Menstrual Disorders Practice Questions

Q: What is the treatment for dysfunctional uterine bleeding (DUB) in a 32-year-old multiparous woman?

Progesterone. **Explanation:** Dysfunctional Uterine Bleeding (DUB) is a diagnosis of exclusion, most commonly caused by **anovulation**. In anovulatory cycles, there is continuous estrogen stimulation of the endometrium without the stabilizing effect of progesterone (due to the absence of a corpus luteum). This leads to an unstable, thickened endometrium that sheds irregularly and excessively. **1. Why Progesterone is Correct:** Progesterone is the mainstay of medical management for DUB. It acts by converting the proliferative endometrium into a secretory one, stabilizing the endometrial lining, and inducing a "medical curettage" upon withdrawal. In a 32-year-old multiparous woman, cyclic progestogens or a Levonorgestrel-releasing Intrauterine System (LNG-IUS) are first-line treatments to regulate the cycle and reduce blood loss. **2. Why Other Options are Incorrect:** * **Danazol:** While it causes endometrial atrophy, it is rarely used due to significant androgenic side effects (hirsutism, acne, weight gain). It is reserved for resistant cases, not first-line therapy. * **Prostaglandins:** Prostaglandin *inhibitors* (NSAIDs like Mefenamic acid) are used to reduce blood loss, but prostaglandins themselves would worsen uterine cramping and are not a treatment for DUB. * **Endometrial Ablation:** This is a surgical intervention. In a 32-year-old, medical management must be exhausted first. Surgery is generally reserved for women who have completed their family and failed medical therapy. **Clinical Pearls for NEET-PG:** * **DOC for DUB (Acute bleeding):** High-dose Estrogen or OCPs. * **DOC for DUB (Maintenance/Long-term):** LNG-IUS (Mirena) is currently considered the gold standard medical treatment. * **Investigation of Choice:** Transvaginal Ultrasound (TVS) is the initial investigation; however, **Endometrial Biopsy** is mandatory if the patient is >35 years old to rule out endometrial hyperplasia or malignancy.

Q: Which of the following conditions microscopically shows cystic glandular hyperplasia of all the endometrial components?

Metropathia haemorrhagica. **Explanation:** **Metropathia Haemorrhagica** (also known as Schroeder’s Disease) is a specialized form of Dysfunctional Uterine Bleeding (DUB) typically seen in perimenopausal women. 1. **Why it is correct:** The condition is characterized by **persistent unovulation**, leading to a state of absolute hyperestrogenism without the balancing effect of progesterone. This continuous estrogenic stimulation causes the endometrium to become markedly thickened and hyperplastic. Microscopically, it shows **Cystic Glandular Hyperplasia**, classically described as a **"Swiss-Cheese" appearance**, where glands of varying sizes (some dilated and cystic) are lined by pseudostratified epithelium. All components—glands, stroma, and vessels—undergo hyperplasia. 2. **Why other options are incorrect:** * **Menorrhagia:** This is a clinical symptom (heavy cyclic bleeding) rather than a specific pathological diagnosis. While it can be caused by hyperplasia, it is also caused by fibroids, adenomyosis, or copper-Ts, which do not show this specific microscopic pattern. * **Polymenorrhea:** This refers to a shortened menstrual cycle ( 35 days). While often associated with PCOS (which can lead to hyperplasia), it is a clinical description and not a microscopic diagnosis of all endometrial components. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Characterized by a period of **amenorrhea** (due to high estrogen) followed by **profuse, painless, prolonged bleeding**. * **Classic Triad:** Amenorrhea, Hyperestrogenism, and Cystic Glandular Hyperplasia. * **Ovarian finding:** Presence of a persistent follicular cyst (unruptured follicle). * **Microscopy:** "Swiss-Cheese" pattern is the hallmark buzzword for exams.

