Gynecological Disorders Practice Questions

Q: A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for which of the following?

Chlamydia. **Chlamydia** - Due to the high rate of **co-infection** between *Neisseria gonorrhoeae* and *Chlamydia trachomatis*, it is standard practice to empirically treat for chlamydia when gonorrhea is diagnosed. - The patient's symptoms (vaginal discharge, dysuria, cervical erythema) are consistent with both infections, and co-treatment ensures all likely pathogens are addressed. *Herpes* - Genital herpes typically presents with **painful vesicular or ulcerative lesions**, which are not described in this patient. - While sexually transmitted, there is no high co-infection rate with gonorrhea that mandates empirical treatment. *Bacterial vaginosis* - This is an imbalance of vaginal flora, often characterized by a **fishy odor** and a thin, gray discharge, which are not mentioned here. - It is not routinely co-treated with gonorrhea unless specifically diagnosed, and its symptoms do not mimic gonorrhea as closely as chlamydia. *Syphilis* - Syphilis presents with distinct stages, such as a **painless chancre** in primary syphilis or a rash in secondary syphilis, none of which are described. - While also sexually transmitted, there is no automatic co-treatment recommendation for syphilis with gonorrhea due to a low rate of co-infection and different testing/treatment protocols.

Q: The most common cause of menstrual toxic shock syndrome is -

Prolonged use of tampons. ***Prolonged use of tampons*** - **Toxic shock syndrome (TSS)** is primarily associated with the use of **highly absorbent tampons** left in place for extended periods, creating an environment for bacterial overgrowth. - This allows ***Staphylococcus aureus*** to produce toxins, leading to a systemic inflammatory response. *IUCD* - While an **intrauterine contraceptive device (IUCD)** can rarely be associated with pelvic infections, it is not the most common cause of **menstrual toxic shock syndrome**. - IUCDs are more commonly linked to **pelvic inflammatory disease (PID)** or localized infections, not the systemic shock seen in TSS. *Septic abortion* - **Septic abortion** involves a severe uterine infection after an abortion, leading to systemic infection and potential septic shock [1]. - However, it is a distinct condition from **menstrual TSS**, which is specifically linked to menstruation and tampon use. *Pelvic examination* - A **pelvic examination** is a routine medical procedure and does not typically cause **toxic shock syndrome**. - While it carries a minimal risk of introducing bacteria, it is not a recognized risk factor for the development of menstrual TSS.

Q: A 60 years old Female with intermittent bleeding per vagina, endometrial collection, and thickening with anterior bulging of the fundal area on ultrasound. What is the most probable diagnosis?

Endometrial Polyp. ***Endometrial Polyp*** - Intermittent bleeding and an **endometrial collection** with **thickening** are classic signs of an endometrial polyp. - The **anterior bulging of the fundal area** on ultrasound is characteristic of a **localized, sessile polyp** protruding into the endometrial cavity. - Polyps are benign overgrowths of endometrial tissue that commonly present with postmenopausal bleeding. *Submucous Fibroid* - While submucous fibroids can cause intermittent bleeding and fundal bulging, they typically appear as a distinct **hypoechoic mass arising from the myometrium** with a whorled pattern. - Fibroids are solid lesions, whereas the description of "endometrial collection" suggests a more cystic or polypoid nature. *Adenomyosis* - Adenomyosis involves **endometrial tissue within the myometrium**, typically causing diffuse uterine enlargement with a heterogeneous myometrial echotexture. - It usually presents with **dysmenorrhea and menorrhagia** rather than intermittent bleeding with focal fundal bulging. - The ultrasound findings described are more consistent with an **intracavitary lesion** rather than myometrial pathology. *Endometrial Cancer* - Endometrial cancer is an important consideration in postmenopausal bleeding with endometrial thickening. - However, malignancy typically presents with a **heterogeneous, irregular endometrial pattern** with increased vascularity on Doppler. - The description of a **discrete collection with focal bulging** points more toward a **benign, localized lesion** like a polyp rather than diffuse malignancy.

