Menstrual Disorders — MCQs

Menstrual Disorders Indian Medical PG Practice Questions and MCQs

Question 181: Withdrawal bleeding following administration of progesterone in a case of secondary amenorrhea indicates all EXCEPT:

A. Defect in pituitary gland (Correct Answer)
B. Absence of pregnancy
C. Endometrium is responsive to estrogen
D. Production of endogenous estrogen

Explanation: ***Defect in pituitary gland*** - While withdrawal bleeding after progesterone suggests the problem lies at the **hypothalamic-pituitary level** (anovulation with adequate estrogen), it does **not definitively rule out all pituitary defects**. - The pituitary may still produce sufficient **FSH to stimulate ovarian estrogen production** but have defective **LH surge mechanism** (WHO Group II anovulation). - Examples include **hyperprolactinemia** or **functional hypothalamic amenorrhea** where estrogen production is preserved despite pituitary-hypothalamic dysfunction. - This is the **EXCEPT answer** because the other options are more definitively confirmed by withdrawal bleeding. *Absence of pregnancy* - Withdrawal bleeding after progesterone administration **definitively confirms absence of pregnancy**. - Pregnancy would prevent withdrawal bleeding due to sustained progesterone production by the corpus luteum and placenta. - This is a key diagnostic exclusion in the evaluation of **secondary amenorrhea**. *Endometrium is responsive to estrogen* - The occurrence of withdrawal bleeding **definitively demonstrates** that the endometrium has been exposed to adequate estrogen and has proliferated. - This proliferative endometrium then sheds when progesterone is withdrawn, confirming **normal endometrial responsiveness to hormonal stimulation**. - This rules out **Asherman syndrome** and other uterine factors. *Production of endogenous estrogen* - Withdrawal bleeding **definitively confirms** that there has been sufficient **endogenous estrogen production** to prime the endometrium. - The estrogen causes endometrial thickening, which then sheds when progesterone is withdrawn. - This indicates **adequate ovarian function** in terms of estrogen synthesis and rules out **hypergonadotropic hypogonadism** (ovarian failure).

Question 182: A teenage girl presented with irregular cycles and increased facial hair. Her ovaries showed increased volume. Which of the following are used in the first line treatment? 1. Laparoscopic ovarian drilling 2. Anti-androgens 3. Lifestyle modifications 4. Combined oral contraceptive pills

A. 2,3,4 (Correct Answer)
B. 1,2,3
C. 1,2,4
D. 1,3,4

Explanation: ***2,3,4 (Correct Answer)*** - **Lifestyle modifications (3)** are the foundational first-line intervention for all PCOS patients, particularly those who are overweight or obese, as they improve insulin sensitivity, reduce androgen levels, and improve both metabolic and reproductive outcomes. - **Combined oral contraceptive pills/COCs (4)** are the first-line pharmacological treatment for menstrual irregularity and hyperandrogenism in PCOS when fertility is not desired. They regulate cycles, suppress ovarian androgen production, and reduce hirsutism and acne. - **Anti-androgens (2)** such as spironolactone are used in first-line management of moderate-to-severe hirsutism and acne in PCOS, typically in combination with COCs. They block androgen receptors or inhibit androgen synthesis, providing additional benefit for hyperandrogenic symptoms like the increased facial hair in this patient. *1,2,3* - **Laparoscopic ovarian drilling (1)** is a second-line surgical treatment reserved for anovulatory infertility in PCOS patients who fail to respond to ovulation induction with clomiphene citrate. It is NOT a first-line treatment for menstrual irregularity and hirsutism. - While lifestyle modifications (3) and anti-androgens (2) are appropriate first-line components, the inclusion of ovarian drilling makes this combination incorrect as a first-line approach. *1,2,4* - **Laparoscopic ovarian drilling (1)** is an invasive procedure indicated only as second-line therapy for specific cases of anovulatory infertility, not for initial management of irregular cycles and hirsutism. - Although anti-androgens (2) and COCs (4) are appropriate first-line pharmacological treatments, the inclusion of ovarian drilling excludes this from being a correct first-line treatment combination. *1,3,4* - This combination includes two appropriate first-line treatments: **lifestyle modifications (3)** and **combined oral contraceptive pills (4)**. - However, **laparoscopic ovarian drilling (1)** is a second-line or third-line surgical intervention for very specific indications (anovulatory infertility resistant to medical management), making this combination incorrect as a first-line approach for this clinical presentation.

