Endometriosis

ENDOMETRIOSIS

Q. 1

Infertility is seen in :

 A

Fibroid uterus

 B

Endometriosis

 C

Adenomyosis and PID both

 D

All Correct

Q. 1

Infertility is seen in :

 A

Fibroid uterus

 B

Endometriosis

 C

Adenomyosis and PID both

 D

All Correct

Ans. D

Explanation:

Ans. is a, b, c  i.e. Fibroid uterus; Endometriosis; Adenomyosis; and PID

Before going into the details of the causes of Infertility, lets first have a look at the prevalence of various causes.

    Etiology of Inlertility

Male W                              25%

Ovulatory                         27%

Tubal / Uterine                 22%

Others                              9%

Unexplained                     17%

Common causes of female Infertility are :

a.     Decreased ovarian reserve

b.     Ovarian Factor It is the most easily diagnosed and most treatable cause of infertility°. It includes :

Anovulation / Dysovulation

  • Like in case of hypothalamic dysfunction°, Kaltman syndrome
  • Hyperprolactinemia (due to drugs, pituitary adenoma°)
  • Primary hypothyroidism°
  •  
  • Sub clinical adrenal failure
  • Diabetes mellitus

Luteinized unruptured follicle Luteal phase defect

c. Tubal Factors : Partial or Complete Bilateral tubal obstruction resulting from previous salpingitis / PID. It could be : — Postabortal°

—  Gonococcal°

—  Chlamydial°

—  Tuberculous°

  • Tubal inflammation related to endometriosis
  • Following Inflammatory bowel disease
  • Following surgical trauma

d.   Peritoneal Factors : — Pelvic adhesions — Endometriosis

e.   Uterine Factors :

  • Uterine absence, atrophy
  • Congenital malformations (Among all congenital uterine abnormalities, septate uterus is the M/C and most highly associated with reproductive failure and obstetrics complications).
  • Intrauterine adhesions (Asherman’s syndrome)°
  • Endometrial polyps
  • Leiomyomas (most common with sub mucous variety)°
  • Chronic endometritis (TB)°
  • Exposure to DES in utero

f. Cervical Factors :

  • Impenetrable cervical mucus or poorly penetrable cervical mucus due to presence of local sperm antibodies.
  • Loss of mucus due to amputation of cervix, cone biopsy or over enthusiastic cervical diathermy.
  • Faulty direction of cervix as seen in retroversion or severe prolapse.
  • Cervical stenosis.

g. Others : Anxiety / apprehension use of contraceptives; anorexia nervosa.

As such adenomyosis is not given as a cause of infertility but if you go through the chapter of adenomyosis: (In chapter on Adenomyosis) : “The patient may also complain of infertility”. So, I am including it in the correct options


Q. 2

Uterine fibromyoma is associated with :

 A

Endometriosis

 B

Pelvic inflammatory disease

 C

Ovarian Ca

 D

Amenorrhea

Q. 2

Uterine fibromyoma is associated with :

 A

Endometriosis

 B

Pelvic inflammatory disease

 C

Ovarian Ca

 D

Amenorrhea

Ans. A

Explanation:

Ans. is a i.e. Endometriosis


Q. 3

True about endometriosis is/are :

 A

MC in 3rd or 4th decade

 B

Premenstrual spotting

 C

True cyst

 D

All Correct

Q. 3

True about endometriosis is/are :

 A

MC in 3rd or 4th decade

 B

Premenstrual spotting

 C

True cyst

 D

All Correct

Ans. D

Explanation:

All Correct 

Most common in 3rd or 4th decade; Premenstrual spotting; and True cyst; and 1st

degree relative seen  

Friends endometriosis is not one of the favourate topics for All India / AIIMS exams but has been asked often in PGI Chandigarh and other state level exams. I am penning down some important points on endometriosis on which questions could be asked.

Endometriosis :

  • Occurence of functioning endometrial tissue (both glands + stroma)° outside the cavity of uterus.
  • Age group – 30 – 40 years (Most commonl°                                                                             
  • Seen in high socio-economic status because of late marriage°, late child bearing°.
  • Most common in nulliparous females°.       
  • Familial predisposition (risk is seven times higher if a first degree relative has diseases. Risk is further increased in homozygous twins).
  • It is a hormone dependant condition (Estrogen dependant)°.

Sites : It can occur anywhere in the body. Most common site is ovary (30-40% cases)°, 2nd most common site is pouch of douglas° other sites are Round ligament, Uterosacral ligament, Rectovaginal septum, Fallopian tube, Intestine, Bladder, Vagina, Vulva, Abdominal wall. Lungs, Pleura, Brain and Arm.

Scar endometriosis is seen in : — hysterotomy

—   classical cesarean section

—    myomectomy ventrofixation scar involving section of fallopian tube operation.

Pathology :

Peritoneum : Earliest lesion is red petechial, later becoming cystic. dark brown, dark blue black in appearance called as r (Jo/der barn appearance / Gun shot appearance.

Ovary : Characteristic bilateral° chocolate cyst° or endometrioma (which is a true cyst° with columnar lining epithelium)°. Beneath the epithelium are large cells with brown cytoplasm due to ingested pigments like hemosiderin called as Pseudoxanthoma cells Cyst contains tarry brown fluid.°                                                                                                                    … Shaw 14/e, p 421

Peritoneal cavity : Contains yellow brown fluid which has prostaglandin responsible for the pain of endometriosis. Symptoms : Patients present with a characteristic triad of : — infertility°

—  progressively increasing dysmenorrhea°

—  dyspareunia°.