Q: Dysfunctional uterine bleeding is commonly encountered in all of the following except:

Postmenopausal period. **Explanation:** **Dysfunctional Uterine Bleeding (DUB)**, now often categorized under the PALM-COEIN classification as AUB-O (Ovulatory dysfunction), refers to abnormal uterine bleeding in the absence of any detectable organic pelvic pathology, systemic disease, or pregnancy. **1. Why Postmenopausal period is the correct answer:** DUB is fundamentally a disorder of the **Hypothalamic-Pituitary-Ovarian (HPO) axis**. In the postmenopausal period, the ovaries have failed and the endometrium is typically atrophic. Any bleeding occurring after menopause is considered **Postmenopausal Bleeding (PMB)** and is highly suspicious of malignancy (e.g., Endometrial Carcinoma) or local pathology (e.g., Atrophic Vaginitis). It is **never** classified as DUB, as the hormonal cycling required for DUB no longer exists. **2. Analysis of incorrect options:** * **Adolescence:** DUB is very common here due to an **immature HPO axis**, leading to frequent anovulatory cycles. * **Following childbirth:** The HPO axis takes time to re-establish its rhythm post-delivery, especially during lactation, often resulting in temporary hormonal imbalances and DUB. * **Premenopausal period:** This is the most common age group for DUB. As ovarian reserve declines, cycles become increasingly anovulatory due to erratic estrogen levels and progesterone deficiency. **Clinical Pearls for NEET-PG:** * **Most common cause of DUB:** Anovulation (leads to "unopposed estrogen" action on the endometrium). * **Gold Standard Investigation for DUB (>40 years):** Fractional Curettage or Endometrial Biopsy to rule out endometrial hyperplasia/malignancy. * **Drug of Choice:** In acute heavy bleeding, high-dose Estrogen or Tranexamic acid; for long-term management, the **Levonorgestrel Intrauterine System (LNG-IUS)** is the medical treatment of choice.

Q: Amenorrhea due to high LH and FSH is due to:

Ovarian failure. **Explanation:** The core concept behind this question is the **Hypothalamic-Pituitary-Ovarian (HPO) axis** and the principle of **negative feedback**. 1. **Why Ovarian Failure is correct:** In Ovarian Failure (e.g., Premature Ovarian Insufficiency or Menopause), the ovaries fail to produce sufficient estrogen and inhibin. The absence of negative feedback on the hypothalamus and pituitary leads to a compensatory increase in the secretion of **GnRH, FSH, and LH**. This condition is termed **Hypergonadotropic Hypogonadism**. High FSH (>40 IU/L) is the diagnostic hallmark of ovarian failure. 2. **Why other options are incorrect:** * **Asherman Syndrome:** This is a uterine cause of amenorrhea (outflow tract obstruction) due to intrauterine adhesions. The HPO axis remains intact; therefore, hormone levels (FSH/LH) are typically **normal** (Eugonadotropic). * **Pituitary Adenoma:** Most functional pituitary adenomas (like Prolactinomas) or destructive lesions cause **Hypogonadotropic Hypogonadism**. High prolactin suppresses GnRH, leading to **low** or inappropriately normal FSH and LH levels. **High-Yield Clinical Pearls for NEET-PG:** * **Hypergonadotropic Hypogonadism (High FSH/LH):** Think Ovarian failure, Turner Syndrome, or Swyer Syndrome. * **Hypogonadotropic Hypogonadism (Low FSH/LH):** Think Kallmann syndrome, stress, weight loss, or pituitary tumors. * **Eugonadotropic Amenorrhea (Normal FSH/LH):** Think PCOS (though LH:FSH ratio may be 2:1 or 3:1) or anatomical causes like Asherman syndrome and Mullerian agenesis. * **Progesterone Challenge Test:** Patients with ovarian failure will have a **negative** withdrawal bleed because of low endogenous estrogen.

Q: Which of the following modalities has shown the best results for premenstrual syndrome?

