Menstrual Disorders Practice Questions

Q: Secondary amenorrhea after abortion due to intrauterine adhesions is seen in:

Asherman's syndrome. **Explanation:** **Asherman’s Syndrome** is the correct answer because it refers to the formation of intrauterine adhesions (synechiae) following trauma to the basal layer of the endometrium. This most commonly occurs after vigorous curettage (D&C) for an incomplete abortion or postpartum hemorrhage. The destruction of the endometrium leads to the fusion of the uterine walls, resulting in secondary amenorrhea or hypomenorrhea and infertility. **Analysis of Incorrect Options:** * **Uterine Inertia:** This refers to weak or absent uterine contractions during labor (primary or secondary). It is a functional complication of the first or second stage of labor and has no association with intrauterine adhesions or amenorrhea. * **Imperforate Hymen:** This is a congenital anatomical cause of **primary amenorrhea**. It leads to cryptomenorrhea (hidden menstruation) where blood collects in the vagina (hematocolpos), but it is not acquired after an abortion. * **Bicornuate Uterus:** This is a congenital Mullerian duct anomaly where the uterus is heart-shaped with two horns. While it can lead to recurrent pregnancy loss or malpresentation, it does not cause secondary amenorrhea or adhesions. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Hysteroscopy is the gold standard for both diagnosis and treatment (adhesiolysis) of Asherman’s Syndrome. * **HSG Finding:** Classically shows "filling defects" within the uterine cavity. * **Treatment:** Hysteroscopic adhesiolysis followed by the placement of an IUCD or Foley catheter and high-dose estrogen therapy to promote endometrial regrowth. * **Amniotic Band Syndrome** is a different entity; do not confuse it with intrauterine synechiae.

Q: Which of the following statements regarding spasmodic dysmenorrhea is false?

Pain persists for 2-3 days. ### Explanation **Spasmodic (Primary) Dysmenorrhea** is characterized by painful uterine contractions caused by the release of **Prostaglandin F2α (PGF2α)** from the secretory endometrium. #### Why Option C is False (The Correct Answer) In spasmodic dysmenorrhea, the pain typically begins a few hours before or exactly at the onset of menstruation. Crucially, the pain is **short-lived**, usually lasting only **12 to 24 hours**. It rarely persists beyond the first 48 hours. If pain persists for 2–3 days or longer, clinicians should suspect **Congestive (Secondary) Dysmenorrhea**, often associated with conditions like endometriosis or PID. #### Analysis of Other Options * **A. Often cured by delivery:** This is **true**. Vaginal delivery causes stretching of the adrenergic nerves in the isthmus and cervix (Frankenhauser’s plexus) and widens the cervical canal, which significantly reduces or eliminates primary dysmenorrhea. * **B. Pain appears on the first day:** This is **true**. The pain is spasmodic/colicky in nature and coincides with the peak of prostaglandin release and the heaviest menstrual flow on day one. * **D. Rare above the age of 35:** This is **true**. Primary dysmenorrhea typically begins shortly after menarche (once ovulatory cycles are established) and tends to improve with increasing age and parity. #### High-Yield Clinical Pearls for NEET-PG * **Mechanism:** High levels of PGF2α → Uterine hypercontractility → Ischemia → Pain. * **Prerequisite:** It occurs only in **ovulatory cycles** (Progesterone is required for PGF2α production). * **First-line Treatment:** NSAIDs (Mefenamic acid), which act as prostaglandin synthetase inhibitors. * **Drug of Choice for Contraception Seekers:** Combined Oral Contraceptive Pills (OCPs), which induce anovulation.

Q: Which of the following statements is false regarding ablative procedures for abnormal uterine bleeding?

