Menstrual Disorders — MCQs
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A 39-year-old woman presents for a routine exam and mentions intermittent heavy menstrual bleeding. What is the most appropriate minimally invasive treatment that can be offered initially?
A mother brought her 16-year-old daughter to Gynaecology OPD with a complaint of not attaining menarche. She gives a history of cyclic abdominal pain. On further examination, a midline abdominal swelling is seen. Per rectal examination reveals a bulging mass in the vagina. Which of the following conditions is most likely responsible for these findings?
What is the most common cause of primary amenorrhea?
Cryptomenorrhea occurs due to which of the following conditions?
Which of the following is least likely to cause dysmenorrhea?
Asherman's syndrome is associated with which of the following symptoms?
A 46-year-old P3L3 complains of menorrhagia since 3 months. Initial diagnostic steps, including history, physical examination, and imaging, have been performed. The next line of management is?
A woman experiences menstrual blood loss of 100 ml every 30 days. How would this condition be classified?
What is the definition of menometrorrhagia?
Which of the following is not correlated with the ovarian cycle?
Menstrual Disorders Indian Medical PG Practice Questions and MCQs
Question 191: A 39-year-old woman presents for a routine exam and mentions intermittent heavy menstrual bleeding. What is the most appropriate minimally invasive treatment that can be offered initially?
- A. Levonorgestrel-releasing intrauterine system (Correct Answer)
- B. Endometrial ablation
- C. Uterine artery embolization
- D. Hormonal therapy
Explanation: ***Levonorgestrel-releasing intrauterine system*** - This is a highly effective, **minimally invasive**, and long-acting reversible option that is also approved for the management of **heavy menstrual bleeding** (menorrhagia). - It works by continuously releasing **progestin** locally into the uterus, causing endometrial suppression and significantly reducing menstrual blood loss by **up to 90%**. - It is recommended as **first-line treatment** for heavy menstrual bleeding in women who also desire contraception or long-term management. *Endometrial ablation* - This is a **surgical procedure** that destroys the uterine lining to reduce or stop menstrual bleeding and is more invasive than LNG-IUS. - It is typically reserved for women who have **completed childbearing** and for whom medical or hormonal management has been unsuccessful. - It is not reversible and significantly impairs future fertility. *Uterine artery embolization* - This is an **invasive radiological procedure** involving catheterization and blocking the blood supply to the uterus. - Primarily used to treat **uterine fibroids** causing heavy bleeding, not as first-line treatment for undiagnosed menorrhagia. - Carries risks including infection, pain, and potential impact on ovarian function. *Hormonal therapy* - While **oral contraceptives** or progestin-only pills are effective and truly non-invasive, they require daily compliance and may have systemic side effects. - The question asks for a **treatment** (device-based intervention), and LNG-IUS is superior due to its **local action**, minimal systemic effects, and **long-term efficacy** without daily adherence requirements.
Question 192: A mother brought her 16-year-old daughter to Gynaecology OPD with a complaint of not attaining menarche. She gives a history of cyclic abdominal pain. On further examination, a midline abdominal swelling is seen. Per rectal examination reveals a bulging mass in the vagina. Which of the following conditions is most likely responsible for these findings?
- A. Vaginal agenesis
- B. Transverse vaginal septum
- C. Imperforate hymen (Correct Answer)
- D. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome
Explanation: ***Imperforate hymen*** - An **imperforate hymen** obstructs the outflow of menstrual blood, leading to its accumulation in the vagina (**hematocolpos**) and uterus (**hematometra**), causing **cyclic abdominal pain** and a bulging mass (due to accumulated blood) in the vagina. - The patient presents with **primary amenorrhea** (not having attained menarche) and cyclical abdominal pain caused by the inability of menstrual blood to exit the body. *Transverse vaginal septum* - A **transverse vaginal septum** can also cause primary amenorrhea and cyclic abdominal pain due to obstruction of menstrual flow. However, it is a less common cause than an imperforate hymen. - While it can lead to hematocolpos, the characteristic bulging mass on per rectal examination is more strongly associated with an imperforate hymen presenting at the vaginal introitus. *Vaginal agenesis* - **Vaginal agenesis** (complete absence of the vagina) would present with primary amenorrhea, but there would be no cyclic abdominal pain if the uterus is also absent or rudimentary. If a uterus is present, there would be no accumulation of blood in the vagina or a bulging mass per rectum as there is no vaginal canal. - This condition is typically associated with a rudimentary or absent uterus, leading to an inability to menstruate rather than obstructed flow. *Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome* - **MRKH syndrome** is characterized by congenital aplasia of the uterus and the upper two-thirds of the vagina, with normal ovaries and external genitalia. - Patients present with **primary amenorrhea** but typically do not experience **cyclic abdominal pain** or a bulging vaginal mass because there is no functional uterus to produce menstrual blood or a vaginal canal for blood accumulation.
