Menstrual Disorders — MCQs

Menstrual Disorders Indian Medical PG Practice Questions and MCQs

Question 41: What is the most common cause of menorrhagia in the childbearing period?

A. Fibroid
B. Dysfunctional uterine bleeding (Correct Answer)
C. Pelvic endometriosis
D. Adenomyosis

Explanation: **Explanation:** **1. Why Dysfunctional Uterine Bleeding (DUB) is correct:** Dysfunctional Uterine Bleeding (now often classified under the FIGO PALM-COEIN system as 'Non-structural' causes) remains the most common cause of menorrhagia in women of reproductive age. It is defined as abnormal bleeding from the uterine endometrium unrelated to structural or systemic disease. In the childbearing period, it is most frequently associated with **anovulatory cycles**, where the absence of progesterone leads to prolonged estrogen stimulation, resulting in an unstable, thickened endometrium that sheds irregularly and heavily. **2. Why the other options are incorrect:** * **Fibroid (Leiomyoma):** While fibroids are the most common **benign tumor** of the uterus and a very frequent cause of menorrhagia, they are statistically secondary to DUB in overall prevalence across the entire childbearing population. * **Adenomyosis:** This typically presents in multiparous women in their late 30s or 40s. While it causes menorrhagia and dysmenorrhea, its incidence is lower than DUB and fibroids. * **Pelvic Endometriosis:** The hallmark of endometriosis is **dysmenorrhea** (pain) and infertility, not menorrhagia. If heavy bleeding occurs with endometriosis, it is usually due to associated pathology like fibroids or adenomyosis. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation** for menorrhagia in women >35 years: Endometrial biopsy (to rule out hyperplasia/malignancy). * **Investigation of Choice** for structural causes: Transvaginal Ultrasound (TVS). * **Medical Management:** Levonorgestrel Intrauterine System (LNG-IUS/Mirena) is the first-line treatment for DUB. * **Terminology Note:** The term "DUB" is being replaced by the **PALM-COEIN** classification, where DUB corresponds primarily to Coagulopathy, Ovulatory dysfunction, or Endometrial causes.

Question 42: Dysfunctional uterine bleeding (DUB) is due to:

A. Endometriosis
B. Fibroid
C. Endometrial carcinoma
D. Irregular shedding of the endometrium (Correct Answer)

Explanation: **Explanation:** **Dysfunctional Uterine Bleeding (DUB)** is defined as abnormal uterine bleeding in the absence of any detectable organic, systemic, or iatrogenic cause (e.g., pelvic tumors, inflammation, or pregnancy). It is primarily a diagnosis of exclusion and is caused by an endocrine imbalance affecting the hypothalamic-pituitary-ovarian axis. **Why Option D is Correct:** **Irregular shedding of the endometrium** is a classic subtype of ovulatory DUB. It occurs due to the persistent action of the corpus luteum, leading to prolonged progesterone secretion. This prevents the synchronous shedding of the endometrium, resulting in heavy and prolonged menses (menorrhagia). On a biopsy, this is characterized by the presence of both secretory and proliferative patterns simultaneously. **Why Other Options are Incorrect:** * **A. Endometriosis:** This is an organic condition where endometrial tissue grows outside the uterus. While it causes dysmenorrhea and pelvic pain, it is not classified as DUB. * **B. Fibroid (Leiomyoma):** This is a benign monoclonal tumor of the myometrium. It is a structural/organic cause of bleeding (categorized under "L" in the PALM-COEIN classification). * **C. Endometrial Carcinoma:** This is a malignant neoplastic condition. DUB, by definition, excludes any pelvic malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **PALM-COEIN Classification:** DUB now falls under the "COEIN" (Non-structural) category of Abnormal Uterine Bleeding (AUB). * **Anovulatory DUB:** The most common type (80%), often seen at extremes of reproductive life (puberty and perimenopause) due to "unopposed estrogen." * **Irregular Ripening:** Another ovulatory DUB caused by poor corpus luteum function (progesterone deficiency), leading to premenstrual spotting. * **Gold Standard Diagnosis:** Dilatation and Curettage (D&C) or endometrial biopsy is essential in women >35 years to rule out malignancy before labeling it as DUB.