Fertility is preserved.. **Explanation:** Endometrial ablation is a surgical procedure designed to destroy the uterine lining (endometrium) to treat heavy menstrual bleeding (AUB-E/AUB-P) in women who wish to avoid a hysterectomy. **Why Option C is the correct (False) statement:** The primary goal of endometrial ablation is the permanent destruction of the basal layer of the endometrium. While it is not a guaranteed form of sterilization, it **significantly impairs fertility** and makes the uterine environment hostile for implantation. Furthermore, if pregnancy does occur, it is associated with high risks of placenta accreta, miscarriage, and growth restriction. Therefore, patients must be counseled that the procedure is **not fertility-preserving**, and reliable contraception is mandatory post-procedure. **Analysis of other options:** * **Options A & B:** These are **true**. Compared to hysterectomy, ablative procedures (like thermal balloons or radiofrequency) are minimally invasive, have lower morbidity (no major abdominal incision, less blood loss), and offer a much faster recovery time (usually returning to work within 1–2 days). * **Option D:** This is **true**. To ensure the endometrium does not regenerate, the procedure must destroy the entire thickness of the endometrium plus **2–3 mm of the underlying myometrium**, where the deep basal glands reside. **NEET-PG High-Yield Pearls:** * **Prerequisites:** Before ablation, a **hysteroscopy and endometrial biopsy** are mandatory to rule out malignancy or atypical hyperplasia. * **Ideal Candidate:** Women with AUB who have completed childbearing, have a uterine size <10–12 weeks, and no structural abnormalities like large submucosal fibroids. * **Amenorrhea Rate:** Approximately 30–50% of women achieve total amenorrhea, while the rest experience significantly reduced flow.

Q: What is the most common endometrial pattern in dysfunctional uterine bleeding?

Normal. **Explanation:** Dysfunctional Uterine Bleeding (DUB) is defined as abnormal uterine bleeding in the absence of any detectable organic pelvic pathology, systemic disease, or pregnancy. **1. Why "Normal" is correct:** In the majority of cases, particularly in women of reproductive age, the endometrial histology in DUB is found to be **normal (proliferative or secretory)**. This occurs because the bleeding is often due to transient hormonal imbalances or local vascular dysregulation rather than a persistent structural change in the endometrium. While DUB is a diagnosis of exclusion, statistical data and clinical studies confirm that a "normal" endometrial pattern is the most frequent finding upon biopsy. **2. Analysis of Incorrect Options:** * **Hyperplastic (Swiss-Cheese pattern):** This is characteristic of cystic glandular hyperplasia, typically seen in **metropathia haemorrhagica** (a specific type of anovulatory DUB). While high-yield for exams, it is not the *most* common overall pattern. * **Nonsecretory (Proliferative):** This indicates anovulatory cycles. While common in extremes of reproductive life (puberty and perimenopause), it ranks second to a normal pattern across the general population. * **Atrophic:** This is the most common cause of postmenopausal bleeding, but it is a less common finding in DUB during the reproductive years. **Clinical Pearls for NEET-PG:** * **Most common cause of DUB:** Anovulation (approx. 80% of cases). * **Metropathia Haemorrhagica (Schroeder’s Disease):** Characterized by specialized "Swiss-cheese" hyperplasia, usually occurring in perimenopausal women due to persistent estrogen stimulation without progesterone. * **Gold Standard Investigation:** For women >35 years with DUB, **Fractional Curettage or Endometrial Biopsy** is mandatory to rule out endometrial carcinoma.

Q: A 30-year-old multiparous hypertensive woman complains of menorrhagia. What is the best treatment for her?

Levonorgestrel-releasing intrauterine system (Mirena). **Explanation:** The patient is a 30-year-old multiparous woman with **menorrhagia** (Heavy Menstrual Bleeding) and a co-morbidity of **hypertension**. **Why Option B is Correct:** The **Levonorgestrel-releasing intrauterine system (LNG-IUS/Mirena)** is currently the first-line medical management for heavy menstrual bleeding (NICE guidelines). It works by releasing progestogen locally, causing endometrial atrophy and reducing menstrual blood loss by up to 90%. In this specific case, the patient is **hypertensive**; LNG-IUS is safe as it lacks the systemic estrogenic effects that can worsen blood pressure. Being multiparous, she is also an ideal candidate for an intrauterine device. **Why Other Options are Incorrect:** * **Option A (COCPs):** Combined oral contraceptive pills are generally **contraindicated** in women with hypertension (especially if poorly controlled) due to the risk of stroke, myocardial infarction, and further elevation of blood pressure caused by the estrogen component. * **Option C (Hysterectomy):** This is a major surgical intervention. It is reserved for patients who have completed their family and failed medical management. At age 30, conservative medical management is preferred first. * **Option D (TCRE):** Endometrial ablation/resection is a second-line surgical option for those who fail medical therapy. It is generally avoided in younger women due to higher failure and regeneration rates. **Clinical Pearls for NEET-PG:** * **First-line for Menorrhagia:** LNG-IUS (Mirena). * **Mechanism of LNG-IUS:** Local endometrial decidualization and atrophy. * **Hypertension & Contraception:** Avoid Estrogen (COCPs); Progesterone-only methods (LNG-IUS, POPs, DMPA) are preferred. * **Non-hormonal first-line:** Tranexamic acid (antifibrinolytic) is the preferred non-hormonal treatment for menorrhagia.

