Menstrual disorders, PCOS and endometriosis

33 NEET-PG practice questions on Menstrual disorders, PCOS and endometriosis, part of Obstetrics & Gynaecology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Hard

   A 25-year-old has had periods every 2-4 months since menarche, with acne and hirsutism, and has been trying to conceive for 2 years. After 6 months of diet and exercise she has lost 6% of her weight and her BMI is 28 kg/m2, but she is still not ovulating. TSH, prolactin and 17-hydroxyprogesterone are normal and ultrasound shows polycystic ovaries. HSG shows patent tubes and her husband's semen analysis is normal. Which drug is the first choice to induce ovulation?

   1. AMetformin alone
   2. BGonadotropin injections
   3. CClomiphene citrate
   4. DLetrozole

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   Answer: D · Letrozole

   Oligo-ovulation, clinical hyperandrogenism and polycystic ovaries, with thyroid disease, hyperprolactinaemia and non-classic congenital adrenal hyperplasia excluded, make this polycystic ovary syndrome by the Rotterdam criteria. Lifestyle change comes first; when anovulation persists, the international evidence-based PCOS guideline names letrozole as the first-line drug for ovulation induction. Letrozole, an aromatase inhibitor, lowers oestrogen briefly so the pituitary releases more FSH, and in PCOS it gives higher ovulation and live-birth rates than clomiphene. Clomiphene is the alternative, while gonadotropins or laparoscopic ovarian drilling are second-line, with closer monitoring for multiple pregnancy.

   • A: Metformin alone is a weak ovulation inducer.
   • B: Gonadotropins are second-line because of multiple pregnancy and OHSS.
   • C: Clomiphene works but gives lower live-birth rates than letrozole in PCOS.

2. Question 2 · Medium

   A 14-year-old girl is brought to the gynae OPD with heavy periods since menarche a year ago, each lasting 8-9 days with clots and flooding at night. She has had nosebleeds since childhood, and her mother also has heavy periods. Hb is 8.2 g/dL, platelet count 2.6 lakh/µL, PT normal and aPTT slightly prolonged. Which investigation is most likely to reveal the cause?

   1. AVon Willebrand factor antigen and activity
   2. BBone marrow aspiration and biopsy
   3. CSerum TSH and prolactin levels
   4. DPelvic ultrasound to look for a submucous fibroid

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   Answer: A · Von Willebrand factor antigen and activity

   Heavy bleeding from menarche with lifelong mucosal bleeding and a family history of heavy periods should prompt testing for a bleeding disorder, most often von Willebrand disease (AUB-C). Von Willebrand factor carries factor VIII, so a deficiency can prolong the aPTT slightly while the platelet count and PT stay normal. Testing includes vWF antigen, vWF activity (ristocetin cofactor) and factor VIII. Treatment uses tranexamic acid, desmopressin in type 1 disease or hormones, and NSAIDs are avoided.

   • B: Normal platelets and PT give no reason for a marrow study.
   • C: Thyroid and prolactin disorders do not cause lifelong mucosal bleeding.
   • D: Fibroids are rare at 14 and do not explain the nosebleeds.

3. Question 3 · Hard

   A 30-year-old para 2 has had no periods for 8 months since a repeat curettage for retained products after a postpartum haemorrhage. She breastfed normally. Pregnancy test is negative, and prolactin, TSH and FSH are normal. She has no withdrawal bleed after a 5-day course of medroxyprogesterone, nor after 21 days of oestrogen followed by a progestogen. What is the investigation of choice to confirm the diagnosis?

   1. AHysteroscopy
   2. BSerum anti-Müllerian hormone
   3. CKaryotype
   4. DMRI of the pituitary

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   Answer: A · Hysteroscopy

   No bleeding after either a progestogen or an oestrogen-progestogen challenge, with normal gonadotropins and prolactin, places the defect in the uterus or outflow tract. Vigorous curettage of a recently pregnant uterus can strip the basal endometrium and cause intrauterine adhesions (Asherman syndrome). Hysteroscopy confirms the adhesions and allows adhesiolysis in the same sitting, with measures to stop them re-forming. Sheehan syndrome is unlikely because she lactated and her FSH is normal.

