Primary Dysmenorrhea — MCQs
All of the following occurs because of prostaglandin use except?
Which of the following is NOT a cause of metrorrhagia?
Primary amenorrhea is defined as:
A 16-year-old girl presents with cyclical pelvic pain every month. She has not achieved menarche yet. On examination, a suprapubic bulge can be seen in the lower abdomen. PR examination reveals a bulging swelling in the anterior aspect. What is the most likely diagnosis?
All of the following are true regarding after pains except:
A 28-year-old woman, G2 P1, with severe PPH unresponsive to oxytocin presents with hypotension and tachycardia. She has a soft uterus and ongoing bleeding. What is the next best step in management?
A 29 year old female presented with infertility. There is history of abdominal pain, dyspareunia, dysmenorrhea, menorrhagia. Most likely cause:
The contraceptive choice for a 38 year old woman with chronic hypertension and history of dysmenorrhea and menorrhagia (malignancy ruled out) is:
A 15-year old unmarried girl comes with history of dysmenorrhea. Age of menarche is 12 years. Per abdominal and per rectum examination reveal nothing abnormal. You will treat the patient with :
Which one of the following about primary dysmenorrhea is NOT true?
Primary Dysmenorrhea Indian Medical PG Practice Questions and MCQs
Question 1: All of the following occurs because of prostaglandin use except?
- A. Increased motility of bowel
- B. Nausea
- C. Excess water retention (Correct Answer)
- D. Flushes
Explanation: ***Excess water retention*** - **Prostaglandins** generally promote **diuresis** and natriuresis, meaning they help the body excrete water and sodium, rather than retain them [2]. - While some prostaglandins can affect renal blood flow, direct causation of **excess water retention** as a primary side effect is not typical. *Flushes* - **Prostaglandins**, particularly **PGE1** and **PGE2**, are potent **vasodilators** and can cause cutaneous vasodilation, leading to **flushing** and a sensation of warmth [3]. - This effect is often mediated by the relaxation of vascular smooth muscle. *Increased motility of bowel* - Many **prostaglandins**, especially **PGE** and **PGF** series, stimulate **smooth muscle contraction**, including in the gastrointestinal tract [1]. - This increased contraction can lead to **enhanced bowel motility**, sometimes causing diarrhea or abdominal cramping [1]. *Nausea* - **Prostaglandins** can have various systemic effects, and activation of pathways in the central nervous system or direct irritation of the GI tract can lead to symptoms like **nausea** and vomiting [1]. - This is a common side effect, especially with systemic administration.
Question 2: Which of the following is NOT a cause of metrorrhagia?
- A. Polyp
- B. CA endometrium
- C. IUD
- D. Intramural fibroid (Correct Answer)
Explanation: ***Intramural fibroid*** - **Intramural fibroids** are located within the uterine wall and are **primarily associated with menorrhagia** (heavy or prolonged menstrual bleeding during regular periods) rather than metrorrhagia. - Their main effect is to increase the endometrial surface area and impair uterine contractility, leading to **heavy regular menstrual flow**. - While they can occasionally cause irregular bleeding if complicated by degeneration or severe distortion, this is **not their typical presentation**, making them the **least characteristic cause** of metrorrhagia among the given options. *Polyp* - **Endometrial polyps** are **classic causes of metrorrhagia** because their friable surface bleeds irregularly, especially with hormonal fluctuations or minor trauma. - They commonly present with **intermenstrual spotting** and post-coital bleeding, making them a typical cause of irregular bleeding. *CA endometrium* - **Endometrial carcinoma** is a **frequent cause of metrorrhagia**, particularly in postmenopausal women, due to irregular shedding of friable malignant tissue. - The abnormal vascular supply and tissue breakdown in cancer results in **unpredictable, irregular bleeding episodes** characteristic of metrorrhagia. *IUD* - **Intrauterine devices** are **well-known causes of metrorrhagia**, particularly copper IUDs, which cause endometrial irritation and increased prostaglandin release. - Both copper and hormonal IUDs frequently cause **spotting and irregular intermenstrual bleeding**, especially in the first 3-6 months after insertion.
