Menstrual Disorders — MCQs

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?

Q26Medium

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

Q27Easy

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

Q28Easy

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

Q29Easy

What is the commonest condition associated with menorrhagia?

Q30Easy

What is the most common cause of secondary amenorrhea?

Menstrual Disorders Indian Medical PG Practice Questions and MCQs

Question 21: A 16-year-old girl presents with acute vaginal bleeding. What is the immediate management?

A. Uterine ablation
B. Uterine artery embolization
C. Progesterone (Correct Answer)
D. Hysteroscopy examination

Explanation: **Explanation:** The most common cause of acute vaginal bleeding in a 16-year-old is **Anovulatory Abnormal Uterine Bleeding (AUB)** due to an immature Hypothalamic-Pituitary-Ovarian (HPO) axis. In anovulatory cycles, there is "unopposed estrogen" action on the endometrium without the stabilizing effect of progesterone. This leads to an overgrowth of a fragile, vascular endometrium that sheds irregularly and heavily. **Why Progesterone is the Correct Choice:** The immediate goal in acute adolescent AUB is to stabilize the endometrium. Administering **Progesterone** (or high-dose OCPs) converts the proliferative endometrium into a secretory one. Upon withdrawal, it allows for a "medical curettage," leading to a controlled and complete shedding of the lining, thereby stopping the acute hemorrhage. **Analysis of Incorrect Options:** * **Uterine Ablation (A):** This is contraindicated in adolescents as it destroys the endometrium, leading to permanent infertility and potential menstrual complications. It is reserved for older women who have completed their childbearing. * **Uterine Artery Embolization (B):** This is an invasive radiological procedure used typically for massive postpartum hemorrhage or symptomatic fibroids. It is not a first-line treatment for hormonal adolescent bleeding. * **Hysteroscopy (D):** While useful for diagnosing structural issues (like polyps), it is not the *immediate* management for acute hormonal bleeding in a virgin/adolescent patient. **Clinical Pearls for NEET-PG:** * **First-line for Acute AUB:** Medical management (Hormones/TXA) is always preferred over surgery in adolescents. * **Drug of Choice:** High-dose Estrogen can be used to stop profuse bleeding quickly (denudation repair), but Progesterone is the mainstay for cycle stabilization. * **Rule Out:** Always exclude pregnancy (Urine Pregnancy Test) and bleeding disorders (e.g., von Willebrand disease) in adolescents presenting with heavy menstrual bleeding.

Question 22: Which of the following is NOT a contraindication to tranexamic acid in the management of heavy menstrual bleeding?

A. Concurrent combined oral contraceptives use
B. Colour blindness
C. Disseminated intravascular coagulation
D. Intermenstrual bleeding (Correct Answer)

Explanation: **Explanation:** **Tranexamic Acid (TXA)** is an antifibrinolytic agent that works by reversibly binding to plasminogen, preventing its conversion to plasmin and thereby inhibiting the breakdown of fibrin clots. **Why Intermenstrual Bleeding (IMB) is the Correct Answer:** Intermenstrual bleeding is a **clinical symptom**, not a contraindication. While TXA is primarily indicated for cyclic heavy menstrual bleeding (HMB), the presence of IMB necessitates a thorough diagnostic workup (such as ultrasound or endometrial biopsy) to rule out structural pathologies like polyps or malignancy. However, TXA itself is not pharmacologically contraindicated in these patients; it simply may not be the definitive treatment for the underlying cause. **Analysis of Incorrect Options (Contraindications):** * **Concurrent COCP Use:** Using TXA with Combined Oral Contraceptive Pills significantly increases the risk of **thromboembolism** (DVT/PE) due to the additive prothrombotic effects of estrogen and the antifibrinolytic. * **Colour Blindness:** TXA is contraindicated in patients with acquired disturbances in color vision. This is because retinal toxicity has been observed in animal studies, and pre-existing color blindness makes it impossible to monitor for drug-induced visual changes. * **Disseminated Intravascular Coagulation (DIC):** In DIC, there is widespread systemic activation of coagulation. TXA can prevent the necessary breakdown of these systemic microthrombi, leading to multi-organ failure. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism:** Competitive inhibition of plasminogen activation. * **First-line Non-hormonal Rx:** TXA is the first-line non-hormonal treatment for HMB (reduces blood loss by ~40-50%). * **Dosage:** Usually 1g three times daily for up to 4 days during menstruation. * **Absolute Contraindications:** Active thromboembolic disease, history of venous/arterial thrombosis, hypersensitivity, and subarachnoid hemorrhage (due to risk of cerebral edema/infarction).

