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 Test Information
Test Name 018-CT-GYNECOLOGY-(75)-2018 Total Questions 75

Test Type Examination Difficulty Level Difficult

Total Marks 300 Duration 60minutes

Test Question Language:- ENGLISH

(1). Which of the following is the likely diagnosis in a patient being evaluated for amenorrhoea and has a negative progesterone challenge
test but a positive E+P challenge test

a. Anovulation

b. Ashermans syndrome

c. Ovarian failure

d. Hyperprolactenemia

Solution. C
A positive E+P challenge test and a negative progesterone challenge test indicates absence of estrogen and intact functioning uterus and
hence the answer is ovarian failure. In anovulation the progesterone challenge test should be positive and in ashermans both the tests
will be negative. Hyperprolactinemia just behaves like anovulation. progesterone challenge test should be positive and in ashermans both
the tests will be negative. Hyperprolactinemia just behaves like anovulation.

Correct Answer. c

(2). What is the next step in a 35 year old female P2L2 who has a PAP smear report of HSIL

a. Cryoablation

b. Colposcopy directed biopsy with endocervical curettage

c. LEEP

d. HPV DNA testing

Solution. B
LSIL especially in young women is generally a transient HPV infection whereas HSIL is more likely to be associated with persistent HPV
infection and a higher risk of progression to cervical cancer. These women should be followed up with colposcopy and biopsy and
endocervical sampling. Alternately an immediate LEEP may be performed but is usually used for women who are at risk for loss of follow
up, an ablative procedure should not be done if colposcopy has not been performed. Most women with HSIL are positive for high risk
types of HPV and the risk of high grade CIN or cancer is high even for those who are HPV negative therefor HPV testing is not
recommended. Further management will depend on results of colposcopy Pregnant women with HSIL should be evaluated with
colposcopy, in poregnant women LEEP should not be done and endocervical sampling should not be performed

Correct Answer. b

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(3). Which of the following is true regarding clinical performance of PAP test

a. Higher sensitivity than specificity

b. Higher specificity than sensitivity

c. Equally low sensitivity and specificity

d. Equally high sensitivity and specificity

Solution. B
The Pap test’s specificity is consistently high, approximating 98 percent. However, estimates of its sensitivity or detection o CIN 2 or
worse are lower, are more variable, and range from 45 to 65 percent (Whitlock, 2011). This imperfect sensitivity is balanced by
recommendations or repetitive screening throughout a woman’s life.
Conventional glass slides (traditionally called the Pap smear) and liquid-based Pap tests are considered equally acceptable or screening
by all current guidelines (American College of Obstetricians and Gynecologists, 2012b; Saslow, 2012; U.S. Preventive Services ask Force,
2012) Ideally, Pap tests are scheduled to avoid menstruation. Patients should abstain from vaginal intercourse, douching, vaginal tampon
use, and intravaginal medicinal or contraceptive creams or a minimum of 24 to 48 hours before a test. Treatment of cervicitis or vaginitis
prior to Pap testing is optimal. However, Pap testing is not de erred due to unexplained discharge or unscheduled bleeding, as these may
be signs
of cervical or other genital tract cancers.
Sampling of the transformation zone at the SCJ is paramount to the sensitivity of the Pap test. Techniques are adapted and sampling
devices chosen according to SCJ location, which varies widely with age, obstetric trauma, and hormonal status. Tree types o plastic
devices are commonly used to sample the cervix: the spatula, broom, and endocervical brush (also known as a cytobrush . A spatula
predominantly samples the ectocervix. An endocervical brush samples the endocervical canal and is used in combination with a spatula.
A broom samples both endo- and ectocervical epithelia simultaneously but can be supplemented by an endocervical brush.

Correct Answer. b

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(4). During laparoscopy for chronic pelvic pain these findings seen in right upper quadrant are most consistent with which of the following

a. Endometriosis

b. Chronic appendicitis

c. Pelvic inflammatory disease

d. Salpingitis isthmica nodosa

Solution. C
Laparoscopy allows direct identi cation and, in many cases, treatment of intraabdominal pathology. Therefore, laparoscopy is considered
by many to be a “gold standard” or CPP evaluation The finding represents Fitz hugh Curtis syndrome which is perihepatitis and is seen in
patients of PID and most commonly the microbiological agent is chlamydia. There is inflammation of liver capsule leading to creation
adhesions. The symptoms are acute right upper quadrant pain aggravated buy breathing or coughing and may be referred to right
quadrant

Correct Answer. c

(5). The following drugs are correctly paired with their use except

a. Gonadorelin- pituitary function

b. Cetrorelix- delayed puberty

c. Ulipristal-fibroid uterus

d. Raloxifene- postmenopausal osteoporosis

Solution. B
Cetrorelix is a a GnRH antagonist and hence cannot be used for delayed puberty. It is used mainly in controlled ovarian hyperstimulation
for the inhibition of premature LH surges and can also be used for prevention of ovarian hyperstimulation syndrome. It is used as a
subcutaneous injection.
Gonadorelin is another name for GnRH, it is a synthetic decapeptide. It is responsible for release of FSH and LH from anterior pituitary.
It is used to differentiate pituitary causes from hypothalamic causes of amenorrhoea. It can also be used for infertility caused by
hypogonadotropic hypogonadism and delayed puberty. It has a very short half life and has to be giuven by infusion pumps. Ulipristal is a
selective progesterone receptor modulator and can be sued to reduce the size of fibroid uterus. It is also used as emergency
contraceptive.
Raloxifene is a SERM and can be used for postmenopausal osteoporosis a;though the drug of choice for the same is bisphosphonates. It
may also lower the chance of breast cancer in postmenopausal women. Raloxifene does not increase the risk of endometrial cancer
unlike tamoxifen.

Correct Answer. b

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(6). Diagnostic criteria for bacterial vaginosis include clue cells ssen on saline slide preparation, a positive whiff test and a high vaginal pH.
At least what percentage of squamous cells should be clue cells to confirm the diagnosis

a. 20

b. 40

c. 60

d. 80

Solution. A
Bacterial vaginosis is the most common cause of vaginal discharge among reproductive-aged women. Of symptoms, a nonirritating,
malodorous vaginal discharge is characteristic, but may not always be present. The vagina is usually not erythematous, and cervical
examination reveals no abnormalities. Clinical diagnostic criteria were first proposed by Amsel and associates (1983) and include: (1)
microscopic evaluation of a vaginal-secretion saline preparation, (2) release of volatile amines produced by anaerobic metabolism, and
(3) determination o the vaginal pH.
A saline preparation, also known as a “wet prep,” contains a swab-collected sample o discharge mixed with drops o saline on a
microscope slide. Clue cells are the most reliable indicators o BV and were originally described by Gardner and Dukes (1955) . These
vaginal epithelial cells contain many attached bacteria, which create a poorly defined stippled cellular border. At least 20 percent of the
epithelial cells should be clue cells. T e positive predictive value of this test or BV is 95 percent

Correct Answer. a

(7). A 11 year old girl came with history of sexual abuse by her uncle, on medicolegal examination a swab from lateral vaginal fornix shows a
maturation index of 0/98/2. Which of the following is the likely explanation

a. She has had an abortion in last 6 months

b. She is pregnant

c. Hypertrophy due to foreign object

d. Normal prepubertal

Solution. B
MATURATION INDEX tells us about hormonal status in the female and it is the ratio of Basal:intermediate:superficial cells in vaginal
cytology
Pregnancy,newborn – 0/95/5
Children- 80/20/0
Ovulation- 0/30/70
Menopause – 90/10/0
Postpartum -100/0/0

Correct Answer. b

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(8). All the following are correct about complex atypical hyperplasia except

a. The risk of future malignancy is 29%

b. Treatment of choice is hysterectomy with BSO in postmenopausal women

c. Premenopausal women should be first given progesterone for 6 months

d. On histology the glands show crowding and papillary infoldings

Solution. C
Hysterectomy is the pre erred treatment or women with atypical endometrial hyperplasia because the risk o progression to cancer over
time approximates 29 percent. T ere is also a high rate of finding concurrent invasive malignancy coexistent with the atypical
hyperplasia. In postmenopausal women, a hysterectomy with removal of both tubes and ovaries is recommended. In premenopausal
women who have completed childbearing, hysterectomy is performed for atypical hyperplasia. Riskr educing salpingectomy is
encouraged to potentially lower cancer risk that arises from the allopian tubes (American College o Obstetricians and Gynecologists,
2015d). For premenopausal women, removal of the ovaries is optional
Premenopausal women who strongly wish to preserve fertility can be treated with progestins. High-dose progestin therapy, megestrol
acetate 80 mg orally twice daily, is an option or motivated patients who will be compliant with surveillance. The IUD that releases 20 μg
o intrauterine levonorgestrel daily (Mirena) is also suitable.