Question 3: Primary amenorrhea is defined as:
- A. Imperforate hymen exists
- B. None of the above
- C. Menstruation does not occur even after 15 years of age (Correct Answer)
- D. Menstruation does not occur even after 18 years
Explanation: ***Menstruation does not occur even after 15 years of age*** - Primary amenorrhea is defined as the **absence of menstruation by age 15** in individuals with normal secondary sexual characteristics. - This definition is crucial for determining when to initiate investigation for underlying causes. *Imperforate hymen exists* - While an imperforate hymen can cause **cryptomenorrhea** (menstruation occurring but not flowing out), it is a specific cause of primary amenorrhea, not the definition itself. - An imperforate hymen is identified by a **bulging, bluish membrane** at the vaginal introitus. *None of the above* - This option is incorrect because the first option accurately defines primary amenorrhea. - The definition of primary amenorrhea is clinically well-established and widely accepted. *Menstruation does not occur even after 18 years* - This age cut-off is **too late** for the definition of primary amenorrhea, as investigations should ideally begin earlier. - Delaying evaluation until age 18 could potentially delay the diagnosis and treatment of underlying conditions affecting fertility and overall health.
Question 4: A 16-year-old girl presents with cyclical pelvic pain every month. She has not achieved menarche yet. On examination, a suprapubic bulge can be seen in the lower abdomen. PR examination reveals a bulging swelling in the anterior aspect. What is the most likely diagnosis?
- A. Transverse vaginal septum
- B. Vaginal atresia
- C. Imperforate hymen (Correct Answer)
- D. Cervical agenesis
Explanation: ***Imperforate hymen*** - The combination of **cyclical pelvic pain** without menarche (primary amenorrhea) and a **suprapubic bulge** with **bulging swelling on PR examination** strongly suggests an imperforate hymen. - This condition leads to the **accumulation of menstrual blood (hematocolpos)**, causing the observed swelling and pain. - Imperforate hymen is the **most distal obstruction** of the female genital tract, presenting with a characteristic **bulging membrane at the vaginal opening**. *Transverse vaginal septum* - This condition also causes **primary amenorrhea** and **hematocolpos** leading to cyclical pain. - However, a transverse vaginal septum is located **higher in the vagina** (not at the introitus) and would not typically present with such an obvious **bulging swelling on examination** at the vaginal opening. *Vaginal atresia* - **Vaginal atresia** involves the complete or partial absence of the vagina, which would prevent menarche and cause cyclical pain. - While it results in hematocolpos (if the uterus is present), the presentation differs from the classic **bulging membrane** seen with imperforate hymen. *Cervical agenesis* - **Cervical agenesis** is the congenital absence or incomplete formation of the cervix, leading to **primary amenorrhea** and severe cyclical pain due to retained menstrual blood in the uterus (**hematometra**). - This condition would not present with a **bulging mass on PR examination** at the vaginal level, but rather with an enlarged uterus above, as the obstruction is at the cervical level, not at the vaginal outlet.
Question 5: All of the following are true regarding after pains except:
- A. They become more pronounced as parity increases
- B. Most common in multiparous females
- C. Pain worsens when infant suckles
- D. Most severe on the 7th postpartum day (Correct Answer)
Explanation: ***Most severe on the 7th postpartum day*** - This is **INCORRECT** - afterpains are most severe immediately after delivery and typically resolve within **2-3 days postpartum**, not persisting until day 7. - Afterpains rapidly decrease in intensity as the uterus involutes, with the most noticeable pain occurring in the first 24-48 hours. - By the 7th postpartum day, the uterus has undergone significant involution, and afterpains have usually completely subsided. *Most common in multiparous females* - Afterpains are indeed more common and more severe in **multiparous women** because their uterine muscle tone is reduced after multiple pregnancies. - The uterus requires stronger contractions to achieve involution, resulting in more noticeable afterpains. *Pain worsens when infant suckles* - When the infant **suckles**, it stimulates the release of **oxytocin** from the posterior pituitary. - Oxytocin causes the uterus to contract more strongly, temporarily worsening afterpain. - This mechanism is beneficial as it promotes uterine involution and helps prevent postpartum hemorrhage. *They become more pronounced as parity increases* - With each subsequent pregnancy (increased parity), the uterus loses tone and elasticity. - This requires **stronger contractions** during involution to return to pre-pregnancy size. - Therefore, multiparous women typically experience more pronounced and painful afterpains compared to primiparous women.
