Menstrual Disorders Practice Questions

Q: Dysfunctional uterine bleeding is defined as abnormal bleeding due to which of the following?

Anovulatory cycle. **Explanation:** **Dysfunctional Uterine Bleeding (DUB)** is defined as a state of abnormal uterine bleeding (AUB) in the absence of any detectable organic, systemic, or iatrogenic cause (e.g., pelvic pathology, pregnancy, or blood disorders). It is essentially a **diagnosis of exclusion**. **Why C is correct:** The underlying pathophysiology of DUB is almost always **hormonal imbalance**, most commonly resulting from an **anovulatory cycle**. In anovulation, there is no corpus luteum formation, leading to a lack of progesterone. This results in "unopposed estrogen" action on the endometrium, causing it to proliferate excessively. Eventually, the endometrium outgrows its blood supply, leading to asynchronous breakdown and heavy, irregular bleeding (Estrogen Breakthrough Bleeding). **Why other options are incorrect:** * **A & D (Thyroid dysfunction and Blood dyscrasias):** These are **systemic causes** of abnormal uterine bleeding. Once a systemic cause is identified, the diagnosis is no longer "dysfunctional" but rather AUB secondary to a specific medical condition. * **B (Functioning ovarian tumor):** This is an **organic/structural cause**. DUB specifically excludes any pelvic pathology or tumors. **NEET-PG High-Yield Pearls:** * **PALM-COEIN Classification:** The FIGO nomenclature has largely replaced the term DUB with **AUB-O** (Ovulatory dysfunction). * **Most common age groups for DUB:** Adolescence (due to immature HPO axis) and Perimenopause. * **Gold Standard Investigation:** Endometrial biopsy (to rule out hyperplasia/malignancy) in women >35 years or those with risk factors. * **Management:** Combined Oral Contraceptive Pills (COCs) or Progesterone are first-line medical treatments; the **Levonorgestrel Intrauterine System (LNG-IUS)** is the most effective medical management.

Q: What is the commonest cause of primary amenorrhea?

Ovarian dysgenesis. **Explanation:** Primary amenorrhea is defined as the absence of menarche by age 13 in the absence of secondary sexual characteristics, or by age 15 if secondary sexual characteristics are present. **Why Ovarian Dysgenesis is Correct:** **Ovarian dysgenesis (specifically Turner Syndrome, 45,XO)** is the most common cause of primary amenorrhea, accounting for approximately **40-50%** of cases. In these patients, the ovaries fail to develop properly and are replaced by fibrous "streak gonads." This leads to hypergonadotropic hypogonadism (elevated FSH/LH due to lack of estrogen feedback). **Analysis of Incorrect Options:** * **Genital Tuberculosis:** While a significant cause of secondary amenorrhea and infertility in developing countries (due to endometrial destruction/Asherman’s syndrome), it is a rare cause of primary amenorrhea. * **Mullerian Duct Anomalies:** Conditions like MRKH syndrome (Mullerian agenesis) are the **second** most common cause of primary amenorrhea (~15-20%). These patients have normal ovaries and secondary sexual characteristics but lack a uterus and upper vagina. * **Hypothyroidism:** Endocrine disorders can cause menstrual irregularities, but they are much less frequent causes of primary amenorrhea compared to genetic or structural defects. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause overall:** Ovarian Dysgenesis (Turner Syndrome). * **Most common cause with normal secondary sexual characteristics:** MRKH Syndrome. * **Initial investigation:** Karyotyping (if FSH is high) or Ultrasound (to check for the presence of a uterus). * **Turner Syndrome Hallmark:** Short stature, webbed neck, and high FSH levels.

Q: Which of the following is NOT an evidence-based treatment for menorrhagia?