Question 183: Which of the following is not a cause of secondary amenorrhea?

A. Kallman syndrome (Correct Answer)
B. Asherman's syndrome
C. Sheehan's syndrome
D. Turner's mosaic

Explanation: ***Kallman syndrome*** - This is a cause of **primary amenorrhea** because it involves congenital **GnRH deficiency**, preventing the onset of puberty and menstruation from the beginning. - Patients typically present with failure of pubertal development and **anosmia** (inability to smell). *Asherman's syndrome* - Characterized by **intrauterine adhesions** or scarring, often following uterine surgeries like D&C. - These adhesions can prevent the proper shedding of the endometrium, leading to **secondary amenorrhea** after previously established menses. *Sheehan's syndrome* - Occurs due to **ischemic necrosis of the pituitary gland** following severe postpartum hemorrhage, typically presenting with failure of lactation, fatigue, and **secondary amenorrhea**. - The pituitary damage leads to **deficiency of multiple pituitary hormones**, including FSH and LH. *Turner's mosaic* - While classic **Turner syndrome (45,XO)** is a common cause of primary amenorrhea and gonadal dysgenesis, **Turner's mosaic** (e.g., 45,XO/46,XX) can sometimes result in variable ovarian function. - In some mosaic cases, individuals may experience **menarche** and then develop premature ovarian failure, leading to **secondary amenorrhea**.

Question 184: Ovulation occurs:

A. 14 days prior to next menstruation (Correct Answer)
B. 14 days after menstruation
C. On 14th day of the cycle
D. None of the options

Explanation: ***14 days prior to next menstruation*** - Ovulation consistently occurs approximately **14 days before** the onset of the next menstrual period, regardless of the total cycle length. - This is because the **luteal phase** (from ovulation to menstruation) is relatively constant in duration, typically lasting 14 days. *14 days after menstruation* - This statement assumes a 28-day cycle, which is not universally true, as cycle lengths vary between individuals. - In shorter cycles, ovulation would occur earlier than 14 days after menstruation, and in longer cycles, it would be later. *On 14th day of the cycle* - This is only true for women with a **perfect 28-day menstrual cycle**, which is an average and not universally applicable. - For women with longer cycles (e.g., 35 days), ovulation would occur around day 21, and for shorter cycles (e.g., 21 days), it would occur around day 7. *None of the options* - One of the provided options accurately describes the timing of ovulation in relation to the next menstruation. - Therefore, this choice is incorrect.

Question 185: Swiss cheese pattern endometrium is seen in

A. Halban's disease
B. Carcinoma endometrium
C. Hydatidiform mole
D. Metropathia hemorrhagica (Correct Answer)

Explanation: ***Correct Answer: Metropathia hemorrhagica*** - Also known as **anovulatory dysfunctional uterine bleeding** or **cystic glandular hyperplasia** - The "Swiss cheese pattern" describes the **characteristic histological appearance** where endometrial glands are dilated and irregular, resembling holes in Swiss cheese - Results from **prolonged unopposed estrogen stimulation** causing overgrowth of benign endometrial tissue - Classic finding in anovulatory cycles with persistent estrogen exposure *Incorrect Option: Halban's disease* - Refers to **cystic changes within the fallopian tube** or paratubal cysts - Not related to endometrial morphology or the Swiss cheese pattern *Incorrect Option: Carcinoma endometrium* - Involves **malignant proliferation** with complex atypical hyperplasia - May show glandular atypia and crowding, but not the characteristic simple cystic glandular hyperplasia pattern - Swiss cheese appearance is typically seen in benign hyperplasia, not malignancy *Incorrect Option: Hydatidiform mole* - A **gestational trophoblastic disease** with abnormal placental development - Characterized by grape-like vesicles with **trophoblastic proliferation** and hydropic villi - Does not involve the Swiss cheese endometrial pattern

Question 186: Borax causes which of the following effects?

