Menstrual Disorders Practice Questions

Q: A 30-year-old woman with a Gravida 2 Para 0 pregnancy status presents with menorrhagia and hypertension. What is the best treatment for her?

Levonorgestrel-releasing intrauterine system (Mirena). ### Explanation The patient presents with **menorrhagia** (Heavy Menstrual Bleeding - HMB) and comorbid **hypertension**. According to the FIGO and NICE guidelines, the **Levonorgestrel-releasing intrauterine system (LNG-IUS/Mirena)** is the first-line medical management for HMB when no structural pathology is present. **Why Option B is Correct:** The LNG-IUS provides local progestogen effect, leading to profound endometrial atrophy and a significant reduction in menstrual blood loss (up to 90% at 6 months). In this patient, it is particularly advantageous because it is **non-hormonal in its systemic effect**, making it safe for patients with hypertension, unlike estrogen-containing options. **Why Other Options are Incorrect:** * **Option A (COCPs):** These are contraindicated or should be used with extreme caution in patients with hypertension due to the estrogen component, which can further increase blood pressure and the risk of thromboembolic events. * **Option C (Hysterectomy):** This is a definitive surgical treatment but is reserved for patients who have completed their family or when medical/less invasive treatments fail. This patient is G2P0, suggesting she may still desire future fertility. * **Option D (TCRE):** Endometrial ablation/resection is a second-line surgical option for those who do not wish to conceive. It is generally avoided in women who still desire pregnancy. **Clinical Pearls for NEET-PG:** * **First-line for HMB:** LNG-IUS (Mirena). * **Mechanism of LNG-IUS:** Local release of 20μg levonorgestrel/day → Endometrial decidualization and atrophy. * **Hypertension & Contraception:** Avoid Estrogen (COCPs). Progestogen-only methods (LNG-IUS, POP, DMPA) are preferred. * **Mirena Lifespan:** Approved for 5 years (recently extended to 8 years for contraception, but check latest guidelines for HMB).

Q: What is the treatment for dysfunctional uterine bleeding (DUB) in a 32-year-old multiparous woman?

Progesterone. **Explanation:** Dysfunctional Uterine Bleeding (DUB) is a diagnosis of exclusion, most commonly caused by **anovulation**. In anovulatory cycles, there is continuous estrogen stimulation of the endometrium without the stabilizing effect of progesterone (due to the absence of a corpus luteum). This leads to an unstable, thickened endometrium that sheds irregularly and excessively. **1. Why Progesterone is Correct:** Progesterone is the mainstay of medical management for DUB. It acts by converting the proliferative endometrium into a secretory one, stabilizing the endometrial lining, and inducing a "medical curettage" upon withdrawal. In a 32-year-old multiparous woman, cyclic progestogens or a Levonorgestrel-releasing Intrauterine System (LNG-IUS) are first-line treatments to regulate the cycle and reduce blood loss. **2. Why Other Options are Incorrect:** * **Danazol:** While it causes endometrial atrophy, it is rarely used due to significant androgenic side effects (hirsutism, acne, weight gain). It is reserved for resistant cases, not first-line therapy. * **Prostaglandins:** Prostaglandin *inhibitors* (NSAIDs like Mefenamic acid) are used to reduce blood loss, but prostaglandins themselves would worsen uterine cramping and are not a treatment for DUB. * **Endometrial Ablation:** This is a surgical intervention. In a 32-year-old, medical management must be exhausted first. Surgery is generally reserved for women who have completed their family and failed medical therapy. **Clinical Pearls for NEET-PG:** * **DOC for DUB (Acute bleeding):** High-dose Estrogen or OCPs. * **DOC for DUB (Maintenance/Long-term):** LNG-IUS (Mirena) is currently considered the gold standard medical treatment. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the initial investigation; however, **Endometrial Biopsy** is mandatory if the patient is >35 years old to rule out endometrial hyperplasia or malignancy.

Q: Which of the following conditions microscopically shows cystic glandular hyperplasia of all the endometrial components?

