Gynecological Disorders Practice Questions

Q: Simple hyperplasia of the endometrium is treated with progesterone for how many days?

21. **Explanation:** Endometrial hyperplasia without atypia (Simple Hyperplasia) is primarily caused by **unopposed estrogen** stimulation. The goal of treatment is to counteract this effect using progestogens, which induce secretory changes in the endometrium, leading to its thinning and eventual shedding. **Why 21 days is correct:** For the medical management of simple hyperplasia, the standard protocol involves cyclic progestogen therapy (e.g., Medroxyprogesterone acetate 10mg). It is typically administered for **21 days per month** (usually from Day 5 to Day 25 of the cycle) for a duration of 3 to 6 months. This extended duration is necessary to ensure adequate transformation of the proliferative endometrium and to prevent progression to atypia or malignancy. **Analysis of incorrect options:** * **10 & 14 days:** While a 10–14 day course of progesterone is often used to induce a withdrawal bleed in cases of secondary amenorrhea or PCOS, it is considered **insufficient** for the therapeutic reversal of established endometrial hyperplasia. * **5 days:** This duration is too short to achieve any significant histological change in the endometrial lining and is clinically ineffective for hyperplasia. **High-Yield NEET-PG Pearls:** * **Gold Standard Treatment:** For hyperplasia *without* atypia, the **Levonorgestrel Intrauterine System (LNG-IUS)** is now considered the first-line treatment due to higher regression rates compared to oral progestogens. * **Atypical Hyperplasia:** This is a premalignant condition. In postmenopausal women or those who have completed their family, the treatment of choice is **Total Abdominal Hysterectomy**. * **Follow-up:** Patients on medical management require a repeat endometrial biopsy every 3–6 months until two consecutive negative results are obtained.

Q: A 31-year-old woman presents to the emergency department because of two days of abdominal pain without vaginal bleeding. Pelvic examination reveals a closed cervical os and right adnexal pain. The serum beta hCG level is 9,000 mIU/mL. An endovaginal ultrasound demonstrates no intrauterine gestational sac. Which of the following is the most likely diagnosis?

Ectopic pregnancy. **Explanation:** The diagnosis of **Ectopic Pregnancy** is established based on the concept of the **Discriminatory Zone**. This is the serum $\beta$-hCG level above which a gestational sac should be visible on ultrasound in a normal intrauterine pregnancy (IUP). 1. **Why it is correct:** For transvaginal sonography (TVS), the discriminatory zone is typically **1,500–2,000 mIU/mL**. In this patient, the $\beta$-hCG is significantly elevated at **9,000 mIU/mL**, yet the ultrasound shows an empty uterus. The combination of a positive pregnancy test, abdominal pain, adnexal tenderness, and the absence of an intrauterine sac despite high $\beta$-hCG levels is pathognomonic for an ectopic pregnancy. 2. **Why other options are incorrect:** * **Incomplete Abortion:** This would typically present with vaginal bleeding and an **open cervical os** on examination. Ultrasound would show retained products of conception within the uterus. * **Ovarian Torsion:** While it causes acute pelvic pain and adnexal tenderness, it does not explain the elevated $\beta$-hCG level. * **Ruptured Ovarian Cyst:** This can cause sudden pain and peritoneal irritation, but like torsion, it is unrelated to a positive pregnancy test unless it is a ruptured corpus luteum of pregnancy (which would usually still show an IUP). **NEET-PG High-Yield Pearls:** * **Most common site:** Ampulla of the Fallopian tube. * **Most common site for rupture:** Isthmus (due to narrow lumen). * **Gold Standard Diagnosis:** Laparoscopy. * **Medical Management (Methotrexate) Criteria:** Hemodynamically stable, $\beta$-hCG < 5,000 mIU/mL, mass < 3.5–4 cm, and no fetal heart activity.

Q: What is the most reliable method for diagnosing hydatidiform mole?

Ultrasound. **Explanation:** The diagnosis of a hydatidiform mole (molar pregnancy) is primarily clinical and radiological. **Ultrasound (USG)** is considered the most reliable and gold-standard diagnostic tool. **Why Ultrasound is the Correct Answer:** USG provides a definitive visual diagnosis. In a **complete mole**, it reveals the characteristic **"Snowstorm appearance"** or "honeycomb pattern," which represents the multiple hydropic villi and the absence of a fetus or amniotic sac. In a **partial mole**, it shows focal cystic changes in the placenta and a distorted gestational sac or fetal parts. It is non-invasive, widely available, and provides immediate confirmation. **Analysis of Incorrect Options:** * **A. HCG Estimation:** While hCG levels are typically markedly elevated (often >100,000 mIU/ml), a single high value is not diagnostic. High hCG can also be seen in multiple pregnancies or incorrect dating. It is more useful for **monitoring follow-up** and detecting persistent gestational trophoblastic neoplasia (GTN). * **B. Amniography:** Historically used to show a "moth-eaten" appearance, this invasive technique has been entirely replaced by ultrasound and is no longer practiced. * **D. Absence of FHS:** While the absence of fetal heart sounds is a clinical feature of a complete mole, it is a non-specific finding also seen in missed abortions or pseudocyesis. It cannot confirm a molar pregnancy. **Clinical Pearls for NEET-PG:** * **Theca Lutein Cysts:** Found in 25-30% of cases due to high hCG levels; they usually regress after evacuation. * **Treatment of Choice:** Suction Evacuation (regardless of uterine size). * **Most common site of metastasis:** Lungs (followed by the vagina). * **Follow-up:** Weekly hCG until three consecutive negative results, then monthly for 6 months. Contraception (preferably OCPs) is mandatory during this period.