A. Induces uterine contractions (labor-inducing)
B. Irritates genitourinary tract (side effect)
C. Traditionally used to stimulate menstrual flow
D. Causes gastrointestinal irritation (side effect) (Correct Answer)

Explanation: ***Causes gastrointestinal irritation (side effect)*** - Borax, specifically its component **boric acid**, is rapidly absorbed through the **gastrointestinal tract** and can cause symptoms like nausea, vomiting, and diarrhea even in small amounts. - This **gastrointestinal irritation** is a common sign of acute borax toxicity. *Induces uterine contractions (labor-inducing)* - While certain substances can induce uterine contractions, **borax is not known** or traditionally used for this purpose. - It is **not an oxytocic agent** and does not act on uterine smooth muscle in a way that would induce labor. *Irritates genitourinary tract (side effect)* - Although borax can be toxic, its primary route of significant irritation and toxicity is not typically the **genitourinary tract** in the way implied for adverse effects. - While it can be absorbed through mucous membranes, the genitourinary tract is not its primary target for **direct irritant effects** in systemic exposure. *Traditionally used to stimulate menstrual flow* - There is **no reliable scientific or traditional medical evidence** to support the use of borax to stimulate menstrual flow. - Substances used for this purpose, known as **emmenagogues**, are typically herbal or pharmaceutical preparations, and borax is **not among them**.

Question 187: 35 yr old lady attends gynaec OPD with excessive bleeding since 6 months, not controlled with non hormonal drugs. USG and clinical examination reveals no abnormality. Next step is?

A. Hysterectomy
B. Endometrial sampling (Correct Answer)
C. Endometrial ablation
D. Hormonal therapy

Explanation: ***Endometrial sampling*** - In a 35-year-old with **excessive uterine bleeding** not controlled by non-hormonal drugs and with normal imaging/clinical exam, endometrial sampling is crucial to **rule out endometrial hyperplasia or malignancy**. - This diagnostic step is essential before considering definitive treatments, as it provides a **histological diagnosis** of the endometrial lining. *Hysterectomy* - Hysterectomy is a **definitive surgical treatment** for excessive bleeding, but it is typically reserved for cases where conservative or less invasive treatments have failed, or if there's a serious underlying pathology like malignancy. - It involves removing the uterus and is a **major surgery** with potential complications, thus not usually the first step given an otherwise normal examination and imaging. *Endometrial ablation* - Endometrial ablation is a procedure to destroy the lining of the uterus, aiming to **reduce or stop menstrual bleeding**. - It is a treatment option for **abnormal uterine bleeding (AUB)**, but it's typically performed after other diagnostic steps (like endometrial sampling) have ruled out malignancy or high-risk hyperplasia, and when conservative medical management has failed. *Hormonal therapy* - Hormonal therapy (e.g., combined oral contraceptives, progestin-only pills, levonorgestrel-releasing intrauterine device) is often a **first-line medical treatment** for excessive uterine bleeding. - However, the question states that non-hormonal drugs have already failed, and without a clear diagnosis, initiating new hormonal therapy without **evaluating the endometrium** is not the next best step for persistent bleeding.

Question 188: What is the predominant hormone secreted by the corpus luteum that influences the secretory changes in the endometrium?

A. Estrogen
B. Progesterone (Correct Answer)
C. Luteinizing hormone
D. Follicle-stimulating hormone

Explanation: **Progesterone** - The **corpus luteum** is the primary source of **progesterone** after ovulation, which is crucial for maintaining the uterine lining to support a potential pregnancy. - **Progesterone** induces **secretory changes** in the endometrium, such as increased vascularity and glandular secretion, preparing it for **implantation** of a fertilized egg. *Estrogen* - While the corpus luteum does produce some **estrogen**, its primary role in the secretory phase is to work in conjunction with progesterone to prepare the endometrium, not as the predominant hormone responsible for secretory changes. - **Estrogen** is predominantly secreted by the **developing follicle** in the proliferative phase, primarily responsible for endometrial growth. *Luteinizing hormone* - **Luteinizing hormone (LH)** is responsible for triggering **ovulation** and stimulating the development and function of the corpus luteum, but it is a pituitary hormone, not secreted by the corpus luteum itself. - LH levels peak just before ovulation and then decline, whereas progesterone secretion by the corpus luteum rises significantly after ovulation. *Follicle-stimulating hormone* - **Follicle-stimulating hormone (FSH)** is primarily involved in **follicle development** during the follicular phase of the menstrual cycle and is secreted by the anterior pituitary gland. - FSH levels are highest early in the cycle and decrease after ovulation, playing no direct role in the secretory function of the endometrium and not being secreted by the corpus luteum.