Most common symptom is Secondary dysmenorrhee commencing after 30 years°and gradually increasing°. Dyspareunia : Occurs when POD and rectovaginal septum are involved.

Menstrual irregularities : like Menorrhagia, Polymenorrhea are seen.

 

 

Premenstrual spotting may occur and is more likely to be associated with endometriosis than with luteal phase inadequacy. CGDT 10/e, p 770 Other symptom : Chronic pelvic pain, pain during defecation. Intermittent pyrexia and urinary symptoms.

Signs :

P/A = Cystic swelling may be present

P/S = Blue / black puckered spots in posterior fornix which may be tender (Pathognomic of endometriosis)°.
P/V = Tender° fixed° retroverted° uterus°.

If uterosacral ligaments and pouch of douglas is involved it gives then a cobble stone feel (multiple shotty. small nodules are palpable).

Unilateral or bilateral adnexal mass may be felt.


Q. 4

All are true regarding endometriosis, except :

 A

Hormone dependent condition 

 B

Can involve lung. pleura

 C

Contains clear fluid

 D

Ovary is the most common site

Q. 4

All are true regarding endometriosis, except :

 A

Hormone dependent condition 

 B

Can involve lung. pleura

 C

Contains clear fluid

 D

Ovary is the most common site

Ans. C

Explanation:

Ans. is c i.e. Contains clear fluid

As already explained in previous question, endometriosis is occurence of functioning endometrial tissue (glands + stroma) outside the uterine cavity.

Whatever the inital genesis of endometriosis its further development depends mainly on estrogen (Option “a) 

It can occur anywhere in body, Most common site being ovary° (Option “d”).  

Can also involve lungs and pleura° (Option “b”).                                              

–   In endometriosis ovary contains tarry dark brown fluid (due to presence of blood pigments like hemosiderin) and cul de sac has yellow brown fluid.

Clear fluid is not seen anywhere. So, Option “c” is incorrect.

For more details about endometriosis, see answer 1


Q. 5

Endometriosis is commonly associated with :

 A

B/L chocolate cyst of ovary

 B

Adenomyosis

 C

Fibroid

 D

Luteal cyst

Q. 5

Endometriosis is commonly associated with :

 A

B/L chocolate cyst of ovary

 B

Adenomyosis

 C

Fibroid

 D

Luteal cyst

Ans. A

Explanation:

Ans. is ai.e. B/L chocolate cyst of ovary

“The ovary is the commonest site and is involved in 30-40% of cases. The lesion is nearly always bilateral. It sometimes appears as multiple burnt match head spots on the surface of the ovary and sometimes as the typical tarry cysts in a disorganised organ surrounded by dense adhesinos.”  

  • They are true cysts° with columnar lining epithelium.°
  • The cysts enlarge with cyclic bleeding. The serum gets absorbed in between periods and the content inside becomes chocolate, tarry brown in colour°.
  • Histology

–         Lining epithelium is columnar epithelium°.

–         Beneath the epithelium are large macrophages called as Pseudoxanthoma cells which have brown cytoplasm due to ingested blood pigments like hemosiderin.

  • Treatment of chocolate cyst / endometrioma.

Small        < 3cm                                Large > 3cm

Laparoscopic aspiration/                  Associated with extensive adhesions to other pelvic

Laparoscopic cystectomy                structures and therefore laparotomy is necessary.

Other conditions associated with Endometriosis

  • Anovulation°
  • Abnormal follicular development
  • Reduced circulating E2 levels during pre ovulatory phase°
  • Disturbed LH surge patterns°
  • Premenstrual spotting°

  • Luteinized unruptured follicle syndrome°
  • Hyperprolactinemia°
  • Galactorrhea°
  • Before concluding lets rule out other options.

    • Adenomyosis is associated with endometriosis but vice versa is not true: similarly fibroid uterus is associated with endometriosis but vice versa is not true (Ruling out options “b” and “c”).
    • Multiple luteal cysts in the ovary are seen in case of : a. Pregnancy
    1. Multiple pregnancy°
    2. HCG therapy°
    3. H. Mole°
    4. Chorio carcinoma°

    Thus option “d” is incorrect. There is no association between endometritis and endometriosis.


Q. 6

Pain in endometriosis correlates with :

 A

Depth

 B

Multiple sites

 C

T CA 125

 D

Stage of disease

Q. 6

Pain in endometriosis correlates with :

 A

Depth

 B

Multiple sites

 C

T CA 125

 D

Stage of disease

Ans. A

Explanation:

Ans. is a i.e. Depth invasion        

-Deep penetrating endometriosis is a form of the disease which was described by Koninck’s group. These lesion can extend 1 Omm or more down from the peritoneal surface and the deeper lesions appear to have a closer associations with pain than infertility, whereas less deep lesions have a closer association with infertility than pain.”   