Question 43: Cystoglandular hyperplasia is seen in which of the following conditions?

A. Menorrhagia
B. Polymenorrhea
C. Oligomenorrhea
D. Metropathia hemorrhagica (Correct Answer)

Explanation: **Explanation:** **Metropathia Hemorrhagica** (also known as Schroeder’s Disease) is a specific type of Dysfunctional Uterine Bleeding (DUB) typically seen in perimenopausal women. The underlying pathophysiology is **anovulation**, which leads to a state of **unopposed estrogen**. Without ovulation, no corpus luteum is formed, resulting in a lack of progesterone. The continuous estrogenic stimulation causes the endometrium to proliferate excessively without shedding, leading to **Cystoglandular Hyperplasia**. Histologically, this is characterized by a "Swiss-cheese appearance," where endometrial glands are dilated into various sizes (some cystic) and the stroma is hyperplastic. Clinically, this manifests as a period of amenorrhea (due to high estrogen) followed by heavy, painless, prolonged bleeding. **Analysis of Incorrect Options:** * **A. Menorrhagia:** This is a symptom (cyclic heavy bleeding) rather than a specific pathological entity. While it can be caused by hyperplasia, it is also caused by fibroids, adenomyosis, or IUDs, which do not show cystoglandular changes. * **B. Polymenorrhea:** Refers to frequent cycles (<21 days). It is usually due to a shortened follicular phase or luteal phase deficiency, not the prolonged unopposed estrogen seen in cystoglandular hyperplasia. * **C. Oligomenorrhea:** Refers to infrequent cycles (>35 days). While often anovulatory (e.g., PCOS), it does not specifically define the pathological state of Metropathia Hemorrhagica. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Amenorrhea followed by heavy bleeding in a perimenopausal woman. * **Histology:** "Swiss-cheese" endometrium (dilated glands). * **Ovarian finding:** Presence of a follicular cyst (unruptured follicle); absence of corpus luteum. * **Treatment of choice:** Dilation and Curettage (D&C) serves both a diagnostic and therapeutic purpose.

Question 44: Hypothalamic amenorrhea is seen in which of the following conditions?

A. Stein-leventhal syndrome
B. Asherman syndrome
C. Kallman syndrome (Correct Answer)
D. Sheehan's syndrome

Explanation: **Explanation:** **Kallmann Syndrome (Correct Answer):** Kallmann syndrome is a form of **hypogonadotropic hypogonadism** caused by the failure of GnRH-secreting neurons to migrate from the olfactory placode to the **hypothalamus**. This results in a deficiency of Gonadotropin-Releasing Hormone (GnRH), leading to low levels of FSH and LH, and subsequent amenorrhea. A hallmark clinical feature is **anosmia** (loss of smell) due to the agenesis of olfactory bulbs. **Analysis of Incorrect Options:** * **A. Stein-Leventhal Syndrome (PCOS):** This is an ovarian/endocrine disorder characterized by hyperandrogenism and insulin resistance. While it involves altered GnRH pulsatility, it is primarily classified as an **ovulatory dysfunction** rather than a primary hypothalamic failure. * **B. Asherman Syndrome:** This is a cause of **outflow tract obstruction** (uterine/anatomical amenorrhea). It involves the formation of intrauterine adhesions (synechiae), usually post-curettage, preventing the menstrual flow despite normal hormonal axes. * **C. Sheehan’s Syndrome:** This is a **pituitary** cause of amenorrhea. It results from ischemic necrosis of the anterior pituitary gland due to severe postpartum hemorrhage (PPH). **High-Yield Clinical Pearls for NEET-PG:** * **Hypothalamic Amenorrhea** can also be "functional," triggered by excessive exercise (Female Athlete Triad), severe weight loss (Anorexia Nervosa), or psychological stress. * **Kallmann Syndrome Inheritance:** Most commonly X-linked recessive (KAL1 gene). * **Diagnostic Tip:** In hypothalamic or pituitary amenorrhea, the **Progesterone Challenge Test** will be negative (no withdrawal bleed) because the endometrium has not been primed by estrogen.