Q: A 6-year-old girl presents with vaginal spotting. What is the most likely diagnosis?

Foreign body in the vagina. **Explanation:** The most common cause of prepubertal vaginal bleeding (spotting) and foul-smelling discharge is a **foreign body in the vagina**. In a 6-year-old girl, curiosity often leads to the insertion of small objects (most commonly wadded toilet paper). This causes local irritation, secondary infection, and friable mucosa, leading to spotting. Diagnosis is usually clinical or via bedside examination (vaginoscopy), and management involves simple removal. **Analysis of Options:** * **Ovarian Malignancy (A):** While germ cell tumors can occur in children, they typically present with a palpable abdominal mass or signs of precocious puberty (due to hormone secretion) rather than isolated vaginal spotting. * **Sexual Abuse (C):** This must always be considered in the differential diagnosis of pediatric genital trauma or bleeding. However, statistically, a foreign body is the more frequent cause of isolated, non-traumatic spotting in this age group. Abuse is suspected if there are lacerations, bruising, or behavioral changes. * **Normal Variation (D):** Vaginal bleeding is never "normal" in a 6-year-old. It is only considered physiological during the first week of life (neonatal withdrawal bleeding due to maternal estrogens). **Clinical Pearls for NEET-PG:** * **Most common cause of prepubertal bleeding:** Foreign body. * **Most common foreign body:** Toilet paper. * **Most common malignant cause:** Sarcoma botryoides (Rhabdomyosarcoma), which presents with "grape-like" masses. * **Precocious Puberty:** If bleeding is accompanied by breast development (thelarche), suspect central or peripheral precocious puberty.

Q: What is the preferred procedure for obtaining an endometrial sample for histopathology?

Endometrial aspiration. **Explanation:** The preferred first-line procedure for obtaining an endometrial sample is **Endometrial Aspiration** (e.g., using a Pipelle catheter). This is because it is a simple, cost-effective, office-based procedure that does not require general anesthesia or cervical dilatation. It has a high sensitivity (approx. 90-99%) for detecting endometrial carcinoma and hyperplasia, making it the gold standard for initial screening in cases of Abnormal Uterine Bleeding (AUB) or postmenopausal bleeding. **Analysis of Options:** * **Dilatation and Curettage (D&C):** Formerly the gold standard, it is now reserved for cases where aspiration is not possible (e.g., cervical stenosis) or when the sample is inadequate. It is an invasive procedure usually requiring anesthesia and carries risks like uterine perforation. * **Dilatation and Evacuation (D&E):** This is a surgical procedure used for the termination of pregnancy (usually in the second trimester) or for managing retained products of conception, not for diagnostic endometrial sampling. * **Hysteroscopy:** While hysteroscopy allows for direct visualization and "targeted" biopsy of focal lesions (like polyps or submucous fibroids), it is more invasive and expensive. It is typically performed if aspiration results are inconclusive or if a focal lesion is suspected on ultrasound. **High-Yield Clinical Pearls for NEET-PG:** * **Pipelle Catheter:** The most common device used for endometrial aspiration; it works on the principle of creating negative pressure. * **Indications:** Any woman >40 years with AUB or any postmenopausal woman with a thickened endometrial stripe (>4mm on TVS) requires sampling. * **Accuracy:** Endometrial aspiration samples only about 4% of the surface area but is highly accurate for global pathologies like malignancy.

Q: What is the most common site of extra-pelvic endometriosis?

Intestinal tract. **Explanation:** Endometriosis is defined as the presence of endometrial-like tissue outside the uterine cavity. While it most commonly occurs within the pelvis (ovaries being the #1 site), it can involve almost any organ system. **1. Why the Intestinal Tract is Correct:** The **intestinal tract** is the most common site for extra-pelvic (and extra-genital) endometriosis, occurring in approximately 5–15% of women with the disease. Within the bowel, the **rectosigmoid colon** is the most frequently affected segment (70–90% of bowel cases), followed by the appendix and terminal ileum. Symptoms often include catamenial dyschezia (painful defecation during menses) or cyclic rectal bleeding. **2. Analysis of Incorrect Options:** * **Bladder & Ureter:** While urinary tract endometriosis exists, it is less common than bowel involvement. The bladder is the most common site *within* the urinary system, but it ranks lower than the gastrointestinal tract in overall extra-pelvic frequency. * **Lungs:** Thoracic endometriosis (leading to catamenial pneumothorax) is the most common site *above the diaphragm*, but it is significantly rarer than intestinal involvement. **3. NEET-PG High-Yield Pearls:** * **Most common site overall:** Ovary (often forming "Chocolate cysts" or Endometriomas). * **Most common site for extra-pelvic/extra-genital disease:** Rectosigmoid colon. * **Most common site for cutaneous endometriosis:** Umbilicus (Villar’s nodule), often following laparoscopic surgery. * **Gold Standard Diagnosis:** Laparoscopy with biopsy (visual confirmation of "powder-burn" or "mulberry" lesions). * **Classic Triad:** Dysmenorrhea, Dyspareunia, and Dyschezia.