Q: A 45-year-old lady presented with dysfunctional uterine bleeding. On transvaginal ultrasound, the thickness of the endometrium was found to be 8 mm. What should be the next step in the management of this patient?

Histopathology. **Explanation:** The primary concern in a perimenopausal woman (age >40–45 years) presenting with Abnormal Uterine Bleeding (AUB) is excluding **Endometrial Hyperplasia or Malignancy**. **1. Why Histopathology is Correct:** In women over 45 years, any case of dysfunctional uterine bleeding (now classified under AUB) requires a tissue diagnosis as the first-line investigation. While Transvaginal Ultrasound (TVUS) is a screening tool, an endometrial thickness (ET) of **>4 mm** in postmenopausal women or persistent bleeding in perimenopausal women (regardless of ET, though 8 mm is significantly thickened) necessitates **Endometrial Biopsy** or Fractional Curettage for histopathological examination. This is the "Gold Standard" to rule out premalignant or malignant lesions before starting medical or surgical therapy. **2. Why Other Options are Incorrect:** * **Hysterectomy:** This is a definitive surgical treatment, not a diagnostic step. It should only be performed after a confirmed diagnosis and if medical management fails or malignancy is detected. * **Progesterone / Oral Contraceptive Pills (OCPs):** These are medical management options for hormonal regulation. Starting these without a biopsy in a 45-year-old is dangerous, as they may temporarily mask the symptoms of an underlying endometrial carcinoma, leading to a delayed diagnosis. **Clinical Pearls for NEET-PG:** * **Cut-off for Postmenopausal bleeding:** ET >4 mm requires biopsy. * **Age Factor:** Any woman **>45 years** with AUB needs histopathology. * **AUB in <45 years:** Biopsy is indicated only if there are risk factors (obesity, PCOS, family history) or failure of medical management. * **Gold Standard for AUB diagnosis:** Hysteroscopy-guided biopsy (more accurate than blind D&C).

Q: Which of the following is false regarding Mittelschmerz?

Treatment is with estrogen. **Explanation:** **Mittelschmerz** (German for "middle pain") refers to mid-cycle ovulatory pain. The correct answer is **A** because the treatment for Mittelschmerz is **not** estrogen; rather, it is managed with reassurance, analgesics (NSAIDs), or **Combined Oral Contraceptive Pills (COCPs)** if the pain is recurrent and severe. COCPs work by suppressing ovulation, which is the underlying cause of the pain. **Analysis of Options:** * **Option B (Duration):** This is a true statement. The pain typically lasts from a few minutes to a few hours and rarely exceeds 12–24 hours. * **Option C (Spotting):** This is true. The sudden drop in estrogen levels just before ovulation can cause slight endometrial shedding, leading to mid-cycle "spotting." * **Option D (Timing):** This is true. In a typical 28-day cycle, ovulation occurs around day 14. The pain coincides with the rupture of the Graafian follicle. **Pathophysiology & Clinical Pearls:** The pain is attributed to the rapid expansion of the dominant follicle or the irritation of the pelvic peritoneum by follicular fluid and blood released during ovulation. **High-Yield Facts for NEET-PG:** 1. **Diagnosis:** It is a diagnosis of exclusion. One must rule out appendicitis, ectopic pregnancy, and PID. 2. **Lateralization:** The pain is typically unilateral and switches sides from month to month depending on which ovary is ovulating. 3. **Key Feature:** It is a physiological condition, not a pathological one. 4. **Management:** Reassurance is the first line of management. For severe cases, **ovulation suppression** (via COCPs) is the definitive medical approach.

Q: Which of the following is NOT a benefit of using a levonorgestrel intrauterine system (IUS) for the treatment of abnormal uterine bleeding?