Metropathia haemorrhagica. **Explanation:** **Metropathia Haemorrhagica** (also known as Schroeder’s Disease) is a specialized form of Dysfunctional Uterine Bleeding (DUB) typically seen in perimenopausal women. 1. **Why it is correct:** The condition is characterized by **persistent unovulation**, leading to a state of absolute hyperestrogenism without the balancing effect of progesterone. This continuous estrogenic stimulation causes the endometrium to become markedly thickened and hyperplastic. Microscopically, it shows **Cystic Glandular Hyperplasia**, classically described as a **"Swiss-Cheese" appearance**, where glands of varying sizes (some dilated and cystic) are lined by pseudostratified epithelium. All components—glands, stroma, and vessels—undergo hyperplasia. 2. **Why other options are incorrect:** * **Menorrhagia:** This is a clinical symptom (heavy cyclic bleeding) rather than a specific pathological diagnosis. While it can be caused by hyperplasia, it is also caused by fibroids, adenomyosis, or copper-Ts, which do not show this specific microscopic pattern. * **Polymenorrhea:** This refers to a shortened menstrual cycle ( 35 days). While often associated with PCOS (which can lead to hyperplasia), it is a clinical description and not a microscopic diagnosis of all endometrial components. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Characterized by a period of **amenorrhea** (due to high estrogen) followed by **profuse, painless, prolonged bleeding**. * **Classic Triad:** Amenorrhea, Hyperestrogenism, and Cystic Glandular Hyperplasia. * **Ovarian finding:** Presence of a persistent follicular cyst (unruptured follicle). * **Microscopy:** "Swiss-Cheese" pattern is the hallmark buzzword for exams.

Q: Dysfunctional uterine bleeding is commonly encountered in all of the following except:

Postmenopausal period. **Explanation:** **Dysfunctional Uterine Bleeding (DUB)**, now often categorized under the PALM-COEIN classification as AUB-O (Ovulatory dysfunction), refers to abnormal uterine bleeding in the absence of any detectable organic pelvic pathology, systemic disease, or pregnancy. **1. Why Postmenopausal period is the correct answer:** DUB is fundamentally a disorder of the **Hypothalamic-Pituitary-Ovarian (HPO) axis**. In the postmenopausal period, the ovaries have failed and the endometrium is typically atrophic. Any bleeding occurring after menopause is considered **Postmenopausal Bleeding (PMB)** and is highly suspicious of malignancy (e.g., Endometrial Carcinoma) or local pathology (e.g., Atrophic Vaginitis). It is **never** classified as DUB, as the hormonal cycling required for DUB no longer exists. **2. Analysis of incorrect options:** * **Adolescence:** DUB is very common here due to an **immature HPO axis**, leading to frequent anovulatory cycles. * **Following childbirth:** The HPO axis takes time to re-establish its rhythm post-delivery, especially during lactation, often resulting in temporary hormonal imbalances and DUB. * **Premenopausal period:** This is the most common age group for DUB. As ovarian reserve declines, cycles become increasingly anovulatory due to erratic estrogen levels and progesterone deficiency. **Clinical Pearls for NEET-PG:** * **Most common cause of DUB:** Anovulation (leads to "unopposed estrogen" action on the endometrium). * **Gold Standard Investigation for DUB (>40 years):** Fractional Curettage or Endometrial Biopsy to rule out endometrial hyperplasia/malignancy. * **Drug of Choice:** In acute heavy bleeding, high-dose Estrogen or Tranexamic acid; for long-term management, the **Levonorgestrel Intrauterine System (LNG-IUS)** is the medical treatment of choice.

Q: Amenorrhea due to high LH and FSH is due to:

