Menstrual Disorders Practice Questions

Q: A 30-year-old woman, para 2, with hypertension presents with menorrhagia. What is the best treatment for her?

Mirena (Levonorgestrel-releasing intrauterine system). **Explanation:** The patient is a 30-year-old multiparous woman presenting with **menorrhagia** (Heavy Menstrual Bleeding) and a co-morbidity of **hypertension**. **Why Option B is Correct:** The **Mirena (LNG-IUS)** is the medical treatment of choice for menorrhagia. It works by releasing levonorgestrel directly into the uterine cavity, causing profound endometrial atrophy and reducing menstrual blood loss by up to 90-97%. In this specific case, Mirena is preferred over hormonal pills because the patient is **hypertensive**. Estrogen-containing contraceptives are generally avoided or used with caution in hypertension due to the risk of stroke and worsening blood pressure. Mirena provides effective local treatment without the systemic risks associated with estrogen. **Why Other Options are Incorrect:** * **Option A (COCPs):** Combined oral contraceptive pills contain estrogen, which is contraindicated in patients with uncontrolled hypertension or those with high cardiovascular risk. * **Option C (Hysterectomy):** This is a major surgical intervention. It is considered the definitive treatment but is reserved for cases where medical management fails or the patient has completed her family and specifically requests surgery. * **Option D (TCRE):** Endometrial ablation/resection is a second-line surgical alternative to hysterectomy. Medical management (Mirena) should always be attempted first in a 30-year-old. **NEET-PG High-Yield Pearls:** * **First-line medical management for HMB:** LNG-IUS (Mirena). * **Mechanism of Mirena:** Endometrial decidualization followed by atrophy. * **WHO Eligibility Criteria:** Estrogen is Category 3/4 for smokers >35 years and those with severe hypertension (BP >160/100). * **Non-hormonal first-line:** Tranexamic acid (Antifibrinolytic).

Q: Primary amenorrhoea is most commonly associated with which of the following?

Chromosomal abnormality. **Explanation:** The most common cause of **Primary Amenorrhoea** is **Chromosomal Abnormality**, accounting for approximately **45-50%** of cases. Among these, **Turner Syndrome (45,XO)** is the single most frequent etiology. These abnormalities lead to gonadal dysgenesis, where ovaries are replaced by non-functional fibrous streaks, resulting in hypergonadotropic hypogonadism (low estrogen, high FSH/LH). **Analysis of Options:** * **A. Developmental defect of the genital tract:** This is the second most common cause (approx. 15-20%). The most frequent defect is **Müllerian Agenesis** (Mayer-Rokitansky-Küster-Hauser syndrome), characterized by the absence of the uterus and upper vagina despite normal ovaries and secondary sexual characteristics. * **B. Tuberculosis:** While Genital TB is a significant cause of *secondary* amenorrhoea in developing countries (due to Asherman’s syndrome), it rarely presents as primary amenorrhoea unless the infection occurs prepubertally and causes extensive endo-myometrial destruction. * **C. Endocrine disorders:** Conditions like PCOS, thyroid dysfunction, or Congenital Adrenal Hyperplasia (CAH) can cause primary amenorrhoea, but statistically, they occur less frequently than chromosomal or structural defects. **High-Yield Clinical Pearls for NEET-PG:** * **Definition:** Absence of menarche by age 13 (without secondary sexual characteristics) or age 15 (with secondary sexual characteristics). * **First Investigation:** The most important initial step is assessing for the presence or absence of **secondary sexual characteristics** (Breast development/Tanner Staging). * **Karyotyping:** Essential if FSH is elevated (to diagnose Turner’s) or if there is Müllerian agenesis (to rule out Androgen Insensitivity Syndrome - 46,XY). * **Most common cause of Secondary Amenorrhoea:** Pregnancy (Physiological); PCOS (Pathological).

Q: All of the following conditions present with secondary amenorrhoea EXCEPT:

Turner syndrome. ### Explanation **Core Concept: Primary vs. Secondary Amenorrhoea** The distinction lies in the timing of onset. **Primary amenorrhoea** is the failure to start menses by age 15 (with secondary sexual characteristics) or age 13 (without them). **Secondary amenorrhoea** is the cessation of previously established menses for ≥3 months (regular cycles) or ≥6 months (irregular cycles). **Why Turner Syndrome (Option D) is the Correct Answer:** Turner Syndrome (45, XO) is the most common cause of **primary amenorrhoea**. It is characterized by gonadal dysgenesis (streak ovaries) due to accelerated oocyte atresia. Since these patients typically never achieve menarche, it is classified as primary amenorrhoea. *Note: Rarely, mosaic Turner (45,X/46,XX) can present with secondary amenorrhoea, but in the context of competitive exams, it is the classic prototype for primary amenorrhoea.* **Analysis of Incorrect Options:** * **A. Pregnancy:** The most common cause of secondary amenorrhoea worldwide. It must always be ruled out first with a UPT. * **B. PCOD (Polycystic Ovarian Disease):** A common endocrine cause of secondary amenorrhoea/oligomenorrhoea due to chronic anovulation and hyperandrogenism. * **C. Asherman’s Syndrome:** An outflow tract cause where intrauterine adhesions (usually post-curettage) prevent menstruation despite normal hormonal axes. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Primary Amenorrhoea:** Turner Syndrome (Hypergonadotropic Hypogonadism). * **Most common cause of Secondary Amenorrhoea:** Pregnancy (Physiological). * **Most common pathological cause of Secondary Amenorrhoea:** PCOD. * **Kallmann Syndrome:** A key differential for primary amenorrhoea presenting with **anosmia** (Hypogonadotropic Hypogonadism). * **Mullerian Agenesis (MRKH):** Second most common cause of primary amenorrhoea; characterized by 46,XX karyotype and normal ovaries but absent uterus/vagina.