No breakthrough bleeding. The Levonorgestrel Intrauterine System (LNG-IUS), such as Mirena, is a highly effective treatment for heavy menstrual bleeding (HMB). However, it is notorious for causing **breakthrough bleeding (spotting)** during the initial 3 to 6 months of use. ### Explanation of Options: * **Correct Answer (C):** The statement "No breakthrough bleeding" is incorrect. Irregular spotting or breakthrough bleeding is the **most common side effect** and the primary reason for early discontinuation. This occurs due to the local effect of progestogen causing endometrial atrophy and vascular fragility before the lining stabilizes. * **Option A:** LNG-IUS provides highly effective, long-term reversible contraception (LARC) with a Pearl Index comparable to sterilization, making it ideal for women needing both therapy and birth control. * **Option B:** By suppressing endometrial proliferation and reducing prostaglandin synthesis, the LNG-IUS significantly improves associated spasmodic dysmenorrhea. * **Option D:** Approximately 20–50% of women become amenorrheic within one year of insertion due to profound endometrial atrophy. This is considered a therapeutic benefit in the context of abnormal uterine bleeding. ### High-Yield Clinical Pearls for NEET-PG: * **Mechanism:** Releases 20 µg of Levonorgestrel daily; primarily acts by thickening cervical mucus and causing endometrial atrophy. * **First-line Treatment:** LNG-IUS is the **medical treatment of choice** for HMB (NICE guidelines) and is also used in endometriosis and endometrial hyperplasia without atypia. * **Life Span:** Currently approved for **8 years** for contraception (Mirena) but usually replaced every 5 years for HMB management. * **Non-Contraceptive Benefit:** It reduces the risk of Pelvic Inflammatory Disease (PID) by thickening cervical mucus, preventing sperm and bacteria from entering the upper genital tract.

Question 1

Secondary amenorrhea after abortion due to intrauterine adhesions is seen in:

Accepted Answer

Asherman's syndrome

Answer

Uterine inertia

Answer

Imperforate hymen

Answer

Bicornuate uterus

Question 2

Which of the following statements regarding spasmodic dysmenorrhea is false?

Accepted Answer

Pain persists for 2-3 days

Answer

Often cured by delivery of a child

Answer

Pain usually appears on the first day of menstruation

Answer

Rare above the age of 35 years

Question 3

Which progestogen has the greatest haemostatic effect for treating dysfunctional uterine bleeding (DUB)?

Accepted Answer

Norethisterone

Answer

Medroxyprogesterone

Answer

Hydroxyprogesterone

Answer

Dydrogesterone

Question 4

Which of the following statements is false regarding ablative procedures for abnormal uterine bleeding?

Accepted Answer

Fertility is preserved.

Answer

They are safe and effective with less morbidity.

Answer

They offer a quicker recovery.

Answer

The method destroys 2-3mm of myometrium.

Question 5

What is the most common endometrial pattern in dysfunctional uterine bleeding?

Accepted Answer

Normal

Answer

Hyperplastic with Swiss-Cheese pattern

Answer

Nonsecretory

Answer

Atrophic

Question 6

A 30-year-old multiparous hypertensive woman complains of menorrhagia. What is the best treatment for her?

Accepted Answer

Levonorgestrel-releasing intrauterine system (Mirena)

Answer

Combined oral contraceptive pills

Answer

Hysterectomy

Answer

Transcervical resection of the endometrium

Question 7

A 45-year-old lady presented with dysfunctional uterine bleeding. On transvaginal ultrasound, the thickness of the endometrium was found to be 8 mm. What should be the next step in the management of this patient?

Accepted Answer

Histopathology

Answer

Hysterectomy

Answer

Progesterone

Answer

Oral contraceptive pills

Question 8

Which of the following is false regarding Mittelschmerz?

Accepted Answer

Treatment is with estrogen

Answer

Rarely lasts more than 12 hours

Answer

Spotting may be present

Answer

Usually occurs around the 14th day of the menstrual cycle

Question 9

Which of the following is NOT a benefit of using a levonorgestrel intrauterine system (IUS) for the treatment of abnormal uterine bleeding?

Accepted Answer

No breakthrough bleeding

Answer

Provides contraceptive cover

Answer

Effective for associated dysmenorrhea

Answer

Women become amenorrheic within one year after insertion

Question 10

Bleeding associated with anovulation is due to which of the following?

Accepted Answer

Persistent proliferative endometrium.

Answer

Alterations in endometrial vascular structure.

Answer

Increased endometrial responsiveness to vasodilating prostaglandins.

Answer

Impaired prostaglandin concentration.

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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