Menstrual Disorders Practice Questions

Q: A young woman presents with pain in the lower abdomen. Her last menstrual period was 2 weeks ago, and she denies any history of fever or leukocytosis. What is the most likely diagnosis?

Mittleschmerz. ### Explanation **Correct Answer: B. Mittelschmerz** **Why it is correct:** The clinical presentation is classic for **Mittelschmerz** (German for "middle pain"). This refers to mid-cycle ovulatory pain. 1. **Timing:** The patient’s last menstrual period was 2 weeks ago. In a typical 28-day cycle, ovulation occurs around Day 14. 2. **Pathophysiology:** The pain is attributed to the rapid expansion of the dominant follicle or the irritation of the peritoneum by follicular fluid/blood released during ovulation. 3. **Clinical Features:** It is typically sudden-onset, unilateral lower abdominal pain that is self-limiting and occurs in the absence of systemic symptoms like fever or leukocytosis. **Why the other options are incorrect:** * **A. Ectopic pregnancy:** This usually presents with a history of amenorrhea (6–8 weeks), vaginal bleeding, and a positive pregnancy test. A period only 2 weeks ago makes this highly unlikely. * **C. Acute intermittent obstruction:** This would typically present with colicky pain, vomiting, and abdominal distension, rather than localized pelvic pain specifically at the mid-cycle point. * **D. Dysuria:** This refers to painful urination, usually associated with Urinary Tract Infections (UTI). While it causes discomfort, it does not explain mid-cycle abdominal pain in a patient without fever or urinary symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Diagnosis of Exclusion:** Mittelschmerz is diagnosed clinically after ruling out more serious causes like appendicitis or ectopic pregnancy. * **Management:** Reassurance and NSAIDs are the first-line treatments. * **Key Differentiator:** Unlike Pelvic Inflammatory Disease (PID) or Appendicitis, Mittelschmerz presents with a **normal white blood cell (WBC) count** and **no fever**. * **USG Finding:** May show a small amount of free fluid in the Pouch of Douglas (POD) during the mid-cycle.

Q: All are used in treating spasmodic dysmenorrhea except?

Bromocriptine. **Explanation:** Spasmodic (Primary) Dysmenorrhea is characterized by painful uterine contractions caused by the excessive release of **Prostaglandins (PGF2α)** from the secretory endometrium. The management focuses on inhibiting prostaglandin synthesis or suppressing ovulation. **Why Bromocriptine is the correct answer:** **Bromocriptine** is a dopamine agonist used primarily to treat hyperprolactinemia, galactorrhea, and prolactinomas. It has **no role** in the pathophysiology or treatment of dysmenorrhea. In fact, by lowering prolactin, it may theoretically enhance gonadotropin release, which does not alleviate menstrual pain. **Analysis of other options:** * **Ibuprofen & Mefenamic Acid (NSAIDs):** These are the **first-line medical treatments** for spasmodic dysmenorrhea. They act by inhibiting the enzyme cyclooxygenase (COX), thereby reducing the production of prostaglandins that cause uterine hypercontractility. * **Norethisterone and Ethinyl Estradiol (OCPs):** Combined Oral Contraceptive Pills are the treatment of choice for patients who also desire contraception. They work by **inhibiting ovulation** and thinning the endometrial lining, which significantly reduces prostaglandin levels. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Dysmenorrhea:** Usually starts 1–2 years after menarche (once cycles become ovulatory). The pain typically begins just before or at the onset of menses. * **Drug of Choice (DOC):** NSAIDs (specifically Mefenamic acid) are the initial DOC. * **Secondary Dysmenorrhea:** Pain due to pelvic pathology (e.g., Endometriosis, Adenomyosis). Unlike primary dysmenorrhea, the pain often starts several days before menses and persists after the flow stops. * **Other treatments:** Heat application, regular exercise, and in refractory cases, TENS (Transcutaneous Electrical Nerve Stimulation).

