Menstrual Disorders Practice Questions

Q: Swiss cheese pattern endometrium is seen in

Metropathia hemorrhagica. ***Correct Answer: Metropathia hemorrhagica*** - Also known as **anovulatory dysfunctional uterine bleeding** or **cystic glandular hyperplasia** - The "Swiss cheese pattern" describes the **characteristic histological appearance** where endometrial glands are dilated and irregular, resembling holes in Swiss cheese - Results from **prolonged unopposed estrogen stimulation** causing overgrowth of benign endometrial tissue - Classic finding in anovulatory cycles with persistent estrogen exposure *Incorrect Option: Halban's disease* - Refers to **cystic changes within the fallopian tube** or paratubal cysts - Not related to endometrial morphology or the Swiss cheese pattern *Incorrect Option: Carcinoma endometrium* - Involves **malignant proliferation** with complex atypical hyperplasia - May show glandular atypia and crowding, but not the characteristic simple cystic glandular hyperplasia pattern - Swiss cheese appearance is typically seen in benign hyperplasia, not malignancy *Incorrect Option: Hydatidiform mole* - A **gestational trophoblastic disease** with abnormal placental development - Characterized by grape-like vesicles with **trophoblastic proliferation** and hydropic villi - Does not involve the Swiss cheese endometrial pattern

Q: 35 yr old lady attends gynaec OPD with excessive bleeding since 6 months, not controlled with non hormonal drugs. USG and clinical examination reveals no abnormality. Next step is?

Endometrial sampling. ***Endometrial sampling*** - In a 35-year-old with **excessive uterine bleeding** not controlled by non-hormonal drugs and with normal imaging/clinical exam, endometrial sampling is crucial to **rule out endometrial hyperplasia or malignancy**. - This diagnostic step is essential before considering definitive treatments, as it provides a **histological diagnosis** of the endometrial lining. *Hysterectomy* - Hysterectomy is a **definitive surgical treatment** for excessive bleeding, but it is typically reserved for cases where conservative or less invasive treatments have failed, or if there's a serious underlying pathology like malignancy. - It involves removing the uterus and is a **major surgery** with potential complications, thus not usually the first step given an otherwise normal examination and imaging. *Endometrial ablation* - Endometrial ablation is a procedure to destroy the lining of the uterus, aiming to **reduce or stop menstrual bleeding**. - It is a treatment option for **abnormal uterine bleeding (AUB)**, but it's typically performed after other diagnostic steps (like endometrial sampling) have ruled out malignancy or high-risk hyperplasia, and when conservative medical management has failed. *Hormonal therapy* - Hormonal therapy (e.g., combined oral contraceptives, progestin-only pills, levonorgestrel-releasing intrauterine device) is often a **first-line medical treatment** for excessive uterine bleeding. - However, the question states that non-hormonal drugs have already failed, and without a clear diagnosis, initiating new hormonal therapy without **evaluating the endometrium** is not the next best step for persistent bleeding.

Q: A 32-year-old P2L2 presents with heavy menstrual bleeding. Ultrasound shows 3cm intramural fibroid. Which management option is associated with the highest long-term patient satisfaction?

Levonorgestrel IUD. ***Levonorgestrel IUD*** - The **levonorgestrel IUD** is highly effective in reducing menstrual blood loss and is associated with high long-term satisfaction due to its continuous, localized hormone release and minimal systemic side effects. - It offers contraception and therapeutic benefits for up to 5 years, making it a convenient and durable solution for **heavy menstrual bleeding** (HMB) caused by fibroids. *Tranexamic acid* - **Tranexamic acid** is an antifibrinolytic agent that reduces menstrual blood loss by inhibiting clot breakdown. - While effective for acute heavy bleeding, it does not address the underlying cause (fibroid) and requires administration during each menstrual cycle, leading to lower long-term satisfaction. *GnRH analogues* - **GnRH analogues** induce a temporary menopausal state, effectively reducing fibroid size and menstrual bleeding. - However, their long-term use is limited by significant side effects (e.g., hot flashes, bone loss) and recurrence of symptoms once treatment is stopped, leading to lower long-term satisfaction. *Oral contraceptive pills* - **Oral contraceptive pills** can reduce menstrual bleeding by thinning the endometrial lining and regulating cycles. - They require daily adherence and may have systemic side effects, which can contribute to lower long-term satisfaction compared to the sustained effect of an IUD.