Ovarian failure. **Explanation:** The core concept behind this question is the **Hypothalamic-Pituitary-Ovarian (HPO) axis** and the principle of **negative feedback**. 1. **Why Ovarian Failure is correct:** In Ovarian Failure (e.g., Premature Ovarian Insufficiency or Menopause), the ovaries fail to produce sufficient estrogen and inhibin. The absence of negative feedback on the hypothalamus and pituitary leads to a compensatory increase in the secretion of **GnRH, FSH, and LH**. This condition is termed **Hypergonadotropic Hypogonadism**. High FSH (>40 IU/L) is the diagnostic hallmark of ovarian failure. 2. **Why other options are incorrect:** * **Asherman Syndrome:** This is a uterine cause of amenorrhea (outflow tract obstruction) due to intrauterine adhesions. The HPO axis remains intact; therefore, hormone levels (FSH/LH) are typically **normal** (Eugonadotropic). * **Pituitary Adenoma:** Most functional pituitary adenomas (like Prolactinomas) or destructive lesions cause **Hypogonadotropic Hypogonadism**. High prolactin suppresses GnRH, leading to **low** or inappropriately normal FSH and LH levels. **High-Yield Clinical Pearls for NEET-PG:** * **Hypergonadotropic Hypogonadism (High FSH/LH):** Think Ovarian failure, Turner Syndrome, or Swyer Syndrome. * **Hypogonadotropic Hypogonadism (Low FSH/LH):** Think Kallmann syndrome, stress, weight loss, or pituitary tumors. * **Eugonadotropic Amenorrhea (Normal FSH/LH):** Think PCOS (though LH:FSH ratio may be 2:1 or 3:1) or anatomical causes like Asherman syndrome and Mullerian agenesis. * **Progesterone Challenge Test:** Patients with ovarian failure will have a **negative** withdrawal bleed because of low endogenous estrogen.

Question 1

A 30-year-old woman with a Gravida 2 Para 0 pregnancy status presents with menorrhagia and hypertension. What is the best treatment for her?

Accepted Answer

Levonorgestrel-releasing intrauterine system (Mirena)

Answer

Combined oral contraceptive pills

Answer

Hysterectomy

Answer

Transcervical resection of the endometrium

Question 2

A 14-year-old girl presents with vaginal bleeding and occasional amenorrhea. What is the next step in management?

Accepted Answer

Clinical history and examination

Answer

Bleeding time (BT) and Clotting time (CT)

Answer

Ultrasound

Answer

Total leucocyte count (TLC), Differential leucocyte count (DLC), and Erythrocyte sedimentation rate (ESR)

Question 3

What is the treatment for dysfunctional uterine bleeding (DUB) in a 32-year-old multiparous woman?

Accepted Answer

Progesterone

Answer

Danazol

Answer

Prostaglandins

Answer

Endometrial ablation

Question 4

Which of the following conditions microscopically shows cystic glandular hyperplasia of all the endometrial components?

Accepted Answer

Metropathia haemorrhagica

Answer

Menorrhagia

Answer

Polymenorrhea

Answer

Oligomenorrhea

Question 5

Dysfunctional uterine bleeding is commonly encountered in all of the following except:

Accepted Answer

Postmenopausal period

Answer

Adolescence

Answer

Following childbirth

Answer

Premenopausal period

Question 6

What is the drug of choice in the management of puberty menorrhagia?

Accepted Answer

Progesterone

Answer

Oral contraceptive pill (OCP)

Answer

Intrauterine contraceptive device (IUCD)

Answer

Endometrial curettage

Question 7

A 16-year-old girl presents with acute vaginal bleeding. What is the immediate management?

Accepted Answer

Progesterone

Answer

Uterine ablation

Answer

Uterine artery embolization

Answer

Hysteroscopy examination

Question 8

Which of the following is NOT a contraindication to tranexamic acid in the management of heavy menstrual bleeding?

Accepted Answer

Intermenstrual bleeding

Answer

Concurrent combined oral contraceptives use

Answer

Colour blindness

Answer

Disseminated intravascular coagulation

Question 9

Amenorrhea due to high LH and FSH is due to:

Accepted Answer

Ovarian failure

Answer

Asherman syndrome

Answer

Pituitary adenoma

Answer

All of the above

Question 10

A 38-year-old woman presents with insidious menstrual irregularities over the past decade. Investigations including pelvic ultrasound, endometrial biopsy (showing proliferative endometrium), and blood tests (revealing mild iron deficiency anemia) are within normal limits, with a negative pregnancy test. What is the most likely diagnosis?

Accepted Answer

Dysfunctional uterine bleeding

Answer

Cervical carcinoma

Answer

Cervical dysplasia

Answer

Endometrial carcinoma

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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