Menstrual Disorders Practice Questions

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**.

Q: Histological type of endometrium that is suggestive of ovulation is :

secretory phase. ***secretory phase*** - The **secretory phase** of the endometrium occurs *after* ovulation and is characterized by the effects of **progesterone** produced by the corpus luteum. - Histologically, this phase shows **tortuous glands** with **secretory activity** (containing glycogen and mucus), and a **stroma that becomes edematous**, preparing the uterus for potential implantation. *cystic glandular hyperplasia* - This is a form of **endometrial hyperplasia** characterized by abundant, dilated glands of varying sizes and stroma, typically occurring due to **unopposed estrogen stimulation**. - It does not indicate ovulation; rather, it often results from **anovulation** or other conditions causing persistent estrogen exposure without a subsequent progesterone phase. *adenomatous hyperplasia* - **Adenomatous hyperplasia** (or complex hyperplasia) involves glandular crowding and architectural abnormalities, representing a more advanced form of hyperplasia compared to simple cystic hyperplasia. - It arises from **unopposed estrogen** and is not indicative of normal ovulation; it can be a precursor to endometrial carcinoma, especially if **atypia** is present. *proliferative phase* - The **proliferative phase** occurs *before* ovulation under the influence of **estrogen**, during which the endometrium regrows and thickens. - Histologically, it features relatively **straight, tubular glands** and a compact stroma, and while it precedes ovulation, it does not confirm that ovulation has occurred.

Q: What is the likely cause of primary amenorrhoea together with retention of urine in an adolescent girl ?

Haematocolpos. ***Haematocolpos*** - **Haematocolpos** is the accumulation of menstrual blood in the vagina due to an **imperforate hymen** or other outflow obstruction, causing primary amenorrhoea. - The retained blood can exert pressure on the urethra and bladder, leading to **urinary retention**. *Testicular Feminizing syndrome* - Also known as **Androgen Insensitivity Syndrome**, individuals have a 46, XY karyotype but appear female externally due to androgen receptor defects. - It causes primary amenorrhoea but typically does not present with urinary retention as the Mullerian ducts regress, meaning there is no uterus and therefore no menstrual blood to accumulate. *Adrenal hyperplasia* - **Congenital adrenal hyperplasia (CAH)** can cause virilization in females, leading to ambiguous genitalia and primary amenorrhoea due to hormonal imbalances. - While it can affect reproductive development, urinary retention due to menstrual blood accumulation is not a typical presentation. *Turner's syndrome* - **Turner's syndrome (45, XO)** is characterized by ovarian dysgenesis and primary amenorrhoea due to the absence of ovarian function. - Individuals often have distinctive features like a short stature and a webbed neck, but urinary retention is not a direct consequence of the syndrome itself.

Q: The common manifestations of genital tuberculosis include the following except

Foul-smelling vaginal discharge. ***Foul-smelling vaginal discharge*** - While infections can cause vaginal discharge, a **foul-smelling discharge** is typically associated with bacterial vaginosis or trichomoniasis, not primarily with genital tuberculosis due to its granulomatous nature. - Genital tuberculosis often presents with **non-specific symptoms** or no symptoms at all, rather than purulent or foul-smelling discharge. *Pelvic pain* - **Chronic pelvic pain** is a very common symptom of genital tuberculosis, often due to inflammation and involvement of pelvic organs. - The pain can be constant or intermittent and may be difficult to localize. *Amenorrhoea* - **Amenorrhea**, particularly secondary amenorrhoea, can occur due to endometrial damage or destruction caused by the tuberculous infection. - This can lead to **intrauterine adhesions (Asherman's syndrome)** or functional impairment of the endometrium, hindering menstruation. *Infertility* - **Infertility** is one of the most frequent and significant manifestations of genital tuberculosis, especially in women. - It often results from **tubal occlusion** or distortion, endometrial damage, or ovarian dysfunction caused by the disease, leading to an inability to conceive or carry a pregnancy to term.

Q: In a patient with dysfunctional uterine bleeding with cyclical menorrhagia, the first line drug is

Tranexamic acid. ***Tranexamic acid*** - **Tranexamic acid** is an **antifibrinolytic** agent that reduces menstrual blood loss by inhibiting the breakdown of blood clots. - It is often considered a **first-line medical treatment** for heavy menstrual bleeding, including cyclical menorrhagia due to its effectiveness and non-hormonal nature. *Progesterone* - While progesterone can be used to manage dysfunctional uterine bleeding, it is typically used for **anovulatory bleeding** or to regulate the cycle, not primarily as a first-line agent for acute, cyclical menorrhagia where heavy bleeding is the main concern. - Its mechanism involves stabilizing the **endometrial lining** and can lead to withdrawal bleeding when stopped. *Oestrogen and progesterone* - Combination oral contraceptives (containing both oestrogen and progesterone) are effective in regulating menstrual cycles and reducing blood loss. - However, for acute, cyclical menorrhagia, especially if the patient does not need contraception, **tranexamic acid** is often preferred as a first-line non-hormonal option due to its rapid effect on bleeding. *Oestrogen* - Oestrogen can be used in cases of acute, very heavy bleeding to rapidly **stabilize the endometrium** and stop hemorrhage, often at high doses. - It helps in the **proliferation of the endometrium** but is not the first-line choice for ongoing cyclical menorrhagia as it can cause its own set of side effects and doesn't address the primary issue of excessive fibrinolysis.

Question 1

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 2

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 3

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 4

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 5

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 6

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

Question 7

Histological type of endometrium that is suggestive of ovulation is :

Accepted Answer

secretory phase

Answer

cystic glandular hyperplasia

Answer

adenomatous hyperplasia

Answer

proliferative phase

Question 8

What is the likely cause of primary amenorrhoea together with retention of urine in an adolescent girl ?

Accepted Answer

Haematocolpos

Answer

Testicular Feminizing syndrome

Answer

Adrenal hyperplasia

Answer

Turner's syndrome

Question 9

The common manifestations of genital tuberculosis include the following except

Accepted Answer

Foul-smelling vaginal discharge

Answer

Pelvic pain

Answer

Amenorrhoea

Answer

Infertility

Question 10

In a patient with dysfunctional uterine bleeding with cyclical menorrhagia, the first line drug is

Accepted Answer

Tranexamic acid

Answer

Progesterone

Answer

Oestrogen and progesterone

Answer

Oestrogen

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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