Q: A 35-year-old woman presents with abnormal uterine bleeding and a negative pregnancy test. Which initial laboratory test is the most appropriate to evaluate her condition?

Complete blood count. ***Complete blood count*** - **CBC is the most appropriate initial laboratory test** for abnormal uterine bleeding to assess for **anemia** secondary to acute or chronic blood loss. - Hemoglobin and hematocrit levels help determine the **severity and urgency** of the bleeding and guide immediate management decisions. - **Universal recommendation** in all major guidelines (ACOG, FIGO) as part of the initial evaluation of abnormal uterine bleeding. - Helps assess the **hemodynamic impact** of bleeding and need for urgent intervention. *Thyroid function tests* - Thyroid dysfunction (both hypo- and hyperthyroidism) can cause abnormal uterine bleeding through effects on the hypothalamic-pituitary-ovarian axis. - **Important part of the comprehensive workup** but not the single most appropriate initial test. - Prevalence of thyroid dysfunction as cause of AUB is approximately 5-10%. - Should be ordered as part of the initial panel but does not take priority over assessing anemia. *Coagulation profile* - Indicated when there is suspicion of **bleeding disorders** (von Willebrand disease, platelet dysfunction). - Consider in patients with heavy menstrual bleeding since menarche, personal or family history of bleeding disorders, or failure to respond to standard therapy. - Not routinely part of initial workup unless clinical history suggests coagulopathy. *Prolactin levels* - Hyperprolactinemia typically causes **oligomenorrhea or amenorrhea** rather than abnormal uterine bleeding. - Would be indicated if patient has associated symptoms like galactorrhea or if anovulation is suspected. - Not the initial priority when evaluating abnormal bleeding patterns.

Q: A 25-year-old woman presents with intermenstrual bleeding and a negative pregnancy test. What is the most appropriate next step in her management?

Pelvic ultrasound. ***Pelvic ultrasound*** - A **pelvic ultrasound** is the most appropriate initial diagnostic step to evaluate the uterus and adnexa specifically for structural causes of **intermenstrual bleeding**, such as **fibroids**, **polyps**, or **cysts**. - It provides valuable information on uterine and ovarian anatomy and pathology, which can guide further management. *Pap smear* - A **Pap smear** screens for **cervical dysplasia** and **cervical cancer**, which can cause abnormal bleeding but is not the primary diagnostic tool for intermenstrual bleeding. - While an important part of routine women's health, its role here would be secondary to ruling out structural causes of the current symptom. *Hormonal therapy* - **Hormonal therapy** is a treatment option for dysfunctional uterine bleeding, but it should generally be initiated **after a definitive diagnosis** is made to rule out serious underlying conditions. - Starting empirical hormonal therapy without investigating the cause risks masking a significant pathology. *Endometrial biopsy* - An **endometrial biopsy** is typically indicated for patients at risk of **endometrial hyperplasia** or **endometrial cancer**, such as those with **postmenopausal bleeding** or persistent abnormal bleeding after initial workup, or women over 45 with abnormal bleeding. - For a 25-year-old with intermenstrual bleeding and a negative pregnancy test, it is usually not the first-line diagnostic step unless other investigations are inconclusive or specific risk factors are present.

Q: A 39-year-old woman presents for a routine exam and mentions intermittent heavy menstrual bleeding. What is the most appropriate minimally invasive treatment that can be offered initially?