Correct Answer. c

(9). A 24 year old woman presents with 8 weeks of pregnancy complaints of right lower quadrant pain. During bimanual examination an
enlarged right ovary is suspected and transvaginal sonography shows the following cyst in the ovary measuring 5 cm. what will be your
advice for her?

a. Post her for elective surgery at 16-18 weeks

b. Reassess with repeat ultrasound in second trimester

c. Counsel her about the possibility of malignancy

d. Plan an ultrasound guided aspiration

Solution. B
The ultrasound shows a simple cyst and in the first trimester of pregnancy this is most likely the corpus luteum of pregnancy, the
approach to first trimester simple cyst will be follow up as it will spontaneously regress after 12 weeks, so we will just ask her to follow
up with repeat ultrasound in second trimester. The cyst has no features of malignancy and there is no other indication to operate on to
the cyst.

Correct Answer. b

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(10). Compared to myomectomy or uterine artery embolism MR-HIFU treatment therapy for fibroid uterus has which of the following

a. More cost effective

b. Few major adverse events

c. Stabilizes size better over time

d. Gradually improves leiomyoma related symptoms

Solution. B
MR-HIFU also called as MR guided focussed ultrasound (MRgFUS), is a safe and feasible minimally invasive alternative or leiomyoma
treatment . Several studies have demonstrated a relatively rapid improvement in patient symptoms, a continue decrease in the
leiomyoma size over time, a quicker recovery, an few major adverse events in comparison with UAE or myomectomy However, little
information is available on long-term results compare with other interventional treatments. Moreover, not all patients are suitable
candidates. Obstructions in the energy path such as abdominal wall scars or intraabdominal clips, total uterine size > 24 weeks, a desire
or future fertility, or general contraindications to MR imaging are limitations. Moreover, leiomyoma characteristics such as size,
perfusion, or location near adjacent organs may limit treatment feasibility.

Correct Answer. b

(11). All the following are contra indications of dilatation and curettage except

a. Viable intrauterine pregnancy

b. Bleeding diathesis

c. Acute pelvic infection

d. Infected products of conception

Solution. Answer D
The management of intrauterine infected products of conception is removal of these septic
products by a d&C. The major contraindication is viable intrauterine pregnancy. Bleeding diathesis
is a relative contraindication. The presence of acute cervical, vaginal or pelvic infection the
procedure is deferred.
Cervical cancer if obstructing the endocervical canal also represents a contraindication as heavy
bleeding or perforation may occur.
Therapeutic indications for D&C are
1) Treatment of incomplete, inevitable, missed septic and induced abortion.
2) Initial treatment of molar pregnancy
3) Temporary management of women with prolonged or excessive vaginal bleeding unresponsive
to hormonal therapy.
4) May be used to manage PPH due to retained products of conception
Diagnostic indications are
1) With a non diagnostic office biopsy
2) With endometrial hyperplasia and in women endometrial cancer need to be ruled out
3) In whom cervical stenosis prevents the completion of an office biopsy
For whom another operative procedure such as hysteroscopy or lparoscopy is deemed necessary

Correct Answer. d

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(12). Which of the following is not correctly matched

a. True hermaphrodite – ovary

b. Male psuedohermaphrodite- testes

c. Female psuedohermaphrodite- ovary

d. Pure gonadal dysgenesis- streak gonads

Solution. A
The male psuedohermaphrodite has male karyotype XY but female phenotype and the gonads are testes. The most common cause is
androgen insensitivity syndrome Female psuedohermaphrodite has female karyotype XX and the gonad is ovary and their genitalia are
virilised. The most common cause is congenital adrenal hyperplasia In pure gonadal dysgenesis the karyotype is normal example is
swyers where the karyotype is XY but the gonads are streak, there are female external genitalia and intact mullerian ducts. True
hermaphrodite is called as ovotesticular disorder, it is characterised by the presence of both ovarian and testicular tissue in the same
individual, either as a separate ovary and testes or ovotestes. In 80% cases it is associated with an XX karyotype. However it can be seen
with an XY karyotype and a mixed XX/XY karyotype.

Correct Answer. a

(13). Which of the following is not a sling operation for prolapse

a. Shirodkar

b. manchester

c. Khanna

d. Abdominocervicopexy

Solution. B
The sling operations for prolapse are abdominocervicopexy, shirodkar abdominal sling surgery, Khanna abdominal sling and purandare
anterior sling and vikruds sling. The sling surgeries are indicated when the ligaments are extremely weak. It preserves reproductive
function. In the sling surgeries with a fascial strip/prosthetic material the cervix is fixedt o the abdominal wall/sacrum /pelvis.
Cystocele/rectocele repair can be done vaginally before or after. All types of sling surgeries can also be done laparoscopically. Enterocele
repair can also be done abdominally. The laparoscopic surgeries for sling need more expertise but the advantages are The other
conservative surgeries of prolapse are small incision, better view, no packing, minimal tissue and bowel handling, short recovery and less
pain. Colporraphy( anterior/posterior) Fothergills repair(Manchester repair)

Correct Answer. b

(14). A 60 year old postmenopausal lady presents for evaluation of genital tract bleeding, which is likely to be uterine in origin by physical
examination. Which procedure is a logical first step in her evaluation?

a. Colposcopy

b. Diagnostic hysteroscopy

c. Transvaginal sonography

d. Endometrial biopsy

Solution. C
There is no one clear sequence to the use of endometrial biopsy, TVS, SIS, and hysteroscopy when evaluating AUB. None of these will
distinguish all anatomic lesions with high sensitivity and speci city. That said, TVS or several reasons is a logical first step. It is well
tolerated, is cost-effective, and requires relatively minimal technical skill. Additionally, it can reliably determine stripe thickness and
whether a lesion is myometrial or endometrial. Once potential anatomic lesions have been identified, subsequent evaluation requires
individualization. If endometrial hyperplasia or cancer is suspected, then endometrial biopsy may offer advantages. Alternatively,
possible focal lesions may be best investigated with either hysteroscopy or SIS. Ultimately, the diagnostic goal is to identify and treat
pathology and specifically to exclude endometrial carcinoma

Correct Answer. c

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(15). A patient presents to the emergency department with 1 day history of heavy vaginal bleeding. She is tachycardic but not hypotensive.
Physical examination demonstrates bleeding from above external os , lab studies reveal she is anemic. Which of the following is the
appropriate first line agent to control her acute bleeding

a. Intravenous estrogen

b. Oral tranexamic acid

c. GnRH agonist

d. Combination OCP pill taper

Solution. A
large percentage of women with AUB have anovulation as the underlying etiology, and the term AUBO denotes this ovulatory
dysfunction. Dysfunctional uterine bleeding is currently a less-preferred term for this (American College o Obstetricians and
Gynecologists, 2012) At times, women with anovulatory bleeding may have severe HMB that requires acute intervention. Fluid
resuscitation is instituted, Medical treatment is simultaneously administered to slow bleeding . As primary choices, equine estrogens can
be given intravenously (IV) in 25-mg doses every 4 hours or up to three doses (DeVore, 1982). Once bleeding has slowed, patients can be
transitioned to an oral taper using Premarin pills or more commonly COCs. tranexamic acid ( XA) is also an option, and the usual IV dose
is 10 mg/kg every 8 hours. As bleeding declines, transition to an oral dose of 1.3 g given three times a day can be implemented As an
alternative to high-dose estrogen therapy or acute HMB, high-dose MPA (10 mg) or NE A (5 to 10 mg) can be used and administered
orally every 4 hours. As with oral COCs, these are then tapered once bleeding has waned.

Correct Answer. a

(16). The condition is commonly associated with which of the following

a. Anorexia

b. Hypertension

c. Hyperlipidemia

d. Polycystic ovarian syndrome

Solution. D
Acanthosis Nigricans This condition is characterized by velvety to warty, brown to black, poorly marginated plaques. These changes are
typically found at skin fexures, especially on the neck, axillae, and genitocrural olds . Acanthosis nigricans is commonly associated with
obesity, diabetes mellitus, and polycystic ovarian syndrome. Thus, if signs or symptoms of these are present, appropriate evaluation is
warranted. Common to these conditions, insulin resistance with compensatory hyperinsulinemia is thought to promote the skin
thickening o acanthosis nigricans.

Correct Answer. d

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(17). Of the following locations where is endometriosis is most likely to be found

a. Pleura

b. Ureter

c. Rectovaginal septum

d. Posterior cul de sac

Solution. D
The most common site of endometriosis is ovary, commonly endometriosis is also found in the dependent areas of the pelvis. As such, the
anterior and posterior cul-de-sacs, other pelvic peritoneum, and uterosacral ligaments are frequently involved. Additionally, the
rectovaginal septum, ureter, and bladder and rarely, pericardium, surgical scars, and pleura may be affected. One pathologic review
revealed that endometriosis has been identified on all organs except the spleen

Correct Answer. d

(18). Which of the following is the potent inducer of aromatase and is thought to create a feed forward loop to potentiate estrogenic
environment of endometriotic implants

a. Prostaglandin E2

b. Matrix metalloproteinase 3

c. COX type 2 inhibitor

d. 17 beta hydroxyl steroid dehydrogenase type 2

Solution. A
Prostaglandin E2 (PGE2) is the most potent inducer of aromatase activity in endometrial stromal cells. Estradiol produced in response to
the increased aromatase activity subsequently augments PGE2 production by stimulating the cyclooxygenase type 2 (COX-2) enzyme in
uterine endothelial cells. This creates a positive feedback loop and potentiates the estrogenic effects on endometriosis proliferation
Endometriotic implants express aromatase and 17β hydroxysteroid dehydrogenase type 1, which are the enzymes responsible or
conversion of androstenedione to estrone and oestrone to estradiol, respectively. Implants, however, are deficient in 17β-hydroxysteroid
dehydrogenase type 2, which inactivates estrogen In addition to an estrogenic environment, normal progesterone effects are attenuated
in endometriosis. T is progesterone resistance is thought to stem from an overall low concentration of progesterone receptors within
implants. Specifically, pathological overexpression oestrogen receptor β in endometriosis suppresses estrogen receptor α expression.