Q: Which of the following is the most common cause of perforation of uterus in non-pregnant state?

Dilatation and curettage. ***Dilatation and curettage*** - **Dilatation and curettage (D&C)** is the most frequent iatrogenic cause of uterine perforation in the non-pregnant state due to the blind nature of the procedure, especially in cases of uterine anatomical variations or reduced uterine wall integrity. - The risk of perforation is higher in postmenopausal women due to **atrophic, thinned uterine walls**, and in procedures performed for conditions like endometrial hyperplasia or polyps. *Laparoscopy* - While laparoscopic procedures involve inserting instruments into the abdomen, **uterine perforation during laparoscopy itself is rare**, as it usually involves instrumentation *outside* the uterus unless direct uterine manipulation or hysteroscopy is part of the procedure. - Laparoscopy more commonly results in complications like bowel or vascular injury due to trocar insertion, rather than uterine perforation. *IUCD* - **Intrauterine contraceptive device (IUCD)** insertion can cause uterine perforation, but it is less common than with D&C, with an estimated incidence of 1-2 per 1000 insertions. - Perforation during IUCD insertion is typically an immediate event, whereas D&C-related perforations can occur at any stage of the curettage. *Carcinoma Endometrium* - **Endometrial carcinoma** does not typically cause spontaneous uterine perforation, though it can weaken the uterine wall, making it more susceptible to perforation during diagnostic or therapeutic procedures like D&C. - Perforation directly attributable to the carcinoma itself without instrumental intervention is exceedingly rare.

Q: A 28-year-old female presents with vaginal discharge and cervical motion tenderness. Which finding best predicts upper genital tract infection?

Elevated CRP. ***Elevated CRP*** - **C-reactive protein (CRP)** is an acute-phase inflammatory marker that indicates systemic inflammation associated with **Pelvic Inflammatory Disease (PID)**, an upper genital tract infection. - While vaginal discharge and cervical motion tenderness suggest PID, an **elevated CRP confirms significant inflammatory response** and supports the diagnosis of upper tract involvement. - CRP rises rapidly in acute inflammation (within 6-8 hours) and is commonly used in PID diagnostic criteria alongside ESR. - In the context of this acute presentation, **CRP may be marginally preferred** as it responds faster to acute infection than ESR. *Presence of clue cells* - **Clue cells** are epithelial cells with adherent bacteria, characteristic of **bacterial vaginosis**, a lower genital tract condition. - Their presence indicates vaginal dysbiosis but does not predict upper genital tract infection. *Elevated ESR* - **Erythrocyte sedimentation rate (ESR)** >15 mm/hr is also an established marker in PID diagnostic criteria. - Both ESR and CRP have similar diagnostic utility for PID, with **comparable sensitivity (70-80%)** in detecting upper tract infection. - ESR rises more slowly than CRP in acute infection, making CRP slightly more useful in acute presentations. - In clinical practice, either marker can support the diagnosis of upper genital tract infection. *Microscopic hematuria* - **Microscopic hematuria** indicates blood in urine, typically associated with **urinary tract pathology** rather than genital tract infection. - It does not predict or correlate with upper genital tract infection.

Q: Regarding vaginal candidiasis, which one of the following is false:

