Menstrual Disorders Practice Questions

Q: All of the following are true about abnormal uterine bleeding except:

Blood loss of less than 50 ml. **Explanation:** Abnormal Uterine Bleeding (AUB) is defined as any variation from the normal menstrual cycle, involving changes in frequency, regularity, duration, or volume of flow. **Why Option A is the Correct Answer:** Normal menstrual blood loss is typically between **5-80 ml** per cycle, with an average of 35 ml. Therefore, a blood loss of **less than 50 ml** falls within the physiological range and is considered normal. For a diagnosis of Menorrhagia (heavy menstrual bleeding), the blood loss must exceed **80 ml**. **Analysis of Other Options:** * **Option B (Cycle duration >35 or 35 days (Oligomenorrhea) or <21 days (Polymenorrhea) are classic presentations of AUB. * **Option C (Bleeding period ≥7 days):** A normal period lasts 3–7 days. Bleeding that persists for 7 days or more is termed prolonged bleeding and is a criterion for AUB. * **Option D (Irregular bleeding during a regular cycle):** This refers to **Intermenstrual bleeding** (metrorrhagia), which is a hallmark of AUB and often indicates structural pathology like polyps or fibroids. **High-Yield Clinical Pearls for NEET-PG:** * **PALM-COEIN Classification:** Used to categorize AUB causes (Structural: Polyp, Adenomyosis, Leiomyoma, Malignancy; Non-structural: Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not classified). * **FIGO Definitions:** The terms "Menorrhagia" and "Metrorrhagia" are being replaced by "Heavy Menstrual Bleeding" (HMB) and "Intermenstrual Bleeding" (IMB). * **Gold Standard:** Alkaline hematin method is the objective way to measure blood loss, though rarely used clinically. * **First-line Investigation:** Transvaginal Ultrasound (TVS).

Q: Halban's disease is due to which of the following?

Persistent corpus luteum. **Explanation:** **Halban’s Disease**, also known as **Corpus Luteum Persistens**, is a clinical condition characterized by the abnormal persistence of the corpus luteum beyond its typical 14-day lifespan in a non-pregnant cycle. **1. Why the Correct Answer is Right:** In a normal menstrual cycle, the corpus luteum undergoes luteolysis if fertilization does not occur, leading to a drop in progesterone and subsequent menstruation. In Halban’s disease, the corpus luteum continues to secrete progesterone. This results in a delayed menstrual period followed by irregular, often heavy bleeding (pseudomenstruation). Clinically, it mimics an ectopic pregnancy because it presents with the classic triad: **amenorrhea, irregular vaginal bleeding, and a tender adnexal mass** (the persistent cyst). **2. Why the Incorrect Options are Wrong:** * **B. Deficient corpus luteum:** This leads to Luteal Phase Defect (LPD), characterized by a short secretory phase and infertility/early miscarriage, rather than a delayed period or adnexal mass. * **C & D. Persistent/Deficient trophoblast:** These relate to gestational conditions (like molar pregnancy or retained products of conception). Halban’s disease is a functional ovarian disorder, not a primary trophoblastic pathology. **3. High-Yield Clinical Pearls for NEET-PG:** * **Differential Diagnosis:** The most important differential is **Ectopic Pregnancy**. To differentiate, a pregnancy test (Urine hCG or Serum β-hCG) is mandatory; it will be negative in Halban’s disease. * **Arias-Stella Reaction:** On endometrial biopsy, Halban’s disease may show the Arias-Stella reaction (hypersecretory changes), which is also seen in ectopic pregnancy. * **Management:** It is usually self-limiting. If the diagnosis is certain (negative hCG), observation or cyclic progesterone may be used.

Q: What is metrorrhagia?