Correct Answer. a

(19). All the following ovarian masses have been correctly paired except

a. Dysgerminoma – High LDH, negative for AFP

b. Granulosa cell- High inhibin and estradiol

c. Yolk sac tumour- high AFP and high HCG

d. Serousadenocarcinoma- High CA125

Solution. C
The following are the tumour markers for ovarian cancers
Dysgerminoma- LDH,HCG,
Serous epithelial-CA125
Mucinous epithelial- CEA
Granulosa cell –inhibin
Endodermal sinus – AFP can produce LDH but does not secrete hcg
Embryonal cell- HCG, may also secrete AFP and LDH
Immature teratoma- does not secrete hcg may secrete AFP,LDH
Choriocarcinoma- HCG
Sertoli-leydig – testosterone

Correct Answer. c

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(20). The sonographic tip of the iceberg sign corresponds to the site within the following tumour , pathologically what is the name of this area

a. Homunculus

b. Struma ovarii

c. Hydatid of Morgagni

d. Rokitansky protuberance

Solution. D
Mature teratoma—T is benign tumor contains mature forms of the three germ cell layers:
1. Mature cystic teratoma develops into a cyst, is common, and is also called benign cystic teratoma or dermoid cyst.
2. Mature solid teratoma has elements ormed into a solid mass.
3. Fetiform teratoma or homunculus forms a doll-shape, as the germ cell layers display considerable normal spatial differentiation. Of
these teratoma types, mature cystic teratoma is by far the most common. These benign tumors comprise approximately 10 to 25 percent
of all ovarian neoplasms When sectioned, most cysts appear unilocular and typically contain one area of localized growth, which
protrudes into the cystic cavity. Alternatively designated as Rokitansky protuberance, dermoid plug, dermoid process, dermoid mamilla,
or embryonal rudiment, this protuberance can be absent or multiple.

Correct Answer. d

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(21). What is the likely pathology in a 35 year old lady with complaints of congestive dysmenorrhoea and the following ultrasound image of the
adnexa

a. Mature cystic teratoma

b. Haemorrhagic cyst

c. Chocolate cyst

d. Pedunculated leiomyoma

Solution. C
Endometriomas can be diagnosed by VS with adequate sensitivity in most settings if they are 20 mm in diameter or greater. Sensitivity
and specificity o VS to diagnose endometriomas range from 64 to 90 percent and rom 22 to 100 percent. An endometrioma classically is
cystic with homogeneous, low-level internal echoes, often described as “ground glass” echogenicity. There is normal surrounding ovarian
tissue. As such, these may have an identical appearance to hemorrhagic corpus luteum cysts

Correct Answer. c

(22). Primary therapy for central precocious puberty consists of which of the following

a. Bromocriptine

b. Depot medroxy progesterone acetate

c. Combination OCPs

d. GnRH agonist

Solution. D
Early activation of the hypothalamic-pituitary-ovarian axis leads to pulsatile GnRH secretion, increased gonadotropin formation, and in
turn, increased gonadal steroid levels. Often termed true precocious puberty, central precocious puberty is rare and affects 1 in 5000 to
10,000 individuals in the general population. The most common cause of central precocious puberty is idiopathic, however, central
nervous system lesions must be excluded. Serum FSH, LH, and estradiol levels are elevated or chronologic age and typically lie in the
pubertal range. Treatment consists of a GnRH agonist, which serves to downregulate pituitary gonadotropes and inhibit FSH and LH
release. Estrogen levels drop, and o ten there is a marked regression o breast and uterine size. I therapy is instituted after menses have
begun, menstrual periods will cease. The time to discontinue the therapy is around 11 years

Correct Answer. d

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(23). Which of the following is the most potent hormonal emergency contraception

a. Levonorgestrel

b. Ulipristal

c. Copper T

d. High dose OCP

Solution. B
Ulipristal is a selective progesterone receptor modulator, it is prescribed as single oral dose of 30mg and can be taken upto 120 hrs of
unprotected intercourse. Its efficacy is 98%. Mifepristone is also progesterone modulator and can be used as EC although there is no
absolute recommended doses any dose from 20-50mg is effective and can also be used up to 5 days of unprotected intercourse. Copper T
is most effective emergency contraceptive and can be inserted within 120 hrs of unprotected intercourse. Levonorgestrel is the most
commonly used EC it can be used as either 0.75mg taken twice 12 hrs apart or as 1.5mg single dose. It is 59-94% effective. The Yuzpe
regimen uses (E+P) 100mcg of EE and 0.5mg of LNG given twice 12 hours apart. This regimen is 47-89% effective and is associated with
more side effects and hence is rarely prescribed .

Correct Answer. b

(24). Which of the following statements is true regarding the effects of female sterilization

a. Ovarian cancer risk is increased

b. The incidence of menorrhagia is increased

c. Approximately 10% of pregnancies occurring after the procedure are ectopic

d. Can be done upto 48 hrs postpartum

Solution. C
several studies have evaluated the risk of heavy menstrual bleeding and intermenstrual bleeding following tubal sterilization, and many
report no link. Perhaps unexpectedly, women who had undergone sterilization had decreased duration and volume of menstrual flow,
they reported less dysmenorrhea, but they had an increased incidence of cycle irregularity. With failures following other methods—ring,
clip, tubal resection—the percentage of ectopic is 10 percent (Peterson, 1999). Importantly, ectopic pregnancy must be excluded when
any symptoms of pregnancy develop in a woman who has undergone tubal sterilization.
. Tubal sterilization appears to have a protective effect against ovarian cancer, but not breast cancer Postpartum sterilization can be
done with 7 days of delivery.

Correct Answer. c

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(25). which method of salpingectomy is shown in the image below

a. Uchida

b. Pomeroy

c. Parkland

d. Kroener

Solution. D

Correct Answer. d

(26). A 29 year old nulligravida presents with secondary amenorrhoea, she also complains of increased hair on her chin and worsening acne.
She states all these changes occurred suddenly
over 6 months. Her examination is notable for clitoromegaly. Which is the most likely cause of her symptoms

a. Swyer syndrome

b. Androgen secreting tumour

c. Polycystic ovarian syndrome

d. Non classical CAH

Solution. B
This patient has features of virilisation as the question says she has clitoromegaly and likely reflect an underlying androgen secreting
tumour, in PCOS there is evidence of hirsutism and not virilisation. Serum testosterone levels are measured in women with suspected
PCOS or with clinical signs of androgen excess. Hormonal evaluation includes measurement of serum total testosterone levels. Mild
elevations in testosterone levels are consistent with the diagnosis of PCOS. However, values > 200 ng/dL may suggest an ovarian tumor
and warrant pelvic sonography. Adrenal adenomas may produce circulating DHEAS levels above 700 μg/dL and merit investigation with
magnetic resonance (MR) imaging or computed tomography (C ) scanning o the adrenals. Measurement o 17-hydroxyprogesterone (17-
OHP) aims to identi y patients with nonclassic CAH.

Correct Answer. b

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(27). All the following are genetic mutations involved in high grade serous ovarian cancers except

a. KRAS

b. TP53

c. WT1

d. P16INK4

Solution. A
The genetic mutations associated with high grade serous ovarian cancers are TP53 and P16 strongly positive, they also express WT1,
estrogen receptor and PAX8. They also show mutations in BRCA1 and BRCA2. The HGSC Have high Ki67 proliferative index While
associated with low grade cancers are associated with genetic mutations of KRAS and BRAF and they have low Ki67 proliferative index
the mucinous ovarian cancers show KRAS mutations, they also express mucin genes MUC2and MUC3 the genetic mutations in
ENDOMETROID ovarian cancer are beta-catenin and PTEN genes in clear cell cancer they are KRAS and PTEN

Correct Answer. a

(28). 16 year old girl presents for evaluation of amenorrhoea, she has advanced breast and sexual hair development. Transvaginal ultrasound
shows normal female anatomy. Her examination is significant for the finding below. What is the expected karyotype ?

a. 45 XO

b. 46XX

c. 46XY

d. 45XO/46XX

Solution. B
The picture is consistent with imperforate hymen which creates outflow tract obstruction. Patients with outflow obstruction have a 46,XX
karyotype, female secondary sexual characteristics, and normal ovarian unction. Thus, the amount of uterine bleeding is normal, but its
normal path or egress is obstructed or absent. Patients may note moliminal symptoms, such as breast tenderness, food cravings, and
mood changes, which are attributable to elevated progesterone levels. With inherited or acquired out ow obstruction, accumulation o
blood behind the blockage frequently results in cyclic abdominal pain. Intrauterine trapping of fluid (hydrometra), pus (pyometra), or
blood (hematometra) creates a soft, enlarged uterus.

