Menstrual Disorders Practice Questions

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.

Q: Which of the following modalities has shown the best results for premenstrual syndrome?

SSRI. **Explanation:** **Premenstrual Syndrome (PMS)** and its more severe form, **Premenstrual Dysphoric Disorder (PMDD)**, are characterized by physical and emotional symptoms occurring during the luteal phase. **Why SSRIs are the Correct Choice:** Selective Serotonin Reuptake Inhibitors (SSRIs) are considered the **first-line pharmacological treatment** for PMS/PMDD. The underlying pathophysiology involves a maladaptive response to normal fluctuations in gonadal steroids (estrogen and progesterone), which leads to a deficit in central **serotonergic transmission**. SSRIs rapidly increase synaptic serotonin levels. Unlike in depression, SSRIs for PMS can be administered in a **luteal-phase-only** regimen (starting on day 14) with high efficacy. **Analysis of Incorrect Options:** * **B. Progesterone:** Historically used based on the "progesterone deficiency" theory; however, clinical trials have shown it is **no more effective than placebo** for treating PMS. * **C. Estrogen:** While estrogen (often via patches) can suppress ovulation, it is not first-line and must be balanced with progesterone to prevent endometrial hyperplasia, which may trigger PMS symptoms. * **D. Anxiolytics:** Drugs like Alprazolam may help with specific symptoms of anxiety or insomnia but are second/third-line due to the risk of dependence and lack of effect on physical symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Prospective charting of symptoms for at least **two consecutive cycles** (e.g., using the Daily Record of Severity of Problems). * **First-line SSRIs:** Fluoxetine, Sertraline, and Paroxetine. * **Non-pharmacological first step:** Lifestyle modifications (exercise, complex carbohydrates, and stress reduction). * **Definitive Treatment:** For refractory cases, **GnRH analogues** (to induce medical menopause) or bilateral oophorectomy may be considered.

Q: Which of the following is not indicated in the management of menorrhagia?

Clomiphene. **Explanation:** The management of menorrhagia (Heavy Menstrual Bleeding) focuses on reducing menstrual blood loss (MBL) through medical or surgical interventions. **Why Clomiphene is the Correct Answer:** Clomiphene citrate is a **Selective Estrogen Receptor Modulator (SERM)** used primarily as an **ovulation-inducing agent** in infertility management. It works by blocking estrogen receptors in the hypothalamus, leading to increased FSH and LH secretion. It is **not** a treatment for menorrhagia; in fact, by inducing ovulation and follicular growth, it may occasionally lead to a thicker endometrium or ovarian hyperstimulation, which does not help in reducing menstrual flow. **Analysis of Other Options:** * **NSAIDs (e.g., Mefenamic acid):** These inhibit cyclooxygenase (COX) enzymes, reducing the levels of prostaglandins (PGE2 and PGF2α) in the endometrium. This leads to vasoconstriction and reduced MBL by approximately 20-30%. * **Norethisterone:** This is a synthetic progestogen. When given in the luteal phase or as a long-term regimen, it stabilizes the endometrium and prevents excessive proliferation, effectively managing dysfunctional uterine bleeding. * **Tranexamic Acid:** An antifibrinolytic agent that inhibits the breakdown of fibrin clots by blocking plasminogen activation. It is one of the most effective non-hormonal treatments, reducing MBL by up to 50%. **High-Yield Clinical Pearls for NEET-PG:** * **First-line medical management** for menorrhagia (WHO/NICE): **Levonorgestrel Intrauterine System (LNG-IUS/Mirena)**. * **Best non-hormonal treatment:** Tranexamic acid. * **Drug of choice for menorrhagia with dysmenorrhea:** NSAIDs (Mefenamic acid). * **Surgical Gold Standard:** Hysterectomy (definitive), though Endometrial Ablation is a less invasive alternative for those who have completed their family.

Q: What is the commonest condition associated with menorrhagia?