   • B: AMH measures ovarian reserve, and a normal FSH already shows the ovaries work.
   • C: A karyotype is for primary amenorrhoea, not an acquired problem.
   • D: The pituitary is not at fault: prolactin and FSH are normal and she lactated.

4. Question 4 · Medium

   A 40-year-old woman has had heavy menstrual bleeding for a year. Her workup finds: 1. A 1.5 cm endometrial polyp. 2. A diffusely enlarged uterus with features of adenomyosis on MRI. 3. Mild von Willebrand disease. 4. A 3 cm intramural fibroid. Which of these fall in the structural (PALM) group of the FIGO classification?

   1. A2 and 4 only
   2. B1 and 4 only
   3. C1, 2 and 4 only
   4. D1, 2, 3 and 4

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   Answer: C · 1, 2 and 4 only

   PALM groups the structural causes that can be seen on imaging or histology: polyp, adenomyosis, leiomyoma, and malignancy or hyperplasia. COEIN groups the non-structural causes (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, not yet classified), so von Willebrand disease is AUB-C. A woman may have several causes, and each is recorded because each may need treatment. A structural finding, such as a small intramural fibroid, is not always the actual cause of the bleeding.

   • A: Leaves out the polyp, the P of PALM.
   • B: Leaves out adenomyosis, the A of PALM.
   • D: Includes von Willebrand disease, a coagulopathy in COEIN.

5. Question 5 · Easy

   A 17-year-old girl has not started her periods. She has no breast development and says she cannot smell food. Her height is normal, serum LH and FSH are low and MRI of the pituitary is normal. What is the most likely diagnosis?

   1. AMayer-Rokitansky-Küster-Hauser syndrome
   2. BTurner syndrome
   3. CKallmann syndrome
   4. DAndrogen insensitivity syndrome

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   Answer: C · Kallmann syndrome

   Primary amenorrhoea with absent puberty, low gonadotropins and anosmia is Kallmann syndrome: GnRH neurons fail to migrate from the olfactory placode to the hypothalamus during development, and the olfactory bulbs are defective. Puberty is induced with oestrogen, followed by cyclical oestrogen and progestogen, and pulsatile GnRH or gonadotropins are used when she wants fertility. Turner syndrome also lacks puberty, but gonadotropins are high because the ovaries fail, and the girl is short. MRKH syndrome and androgen insensitivity both have normal breast development.

   • A: MRKH has normal breasts and ovaries, with an absent uterus.
   • B: Turner syndrome gives high FSH and LH with short stature.
   • D: AIS has normal breasts from aromatised testosterone.

6. Question 6 · Medium

   A 29-year-old woman married for 3 years has been unable to conceive. She has increasingly painful periods that start a day before bleeding, deep pain during intercourse and painful defecation during menses. On examination the uterus is fixed and retroverted, with tender nodules in the uterosacral ligaments. What is the most likely diagnosis?

   1. APrimary dysmenorrhoea
   2. BChronic pelvic inflammatory disease
   3. CEndometriosis
   4. DAdenomyosis

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7. Question 7 · Medium

   A 36-year-old para 2 with regular but heavy periods for a year, soaking a pad every hour on the first two days, has a normal-sized uterus and a normal transvaginal ultrasound. Hb is 10.8 g/dL. She wants long-term treatment and does not plan more children. Which is the most effective first-line medical option?

   1. ANorethisterone in the luteal phase
   2. BTranexamic acid during menses
   3. CMefenamic acid during menses
   4. DLevonorgestrel intrauterine system (52 mg)

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8. Question 8 · Medium

   A 28-year-old woman on risperidone for schizophrenia for 8 months has had no periods for 5 months and milky discharge from both nipples. Pregnancy test is negative, TSH is normal and serum prolactin is 82 ng/mL (reference below 25 ng/mL). What is the mechanism of her amenorrhoea?

   1. AExcess TRH stimulating prolactin release
   2. BProlactin directly destroys the ovarian follicles
   3. CD2 blockade raises prolactin, which suppresses GnRH pulses
   4. DDrug-induced damage to the anterior pituitary

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9. Question 9 · Hard

   A 46-year-old para 2 who has completed her family has had heavy, irregular bleeding for 8 months. Her BMI is 33 kg/m2. Hysteroscopy-guided biopsy shows atypical endometrial hyperplasia (endometrial intraepithelial neoplasia) with no invasion. She is fit for surgery. What is the most appropriate management?

