Menstrual Disorders Practice Questions

Q: A 20-year-old married woman anxious to get pregnant has cyclical cramps and sharp lower abdominal pain which lasts for 3 days starting from the day of her menstrual flow. Her menstrual periods are regular but heavy. On clinical examination, her pelvis is normal. The most probable diagnosis is

Primary dysmenorrhoea. ***Primary dysmenorrhoea*** - This is the **most probable diagnosis** given the classic presentation of **cyclical cramping pain starting on day 1 of menstruation** lasting 3 days. - Primary dysmenorrhea is caused by **excessive prostaglandin production** from the endometrium, leading to uterine cramping and can be associated with **heavy menstrual bleeding**. - The **normal pelvic examination** is a key feature distinguishing primary from secondary causes of dysmenorrhea. - Typically affects young women in their **late teens to early 20s**, shortly after menarche when ovulatory cycles are established. *Endometriosis* - While endometriosis causes cyclical pain, the pain typically begins **1-2 days before menstruation** rather than starting precisely on day 1. - Associated symptoms often include **dyspareunia, dyschezia, and infertility**, which are not mentioned in this case. - Though pelvic examination can be normal in early endometriosis, the **pain timing pattern** does not fit the classic presentation. *Adenomyosis* - Characterized by **endometrial tissue within the myometrium**, typically presents with a **diffusely enlarged, tender, boggy uterus** on examination. - More common in women over 30 years, particularly those with **previous pregnancies**. - The patient's **normal pelvic examination** and young age make adenomyosis unlikely. *Uterine leiomyomata* - These **benign fibroids** typically cause heavy menstrual bleeding with **pressure symptoms** rather than severe cyclical cramping pain. - Usually result in an **irregularly enlarged uterus** on pelvic examination. - The patient's **normal pelvic examination** excludes this diagnosis.

Q: An 18-year-old girl presents with primary amenorrhoea and gives a history of cyclical colicky abdominal pain. The most probable diagnosis is

Haematocolpos. ***Haematocolpos*** - **Primary amenorrhoea** combined with **cyclical colicky abdominal pain** strongly suggests an outflow tract obstruction, leading to the accumulation of menstrual blood. - **Haematocolpos** is the accumulation of menstrual blood in the vagina caused by an imperforate hymen or other anomalies, leading to distension and pain. *Encysted tuberculosis* - While tuberculosis can affect the reproductive system, it typically presents with **chronic abdominal pain**, weight loss, and infertility, not primary amenorrhoea with cyclical pain. - **Encysted tuberculosis** would not directly cause the cyclical colicky pain related to menstrual flow blockage. *Full bladder* - A **full bladder** can cause suprapubic discomfort but generally doesn't present as primary amenorrhoea or cyclical colicky abdominal pain. - This condition is easily resolved by urination and is not a chronic, cyclical issue. *Ovarian cyst* - **Ovarian cysts** can cause abdominal pain, which may be cyclical, but they do not cause primary amenorrhoea as the problem is with ovarian function or morphology, not menstrual outflow. - The pain is usually dull, aching, or sharp upon rupture, distinct from the **colicky pain** associated with retained menstrual blood.

Q: A woman who has secondary amenorrhea experiences withdrawal bleeding following progesterone administration. What is the likely diagnosis?

Anovulation. ***Anovulation*** - Withdrawal bleeding after progesterone indicates that the **endometrium was adequately primed with estrogen** but there was no ovulation to produce progesterone. - This scenario points to **anovulation** as the underlying cause of secondary amenorrhea, where estrogen is present, but a corpus luteum does not form to secrete progesterone. *Asherman's syndrome* - This condition involves **intrauterine adhesions** that prevent endometrial shedding, even in the presence of hormones. - A woman with Asherman's syndrome would typically **not experience withdrawal bleeding** after progesterone, as the endometrium is damaged or absent. *Premature ovarian failure* - In **premature ovarian failure**, the ovaries stop functioning, leading to **low estrogen levels**. - Without sufficient estrogen to prime the endometrium, administering progesterone would **not result in withdrawal bleeding**. *Hypothalamic amenorrhea* - This type of amenorrhea is characterized by **low estrogen levels** due to dysfunction in the hypothalamus. - Similar to premature ovarian failure, a lack of estrogen would mean the endometrium is not prepared, and **progesterone withdrawal bleeding would not occur**.