Q: All of the following are causes of primary amenorrhea EXCEPT?

Sheehan's syndrome. **Explanation:** The core concept in this question is the distinction between **Primary Amenorrhea** (failure to start menses by age 15 with secondary sexual characteristics or age 13 without) and **Secondary Amenorrhea** (cessation of menses after they have already been established). **Why Sheehan’s Syndrome is the correct answer:** Sheehan’s syndrome is **postpartum pituitary necrosis** caused by severe obstetric hemorrhage and hypotension. Since it occurs as a complication of childbirth, the patient must have been fertile and menstruating previously. Therefore, it is a classic cause of **secondary amenorrhea**, not primary. **Analysis of Incorrect Options (Causes of Primary Amenorrhea):** * **MRKH Syndrome (Müllerian Agenesis):** The most common cause of primary amenorrhea with normal secondary sexual characteristics. It involves congenital absence of the uterus and upper 2/3rd of the vagina. * **Kallmann’s Syndrome:** A form of hypogonadotropic hypogonadism (GnRH deficiency) associated with anosmia. It leads to primary amenorrhea due to failure of the hypothalamic-pituitary-ovarian axis to initiate puberty. * **Turner’s Syndrome (45,XO):** The most common genetic cause of primary amenorrhea. It presents with streak ovaries (gonadal dysgenesis), short stature, and lack of secondary sexual characteristics. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Primary Amenorrhea:** Turner’s Syndrome (Overall); MRKH (if secondary sexual characteristics are present). * **Most common cause of Secondary Amenorrhea:** Pregnancy (must always be ruled out first). * **Sheehan’s Syndrome Hallmark:** Failure of lactation (due to prolactin deficiency) is often the earliest clinical sign, followed by loss of pubic/axillary hair and secondary amenorrhea.

Q: A 25-year-old female presents with infertility. Hysterosalpingogram reveals Asherman's syndrome. What are the likely symptoms?

Hypomenorrhea. **Explanation:** **Asherman’s Syndrome** is characterized by the presence of intrauterine adhesions (synechiae) that typically develop following trauma to the basal layer of the endometrium, most commonly due to over-zealous curettage (D&C) post-abortion or postpartum. **Why Hypomenorrhea is Correct:** The underlying pathology involves the partial or complete obliteration of the uterine cavity by fibrous bands. This leads to a significant reduction in the functional surface area of the endometrium available for shedding during menstruation. Consequently, patients present with **hypomenorrhea** (scanty menses) or **amenorrhea** (absence of menses). In this clinical scenario, the destruction of the endometrial lining explains both the infertility (due to lack of receptive tissue for implantation) and the reduced menstrual flow. **Why Incorrect Options are Wrong:** * **Menorrhagia (Heavy flow):** This is typically seen in conditions that increase the endometrial surface area or vascularity, such as uterine fibroids or adenomyosis—the opposite of Asherman’s. * **Oligomenorrhea (Infrequent cycles):** This usually suggests a hormonal or ovulatory dysfunction (e.g., PCOS). In Asherman’s, the cycle regularity is often maintained, but the *volume* is reduced. * **Polymenorrhea (Frequent cycles):** This refers to cycles occurring at intervals of less than 21 days, which is not a feature of structural intrauterine scarring. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** **Hysteroscopy** (allows both diagnosis and therapeutic adhesiolysis). * **HSG Finding:** Characterized by "filling defects" or a "honeycomb appearance." * **Treatment:** Hysteroscopic adhesiolysis followed by an IUCD or Foley catheter insertion and high-dose estrogen therapy to promote endometrial regrowth. * **Most common cause:** Post-traumatic (D&C), but in India, **Genital Tuberculosis** is a significant non-traumatic cause.