Question 23: What is the treatment for puberty menorrhagia?

A. Progesterone
B. Progesterone and estrogen
C. GnRH analogues (Correct Answer)
D. Danazol

Explanation: **Explanation:** **Puberty menorrhagia** is defined as excessive menstrual bleeding occurring between menarche and 19 years of age. The most common cause is an **immature Hypothalamic-Pituitary-Ovarian (HPO) axis**, leading to anovulatory cycles. Without ovulation, there is no corpus luteum formation and no progesterone production, resulting in "unopposed estrogen" causing endometrial hyperplasia and irregular shedding. **Why GnRH Analogues are the correct answer:** In severe or refractory cases of puberty menorrhagia, **GnRH analogues** (e.g., Leuprolide) are used to induce a state of "medical oophorectomy." By downregulating GnRH receptors, they suppress the HPO axis entirely, leading to a temporary cessation of menses (amenorrhea). This allows the patient’s hemoglobin levels to recover and prevents life-threatening hemorrhage when hormonal stabilization fails. **Analysis of Incorrect Options:** * **A & B (Progesterone/Estrogen):** While Combined Oral Contraceptive Pills (OCPs) or cyclic progesterones are often the *first-line* medical management for mild-to-moderate cases, they are not the definitive answer in advanced management scenarios or when rapid suppression is required for severe bleeding. * **D (Danazol):** This is an androgenic steroid used in endometriosis or fibroids. It is rarely used in adolescents due to significant virilizing side effects (acne, hirsutism, voice deepening). **Clinical Pearls for NEET-PG:** * **First-line investigation:** Always rule out hematological disorders (e.g., **von Willebrand Disease**) in any adolescent presenting with menorrhagia at menarche. * **Management Strategy:** * Mild: Iron supplements + Observation. * Moderate: OCPs or Cyclic Progesterone. * Severe/Refractory: GnRH analogues or high-dose IV Estrogen. * **Contraindication:** Dilatation and Curettage (D&C) is generally avoided in virgins/adolescents unless life-threatening bleeding occurs and medical management fails.

Question 24: Amenorrhea due to high LH and FSH is due to:

A. Asherman syndrome
B. Pituitary adenoma
C. Ovarian failure (Correct Answer)
D. All of the above

Explanation: **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 25: 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?

A. Cervical carcinoma
B. Cervical dysplasia
C. Dysfunctional uterine bleeding (Correct Answer)
D. Endometrial carcinoma

Explanation: ### Explanation **1. Why the Correct Answer is Right:** **Dysfunctional Uterine Bleeding (DUB)**, now often classified under **AUB-O (Anovulatory)** in the FIGO PALM-COEIN system, is a diagnosis of exclusion. It refers to abnormal uterine bleeding in the absence of any detectable organic pelvic pathology, systemic disease, or pregnancy. * **Clinical Correlation:** The patient is in the late reproductive age group (38 years) with a long history of irregularities. * **Diagnostic Clues:** The **proliferative endometrium** on biopsy suggests anovulation (estrogen is present, but progesterone from the corpus luteum is absent). The normal ultrasound and negative pregnancy test rule out structural causes (like fibroids or polyps) and gestational complications. Mild iron deficiency anemia is a common secondary finding due to chronic blood loss. **2. Why Incorrect Options are Wrong:** * **A & B (Cervical Carcinoma/Dysplasia):** These typically present with post-coital bleeding or intermenstrual spotting. A normal pelvic examination and the absence of suspicious lesions or contact bleeding make these unlikely. * **D (Endometrial Carcinoma):** While it must be ruled out in women >35 years with AUB, the **endometrial biopsy** in this patient specifically showed proliferative endometrium, effectively ruling out malignancy or hyperplasia. **3. High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** For AUB in women >35 years, **Endometrial Biopsy** is mandatory to rule out hyperplasia or malignancy. * **DUB Patterns:** Most cases (80%) are **Anovulatory**, characterized by "uninterrupted estrogen" leading to endometrial overgrowth and irregular shedding. * **Management:** Medical management is the first line. **Combined Oral Contraceptives (COCs)** or **Progestogens** (like Medroxyprogesterone acetate) are commonly used to regulate the cycle. The **Mirena (LNG-IUS)** is considered the "medical hysterectomy" and is highly effective for DUB.