Correct Answer. b

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(29). Which of the following androgens is not produced by the ovary

a. Testosterone

b. Androstenedione

c. Dihydrotestosterone

d. Dehydroepiandrostenedione

Solution. C
The ovary also produces androgens in response to LH stimulation of theca cell unction. The primary products are the relatively weak
androgens androstenedione and dehydroepiandrosterone (DHEA), although smaller amounts of testosterone are also secreted. in women,
25 percent of circulating testosterone is secreted by the ovary, 25 percent is secreted by the adrenal gland, and the remaining 50
percent is produced by peripheral conversion of androstenedione to testosterone.

Correct Answer. c

(30). Where in the cell are unliganded estrogen receptor located

a. Nucleus

b. Cytoplasm

c. Mitochondria

d. Endoplasmic reticulum

Solution. A
Two isoforms of estrogen receptors, ERα and ERβ, are encoded by separate genes . These receptors are differentially expressed in
tissues and appear to serve distinct functions. For example, both ERα and ERβ are required for normal ovarian unction The progesterone
and testosterone receptors are intracytoplasmic and after ligand binding they move to their site of action which is nucleus

Correct Answer. a

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(31). Endorphin levels in the brain peak during what phase of menstrual cycle

a. Menses

b. Ovulation

c. Luteal phase

d. Follicular phase

Solution. C
Opioids in the brain play a central role in menstrual cyclicity by tonically suppressing the hypothalamic release of GnRH. Estrogen
promotes endorphin secretion, and this is increased further with the addition of progesterone. Thus, endorphin levels increase during the
follicular phase, peak during the luteal phase, and drop markedly during menses. This pattern suggests that both opioid tone and
progesterone decrease GnRH pulse frequency in the luteal phase, thus stimulating FSH secretion. For reasons that are not fully
understood, opioid suppression of GnRH is relieved at the time of ovulation. In addition, functional hypothalamic amenorrhea due to
eating disorders, intensive exercise, and stress is correlated with an increase in endogenous opiate concentrations

Correct Answer. c

(32). The following image of the endometrium corresponds to which phase of the menstrual cycle

a. Proliferative

b. Early secretory

c. Late secretory

d. Menstrual

Solution. B
Following ovulation, the endometrium transforms into a secretory tissue. The period during and after this transformation is defined as
the secretory phase of the endometrium and correlates to the ovary’s luteal phase. Glycogen-rich subnuclear vacuoles appear in cells
lining the glands which corresponds to early secretory phase . Under further stimulation by progesterone, these vacuoles move from the
glandular cells’ base toward their lumen and expel their contents. This secretory process peaks on approximately postovulatory day 6,
coinciding with the day of implantation. Throughout the luteal phase, glands become increasingly tortuous, and the stroma becomes
more edematous corresponding to late luteal phase. In addition, spiral arteries that feed the endometrium increase their number and
coiling.

Correct Answer. b

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 17/41
(33). Which of the following progestins is not derived from 19 nortestosterone?

a. Drospirenone

b. Norgestimate

c. Desogestrel

d. Levonorgestrel

Solution. A
Most progestins used in contraceptives are derived from 19-nortestosterone. These are commonly described as first generation
(norethindrone), second generation (levonorgestrel, norgestrel), or third generation (desogestrel, norgestimate). Each generation has
been designed to have progressively less androgenic effect. The fourth-generation progestin, drospirenone, is unique in that it is derived
from spironolactone. Although it has no androgenic activity, drospirenone has an affinity for the mineralocorticoid receptor
approximately five times that o aldosterone. This explains its diuretic action.

Correct Answer. a

(34). A 28 year old nulligravida presents with primary amenorrhoea. She is diagnosed with premature ovarian failure. Which of the following is
the best test to order next?

a. Hysterosalpingography

b. Progesterone withdrawal test

c. ACTH stimulation test

d. Karyotyping

Solution. D
This category of disorders implies primary dysfunction within the ovary rather than hypothalamic or pituitary dysfunction. This process
can also be termed premature menopause or premature ovarian failure (POF), with a current trend toward the term premature ovarian
insufficiency or primary ovarian insufficiency (POI). Gonadal dysgenesis is the most frequent cause of POF. In this disorder, a normal
complement of germ cells is present in the early fetal ovary. However, oocytes undergo accelerated atresia, and the ovary is replaced by
a fibrous streak—termed a streak gonad. Individuals with gonadal dysgenesis may present with various clinical features and can be
divided into two broad groups based on whether their karyotype is normal or abnormal and further management is based on this.

Correct Answer. d

(35). A 54 year old woman is bothered by vasomotor symptoms and vaginal dryness. She is interested in starting hormone therapy. Her
surgical history is negative for hysterectomy. Which of these treatment options is most appropriate

a. Oral 17beta estrradiol

b. Transdermal 17 beta estradiol

c. Vaginal estradiol acetate

d. Oral conjugated equine estrogen plus bazedoxifene

Solution. D
Based on current literature, HRT is indicated only or treatment of vasomotor symptoms and vaginal atrophy and or osteoporosis
prevention or treatment. Current guidelines recommend reevaluation of the need for HRT at 6- to 12-month intervals. HRT is prescribed
in the lowest effective dose or the shortest period of time. Accordingly, bone-specic agents would likely be more appropriate in women
requiring long-term osteoporosis prevention or treatment. Systemic E is the most effective treatment for vasomotor symptoms, Estrogen
can be administered by oral, parenteral, topical, or transdermal routes with similar effects. Transdermal estrogen patches avoid the
liver’s first pass effect and offer the convenience of less requent administration (once or twice weekly For women with a uterus, a
progestin is combined with an estrogen to lower risks of endometrial cancer. Progestins may be prescribed daily with estrogen, and this
dosing is termed continuous therapy. Another suitable continuous oral agent is the combination of CEE plus the selective estrogen-
receptor modulator (SERM) bazedoxifene The combination o BZA 20 mg plus CEE 0.45 mg reduces BMD loss and incidence of hot fushes
but does not increase V E rates compared with CEE and MPA. Notably, BZA acts as an antagonist in uterine tissue to prevent the
endometrial hyperplasia commonly associated with unopposed

Correct Answer. d

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 18/41
(36). A 28 year old woman with secondary amenorrhoea is seeking infertility treatment. Other than mild hirsutism her examination including
BMI is normal. the transvaginal sonography reveals the following. What is the most appropriate first line treatment for her?

a. Letrozole

b. Gonadotropins

c. Clomiphene citrate

d. Combined OCPs

Solution. C
Women with PCOS will frequently ovulate following treatment with the selective estrogen-receptor modulator clomiphene citrate, or with
an aromatase inhibitor such as letrozole. Clomiphene citrate is believed to act by transient inhibition oestrogen feedback at the
hypothalamus and pituitary gland . This treatment, however, is not effective in those with hypogonadotropic hypogonadism as they lack
significant levels of circulating estrogen and they would need gonadotropins for their infertility or pulsatile GnRH agonist. POF is not
reversible, and affected individuals can be offered in vitro fertilization using a donor oocyte to conceive.

Correct Answer. c

(37). Which of the following statements is false regarding the development of hypothalamic pituitary ovarian axis in female fetus and neonate

a. By 5 months gestation 7 million oocytes have been created from germ cell division

b. The GnRH pulse generator remains functionally dormant until several months after birth

c. At birth, FSH and LH rise and remain high during first 3 months of life

d. Neonatal breast budding, mild uterine bleeding may occur as normal response after birth

Solution. B
In utero, gonadotropin-releasing hormone (GnRH) neurons develop in the olfactory placode. These neurons migrate through the
forebrain to the arcuate nucleus of the hypothalamus by 11 weeks’ gestation. They form axons that extend to the median eminence and
to the capillary plexus o the pituitary portal system. Gonadotropin-releasing hormone, a decapeptide, is influenced by higher cortical
centers and is released from these neurons in a pulsatile fashion into the pituitary portal plexus as a result, by midgestation, the GnRH
“pulse generator” stimulates secretion of gonadotropins, that is, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), rom
the anterior pituitary. In turn, the pulsatile release of gonadotropins stimulates ovarian synthesis and release of gonadal steroid
hormones. Concurrently Accelerated germ cell division and follicular development begins, resulting in the creation of 6 to 7 million
oocytes by 5 months’ gestation. By late gestation, gonadal steroids exert a negative feedback on secretion of both hypothalamic GnRH
and pituitary gonadotropins. During this time, oocyte number decreases through a process of generelated apoptosis to reach a level of 1
to 2 million by birth Following birth LH and FSH levels rise abruptly in response to the fall in placental estrogen levels and are highest in
the first 3 months of life. This transient rise in gonadotropin levels is followed by an increase in gonadal steroid concentrations, which is
thought to explain instances of neonatal breast budding,
minor bleeding rom endometrial shedding, short-lived ovarian cysts, and transient white vaginal mucous discharge. Following these
initial months, gonadotropin levels gradually decline to reach prepubertal levels by age 1 to 2 years