Levonorgestrel-releasing intrauterine system. ***Levonorgestrel-releasing intrauterine system*** - This is a highly effective, **minimally invasive**, and long-acting reversible option that is also approved for the management of **heavy menstrual bleeding** (menorrhagia). - It works by continuously releasing **progestin** locally into the uterus, causing endometrial suppression and significantly reducing menstrual blood loss by **up to 90%**. - It is recommended as **first-line treatment** for heavy menstrual bleeding in women who also desire contraception or long-term management. *Endometrial ablation* - This is a **surgical procedure** that destroys the uterine lining to reduce or stop menstrual bleeding and is more invasive than LNG-IUS. - It is typically reserved for women who have **completed childbearing** and for whom medical or hormonal management has been unsuccessful. - It is not reversible and significantly impairs future fertility. *Uterine artery embolization* - This is an **invasive radiological procedure** involving catheterization and blocking the blood supply to the uterus. - Primarily used to treat **uterine fibroids** causing heavy bleeding, not as first-line treatment for undiagnosed menorrhagia. - Carries risks including infection, pain, and potential impact on ovarian function. *Hormonal therapy* - While **oral contraceptives** or progestin-only pills are effective and truly non-invasive, they require daily compliance and may have systemic side effects. - The question asks for a **treatment** (device-based intervention), and LNG-IUS is superior due to its **local action**, minimal systemic effects, and **long-term efficacy** without daily adherence requirements.

Q: A mother brought her 16-year-old daughter to Gynaecology OPD with a complaint of not attaining menarche. She gives a history of cyclic abdominal pain. On further examination, a midline abdominal swelling is seen. Per rectal examination reveals a bulging mass in the vagina. Which of the following conditions is most likely responsible for these findings?

Imperforate hymen. ***Imperforate hymen*** - An **imperforate hymen** obstructs the outflow of menstrual blood, leading to its accumulation in the vagina (**hematocolpos**) and uterus (**hematometra**), causing **cyclic abdominal pain** and a bulging mass (due to accumulated blood) in the vagina. - The patient presents with **primary amenorrhea** (not having attained menarche) and cyclical abdominal pain caused by the inability of menstrual blood to exit the body. *Transverse vaginal septum* - A **transverse vaginal septum** can also cause primary amenorrhea and cyclic abdominal pain due to obstruction of menstrual flow. However, it is a less common cause than an imperforate hymen. - While it can lead to hematocolpos, the characteristic bulging mass on per rectal examination is more strongly associated with an imperforate hymen presenting at the vaginal introitus. *Vaginal agenesis* - **Vaginal agenesis** (complete absence of the vagina) would present with primary amenorrhea, but there would be no cyclic abdominal pain if the uterus is also absent or rudimentary. If a uterus is present, there would be no accumulation of blood in the vagina or a bulging mass per rectum as there is no vaginal canal. - This condition is typically associated with a rudimentary or absent uterus, leading to an inability to menstruate rather than obstructed flow. *Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome* - **MRKH syndrome** is characterized by congenital aplasia of the uterus and the upper two-thirds of the vagina, with normal ovaries and external genitalia. - Patients present with **primary amenorrhea** but typically do not experience **cyclic abdominal pain** or a bulging vaginal mass because there is no functional uterus to produce menstrual blood or a vaginal canal for blood accumulation.

Q: Asherman's syndrome is associated with which of the following symptoms?

Amenorrhea. ***Amenorrhea*** - **Asherman's syndrome** involves the formation of intrauterine adhesions (scar tissue) which can block the outflow of menstrual blood, leading to **amenorrhea** or significantly reduced menstrual flow (hypomenorrhea). - The scarring often damages the **endometrial basalis layer**, preventing the normal cyclical growth and shedding of the uterine lining necessary for menstruation. *Menorrhagia* - **Menorrhagia** is characterized by abnormally heavy or prolonged menstrual bleeding, which is the opposite of what occurs in Asherman's syndrome. - This symptom is typically associated with conditions like **uterine fibroids**, **adenomyosis**, or **coagulopathies**, not intrauterine adhesions. *Polymenorrhea* - **Polymenorrhea** refers to abnormally frequent menstrual cycles (occurring more often than every 21 days), which is not a hallmark symptom of Asherman's syndrome. - This condition is usually related to **hormonal imbalances** leading to a shortened follicular phase, rather than structural uterine abnormalities. *All of the options* - While other menstrual irregularities can occur, **amenorrhea** or **hypomenorrhea** is the primary and characteristic symptom linked to Asherman's syndrome due to the physical obstruction and endometrial damage caused by intrauterine adhesions. - The other options (menorrhagia, polymenorrhea) represent distinct menstrual abnormalities with different underlying etiologies, not typically seen in Asherman's syndrome.