Intermenstrual bleeding. **Explanation:** **Metrorrhagia** is defined as irregular, acyclic bleeding occurring between expected menstrual periods. In the context of the FIGO nomenclature (AUB system), it is specifically referred to as **Intermenstrual Bleeding (IMB)**. The underlying medical concept involves bleeding that occurs at any time during the cycle other than during the actual menses, often caused by cervical polyps, endometrial hyperplasia, or hormonal fluctuations. **Analysis of Options:** * **Option A (Heavy Menstrual Bleeding):** Formerly known as **Menorrhagia**, this refers to excessive blood loss (>80 ml) or prolonged duration (>7 days) occurring at regular intervals. * **Option C (Breakthrough Bleeding):** This is a specific subtype of intermenstrual bleeding typically associated with the use of hormonal contraceptives (OCPs) or Hormone Replacement Therapy (HRT). * **Option D (Postcoital Bleeding):** This refers to bleeding triggered specifically by vaginal intercourse, most commonly associated with cervical pathology (e.g., cervical cancer or ectropion). **NEET-PG High-Yield Pearls:** * **Polymenorrhea:** Frequent cycles occurring at intervals of less than 21 days. * **Oligomenorrhea:** Infrequent cycles occurring at intervals greater than 35 days. * **Menometrorrhagia:** Heavy, prolonged bleeding occurring at irregular, frequent intervals. * **FIGO PALM-COEIN Classification:** Modern terminology replaces "Metrorrhagia" with **AUB-IMB** (Intermenstrual Bleeding) to standardize clinical diagnosis. Always rule out cervical malignancy in cases of irregular or postcoital bleeding.

Q: A patient presents with a history of dilation & curettage (D&C). Subsequent diagnostic tests reveal all hormone levels, including progesterone and estrogen, to be within the normal range. Based on this clinical presentation, which of the following is the most likely diagnosis?

Asherman Syndrome. ***Asherman Syndrome***- This diagnosis is characterized by the presence of **intrauterine adhesions** (synechiae), typically caused by injury to the **basal layer of the endometrium** following procedures like **D&C**.- The normal **estrogen** and **progesterone** levels indicate normal ovarian function, suggesting the pathology is uterine (end-organ failure to respond to hormones/obstruction) rather than central or ovarian.*Polycystic Ovary Syndrome (PCOS)*- PCOS is associated with chronic **anovulation** and features of **hyperandrogenism** (hirsutism, acne) but usually presents with oligomenorrhea rather than complete amenorrhea following D&C.- Hormonal analysis typically shows an elevated **LH/FSH ratio** and potentially high androgens, resulting in *abnormal* cyclical hormone patterns, unlike the normal levels noted here.*Premature Ovarian Insufficiency (POI)*- POI is characterized by the cessation of ovarian function before age 40, leading to a state of **hypoestrogenism** and low progesterone.- Lab tests would reveal *markedly elevated* **FSH** and *low* **estrogen** due to loss of negative feedback, directly contradicting the finding of normal hormone levels in this patient.*Endometriosis*- Endometriosis involves ectopic endometrial tissue and typically presents with symptoms like **severe dysmenorrhea**, **dyspareunia**, and chronic pelvic pain.- While severe cases can impact fertility, it does not typically cause complete secondary amenorrhea with *normal* cyclical estrogen and progesterone levels; this clinical picture points overwhelmingly to a mechanical uterine issue.

Q: A 36-year-old woman presents with secondary amenorrhea for the past 8 months. Laboratory investigations reveal FSH of 36 IU/L and AMH of 0.05 ng/mL. What is the most likely diagnosis?

Premature ovarian insufficiency (POI). ***Premature ovarian insufficiency (POI)*** - This diagnosis is defined by secondary amenorrhea before the age of 40 associated with **hypergonadotropic hypogonadism**. - The combination of severely elevated **FSH (36 IU/L)** and extremely low **AMH (0.05 ng/mL)** strongly indicates primary ovarian failure and depletion of the ovarian reserve. *Polycystic ovary syndrome (PCOS)* - PCOS is associated with normal or slightly low FSH levels and an elevated **LH:FSH ratio**. - Affected women usually have **normal or high AMH** levels due to an increased pool of small antral follicles, opposite of the findings here. *Hyperprolactinemia* - Amenorrhea is mediated by the inhibitory effect of prolactin on GnRH, leading to **hypogonadotropic hypogonadism** (low or normal FSH and LH). - The primary biochemical finding would be high **serum prolactin**, which doesn't match the high FSH observed. *Hypothalamic amenorrhea* - This is a form of **hypogonadotropic hypogonadism**, characterized by low **FSH** and **LH** levels due to impaired GnRH release. - It is inconsistent with the patient's markedly elevated FSH level, which signifies a problem originating in the ovary, not the hypothalamus.

Q: A 46-year-old woman presents with complaints of irregular menstrual cycles and heavy vaginal bleeding for several months. Transvaginal ultrasound reveals an endometrial thickness of 16 mm. What is the most appropriate next step in management?

