Dysmenorrhea — MCQs
Which of the following statements accurately describes adenomyosis?
Which of the following is NOT a cause of metrorrhagia?
Gold standard technique for diagnosis of endometriosis?
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?
22-year-old female comes to your outpatient department complaining of frequent periods, which occur every 18 days. What is this condition called?
PGF2 alpha maximum dose in PPH is-
A 28-year-old woman, G2 P1, with severe PPH unresponsive to oxytocin presents with hypotension and tachycardia. She has a soft uterus and ongoing bleeding. What is the next best step in management?
A 29 year old female presented with infertility. There is history of abdominal pain, dyspareunia, dysmenorrhea, menorrhagia. Most likely cause:
The contraceptive choice for a 38 year old woman with chronic hypertension and history of dysmenorrhea and menorrhagia (malignancy ruled out) is:
Which one of the following conditions simulates the menstrual pattern of pain?
Dysmenorrhea Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following statements accurately describes adenomyosis?
- A. More common in parous women
- B. More common in middle-aged women
- C. Presents with menorrhagia, dysmenorrhea, and an enlarged uterus (Correct Answer)
- D. Typically resolves after menopause without treatment
Explanation: ***Presents with menorrhagia, dysmenorrhea, and an enlarged uterus*** - **Adenomyosis** is defined by the presence of **endometrial tissue within the myometrium**, leading to symptoms like **heavy menstrual bleeding (menorrhagia)** and **painful menstruation (dysmenorrhea)**. - The infiltration of endometrial glands and stroma into the uterine muscle causes the uterus to become **enlarged** and often **globular** or boggy on examination. *More common in parous women* - While adenomyosis is more common in women who have had children, this statement alone does not fully encompass the characteristic presentation of the condition. - The exact link between parity and adenomyosis is not completely understood, but it is often attributed to uterine trauma during childbirth allowing endometrial tissue to invade the myometrium. *More common in middle-aged women* - Adenomyosis is indeed more prevalent in **women aged 35 to 50**, but this statement only describes its epidemiology, not its clinical manifestation. - Hormonal fluctuations and prolonged estrogen exposure are thought to contribute to its development in this age group. *Typically resolves after menopause without treatment* - This statement is accurate regarding its resolution, but does not describe adenomyosis itself; rather, it describes its natural progression. - Since adenomyosis is **estrogen-dependent**, its symptoms usually regress or disappear after menopause due to the decline in estrogen levels.
Question 2: Which of the following is NOT a cause of metrorrhagia?
- A. Polyp
- B. CA endometrium
- C. IUD
- D. Intramural fibroid (Correct Answer)
Explanation: ***Intramural fibroid*** - **Intramural fibroids** are located within the uterine wall and are **primarily associated with menorrhagia** (heavy or prolonged menstrual bleeding during regular periods) rather than metrorrhagia. - Their main effect is to increase the endometrial surface area and impair uterine contractility, leading to **heavy regular menstrual flow**. - While they can occasionally cause irregular bleeding if complicated by degeneration or severe distortion, this is **not their typical presentation**, making them the **least characteristic cause** of metrorrhagia among the given options. *Polyp* - **Endometrial polyps** are **classic causes of metrorrhagia** because their friable surface bleeds irregularly, especially with hormonal fluctuations or minor trauma. - They commonly present with **intermenstrual spotting** and post-coital bleeding, making them a typical cause of irregular bleeding. *CA endometrium* - **Endometrial carcinoma** is a **frequent cause of metrorrhagia**, particularly in postmenopausal women, due to irregular shedding of friable malignant tissue. - The abnormal vascular supply and tissue breakdown in cancer results in **unpredictable, irregular bleeding episodes** characteristic of metrorrhagia. *IUD* - **Intrauterine devices** are **well-known causes of metrorrhagia**, particularly copper IUDs, which cause endometrial irritation and increased prostaglandin release. - Both copper and hormonal IUDs frequently cause **spotting and irregular intermenstrual bleeding**, especially in the first 3-6 months after insertion.
Question 3: Gold standard technique for diagnosis of endometriosis?
- A. Ca 125 level
- B. Ultrasound
- C. MRI
- D. Laparoscopy (Correct Answer)
Explanation: ***Laparoscopy*** - **Laparoscopy** allows for direct visualization of endometrial implants and enables **biopsy confirmation**, making it the gold standard. - This minimally invasive surgical procedure is crucial for diagnosing, staging, and often treating endometriosis simultaneously. *Ca 125 level* - **CA-125** is a serum marker that can be elevated in endometriosis, but it is **not specific** and can be raised in other conditions like ovarian cancer or physiologic states. - It is primarily used for monitoring treatment response or recurrence, rather than as a primary diagnostic tool. *Ultrasound* - **Transvaginal ultrasound (TVS)** can identify endometriomas (chocolate cysts) and deep infiltrating endometriosis, but it cannot reliably visualize small peritoneal implants. - While it's a good initial imaging modality, its sensitivity for diagnosing all forms of endometriosis is **limited**. *MRI* - **MRI** offers better soft tissue contrast than ultrasound and can identify deep infiltrating endometriosis and some peritoneal implants, especially those involving the bowel or bladder. - However, MRI is **more expensive** and less accessible, and it still cannot definitively rule out all small, superficial endometrial lesions without direct visualization.