Q: What is the most common cause of pubertal menorrhagia?

Anovulation. **Explanation:** **1. Why Anovulation is the Correct Answer:** Pubertal menorrhagia refers to excessive menstrual bleeding occurring between menarche and 19 years of age. The most common cause is an **immature Hypothalamic-Pituitary-Ovarian (HPO) axis**. In the first few years following menarche, the feedback mechanism is not fully developed, 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 proliferate excessively. Eventually, this thickened lining becomes unstable and sheds in an irregular, heavy, and prolonged manner (estrogen breakthrough bleeding). **2. Analysis of Incorrect Options:** * **Malignancy:** Extremely rare in the adolescent age group. Genital tract cancers (like cervical or endometrial cancer) typically present in postmenopausal or older reproductive-age women. * **Endometriosis:** Usually presents with chronic pelvic pain and secondary dysmenorrhea rather than heavy menstrual bleeding (menorrhagia). * **Bleeding Disorders:** While **Von Willebrand Disease (vWD)** is the most common *systemic* or *organic* cause of pubertal menorrhagia (found in up to 20% of severe cases), it is still statistically less common than physiological anovulation. **3. NEET-PG High-Yield Pearls:** * **First-line investigation:** Pelvic Ultrasound (to rule out structural causes) and CBC (to assess anemia). * **Management:** Most cases are managed with reassurance or Combined Oral Contraceptive Pills (COCPs) to stabilize the endometrium. * **Rule of Thumb:** If a teenager presents with menorrhagia requiring hospitalization or blood transfusion from the very first period (menarche), always suspect a **coagulation disorder** (vWD).

Q: All of the following are characteristic of anovulatory uterine (AUB-O) bleeding except:

Increased progesterone levels.. **Explanation:** In **Anovulatory Uterine Bleeding (AUB-O)**, the fundamental pathology is the absence of ovulation, which leads to a lack of corpus luteum formation. Without a corpus luteum, there is no production of **progesterone**. This results in "unopposed estrogen" action on the endometrium, causing it to proliferate continuously without the stabilizing effect of progesterone. Eventually, the endometrium outgrows its blood supply, leading to asynchronous breakdown and heavy, irregular bleeding (estrogen breakthrough bleeding). Therefore, **increased progesterone levels** are never seen; rather, progesterone is characteristically absent or low. **Analysis of Options:** * **A. Dysfunctional uterine bleeding (DUB):** Historically, DUB was defined as abnormal bleeding in the absence of organic pelvic pathology, most commonly caused by anovulation. While the FIGO classification now prefers "AUB-O," the terms are often used interchangeably in exams. * **B. Amenorrhea followed by heavy bleeding:** This is the classic clinical presentation. Unopposed estrogen causes prolonged endometrial buildup (amenorrhea/delayed menses) followed by a heavy, painless collapse of the thickened tissue. * **C. Reduced arachidonic acid:** In anovulatory cycles, the lack of progesterone leads to lower levels of arachidonic acid and altered prostaglandin ratios (PGE2 vs. PGF2α) in the endometrium, contributing to abnormal vascular tone and bleeding. **NEET-PG High-Yield Pearls:** * **Most common cause of AUB-O:** Polycystic Ovary Syndrome (PCOS). * **Age groups:** Most common at the extremes of reproductive life (adolescence and perimenopause) due to immature or failing HPO axis. * **Histology:** Typically shows proliferative or hyperplastic endometrium; never secretory (as secretory changes require progesterone). * **Treatment of choice:** Cyclic progestins or Combined Oral Contraceptive Pills (COCPs) to stabilize the endometrium.

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

Histopathology. **Explanation:** The primary objective in a perimenopausal woman (age >40 years) presenting with Abnormal Uterine Bleeding (AUB) is to **exclude endometrial hyperplasia or malignancy**. **Why Histopathology is correct:** In women over 40 years of age, any change in menstrual pattern or dysfunctional bleeding is considered a high-risk factor for endometrial carcinoma. According to standard protocols, an **endometrial thickness (ET) >4 mm** in postmenopausal women or persistent AUB in perimenopausal women (regardless of ET, though 8 mm is significantly thickened) necessitates an endometrial biopsy. Histopathology via **Pipelle biopsy or D&C** is the gold standard to obtain a definitive tissue diagnosis before initiating medical or surgical therapy. **Why other options are incorrect:** * **Hysterectomy:** This is a definitive surgical treatment and should never be performed without a prior histological diagnosis to rule out malignancy, which would require a different surgical staging approach. * **Progesterone/OCPs:** While hormonal therapy is used to manage dysfunctional bleeding, it should only be started **after** malignancy has been ruled out. Starting hormones blindly can mask the symptoms of underlying cancer and delay diagnosis. **Clinical Pearls for NEET-PG:** * **Cut-off for Postmenopausal bleeding:** ET >4 mm requires biopsy. * **Age Criterion:** Any woman **>40 years** with AUB must undergo endometrial sampling as the first-line investigation. * **Gold Standard for AUB diagnosis:** Hysteroscopy-guided biopsy (more accurate than blind D&C). * **Most common cause of AUB in perimenopause:** Anovulatory cycles (due to waning follicular function).