Question 193: What is the most common cause of primary amenorrhea?
- A. None of the options
- B. Mayer-Rokitansky-Küster-Hauser syndrome
- C. Ovarian dysgenesis (Turner syndrome) (Correct Answer)
- D. Constitutional delay
Explanation: ***Ovarian dysgenesis (Turner syndrome)*** - **Turner syndrome (45,XO karyotype)** is one of the most common causes of **primary amenorrhea**, accounting for approximately **12-15% of cases**. - It results from the complete or partial absence of one of the **X chromosomes**, leading to **gonadal dysgenesis** (streak gonads). - Characterized by **absent secondary sexual characteristics**, short stature, and elevated FSH/LH levels. - Turner syndrome is the most common form of **gonadal dysgenesis**, which collectively represents a leading category of primary amenorrhea. *Mayer-Rokitansky-Küster-Hauser syndrome* - This syndrome is characterized by **congenital agenesis of the uterus and upper two-thirds of the vagina**, but **normal ovaries** and secondary sexual characteristics. - Accounts for approximately **15% of primary amenorrhea** cases. - Less common than gonadal dysgenesis as a category, but MRKH is the second most common cause after gonadal dysgenesis. *None of the options* - This option is incorrect because **Turner syndrome** is a well-established and leading cause of primary amenorrhea among the choices provided. *Constitutional delay* - This refers to a **physiological delay in the onset of puberty**, where the individual will eventually develop secondary sexual characteristics and menarche. - While common, it represents a **delay rather than true amenorrhea**, and is typically diagnosed when other pathological causes are excluded. - Not considered the most common cause of **pathological primary amenorrhea**.
Question 194: Cryptomenorrhea occurs due to which of the following conditions?
- A. Fibroids
- B. PCOS
- C. Imperforate hymen (Correct Answer)
- D. Asherman syndrome
Explanation: ***Imperforate hymen*** - **Cryptomenorrhea** is a condition where monthly cyclical symptoms of menstruation occur, but there is no visible external bleeding due to an **obstruction in the outflow tract**. - An **imperforate hymen** is a congenital anomaly where the hymen completely blocks the vaginal opening, leading to retention of menstrual blood and causing cryptomenorrhea. - Patients typically present with **primary amenorrhea, cyclical pelvic pain, and a bulging hymen** on examination. *Fibroids* - **Uterine fibroids** are benign tumors of the uterus that can cause heavy menstrual bleeding (menorrhagia) or abnormal uterine bleeding, but not cryptomenorrhea. - They do not typically cause an obstruction of the **menstrual outflow tract**. *PCOS* - **Polycystic Ovary Syndrome (PCOS)** is an endocrine disorder characterized by irregular or absent menstruation (oligomenorrhea or amenorrhea) due to anovulation. - While periods may be absent, there is no obstruction preventing menstrual flow, so it does not cause **cryptomenorrhea**. *Asherman syndrome* - **Asherman syndrome** involves intrauterine adhesions that can cause amenorrhea or hypomenorrhea. - While it causes **absent or reduced menstrual flow**, the underlying mechanism is endometrial destruction, not outflow tract obstruction, so true cryptomenorrhea does not occur.
Question 195: Which of the following is least likely to cause dysmenorrhea?
- A. Endometriosis
- B. Adenomyosis
- C. Uterine polyp
- D. Cervical polyp (Correct Answer)
Explanation: ***Cervical polyp*** - Cervical polyps are typically **benign growths** on the cervix and are usually **asymptomatic**, or may cause **light intermenstrual bleeding** or bleeding after intercourse. - They generally do **not cause pain** or dysmenorrhea because they are not involved in the hormonal and inflammatory processes that lead to uterine contractions and pain during menstruation. *Endometriosis* - Endometriosis is characterized by the presence of **stromal and glandular tissue** outside the uterus, which responds to hormonal fluctuations, leading to **inflammation and cyclical pain**. - This often results in severe **secondary dysmenorrhea**, chronic pelvic pain, and dyspareunia. *Adenomyosis* - Adenomyosis involves the invasion of **endometrial tissue into the myometrium**, leading to a thickened, enlarged uterus. - This condition causes significant **dysmenorrhea** due to increased prostaglandin production and uterine cramping, as well as heavy menstrual bleeding. *Uterine polyp* - Uterine polyps (endometrial polyps) are **overgrowths of endometrial tissue** within the uterine cavity. - While they primarily cause **abnormal uterine bleeding**, they can occasionally cause **dysmenorrhea** through interference with normal uterine contractions, though this is **less common** than bleeding symptoms.
