary amenorrhea. *incomplete abortion* - An incomplete abortion would typically present with **vaginal bleeding and abdominal pain**, not secondary amenorrhea, unless it occurred significantly in the past and led to complications. - While D&C can be performed for incomplete abortion, the primary cause of amenorrhea in this context would be the subsequent formation of uterine adhesions, not the incomplete abortion itself. *premature ovarian failure* - This condition involves the cessation of ovarian function before age 40, which would result in **elevated FSH levels** due to lack of negative feedback from estrogen. - The patient's **normal FSH level** (8 IU/L) makes premature ovarian failure an unlikely diagnosis in this case. *Sheehan syndrome* - Sheehan syndrome is caused by **ischemic necrosis of the pituitary gland** typically following severe postpartum hemorrhage, leading to panhypopituitarism. - It would present with symptoms of **multiple hormone deficiencies**, including low FSH and LH (due to pituitary failure), along with other anterior pituitary hormone deficiencies, which contradicts the normal FSH and lack of mention of postpartum hemorrhage.

Q: Premenstrual Syndrome (PMS) should fulfil which of the following criteria? 1. It is not related to any organic lesion. 2. It regularly occurs during the luteal phase and each ovulatory menstruation cycle. 3. Symptoms must be severe enough to disturb the lifestyle of women and seeks medical help. 4. Symptoms persist after the period also.

1. It is not related to any organic lesion.. ***1. It is not related to any organic lesion.*** - PMS is a **functional disorder** and a diagnosis of exclusion, meaning its symptoms should not be attributable to an underlying physical or organic pathology. - While PMS involves hormonal fluctuations during the **luteal phase**, there is no detectable **structural or organic lesion** causing the symptoms. - This is a fundamental criterion to differentiate PMS from other medical conditions. ***2. It regularly occurs during the luteal phase and each ovulatory menstruation cycle.*** - PMS symptoms characteristically occur during the **luteal phase** (after ovulation and before menstruation) and are a key diagnostic feature. - Symptoms must occur in **most cycles** (typically documented in at least 2 out of 3 consecutive cycles) to establish the diagnosis. - This temporal relationship with the menstrual cycle is essential for diagnosis. ***3. Symptoms must be severe enough to disturb the lifestyle of women and seeks medical help.*** - **Functional impairment** is a fundamental diagnostic criterion for PMS. - Symptoms must cause **clinically significant distress** or interfere with work, school, usual activities, or relationships. - This distinguishes PMS from normal premenstrual symptoms that many women experience without functional impairment. *4. Symptoms persist after the period also.* - A key diagnostic criterion for PMS is that symptoms **resolve or significantly improve** with or shortly after the onset of menstruation. - If symptoms persist throughout the menstrual cycle, it suggests a different diagnosis, such as an underlying mood disorder (e.g., depression or anxiety with premenstrual exacerbation) rather than true PMS. - The cyclic nature with symptom-free interval is essential for PMS diagnosis.

Q: In the PALM-COEIN classification by FIGO for abnormal uterine bleeding, ovulatory dysfunction is the cause in which one of the following conditions?

Polycystic ovarian syndrome. ***Polycystic ovarian syndrome*** - **Polycystic ovarian syndrome (PCOS)** is a chronic anovulatory disorder, making it a primary cause of **ovulatory dysfunction (O in PALM-COEIN)**. - The hormonal imbalances in PCOS interfere with normal follicular development and ovulation, leading to irregular or absent periods and abnormal uterine bleeding. *Pelvic inflammatory disease* - **Pelvic inflammatory disease (PID)** is an infection of the upper female reproductive tract causing inflammation, but it does not directly lead to primary ovulatory dysfunction. - PID falls under the **"E" for Endometrial causes** in the PALM-COEIN classification if it causes bleeding through endometrial inflammation or infection. *Adenomyosis* - **Adenomyosis** is a condition where endometrial tissue grows into the muscular wall of the uterus, causing heavy and painful periods. - This condition is classified under **"A" for Adenomyosis** in the PALM-COEIN classification, representing a structural cause of abnormal uterine bleeding, not ovulatory dysfunction. *Ovarian cancer* - **Ovarian cancer** is a malignancy of the ovaries and, while it can cause abnormal bleeding in advanced stages, it is not primarily due to ovulatory dysfunction. - Ovarian cancer is classified under **"M" for Malignancy and hyperplasia** in PALM-COEIN, indicating a structural and pathological cause, rather than an ovulatory problem.