   1. ATotal hysterectomy with bilateral salpingectomy
   2. BLNG-IUS with biopsy every 6 months
   3. CCyclical progestogen for 3 months
   4. DEndometrial resection and ablation by hysteroscopy

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10. Question 10 · Medium

    A 19-year-old has had hirsutism and irregular periods since menarche. Her brother had a salt-wasting crisis in infancy. An early-morning, early follicular-phase 17-hydroxyprogesterone is markedly raised and rises further after ACTH stimulation; serum cortisol is normal. Deficiency of which enzyme explains her condition?

    1. A21-hydroxylase
    2. B3-beta-hydroxysteroid dehydrogenase
    3. C17-alpha-hydroxylase
    4. D11-beta-hydroxylase

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11. Question 11 · Medium

    A 17-year-old girl has cramping lower abdominal pain on the first two days of every period, starting a year after menarche, and misses school because of it. The pain radiates to the thighs and comes with nausea. Abdominal examination and ultrasound are normal and she is not sexually active. What is the best initial treatment?

    1. ANSAID such as mefenamic acid from onset of pain
    2. BDienogest daily for 6 months
    3. CAntispasmodic dicyclomine alone
    4. DDiagnostic laparoscopy for endometriosis

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12. Question 12 · Easy

    A 15-year-old girl, menarche at 13, has cycles of 6-10 weeks with occasional heavy, painless bleeding lasting 10 days. Examination and pelvic ultrasound are normal, coagulation tests are normal and a pregnancy test is negative. Under the FIGO PALM-COEIN system, how is her bleeding classified?

    1. AAUB-C (coagulopathy)
    2. BAUB-E (primary endometrial disorder)
    3. CAUB-N (not yet classified)
    4. DAUB-O (ovulatory dysfunction)

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13. Question 13 · Easy

    A 23-year-old woman attends the gynae OPD with coarse dark hair on her upper lip, chin, chest and lower abdomen. Before starting treatment, the doctor grades hair growth in nine body areas on a 0-4 scale to record a baseline. Which scoring system is being used?

    1. ATanner sexual maturity staging
    2. BModified Bishop cervical score
    3. CModified Ferriman-Gallwey score
    4. DManning biophysical profile score

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14. Question 14 · Medium

    A 47-year-old para 3 with a BMI of 34 kg/m2 and type 2 diabetes has had heavy, irregular bleeding for 6 months. The cervix looks healthy, the uterus is normal in size and transvaginal ultrasound shows an endometrial thickness of 14 mm without a focal lesion. Haemoglobin is 10.1 g/dL. What is the most appropriate next step?

    1. AThermal endometrial ablation
    2. BEndometrial sampling before any treatment
    3. CCombined oral contraceptive pills
    4. DCyclical oral progestogen for 3 months

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15. Question 15 · Medium

    A 29-year-old woman trying to conceive has heavy but regular periods and a normal pelvic ultrasound. She does not want hormonal treatment, so she is prescribed tranexamic acid for the heavy days of each period. How does this drug reduce her blood loss?

    1. AIncreases release of von Willebrand factor from endothelium
    2. BBlocks lysine sites on plasminogen, preventing fibrinolysis
    3. CConverts the endometrium to thin, inactive decidua
    4. DInhibits cyclo-oxygenase, lowering endometrial prostaglandins

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16. Question 16 · Hard

    A 17-year-old with primary amenorrhoea has normal breast development, sparse pubic and axillary hair and a height of 168 cm. The vagina is a short blind pouch, ultrasound shows no uterus, and smooth oval masses are felt in both inguinal canals. Serum testosterone is in the normal male range. What is the most appropriate next step?

    1. ALaparoscopy to look for a uterine remnant
    2. BStart cyclical oestrogen and progestogen
    3. CKaryotype, then gonadectomy after puberty
    4. DKaryotype, then urgent vaginoplasty

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17. Question 17 · Hard

    A 32-year-old woman with previously regular cycles has had amenorrhoea for 5 months, with a deepening voice, frontal balding and clitoromegaly developing over 6 months. Serum total testosterone is 310 ng/dL (reference below 50 ng/dL), while DHEAS and 17-hydroxyprogesterone are normal. Transvaginal ultrasound shows a 4 cm solid right ovarian mass. What is the most likely diagnosis?