Ethamsylate. **Explanation:** The goal of treating menorrhagia (Heavy Menstrual Bleeding) is to reduce menstrual blood loss (MBL) using evidence-based medical or surgical interventions. **Why Ethamsylate is the correct answer:** Ethamsylate is a hemostatic agent that acts by improving platelet adhesiveness and capillary wall stability. While it is frequently used in clinical practice, multiple Cochrane reviews and international guidelines (like NICE) have concluded that **Ethamsylate is not effective** in significantly reducing menstrual blood loss compared to other agents. Therefore, it is no longer recommended as an evidence-based treatment for menorrhagia. **Analysis of Incorrect Options:** * **Oral Contraceptive Pills (OCPs):** These are a first-line hormonal treatment. They work by inducing endometrial atrophy and inhibiting ovulation, typically reducing MBL by 40-50%. * **Cyclical Progesterone:** While 10-day luteal phase progesterone is ineffective, **long-cycle progesterone** (given for 21 days, e.g., from day 5 to 25) is an evidence-based method to regulate the cycle and reduce flow, especially in anovulatory bleeding. (Note: The Levonorgestrel-IUS is the most effective progesterone-based delivery system). * **Tranexamic Acid:** This is an antifibrinolytic that prevents the breakdown of fibrin clots in the uterine vasculature. It is a highly effective non-hormonal treatment, reducing MBL by approximately 50%. **High-Yield Clinical Pearls for NEET-PG:** * **Drug of Choice (DOC):** The **LNG-IUS (Mirena)** is the overall medical DOC for menorrhagia (70-90% reduction in blood loss). * **Non-Hormonal DOC:** Tranexamic acid is the preferred choice for women desiring pregnancy. * **NSAIDs:** (e.g., Mefenamic acid) are also evidence-based treatments, particularly useful if the patient has associated dysmenorrhea.

Q: A 45-year-old woman presents with a history of polymenorrhea for the last six months. What is the first-line management?

Dilatation and curettage. **Explanation:** The primary concern in a perimenopausal woman (age >40 years) presenting with abnormal uterine bleeding (AUB), such as polymenorrhea, is the risk of **Endometrial Hyperplasia or Endometrial Carcinoma**. **Why Dilatation and Curettage (D&C) is correct:** In women over 40, any change in menstrual frequency or flow necessitates a tissue diagnosis to rule out malignancy. D&C serves a dual purpose: it is **diagnostic** (obtaining a sample for histopathology) and **therapeutic** (scraping the functional layer to stop immediate bleeding). While Transvaginal Ultrasound (TVS) is often an initial screening tool to measure endometrial thickness, D&C remains a gold-standard "first-line" intervention in clinical exams to exclude hyperplasia before starting hormonal therapy. **Why other options are incorrect:** * **Hysterectomy (A):** This is a major surgical intervention and is considered definitive management only after a diagnosis is confirmed and medical management has failed. * **Progesterone (B) & Oral Contraceptives (D):** Hormonal therapy is the treatment for Dysfunctional Uterine Bleeding (DUB). However, these should **never** be started in a woman over 40 without first ruling out endometrial cancer via biopsy or D&C. **Clinical Pearls for NEET-PG:** * **Age Cut-off:** For AUB, the threshold for mandatory endometrial sampling is **>45 years**, or **>40 years** if there are additional risk factors (obesity, nulliparity, PCOD). * **Pipelle Biopsy:** In modern practice, Pipelle aspiration is the preferred office procedure, but D&C remains the classic answer for "diagnostic and therapeutic" management in exams. * **Polymenorrhea definition:** Menstrual cycle length **<21 days**.

Q: Which of the following structures normally closes before birth?