Question 45: A 45-year-old woman presents with amenorrhea for 9 months. She expresses a desire to become pregnant again. After excluding pregnancy, what is the next best test indicated in the evaluation of this patient's amenorrhea?

A. LH and FSH levels (Correct Answer)
B. Endometrial biopsy
C. Karyotyping
D. HSG (Hysterosalpingography)

Explanation: ### Explanation The patient is 45 years old and presents with secondary amenorrhea (absence of menses for >6 months). In a woman of this age, the most likely diagnosis is **Premature Ovarian Insufficiency (POI)** or the onset of **Menopause**. **1. Why LH and FSH levels are the correct next step:** After excluding pregnancy (the most common cause of secondary amenorrhea), the goal is to determine the anatomical or hormonal level of the defect. In a 45-year-old, measuring **FSH and LH** is the gold standard to assess ovarian reserve and function. * **High FSH (>40 IU/L)** on two occasions indicates hypergonadotropic hypogonadism (Menopause/POI), confirming that the ovaries are no longer responding to gonadotropins. * Given her desire for pregnancy, these levels are crucial for counseling regarding the feasibility of conception (likely requiring oocyte donation). **2. Why other options are incorrect:** * **Endometrial Biopsy:** Used to evaluate abnormal uterine bleeding or rule out hyperplasia/malignancy. It does not help diagnose the cause of amenorrhea. * **Karyotyping:** Indicated for primary amenorrhea or POI in women **under age 30** (to rule out Turner syndrome or Mosaicism). It is not routine for a 45-year-old. * **HSG:** Used to evaluate tubal patency and uterine cavity in infertility workups, but only after the hormonal cause of amenorrhea is established. **Clinical Pearls for NEET-PG:** * **Definition of Menopause:** 12 months of amenorrhea in a woman over 40. * **Premature Ovarian Insufficiency (POI):** Menopause occurring before age 40. * **Hormonal Profile in Menopause:** ↑ FSH, ↑ LH, ↓ Estrogen (FSH rises more significantly than LH due to loss of Inhibin-B). * **Progesterone Challenge Test:** Historically used to check estrogen priming and outflow tract patency, but FSH measurement is now the preferred initial hormonal assay.

Question 46: Puberty menorrhagia is treated by:

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

Explanation: **Explanation:** **Puberty menorrhagia** is defined as excessive bleeding between the onset of menarche and 19 years of age. The underlying pathophysiology is usually an **unripe Hypothalamic-Pituitary-Ovarian (HPO) axis**, leading to **anovulatory cycles**. Without ovulation, there is no corpus luteum formation and no progesterone production. This results in "unopposed estrogen" action, causing the endometrium to become hyperplastic, fragile, and vascular, leading to heavy, irregular shedding. **Why "All" is the Correct Answer:** The management strategy depends on the severity of the bleeding and the clinical status of the patient: * **Option A (Progesterone):** This is the **first-line hormonal treatment**. It stabilizes the estrogen-primed endometrium and induces a "medical curettage" (withdrawal bleed), effectively stopping the heavy flow. * **Option B (Progesterone and Estrogen):** Combined Oral Contraceptive Pills (COCPs) are highly effective for cycle regulation and are used when progesterone alone is insufficient or if the patient requires long-term cycle control. * **Option C (GnRH Analogues):** These are reserved for **refractory or severe cases** (e.g., patients with underlying bleeding disorders like von Willebrand disease) to induce a temporary state of medical menopause, allowing the patient to recover from severe anemia. **Clinical Pearls for NEET-PG:** 1. **Most common cause:** Anovulatory cycles due to HPO axis immaturity. 2. **Most common systemic cause:** von Willebrand Disease (vWD) should be suspected if menorrhagia occurs from the very first period. 3. **Initial Investigation:** Complete Blood Count (CBC) and Pelvic Ultrasound (to rule out structural causes, though rare in this age group). 4. **Drug of Choice (Acute heavy bleed):** High-dose Progestogens or COCPs. 5. **Non-hormonal options:** Tranexamic acid (antifibrinolytic) and NSAIDs (mefenamic acid) are used for mild cases.