Question 189: A 35-year-old woman presents with abnormal uterine bleeding and a negative pregnancy test. Which initial laboratory test is the most appropriate to evaluate her condition?

A. Coagulation profile
B. Complete blood count (Correct Answer)
C. Thyroid function tests
D. Prolactin levels

Explanation: ***Complete blood count*** - **CBC is the most appropriate initial laboratory test** for abnormal uterine bleeding to assess for **anemia** secondary to acute or chronic blood loss. - Hemoglobin and hematocrit levels help determine the **severity and urgency** of the bleeding and guide immediate management decisions. - **Universal recommendation** in all major guidelines (ACOG, FIGO) as part of the initial evaluation of abnormal uterine bleeding. - Helps assess the **hemodynamic impact** of bleeding and need for urgent intervention. *Thyroid function tests* - Thyroid dysfunction (both hypo- and hyperthyroidism) can cause abnormal uterine bleeding through effects on the hypothalamic-pituitary-ovarian axis. - **Important part of the comprehensive workup** but not the single most appropriate initial test. - Prevalence of thyroid dysfunction as cause of AUB is approximately 5-10%. - Should be ordered as part of the initial panel but does not take priority over assessing anemia. *Coagulation profile* - Indicated when there is suspicion of **bleeding disorders** (von Willebrand disease, platelet dysfunction). - Consider in patients with heavy menstrual bleeding since menarche, personal or family history of bleeding disorders, or failure to respond to standard therapy. - Not routinely part of initial workup unless clinical history suggests coagulopathy. *Prolactin levels* - Hyperprolactinemia typically causes **oligomenorrhea or amenorrhea** rather than abnormal uterine bleeding. - Would be indicated if patient has associated symptoms like galactorrhea or if anovulation is suspected. - Not the initial priority when evaluating abnormal bleeding patterns.

Question 190: A 32-year-old woman presents with menorrhagia and dysmenorrhea. An ultrasound reveals adenomyosis. What is the best initial treatment option for this condition?

A. NSAIDs (Correct Answer)
B. Hysterectomy
C. Endometrial ablation
D. Gonadotropin-releasing hormone agonists

Explanation: **NSAIDs** - **Nonsteroidal anti-inflammatory drugs (NSAIDs)** are often the first-line treatment for pain and heavy bleeding associated with adenomyosis, as they help reduce prostaglandin production and uterine contractions. - They are a conservative, **symptomatic treatment** suitable for women who desire future fertility or milder symptoms. *Hysterectomy* - **Hysterectomy** is a definitive cure for adenomyosis but is typically reserved for women with severe symptoms who have completed childbearing or when other treatments have failed, as it is a major surgical procedure. - It permanently removes the uterus, thus eliminating all symptoms, but it's not the **initial, least invasive** option. *Endometrial ablation* - **Endometrial ablation** involves destroying the uterine lining and is effective for heavy menstrual bleeding, but it does not treat the deep myometrial invasion characteristic of adenomyosis and may provide only temporary relief for pain in such cases. - It is generally less effective for adenomyosis compared to its efficacy in treating typical dysfunctional uterine bleeding because the **adenomyotic tissue** is often located deep within the myometrium, beyond the reach of standard ablation techniques. *Gonadotropin-releasing hormone agonists* - **Gonadotropin-releasing hormone (GnRH) agonists** induce a temporary, reversible menopause-like state by suppressing ovarian hormone production, which can reduce symptoms of adenomyosis. - However, they are typically used for **short-term treatment** due to potential side effects like bone loss and menopausal symptoms, and are often considered after NSAIDs or as a bridge to surgery, not as the primary initial treatment.

Practice by Chapter

Normal Menstrual Physiology

Practice Questions

Primary Dysmenorrhea

Practice Questions

Secondary Dysmenorrhea

Practice Questions

Premenstrual Syndrome and PMDD

Practice Questions

Primary Amenorrhea

Practice Questions

Secondary Amenorrhea

Practice Questions

Polycystic Ovary Syndrome

Practice Questions

Abnormal Uterine Bleeding: Classification

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Evaluation of Menstrual Disorders

Practice Questions

Management Approaches to Menstrual Disorders

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