Correct Answer. b

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 19/41
(38). Which of the following is not correctly paired with its embryological origin

a. Uterus – paramesonephric duct

b. Vaginal mucosa – endoderm of UGS

c. Ovaries – genital ridge

d. Gartners duct- caudal mesonephric tubule

Solution. D
Uterus develops from mullerian ducts also called as paramesonephric ducts, vaginal mucos throughout derived from endoderm of
urogenital sinus. Epoophoron derived from craniual end of mesonephric tubule, paroophoron from caudal end of mesonephric tubule
while the gartners is from caudal end of mesonephric duct The caudal portions of the müllerian ducts approximate one another in the
midline and end behind the cloaca. The cloaca is divided by formation of the urorectal septum by the seventh week and is separated to
create the rectum and the urogenital sinus. The urogenital sinus is considered in three parts: (1) the cephalad or vesicle portion, which
will orm the urinary bladder; (2) the middle or pelvic portion, which
creates the emale urethra; and (3) the caudal or phallic part, which will give rise to the distal vagina and the greater vestibular
(Bartholin), urethral, and paraurethral (Skene) glands. Be ore 7 weeks of embryonic development, embryos of male and female sex are
indistinguishable from one another. During this indeterminate time, the genital ridge begins as coelomic epithelium with underlying
mesenchyme. At this point, the presence or absence of gonadal determinant genes directs fetal gender development n the presence of
SRY, gonads develop as testes. In the female embryo, without the influence o the SRY gene, the bipotential gonad develops into the ovary

Correct Answer. d

(39). Regarding MIS incorrect is

a. Responsible for persistence and development of wolffian ducts

b. Secreted from testes at 7 weeks intrauterine life

c. Released by small preantral follicles of ovary

d. Is responsible for abdominal phase of testicular descent

Solution. A
It is the testosterone secreted by leydig cells at about 8 weeks which stimulates the development of wolffian ducts into seminal vesicles,
ejaculatory ducts epididymis and vas differentia. AMH or MIS is a glycoprotein formed by sertoli cells by 7 weeks which causes
regression of mullerian ducts. AMH in females is produced in small amounts by small preantral follicles of ovary and is used a s a test of
ovarian reserve. Levels less than 0.5ng/ml indicate poor ovarian reserve. It is the best test of ovarian reserve. The abdominal phase of
testicular descent in male fetus is brought about by MIS while the testicular phase is brought by testsosterone.

Correct Answer. a

(40). A 16 year old girl is brought to the OPD for absence of onset of menses. On examination she has breast tanner stage 2 and scanty pubic
and axillary hair and on ultrasound the uterus is absent. Which of the following statements will be incorrect with respect to her
diagnosis?

a. She has normal ovarian function

b. She will have a blind ending vagina

c. She will need a gonadectomy

d. She has a poor reproductive outcome

Solution. A
With secondary sexual characters present and absent uterus and scant pubic hair she is a case of androgen insensitivity syndrome.
Patients with complete androgen-insensitivity syndrome (CAIS) appear as phenotypically normal females at birth. They often present at
puberty with primary amenorrhea. External genitalia appear normal; scant or absent pubic and axillary hair is noted; the vagina is
shortened or blind ending; and the uterus and allopian tubes are absent. However, these girls develop breasts during pubertal
maturation due to abundant androgento-estrogen conversion. estes may be palpable in the labia or inguinal area or may be ound
intraabdominally. In CAIS patients, surgical excision o the testes after puberty is recommended to decrease the associated risk of germ
cell tumors, which may be as high as 20 to 30 percent. Additionally, estrogen is replaced to reach physiologic levels, and a unctional
vagina is created either by dilation or by surgical vaginoplasty. Adequate estrogen replacement in these patients is important to maintain
breast development and bone mass and to provide relief f rom vasomotor symptoms

Correct Answer. a

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 20/41
(41). What is the most likely anomaly depicted in the hsg image below

a. Septate

b. Bicornuate

c. Didelphius

d. Unicornuate

Solution. D
This is an hsg image of unicornuate uterus, With this anomaly, the underdeveloped or rudimentary horn may be absent. If present, it may
or may not be communicating and may or may not contain an endometrium-lined cavity. It may be detected during fertility evaluation by
HSG. Although this study can define the primary cavity contour, noncommunicating or noncavitary rudimentary horns may not fill with
dye. Conventional sonography may be difficult for less-experienced sonographers as the smaller size and lateral deviation of an isolated
unicornuate uterus or a rudimentary horn may not be appreciated. If suspected, 3-D sonography increases diagnostic accuracy, but MR
imaging is often preferred. Importantly, 40 percent of affected women will have renal anomalies, and evaluation for these is indicated.
This müllerian anomaly carries significant obstetrical risks, including first- and secondtrimester miscarriage, malpresentation, fetal-
growth restriction, fetal demise, prematurely ruptured membranes, and preterm delivery.

Correct Answer. d

(42). Reduced secretion of which of the following is most likely responsible for the rising serum FSH level seen as a woman ages?

a. Activing

b. Inhibin B

c. Estradiol

d. Follistatin

Solution. B
Measurement of serum follicle-stimulating hormone (FSH) levels in the early follicular phase is a simple and sensitive predictor of
ovarian reserve. Frequently termed a “cycle day 3” FSH, this may reasonably be drawn between days 2 and 4. With declining ovarian
unction, the support cells (granulosa cells and luteal cells) secrete less inhibin, a peptide hormone that is responsible or inhibiting FSH
secretion by the anterior pituitary gonadotropes . With loss of luteal inhibin, FSH levels rise in the early follicular phase. A value > 10
mIU/mL indicates signifcant loss of ovarian reserve and prompts a more rapid evaluation and more intensive treatment. In a large study
evaluating IVF cycles, a day-3 FSH level exceeding 15 mIU/mL predicted signi cantly lower pregnancy rates.

Correct Answer. b

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 21/41
(43). Which of the following is incorrect about the process of sperm capacitation

a. Involves sperm hyperactivation

b. Aids in acrosomal reaction

c. The major site is cervix

d. Causes changes in permeability of the sperm membrane to calcium

Solution. C
The major site of capacitation is the fallopian tube although the process begins in the cervix. It is a prefertilization activation of sperms,
gaining the ability to
1) Develop hyperactivated motility
2) Bind to zona pellucida
3) Undergo acrosomal reaction
At molecular levels it brings about removal of sperm coating material, removal of cholerterol, a decrease in net negative surface
charge,changes in location of surface antigen, changes in permeability of membrane to calcium. It also reduces the life span of sperms.

Correct Answer. c

(44). Male partner of your patient is being evaluated for infertility, the semen analysis documents azoospermia with normal volume, all the
following tests should be done for further assessment except

a. Levels of LH and FSH

b. Testicular biopsy

c. serum testosterone levels

d. Post ejaculatory urinalysis

Solution. D
Retrograde ejaculation follows failed closure of the bladder neck during ejaculation and allows seminal fuid to flow backward into the
bladder. Retrograde ejaculation is suspected in men with diabetes mellitus, spinal cord damage, or prior prostate or other
retroperitoneal surgery that may have damaged nerves. Medications, particularly β-blockers, may contribute to this problem. A
postejaculatory urinalysis can detect sperm in the bladder and confirm the diagnosis.Sperm abnormalities may be due to central defects
in hypothalamic-pituitary unction or due to defects within the testes. Most urologists will defer testing unless a sperm concentration is
below 10 million/mL. Testing will include measurements of serum FSH and testosterone levels. genetic abnormalities are a relatively
common cause o abnormal semen characteristics (American Society or Reproductive Medicine, 2008a). Approximately 15 percent of
azoospermic men and 5 percent of severely oligospermic men will have an abnormal karyotype. Although genetic abnormalities cannot
be corrected, they may have implications or the health of the patient or their o spring. T ere ore, karyotyping is pursued when indicated
by poor semen analysis results Evaluation of a severely oligospermic or azoospermic male may include either open or percutaneous
testicular biopsy to determine whether viable sperm are present in the seminiferous tubules

Correct Answer. d

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(45). A 32 year old lady undergoes infertility evaluation after trying to conceive for 3 years, she has cyclic bleeding but has noticed scanty
menses over last 2 years. Prior to this she gives history of D&C for a missed abortion. What could be the aetiology of her infertility?

a. Endometrial polyp

b. Ahermans syndrome

c. Submucosal fibroid

d. Hydrosalpinx

Solution. B

Correct Answer. b

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 23/41
(46). Which of the following statements regarding the pathology depicted here is incorrect

a. It is the result of chronic swelling of the fallopian tube

b. It can be associated with chronic pelvic pain

c. May show the beads on string sign

d. Pregnancy rates with IVF are good

Solution. D
hydrosalpinx is a chronic cystic swelling o the allopian tube that orms ollowing distal tubal obstruction. Causes include PID and
endometriosis and rarely allopian tube cancer. Grossly, the ne mbria and tubal ostia are obliterated and replaced by a smooth, clubbed
end Of note, women with a hydrosalpinx who undergo IVF have the pregnancy rate approximately half of other women. The explanation
is unclear, and theories include toxic hydrosalpinx fluid, lowered growth actor concentrations, and mechanical flushing of embryos by
excess fluid. If hydrosalpinges are resected prior to IVF, subsequent rates of pregnancy, implantation, and live births are improved
(Dechaud, 1998; Johnson, 2010; Strandell, 1999). Thus, the American Society of Reproductive Medicine (2012) recommends such surgery
prior to IVF Sonographic interrogation shows a thin-walled, hypoechoic cystic fusiform structure with incomplete septa. In some,
multiple hyperechoic mural nodules measuring 2 to 3 mm arch around the inner circumference of the tube to create the beads on a
string sign. These nodules represent fibrotic endosalpingeal olds.