Q: Which of the following is NOT considered a differential diagnosis for premenstrual tension?

Chronic fatigue syndrome. ### Explanation **Premenstrual Syndrome (PMS)** and **Premenstrual Dysphoric Disorder (PMDD)** are characterized by the cyclic recurrence of physical and psychological symptoms during the **luteal phase** of the menstrual cycle, which resolve completely with the onset of menses. **1. Why Chronic Fatigue Syndrome (CFS) is the correct answer:** The hallmark of PMS/PMDD is its **cyclicity**. Differential diagnoses must include conditions that mimic these cyclic mood or physical changes. **Chronic Fatigue Syndrome** is a persistent, non-cyclic condition characterized by debilitating exhaustion lasting for at least 6 months, regardless of the menstrual cycle phase. While PMS may involve lethargy, CFS does not follow the predictable luteal-phase pattern required for a PMS diagnosis. **2. Why the other options are incorrect:** * **Psychiatric Depressive Disorder (A), Panic Disorder (B), and General Anxiety Disorder (C):** These are the most common differential diagnoses. Many women with underlying psychiatric disorders experience **"Premenstrual Exacerbation" (PME)**, where their baseline symptoms worsen before menses. Distinguishing between a primary psychiatric disorder and PMDD requires a symptom-free interval during the follicular phase, documented via prospective daily charting for at least two cycles. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Prospective daily charting of symptoms for **two consecutive cycles** (e.g., using the Daily Record of Severity of Problems - DRSP). * **Timing:** Symptoms must occur in the 5 days before menses and remit within 4 days of onset. * **First-line Treatment:** Lifestyle modifications and **SSRIs** (Fluoxetine, Sertraline). SSRIs can be given continuously or strictly during the luteal phase. * **Definitive Treatment:** Bilateral Salpingo-oophorectomy (BSO) to eliminate the hormonal cycle (reserved for severe, refractory cases).

Question 1

A 30-year-old woman, para 2, with hypertension presents with menorrhagia. What is the best treatment for her?

Accepted Answer

Mirena (Levonorgestrel-releasing intrauterine system)

Answer

Combined oral contraceptive pills

Answer

Hysterectomy

Answer

Transcervical resection of the endometrium

Question 2

Primary amenorrhoea is most commonly associated with which of the following?

Accepted Answer

Chromosomal abnormality

Answer

Developmental defect of the genital tract

Answer

Tuberculosis

Answer

Endocrine disorders

Question 3

A 30-year-old woman, para 2+0, with hypertension presents with menorrhagia. What is the best treatment option for her?

Accepted Answer

Levonorgestrel-releasing intrauterine system (Mirena)

Answer

Combined oral contraceptive pills

Answer

Hysterectomy

Answer

Transcervical endometrial resection

Question 4

Which of the following is NOT a feature of anovulatory menstruation?

Accepted Answer

May be associated with premenstrual syndrome.

Answer

The only symptom may be failure of conception.

Answer

It is usually associated with painless periods.

Answer

May be associated with dysfunctional uterine bleeding (DUB).

Question 5

In dysmenorrhea, how does indomethacin exert its therapeutic effect?

Accepted Answer

Inhibiting prostaglandin synthetase

Answer

Suppressing ovulation

Answer

Reducing inflammation

Answer

Relaxing smooth muscle

Question 6

All of the following conditions present with secondary amenorrhoea EXCEPT:

Accepted Answer

Turner syndrome

Answer

Pregnancy

Answer

PCOD

Answer

Asherman's syndrome

Question 7

What is the most common cause of pubertal menorrhagia?

Accepted Answer

Anovulation

Answer

Malignancy

Answer

Endometriosis

Answer

Bleeding disorder

Question 8

All of the following are characteristic of anovulatory uterine (AUB-O) bleeding except:

Accepted Answer

Increased progesterone levels.

Answer

Dysfunctional uterine bleeding.

Answer

Amenorrhea for weeks to months followed by heavy bleeding.

Answer

Availability of arachidonic acid is reduced at the cellular level.

Question 9

A 45-year-old lady presented with dysfunctional uterine bleeding. On transvaginal ultrasound, the endometrial thickness 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 10

Which of the following is NOT considered a differential diagnosis for premenstrual tension?

Accepted Answer

Chronic fatigue syndrome

Answer

Psychiatric depressive disorder

Answer

Panic disorder

Answer

General anxiety disorder

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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