Question 6: A 28-year-old woman, G2 P1, with severe PPH unresponsive to oxytocin presents with hypotension and tachycardia. She has a soft uterus and ongoing bleeding. What is the next best step in management?
- A. IM carboprost (Correct Answer)
- B. Immediate hysterectomy
- C. Expectant management
- D. IV tranexamic acid
Explanation: ***IM carboprost*** - The **soft uterus** with ongoing bleeding despite oxytocin indicates **uterine atony** as the cause of PPH - Carboprost (PGF2α) is the **standard second-line uterotonic agent** after oxytocin failure - Effectively stimulates strong **uterine contractions** to control hemorrhage from the placental bed - Given intramuscularly at **0.25 mg every 15-90 minutes** (maximum 8 doses) - Contraindicated in active cardiac, pulmonary, or hepatic disease *Immediate hysterectomy* - Peripartum hysterectomy is a **last-resort surgical intervention** for refractory PPH - Should only be performed after failure of medical management (all uterotonics) and conservative surgical options (uterine tamponade, uterine artery ligation, B-Lynch suture) - **Too aggressive** as the immediate next step when second-line uterotonics haven't been tried *Expectant management* - **Completely inappropriate** for severe PPH with hemodynamic instability (hypotension, tachycardia) - Ongoing bleeding from uterine atony requires **immediate aggressive intervention** - Delays increase risk of hypovolemic shock, DIC, maternal morbidity, and mortality *IV tranexamic acid* - **Antifibrinolytic agent** that inhibits plasminogen activation, promoting clot stability - WHO recommends administration **within 3 hours** of PPH onset as an adjunct therapy - While useful in PPH management, it does **not address uterine atony** (the primary cause indicated by soft uterus) - Should be given **in addition to uterotonics**, not as a substitute for definitive management of atony
Question 7: A 29 year old female presented with infertility. There is history of abdominal pain, dyspareunia, dysmenorrhea, menorrhagia. Most likely cause:
- A. Adenomyosis
- B. Endometriosis (Correct Answer)
- C. Cervicitis
- D. Myomas
Explanation: ***Endometriosis*** - The classic triad of symptoms in this 29-year-old female—**dysmenorrhea**, **dyspareunia**, and **infertility**—is highly suggestive of endometriosis. - **Ectopic endometrial tissue** can cause chronic abdominal pain, menorrhagia, and inflammation, contributing to infertility. *Adenomyosis* - This condition involves the presence of **endometrial tissue within the myometrium**, leading to a thickened uterine wall. - While it can cause dysmenorrhea and menorrhagia, **infertility** is not its primary presentation, and it is less commonly associated with severe dyspareunia compared to endometriosis. *Cervicitis* - **Inflammation of the cervix** typically presents with vaginal discharge, post-coital bleeding, or pelvic pain. - It is not a common cause of primary infertility, severe dysmenorrhea, or dyspareunia as described. *Myomas* - Uterine **fibroids (leiomyomas)** are benign tumors that can cause heavy menstrual bleeding (menorrhagia), pelvic pressure, and sometimes infertility. - However, they are less commonly associated with the triad of severe dysmenorrhea and dyspareunia as prominently as seen in endometriosis.
Question 8: The contraceptive choice for a 38 year old woman with chronic hypertension and history of dysmenorrhea and menorrhagia (malignancy ruled out) is:
- A. Copper intrauterine device
- B. Sterilization
- C. Combined oral contraceptive pills
- D. Levonorgestrel intrauterine device (Correct Answer)
Explanation: ***Levonorgestrel intrauterine device*** - The **Levonorgestrel IUD** is an excellent choice as it provides effective contraception while also treating menorrhagia and dysmenorrhea due to its local progesterone release. - It is safe for women with **hypertension** as it is a **non-estrogen-containing method**, avoiding the increased risk of thrombotic events associated with estrogen. *Copper intrauterine device* - While an effective non-hormonal contraceptive, the **copper IUD** can worsen **dysmenorrhea** and **menorrhagia**, which are existing concerns for the patient. - It does not offer any therapeutic benefits for her heavy and painful periods. *Sterilization* - Although it provides permanent and highly effective contraception, **sterilization** does not address the patient's symptoms of **dysmenorrhea** and **menorrhagia**. - It is an irreversible procedure and typically considered when no further childbearing is desired and symptomatic relief is not a primary concern for the contraceptive method itself. *Combined oral contraceptive pills* - **Combined oral contraceptive pills (COCs)** are generally contraindicated or used with caution in women with uncontrolled **hypertension** due to the estrogen component, which can increase the risk of cardiovascular events, including thrombosis. - While COCs can improve dysmenorrhea and menorrhagia, the cardiovascular risks in a 38-year-old with chronic hypertension outweigh these benefits.