Q: Which of the following is MOST effective as a first-line management for premenstrual syndrome?

Combined oral contraceptive pills. ***Combined oral contraceptive pills*** - **Combined oral contraceptive pills** are the **most comprehensive first-line pharmacological treatment** for **premenstrual syndrome (PMS)** by suppressing ovulation and stabilizing hormonal fluctuations throughout the menstrual cycle. - They address both physical and mood-related symptoms of PMS effectively. - Continuous or extended-cycle regimens can be particularly beneficial by reducing the number of menstrual periods and related symptom flares. *Niacin (vitamin B3)* - There is **no robust scientific evidence** to support the efficacy of **niacin (vitamin B3)** in the management of PMS symptoms. - While **vitamin B6** has some evidence for mild PMS symptoms, **niacin (B3)** is not recommended. - High doses of niacin can cause side effects such as flushing, itching, and gastrointestinal upset. *Diuretics* - **Spironolactone**, a potassium-sparing diuretic, can be effective for managing **specific fluid retention symptoms** associated with PMS, such as bloating and breast tenderness. - However, diuretics are typically used as **adjunctive therapy** for specific symptoms rather than comprehensive first-line management. - They do not address the broader spectrum of emotional and psychological symptoms of PMS. *Hysterectomy with oophorectomy* - **Hysterectomy with oophorectomy** (removal of the uterus and ovaries) is a **last-resort treatment** for severe, refractory Premenstrual Dysphoric Disorder (PMDD) after all medical therapies have failed. - This is an **irreversible surgical procedure** that induces immediate surgical menopause with significant risks and long-term implications. - It is **never a first-line treatment** for PMS management.

Q: The following drugs are effective in the management of menorrhagia except :

Prostaglandins. ***Prostaglandins*** - Prostaglandins, particularly **PGE2** and **PGF2α**, are generally associated with **increased uterine contractions** and **vasodilation**, which can worsen menstrual bleeding rather than reduce it. - While cyclooxygenase inhibitors (NSAIDs) work by inhibiting prostaglandin synthesis, exogenous prostaglandins themselves are not used to treat menorrhagia and can exacerbate it. *Progestational agents* - Progestins help to **stabilize the endometrium**, reducing excessive bleeding by inducing decidualization and limiting endometrial growth. - They can be administered orally, via injection, or through an **intrauterine device (IUD)** like the levonorgestrel-releasing IUD (Mirena), which is highly effective. *Non-steroidal anti-inflammatory drugs* - NSAIDs reduce menorrhagia by **inhibiting prostaglandin synthesis** in the endometrium, which leads to reduced vasodilation and uterine contractions. - They also help alleviate associated **dysmenorrhea** (menstrual pain). *Anti-fibrinolytic drugs* - These drugs, such as **tranexamic acid**, work by **inhibiting plasminogen activation**, thereby preventing the breakdown of fibrin clots within the uterus. - This promotes clot stability and reduces menstrual blood loss significantly.

Q: A 15-year old unmarried girl comes with history of dysmenorrhea. Age of menarche is 12 years. Per abdominal and per rectum examination reveal nothing abnormal. You will treat the patient with :

Reassurance and giving antispasmodics during menses. ***Reassurance and giving antispasmodics during menses*** - The patient presents with **primary dysmenorrhea**, indicated by the onset of symptoms with menarche and normal pelvic examination findings in an unmarried girl. - **Antispasmodics** (e.g., NSAIDs like ibuprofen or mefenamic acid) taken during menses effectively reduce pain by inhibiting prostaglandin synthesis, which causes uterine contractions. *Reassurance and giving antispasmodics throughout the month* - While **reassurance** is appropriate, taking antispasmodics throughout the entire month is **unnecessary** and can lead to adverse effects, as the pain is cyclical and directly related to menstruation. - **Antispasmodics** are most effective when taken a day or two before the onset of menstruation and continued during the painful days. *Hormones* - **Hormonal therapy** (e.g., combined oral contraceptives) is a valid treatment option for dysmenorrhea, especially if non-steroidal anti-inflammatory drugs (NSAIDs) are ineffective or if contraception is also desired. - However, for a 15-year-old unmarried girl with typical primary dysmenorrhea and no other complications, **NSAIDs/antispasmodics** are generally the first-line and usually sufficient treatment. *Antibiotics* - **Antibiotics** are used to treat bacterial infections, and there is no indication of infection (e.g., fever, unusual discharge, pelvic inflammatory disease) in this patient's presentation. - Using antibiotics without an identified infection is inappropriate and contributes to **antibiotic resistance**.