Q: A 13-year-old, obese, unmarried girl presents with the history of amenorrhea and cyclical abdominal pain. On examination, the secondary sex characters are found to be well developed. What should be the next step?

Carry out a per-rectal examination. ***Carry out a per-rectal examination*** - This presentation of **amenorrhea with cyclical abdominal pain** in a girl with developed secondary sexual characteristics strongly suggests a **cryptomenorrhea** caused by an outflow tract obstruction, like an **imperforate hymen**. - A **per-rectal examination** can help identify a bulging hymen or a pelvic mass due to retained menstrual blood (hematocolpos or hematometra), which would guide further management. *Carry out the progesterone challenge test* - A progesterone challenge test assesses the presence of **estrogenization of the endometrium** and a patent outflow tract, but it is typically used for secondary amenorrhea or primary amenorrhea without cyclical pain. - In this case, **cyclical pain** points towards an obstructed outflow tract, making the challenge test less immediate than ruling out the obstruction. *Keep her under observation for the next three months* - Observing for three months would delay the diagnosis and definitive treatment of a potentially painful and concerning condition like **hematocolpos**. - Delaying intervention could lead to worsening pain, complications like **endometriosis**, or impact fertility. *Assess the TSH and Prolactin levels* - While hormonal imbalances can cause amenorrhea, the presence of **cyclical abdominal pain** and **developed secondary sexual characteristics** makes a primary outflow tract obstruction a more likely immediate concern. - **Hypothyroidism** (high TSH) or **hyperprolactinemia** would typically cause amenorrhea without cyclical pain but could be considered later if obstruction is ruled out.

Q: A 30-year-old woman with three children has dysfunctional uterine bleeding. What will be the most appropriate management?

Levonorgestrel-releasing intrauterine device. ***Levonorgestrel-releasing intrauterine device*** - The **levonorgestrel-releasing intrauterine device (Mirena IUD)** is highly effective for reducing **menstrual blood loss** in women with **dysfunctional uterine bleeding (DUB)** due to its local endometrial suppression. - It is an excellent choice for a 30-year-old woman with three children as it offers both **contraception** and **menstrual bleeding control** without permanent sterilization. *Medical management with danazol* - **Danazol** is an **androgen derivative** that can cause significant **androgenic side effects** such as hirsutism and voice changes, making it less desirable for long-term use. - While effective in reducing menstrual blood loss, it is typically reserved for severe cases or when other treatments fail due to its side effect profile. *Transcervical endometrial resection* - **Transcervical endometrial resection**, or **endometrial ablation**, is an effective procedure for reducing heavy menstrual bleeding but is generally considered for women who have completed childbearing and do not desire future pregnancies. - While this patient has three children, the IUD offers a less invasive, reversible, and effective alternative before resorting to surgical intervention. *Abdominal hysterectomy* - **Abdominal hysterectomy** is a major surgical procedure and is considered a definitive treatment for dysfunctional uterine bleeding, but it is the most invasive option. - Given the patient's age and the availability of less invasive and effective treatments, hysterectomy would typically be reserved for cases where conservative treatments have failed or other gynecological pathologies are present.

Q: A 15-year-old unmarried girl presents with complaints of dysmenorrhoea for about one year. She achieved menarche at 12 years of age. On abdominal and rectal examination, she has no abnormality. What will be the most appropriate management?

