Menstrual Disorders — MCQs

Menstrual Disorders Indian Medical PG Practice Questions and MCQs

Question 31: Primary amenorrhoea is seen in all the following conditions except:

A. Klinefelter syndrome
B. Mayer-Rokitansky-Küster-Hauser syndrome
C. Asherman syndrome (Correct Answer)
D. Turner syndrome

Explanation: **Explanation:** The core concept in this question lies in distinguishing between **Primary Amenorrhoea** (failure to initiate menstruation by age 15) and **Secondary Amenorrhoea** (cessation of established menses for >6 months). **Why Asherman Syndrome is the correct answer:** Asherman syndrome refers to the presence of intrauterine adhesions (synechiae) typically resulting from trauma to the basal layer of the endometrium (e.g., over-zealous D&C or genital tuberculosis). Since this condition requires a prior uterine insult or the destruction of an existing functional endometrium, it is a classic cause of **Secondary Amenorrhoea**. It cannot be a cause of primary amenorrhoea because the anatomy is initially normal and functional. **Analysis of Incorrect Options:** * **Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome:** Characterized by Müllerian agenesis (absent uterus and upper 2/3 of the vagina) in a 46,XX female. Since there is no uterus, menstruation never begins. * **Turner Syndrome (45,XO):** The most common cause of primary amenorrhoea. It involves gonadal dysgenesis (streak ovaries), leading to hypergonadotropic hypogonadism. * **Klinefelter Syndrome (47,XXY):** While primarily a male phenotype, it is often included in differential lists for primary amenorrhoea in the context of "disorders of sexual development" or phenotypic confusion in exams. In a phenotypic male, menses never occur; however, in the context of this question, it represents a congenital/chromosomal cause present from birth, unlike the acquired nature of Asherman’s. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common cause of Primary Amenorrhoea:** Turner Syndrome (Gonadal dysgenesis). 2. **Most common cause of Secondary Amenorrhoea:** Pregnancy (Physiological); PCOS (Pathological). 3. **Asherman Syndrome Diagnosis:** Gold standard is **Hysteroscopy**. On HSG, it shows "honeycomb" appearance or filling defects. 4. **MRKH Syndrome:** Patients have normal secondary sexual characters (ovaries are functional) but absent uterus.

Question 32: Dysfunctional uterine bleeding is defined as abnormal bleeding due to which of the following?

A. Thyroid dysfunction
B. Functioning ovarian tumor
C. Anovulatory cycle (Correct Answer)
D. Blood dyscrasias

Explanation: **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.

Question 33: What is the commonest cause of primary amenorrhea?

A. Genital tuberculosis
B. Ovarian dysgenesis (Correct Answer)
C. Mullerian duct anomalies
D. Hypothyroidism

Explanation: **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.

Question 34: Which of the following is NOT an evidence-based treatment for menorrhagia?

A. Oral Contraceptive Pills
B. Progesterone for three months cyclically
C. Tranexamic acid
D. Ethamsylate (Correct Answer)

Explanation: **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.

Question 35: A 45-year-old woman presents with a history of polymenorrhea for the last six months. What is the first-line management?

A. Hysterectomy
B. Progesterone for 3 cycles
C. Dilatation and curettage (Correct Answer)
D. Oral contraceptive for 3 cycles

Explanation: **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**.

Question 36: Which of the following structures normally closes before birth?

A. Ductus arteriosus
B. Ductus venosus
C. Cardinal vein (Correct Answer)
D. Umbilical vein

Explanation: **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.

Question 37: Menstruation occurring every 15 days is:

A. Polymenorrhea (Correct Answer)
B. Epimenorrhea
C. Cryptomenorrhea
D. Hypomenorrhea

Explanation: **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).

Question 38: Which of the following statements is false regarding oligomenorrhoea?

A. It is frequent
B. Regularly timed episodes of bleeding
C. Menstruation occurring at an interval of more than 30 days
D. All of the above (Correct Answer)

Explanation: **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 <21 days) is termed *Polymenorrhoea*. * **Option B (False):** While the episodes can sometimes be regular, oligomenorrhoea is classically associated with **irregularly timed** episodes, often reflecting underlying anovulation or oligo-ovulation. * **Option C (False):** The clinical threshold for oligomenorrhoea is an interval of **>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.

Question 39: Which of the following is the most appropriate treatment for abnormal uterine bleeding - endometrial (AUB-E)?

A. NSAIDs
B. Tranexamic acid
C. Oral progestins (Correct Answer)
D. Combined OCPs

Explanation: **Explanation:** **Abnormal Uterine Bleeding - Endometrial (AUB-E)** refers to heavy menstrual bleeding (HMB) occurring in the presence of regular ovulatory cycles, where no structural or systemic cause is identified. It is primarily a diagnosis of exclusion, attributed to primary dysfunction of the local endometrial mechanisms (e.g., imbalances in prostaglandins or increased fibrinolysis). **Why Oral Progestins are the Correct Answer:** In the context of AUB-E, **Oral Progestins** (specifically during the luteal phase or as long-term therapy) are considered the first-line medical management. They work by stabilizing the endometrium, counteracting the effects of estrogen, and inducing a secretory change that leads to a more controlled and complete shedding of the lining. For acute episodes or chronic management, progestins (like Medroxyprogesterone acetate or Norethisterone) effectively reduce menstrual blood loss. **Analysis of Incorrect Options:** * **NSAIDs (A):** These inhibit prostaglandin synthesis. While they reduce blood loss by 20-30%, they are generally considered secondary or adjunct treatments compared to hormonal stabilization. * **Tranexamic Acid (B):** This is an antifibrinolytic. While highly effective for symptomatic relief of HMB, it does not address the underlying endometrial hormonal environment. * **Combined OCPs (D):** These are effective for AUB-O (Ovulatory dysfunction) or general HMB, but in specific AUB-E cases, pure progestational agents are often prioritized to stabilize the local endometrial environment. **Clinical Pearls for NEET-PG:** * **FIGO Classification (PALM-COEIN):** AUB-E falls under the "Non-structural" (COEIN) category. * **Gold Standard:** The **Levonorgestrel-releasing Intrauterine System (LNG-IUS)** is actually the most effective medical treatment for AUB-E, but among the *oral* options provided, progestins are the standard. * **Diagnosis:** AUB-E is suspected when cycles are regular (predictable) but heavy, and imaging/biopsy are normal.

Question 40: What does polymenorrhea mean?

A. Menses occurring more frequently than every 21 days (Correct Answer)
B. Menses occurring less frequently than every 35 days
C. Painful menses
D. Dysfunctional uterine bleeding

Explanation: **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.

Practice by Chapter

Normal Menstrual Physiology

Practice Questions

Primary Dysmenorrhea

Practice Questions

Secondary Dysmenorrhea

Practice Questions

Premenstrual Syndrome and PMDD

Practice Questions

Primary Amenorrhea

Practice Questions

Secondary Amenorrhea

Practice Questions

Polycystic Ovary Syndrome

Practice Questions

Abnormal Uterine Bleeding: Classification

Practice Questions

Evaluation of Menstrual Disorders

Practice Questions

Management Approaches to Menstrual Disorders

Practice Questions

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free