Endometriosis, Adenomyosis and Fibroids MCQs

Obstetrics & Gynaecology · 111 free questions with answers & explanations.

A 30-year-old nulliparous woman has had dysmenorrhea and dyspareunia for 4 years. Laparoscopy reveals deposits on the uterosacral ligaments, ovarian endometrioma (4 cm) on the right, and bilateral tubal disease with partial obstruction. She desires future fertility. What is the MOST appropriate management?
A 38-year-old woman presents with heavy menstrual bleeding, dysmenorrhea, and a uniformly enlarged, tender uterus measuring 12 weeks size. She has completed her family. Ultrasound shows globular uterus with heterogeneous myometrium and cystic spaces. Serum CA-125 is 78 U/mL. What is the MOST likely diagnosis and definitive management?
A 32-year-old nulliparous woman with Stage IV endometriosis (ASRM revised classification) and deep infiltrating nodule involving the uterosacral ligaments desires pregnancy. Serum AMH is 1.1 ng/mL. Which strategy has the BEST evidence for improving live birth outcomes?
A 38-year-old woman with a 7 cm intramural fibroid and menorrhagia leading to Hb 8.5 g/dL desires uterine conservation. She declines surgery. The BEST non-surgical option to rapidly reduce fibroid volume AND treat anaemia is:
A 32-year-old nulliparous woman with stage III endometriosis (revised ASRM classification) is trying to conceive naturally without success for 18 months. Bilateral ovarian endometriomas of 4 cm are present. What is the MOST appropriate management to improve fertility outcomes?
A 38-year-old woman presents with heavy menstrual bleeding and dysmenorrhea. Ultrasound shows a globular uterus measuring 12×11×10 cm with heterogeneous myometrium and asymmetric posterior wall thickening of 22 mm. The endometrial-myometrial junctional zone is indistinct. There are no discrete fibroids. What is the MOST likely diagnosis?
The ESHRE rASRM (revised American Society for Reproductive Medicine) staging system for endometriosis has been criticized for poor correlation with symptoms and fertility outcomes. The ENZIAN classification (2011, revised 2021) addresses this by:
In a patient with symptomatic uterine fibroids (menorrhagia, 14-week size uterus) who strongly desires fertility preservation, which medical therapy specifically acts on GnRH receptors to reduce fibroid volume prior to surgery?
The pathogenesis of adenomyosis involves ectopic endometrial glands and stroma within the myometrium. The mechanism by which adenomyosis causes heavy menstrual bleeding (HMB) is best explained by:
A 31-year-old with Stage III endometriosis (revised ASRM classification) and primary infertility for 2 years undergoes laparoscopy. She has bilateral endometriomas (4 cm right, 3 cm left) and dense cul-de-sac adhesions. Ovarian reserve is normal (AMH 2.8 ng/mL). Which management strategy is supported by current ESHRE 2022 guidelines for endometriosis-associated infertility in this scenario?
A 42-year-old with a 10 cm intramural fibroid (FIGO leiomyoma Type 3) and progressively worsening heavy menstrual bleeding has failed levonorgestrel intrauterine system and tranexamic acid. She wishes to avoid hysterectomy and pregnancy is not desired. Which minimally invasive option has the highest evidence for long-term fibroid volume reduction and symptom control?
Adenomyosis is characterised on MRI by junctional zone (JZ) thickening. Which JZ thickness threshold on T2-weighted MRI is the current diagnostic criterion for adenomyosis, and why is this zone relevant pathologically?
The revised ASRM (American Society for Reproductive Medicine) classification of endometriosis assigns points based on location, size, and adhesions. In which stage would a patient with bilateral ovarian endometriomas (3 cm each), obliterated cul-de-sac, and dense bowel adhesions be classified?
Dienogest, a 19-nortestosterone derivative used in endometriosis, has a unique combination of properties that distinguishes it from older progestogens. Which of the following correctly characterises dienogest's pharmacological profile?
Which of the following is the MOST specific MRI criterion for diagnosing adenomyosis?