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?
- A. Tranexamic acid
- B. Levonorgestrel IUD (Correct Answer)
- C. GnRH analogues
- D. Oral contraceptive pills
Explanation: ***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.
Question 5: 22-year-old female comes to your outpatient department complaining of frequent periods, which occur every 18 days. What is this condition called?
- A. Polymenorrhea (Correct Answer)
- B. Metrorrhagia
- C. Hypermenorrhea
- D. Menorrhagia
Explanation: ***Polymenorrhea*** - This term describes **menstrual bleeding** that occurs **more frequently than normal**—specifically, an interval of **less than 21 days** between periods. - The patient's 18-day cycle falls within this definition, indicating abnormally frequent menstruation. *Menorrhagia* - **Menorrhagia** refers to **heavy or prolonged menstrual bleeding**, where the duration is typically more than 7 days or blood loss exceeds 80 mL. - It does not specifically describe the frequency of the periods. *Metrorrhagia* - **Metrorrhagia** is characterized by **irregular, acyclic bleeding** between menstrual periods, or bleeding that is not associated with the expected menstrual cycle. - This patient's periods are regular in their frequency, although too frequent, rather than irregular or intermenstrual. *Hypermenorrhea* - This term is often used interchangeably with **menorrhagia**, referring to **excessively heavy menstrual bleeding**. - It does not address the issue of the short interval between menstrual cycles.
Question 6: PGF2 alpha maximum dose in PPH is-
- A. 200 µg
- B. 2 mg (Correct Answer)
- C. 20 mg
- D. 1000 µg
Explanation: ***2 mg*** - The maximum recommended total dose of **PGF2 alpha** (Carboprost/Hemabate) for postpartum hemorrhage (PPH) is **2 mg**. - This limit is typically reached after administering eight doses of 250 µg each. *1000 µg* - This is equivalent to **1 mg**, which is only half of the maximum recommended total dose for PGF2 alpha in PPH. - While individual doses are 250 µg, the cumulative maximum dose is higher. *200 µg* - This dosage is **lower than the standard individual dose** of 250 µg for PGF2 alpha in PPH. - Administering only 200 µg would be suboptimal for managing severe hemorrhage. *20 mg* - This dose is **ten times the maximum recommended total dose** of 2 mg for PGF2 alpha. - Administering 20 mg could lead to severe adverse effects and toxicity.
Question 7: A 28-year-old woman, G2 P1, with severe PPH unresponsive to oxytocin presents with hypotension and tachycardia. She has a soft uterus and ongoing bleeding. What is the next best step in management?
- A. IM carboprost (Correct Answer)
- B. Immediate hysterectomy
- C. Expectant management
- D. IV tranexamic acid
Explanation: ***IM carboprost*** - The **soft uterus** with ongoing bleeding despite oxytocin indicates **uterine atony** as the cause of PPH - Carboprost (PGF2α) is the **standard second-line uterotonic agent** after oxytocin failure - Effectively stimulates strong **uterine contractions** to control hemorrhage from the placental bed - Given intramuscularly at **0.25 mg every 15-90 minutes** (maximum 8 doses) - Contraindicated in active cardiac, pulmonary, or hepatic disease *Immediate hysterectomy* - Peripartum hysterectomy is a **last-resort surgical intervention** for refractory PPH - Should only be performed after failure of medical management (all uterotonics) and conservative surgical options (uterine tamponade, uterine artery ligation, B-Lynch suture) - **Too aggressive** as the immediate next step when second-line uterotonics haven't been tried *Expectant management* - **Completely inappropriate** for severe PPH with hemodynamic instability (hypotension, tachycardia) - Ongoing bleeding from uterine atony requires **immediate aggressive intervention** - Delays increase risk of hypovolemic shock, DIC, maternal morbidity, and mortality *IV tranexamic acid* - **Antifibrinolytic agent** that inhibits plasminogen activation, promoting clot stability - WHO recommends administration **within 3 hours** of PPH onset as an adjunct therapy - While useful in PPH management, it does **not address uterine atony** (the primary cause indicated by soft uterus) - Should be given **in addition to uterotonics**, not as a substitute for definitive management of atony
Question 8: A 29 year old female presented with infertility. There is history of abdominal pain, dyspareunia, dysmenorrhea, menorrhagia. Most likely cause:
- A. Adenomyosis
- B. Endometriosis (Correct Answer)
- C. Cervicitis
- D. Myomas