Most common in non-pregnant women. ***Most common in non-pregnant women*** - This statement is **false** because **vaginal candidiasis** is more prevalent in **pregnant women** due to hormonal changes, particularly increased estrogen, which alters the vaginal environment. - **Elevated estrogen levels** during pregnancy increase glycogen content in vaginal epithelial cells, providing a nutrient source for *Candida* growth. - Other risk factors include diabetes, immunosuppression, and antibiotic use. *Intense pruritus* - **Intense pruritus** (itching) is a **hallmark symptom** of vaginal candidiasis, caused by the inflammatory response to fungal overgrowth. - This symptom is often accompanied by **vaginal irritation**, burning, and dyspareunia. *Wet mount with KOH is the preferred diagnostic method* - **Wet mount microscopy** with 10% potassium hydroxide (KOH) preparation is the **preferred rapid diagnostic method** for vaginal candidiasis. - KOH dissolves non-fungal cells, making **pseudohyphae and budding yeast cells** clearly visible under microscopy. - Culture on Sabouraud's agar is the gold standard for confirmation but takes longer. *Cottage cheese like secretions are seen* - The characteristic **thick, white, "cottage cheese-like" vaginal discharge** is a classic clinical sign of vaginal candidiasis. - This discharge is typically **odorless** and non-adherent, unlike the discharge in bacterial vaginosis or trichomoniasis.

Q: A patient presents with frothy green vaginal discharge. What is the most likely diagnosis?

Trichomoniasis. ***Trichomoniasis*** - The classic presentation of **frothy, greenish-yellow vaginal discharge** is highly characteristic of *Trichomonas vaginalis* infection. - This discharge is often associated with a **foul smell**, **itching**, and **dysuria**. *Candidiasis* - Typically presents with **thick, white, curd-like discharge** and intense vaginal itching, often described as cottage cheese-like. - It is not associated with a frothy or green appearance. *Bacterial vaginosis* - Characterized by a **thin, grayish-white discharge** with a **fishy odor**, especially after intercourse, due to amines. - This discharge is generally not frothy or green. *Chlamydia* - Often **asymptomatic**, but when symptoms occur, they may include **mucopurulent cervical discharge**, intermenstrual bleeding, or dysuria. - The discharge is usually not frothy or green, and instead tends to be yellowish and watery.

Q: A 14-year-old female presented with acute retention of urine. She complains of cyclical pain in the abdomen. On examination, a tense blue swelling is seen on local examination. On PR examination - suprapubic bulge present. Her condition is most likely due to?

Imperforate hymen. ***Imperforate hymen*** - This condition is characterized by a **complete obstruction** of the vaginal opening, leading to the accumulation of menstrual blood (hematocolpos) behind the hymen. - The classic presentation includes **cyclical abdominal pain** (due to trapped menstrual bleeding), **amenorrhea**, and a visible **tense, blue bulging mass** at the introitus, which can cause urinary retention due to pressure on the urethra. *Transverse vaginal septum* - A **transverse vaginal septum** is a congenital anomaly where a band of tissue completely or partially blocks the vaginal canal, typically higher up than the hymen. - While it can also cause **hematocolpos** and cyclical pain, the physical examination would reveal the obstruction deeper within the vagina rather than a bulging blue mass at the introitus. *Cervical agenesis* - **Cervical agenesis** refers to the congenital absence of the cervix. This condition would lead to obstruction of menstrual flow, causing hematometra (blood in the uterus) and hematocolpos. - However, unlike imperforate hymen, it would not present with a **tense blue swelling at the introitus**, as the obstruction is higher up at the level of the cervix. *Longitudinal vaginal septum* - A **longitudinal vaginal septum** divides the vagina into two separate canals, often associated with a uterine anomaly like uterus didelphys. - This condition does **not typically cause obstruction** of menstrual flow or urinary retention, as menstrual blood can still exit through one of the vaginal canals.

Q: A 36-year-old woman with a history of endometriosis presents with chronic pelvic pain and infertility. What is the best initial management?