Reassure her and prescribe analgesics. ***Reassure her and prescribe analgesics*** - This presentation is typical for **primary dysmenorrhea**, which is common in adolescent girls and not associated with underlying pathology. - Initial management involves **reassurance** about the benign nature of the condition and symptomatic relief with **analgesics**, particularly **NSAIDs**. *Prescribe clotrimazole vaginal ovules* - **Clotrimazole** is an antifungal medication indicated for candidal vaginitis, which is not suggested by the presented symptoms or examination findings. - Dysmenorrhea is pain associated with menstruation, not typically a symptom of **vaginal infection**. *Perform dilatation and curettage* - **Dilatation and curettage (D&C)** is an invasive surgical procedure used for various uterine conditions, such as abnormal uterine bleeding or miscarriage. - It is completely inappropriate for the initial management of **primary dysmenorrhea** in an adolescent with a normal examination. *Prescribe antibiotics* - **Antibiotics** are indicated for bacterial infections, which are not suggested by the patient's complaints of dysmenorrhea and normal abdominal/rectal examination. - There is no clinical evidence of **pelvic inflammatory disease** or other infectious causes.

Q: A 40-year-old woman presents with excessive menstrual bleeding. The most appropriate first surgical treatment will be

Hysteroscopy. ***Hysteroscopy*** - This procedure allows for **direct visualization of the uterine cavity**, enabling the identification and potential treatment of intracavitary causes of excessive menstrual bleeding, such as polyps or fibroids. - It is considered the **first-line surgical diagnostic and therapeutic approach** for abnormal uterine bleeding when medical management fails or a structural cause is suspected. *Hysterectomy* - While it definitively treats excessive menstrual bleeding by **removing the uterus**, it is generally considered a **definitive and more invasive treatment** reserved for cases where conservative methods have failed or when the patient desires no future pregnancies. - As a first surgical option, it is **overly aggressive** without first attempting less invasive diagnostic and therapeutic procedures. *Myomectomy* - This procedure involves the **surgical removal of uterine fibroids**, which can cause excessive menstrual bleeding. - However, performing a myomectomy without first **diagnosing the presence and location of fibroids** (which hysteroscopy can help identify) is not the appropriate first surgical step. *Dilatation and curettage* - This procedure involves the **scraping of the uterine lining** and can provide a sample for pathology, offering temporary relief from bleeding. - It is primarily a **diagnostic procedure** to obtain endometrial tissue and may offer temporary symptomatic relief, but it is less effective for treating structural causes and is not the most appropriate first-line surgical treatment in terms of diagnostic precision and targeted therapy for all causes of excessive bleeding compared to hysteroscopy.

Q: A 16-year-old girl presents with primary amenorrhoea and repeated periodic pain. On examination, a suprapubic mass is felt up to the umbilicus. The most likely diagnosis is

cryptomenorrhoea. ***cryptomenorrhoea*** - Primary amenorrhoea with a palpable suprapubic mass and repeated periodic pain is highly suggestive of **cryptomenorrhoea**, where menstrual blood accumulates due to an outflow tract obstruction. - The accumulated blood (often due to an imperforate hymen or transverse vaginal septum) forms a **hematocolpos**, leading to the palpable suprapubic mass and cyclical pain. *uterine leiomyoma* - **Uterine leiomyomas** are benign tumors that are rare in adolescents, especially as a cause of primary amenorrhea. - While they can cause a palpable mass, they typically present with **menorrhagia** or pelvic pressure, not primary amenorrhea with cyclical pain due to retained menstrual flow. *bladder-neck hypertrophy* - **Bladder-neck hypertrophy** is an uncommon condition in adolescent females and primarily causes obstructive urinary symptoms, not primary amenorrhea or a palpable suprapubic mass from retained menstrual blood. - It would manifest as difficulty voiding or recurrent urinary tract infections, unrelated to menstrual function. *large ovarian cyst* - A **large ovarian cyst** can present as a pelvic/suprapubic mass and cause pain, but it would not typically cause **primary amenorrhoea** with cyclical pain representing trapped menstrual blood. - Ovarian cysts usually interfere with menstrual regularity or cause acute pain, but not complete absence of menstruation due to an anatomical obstruction of the outflow tract.

