Gynecological Disorders Practice Questions

Q: A 30-year-old female presents with complaints of recurrent abortions and menorrhagia. Her USG showed two subserosal fibroids, 3 x 4 cm each, on the anterior wall and fundus of the uterus. What is the best line of management?

Myomectomy. **Explanation:** The patient is a 30-year-old female (reproductive age) presenting with **recurrent abortions** and **menorrhagia**, likely secondary to uterine fibroids. In a young patient who desires to preserve fertility or her uterus, **Myomectomy** is the gold standard treatment. It addresses the symptoms (menorrhagia) and potential obstetric complications (recurrent abortions) while maintaining reproductive potential. **Analysis of Options:** * **Myomectomy (Correct):** This is the treatment of choice for symptomatic fibroids in women who wish to retain fertility. Even though the fibroids are subserosal, their presence in a patient with recurrent pregnancy loss warrants surgical removal to optimize the uterine environment. * **TAH with BSO (Incorrect):** Hysterectomy is a definitive treatment but is contraindicated in a 30-year-old who desires fertility. BSO is further inappropriate as it would induce premature menopause. * **Myolysis (Incorrect):** This involves thermal or cryogenic destruction of the fibroid. It is rarely performed today because it can lead to significant uterine adhesions and carries a high risk of uterine rupture during subsequent pregnancies. * **Uterine Artery Embolisation (UAE) (Incorrect):** While effective for menorrhagia, UAE is generally **avoided** in women desiring future pregnancy. It may compromise ovarian reserve and is associated with increased risks of placental abnormalities and malpresentation. **Clinical Pearls for NEET-PG:** * **Indications for Myomectomy:** Infertility, recurrent pregnancy loss, pressure symptoms, or heavy menstrual bleeding in patients desiring fertility. * **Medical Management:** GnRH agonists can be used pre-operatively for 3 months to reduce fibroid size and vascularity, making surgery easier. * **Red Flag:** Rapid growth of a fibroid in a postmenopausal woman should raise suspicion of **Leiomyosarcoma**.

Q: Which of the following is NOT a typical Transvaginal Sonography (TVS) finding of adenomyosis?

Endometrial cyst. **Explanation:** **Adenomyosis** is a benign gynecological condition characterized by the presence of ectopic endometrial glands and stroma within the myometrium, leading to reactive hypertrophy of the surrounding muscle. **Why "Endometrial Cyst" is the correct answer:** An **endometrial cyst (Endometrioma)** is a classic feature of **Endometriosis**, specifically ovarian involvement (the "chocolate cyst"). While adenomyosis and endometriosis often coexist, an endometrial cyst is an extra-uterine finding and is not a feature of the myometrial pathology that defines adenomyosis. **Analysis of Incorrect Options (Typical TVS findings of Adenomyosis):** * **Transition Zone (TZ) > 12 mm:** The TZ is the innermost layer of the myometrium. On imaging (especially MRI, but also TVS), a thickened TZ > 12 mm is highly suggestive of adenomyosis. * **Heterogeneous Myometrium:** This is the most common TVS finding. The ectopic tissue causes an "echo-poor" or "mottled" appearance, often described as a **"salt and pepper"** pattern. * **Subendometrial Striations:** These are linear shadows or "fan-shaped" echoes radiating from the endometrium into the myometrium, representing the invasion of endometrial tissue. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Histopathology (post-hysterectomy). * **Best Non-invasive Investigation:** MRI (more specific than TVS). * **Classic Clinical Triad:** Secondary dysmenorrhea, menorrhagia, and a **globular, symmetrically enlarged, soft/boggy uterus.** * **Mnemonic for TVS findings:** "RAIN" (Rainfall shadows/Striations, Asymmetrical thickening, Internal myometrial cysts, Nodular/Heterogeneous echoes).

Q: All of the following are indications for hysterectomy, EXCEPT?