Cardinal vein. **Explanation:** The correct answer is **C. Cardinal vein**. In fetal development, the **cardinal veins** are the main venous drainage system of the embryo. Most components of the cardinal system (specifically the posterior cardinal veins) undergo spontaneous regression and remodeling into the permanent venous system (like the IVC and azygos system) **during the embryonic and early fetal period (around 8 weeks)**. Therefore, they "close" or transform long before birth. **Why the other options are incorrect:** * **A. Ductus arteriosus:** This shunts blood from the pulmonary artery to the aorta. It closes **functionally** within 10–15 hours after birth due to increased oxygen tension and decreased prostaglandins, and **anatomically** by 2–3 weeks (becoming the *ligamentum arteriosum*). * **B. Ductus venosus:** This shunts oxygenated blood from the umbilical vein to the IVC, bypassing the liver. It closes after birth, becoming the *ligamentum venosum*. * **D. Umbilical vein:** This carries oxygenated blood from the placenta to the fetus. It collapses after the umbilical cord is clamped at birth, eventually becoming the *ligamentum teres hepatis*. **High-Yield NEET-PG Pearls:** * **Remnants to Remember:** * Umbilical Vein $\rightarrow$ Ligamentum teres. * Umbilical Artery $\rightarrow$ Medial umbilical ligament. * Ductus Arteriosus $\rightarrow$ Ligamentum arteriosum. * Ductus Venosus $\rightarrow$ Ligamentum venosum. * Foramen Ovale $\rightarrow$ Fossa ovalis. * **Clinical Note:** Indomethacin (a prostaglandin inhibitor) is used to close a Patent Ductus Arteriosus (PDA), while PGE1 is used to keep it open in cyanotic heart diseases.

Q: Menstruation occurring every 15 days is:

Polymenorrhea. **Explanation:** The correct answer is **Polymenorrhea**. **1. Why Polymenorrhea is correct:** Polymenorrhea is defined as a menstrual cycle that is abnormally frequent, occurring at intervals of **less than 21 days**. In this case, menstruation every 15 days falls well below the normal range (21–35 days). It is often associated with a shortened follicular phase or luteal phase deficiency. **2. Analysis of Incorrect Options:** * **Epimenorrhea:** This is an older, synonymous term for polymenorrhea. However, in modern medical terminology and standard textbooks (like Dutta or Williams), **Polymenorrhea** is the preferred and more frequently tested term in competitive exams. * **Cryptomenorrhea:** This refers to "hidden menstruation." Menstrual blood is produced but fails to escape the genital tract due to an anatomical obstruction, such as an **imperforate hymen** or transverse vaginal septum. * **Hypomenorrhea:** This refers to an abnormally low amount of menstrual bleeding (scanty flow) or a short duration of flow (less than 2 days), while the cycle interval remains normal. **3. NEET-PG High-Yield Clinical Pearls:** * **Normal Menstrual Cycle:** Interval: 21–35 days; Duration: 2–7 days; Blood loss: 20–80 ml. * **Oligomenorrhea:** Cycle interval >35 days (infrequent periods). * **Menorrhagia (Hypermenorrhea):** Cyclic bleeding that is excessive in amount (>80 ml) or duration (>7 days). * **Metrorrhagia:** Acyclic, irregular bleeding occurring between periods. * **Menometrorrhagia:** Bleeding that is both excessive in amount and irregular in frequency. * **PALM-COEIN:** Remember this FIGO classification for the causes of Abnormal Uterine Bleeding (AUB).

Q: Which of the following statements is false regarding oligomenorrhoea?

All of the above. **Explanation:** Oligomenorrhoea is defined as infrequent menstruation occurring at intervals of **more than 35 days** (or fewer than 9 cycles per year). The question asks for the **false** statement; since all three individual options (A, B, and C) contain factual inaccuracies regarding the definition of oligomenorrhoea, "All of the above" is the correct choice. **Breakdown of Options:** * **Option A (False):** Oligomenorrhoea refers to **infrequent** periods, not frequent ones. Frequent menstruation (intervals 35 days**. An interval of 30 days is considered within the normal physiological range (21–35 days). **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Cause:** Polycystic Ovary Syndrome (PCOS) is the leading cause of oligomenorrhoea in reproductive-age women. * **Normal Cycle:** 28 days ± 7 days (Range: 21–35 days). * **Amenorrhoea vs. Oligomenorrhoea:** If the interval exceeds **6 months** (or 3 cycles in a previously regular woman), it is classified as secondary amenorrhoea. * **Adolescence:** Oligomenorrhoea is often physiological in the first 1–2 years post-menarche due to the immaturity of the Hypothalamic-Pituitary-Ovarian (HPO) axis. * **Other Causes:** Hyperprolactinemia, thyroid dysfunction (hypothyroidism), and perimenopause.