The ENZIAN classification (revised 2021) of endometriosis was developed to improve upon the ASRM r-AFS staging. What is the primary advantage of the ENZIAN classification over the r-AFS staging system?
A 35-year-old woman with a 9 cm subserosal uterine fibroid is to undergo myomectomy. Preoperative gonadotropin-releasing hormone (GnRH) agonist therapy was administered for 3 months. Which is the primary unintended consequence of preoperative GnRH agonist use that can complicate intraoperative myomectomy?
Dienogest is used for the medical treatment of endometriosis. Compared to progestins used in contraception, dienogest has unique pharmacological properties. Which of the following best describes dienogest's pharmacological profile?
Endometrioma repair prior to IVF is controversial. The ENDOVA trial and ESHRE guidelines (2022) recommend which approach for an isolated, unilateral 5 cm endometrioma in a woman who has not undergone prior ovarian surgery and is planning IVF?
The rASRM (revised American Society for Reproductive Medicine) classification of endometriosis scores peritoneal implants, ovarian endometrioma, and adhesions. A patient with bilateral ovarian endometriomas (3 cm each), dense cul-de-sac obliteration, and bilateral adnexal adhesions would be classified as:
GnRH antagonist (relugolix, elagolix) add-back therapy is now approved for symptomatic fibroids. Regarding elagolix (Oriahnn) for heavy menstrual bleeding due to fibroids, which pharmacodynamic mechanism distinguishes it from GnRH agonists?
The #ENZIAN classification (2021) is the most comprehensive staging system for deep infiltrating endometriosis (DIE). It classifies DIE into four compartments. Which compartment does the 'F' subdivision in the #ENZIAN classification represent?
Ulipristal acetate (UPA) is a selective progesterone receptor modulator (SPRM) used for fibroid treatment. The mechanism underlying its fibroid volume reduction differs from GnRH analogues because:
In the FEMME trial comparing uterine artery embolization (UAE) with myomectomy for symptomatic fibroids in women wishing to preserve uterus, the primary outcome at 4 years showed:
The ESHRE 2022 revised guideline on endometriosis recommends empirical hormonal treatment without prior surgical diagnosis in women with suspicious symptoms. The first-line recommended agent is:
Regarding the STEPPS (Stepping up Treatment for Endometriosis and PELVIC Pain Study) concept, which biomarker in peritoneal fluid is MOST consistently elevated in women with active endometriosis and directly promotes lesion survival and proliferation?
Ulipristal acetate (UPA) used for fibroid treatment works via which mechanism, and is associated with which histological endometrial change?
The American Society for Reproductive Medicine (ASRM) revised classification of endometriosis (r-ASRM) assigns scores based on lesion characteristics. Which anatomical feature, when present, contributes the HIGHEST single-lesion score in the r-ASRM system?
A 36-year-old woman with symptomatic fibroids (menorrhagia, bulk symptoms, uterus 16-week size) desires future fertility. Uterine artery embolization (UAE) is proposed. Compared to myomectomy, which statement about UAE outcomes for fertility is MOST accurate based on current evidence?
The revised American Society for Reproductive Medicine (rASRM) classification of endometriosis scores 1–15 points as Stage I (minimal), 16–40 as Stage II (mild), and >40 as Stage III/IV. A woman with Stage IV deep infiltrating endometriosis with rectovaginal nodule is being considered for medical treatment to reduce pain before planned surgery. Dienogest (progestogen) exerts its anti-endometriotic effect via which specific mechanism?
Ulipristal acetate (UPA) is a selective progesterone receptor modulator (SPRM) used for uterine fibroid treatment. In 2020, the EMA restricted its use due to rare but serious liver injury cases. UPA's mechanism for causing fibroid regression differs from GnRH agonists. Which best describes how UPA reduces fibroid size without complete oestrogen deprivation?
Adenomyosis is diagnosed on MRI by a junctional zone (JZ) thickness >12 mm. The junctional zone represents the innermost layer of the myometrium (subendometrial myometrium). Which MRI finding most reliably distinguishes diffuse adenomyosis from leiomyoma on T2-weighted imaging?