Dysmenorehea : … Williams Gyane. 1/e, p 230 “Cyclical pain with menstruation is noted commonly in women with endometriosis. Typically. endometriosis associated dysmenorrhea preceedes menses by 24 to 48 hours and is less responsive to NSAID and combination oral contraceptives. This pain is thought to be more severe in comparison with primary dysmenorrhea and Crammer and associates demonstrated a positive correlation between the severity of dysmenorrhea and the risk of endometriosis. Furthermore, deeply infiltrating endometriosis, that is disease that extends > 5 mm under the peritoneal surface, also appears to have positive correlation to the severity of dysmenorrhea.”

From above lines it is clear that pain in endometriosis coincides with the depth of lesion.

As far as other options are concerned ‑

“The levels of CA 125 correlate with severity of the disease, but since there is a wide variety of conditions in which the levels are elevated. lts greatest use may be in monitoring a patient serially for recurrence.” (ruling out “option c”)  

“Most studies have failed to detect a correlation between the degree of pelvic pain and severity of endometriosis. Some women with extensive disease have no pain, whereas others with only minimal disease may experience severe pelvic pain and dyspareunia may be associated with infiltrating sub peritoneal endometriosis.” (ruling out option “d”).


Q. 7

Best investigation to establish the diagnosis of endometriosis is 

 A

Laparoscopy

 B

USG

 C

X-ray pelvis

 D

CT Scan

Q. 7

Best investigation to establish the diagnosis of endometriosis is 

 A

Laparoscopy

 B

USG

 C

X-ray pelvis

 D

CT Scan

Ans. A

Explanation:

Ans. is a i.e. Laparoscopy    

 Diagnostic laparoscopy is the gold standard for diagnosing endometriosis.

Typical lesion : Powder burn / gun shot lesions (black, dark brown or bluish cysts with old hemorrhage surrounded by variable degree of fibrosis).

Other non typical findings could be : Red implants°

–  Serous or clear vesicles

White plaques / scarring]

– Yellowish brown discolouration of peritoneum° Sub ovarian adhesions°.

Histological confirmation of laparoscopic impression is essential for diagnosis of endometriosis.

Danazol



By its multiple effects, produces a high andro­gen & low estrogen environment that does not support the growth of endometriosis. It inhibits pituitary gonadotropins & produces pseudo menopause like state.

Danazol is not more effective than other available medications to treat endometriosis. Due to its andro­genic property has significant side effect like weight gain, fluid retention, acne oily skin, hirsutism, hot flashes, atrophic vaginitis, reduced breast-size. reduced libido, fatigue, muscle cramps. Deepening of voice is an  rreversible side effect.

Gestrinone



It is a 19 nortesto sterone derivative. It acts centrally & peripherally to increase free testosterone, reduce SHBG. serum estradiol & LH which inturn obliterates LH & FSH surge. Its actions are similar to Danazol but is longer acting. So, can be given twice weekly.

Side effects – similar to Danazol but less intense.



Gonadotropin releasing hormone agonist

When given continously suppress pituitary gonadotropin. They are inactive orally; & have to be given intramuscular, intra nasal or

subcutaneous.

Side effects due to hypo estrogen are hot-flashes, vaginal dryness, reduced libido and osteoporosis. GnRH should not be prescribed to girls who have not yet attained their maximum bone density (i.e., in age < 16 years).


Q. 8

All are used in treatment of endometriosis except:

 A

Medroxyprogesterone acetate

 B

Tibolone

 C

OCP

 D

Danazol

Q. 8

All are used in treatment of endometriosis except:

 A

Medroxyprogesterone acetate

 B

Tibolone

 C

OCP

 D

Danazol

Ans. B

Explanation:

Ans. is b i.e. Tibolone 

Friends this is the most often asked question on endometriosis. It is worth while to know a few details on this topic.

Emperical treatment : is for pain presumed to be due to endometriosis. (in absence of definitive diagnosis) and includes :— Counselling

—            Analgesia

—            Nutritional therapy

—            Progestin or OCP’s

Analgesia : Studies have shown NSAID’s except niflumic acid are more effective in chronic pain relief due to endometriosis or dysmenorrhea suspected to be due to endometriosis.

Hormonal medical treatment :

Basis of management : Since estrogen is known to stimulate the growth of endometriosis, hormonal therapy has been designed to suppress estrogen synthesis, thereby inducing atrophy of ectopic endometrial implants or interrupting the cycle of stimulation and bleeding.

Indication : — Mild pelvic endometriosis in young women.°

— Treatment of residual and recurrent disease following conservative surgery.


Q. 9

Scar endometriosis can occur following :

 A

Classical Cesarean Section

 B

Hysterotomy

 C

Episiotomy

 D

All of the above

Q. 9

Scar endometriosis can occur following :

 A

Classical Cesarean Section

 B

Hysterotomy

 C

Episiotomy

 D

All of the above

Ans. D

Explanation:

Ans. is d i.e. All of the above                   

Endometriosis sometimes occurs in abdominal wall scars following operations on uterus or tubes and is known as Scar endometriosis.