Explanation: ***Endometriosis*** - The classic triad of symptoms in this 29-year-old female—**dysmenorrhea**, **dyspareunia**, and **infertility**—is highly suggestive of endometriosis. - **Ectopic endometrial tissue** can cause chronic abdominal pain, menorrhagia, and inflammation, contributing to infertility. *Adenomyosis* - This condition involves the presence of **endometrial tissue within the myometrium**, leading to a thickened uterine wall. - While it can cause dysmenorrhea and menorrhagia, **infertility** is not its primary presentation, and it is less commonly associated with severe dyspareunia compared to endometriosis. *Cervicitis* - **Inflammation of the cervix** typically presents with vaginal discharge, post-coital bleeding, or pelvic pain. - It is not a common cause of primary infertility, severe dysmenorrhea, or dyspareunia as described. *Myomas* - Uterine **fibroids (leiomyomas)** are benign tumors that can cause heavy menstrual bleeding (menorrhagia), pelvic pressure, and sometimes infertility. - However, they are less commonly associated with the triad of severe dysmenorrhea and dyspareunia as prominently as seen in endometriosis.
Question 9: The contraceptive choice for a 38 year old woman with chronic hypertension and history of dysmenorrhea and menorrhagia (malignancy ruled out) is:
- A. Copper intrauterine device
- B. Sterilization
- C. Combined oral contraceptive pills
- D. Levonorgestrel intrauterine device (Correct Answer)
Explanation: ***Levonorgestrel intrauterine device*** - The **Levonorgestrel IUD** is an excellent choice as it provides effective contraception while also treating menorrhagia and dysmenorrhea due to its local progesterone release. - It is safe for women with **hypertension** as it is a **non-estrogen-containing method**, avoiding the increased risk of thrombotic events associated with estrogen. *Copper intrauterine device* - While an effective non-hormonal contraceptive, the **copper IUD** can worsen **dysmenorrhea** and **menorrhagia**, which are existing concerns for the patient. - It does not offer any therapeutic benefits for her heavy and painful periods. *Sterilization* - Although it provides permanent and highly effective contraception, **sterilization** does not address the patient's symptoms of **dysmenorrhea** and **menorrhagia**. - It is an irreversible procedure and typically considered when no further childbearing is desired and symptomatic relief is not a primary concern for the contraceptive method itself. *Combined oral contraceptive pills* - **Combined oral contraceptive pills (COCs)** are generally contraindicated or used with caution in women with uncontrolled **hypertension** due to the estrogen component, which can increase the risk of cardiovascular events, including thrombosis. - While COCs can improve dysmenorrhea and menorrhagia, the cardiovascular risks in a 38-year-old with chronic hypertension outweigh these benefits.
Question 10: Which one of the following conditions simulates the menstrual pattern of pain?
- A. Adenomyosis (Correct Answer)
- B. Intramural fibroid
- C. Granulosa cell tumour of ovary
- D. Haematometra
Explanation: ***Adenomyosis*** - Adenomyosis is characterized by the presence of **endometrial tissue within the myometrium**, which responds cyclically to hormonal changes, similar to normal endometrium. - This leads to **dysmenorrhea** (painful periods) and **menorrhagia** (heavy bleeding) due to the cyclic growth and shedding of endometrial tissue within the uterine muscular wall. *Intramural fibroid* - Intramural fibroids are **benign uterine tumors** within the muscular wall that can cause heavy bleeding and pressure symptoms. - While they can cause pain and heavy bleeding, the pain is typically not directly related to a **menstrual pattern of cyclic pain** in the same manner as adenomyosis, as the fibroid tissue itself does not undergo cyclic shedding. *Granulosa cell tumour of ovary* - This is a **sex cord-stromal tumor** of the ovary that often produces **estrogen**, which can lead to irregular uterine bleeding or postmenopausal bleeding. - It does not directly cause pain that simulates a **regular menstrual pattern**, as its hormonal effects are typically sustained or irregular, not cyclic in the way normal menstruation or adenomyosis pain is. *Haematometra* - Haematometra is the accumulation of **menstrual blood within the uterus** due to an obstruction of the outflow tract, such as cervical stenosis. - This condition causes increasing pain and distension as blood accumulates, but the pain is usually **constant or progressively worsening**, not cyclic in a pattern that simulates normal menstruation, and typically leads to **amenorrhea** rather than patterned bleeding.
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