Perform an endometrial biopsy. ***Perform an endometrial biopsy*** - A thickened **endometrium (16 mm)** in a perimenopausal woman (46 years old) with **Abnormal Uterine Bleeding (AUB)** significantly increases the risk of endometrial pathology, including **endometrial hyperplasia** or **carcinoma**. - **Endometrial biopsy** is the most appropriate next step, as it provides a definitive tissue diagnosis required to guide subsequent, targeted treatment. *Hysterectomy* - Hysterectomy is a definitive treatment and is typically reserved only after a histological diagnosis of a high-grade abnormality, such as **endometrial cancer**, has been confirmed. - It is premature to proceed with such an invasive surgery before obtaining a tissue diagnosis. *Start combined oral contraceptive pills* - Hormonal therapy like COCPs is used to manage functional causes of AUB (e.g., anovulation), but it should be initiated only after **malignancy is ruled out** by biopsy, as it can mask symptoms of cancer. - A 16 mm endometrial thickness mandates tissue sampling due to the high index of suspicion for premalignant or malignant change. *Observe and reassess after a few months* - Delayed evaluation in this setting significantly increases the risk of diagnosing **endometrial carcinoma** at an advanced stage. - Any woman over 45 years presenting with AUB must undergo investigation, and observation is not acceptable given the pathological **endometrial thickness**.

Q: Identify the instrument shown in the image:

Karman syringe. ***Karman syringe*** - This image displays a **Karman syringe**, characterized by its large capacity and specialized tip designed for manual vacuum aspiration (MVA) procedures. - It is specifically used in **gynecology** for procedures such as uterine evacuation, often in cases of miscarriage or abortion. *Gastric lavage aspirator* - A gastric lavage aspirator would be connected to a **nasogastric tube** for stomach irrigation, which is not depicted here. - Its purpose is to remove stomach contents, typically in cases of poisoning or overdose, and it generally does not resemble a simple syringe. *Disposable syringe* - While it shares some features with a disposable syringe, the **volume capacity** and the **specific design of the plunger handle** are distinct. - A standard disposable syringe, usually smaller (e.g., 1-60 mL), is used for injections, aspirations, or drawing blood, and typically has a simpler plunger. *Hegar dilator* - A Hegar dilator is a **solid, rod-shaped instrument** used to gradually widen the **cervix**. - It does not have a plunger or barrel for aspiration, making it visually distinct from the instrument shown.

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: 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.

Question 1

All of the following are true about abnormal uterine bleeding except:

Accepted Answer

Blood loss of less than 50 ml

Answer

Cycle duration is more than 35 days or less than 21 days

Answer

Bleeding period lasting 7 days or more

Answer

Irregular bleeding during a regular cycle

Question 2

Halban's disease is due to which of the following?

Accepted Answer

Persistent corpus luteum

Answer

Deficient corpus luteum

Answer

Persistent trophoblast

Answer

Deficient trophoblast

Question 3

What is metrorrhagia?

Accepted Answer

Intermenstrual bleeding

Answer

Heavy menstrual bleeding

Answer

Breakthrough bleeding

Answer

Postcoital bleeding

Question 4

A patient presents with a history of dilation & curettage (D&C). Subsequent diagnostic tests reveal all hormone levels, including progesterone and estrogen, to be within the normal range. Based on this clinical presentation, which of the following is the most likely diagnosis?

Accepted Answer

Asherman Syndrome

Answer

Endometriosis

Answer

Premature Ovarian Insufficiency (POI)

Answer

Polycystic Ovary Syndrome (PCOS)

Question 5

A 36-year-old woman presents with secondary amenorrhea for the past 8 months. Laboratory investigations reveal FSH of 36 IU/L and AMH of 0.05 ng/mL. What is the most likely diagnosis?

Accepted Answer

Premature ovarian insufficiency (POI)

Answer

Hypothalamic amenorrhea

Answer

Polycystic ovary syndrome (PCOS)

Answer

Hyperprolactinemia

Question 6

A 46-year-old woman presents with complaints of irregular menstrual cycles and heavy vaginal bleeding for several months. Transvaginal ultrasound reveals an endometrial thickness of 16 mm. What is the most appropriate next step in management?

Accepted Answer

Perform an endometrial biopsy

Answer

Hysterectomy

Answer

Start combined oral contraceptive pills

Answer

Observe and reassess after a few months

Question 7

Identify the instrument shown in the image:

Accepted Answer

Karman syringe

Answer

Gastric lavage aspirator

Answer

Disposable syringe

Answer

Hegar dilator

Question 8

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 9

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 10

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

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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