Surgical resection. ***Surgical resection*** - For women with **moderate-to-severe endometriosis** (Stage III-IV) presenting with infertility and chronic pelvic pain, surgical resection of endometriotic implants is often the **best initial management**. - Surgery aims to **reduce disease burden**, restore normal pelvic anatomy, and remove endometriomas, which can **improve spontaneous conception rates** and alleviate pain. - **Laparoscopic excision** is preferred, as it provides both diagnostic confirmation and therapeutic benefit, with studies showing improved pregnancy rates post-operatively in appropriately selected patients. - This approach is particularly beneficial when there are **visible lesions, adhesions, or ovarian endometriomas** affecting fertility. *NSAIDs* - **NSAIDs** provide **symptomatic pain relief** but do not address the underlying endometriosis or improve fertility outcomes. - While useful as adjunctive therapy, they are insufficient as sole initial management for patients seeking conception. *GnRH agonists* - **GnRH agonists** induce a **hypoestrogenic state** that reduces endometriotic lesions and pain by suppressing ovarian function. - However, they cause **temporary anovulation**, making them unsuitable for women actively trying to conceive. - They may be used preoperatively to reduce lesion size or postoperatively to prevent recurrence, but not as initial management for infertility. *IVF* - **In vitro fertilization (IVF)** is an effective option for endometriosis-related infertility, particularly in **minimal-to-mild disease** or after failed surgical management. - While IVF bypasses tubal and peritoneal factors, it does **not treat the underlying endometriosis** or alleviate chronic pelvic pain. - In cases with significant anatomical distortion or endometriomas, **surgical management is typically preferred initially** to optimize pelvic environment before considering assisted reproductive technology.

Question 1

A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for which of the following?

Accepted Answer

Chlamydia

Answer

Herpes

Answer

Bacterial vaginosis

Answer

Syphilis

Question 2

The most common cause of menstrual toxic shock syndrome is -

Accepted Answer

Prolonged use of tampons

Answer

IUCD

Answer

Septic abortion

Answer

Pelvic examination

Question 3

A 60 years old Female with intermittent bleeding per vagina, endometrial collection, and thickening with anterior bulging of the fundal area on ultrasound. What is the most probable diagnosis?

Accepted Answer

Endometrial Polyp

Answer

Submucous Fibroid

Answer

Adenomyosis

Answer

Endometrial Cancer

Question 4

Which of the following is the most common cause of perforation of uterus in non-pregnant state?

Accepted Answer

Dilatation and curettage

Answer

Laparoscopy

Answer

IUCD

Answer

Carcinoma Endometrium

Question 5

A 28-year-old female presents with vaginal discharge and cervical motion tenderness. Which finding best predicts upper genital tract infection?

Accepted Answer

Elevated CRP

Answer

Presence of clue cells

Answer

Elevated ESR

Answer

Microscopic hematuria

Question 6

Regarding vaginal candidiasis, which one of the following is false:

Accepted Answer

Most common in non-pregnant women

Answer

Intense pruritus

Answer

Wet mount with KOH is the preferred diagnostic method

Answer

Cottage cheese like secretions are seen

Question 7

A patient presents with frothy green vaginal discharge. What is the most likely diagnosis?

Accepted Answer

Trichomoniasis

Answer

Candidiasis

Answer

Bacterial vaginosis

Answer

Chlamydia

Question 8

A 14-year-old female presented with acute retention of urine. She complains of cyclical pain in the abdomen. On examination, a tense blue swelling is seen on local examination. On PR examination - suprapubic bulge present. Her condition is most likely due to?

Accepted Answer

Imperforate hymen

Answer

Transverse vaginal septum

Answer

Cervical agenesis

Answer

Longitudinal vaginal septum

Question 9

A 38-year-old woman presents with chronic pelvic pain and a mass on pelvic examination. An MRI reveals a complex adnexal mass with solid and cystic components. What is the most appropriate management?

Accepted Answer

Laparoscopic cystectomy

Answer

Watchful waiting with repeat imaging

Answer

Hormonal therapy

Answer

Laparotomy with removal of the mass

Question 10

A 36-year-old woman with a history of endometriosis presents with chronic pelvic pain and infertility. What is the best initial management?

Accepted Answer

Surgical resection

Answer

GnRH agonists

Answer

IVF

Answer

NSAIDs

Gynecological Disorders — MCQs

Gynecological Disorders — MCQs

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