Question 196: Asherman's syndrome is associated with which of the following symptoms?
- A. All of the options
- B. Amenorrhea (Correct Answer)
- C. Menorrhagia
- D. Polymenorrhea
Explanation: ***Amenorrhea*** - **Asherman's syndrome** involves the formation of intrauterine adhesions (scar tissue) which can block the outflow of menstrual blood, leading to **amenorrhea** or significantly reduced menstrual flow (hypomenorrhea). - The scarring often damages the **endometrial basalis layer**, preventing the normal cyclical growth and shedding of the uterine lining necessary for menstruation. *Menorrhagia* - **Menorrhagia** is characterized by abnormally heavy or prolonged menstrual bleeding, which is the opposite of what occurs in Asherman's syndrome. - This symptom is typically associated with conditions like **uterine fibroids**, **adenomyosis**, or **coagulopathies**, not intrauterine adhesions. *Polymenorrhea* - **Polymenorrhea** refers to abnormally frequent menstrual cycles (occurring more often than every 21 days), which is not a hallmark symptom of Asherman's syndrome. - This condition is usually related to **hormonal imbalances** leading to a shortened follicular phase, rather than structural uterine abnormalities. *All of the options* - While other menstrual irregularities can occur, **amenorrhea** or **hypomenorrhea** is the primary and characteristic symptom linked to Asherman's syndrome due to the physical obstruction and endometrial damage caused by intrauterine adhesions. - The other options (menorrhagia, polymenorrhea) represent distinct menstrual abnormalities with different underlying etiologies, not typically seen in Asherman's syndrome.
Question 197: A 46-year-old P3L3 complains of menorrhagia since 3 months. Initial diagnostic steps, including history, physical examination, and imaging, have been performed. The next line of management is?
- A. OC pills x 6 months
- B. Hysterectomy
- C. Dilation and Curettage (D & C)
- D. Progesterone x 6 months (Correct Answer)
Explanation: ***Progesterone x 6 months*** - After initial diagnostic evaluation has ruled out structural pathology, **medical management** is the appropriate next step for menorrhagia in this 46-year-old patient. - **Cyclical progesterone therapy** (typically given for 10-14 days per cycle) is a commonly used first-line hormonal treatment for menorrhagia, particularly in perimenopausal women. - Progesterone helps **stabilize the endometrium** and regulate menstrual cycles by counteracting unopposed estrogen effects that can lead to excessive endometrial proliferation and bleeding. - In this age group approaching menopause, progesterone therapy is often preferred as it addresses the likely hormonal imbalance without introducing exogenous estrogen. *OC pills x 6 months* - **Combined oral contraceptive pills (OCPs)** are also an evidence-based first-line medical treatment for menorrhagia, reducing menstrual blood loss by 40-50%. - However, for a **46-year-old patient**, there may be relative contraindications to estrogen-containing preparations (smoking, hypertension, thrombosis risk) that need consideration. - While OCPs are effective, in perimenopausal women without need for contraception, **progesterone-only therapy** is often chosen as the initial approach with a more favorable risk-benefit profile. *Dilation and Curettage (D & C)* - **D & C** is primarily a **diagnostic procedure** for obtaining endometrial tissue when there's suspicion of endometrial pathology or hyperplasia. - It may provide temporary relief but is **not a definitive medical treatment** for menorrhagia and has been largely replaced by endometrial biopsy and hysteroscopy for diagnosis. - Since initial diagnostic steps including imaging have already been performed, D & C would only be indicated if there was suspicion of intrauterine pathology requiring tissue diagnosis. *Hysterectomy* - **Hysterectomy** is the definitive surgical treatment for menorrhagia but is reserved for cases where **medical management has failed** or there are significant structural pathologies (large fibroids, adenomyosis, severe endometrial pathology). - Given that this patient has just completed initial workup, surgical intervention is premature before attempting medical management. - Hysterectomy should only be considered after failure of conservative medical treatments.