Correct Answer. d

(47). IVF is indicated for all the following except

a. Severe male factor infertility

b. Severe tubal injury

c. PCOS

d. Premature ovarian failure

Solution. C
The indications of IVF are the following
1) Tubal factor –IVF is primary therapy if tubes are completely blocked
2) Severe male factor infertility- mild male factor infertility may be treated with IUI
3) Diminished ovarian reserve- time to conception is critical and success with other therapies is low
4) Moderate to severe endometriosis
5) Ovarian failure –donor eggs must be used in this case
6) Uterine factor –like ashermans or irreparable damage to uterine cavity- surrogacy may be needed with IVF
7) PIGD
The most important factor affecting the success are the number of oocytes retrieved and the number of high quality embryos derived.
The major reason for failure to achieve pregnancy with IVF is lack of implantation due to poor embryo quality, poor endometrial
receptivity or poor embryo transfer efficiency.

Correct Answer. c

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 24/41
(48). All the following are causes of chronic pelvic pain

a. PID

b. Interstitial cystitis

c. Gartners cyst

d. Endometriosis

Solution. C
Chronic pelvic pain is defined as non-cyclic pain perceived to be in pelvic area that lasts for 3-6 months or longer and is unrelated to
pregnancy. The pain may radiate beyond pelvis and there may also be urinary or gastrointestinal symptoms. Laparoscopy can be sued for
both diagnosis and treatment in women with some causes of chronic pelvic pain. The common causes of chronic pelvic pain are the
following
GYNECOLOGIC
Endometriosis, leiomyoma, adenomyosis, PID, ovarian remnant syndrome, hydrosalpinx, adhesions
UROLOGIC
Interstitial cystitis, radiation cystitis, bladder cancer
GASTROENTEROLOGIC
IBS, inflammatory bowel disease, chronic constipation, colorectal carcinoma
Musculoskeletal
Fibromyalgia, coccygodynia, pelvic floor tension, myofascial pain.
NEUROLOGIC
Ilioinguinal and iliohypogastric nerve entrapment
VASCULAR
Pelvic congestion syndrome

Correct Answer. c

(49). Despite achieving ovulation in most women clomiphene citrate results in pregnancy rates of 50% or less. The disappointing pregnancy
rate is attributed to which of the following

a. Long drug half life

b. Changes in cervical mucus

c. Antiestrogenic effects on endometrium

d. All the above

Solution. D
pregnancy rates are disappointing and approximate ≤ 50 percent (Raj, 1977; Zarate, 1971). Lower than expected pregnancy rates with
CC have been attributed to its long hal -li e and peripheral antiestrogenic effects, mainly on the endometrium and cervical mucus. For
such individuals, who are o ten classified as “clomiphene resistant,” the next step is traditionally the administration of gonadotropins via
injections. Most clinicians begin ovulation induction attempts at a low gonadotropin dosage o 50 to 75 IU injected daily. This is gradually
increased if no ovarian response (as assessed by serum estradiol measurements) is noted after several days. This is referred to as a
“step-up” protocol. The most widely used aromatase inhibitor to induce ovulation in anovulatory and ovulatory infertile women is
letrozole (Femara). Compared with CC, its use is associated with higher pregnancy rates following ovulation induction . When used in
combination with gonadotropins, letrozole leads to lower gonadotropin requirements and may achieve pregnancy rates comparable to
gonadotropin treatment alone. The typical dosage used is 2.5 mg to 5 mg orally daily for 5 days.

Correct Answer. d

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 25/41
(50). All are indications of intrauterine insemination except

a. Cervical factor infertility

b. Sexual dysfunction

c. Unexplained infertility

d. Severe male factor infertility

Solution. D
This technique uses a thin flexible catheter to place a prepared semen sample into the uterine cavity. First, motile, morphologically
normal spermatozoa are separated from dead sperm, leukocytes, and seminal plasma. This highly motile fraction is then inserted
transcervically near the anticipated time of ovulation. Intrauterine insemination can be performed with or without superovulation and is
appropriate therapy or treatment of cervical factors, mild and moderate male actors, and unexplained infertility and minimal to mild
endometriosis

Correct Answer. d

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 26/41
(51). A lady with PCOS undergoing infertility treatment with gonadotropins suddenly presents with abdominal pain and distension. The
following is the ultrasound of the patient which statement is true for her

a. Her lab evaluation will show hemodilution

b. Hcg is implicated in aetiology

c. Treatment is supportive

d. Young age is risk factor

Solution. A
The clinical features and the ultrasound image are consistent with the diagnosis of ovarian hyperstimulation syndrome The aetiology o
ovarian hyperstimulation syndrome (OHSS) is complex, but hCG, either exogenous or endogenous (derived from a resulting pregnancy),
is believed to be an early contributing actor. Development of OHSS involves increased vascular permeability and loss o uid, protein, and
electrolytes into the peritoneal cavity, which leads to hemoconcentration. Increased capillary permeability is elt to result rom vasoactive
substances produced by the corpus luteum. Vascular endothelial growth actor (VEGF) is thought to play a major role, and angiotensin II
may also be involved. Predisposing actors or OHSS include multi ollicular ovaries such as with PCOS, young age, high estradiol levels
during ovulation induction, and pregnancy

Correct Answer. a

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 27/41
(52). All are true about the procedure shown except

a. This can usually be done as a day care surgery

b. It is also called as mid urethral slinG

c. It’s a retropubic surgery

d. Its an abdominal surgery

Solution. D
control of urethral closure involves the interplay of three structures: the pubourethral ligaments, the suburethral vaginal hammock, and
the pubococcygeus muscle. Loss of these supports lead to urinary incontinence and pelvic floor dysfunction. Midurethral slings are
believed to recreate this structural support. There are diferent variations of these procedures, but all use a vaginal approach to place
synthetic mesh beneath the midurethra. Recovery rom midurethral sling placement is rapid and is usually done as a day care surgery this
image is of TVT. With this, the sling (tape) is placed through a vaginal incision to create a hammock beneath the urethra. On each side of
the urethra, the sling’s arms are brought out to the lower anterior abdominal wall and affixed. For this procedure, sharp trocars traverse
the retropubic space and thus, bladder puncture and retropubic space vessel laceration are specific risks.

Correct Answer. d

(53). When describing levels of vaginal support which statement is most accurate

a. Level 1 support describes the upper vaginal support via lateral attachments to arcus tendinous

b. Level 2 describes midvaginal support via the cardinal and uterosacral ligaments

c. Level 3 describes attachment of distal vagina to the perineal body and superficial and deep perineal muscles

d. Level 4 describes the global support of an intact endopelvic fascia

Solution. C
Level I support consists of the cardinal and uterosacral ligaments attachment to the cervix and upper vagina. Defects in this support
complex may lead to apical prolapse. T is is requently associated with small bowel herniation into the vaginal wall, that is, enterocele.
Level II support consists of the paravaginal attachments lateral vagina anteriorly to the arcus tendineus ascia pelvis and posteriorly to
the arcus tendineus rectovaginalis. Detachment of this connective tissue from the arcus tendineus ascia pelvis leads to lateral or
paravaginal anterior vaginal wall prolapse Level III support is composed o the perineal body, superficial and deep perineal muscles, and
fibromuscular connective tissue. Collectively, these support the distal one third of the vagina and introitus. T e perineal body is essential
or distal vaginal support and proper function of the anal canal. Damage to level III support contributes to anterior and posterior vaginal
wall prolapse, gaping introitus, and perineal descent.

Correct Answer. c

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 28/41
(54). At the conclusion of vaginal hysterectomy which ligaments are sutured to the lateral aspect of vaginal cuff to improve long term vaginal
vault suspension

a. Cardinal ligament

b. Round ligamenT

c. Infundibulopelvic ligament

d. Uterosacral ligament

Solution. D
To help prevent later vaginal apex prolapse, the uterosacral ligament pedicles are incorporated within the cuff closure. For this, the
interrupted or continuous running closure suture is initially passed through the anterior vaginal wall, through the ligament, through the
posterior peritoneum, and finally through the posterior vaginal wall on one side. This is repeated on the other side. Suturing then
progresses rom each side to the midline, or a single running suture may close the entire cuff line.