Operations most likely to be followed by scar endometriosis

  • Hysterotomy°                                                                               • Classical cesarean section°
  • Myomectomy°                                                                              • Ventrofixation°
  • Following operations for section of Fallopian tube°                    • Following operations for removal of pelvic
  • Episiotomy°                                                                                     endometriosis°

Q. 10

Treatment of a cause of Endometriosis at a younger age group :

 A

Progestin

 B

Danazol

 C

GnRH analogues

 D

Hysterectomy with oophorectorny

Q. 10

Treatment of a cause of Endometriosis at a younger age group :

 A

Progestin

 B

Danazol

 C

GnRH analogues

 D

Hysterectomy with oophorectorny

Ans. A

Explanation:

Ans. is a i.e. Progestin      

Adolescent Endometriosis :

The incidental finding of minimal to mild endometriosis in a young woman without immediate interest in pregnancy is a common clinical problem. 70% of girls with chronic pelvic pain unresponsive to OCP’s or NSAID’s are affected by endometriosis. Mild disease can be treated by surgical removal of implants at the time of diagnosis followed by continuous administration of low dose combination oral pills to prevent recurrence. More advanced disease can be treated medically for 6 months, followed by continuous OCP’s to prevent disease progression.

The question now arises – which medical therapy is best suited for young women.

Danazol causes virilising side effects and so not should be given to young women.

GnRH causes severe osteoporosis and without backup therapy (like progesterone, OCP or tibolone) should not be used in young women especially in adolescent less than 16 years. So, best option is progestin.


Q. 11

A 40 year old primiparous woman suspected to be suffering from endometriosis is subjected to diagnostic laparoscopy. Findings indicate – Uterus normal, both the ovaries show presence of choco­late cysts; endometriotic deposits are seen on the round ligament right side, both the fallopian tubes and the pouch of Douglas; moderately dens ad­hesions are present between the fallopian tubes and the pouch of Douglas. The treatment of choice in this case is :

 A

Total hysterectomy with bilateral salpingo­oophorectomy

 B

Danazol therapy

 C

Progesterone therapy

 D

Fulguration of endometriotic deposits

Q. 11

A 40 year old primiparous woman suspected to be suffering from endometriosis is subjected to diagnostic laparoscopy. Findings indicate – Uterus normal, both the ovaries show presence of choco­late cysts; endometriotic deposits are seen on the round ligament right side, both the fallopian tubes and the pouch of Douglas; moderately dens ad­hesions are present between the fallopian tubes and the pouch of Douglas. The treatment of choice in this case is :

 A

Total hysterectomy with bilateral salpingo­oophorectomy

 B

Danazol therapy

 C

Progesterone therapy

 D

Fulguration of endometriotic deposits

Ans. D

Explanation:

Ans. is d i.e. Fulguration of endometriotic deposits 

The situation given in the question is such that it points towards moderate endometriosis (as chocolate cyst, dense adhesions are present). Dense adhesions and cysts cannot be fully treated by medical therapy and so, some form of surgery is required.

Main question is whether we would like to go for conservative surgery or Radical surgery (i.e. TAH with BSO).

Conservative surgery : The clinical situations involving conservative surgery include ovarian endometrioma, pelvic adhesions, peritoneal implants and deep infiltrative recto vaginal septum disease. In addition laser laparoscopy can be used in order to perform uterine nerve ablation. ..

Radical Surgery : Whilst repeated conservative surgery and medical therapy help many women, only some women fail to find pain relief after recurrence, which is the major drawback of conservative surgery. For these women, radical surgery is the only option and involves Hysterectomy with Bilateral salpingo-oophorectomy.

According to 

“Hysterectomy with bilateral oopherectomy should be reserved for women who have completed childbearing and recognise the risk of premature hypoestrogenism including possible osteoporosis and decrease libido.”

Note :  Hysterectomy without BSO is not done in case of endometriosis due to 6 fold increase risk of recurrent
chronic pelvic pain and 8 fold risk of repeat surgery.


Q. 12

Endometriosis is explained by :

 A

Sarnpson’s Implantation theory

 B

Metastatic epithelium

 C

Histogenesis by induction and Coelomic metaplasia theory both

 D

All of the above   

Q. 12

Endometriosis is explained by :

 A

Sarnpson’s Implantation theory

 B

Metastatic epithelium

 C

Histogenesis by induction and Coelomic metaplasia theory both

 D

All of the above   

Ans. D

Explanation:

Ans. is d i.e. All of the above   

Endometriosis is the occurrence of ectopic endometrial tissue (both glands and stroma) outside the cavity of uterus.

Theory Proposed by Mechanism

Sampson’s Implantation theory

Sampson

Endometriosis occurs as a result of reflux of menstrual endorne­trium through the fallopian tubes and its subsequent implantation and growth on pelvic peritoneum and surrounding structures. ,

Coelomic Metaplasia

Meyer & Ivanotf

Endometriosis arises as a result of metaplastic changes in embroynal cell rests of embryonic mesotheluim, which are capable of responding to hormone stimulation.

Metastatic theory

Halban

Explains occurrence of endometriosis at less accessible sites like umblicus, pelvic nodes, ureter etc.

Histogenesis by induction

 

The theory suggests embolization of menstrual fragments occurs through vascular or lymphatic channels. This leads to launching of endometriosis at distant sites. Proposes that an endogenous (undefined) biochemical factor can induce undifferentiated peritoneal cells to develop into endometrial tissue.



Q. 13

A female with menorrhagia and endometriosis cannot be treated by :

 A

OCP

 B

Surgical procedure

 C

D & C

 D

Option B and C both

Q. 13

A female with menorrhagia and endometriosis cannot be treated by :

 A

OCP

 B

Surgical procedure

 C

D & C

 D

Option B and C both

Ans. D

Explanation:

Ans:D.)Option B and C both.

