Menstrual Disorders Practice Questions

Q: A 44 year old woman presents with polymenorrhoea for one year. Clinical examination reveals bulky uterus with no other abnormality. D & C report is simple hyperplasia. What is the treatment of choice?

Progestogen therapy. ***Progestogen therapy*** - **Simple hyperplasia** is a benign condition of the endometrium and typically responds well to progestogen therapy, which helps to **antagonize estrogen's proliferative effects** on the endometrium. - This treatment helps to induce secretory changes and shedding of the hyperplastic tissue, effectively managing the associated **polymenorrhoea**. *GnRH analogues* - While GnRH analogues can induce a **hypoestrogenic state**, they are generally reserved for more severe forms of endometrial hyperplasia (e.g., atypical hyperplasia) or conditions like **endometriosis** and **fibroids** that do not respond to progestogens. - Their significant side effects, resembling menopause, make them less suitable as an initial choice for simple hyperplasia. *Combined oral pills* - Combined oral contraceptive pills primarily work by **suppressing ovulation** and thinning the endometrial lining, which can help with heavy bleeding but are not the primary treatment for established endometrial hyperplasia. - While they contain progestins, the progestin dose and regimen in combined oral pills are typically not sufficient or specifically tailored to reverse significant endometrial hyperplasia. *Total hysterectomy with bilateral salpingo-oophorectomy* - This is a **surgical intervention** and is an overly aggressive treatment for simple endometrial hyperplasia, which carries a very low risk of progression to cancer. - It would be considered only for persistent atypical hyperplasia, cancer, or if a woman has completed childbearing and has other compelling reasons for surgery.

Q: The treatment of primary spasmodic dysmenorrhoea in a young girl as a first measure would be:

Analgesics and antispasmodics. ***Analgesics and antispasmodics*** - **NSAIDs (analgesics)** like ibuprofen, naproxen, or mefenamic acid are the **first-line treatment** for primary spasmodic dysmenorrhea - They work by **inhibiting prostaglandin synthesis**, reducing uterine contractions and pain - **Antispasmodics** help relax the uterine muscle and alleviate cramping - Should be started at the onset of menses or just before for maximum effectiveness *Oral contraceptives* - Effective **second-line treatment** by suppressing ovulation and reducing endometrial prostaglandin production - Used when NSAIDs fail or are contraindicated - May be less suitable as a first measure for a young girl, especially if contraception is not desired *Presacral neurectomy* - **Surgical procedure** involving division of the superior hypogastric plexus - Reserved for **severe, refractory cases** that fail conservative management - Major surgery with potential complications—never a first-line option *Dilatation and curettage* - Diagnostic/therapeutic procedure for abnormal uterine bleeding or retained products - **No role in primary dysmenorrhea**, which is functional pain without organic pathology - D&C does not address the prostaglandin-mediated mechanism of primary dysmenorrhea

Q: A 45 year old woman presents with continuous vaginal bleeding for 15 days. Her bleeding should be controlled by:

Synthetic progestogens. ***Synthetic progestogens*** - **Synthetic progestogens** are the **classic first-line medical treatment** for dysfunctional uterine bleeding (DUB) in the perimenopausal age group. - They work by **stabilizing the endometrium**, counteracting unopposed estrogen effects, and inducing organized withdrawal bleeding. - For **continuous moderate bleeding**, cyclic or continuous progestogens (e.g., norethisterone 5 mg BD for 21 days) are effective and non-invasive. - This represents the **traditional textbook approach** for anovulatory DUB management. *Testosterone propionate* - **Testosterone propionate** is an androgen with no role in managing dysfunctional uterine bleeding in women. - Its use is limited to male hypogonadism and specific anabolic requirements. *Curettage followed by progestogens* - While **curettage (D&C)** is both diagnostic and therapeutic, it is an **invasive procedure**. - In clinical practice, especially for a **45-year-old woman**, endometrial sampling is often warranted to rule out hyperplasia or malignancy, making this a reasonable clinical approach. - However, **medical management with progestogens alone** is traditionally considered first-line when the patient is hemodynamically stable and malignancy risk is low. - This option represents sound clinical practice but is not the classic "first choice" in exam contexts. *Conjugated equine oestrogens* - **High-dose estrogens** (25 mg IV every 4-6 hours) are actually used for **acute severe bleeding** and can stop bleeding within 24 hours by rapidly proliferating the endometrium. - However, for **continuous moderate bleeding** over 15 days in a perimenopausal woman, estrogen alone would not address the underlying issue of **unopposed estrogen** causing anovulatory cycles. - Estrogen is reserved for acute emergency management, not for the scenario described in this question.