Q: What does polymenorrhea mean?

Menses occurring more frequently than every 21 days. **Explanation:** **Polymenorrhea** is a term used to describe a menstrual cycle that is abnormally short. In a normal clinical scenario, the average menstrual cycle lasts between 21 to 35 days. Polymenorrhea occurs when the cycle length is **less than 21 days**, leading to menses occurring more frequently than normal. This is often associated with an abbreviated follicular phase or a luteal phase defect. **Analysis of Options:** * **Option A (Correct):** This aligns with the clinical definition. Frequent cycles (<21 days) mean the patient has more periods in a calendar year. * **Option B (Incorrect):** Menses occurring less frequently than every 35 days is termed **Oligomenorrhea**. * **Option C (Incorrect):** Painful menstruation is termed **Dysmenorrhea**. * **Option D (Incorrect):** **Dysfunctional Uterine Bleeding (DUB)**—now largely replaced by the PALM-COEIN classification—refers to abnormal uterine bleeding (AUB) not caused by pelvic pathology, medications, or systemic disease. **High-Yield Clinical Pearls for NEET-PG:** * **Terminology Update:** According to FIGO nomenclature, the term "Polymenorrhea" is being replaced by **"Frequent Menstrual Bleeding."** * **Menorrhagia:** Cyclic bleeding that is excessive in amount (>80 ml) or duration (>7 days). * **Metrorrhagia:** Irregular, acyclic bleeding occurring between periods. * **Hypomenorrhea:** Regularly timed but scanty bleeding (<2 days or <20 ml). * **Key Rule:** Always rule out pregnancy and thyroid dysfunction (Hypothyroidism) in any patient presenting with menstrual irregularities.

Question 1

Primary amenorrhoea is seen in all the following conditions except:

Accepted Answer

Asherman syndrome

Answer

Klinefelter syndrome

Answer

Mayer-Rokitansky-Küster-Hauser syndrome

Answer

Turner syndrome

Question 2

Dysfunctional uterine bleeding is defined as abnormal bleeding due to which of the following?

Accepted Answer

Anovulatory cycle

Answer

Thyroid dysfunction

Answer

Functioning ovarian tumor

Answer

Blood dyscrasias

Question 3

What is the commonest cause of primary amenorrhea?

Accepted Answer

Ovarian dysgenesis

Answer

Genital tuberculosis

Answer

Mullerian duct anomalies

Answer

Hypothyroidism

Question 4

Which of the following is NOT an evidence-based treatment for menorrhagia?

Accepted Answer

Ethamsylate

Answer

Oral Contraceptive Pills

Answer

Progesterone for three months cyclically

Answer

Tranexamic acid

Question 5

A 45-year-old woman presents with a history of polymenorrhea for the last six months. What is the first-line management?

Accepted Answer

Dilatation and curettage

Answer

Hysterectomy

Answer

Progesterone for 3 cycles

Answer

Oral contraceptive for 3 cycles

Question 6

Which of the following structures normally closes before birth?

Accepted Answer

Cardinal vein

Answer

Ductus arteriosus

Answer

Ductus venosus

Answer

Umbilical vein

Question 7

Menstruation occurring every 15 days is:

Accepted Answer

Polymenorrhea

Answer

Epimenorrhea

Answer

Cryptomenorrhea

Answer

Hypomenorrhea

Question 8

Which of the following statements is false regarding oligomenorrhoea?

Accepted Answer

All of the above

Answer

It is frequent

Answer

Regularly timed episodes of bleeding

Answer

Menstruation occurring at an interval of more than 30 days

Question 9

Which of the following is the most appropriate treatment for abnormal uterine bleeding - endometrial (AUB-E)?

Accepted Answer

Oral progestins

Answer

NSAIDs

Answer

Tranexamic acid

Answer

Combined OCPs

Question 10

What does polymenorrhea mean?

Accepted Answer

Menses occurring more frequently than every 21 days

Answer

Menses occurring less frequently than every 35 days

Answer

Painful menses

Answer

Dysfunctional uterine bleeding

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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