Correct Answer. d

(55). Risk of CIN is most strongly related to persistent genital high risk HPV Infection plus which of the following

a. Tobacco use

b. Increasing age

c. Increasing parity

d. Increasing number of sexual partners

Solution. B
Risk actors are similar to those o invasive cervical cancer, and CIN is most strongly related to persistent genital HR HPV infection and
increasing age. In an older woman, HPV infection is more likely to persist than resolve. Older age is linked with waning immune
competence and also allows accumulation of genetic mutations over time that can lead to malignant cellular transformation Additionally,
adverse socioeconomic actors and decreased need or prenatal care and contraception cause older women to be screened less often

Correct Answer. b

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 29/41
(56). Which of the following is true of the prophylactic HPV vaccines currently available

a. All three use type specific virus like particles to induce immunity

b. They require one initial dose followed by booster dose 2 years later

c. They are protective against HPV types that account for 40% of cervical cancers

d. All 3 are FDA approved for prevention of anogenital and oropharyngeal neoplasia

Solution. A
Currently, three HPV vaccines are FDA approved or prevention o incident HPV in ection and cervical neoplasia. T ey use recombinant
technologies or the synthetic production o the L1 capsid proteins o each HPV type included in the vaccine. T e resultant virus-like
particles are highly immunogenic but are not in ectious as they lack viral DNA Cervarix (HPV2) is a bivalent vaccine against HPVs 16 and
18. Gardasil (HPV4) is a quadrivalent vaccine against HPV types 6, 11, 16, and 18. HPV4 is being replaced by Gardasil 9 (HPV9), a
nonavalent vaccine. HPV9 protects against all HPV types in HPV4 plus types 31, 33, 45, 52, and 58. Coverage o these additional HR HPV
types will bring the theoretical percentage o cervical cancers prevented from 70% percent to approximately 80 percent. They are
administered in three intramuscular doses during a 6- month period. Specifically, the second dose is given 1 to 2 months after the first
dose, and the third dose is given 6 months after the first dose. the Advisory Committee on Immunization Practices (ACIP) currently
recommends that HPV vaccine be administered routinely to girls aged 11 to 12 years (as early as age 9 years). Vaccination is also
recommended or 13- to 26-year-old women not previously vaccinated (Markowitz, 2014; Petrosky, 2015). Vaccination can be given during
lactation but is avoided during pregnancy (American College o Obstetricians and Gynecologists, 2014a). HPV vaccines are highly
immunogenic with maintenance of protection or at least 5 to 8 years after vaccination (Ferris, 2014; Harper, 2006). No evidence
supports the need or later booster dosing.

Correct Answer. a

(57). What is the most appropriate surgical approach for a woman who has a stage 1A1 squamous cell cancer and has completed child bearing

a. Cold knife conisation

b. Extrafascial hysterectomy

c. Type 3 radical hysterectomy

d. Type 2 radical hysterectomy

Solution. B
Stage IA1 These microinvasive tumors invade no deeper than 3 mm, spread no wider than 7 mm, and are associated with the lowest risk
or lymph node metastasis In stage IA1 microinvasive cancers, Because of the low risk of spread into the parametrial or uterosacral
nodes, these lesions may be effectively treated with cervical conization alone ). However, a total extra ascial hysterectomy (type I
hysterectomy) is pre erred or women who have completed childbearing. the presence of LVSI increases the risk of lymph node metastasis
and cancer recurrence to approximately 5 percent. Accordingly, these cases are traditionally managed with modified radical
hysterectomy (type II hysterectomy) and pelvic lymphadenectomy. Radical trachelectomy with pelvic lymph node dissectionan be
considered in women desiring fertility preservation

Correct Answer. b

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(58). Which of the labels in this diagram indicate where the uterosacral ligament is ligated during type 2 radical hysterectomy.

a. A

b. B

c. C

d. None of the above

Solution. B

Correct Answer. b

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 31/41
(59). Most common hysterectomy to cause ureteric injury is

a. Vaginal hysterectomy

b. Abdominal hysterectomy

c. Wertheims hysterectomy

d. Laparoscopic hysterectomy

Solution. C
The ureter is injured in roughly 0.5-2%of all hysterectomies and routine gynaecological pelvic operations and it occurs in 10% of radical
hysterectomies. 50% of all ureteric injuries in gynaecological surgeries are from radical hysterectomies. The segment of the ureter
injured in gynae surgeries is distal 1/3rd of the ureter.
Ureteral Injury is uncommon in benign gynaecologic surgery, and the incidence approximates 0.2 to 7.3 per 1000 surgeries. For
hysterectomy, the highest rate of ureteral injury is linked with laparoscopic hysterectomy, and the lowest with vaginal hysterectomy.
Gynecologic ureteral injury typically occurs in the distal third and includes transection, ligation, kinking,
and crushing. Trauma to the outer sheath can also disrupt ureteral blood supply. Of these, the ureter more often is transected or kinked,
and each accounts or approximately 40 percent of injuries. During hysterectomy, the most common trauma site is at the level of the
uterine artery and accounts or 80 percent of injuries. The ureter is also vulnerable near the pelvic brim during adnexectomy and at the
distal uterosacral ligaments. Mechanisms of injury include clamping or suturing with the ureter poorly visualized. Thermal insult or
devascularization may lead to stricture or leak.

Correct Answer. c

(60). Which of the following does not increase a woman’s risk of developing endometrial cancer

a. Obesity

b. Cigarette smoking

c. Tamoxifen

d. Unopposed estrogen

Solution. -NA-

Correct Answer. b

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(61). What is the most important prognostic marker for a woman with endometroid adenocarcinoma of the uterus

a. Age

b. Grade

c. Stage

d. Positive peritoneal washings

Solution. C
Many clinical and pathologic actors influence the likelihood of endometrial cancer recurrence and survival. Of these, FIGO surgical stage
is the most important overriding variable because it incorporates many of the most important risk factors. Metastatic disease to the
adnexa, pelvic/paraaortic lymph nodes, and peritoneal surfaces is reflected by the FIGO stage.

Correct Answer. c

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(62). A 40 year old woman presents with complaints of heavy menstrual bleeding. During examination an irregularly contoured uterus is
palpable and transvaginal sonography reveals the following.

All except which of the following can be used as first line management for her

a. OCP

b. MIRENA

c. GnRH agonist

d. Tranexamic acid

Solution. C
The ultrasound demonstrates a fibroid uterus which is consistent with her presentation, all except GnRH agonist can be used to improve
her symptoms. GnRH agonists although when given continuously can reduce the menstrual blood loss but produces hypoestrogenic state
and when given for more than 6 months it can cause severe bone loss.

Correct Answer. c

(63). What is the likely diagnosis of the post hysterectomy specimen shown below?

a. Polyp

b. Leiomyoma

c. Endometrial cancer

d. Adenomyosis

Solution. B
The gross specimen shows a growth from the body of uterus, and is a leiomyoma. The polyp is a growth from the mucosa and it will have
a narrow base of attachment. Endometrial cancer will not be a smooth growth. Adenomyosis is a symmetrical growth of uterus and not a
focal lesion like this

Correct Answer. b

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(64). The vestibule is an almond shaped area bound by which of the following

a. Laterally by the hart line

b. Anteriorly by the fourchette

c. Laterally by labia minora

d. Laterally by the external surface of hymen

Solution. A
Vestibule is the functionally mature female structure derived from the embryonic urogenital membrane. In adult women, it is an almond-
shaped area that is enclosed by Hart line laterally, the external surface of the hymen medially, the clitoral frenulum anteriorly, and the
fourchette posteriorly. The vestibule usually is perforated by six openings: the urethra, the vagina, two Bartholin gland ducts, and at
times, two ducts of the largest paraurethral glands—the Skene glands. The posterior portion of the vestibule between the fourchette and
the vaginal opening is called the fossa navicularis. It is usually observed only in nulliparas

Correct Answer. a

(65). Referring to the diagram, which of the following is marked by the capital letter A

a. Ureter

b. Uterine artery

c. Uteroovarian ligament

d. Infundibulopelvic ligament

Solution. B
The uterine artery crosses over the ureter approximately 2cm lateral to cervix , this area is called as water under the bridge and is the
most common site if ureteric injury in obstetric and gynaecology surgeries. The uterine artery is a branch of anterior division of internal
iliac artery.

Correct Answer. b

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(66). The progesterone only pills are characterised by all the following except

a. Alteration of cervical mucus

b. Make endometrium thin

c. Inhibition of ovulation consistently

d. Irregular bleeding

Solution. C
The progesterone only pills do not inhibit ovulation consistently and therefore the effects on cervical mucus and endometrium represent
critical factors in prevention of conception. Within hours of administration the POPs reduce the volume of cervical mucus and increase its
viscosity which prevents the sperm from passing through the cervical canal and endometrial cavity. The women in whom estrogens are
contraindicated are good candidates for POPs, they should be initiated on first day of menses, back up contraception is not necessary if
POPs are started within first 5 days of menses. As the pill has short half life the pill should be taken at the same time each day. The safe
period of the pill is 3 hours. Intermenstrual bleeding and formation of follicular cysts are the most common side effects .