Question 198: A woman experiences menstrual blood loss of 100 ml every 30 days. How would this condition be classified?
- A. Menorrhagia (Correct Answer)
- B. Polymenorrhea
- C. Hypomenorrhea
- D. Normal menses
Explanation: ***Menorrhagia*** - **Menorrhagia** is characterized by abnormally **heavy or prolonged menstrual bleeding**, typically defined as blood loss exceeding **80 mL** per cycle or bleeding lasting more than 7 days. - In this case, a 100 mL blood loss is above the normal threshold, classifying it as menorrhagia. *Polymenorrhea* - **Polymenorrhea** refers to **frequently recurring menstrual cycles**, defined as a cycle length of fewer than **21 days**. - The woman's cycle length of 30 days falls within the normal range, so this term does not apply. *Hypomenorrhea* - **Hypomenorrhea** describes **unusually light or scanty menstrual bleeding**, with blood loss typically less than **30 mL** per cycle. - The 100 mL blood loss is significantly higher than what is seen in hypomenorrhea. *Normal menses* - **Normal menses** involve a typical blood loss ranging from **30 to 80 mL** per cycle and a cycle length between **21 and 35 days**. - A 100 mL blood loss exceeds the upper limit for normal menses, indicating an abnormal condition.
Question 199: What is the definition of menometrorrhagia?
- A. Excessive menstrual bleeding
- B. Bleeding between menstrual periods
- C. Heavy and irregular menstrual bleeding (Correct Answer)
- D. Regular uterine bleeding
Explanation: ***Heavy and irregular menstrual bleeding*** - **Menometrorrhagia** is defined by menstrual bleeding that is both **excessively heavy** (menorrhagia) and **irregularly timed** (metrorrhagia), occurring frequently and lasting longer than usual. - This condition can lead to significant blood loss and impact a woman's quality of life. *Excessive menstrual bleeding* - This is the definition of **menorrhagia**, which refers only to the quantity of blood loss during a normal duration and frequency of menstruation. - It does not account for the **irregularity** in timing or duration of bleeding. *Bleeding between menstrual periods* - This symptom is primarily known as **metrorrhagia**, indicating irregular bleeding that occurs outside of the normal menstrual cycle. - It does not specifically describe the **heaviness** of the bleeding episodes. *Regular uterine bleeding* - **Regular uterine bleeding** is the characteristic of a normal menstrual cycle, which is predictable in its timing and duration. - This option does not describe any abnormal bleeding pattern, such as being **heavy** or **irregular**.
Question 200: Which of the following is not correlated with the ovarian cycle?
- A. Vaginal cytology
- B. Blood hormonal levels
- C. Endometrial sampling
- D. Estrous cycle (Correct Answer)
Explanation: ***Estrous cycle*** - The **estrous cycle** is characteristic of most mammals (e.g., cows, dogs, cats) and differs fundamentally from the human **menstrual cycle**. - Unlike the menstrual cycle which involves endometrial shedding, the estrous cycle typically involves the reabsorption of the **endometrium** with no bleeding. *Endometrial sampling* - **Endometrial sampling** (e.g., biopsy) is directly impacted by the ovarian cycle, as the **endometrium** undergoes proliferative and secretory phases under hormonal influence. - The appearance and cellular characteristics of the **endometrium** vary significantly depending on the cycle phase (e.g., changes in glandular architecture, stromal edema). *Vaginal cytology* - **Vaginal cytology** reflects the hormonal changes of the ovarian cycle, particularly the influence of **estrogen** and **progesterone**. - The types and proportions of **squamous cells** in a vaginal smear (e.g., basal, parabasal, intermediate, superficial cells) vary with the follicular and luteal phases. *Blood hormonal levels* - **Blood hormonal levels** (e.g., **estradiol**, **progesterone**, **LH**, **FSH**) are direct indicators and regulators of the ovarian cycle. - Fluctuations in these hormones drive the development of the **follicle**, **ovulation**, and the formation and regression of the **corpus luteum**.
Practice by Chapter
Normal Menstrual Physiology
Practice Questions
Primary Dysmenorrhea
Practice Questions
Secondary Dysmenorrhea
Practice Questions
Premenstrual Syndrome and PMDD
Practice Questions
Primary Amenorrhea
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Secondary Amenorrhea
Practice Questions
Polycystic Ovary Syndrome
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Abnormal Uterine Bleeding: Classification
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Evaluation of Menstrual Disorders
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Management Approaches to Menstrual Disorders
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