Q: All of the following are true about abnormal uterine bleeding except:

Blood loss of less than 50 ml. **Explanation:** Abnormal Uterine Bleeding (AUB) is defined as any variation from the normal menstrual cycle, involving changes in frequency, regularity, duration, or volume of flow. **Why Option A is the Correct Answer:** Normal menstrual blood loss is typically between **5-80 ml** per cycle, with an average of 35 ml. Therefore, a blood loss of **less than 50 ml** falls within the physiological range and is considered normal. For a diagnosis of Menorrhagia (heavy menstrual bleeding), the blood loss must exceed **80 ml**. **Analysis of Other Options:** * **Option B (Cycle duration >35 or 35 days (Oligomenorrhea) or <21 days (Polymenorrhea) are classic presentations of AUB. * **Option C (Bleeding period ≥7 days):** A normal period lasts 3–7 days. Bleeding that persists for 7 days or more is termed prolonged bleeding and is a criterion for AUB. * **Option D (Irregular bleeding during a regular cycle):** This refers to **Intermenstrual bleeding** (metrorrhagia), which is a hallmark of AUB and often indicates structural pathology like polyps or fibroids. **High-Yield Clinical Pearls for NEET-PG:** * **PALM-COEIN Classification:** Used to categorize AUB causes (Structural: Polyp, Adenomyosis, Leiomyoma, Malignancy; Non-structural: Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Not classified). * **FIGO Definitions:** The terms "Menorrhagia" and "Metrorrhagia" are being replaced by "Heavy Menstrual Bleeding" (HMB) and "Intermenstrual Bleeding" (IMB). * **Gold Standard:** Alkaline hematin method is the objective way to measure blood loss, though rarely used clinically. * **First-line Investigation:** Transvaginal Ultrasound (TVS).

Q: A patient presents with a history of dilation & curettage (D&C). Subsequent diagnostic tests reveal all hormone levels, including progesterone and estrogen, to be within the normal range. Based on this clinical presentation, which of the following is the most likely diagnosis?

Asherman Syndrome. ***Asherman Syndrome***- This diagnosis is characterized by the presence of **intrauterine adhesions** (synechiae), typically caused by injury to the **basal layer of the endometrium** following procedures like **D&C**.- The normal **estrogen** and **progesterone** levels indicate normal ovarian function, suggesting the pathology is uterine (end-organ failure to respond to hormones/obstruction) rather than central or ovarian.*Polycystic Ovary Syndrome (PCOS)*- PCOS is associated with chronic **anovulation** and features of **hyperandrogenism** (hirsutism, acne) but usually presents with oligomenorrhea rather than complete amenorrhea following D&C.- Hormonal analysis typically shows an elevated **LH/FSH ratio** and potentially high androgens, resulting in *abnormal* cyclical hormone patterns, unlike the normal levels noted here.*Premature Ovarian Insufficiency (POI)*- POI is characterized by the cessation of ovarian function before age 40, leading to a state of **hypoestrogenism** and low progesterone.- Lab tests would reveal *markedly elevated* **FSH** and *low* **estrogen** due to loss of negative feedback, directly contradicting the finding of normal hormone levels in this patient.*Endometriosis*- Endometriosis involves ectopic endometrial tissue and typically presents with symptoms like **severe dysmenorrhea**, **dyspareunia**, and chronic pelvic pain.- While severe cases can impact fertility, it does not typically cause complete secondary amenorrhea with *normal* cyclical estrogen and progesterone levels; this clinical picture points overwhelmingly to a mechanical uterine issue.

Q: A 46-year-old woman presents with complaints of irregular menstrual cycles and heavy vaginal bleeding for several months. Transvaginal ultrasound reveals an endometrial thickness of 16 mm. What is the most appropriate next step in management?