Question 47: Metropathia hemorrhagica is best treated by:

A. Curettage of uterus
B. Progestogen (Correct Answer)
C. Oestrogen
D. Clomiphene

Explanation: **Metropathia Hemorrhagica** (also known as Schroeder’s Disease) is a specific form of Dysfunctional Uterine Bleeding (DUB) characterized by anovulation. The underlying pathophysiology involves a persistent unruptured follicle, leading to **continuous estrogen stimulation** without the counter-balancing effect of progesterone. This results in endometrial hyperplasia, which eventually breaks down, causing heavy, irregular, and painless bleeding. ### Why Progestogen is the Correct Answer: Since the primary defect is the **absence of progesterone** (due to lack of a corpus luteum), the most logical and effective treatment is the administration of exogenous progestogens. Progestogens convert the proliferative/hyperplastic endometrium into a secretory one, stabilize the endometrial lining, and induce a "chemical curettage" upon withdrawal, thereby controlling the bleeding. ### Explanation of Incorrect Options: * **A. Curettage of uterus:** While diagnostic curettage helps rule out malignancy and provides temporary symptomatic relief, it is not the definitive treatment for the underlying hormonal imbalance. * **C. Oestrogen:** Estrogen is already in excess in this condition. Adding more would worsen the endometrial hyperplasia and increase the risk of endometrial carcinoma. * **D. Clomiphene:** This is an ovulation-inducing agent. While it may be used if the patient desires pregnancy, it is not the primary treatment for the acute management of the bleeding episode in Metropathia Hemorrhagica. ### Clinical Pearls for NEET-PG: * **Classic Presentation:** A period of amenorrhea (6–8 weeks) followed by heavy, painless bleeding. * **Histology:** Shows **Cystic Glandular Hyperplasia** (Swiss-cheese pattern). * **Ovarian Finding:** Presence of a follicular cyst (persistent unruptured follicle) and absence of corpus luteum. * **Uterine Finding:** The uterus is often slightly enlarged, soft, and symmetrical (myometrial hypertrophy due to hyperestrogenism).

Question 48: Which is not a feature of dysfunctional uterine bleeding?

A. Tender uterus (Correct Answer)
B. Uterine size of 8-10 weeks
C. Menorrhagia
D. Proliferative endometrium

Explanation: **Explanation:** **Dysfunctional Uterine Bleeding (DUB)** is defined as abnormal uterine bleeding in the absence of any detectable organic pelvic pathology, systemic disease, or pregnancy. It is a diagnosis of exclusion. **1. Why "Tender Uterus" is the correct answer:** Tenderness is a hallmark of **inflammatory or infective conditions** (like Pelvic Inflammatory Disease/Endometritis) or **Adenomyosis**. Since DUB is by definition non-organic and non-inflammatory, the uterus should be **non-tender**. Finding a tender uterus points toward an alternative diagnosis, making it "not a feature" of DUB. **2. Analysis of Incorrect Options:** * **Uterine size of 8-10 weeks:** In DUB, the uterus is typically normal in size or slightly bulky (up to 8–10 weeks) due to prolonged estrogen stimulation causing myometrial hypertrophy. Sizes beyond 12 weeks usually suggest fibroids or pregnancy. * **Menorrhagia:** This is the most common clinical presentation of DUB, particularly in ovulatory cycles or due to irregular shedding in anovulatory cycles. * **Proliferative endometrium:** This is a classic finding in **anovulatory DUB**. Without ovulation, there is no corpus luteum and no progesterone; the endometrium remains in the proliferative phase under the influence of unopposed estrogen until it outgrows its blood supply and sheds irregularly. **Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Dilation and Curettage (D&C) or Hysteroscopy-guided biopsy to rule out malignancy (especially in patients >35 years). * **Most common type:** Anovulatory DUB (80%), common at extremes of reproductive life (puberty and perimenopause). * **Management:** Combined Oral Contraceptives (COCs) are first-line for most; **Levonorgestrel Intrauterine System (LNG-IUS)** is the most effective medical management for heavy menstrual bleeding.