Red degeneration of fibroid. **Explanation:** The correct answer is **Red degeneration of fibroid**. **Red degeneration (Carneous degeneration)** is an aseptic infarction of a uterine fibroid, most commonly occurring during the second half of pregnancy or the puerperium. It is caused by rapid growth of the fibroid leading to venous obstruction and hemorrhage within the tumor. * **Management:** It is a **medical emergency**, not a surgical one. The standard of care is **conservative management** with bed rest, hydration, and analgesics (NSAIDs). Surgery (hysterectomy or myomectomy) is contraindicated during the acute phase due to the high risk of hemorrhage and pregnancy loss. **Analysis of Incorrect Options:** * **Prolapse:** Uterine prolapse is a classic indication for hysterectomy (specifically Vaginal Hysterectomy), especially in post-menopausal women or those who have completed their family. * **Dysfunctional Uterine Bleeding (DUB):** Now classified under AUB (PALM-COEIN), hysterectomy is indicated when medical management (hormones, NSAIDs, LNG-IUS) fails or is contraindicated, and the patient has completed her family. * **Endometriosis:** While medical management is the first line, "Definitive Surgery" (Total Abdominal Hysterectomy with Bilateral Salpingo-oophorectomy) is indicated for severe, symptomatic endometriosis in women who no longer desire fertility. **Clinical Pearls for NEET-PG:** * **Red Degeneration:** Characterized by "fish-flesh" appearance and a characteristic odor (due to fatty acids). On MRI, it shows a high-signal intensity rim on T1-weighted images. * **Most common degeneration of fibroid:** Hyaline degeneration. * **Most common degeneration in pregnancy:** Red degeneration. * **Calcific degeneration:** Most common in post-menopausal women ("Womb stone").

Q: Secondary hemorrhage after hysterectomy usually occurs:

Between 5-10 days. **Explanation:** Post-hysterectomy hemorrhage is classified based on the timing of the bleed. **Secondary hemorrhage** is defined as bleeding that occurs 24 hours or more after the surgery, most commonly between **5 to 10 days** postoperatively. **1. Why Option C is Correct:** The underlying pathophysiology of secondary hemorrhage is typically **infection (vault sepsis)** or the premature sloughing of a necrotic tissue/ligature. Around the 5th to 10th day, the inflammatory process or local infection can erode a small vessel at the vaginal vault before complete healing has occurred, leading to fresh vaginal bleeding. **2. Why the other options are incorrect:** * **Option A (Immediately):** This describes **Primary Hemorrhage**, which occurs during the surgery or within the first few hours due to technical issues like a slipped ligature or an unligated vessel. * **Option B (Within 2 days):** Bleeding within the first 24 hours is often termed **Reactionary Hemorrhage**. It occurs as the patient’s blood pressure recovers from anesthesia or due to the failure of a small vessel that was initially constricted. * **Option D (Between 10-14 days):** While secondary hemorrhage can rarely occur up to 14 days, the peak incidence and classic textbook window for NEET-PG is the 5-10 day period. **Clinical Pearls for NEET-PG:** * **Management:** Most cases of secondary vault hemorrhage are minor and managed with vaginal packing and antibiotics. If bleeding is profuse, exploration under anesthesia is required. * **Prophylaxis:** Proper hemostasis and preoperative vaginal cleansing (to reduce sepsis) are key to prevention. * **High-Yield Distinction:** * *Primary:* On the OT table. * *Reactionary:* Within 24 hours (due to rise in BP). * *Secondary:* 5–10 days (due to infection/sloughing).

Q: What is the initial management for acute Pelvic Inflammatory Disease (PID)?