Question 26: What is the best line of management for a 45-year-old lady with polymenorrhoea for 6 months?

A. Progesterone for 6 months
B. Oral contraceptive pills for 6 months (Correct Answer)
C. Dilation and curettage
D. Hysterectomy

Explanation: **Explanation:** The primary goal in managing a 45-year-old with polymenorrhoea (menstrual cycles <21 days) is to regulate the cycle and stabilize the endometrium. **Why Option B is Correct:** In the perimenopausal age group (40–50 years), polymenorrhoea is frequently caused by **shortened follicular phases** or **anovulatory cycles** due to declining ovarian reserve. **Combined Oral Contraceptive Pills (OCPs)** are the first-line medical management because they provide exogenous estrogen and progesterone in a fixed ratio. This suppresses the endogenous pituitary-ovarian axis, prevents irregular endometrial shedding, and ensures predictable withdrawal bleeds, thereby regulating the cycle effectively. **Analysis of Incorrect Options:** * **Option A (Progesterone):** While progesterone is used for DUB (Dysfunctional Uterine Bleeding), it is typically used for heavy menstrual bleeding or to induce withdrawal in amenorrhea. In polymenorrhoea, OCPs are superior as they provide better cycle control by addressing the estrogen-progesterone imbalance. * **Option C (Dilation & Curettage):** D&C is primarily a diagnostic tool to rule out endometrial hyperplasia or malignancy in women >40 years. While it may be indicated if medical therapy fails or if the endometrium is thickened on USG, it is not the "best line of management" for initial cycle regulation. * **Option D (Hysterectomy):** This is a definitive surgical treatment and is reserved for cases where medical management fails or when there is associated pathology like large fibroids or malignancy. **NEET-PG High-Yield Pearls:** * **Polymenorrhoea** is defined as a cycle length of less than 21 days. * In perimenopausal women with AUB (Abnormal Uterine Bleeding), always perform a **Transvaginal Ultrasound (TVS)** first to check **Endometrial Thickness (ET)**. * If ET is **>4 mm** in postmenopausal women or **>12 mm** in perimenopausal women, an endometrial biopsy/D&C is mandatory to rule out malignancy.

Question 27: Which of the following modalities has shown the best results for premenstrual syndrome?

A. SSRI (Correct Answer)
B. Progesterone
C. Estrogen
D. Anxiolytics

Explanation: **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.

Question 28: Which of the following is not indicated in the management of menorrhagia?

A. NSAIDs
B. Clomiphene (Correct Answer)
C. Norethisterone
D. Tranexamic acid

Explanation: **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.

Question 29: What is the commonest condition associated with menorrhagia?

A. Adenomyosis
B. Fibroid (Correct Answer)
C. Granulosa cell tumour
D. Polycystic ovary

Explanation: **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**.

Question 30: What is the most common cause of secondary amenorrhea?

A. Hypogonadism
B. Hypopituitarism
C. Pregnancy (Correct Answer)
D. Ovarian tumor

Explanation: **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.

Practice by Chapter

Normal Menstrual Physiology

Practice Questions

Primary Dysmenorrhea

Practice Questions

Secondary Dysmenorrhea

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Premenstrual Syndrome and PMDD

Practice Questions

Primary Amenorrhea

Practice Questions

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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