Q: A 30 year old healthy woman presents with decreased bleeding during menstruation. The cause could be all of the following except:

Endometriosis. ***Endometriosis*** - **Endometriosis** is a condition where endometrial-like tissue grows outside the uterus, typically causing **heavy menstrual bleeding (menorrhagia)**, pelvic pain, and dyspareunia. - It does not typically lead to **decreased menstrual bleeding**; in fact, its cardinal symptom related to menstruation is often an increase in volume and pain. *Intrauterine adhesions* - **Intrauterine adhesions**, also known as **Asherman's syndrome**, involve scarring within the uterine cavity, often resulting from uterine trauma like D&C. - These adhesions can reduce the functional endometrial surface, leading to **hypomenorrhea** or amenorrhea (decreased or absent menstrual bleeding). *Breastfeeding* - **Breastfeeding** (lactational amenorrhea) causes the release of **prolactin**, which inhibits the pulsatile release of GnRH from the hypothalamus. - This suppression of ovarian function leads to **anovulation** and significantly reduced or absent menstrual bleeding. *Tuberculosis* - **Genital tuberculosis** can affect the endometrium, leading to widespread destruction and subsequent fibrosis and **adhesion formation** within the uterine cavity. - This damage to the endometrial lining can result in **asherman's syndrome**, causing hypomenorrhea or amenorrhea.

Q: Which one of the following is true regarding normal menstrual physiology?

Ovulation occurs after 12 hours of LH peak. ***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.

Q: Which one of the following is the most important haematological condition to be ruled out while investigating a case of puberty menorrhagia ?

Coagulation disorder. ***Coagulation disorder*** - Puberty menorrhagia (excessive menstrual bleeding at puberty) is frequently linked to underlying **hemostatic dysfunction**, with **Von Willebrand Disease** being the most common cause. - A coagulation disorder can lead to **uncontrolled bleeding** during menstruation, necessitating thorough investigation to prevent severe blood loss and complications. *Leukemia* - While leukemia can cause **easy bruising** and **bleeding tendencies** due to thrombocytopenia or impaired platelet function, it is less common as the primary cause of isolated menorrhagia in puberty. - Leukemia would typically present with a broader range of symptoms, including systemic signs like **fatigue**, **fever**, and **lymphadenopathy**. *G-6PD deficiency* - G-6PD deficiency is primarily a cause of **hemolytic anemia**, triggered by certain drugs or foods, leading to red blood cell breakdown. - It does not directly cause prolonged or heavy menstrual bleeding (menorrhagia) as a primary symptom. *Anaemia* - Anaemia is often a **consequence** of heavy menstrual bleeding (menorrhagia) rather than its direct cause. - While iron deficiency anemia is common in young women with menorrhagia, addressing the underlying cause of the bleeding is crucial, which might be a coagulation disorder.

Q: Primary Dysmenorrhoea can be treated by which of the following? 1. Antiprostaglandin 2. Cyclic combined estrogen and progesterone preparations 3. Pre-sacral neurectomy 4. Uterine curettage

1, 2 and 3. ***1, 2 and 3*** - **Antiprostaglandins (NSAIDs)** are the first-line treatment for primary dysmenorrhea as they inhibit prostaglandin synthesis, reducing uterine contractions and pain. - **Cyclic combined estrogen and progesterone preparations (oral contraceptives)** are second-line therapy that suppress ovulation, leading to a thinner endometrium and reduced prostaglandin production, thereby alleviating dysmenorrhea. - **Pre-sacral neurectomy** is a surgical procedure that may be considered for severe, refractory primary dysmenorrhea that has failed medical management, though it is more commonly used for secondary dysmenorrhea and chronic pelvic pain. *1, 2, 3 and 4* - This option incorrectly includes **uterine curettage**, which is not a treatment for primary dysmenorrhea. - Uterine curettage is a diagnostic or therapeutic procedure for conditions like abnormal uterine bleeding or retained products of conception, not for menstrual pain management. *1, 2 and 4* - This option incorrectly includes **uterine curettage** while excluding pre-sacral neurectomy. - Curettage has no role in primary dysmenorrhea treatment, whereas the other interventions target the underlying pathophysiology. *2, 3 and 4* - This option incorrectly excludes **antiprostaglandins (NSAIDs)**, which are the cornerstone first-line therapy for primary dysmenorrhea. - It also incorrectly includes uterine curettage, which has no role in dysmenorrhea management.

Q: Which one of the following conditions simulates the menstrual pattern of pain?

Adenomyosis. ***Adenomyosis*** - Adenomyosis is characterized by the presence of **endometrial tissue within the myometrium**, which responds cyclically to hormonal changes, similar to normal endometrium. - This leads to **dysmenorrhea** (painful periods) and **menorrhagia** (heavy bleeding) due to the cyclic growth and shedding of endometrial tissue within the uterine muscular wall. *Intramural fibroid* - Intramural fibroids are **benign uterine tumors** within the muscular wall that can cause heavy bleeding and pressure symptoms. - While they can cause pain and heavy bleeding, the pain is typically not directly related to a **menstrual pattern of cyclic pain** in the same manner as adenomyosis, as the fibroid tissue itself does not undergo cyclic shedding. *Granulosa cell tumour of ovary* - This is a **sex cord-stromal tumor** of the ovary that often produces **estrogen**, which can lead to irregular uterine bleeding or postmenopausal bleeding. - It does not directly cause pain that simulates a **regular menstrual pattern**, as its hormonal effects are typically sustained or irregular, not cyclic in the way normal menstruation or adenomyosis pain is. *Haematometra* - Haematometra is the accumulation of **menstrual blood within the uterus** due to an obstruction of the outflow tract, such as cervical stenosis. - This condition causes increasing pain and distension as blood accumulates, but the pain is usually **constant or progressively worsening**, not cyclic in a pattern that simulates normal menstruation, and typically leads to **amenorrhea** rather than patterned bleeding.