Correct Answer. c

(67). All the following are contraindications for IUCD contraceptive except

a. Mucopurulent cervicitis

b. Undiagnosed vaginal bleeding

c. distorted uterine cavity

d. Infected abortion in last 1 year

Solution. D
IUDs can be inserted for women who are atleast 3 months post treatment for PID,puerperal or postabortal sepsis
Contraindiactions for IUCD are
Undiagnosed vaginal bleeding
Acute pelvic infectiomn including PID, endometriosis,mucopurulent cervicitis,pelvic tuberculosis
Known or suspected pregnancy
Wilsoms disease for copper devices and
Breast cancer for LNG iud

Correct Answer. d

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(68). A 34 year old multipara with a copper containing IUD, presents because she cannot feel the threads, her LMP was 8 weeks ago, an
ultrasound was done for her and the image is given below. What is the best management for her

a. Remove the IUD and evacuate the uterine contents

b. Remove IUD and plan expectant pregnancy management

c. Leave the IUD in place and plan expectant management

d. Leave the IUD in place and give antibiotics for next 4 weeks

Solution. B
First, a device may penetrate the uterine wall in varying degrees. It should be removed, and this approach varies by IUD location.
Devices with a predominantly intrauterine location are typically managed by hysteroscopic IUD removal. In contrast, devices that have
nearly completely per orated through the uterine wall are more easily removed laparoscopically. In those with pregnancy and an IUD,
early pregnancy identification is important. Up to approximately 14 weeks’ gestation, the IUD strings may be visible within the cervix,
and if een, they are grasped to remove the entire IUD. This action reduces subsequent complications such as late abortion, sepsis, and
preterm birth. However, if the strings are not visible, attempts to locate and remove the device may result in pregnancy loss. This risk
must be weighed against the risk of leaving the device in place. If removal is attempted, TVS can be used.

Correct Answer. b

(69). Which of the following statements regarding atrophic vaginitis is not correct

a. Acidic vaginal Ph

b. Regular intercourse prevents atrophy

c. Estrogen cream provides temporary relief

d. Causes dyspareunia and bleeding

Solution. A
ATROPHIC VAGINITIS has a alkaline vaginal Ph usually in the range of 6.5-7.5 The main pathophysiology is decline in serum estrogen.
Estrogen is responsible for maintaining a well
epithelized vaginal vault by maintaining collagen content, hyaluronic acid and by maintaining the genital blood flow. In the absence of
keratinization the epithelium is thin which leads to bleeding ulceration and even infection, the shifting flora results in inflammatory
changes and that’s why the condition is called as atrophic vaginitis. The clinical manifestations are the following
1) Vaginal dryness
2) Vaginal burning
3) Dyspareunia
4) Bleeding
5) Vaginal discharge
6) Urinary tract symptoms like frequency, dysuria,hematuria
the initial treatment for dryness and dyspareunia is application of vaginal moisturizers and estrogen creams while the mechanical
method can also be used. The mechanical methods include sexual activity and dilators. Postmenopausal women who have higher
frequency of intercourse have less severe vaginal atrophy.

Correct Answer. a

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(70). All are non contraceptive uses of combined oral contraceptive pills except

a. Premenstrual syndrome

b. Menorehagia

c. Menstrual migraine

d. Breakthrough bleeding

Solution. D
Breakthrough bleeding is the nmost common side effect of very low dose OCPs
The non contraceptive uses of ocps are the following
1) Menorrhagia
2) Dysmenorrhoea
3) PMS and PMDD
4) Prevention of menstrual migraine
5) Treatment of acne and hirsutism
6) Bleeding due to leiomyomas
7) Pain due to endometriosis
8) Decreased risk of endometrial ovarian and colon cancer

Correct Answer. d

(71). All the following are features of primary dysmenorrhoea except

a. Starts 3 days before menses

b. Relieved by NSAIDS

c. Improves with menstrual flow

d. Pain is strongest in midline

Solution. A
PRIMARY DYSMENORRHOEA begins during adolescence after ovulatory cycles first become established. The pain usually starts on the
day of menses but may start 1-2 days before.it gradually diminishes over 12 -72 hrs. the pain is crampy, confined to lower abdomen and
suprapubic area and is usually strongest in midline. Non midline pain specially if unilateral suggest a uterine anomaly or alternative
diagnosis. Women with primary dysmenorrhoea have a normal pelvic examination The pathophysiology is release of prostaglandins from
the endometrium which cause strong uterine contractions that cause uterine ischaemia and pain NSAIDS and hormonal contraceptives
are the mainstay of therapy. Women not responding to these may have an underlying pathology and should be evaluated.

Correct Answer. a

(72). All the following are true about antara contraceptive except

a. Can be used by breast feeding women

b. Causes dysmenorrhoea

c. Causes amenorrhoea

d. Effective for 3 months

Solution. B
Antara is an intramuscular injectable contraceptive containing medroxyprogesterone acetate, each dose prevents pregnancy for 3
months. It can be used by breast feeding women as it does not affect the quantity quality and composition of breast milk. It reduces blood
loss and menstrual cramps and also reduces premenstrual tension.
There is delay in return of fertility after stopping the use and average delay is 12 months. It may cause amenorrhoea by thinning of the
endometrium. This has been introduced free of cost in 10 states in India under mission parivaar vikaas. The same contraceptive was
earlier available as depo-provera

Correct Answer. b

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 38/41
(73). The following histopathology is seen in which of the following ovarian malignancy

a. Serous

b. Brenners

c. Krukenbergs

d. Clear cell

Solution. C
These are signet ring cells which are seen in
Hobnail cell is a feature of clear cell cancer and not brenners.
Brenners will show wallthard cell nest
Serous will show psammoma bodies
Granulosa cell will show call exner bodies
Leydig cell tumour will show reinkes crystal

Correct Answer. c

Copyright © 2014 Delhi Academy of Medical Sciences, All Rights Reserved. 39/41
(74). During which of the following hysteroscopy procedures does carbon dioxide serve as best distension media

a. Leiomyomata resection

b. Uterine septum excision

c. Diagnostic hysteroscopy

d. Endometrial polyp resection

Solution. C

be used with monopolar electrosurgery. Specifically, these solutions conduct current; thus, dissipate the energy; and thereby render the
instrument useless. In addition to fluid overload, uterine per oration or bleeding may complicate hysteroscopy. The uterus may be per orated
during uterine sounding, cervical dilatation, or hysteroscopic procedures. Fundal per orations created by sounds, dilators, or hysteroscopes
can be managed conservatively, as the myometrium will typically contract around these defects. In contrast, lateral per oration may per orate
the broad ligament or injure larger pelvic vessels; posterior per oration may injure the rectum; and those caused by electrosurgical tools may
cause organ laceration or burn. Diagnostic laparoscopy is indicated in these cases. Similarly, anterior per orations should prompt cystoscopy
to evaluate associated bladder injury

Correct Answer. c

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(75). A female being evaluated for infertility on evaluation has the following HSG finding. What is the likely organism associated with this
finding

a. Chlamydia

b. Tuberculosis

c. Mycoplasma

d. Gonorrhoea

Solution. B
this is the beads on string appearance of genital tuberculosis, the other characteristic appearance are golf club, tobacco pouch,
cobblestone, lead pipe, peritubal halo. Fallopian tube is the most common site of genital tuberculosis, affected in 90% of cases. Within
the tube the ampulla is the most common site and the route of spread is hematogenous The endometrium is the second most common
site in genital tuberculosis and may show filling defects in hsg.

Correct Answer. b

Test Answer
1.(c) 2.(b) 3.(b) 4.(c) 5.(b) 6.(a) 7.(b) 8.(c) 9.(b) 10.(b)

11.(d) 12.(a) 13.(b) 14.(c) 15.(a) 16.(d) 17.(d) 18.(a) 19.(c) 20.(d)

21.(c) 22.(d) 23.(b) 24.(c) 25.(d) 26.(b) 27.(a) 28.(b) 29.(c) 30.(a)

31.(c) 32.(b) 33.(a) 34.(d) 35.(d) 36.(c) 37.(b) 38.(d) 39.(a) 40.(a)

41.(d) 42.(b) 43.(c) 44.(d) 45.(b) 46.(d) 47.(c) 48.(c) 49.(d) 50.(d)

51.(a) 52.(d) 53.(c) 54.(d) 55.(b) 56.(a) 57.(b) 58.(b) 59.(c) 60.(b)

61.(c) 62.(c) 63.(b) 64.(a) 65.(b) 66.(c) 67.(d) 68.(b) 69.(a) 70.(d)

71.(a) 72.(b) 73.(c) 74.(c) 75.(b)

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