Question 9: A 15-year old unmarried girl comes with history of dysmenorrhea. Age of menarche is 12 years. Per abdominal and per rectum examination reveal nothing abnormal. You will treat the patient with :
- A. Reassurance and giving antispasmodics throughout the month
- B. Hormones
- C. Antibiotics
- D. Reassurance and giving antispasmodics during menses (Correct Answer)
Explanation: ***Reassurance and giving antispasmodics during menses*** - The patient presents with **primary dysmenorrhea**, indicated by the onset of symptoms with menarche and normal pelvic examination findings in an unmarried girl. - **Antispasmodics** (e.g., NSAIDs like ibuprofen or mefenamic acid) taken during menses effectively reduce pain by inhibiting prostaglandin synthesis, which causes uterine contractions. *Reassurance and giving antispasmodics throughout the month* - While **reassurance** is appropriate, taking antispasmodics throughout the entire month is **unnecessary** and can lead to adverse effects, as the pain is cyclical and directly related to menstruation. - **Antispasmodics** are most effective when taken a day or two before the onset of menstruation and continued during the painful days. *Hormones* - **Hormonal therapy** (e.g., combined oral contraceptives) is a valid treatment option for dysmenorrhea, especially if non-steroidal anti-inflammatory drugs (NSAIDs) are ineffective or if contraception is also desired. - However, for a 15-year-old unmarried girl with typical primary dysmenorrhea and no other complications, **NSAIDs/antispasmodics** are generally the first-line and usually sufficient treatment. *Antibiotics* - **Antibiotics** are used to treat bacterial infections, and there is no indication of infection (e.g., fever, unusual discharge, pelvic inflammatory disease) in this patient's presentation. - Using antibiotics without an identified infection is inappropriate and contributes to **antibiotic resistance**.
Question 10: Which one of the following about primary dysmenorrhea is NOT true?
- A. Most commonly seen in adolescents and young women
- B. Pain is related to uterine hypoxia
- C. Pain increases following pregnancy and delivery (Correct Answer)
- D. Always confined to ovulatory cycles
Explanation: ***Pain increases following pregnancy and delivery*** - It is a common clinical observation that primary dysmenorrhea often **improves or resolves** after pregnancy and childbirth, likely due to cervical dilatation, changes in uterine structure, or altered innervation. - Therefore, the statement that pain *increases* following pregnancy and delivery is **NOT true** and is the correct answer. *Most commonly seen in adolescents and young women* - This statement is **TRUE**. Primary dysmenorrhea typically begins within **6-12 months** after menarche once ovulatory cycles are established. - It is **most prevalent in adolescents and women in their 20s**, though it can persist into later reproductive years. - Incidence decreases with age and often improves after childbirth. *Pain is related to uterine hypoxia* - This statement is **TRUE**. The pain in primary dysmenorrhea is primarily caused by **excessive prostaglandin F2α production** during endometrial breakdown. - Prostaglandins cause **intense uterine contractions** leading to **ischemia** and reduced blood flow (hypoxia) to the myometrium. - This **uterine hypoxia** and ischemia are significant contributors to the painful cramps experienced. *Always confined to ovulatory cycles* - This statement is **TRUE**. Primary dysmenorrhea is intrinsically linked to **ovulatory menstrual cycles**. - It involves prostaglandin production in response to progesterone withdrawal and endometrial breakdown, which **only occurs in ovulatory cycles**. - Anovulatory cycles (common immediately after menarche) are typically **painless**.
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