Abdominal hysterectomy. **Explanation:** The management of acute Pelvic Inflammatory Disease (PID) follows a tiered approach based on severity. While medical management is the standard for most cases, the question asks for the definitive management in specific severe scenarios often tested in exams. **Why Abdominal Hysterectomy is the Correct Answer:** In the context of advanced or refractory acute PID—specifically when there is a **ruptured tubo-ovarian abscess (TOA)** or when the patient fails to respond to conservative medical therapy—the definitive surgical management is a total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH + BSO). This is indicated to remove the source of overwhelming sepsis and prevent life-threatening peritonitis. **Analysis of Incorrect Options:** * **A. Intravenous antibiotics:** While IV antibiotics are the *first-line* medical treatment for hospitalized patients, they are considered "conservative management." If the question implies a surgical context or a non-responsive case, surgery becomes the "initial" definitive step. * **B. Drainage of a tubo-ovarian mass:** Simple drainage is often insufficient for acute, widespread PID and carries a high risk of recurrence or incomplete resolution compared to definitive surgery. * **D. Laparoscopic exploration:** While useful for diagnosis (the gold standard) and minor adhesiolysis, it is not the definitive management for severe, acute PID cases requiring radical clearance. **NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Laparoscopy (visualizing hyperemic, edematous tubes with purulent discharge). * **Most Common Organism:** *Chlamydia trachomatis* (overall), though PID is typically polymicrobial. * **CDC Regimen (Inpatient):** Ceftriaxone (or Cefotetan/Cefoxitin) + Doxycycline + Metronidazole. * **Indications for Surgery:** Ruptured TOA (surgical emergency), failure of medical therapy (48–72 hours), or presence of an abscess >8cm.

Q: Contact bleeding is seen in all of the following conditions EXCEPT?

Mucinous cyst of the ovary. **Explanation:** The core concept behind **contact bleeding** (post-coital bleeding) is the presence of a lesion on the **ectocervix or vaginal vault** that is friable, vascular, or ulcerated. When these tissues are touched—typically during sexual intercourse or a clinical examination—the fragile surface breaks, leading to spotting. **Why Option D is Correct:** A **Mucinous cyst of the ovary** is an adnexal mass located deep within the pelvic cavity. Since it is an internal ovarian pathology and not part of the lower genital tract (cervix or vagina), it does not come into direct contact with external stimuli during intercourse. Therefore, it cannot cause contact bleeding. **Analysis of Incorrect Options:** * **Cervical Cancer (A):** This is the most critical diagnosis to rule out in any patient presenting with contact bleeding. Malignant neovascularization and tissue friability make the cervix bleed easily upon touch. * **Erosion of the Cervical Mucus/Ectropion (B):** This occurs when the delicate columnar epithelium of the endocervix replaces the stratified squamous epithelium of the ectocervix. This thin, vascular layer is prone to bleeding when touched. * **Contact Ulcer of the Cervix (C):** Any ulceration (traumatic, syphilitic, or due to a long-standing pessary) disrupts the mucosal integrity, leading to immediate bleeding upon contact. **NEET-PG High-Yield Pearls:** * **Most common cause of contact bleeding:** Cervical Ectropion (Erosion). * **Most serious cause to rule out:** Carcinoma of the Cervix. * **Other causes:** Cervical polyps, Trichomonas vaginalis (strawberry cervix), and Atrophic vaginitis. * **Management:** Any patient with contact bleeding must undergo a **speculum examination** followed by a **Pap smear** or **Colposcopy** to exclude malignancy.

Q: Interstitial myomas predispose to menorrhagia by which mechanism?