Question 1

Causes of AUB are subdivided by the acronym PALM-COEIN. What are the characteristics of PALM causes?
I. Structural lesions
II. Diagnosed by ultrasound
III. Confirmed by histopathology

Select the correct answer using the code given below :

Accepted Answer

I, II and III

Answer

I and III only

Answer

I and II only

Answer

II and III only

Question 2

Which one of the following is a prerequisite for Endometrial Ablation ?

Accepted Answer

Completed childbearing

Answer

Desire to maintain fertility

Answer

Uterine size >16 weeks

Answer

Presence of large submucous fibroids

Question 3

A 16-year-old girl with primary amenorrhoea presents to the gynaecology OPD for evaluation. She has normal secondary sexual characters. Her karyotype is 46,XX and ultrasound reveals normal ovaries and tubes but absent uterus. What is her clinical diagnosis?

Accepted Answer

Mayer-Rokitansky-Küster-Hauser syndrome

Answer

Primary ovarian failure

Answer

Androgen insensitivity syndrome

Answer

Turner syndrome

Question 4

A 25-year-old female comes to the gynaecology OPD for evaluation of secondary amenorrhoea. She gives history of previous dilatation and curettage, and her FSH levels are 8 IU/L. The probable cause of amenorrhoea is

Accepted Answer

Asherman syndrome

Answer

incomplete abortion

Answer

premature ovarian failure

Answer

Sheehan syndrome

Question 5

Premenstrual Syndrome (PMS) should fulfil which of the following criteria?

1. It is not related to any organic lesion.
2. It regularly occurs during the luteal phase and each ovulatory menstruation cycle.
3. Symptoms must be severe enough to disturb the lifestyle of women and seeks medical help.
4. Symptoms persist after the period also.

Accepted Answer

1. It is not related to any organic lesion.

Answer

4. Symptoms persist after the period also.

Answer

2. It regularly occurs during the luteal phase and each ovulatory menstruation cycle.

Answer

3. Symptoms must be severe enough to disturb the lifestyle of women and seeks medical help.

Question 6

In the PALM-COEIN classification by FIGO for abnormal uterine bleeding, ovulatory dysfunction is the cause in which one of the following conditions?

Accepted Answer

Polycystic ovarian syndrome

Answer

Pelvic inflammatory disease

Answer

Adenomyosis

Answer

Ovarian cancer

Question 7

Which of the following is MOST effective as a first-line management for premenstrual syndrome?

Accepted Answer

Combined oral contraceptive pills

Answer

Hysterectomy with oophorectomy

Answer

Diuretics

Answer

Niacin (vitamin B3)

Question 8

Match List-I with List-II and select the correct answer using the code given below the Lists:

Accepted Answer

A→3  B→4  C→1  D→2

Answer

A→1  B→2  C→3  D→4

Answer

A→2  B→1  C→4  D→3

Answer

A→4  B→3  C→2  D→1

Question 9

The following drugs are effective in the management of menorrhagia except :

Accepted Answer

Prostaglandins

Answer

Progestational agents

Answer

Non-steroidal anti-inflammatory drugs

Answer

Anti-fibrinolytic drugs

Question 10

A 15-year old unmarried girl comes with history of dysmenorrhea. Age of menarche is 12 years. Per abdominal and per rectum examination reveal nothing abnormal. You will treat the patient with :

Accepted Answer

Reassurance and giving antispasmodics during menses

Answer

Reassurance and giving antispasmodics throughout the month

Answer

Hormones

Answer

Antibiotics

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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