Question 49: Which of the following is not a cause of primary amenorrhea?

A. Sheehan's syndrome (Correct Answer)
B. Kallman's syndrome
C. Turner's syndrome
D. Rokitansky syndrome

Explanation: **Explanation:** The distinction between primary and secondary amenorrhea is a high-yield concept in NEET-PG. **Primary amenorrhea** refers to the failure of menses to occur by age 15 (with secondary sexual characteristics) or age 13 (without them). **Secondary amenorrhea** is the cessation of menses for >3–6 months in a woman who previously had regular cycles. **Why Sheehan’s Syndrome is the correct answer:** Sheehan’s syndrome is **postpartum pituitary necrosis** caused by severe obstetric hemorrhage. Since it occurs as a complication of childbirth, the patient must have been menstruating and fertile previously. Therefore, it is a classic cause of **secondary amenorrhea**, not primary. **Analysis of Incorrect Options:** * **Kallmann’s Syndrome:** A hypogonadotropic hypogonadism caused by failure of GnRH neurons to migrate. It presents with primary amenorrhea and anosmia. * **Turner’s Syndrome (45,XO):** The most common cause of primary amenorrhea. It involves gonadal dysgenesis (streak ovaries), leading to hypergonadotropic hypogonadism. * **Rokitansky Syndrome (MRKH):** Characterized by Müllerian agenesis (absent uterus and upper 2/3 of the vagina) despite a 46,XX karyotype and normal ovaries. It is a common cause of primary amenorrhea with normal secondary sexual characteristics. **Clinical Pearls for NEET-PG:** * **Most common cause of Primary Amenorrhea:** Turner’s Syndrome. * **Most common cause of Secondary Amenorrhea:** Pregnancy (always rule this out first!). * **Sheehan’s Syndrome presentation:** Failure of lactation (earliest sign), followed by loss of pubic/axillary hair and secondary amenorrhea. * **Kallmann’s Syndrome:** Look for the keyword "anosmia" or "hyposmia" in the clinical stem.

Question 50: What is the most common cause of menorrhagia?

A. Anovulation (Correct Answer)
B. Malignancy
C. Endometriosis
D. Bleeding disorder

Explanation: **Explanation:** **Correct Answer: A. Anovulation** Anovulation is the most common cause of menorrhagia, particularly in the adolescent and perimenopausal age groups. In an anovulatory cycle, 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 hyperplastic endometrium outgrows its blood supply and undergoes irregular, asynchronous shedding, manifesting as heavy and prolonged menstrual bleeding (menorrhagia). **Analysis of Incorrect Options:** * **B. Malignancy:** While endometrial or cervical cancer can cause abnormal uterine bleeding (AUB), they are statistically less common than functional causes like anovulation, especially in younger populations. * **C. Endometriosis:** This typically presents with dysmenorrhea (painful periods) and chronic pelvic pain. While it can coexist with menorrhagia, it is not the primary cause of heavy bleeding; Adenomyosis is a more common structural cause of menorrhagia than endometriosis. * **D. Bleeding disorder:** Conditions like Von Willebrand Disease (vWD) are significant causes of menorrhagia (especially in adolescents), but they account for a much smaller percentage of cases compared to hormonal anovulation. **NEET-PG High-Yield Pearls:** * **PALM-COEIN Classification:** The FIGO system classifies AUB into Structural (Polyp, Adenomyosis, Leiomyoma, Malignancy) and Non-structural (Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, Not yet classified). * **AUB-O (Ovulatory dysfunction):** This is the category for anovulation and is the most frequent diagnosis in clinical practice. * **First-line Investigation:** Transvaginal Ultrasound (TVS) is the gold standard for initial assessment of the uterus and adnexa. * **Gold Standard for Endometrial Assessment:** Endometrial biopsy (D&C or Pipelle) is mandatory in women >45 years (or >35 with risk factors) to rule out hyperplasia or malignancy.

Practice by Chapter

Normal Menstrual Physiology

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Primary Dysmenorrhea

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Secondary Dysmenorrhea

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Premenstrual Syndrome and PMDD

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Primary Amenorrhea

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Secondary Amenorrhea

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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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