OC pills alleviates the pain of endometriosis by suppressing menstruation and inhibiting the growth of the endometrial implants.


Q. 14

Which of the following pairs are correctly matched:

  1. Endometriosis                      Danazol
  2. Endometrial carcinoma       Oestrogen
  3. Anovulatory infertility         Clomiphene
  4. Prolactinoma                       Alpha-Bromocriptine

Select the correct answer using the codes given be­low :

 A

1.2,3 and 4

 B

1.3 and 4

 C

2. 3 and 4

 D

1 and 2

Q. 14

Which of the following pairs are correctly matched:

  1. Endometriosis                      Danazol
  2. Endometrial carcinoma       Oestrogen
  3. Anovulatory infertility         Clomiphene
  4. Prolactinoma                       Alpha-Bromocriptine

Select the correct answer using the codes given be­low :

 A

1.2,3 and 4

 B

1.3 and 4

 C

2. 3 and 4

 D

1 and 2

Ans. B

Explanation:

1.3 and 4


Q. 15

Which is true of endometriosis :

 A

Always associated with tubal blood

 B

Painful

 C

Amenorrhoea

 D

Surgery Is curative

Q. 15

Which is true of endometriosis :

 A

Always associated with tubal blood

 B

Painful

 C

Amenorrhoea

 D

Surgery Is curative

Ans. B

Explanation:

Painful


Q. 16

In endometriosis, cause of infertility is :

 A

Immobility of tubes

 B

Anovulation

 C

Tubal block

 D

A, B and C All Correct

Q. 16

In endometriosis, cause of infertility is :

 A

Immobility of tubes

 B

Anovulation

 C

Tubal block

 D

A, B and C All Correct

Ans. D

Explanation:

A, B and C All Correct


Q. 17

Endometriosis mostly occurs in ….. women :

 A

Multiparous

 B

Young

 C

Post menopausal

 D

Nulliparous

Q. 17

Endometriosis mostly occurs in ….. women :

 A

Multiparous

 B

Young

 C

Post menopausal

 D

Nulliparous

Ans. D

Explanation:

Nulliparous


Q. 18

The surgery of choice for diffuse endometriosis interna is :

 A

Total hysterectomy

 B

Localised excision of the affected area

 C

Hysterectomy + Oophorectomy

 D

Oophorectomy

Q. 18

The surgery of choice for diffuse endometriosis interna is :

 A

Total hysterectomy

 B

Localised excision of the affected area

 C

Hysterectomy + Oophorectomy

 D

Oophorectomy

Ans. A

Explanation:

Total hysterectomy


Q. 19

Which of the following is the drug of choice to treat endometriosis :

 A

Testosterone propionate

 B

Norethisterone

 C

Medroxy progesterone

 D

Danazol

Q. 19

Which of the following is the drug of choice to treat endometriosis :

 A

Testosterone propionate

 B

Norethisterone

 C

Medroxy progesterone

 D

Danazol

Ans. C

Explanation:

Medroxy progesterone


Q. 20

Which one of the following is the most common extrauterine site to be affected by endometriosis:

 A

Vagina

 B

Rectovaginal septum

 C

Sigmoid colon

 D

Broad ligament (except tubes and ovaries) 

Q. 20

Which one of the following is the most common extrauterine site to be affected by endometriosis:

 A

Vagina

 B

Rectovaginal septum

 C

Sigmoid colon

 D

Broad ligament (except tubes and ovaries) 

Ans. D

Explanation:

Broad ligament (except tubes and ovaries) 


Q. 21

The severity of pelvic pain in endometriosis correlates best with :

 A

Number of implants

 B

Depth of invasion

 C

Stage of disease

 D

Ca 125 levels

Q. 21

The severity of pelvic pain in endometriosis correlates best with :

 A

Number of implants

 B

Depth of invasion

 C

Stage of disease

 D

Ca 125 levels

Ans. B

Explanation:

Depth of invasion


Q. 22

Treatment of endometriosis in an infertile female:

 A

Danazol

 B

Clomiphene

 C

Gn RH analogue

 D

Progesterone

Q. 22

Treatment of endometriosis in an infertile female:

 A

Danazol

 B

Clomiphene

 C

Gn RH analogue

 D

Progesterone

Ans. B

Explanation:

Clomiphene


Q. 23

Cause of unilateral dysmenorrhea : 

 A

One horn of malformed uterus

 B

Endometriosis with unilateral distribution

 C

Small fibroid at the utero tubal junction

 D

All of the above

Q. 23

Cause of unilateral dysmenorrhea : 

 A

One horn of malformed uterus

 B

Endometriosis with unilateral distribution

 C

Small fibroid at the utero tubal junction

 D

All of the above

Ans. D

Explanation:

All of the above


Q. 24

CA 125 is elevated in all except :

 A

Tuberculosis

 B

Endometriosis

 C

Ovarian tumour

 D

Polycystic ovarian disease

Q. 24

CA 125 is elevated in all except :

 A

Tuberculosis

 B

Endometriosis

 C

Ovarian tumour

 D

Polycystic ovarian disease

Ans. D

Explanation:

Ans. is d i.e. Polycystic Ovarian Disease (PCOD)

  • CA – 125 is a glycoprotein secreted by malignant epithelial tumours of ovary.
  • CA – 125 levels correlate with volume of tumour and is elevated in 50% of Stage I tumour and 90% of tumours with Stage II or higher.
  • CA – 125 level is also useful for follow up after treatment. Levels 35 units/ml suggests residual tumour.