Q: Which one of the following about primary dysmenorrhea is NOT true?

Pain increases following pregnancy and delivery. ***Pain increases following pregnancy and delivery*** - It is a common clinical observation that primary dysmenorrhea often **improves or resolves** after pregnancy and childbirth, likely due to cervical dilatation, changes in uterine structure, or altered innervation. - Therefore, the statement that pain *increases* following pregnancy and delivery is **NOT true** and is the correct answer. *Most commonly seen in adolescents and young women* - This statement is **TRUE**. Primary dysmenorrhea typically begins within **6-12 months** after menarche once ovulatory cycles are established. - It is **most prevalent in adolescents and women in their 20s**, though it can persist into later reproductive years. - Incidence decreases with age and often improves after childbirth. *Pain is related to uterine hypoxia* - This statement is **TRUE**. The pain in primary dysmenorrhea is primarily caused by **excessive prostaglandin F2α production** during endometrial breakdown. - Prostaglandins cause **intense uterine contractions** leading to **ischemia** and reduced blood flow (hypoxia) to the myometrium. - This **uterine hypoxia** and ischemia are significant contributors to the painful cramps experienced. *Always confined to ovulatory cycles* - This statement is **TRUE**. Primary dysmenorrhea is intrinsically linked to **ovulatory menstrual cycles**. - It involves prostaglandin production in response to progesterone withdrawal and endometrial breakdown, which **only occurs in ovulatory cycles**. - Anovulatory cycles (common immediately after menarche) are typically **painless**.

Q: An 18-year-old unmarried girl comes with complaints of heavy, prolonged bleeding during menses. Which among the following investigations is NOT usually advised?

Dilatation and curettage. ***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 1

A 44 year old woman presents with polymenorrhoea for one year. Clinical examination reveals bulky uterus with no other abnormality. D & C report is simple hyperplasia. What is the treatment of choice?

Accepted Answer

Progestogen therapy

Answer

GnRH analogues

Answer

Combined oral pills

Answer

Total hysterectomy with bilateral salpingo-oophorectomy

Question 2

The treatment of primary spasmodic dysmenorrhoea in a young girl as a first measure would be:

Accepted Answer

Analgesics and antispasmodics

Answer

Oral contraceptives

Answer

Presacral neurectomy

Answer

Dilatation and curettage

Question 3

A 45 year old woman presents with continuous vaginal bleeding for 15 days. Her bleeding should be controlled by:

Accepted Answer

Synthetic progestogens

Answer

Testosterone propionate

Answer

Curettage followed by progestogens

Answer

Conjugated equine oestrogens

Question 4

A 30 year old healthy woman presents with decreased bleeding during menstruation. The cause could be all of the following except:

Accepted Answer

Endometriosis

Answer

Intrauterine adhesions

Answer

Breastfeeding

Answer

Tuberculosis

Question 5

Which one of the following is true regarding normal menstrual physiology?

Accepted Answer

Ovulation occurs after 12 hours of LH peak

Answer

Ovulation occurs after 48 hours of LH surge

Answer

Oestradiol levels peak at 48 hours prior to ovulation

Answer

LH surge duration is typically 12-24 hours

Question 6

Which one of the following is the most important haematological condition to be ruled out while investigating a case of puberty menorrhagia ?

Accepted Answer

Coagulation disorder

Answer

Leukemia

Answer

G-6PD deficiency

Answer

Anaemia

Question 7

Primary Dysmenorrhoea can be treated by which of the following?

1. Antiprostaglandin
2. Cyclic combined estrogen and progesterone preparations
3. Pre-sacral neurectomy
4. Uterine curettage

Accepted Answer

1, 2 and 3

Answer

1, 2, 3 and 4

Answer

1, 2 and 4

Answer

2, 3 and 4

Question 8

Which one of the following conditions simulates the menstrual pattern of pain?

Accepted Answer

Adenomyosis

Answer

Intramural fibroid

Answer

Granulosa cell tumour of ovary

Answer

Haematometra

Question 9

Which one of the following about primary dysmenorrhea is NOT true?

Accepted Answer

Pain increases following pregnancy and delivery

Answer

Most commonly seen in adolescents and young women

Answer

Pain is related to uterine hypoxia

Answer

Always confined to ovulatory cycles

Question 10

An 18-year-old unmarried girl comes with complaints of heavy, prolonged bleeding during menses. Which among the following investigations is NOT usually advised?

Accepted Answer

Dilatation and curettage

Answer

Urine pregnancy test

Answer

Coagulation profile

Answer

Ultrasound uterus and adnexa

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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