Q: A 28 year old woman develops amenorrhoea after having dilatation and curettage. The most likely diagnosis is :

Asherman syndrome. ***Asherman syndrome*** - It is characterized by the formation of **intrauterine adhesions** or **synechiae** that occur due to trauma to the endometrial lining, most commonly following a **D&C procedure**. - These adhesions can lead to **amenorrhea**, hypomenorrhea, infertility, and recurrent pregnancy loss due to the obstruction of the uterine cavity. *Kallman syndrome* - This is a **congenital hypogonadotropic hypogonadism** characterized by a deficiency in GnRH production and an associated **anosmia** (loss of smell), neither of which are suggested by the clinical presentation. - Patients typically present with **primary amenorrhea** and delayed puberty, not secondary amenorrhea following a D&C. *Turner syndrome* - A **chromosomal disorder (45, XO)** leading to **gonadal dysgenesis** and ovarian failure. - It typically presents with **primary amenorrhea**, short stature, webbed neck, and other distinct physical features, which are not mentioned here. *Anorexia nervosa* - This is an **eating disorder** associated with severe caloric restriction and low body weight. - It can cause **hypothalamic amenorrhea** due to impaired GnRH pulsatility but is usually accompanied by significant weight loss and psychological symptoms, not typically heralded by a D&C.

Question 1

Which of the following statements regarding functional epimenorrhoea is not correct ?

Accepted Answer

If epimenorrhoea is associated with heavy menstrual loss it is called menometrorrhagia

Answer

It is seen more frequently at the ends of reproductive life

Answer

The cycle is reduced to an arbitrary limit of 21 days or less

Answer

It is a cyclic bleeding

Question 2

A 20-year-old married woman anxious to get pregnant has cyclical cramps and sharp lower abdominal pain which lasts for 3 days starting from the day of her menstrual flow. Her menstrual periods are regular but heavy. On clinical examination, her pelvis is normal. The most probable diagnosis is

Accepted Answer

Primary dysmenorrhoea

Answer

Adenomyosis

Answer

Uterine leiomyomata

Answer

Endometriosis

Question 3

An 18-year-old girl presents with primary amenorrhoea and gives a history of cyclical colicky abdominal pain. The most probable diagnosis is

Accepted Answer

Haematocolpos

Answer

Encysted tuberculosis

Answer

Full bladder

Answer

Ovarian cyst

Question 4

A woman who has secondary amenorrhea experiences withdrawal bleeding following progesterone administration. What is the likely diagnosis?

Accepted Answer

Anovulation

Answer

Asherman's syndrome

Answer

Premature ovarian failure

Answer

Hypothalamic amenorrhea

Question 5

A 13-year-old, obese, unmarried girl presents with the history of amenorrhea and cyclical abdominal pain. On examination, the secondary sex characters are found to be well developed. What should be the next step?

Accepted Answer

Carry out a per-rectal examination

Answer

Carry out the progesterone challenge test

Answer

Keep her under observation for the next three months

Answer

Assess the TSH and Prolactin levels

Question 6

A 30-year-old woman with three children has dysfunctional uterine bleeding. What will be the most appropriate management?

Accepted Answer

Levonorgestrel-releasing intrauterine device

Answer

Medical management with danazol

Answer

Transcervical endometrial resection

Answer

Abdominal hysterectomy

Question 7

A 15-year-old unmarried girl presents with complaints of dysmenorrhoea for about one year. She achieved menarche at 12 years of age. On abdominal and rectal examination, she has no abnormality. What will be the most appropriate management?

Accepted Answer

Reassure her and prescribe analgesics

Answer

Prescribe clotrimazole vaginal ovules

Answer

Perform dilatation and curettage

Answer

Prescribe antibiotics

Question 8

A 40-year-old woman presents with excessive menstrual bleeding. The most appropriate first surgical treatment will be

Accepted Answer

Hysteroscopy

Answer

Hysterectomy

Answer

Myomectomy

Answer

Dilatation and curettage

Question 9

A 16-year-old girl presents with primary amenorrhoea and repeated periodic pain. On examination, a suprapubic mass is felt up to the umbilicus. The most likely diagnosis is

Accepted Answer

cryptomenorrhoea

Answer

uterine leiomyoma

Answer

bladder-neck hypertrophy

Answer

large ovarian cyst

Question 10

A 28 year old woman develops amenorrhoea after having dilatation and curettage. The most likely diagnosis is :

Accepted Answer

Asherman syndrome

Answer

Kallman syndrome

Answer

Turner syndrome

Answer

Anorexia nervosa

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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