Also know : Besides being the specific marker of epithelial ovarian tumors – CA 125 is raised in a number of malignant and non malignant conditions.


Q. 25

Trans-Cervical Endometrial Resection (TCER) is used in A/E :

 A

Endometriosis

 B

DUB

 C

Carcinoma endometrium

 D

Submucous fibroid

Q. 25

Trans-Cervical Endometrial Resection (TCER) is used in A/E :

 A

Endometriosis

 B

DUB

 C

Carcinoma endometrium

 D

Submucous fibroid

Ans. B

Explanation:

Ans. is b i.e. DUB

Transcervical endometrial resection (Hysteroscopic endometrial ablation) is a technique for management of DUB.

Aim of the procedure is to produce a therapeutic Asherman’s syndrome and produce amenorrhea. It destroys the endometrium –4 formation of synchea Asherman syndrome —) amenorrhea. It is essential to destroy endometrial functionalis and basalis as well as 3mm of rnyometrial depth.

Procedure : After appropriate inspection of the landmarks and endometrial cavity, a wire loop electrode is used to resect several strips of endornyometrium, to a depth of 4mm. Resected tissue is used for pathologic examination and documentation of the absence of cellular atypia. After a few strips are resected initially from the posterior uterine wall, resection of almost all the remaining surface with loop electrode by vaporisation is performed. The procedure should be performed soon after menstruation or the woman should be given progesterone. danazol or GnRH to suppress the endometrium.

Result : Short term and long term studies show amenorrhea rates of 20 – 50%, overall improved bleeding patterns (including amenorrhea) in 85 – 95%, with failure rates of 5 – 10% which requires additional surgery i.e. hysterectomy.

Extra Edge:

A COG recommends endometrial sampling prior to surgery. Women should with endometrial hyperplasia or  cancer

  • Absolution contraindications for endometrial ablation : Genital tract malignancy

Women wishing to preserve their fertility

Pregnancy

Expectation of amenorrhea

Acute pelvic infection

Prior uterine surgery – Classical cesarean delivery, transmural myomectomy

—  Uterine size > 12wks

Adenomyosis as TCRE causes dysmenorrhea


Q. 26

Which is true regarding retroverted uterus :

 A

Causes menorrhagia

 

 B

Associated with endometriosis

 C

It is a cause of infertility

 D

All

Q. 26

Which is true regarding retroverted uterus :

 A

Causes menorrhagia

 

 B

Associated with endometriosis

 C

It is a cause of infertility

 D

All

Ans. D

Explanation:

Ans. is a, b and c i.e. Associated with endometriosis; It is a cause of infertility; Causes menorrhagia; and Associated with PID

The usual position of the uterus is one of anteversion and anteflexion, in which the body of the uterus is bent forward at its junction with cervix.

Retroversion is a condition in which axis of cervix is directed upward and backward (instead of forward).

Causes

  • Seen in 20% of patients                                      Mobile retroversion               Fixed retroversion
  • Retroversion can never be                                  • Prolapse                              • PID

congenital (it is always developmental)                        • Puerperium                          • Pelvic tumors

malformation as the uterus is without                           • Fibroid                                   • Chocolate cyst of ovary

version and flexion at birth.                                          • Ovarian cyst                          • Pelvic endometriosis

                                                                                      (pushes uterus backward)

Symptoms :

  • Mobile retroversion is usually symptomless, main disadvantage being increased risk of perforation of the uterus at the time of instrumentation.

Symptoms which can be seen are :

  • Spasmodic dysmenorrhea°
  • Pelvic congestion syndrome causing :

– Congestive dysmenorrhea

–        Polymenorrhagia

–        Premenstrual low backache

–    Dyspareunia (it is the most specific and genuine complain in case of retroversion)

–        Leucorrhoea

  • Infertility as cervix is directed forward away from the seminal pool and the ejaculation of semen directly into the external os.
  • Abortion : can cause abortion between 10th to 14th week.

Treatment :

  • If retroversion is mobile no treatment is required.
  • In patient complaining of dyspareunia backache with retroverted uterus Hodge pessary may be used to keep uterus in anteverted position.
  • Surgical management : – Modified Gilliams operation

Plication of round ligament°

Baldy webster open9tion°


Q. 27

The condition of genital organs whlch may lead to leslons in surgicalscars, rectum, lymph nodes, lung ls :

 A

Teratoma

 B

Endometriosis

 C

Adenomyosis

 D

Fibroid

Q. 27

The condition of genital organs whlch may lead to leslons in surgicalscars, rectum, lymph nodes, lung ls :

 A

Teratoma

 B

Endometriosis

 C

Adenomyosis

 D

Fibroid

Ans. B

Explanation:

Endometriosis


Q. 28

Pawaer burr, appearance on laparoscopy is characteristic of :

 A

Endometriosis

 B

Endometroid tumour

 C

Epithelial ovarian tumour

 D

Endometrial cancer

Q. 28

Pawaer burr, appearance on laparoscopy is characteristic of :