Perform an endometrial biopsy. ***Perform an endometrial biopsy*** - A thickened **endometrium (16 mm)** in a perimenopausal woman (46 years old) with **Abnormal Uterine Bleeding (AUB)** significantly increases the risk of endometrial pathology, including **endometrial hyperplasia** or **carcinoma**. - **Endometrial biopsy** is the most appropriate next step, as it provides a definitive tissue diagnosis required to guide subsequent, targeted treatment. *Hysterectomy* - Hysterectomy is a definitive treatment and is typically reserved only after a histological diagnosis of a high-grade abnormality, such as **endometrial cancer**, has been confirmed. - It is premature to proceed with such an invasive surgery before obtaining a tissue diagnosis. *Start combined oral contraceptive pills* - Hormonal therapy like COCPs is used to manage functional causes of AUB (e.g., anovulation), but it should be initiated only after **malignancy is ruled out** by biopsy, as it can mask symptoms of cancer. - A 16 mm endometrial thickness mandates tissue sampling due to the high index of suspicion for premalignant or malignant change. *Observe and reassess after a few months* - Delayed evaluation in this setting significantly increases the risk of diagnosing **endometrial carcinoma** at an advanced stage. - Any woman over 45 years presenting with AUB must undergo investigation, and observation is not acceptable given the pathological **endometrial thickness**.

Question 1

Which of the following can be causes of dysfunctional uterine bleeding?

Accepted Answer

Irregular shedding of endometrium

Answer

Uterine polyp

Answer

Fibroid

Answer

Granulosa cell tumor

Question 2

A young woman presents with pain in the lower abdomen. Her last menstrual period was 2 weeks ago, and she denies any history of fever or leukocytosis. What is the most likely diagnosis?

Accepted Answer

Mittleschmerz

Answer

Ectopic pregnancy

Answer

Acute intermittent obstruction

Answer

Dysuria

Question 3

All are used in treating spasmodic dysmenorrhea except?

Accepted Answer

Bromocriptine

Answer

Ibuprofen

Answer

Mefenamic acid

Answer

Norethisterone and ethinyl estradiol

Question 4

Absence of corkscrew glands is seen in which of the following conditions?

Accepted Answer

Metropathia hemorrhagica

Answer

Halban's disease

Answer

Polycystic ovarian disease

Answer

Irregular ripening

Question 5

All of the following are causes of primary amenorrhea EXCEPT?

Accepted Answer

Sheehan's syndrome

Answer

MRKH syndrome

Answer

Kallmann's syndrome

Answer

Turner's syndrome

Question 6

A 25-year-old female presents with infertility. Hysterosalpingogram reveals Asherman's syndrome. What are the likely symptoms?

Accepted Answer

Hypomenorrhea

Answer

Menorrhagia

Answer

Oligomenorrhea

Answer

Polymenorrhea

Question 7

A 28-year-old woman experiences emotional lability and depression approximately 10 days before her menses. She reports feeling normal once her menstrual bleeding begins. She also describes premenstrual fatigue, bloating, and breast tenderness. What is the most appropriate treatment for this patient?

Accepted Answer

Fluoxetine

Answer

Evening primrose oil

Answer

Vitamin B6

Answer

Progesterone

Question 8

All of the following are true about abnormal uterine bleeding except:

Accepted Answer

Blood loss of less than 50 ml

Answer

Cycle duration is more than 35 days or less than 21 days

Answer

Bleeding period lasting 7 days or more

Answer

Irregular bleeding during a regular cycle

Question 9

A patient presents with a history of dilation & curettage (D&C). Subsequent diagnostic tests reveal all hormone levels, including progesterone and estrogen, to be within the normal range. Based on this clinical presentation, which of the following is the most likely diagnosis?

Accepted Answer

Asherman Syndrome

Answer

Endometriosis

Answer

Premature Ovarian Insufficiency (POI)

Answer

Polycystic Ovary Syndrome (PCOS)

Question 10

A 46-year-old woman presents with complaints of irregular menstrual cycles and heavy vaginal bleeding for several months. Transvaginal ultrasound reveals an endometrial thickness of 16 mm. What is the most appropriate next step in management?

Accepted Answer

Perform an endometrial biopsy

Answer

Hysterectomy

Answer

Start combined oral contraceptive pills

Answer

Observe and reassess after a few months

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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