    1. ANon-classic congenital adrenal hyperplasia
    2. BAndrogen-secreting adrenal carcinoma
    3. CPolycystic ovary syndrome
    4. DSertoli-Leydig cell tumour of the ovary

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18. Question 18 · Medium

    A 34-year-old woman with laparoscopically proven pelvic endometriosis has coughed up blood on the first day of her last four periods. CT done during menses shows a small nodular opacity in the right lung, and bronchoscopy is otherwise normal. Which theory best explains endometriosis at this site?

    1. ACoelomic metaplasia of the peritoneum
    2. BDirect implantation at a surgical scar
    3. CRetrograde menstruation through the fallopian tubes
    4. DVascular or lymphatic spread of endometrial cells

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19. Question 19 · Medium

    A 31-year-old nulliparous woman with dysmenorrhoea has a 5 cm left ovarian cyst on transvaginal ultrasound. It is unilocular with uniform low-level 'ground-glass' echoes, a smooth wall, no papillary projections and no internal flow on Doppler. CA-125 is 58 U/mL (reference below 35 U/mL). What is the most likely nature of the cyst?

    1. ASerous cystadenocarcinoma
    2. BHaemorrhagic corpus luteum
    3. CMature cystic teratoma
    4. DEndometrioma

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20. Question 20 · Medium

    A 22-year-old college student with PCOS has cycles every 3-4 months, hirsutism on the chin and lower abdomen, and acne. Her BMI is 24 kg/m2, BP is normal, and she does not smoke or have migraine. She does not want pregnancy for several years. Which treatment best addresses both her cycles and her hirsutism?

    1. AMetformin 500 mg twice daily
    2. BCombined oral contraceptive pill
    3. CCyclical oral progestogen without other drugs
    4. DClomiphene citrate from day 2

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21. Question 21 · Medium

    A 33-year-old teacher with infertility asks about her newly diagnosed endometriosis. The gynaecologist considers four statements: 1. The severity of pain closely matches the extent of disease seen at laparoscopy. 2. Serum CA-125 may be mildly raised. 3. The ovary is the commonest site of endometriosis. 4. Symptoms often improve during pregnancy. Which statements are correct?

    1. A2, 3 and 4 only
    2. B3 and 4 only
    3. C1, 2, 3 and 4
    4. D1, 2 and 3 only

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22. Question 22 · Easy

    For research purposes, heavy menstrual bleeding has traditionally been defined as a measured blood loss per cycle of more than:

    1. A200 mL
    2. B40 mL
    3. C80 mL
    4. D120 mL

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23. Question 23 · Hard

    A 32-year-old para 1 has had no periods for 7 months, with hot flushes and night sweats. Pregnancy test is negative. FSH is 62 IU/L and, repeated 6 weeks later, 70 IU/L; oestradiol is low, and prolactin and TSH are normal. She does not want more children. Besides a karyotype and screening for autoimmune disease, what is the best long-term management?

    1. AHormone therapy only while hot flushes persist
    2. BClomiphene citrate to restore ovulation
    3. CHormone therapy until about the natural age of menopause
    4. DReassurance, as her periods are likely to return

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24. Question 24 · Medium

    A 15-year-old girl, menarche 2 years ago, comes with her mother to the gynae OPD with cycles of 50-90 days and moderate acne. A private scan report says 'multifollicular ovaries, suggestive of PCOS'. Her BMI is 23 kg/m2 and total testosterone is mildly raised. Which statement about her evaluation is correct?

    1. APCOS is confirmed by the ultrasound report alone
    2. BA serum AMH level is needed to confirm the diagnosis
    3. CPCOS can never be diagnosed before 18 years of age
    4. DUltrasound should not be used for diagnosis at her age

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25. Question 25 · Easy

    A 30-year-old woman has severe irritability, low mood, bloating and breast tenderness in the week before each period for over a year; the symptoms vanish within a few days of bleeding and strain her marriage and work. A symptom diary over two cycles confirms the pattern. What is the first-line drug treatment?

    1. ADanazol throughout the cycle
    2. BSpironolactone as a diuretic
    3. COral progesterone in the luteal phase
    4. DSelective serotonin reuptake inhibitor

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