 A

Endometriosis

 B

Endometroid tumour

 C

Epithelial ovarian tumour

 D

Endometrial cancer

Ans. A

Explanation:

Endometriosis


Q. 29

Ectopic pregnancy is common in :

 A

Tuboplasty

 B

Endometriosis

 C

Copper T users

 D

All

Q. 29

Ectopic pregnancy is common in :

 A

Tuboplasty

 B

Endometriosis

 C

Copper T users

 D

All

Ans. D

Explanation:

All


Q. 30

A 25-year-old female states that she and her husband have been trying to have a baby for the last two years. The patients medical history included cyclical pelvic pain, dysmenorrhea, dyspareunia, and, not uncommonly, infertility. The physical exam reveals the following: diffuse abdominal or pelvic pain of variable location, nodular thickening and tenderness along the uterosacral ligaments, on the posterior surface of the uterus, and in the posterior cul-de-sac, scarring and narrowing of the posterior vaginal fornix, and adnexal enlargement and tenderness. What is your diagnosis?

 A

Endometriosis

 B

Ectopic pregnancy

 C

Adnexal mass

 D

Pelvic relaxation

Q. 30

A 25-year-old female states that she and her husband have been trying to have a baby for the last two years. The patients medical history included cyclical pelvic pain, dysmenorrhea, dyspareunia, and, not uncommonly, infertility. The physical exam reveals the following: diffuse abdominal or pelvic pain of variable location, nodular thickening and tenderness along the uterosacral ligaments, on the posterior surface of the uterus, and in the posterior cul-de-sac, scarring and narrowing of the posterior vaginal fornix, and adnexal enlargement and tenderness. What is your diagnosis?

 A

Endometriosis

 B

Ectopic pregnancy

 C

Adnexal mass

 D

Pelvic relaxation

Ans. A

Explanation:

Endometriosis is the growth of tissue outside the uterus.
The ectopic endometrial tissue can proliferate, and infiltrate, and spread to remote sites elsewhere in the body.
Sites that endometriosis is most often found are, ovarian, pelvic peritoneum, anterior and posterior cul-de-sac, uterosacral, round, and broad ligaments, and fallopian tubes. 
 
An ectopic pregnancy is one that develops at any site other than the endometrium.
Symptoms of an ectopic pregnancy are abdominal pain possible a missed period, abnormal bleeding at the time of presentation is not uncommon.
Physical characteristics of an adnexal mass that may give a presumptive diagnosis: consistency (cystic, solid or both), size (in centimeters) morphology and surface contour (smooth, nodular, vague or sharp borders), location around the uterus, mobility (free or fixed to adjacent structures) tenderness, unilateral or bilateral.
 
Ref: Cunningham F.G., Leveno K.J., Bloom S.L., Hauth J.C., Rouse D.J., Spong C.Y. (2010). Chapter 40. Reproductive Tract Abnormalities. In F.G. Cunningham, K.J. Leveno, S.L. Bloom, J.C. Hauth, D.J. Rouse, C.Y. Spong (Eds), Williams Obstetrics, 23e. 

Q. 31

A patient with a long-standing intrauterine contraceptive device (IUCD) develops chronic pelvic pain. The device is removed, and a biopsy of the endometrium is performed. The biopsy specimen shows a prominent infiltrate composed of lymphocytes, plasma cells, and histiocytes. Which of the following is the most likely diagnosis?

 A

Acute endometritis

 B

Adenomyosis

 C

Chronic endometritis

 D

Endometriosis

Q. 31

A patient with a long-standing intrauterine contraceptive device (IUCD) develops chronic pelvic pain. The device is removed, and a biopsy of the endometrium is performed. The biopsy specimen shows a prominent infiltrate composed of lymphocytes, plasma cells, and histiocytes. Which of the following is the most likely diagnosis?

 A

Acute endometritis

 B

Adenomyosis

 C

Chronic endometritis

 D

Endometriosis

Ans. C

Explanation:

This is chronic endometritis, evidenced by the chronic inflammatory infiltrate of lymphocytes, plasma cells, and histiocytes.

This disorder may be idiopathic but is more often associated with an obvious predisposing factor, such as chronic pelvic inflammatory disease, tuberculosis, retained gestational tissue, or as in this case, an intrauterine contraceptive device.

Chronic endometritis can cause abnormal bleeding, pain, and infertility.

Acute endometritis is characterized by a prominent neutrophilic infiltrate and usually occurs after delivery or miscarriage.
 
Adenomyosis refers to endometrium abnormally located in myometrium.
 
Endometriosis refers to abnormally located patches of endometrium (except in the myometrium, where it would be called adenomyosis).

Q. 32

Medical and surgical aspects of treatment are available for endometriosis. All of the following drugs are used in treatment of endometriosis, EXCEPT:

 A

Progestins

 B

Estrogen

 C

Aromatase inhibitors

 D

OCP

Q. 32

Medical and surgical aspects of treatment are available for endometriosis. All of the following drugs are used in treatment of endometriosis, EXCEPT:

 A

Progestins

 B

Estrogen

 C

Aromatase inhibitors

 D

OCP

Ans. B

Explanation:

Medical treatment of endometriosis:

  • Combination oral contraceptives have been standard first-line treatment for symptoms of endometriosis.
  • Progestins also have been used to promote decidualization of the ectopic endometrial tissue. 
  • The levonorgestrel intrauterine system, which is approved for contraception, also has been used off label for this indication, as well as for menorrhagia.
  • Stable GnRH agonists can suppress gonadotropin secretion and thus affect medical castration.
  • Synthetic androgen that inhibits gonadotropin production via feedback inhibition of the pituitary-ovarian axis.
  • Inhibitors of aromatase are also useful for endometriosis.
 