SSRI. **Explanation:** **Premenstrual Syndrome (PMS)** and its more severe form, **Premenstrual Dysphoric Disorder (PMDD)**, are characterized by physical and emotional symptoms occurring during the luteal phase. **Why SSRIs are the Correct Choice:** Selective Serotonin Reuptake Inhibitors (SSRIs) are considered the **first-line pharmacological treatment** for PMS/PMDD. The underlying pathophysiology involves a maladaptive response to normal fluctuations in gonadal steroids (estrogen and progesterone), which leads to a deficit in central **serotonergic transmission**. SSRIs rapidly increase synaptic serotonin levels. Unlike in depression, SSRIs for PMS can be administered in a **luteal-phase-only** regimen (starting on day 14) with high efficacy. **Analysis of Incorrect Options:** * **B. Progesterone:** Historically used based on the "progesterone deficiency" theory; however, clinical trials have shown it is **no more effective than placebo** for treating PMS. * **C. Estrogen:** While estrogen (often via patches) can suppress ovulation, it is not first-line and must be balanced with progesterone to prevent endometrial hyperplasia, which may trigger PMS symptoms. * **D. Anxiolytics:** Drugs like Alprazolam may help with specific symptoms of anxiety or insomnia but are second/third-line due to the risk of dependence and lack of effect on physical symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Prospective charting of symptoms for at least **two consecutive cycles** (e.g., using the Daily Record of Severity of Problems). * **First-line SSRIs:** Fluoxetine, Sertraline, and Paroxetine. * **Non-pharmacological first step:** Lifestyle modifications (exercise, complex carbohydrates, and stress reduction). * **Definitive Treatment:** For refractory cases, **GnRH analogues** (to induce medical menopause) or bilateral oophorectomy may be considered.

Question 1

What is the treatment for dysfunctional uterine bleeding (DUB) in a 32-year-old multiparous woman?

Accepted Answer

Progesterone

Answer

Danazol

Answer

Prostaglandins

Answer

Endometrial ablation

Question 2

Which of the following conditions microscopically shows cystic glandular hyperplasia of all the endometrial components?

Accepted Answer

Metropathia haemorrhagica

Answer

Menorrhagia

Answer

Polymenorrhea

Answer

Oligomenorrhea

Question 3

Dysfunctional uterine bleeding is commonly encountered in all of the following except:

Accepted Answer

Postmenopausal period

Answer

Adolescence

Answer

Following childbirth

Answer

Premenopausal period

Question 4

What is the drug of choice in the management of puberty menorrhagia?

Accepted Answer

Progesterone

Answer

Oral contraceptive pill (OCP)

Answer

Intrauterine contraceptive device (IUCD)

Answer

Endometrial curettage

Question 5

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

Accepted Answer

Progesterone

Answer

Uterine ablation

Answer

Uterine artery embolization

Answer

Hysteroscopy examination

Question 6

Which of the following is NOT a contraindication to tranexamic acid in the management of heavy menstrual bleeding?

Accepted Answer

Intermenstrual bleeding

Answer

Concurrent combined oral contraceptives use

Answer

Colour blindness

Answer

Disseminated intravascular coagulation

Question 7

Amenorrhea due to high LH and FSH is due to:

Accepted Answer

Ovarian failure

Answer

Asherman syndrome

Answer

Pituitary adenoma

Answer

All of the above

Question 8

A 38-year-old woman presents with insidious menstrual irregularities over the past decade. Investigations including pelvic ultrasound, endometrial biopsy (showing proliferative endometrium), and blood tests (revealing mild iron deficiency anemia) are within normal limits, with a negative pregnancy test. What is the most likely diagnosis?

Accepted Answer

Dysfunctional uterine bleeding

Answer

Cervical carcinoma

Answer

Cervical dysplasia

Answer

Endometrial carcinoma

Question 9

What is the best line of management for a 45-year-old lady with polymenorrhoea for 6 months?

Accepted Answer

Oral contraceptive pills for 6 months

Answer

Progesterone for 6 months

Answer

Dilation and curettage

Answer

Hysterectomy

Question 10

Which of the following modalities has shown the best results for premenstrual syndrome?

Accepted Answer

SSRI

Answer

Progesterone

Answer

Estrogen

Answer

Anxiolytics

Menstrual Disorders — MCQs

Menstrual Disorders — MCQs

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