Fibroid. **Explanation:** **Why Fibroid is the correct answer:** Uterine leiomyomas (fibroids) are the most common benign tumors of the uterus and the **most common cause of menorrhagia** (heavy menstrual bleeding). The increased bleeding is primarily due to: 1. **Increased Surface Area:** The presence of fibroids increases the total surface area of the endometrial cavity. 2. **Vascular Changes:** Fibroids cause congestion and dilatation of the overlying endometrial veins. 3. **Impaired Contractility:** They interfere with the normal myometrial contractions required to clamp down on spiral arteries during menstruation. *Note: Submucosal fibroids are most notorious for causing heavy bleeding, even when small.* **Analysis of Incorrect Options:** * **A. Adenomyosis:** While a significant cause of menorrhagia and dysmenorrhea, it is statistically less common than fibroids in the general population. It typically presents in multiparous women in their 40s. * **C. Granulosa Cell Tumour:** This is an estrogen-secreting ovarian tumor. While it can cause endometrial hyperplasia and subsequent bleeding, it is a rare clinical entity compared to the high prevalence of fibroids. * **D. Polycystic Ovary (PCOS):** PCOS is typically associated with **oligomenorrhea** (infrequent periods) or amenorrhea due to chronic anovulation. When bleeding does occur, it is often irregular (metrorrhagia) rather than heavy cyclical flow (menorrhagia). **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation** for Fibroids: Transvaginal Ultrasound (TVS). * **Medical Management of Choice:** Levonorgestrel Intrauterine System (LNG-IUS) is often the first-line medical treatment for menorrhagia. * **Surgical Management:** Myomectomy (if fertility is desired) or Hysterectomy (definitive). * **Red Flag:** If a postmenopausal woman presents with bleeding and a "fibroid," suspect **Leiomyosarcoma**.

Q: What is the most common cause of secondary amenorrhea?

Pregnancy. **Explanation:** **1. Why Pregnancy is the Correct Answer:** In any woman of reproductive age presenting with a cessation of menses, **pregnancy** is statistically the most common cause of secondary amenorrhea. Physiologically, during pregnancy, the persistent production of progesterone by the corpus luteum (and later the placenta) maintains the endometrial lining and inhibits the hypothalamic-pituitary-ovarian (HPO) axis through negative feedback, preventing further menstruation. In clinical practice and for NEET-PG, the first step in investigating secondary amenorrhea is always a urine pregnancy test (UPT) to rule this out. **2. Analysis of Incorrect Options:** * **A. Hypogonadism:** While conditions like Polycystic Ovary Syndrome (PCOS) or Premature Ovarian Insufficiency (POI) are significant causes of secondary amenorrhea, they are statistically less frequent than pregnancy. * **B. Hypopituitarism:** This involves a failure of the pituitary to secrete FSH/LH (e.g., Sheehan’s syndrome). While it causes amenorrhea, it is a rare clinical entity compared to physiological causes. * **D. Ovarian Tumor:** Certain tumors (like Sertoli-Leydig cell tumors) can cause amenorrhea due to hormone secretion, but these represent a very small fraction of cases. **3. NEET-PG High-Yield Pearls:** * **Definition:** Secondary amenorrhea is the absence of menses for **3 months** in a woman with previously regular cycles, or **6 months** in those with irregular cycles. * **Most common pathological cause:** Polycystic Ovary Syndrome (PCOS). * **Most common cause of primary amenorrhea:** Gonadal dysgenesis (Turner Syndrome). * **Asherman’s Syndrome:** The most common uterine cause of secondary amenorrhea, often following over-zealous curettage. * **First-line Investigation:** Urine Pregnancy Test (UPT) or serum beta-hCG.

Question 1

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 2

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 3

What is the treatment for puberty menorrhagia?

Accepted Answer

GnRH analogues

Answer

Progesterone

Answer

Progesterone and estrogen

Answer

Danazol

Question 4

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 5

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

Question 6

What is the best line of management for a 45-year-old lady with polymenorrhoea for 6 months?

Accepted Answer

Oral contraceptive pills for 6 months

Answer

Progesterone for 6 months

Answer

Dilation and curettage

Answer

Hysterectomy

Question 7

Which of the following modalities has shown the best results for premenstrual syndrome?

Accepted Answer

SSRI

Answer

Progesterone

Answer

Estrogen

Answer

Anxiolytics

Question 8

Which of the following is not indicated in the management of menorrhagia?

Accepted Answer

Clomiphene

Answer

NSAIDs

Answer

Norethisterone

Answer

Tranexamic acid

Question 9

What is the commonest condition associated with menorrhagia?

Accepted Answer

Fibroid

Answer

Adenomyosis

Answer

Granulosa cell tumour

Answer

Polycystic ovary

Question 10

What is the most common cause of secondary amenorrhea?

Accepted Answer

Pregnancy

Answer

Hypogonadism

Answer

Hypopituitarism

Answer

Ovarian tumor

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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