Ref: Schimmer B.P., Parker K.L. (2011). Chapter 66. Contraception and Pharmacotherapy of Obstetrical and Gynecological Disorders. In L.L. Brunton, B.A. Chabner, B.C. Knollmann (Eds), Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 12e.

Q. 33

Which of the following pairs are correctly matched:
1. Endometriosis – Danazol
2. Endometrial carcinoma – Oestrogen
3. Anovulatory infertility – Clomiphene
4. Prolactinoma – Bromocriptine
Select the correct answer using the codes given below:
 A

1, 2, 3 and 4

 B

1, 3 and 4

 C

2, 3 and 4

 D

1 and 2

Q. 33

Which of the following pairs are correctly matched:
1. Endometriosis – Danazol
2. Endometrial carcinoma – Oestrogen
3. Anovulatory infertility – Clomiphene
4. Prolactinoma – Bromocriptine
Select the correct answer using the codes given below:
 A

1, 2, 3 and 4

 B

1, 3 and 4

 C

2, 3 and 4

 D

1 and 2

Ans. B

Explanation:

The use of estrogen replacement therapy in women who have been treated for endometrial cancer is controversial.
Risk factors for endometrial carcinoma include unopposed estrogen, obesity, nulliparity, chronic anovulation, late menopause, hypertension, diabetes, hyperplasia with atypia, Lynch II syndrome, and prolonged use of tamoxifen.
 
Danazol acts via several mechanisms to treat endometriosis. 
 
Clomiphene citrate (CC) is the initial treatment for most anovulatory infertile women.
 
The ergot alkaloid bromocriptine mesylate is a dopamine receptor agonist that suppresses prolactin secretion in prolactinoma.
 
Ref: Suh G.K., Hennessy B.T., Markman M. (2011). Chapter 29. Tumors of the Uterine Corpus. In H.M. Kantarjian, R.A. Wolff, C.A. Koller (Eds), The MD Anderson Manual of Medical Oncology, 2e.

Q. 34

Most common symptom of endometriosis is:

September 2011, March 2013

 A

Dysmenorrhoea

 B

Dyspareunia

 C

Infertility

 D

Abdominal pain

Q. 34

Most common symptom of endometriosis is:

September 2011, March 2013

 A

Dysmenorrhoea

 B

Dyspareunia

 C

Infertility

 D

Abdominal pain

Ans. A

Explanation:

Ans. A: Dysmenorrhoea

Dysmenorrhoea is the most common symptom of endometriosis

Endometriosis:

  • MC site: Ovary
  • Common in nullipara
  • Choclate cyst
  • Most widely accepted theory: Sampsons theory of retrograde menstruation
  • MC manifestation: Pelvic pain
  • Treatment:

– Progesterone

– Clomiphene (infertile women)

– GnRH analogues (leupolide)

Surgical procedure:

Ovarian cystectomy/ oopherectomy/ wedge resection


Q. 35

A female presented with dysmenorrhea and dysuria.Ovary shows the following features.What can be the most probable diagnosis?

 A

Ovarian teratoma

 B

Endometriosis

 C

Ovarian mucinous Cystadenoma

 D

Pelvic inflammatory disease

Q. 35

A female presented with dysmenorrhea and dysuria.Ovary shows the following features.What can be the most probable diagnosis?

 A

Ovarian teratoma

 B

Endometriosis

 C

Ovarian mucinous Cystadenoma

 D

Pelvic inflammatory disease

Ans. B

Explanation:

Ans:B.)Endometriosis.

Image shows:Ovarian endometriosis. Sectioning of ovary reveals a large endometriotic cyst with degenerated blood (“chocolate cyst”).

ENDOMETRIOSIS

  • Endometriosis is defined by the presence of endometrial glands and stroma in a location outside the endomyometrium.
  • It frequently is multifocal and often involves pelvic structures (ovaries, pouch of Douglas, uterine ligaments, tubes, and rectovaginal septum).

MORPHOLOGY

  • In contrast with adenomyosis, endometriosis almost always contains functioning endometrium, which undergoes cyclic bleeding.
  • Because blood collects in these aberrant foci, they usually appear grossly as red-brown nodules or implants.
  • They range in size from microscopic to 1 to 2 cm in diameter and lie on or just under the affected serosal surface.
  • When the ovaries are involved, the lesions may form large, blood-filled cysts that turn brown (chocolate cysts) as the blood ages .
  • With seepage and organization of the blood, widespread fibrosis occurs, leading to adhesions among pelvic structures, sealing of the tubal fimbriated ends, and distortion of the oviducts and ovaries.
  • The histologic diagnosis at all sites depends on finding two of the following three features within the lesions: endometrial glands, endometrial stroma, and hemosiderin pigment.


Leave a Reply

%d bloggers like this:
Malcare WordPress Security