Q: Which of the following is least likely to cause dysmenorrhea?

Cervical polyp. ***Cervical polyp*** - Cervical polyps are typically **benign growths** on the cervix and are usually **asymptomatic**, or may cause **light intermenstrual bleeding** or bleeding after intercourse. - They generally do **not cause pain** or dysmenorrhea because they are not involved in the hormonal and inflammatory processes that lead to uterine contractions and pain during menstruation. *Endometriosis* - Endometriosis is characterized by the presence of **stromal and glandular tissue** outside the uterus, which responds to hormonal fluctuations, leading to **inflammation and cyclical pain**. - This often results in severe **secondary dysmenorrhea**, chronic pelvic pain, and dyspareunia. *Adenomyosis* - Adenomyosis involves the invasion of **endometrial tissue into the myometrium**, leading to a thickened, enlarged uterus. - This condition causes significant **dysmenorrhea** due to increased prostaglandin production and uterine cramping, as well as heavy menstrual bleeding. *Uterine polyp* - Uterine polyps (endometrial polyps) are **overgrowths of endometrial tissue** within the uterine cavity. - While they primarily cause **abnormal uterine bleeding**, they can occasionally cause **dysmenorrhea** through interference with normal uterine contractions, though this is **less common** than bleeding symptoms.

Question 1

A 16-year-old girl with acute vaginal bleeding presents to the clinic. What is the immediate management?

Accepted Answer

Stabilize the patient and investigate the cause of bleeding

Answer

Administer high-dose estrogen

Answer

Perform dilation and curettage

Answer

Start tranexamic acid

Question 2

Swiss cheese pattern endometrium is seen in

Accepted Answer

Metropathia hemorrhagica

Answer

Halban's disease

Answer

Carcinoma endometrium

Answer

Hydatidiform mole

Question 3

35 yr old lady attends gynaec OPD with excessive bleeding since 6 months, not controlled with non hormonal drugs. USG and clinical examination reveals no abnormality. Next step is?

Accepted Answer

Endometrial sampling

Answer

Hysterectomy

Answer

Endometrial ablation

Answer

Hormonal therapy

Question 4

A 32-year-old P2L2 presents with heavy menstrual bleeding. Ultrasound shows 3cm intramural fibroid. Which management option is associated with the highest long-term patient satisfaction?

Accepted Answer

Levonorgestrel IUD

Answer

Tranexamic acid

Answer

GnRH analogues

Answer

Oral contraceptive pills

Question 5

A 35-year-old woman presents with abnormal uterine bleeding and a negative pregnancy test. Which initial laboratory test is the most appropriate to evaluate her condition?

Accepted Answer

Complete blood count

Answer

Coagulation profile

Answer

Thyroid function tests

Answer

Prolactin levels

Question 6

A 25-year-old woman presents with intermenstrual bleeding and a negative pregnancy test. What is the most appropriate next step in her management?

Accepted Answer

Pelvic ultrasound

Answer

Pap smear

Answer

Hormonal therapy

Answer

Endometrial biopsy

Question 7

A 39-year-old woman presents for a routine exam and mentions intermittent heavy menstrual bleeding. What is the most appropriate minimally invasive treatment that can be offered initially?

Accepted Answer

Levonorgestrel-releasing intrauterine system

Answer

Endometrial ablation

Answer

Uterine artery embolization

Answer

Hormonal therapy

Question 8

A mother brought her 16-year-old daughter to Gynaecology OPD with a complaint of not attaining menarche. She gives a history of cyclic abdominal pain. On further examination, a midline abdominal swelling is seen. Per rectal examination reveals a bulging mass in the vagina. Which of the following conditions is most likely responsible for these findings?

Accepted Answer

Imperforate hymen

Answer

Vaginal agenesis

Answer

Transverse vaginal septum

Answer

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome

Question 9

Asherman's syndrome is associated with which of the following symptoms?

Accepted Answer

Amenorrhea

Answer

All of the options

Answer

Menorrhagia

Answer

Polymenorrhea

Question 10

Which of the following is least likely to cause dysmenorrhea?

Accepted Answer

Cervical polyp

Answer

Endometriosis

Answer

Adenomyosis

Answer

Uterine polyp

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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