Q: Fundal myomas commonly present as:

Menorrhagia. **Explanation:** **1. Why Menorrhagia is the Correct Answer:** Uterine leiomyomas (fibroids) are the most common benign tumors of the uterus. Regardless of their specific location (fundal, body, or cornual), the most frequent clinical presentation is **menorrhagia** (heavy menstrual bleeding). Fundal myomas, especially those with an intramural or submucosal component, increase the total surface area of the endometrium. This leads to increased shedding during menstruation. Furthermore, they interfere with normal uterine contractility and cause congestion of the perimyomatous veins, preventing effective hemostasis during the menstrual cycle. **2. Analysis of Incorrect Options:** * **A. Inversion of uterus:** While a pedunculated fundal submucosal myoma can theoretically cause chronic uterine inversion by pulling the fundus downward (acting as a lead point), this is a **rare** complication rather than a common presentation. * **B. Dysmenorrhea:** While fibroids can cause pelvic pain or secondary dysmenorrhea due to the uterus attempting to expel a submucosal polyp, it is less common than the primary symptom of heavy bleeding. * **C. Urinary retention:** This is typically a feature of **cervical fibroids** or large posterior wall fibroids (impacted in the pouch of Douglas) that compress the urethra or displace the bladder neck. Fundal myomas usually grow upward into the abdominal cavity and are less likely to cause acute urinary symptoms. **3. NEET-PG High-Yield Pearls:** * **Most common symptom of fibroid:** Menorrhagia (specifically for intramural and submucosal types). * **Most common type of fibroid:** Intramural. * **Most common fibroid to undergo torsion:** Pedunculated subserosal fibroid. * **Red Degeneration:** Most common during the 2nd trimester of pregnancy; presents with acute pain and fever. * **Hyaline Degeneration:** The most common overall type of degeneration in fibroids.

Question 1

Endometrial hyperplasia is caused by:

Accepted Answer

Estrogen

Answer

Smoking

Answer

Ovulation-inducing drugs

Answer

Asherman's syndrome

Question 2

Simple hyperplasia of the endometrium is treated with progesterone for how many days?

Accepted Answer

21

Answer

14

Answer

5

Answer

10

Question 3

A 31-year-old woman presents to the emergency department because of two days of abdominal pain without vaginal bleeding. Pelvic examination reveals a closed cervical os and right adnexal pain. The serum beta hCG level is 9,000 mIU/mL. An endovaginal ultrasound demonstrates no intrauterine gestational sac. Which of the following is the most likely diagnosis?

Accepted Answer

Ectopic pregnancy

Answer

Incomplete abortion

Answer

Ovarian torsion

Answer

Ruptured ovarian cyst

Question 4

What is the procedure of choice for diagnosing uterus didelphys?

Accepted Answer

Ultrasonography (USG)

Answer

Laparoscopy

Answer

Intravenous pyelography (IVP)

Answer

Hysterosalpingography (HSG)

Question 5

Which Mullerian duct anomaly is associated with the best reproductive outcome?

Accepted Answer

Bicornuate uterus

Answer

Arcuate uterus

Answer

Didelphic uterus

Answer

Unicornuate uterus

Question 6

What is the most reliable method for diagnosing hydatidiform mole?

Accepted Answer

Ultrasound

Answer

HCG estimation

Answer

Amniography

Answer

Absence of Fetal Heart Sounds (FHS)

Question 7

A 6-year-old girl presents with vaginal spotting. What is the most likely diagnosis?

Accepted Answer

Foreign body in the vagina

Answer

Ovarian malignancy

Answer

Sexual abuse

Answer

Normal variation

Question 8

What is the preferred procedure for obtaining an endometrial sample for histopathology?

Accepted Answer

Endometrial aspiration

Answer

Dilatation and curettage

Answer

Dilatation and evacuation

Answer

Hysteroscopy

Question 9

What is the most common site of extra-pelvic endometriosis?

Accepted Answer

Intestinal tract

Answer

Bladder

Answer

Ureter

Answer

Lungs

Question 10

Fundal myomas commonly present as:

Accepted Answer

Menorrhagia

Answer

Inversion of uterus

Answer

Dysmenorrhea

Answer

Urinary retention

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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