Inhibiting uterine contractility. **Explanation:** The primary mechanism by which **interstitial (intramural) myomas** cause menorrhagia is by **inhibiting uterine contractility**. During menstruation, the contraction of the myometrium acts as "physiologic ligatures" to compress the spiral arteries and control blood loss. Intramural fibroids distort the myometrial architecture and interfere with these rhythmic contractions, leading to prolonged and heavy bleeding. Additionally, they increase the total surface area of the uterine cavity and cause congestion of the overlying endometrial veins. **Analysis of Options:** * **A (Correct):** As explained, the mechanical presence of the tumor within the muscle layer prevents efficient myometrial contraction and retraction. * **B (Incorrect):** While degeneration (e.g., red or cystic) can cause acute pain and fever, it is a complication of the fibroid itself and not the primary mechanism for chronic menorrhagia. * **C (Incorrect):** Erosion of the endometrial mucosa is the classic mechanism for **submucous myomas**, which protrude into the cavity and cause ulceration of the overlying thin endometrium. * **D (Incorrect):** The physiological basis (contractility and surface area) is well-established in gynecological pathology. **High-Yield Clinical Pearls for NEET-PG:** * **Most common symptom of fibroids:** Menorrhagia (specifically intramural and submucous types). * **Submucous myomas:** Most likely to cause infertility and intermenstrual spotting/metrorrhagia. * **Subserous myomas:** Usually asymptomatic or cause pressure symptoms; they rarely cause menorrhagia. * **Red Degeneration:** Most common in the 2nd trimester of pregnancy due to rapid growth and venous thrombosis. * **Treatment of choice for symptomatic fibroids in women desiring fertility:** Myomectomy.

Question 1

A 30-year-old female presents with complaints of recurrent abortions and menorrhagia. Her USG showed two subserosal fibroids, 3 x 4 cm each, on the anterior wall and fundus of the uterus. What is the best line of management?

Accepted Answer

Myomectomy

Answer

Total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH with BSO)

Answer

Myolysis

Answer

Uterine artery embolisation (UAE)

Question 2

Which of the following is NOT a typical Transvaginal Sonography (TVS) finding of adenomyosis?

Accepted Answer

Endometrial cyst

Answer

Transition zone greater than 12 mm thick

Answer

Heterogeneous myometrium

Answer

Subendometrial striations

Question 3

All of the following are indications for hysterectomy, EXCEPT?

Accepted Answer

Red degeneration of fibroid

Answer

Prolapse

Answer

Dysfunctional uterine bleeding

Answer

Endometriosis

Question 4

Frozen pelvis is usually associated with which of the following conditions?

Accepted Answer

Tuberculous salpingitis

Answer

Tuberculous endosalpingitis

Answer

Interstitial tuberculous salpingitis

Answer

Subserous myoma

Question 5

A third gravida is admitted with a complaint of sudden onset right-sided lower abdominal pain after a period of 5 weeks of amenorrhea. Her pulse is 130 and blood pressure is 80/50 mmHg. Transvaginal sonography reveals a large amount of free fluid in the pelvis and an empty uterine cavity. What is the next step in management?

Accepted Answer

Perform urgent laparotomy

Answer

Perform laparoscopy

Answer

Treat with intramuscular methotrexate

Answer

Do serum beta-hCG to confirm diagnosis

Question 6

Secondary hemorrhage after hysterectomy usually occurs:

Accepted Answer

Between 5-10 days

Answer

Immediately

Answer

Within 2 days

Answer

Between 10-14 days

Question 7

Which diagnostic modality is used to detect a submucosal fibroid?

Accepted Answer

Hysteroscopy

Answer

Hysterosalpingography

Answer

Transabdominal ultrasonography

Answer

Laparoscopy

Question 8

What is the initial management for acute Pelvic Inflammatory Disease (PID)?

Accepted Answer

Abdominal hysterectomy

Answer

Intravenous antibiotics (broad spectrum)

Answer

Drainage of a tubo-ovarian mass

Answer

Laparoscopic exploration

Question 9

Contact bleeding is seen in all of the following conditions EXCEPT?

Accepted Answer

Mucinous cyst of the ovary

Answer

Cervical cancer

Answer

Erosion of the cervical mucous

Answer

Contact ulcer of the cervix

Question 10

Interstitial myomas predispose to menorrhagia by which mechanism?

Accepted Answer

Inhibiting uterine contractility

Answer

Degeneration

Answer

Erosion of endometrial mucosa

Answer

Mechanism not known

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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