The Sampson theory (retrograde menstruation) does not fully explain endometriosis pathogenesis. The 'stem cell' theory proposes bone marrow-derived stem cells contribute. Which histological/immunohistochemical finding in ectopic endometrial lesions best supports a metaplastic or stem cell origin rather than simply transplanted endometrial cells?
Dienogest (2 mg daily) is a selective progestogen used in endometriosis. Its mechanism differs from combined OCP progestins because it acts via which specific pathway most relevant to endometriosis suppression?
A 38-year-old with a 7 cm intramural fibroid causing heavy menstrual bleeding has completed her family. She is counselled about uterine artery embolisation (UAE) versus myomectomy. According to the EMMY trial, what was the key finding regarding UAE compared to hysterectomy that informs counselling?
A 32-year-old woman with severe endometriosis (ASRM Stage IV, r-AFS score 68, bilateral endometriomas 4 cm) desires fertility. MRI pelvis shows deep infiltrating endometriosis (DIE) of the recto-vaginal septum. According to the ESHRE 2022 endometriosis guidelines, which management approach is recommended BEFORE IVF to optimise outcomes?
A 38-year-old woman with heavy menstrual bleeding and a 7 cm intramural fibroid (FIGO Type 3) on MRI is being counselled about uterine artery embolisation (UAE). Which of the following correctly describes the mechanism of action and a key clinical consideration for UAE in this setting?
The American Society for Reproductive Medicine (ASRM) revised classification of endometriosis scores lesions based on size, depth of invasion, and location. A woman with bilateral ovarian endometriomas (combined score 16), no adnexal adhesions, and mild cul-de-sac obliteration would be assigned which stage?
Regarding GnRH antagonist add-back therapy in endometriosis management, which of the following represents the mechanism of action of relugolix-estradiol-norethindrone acetate (Myfembree) in preserving bone mineral density?
A 38-year-old woman with a 7 cm intramural fibroid and 4 cm submucosal fibroid (FIGO classification type 2) presents with heavy menstrual bleeding and subfertility. Her AMH is 2.1 ng/mL. According to FIGO leiomyoma classification, the submucosal fibroid is type 2 because:
A 34-year-old with known endometriosis and a 6 cm right endometrioma has a serum CA-125 of 72 U/mL. She wishes to conceive. According to ESHRE 2022 endometriosis guidelines, what is the recommended surgical approach?
A 40-year-old woman with symptomatic uterine fibroids (total uterine volume 580 mL, largest 6 cm intramural, heavy menstrual bleeding, Hb 8.9 g/dL) has completed her family. She refuses hysterectomy. According to current NICE guidelines, which pharmacological treatment is approved as a pre-surgical or standalone treatment for uterine fibroids?
Revised American Society for Reproductive Medicine (rASRM) staging of endometriosis (I–IV) is based on surgical findings. However, this staging system has which well-recognised clinical limitation?
Uterine adenomyosis is confirmed histologically when endometrial glands and stroma are found at what minimum depth from the endometrial-myometrial junction (EMJ)?
Ulipristal acetate (UPA), a selective progesterone receptor modulator used for fibroid treatment, was associated with drug-induced liver injury (DILI) leading to regulatory restrictions. The unique histological finding on liver biopsy associated with UPA-induced DILI is:
The revised American Society for Reproductive Medicine (rASRM) classification of endometriosis assigns scores based on lesion characteristics. Which finding on laparoscopy would qualify as Stage IV (severe) endometriosis independent of all other findings?
A woman has a 10 cm intramural fibroid with submucosal component (FIGO type 2-5) and menorrhagia. She desires uterine conservation for future fertility. Her hemoglobin is 8.2 g/dL. What is the role of GnRH agonist preoperatively?
Adenomyosis on MRI is characterized by a junctional zone (JZ) thickness. What is the current recommended diagnostic threshold for adenomyosis on MRI?
A 34-year-old woman with Stage IV (revised ASRM) endometriosis involving bilateral ovarian endometriomas (4 cm and 3.5 cm) and deep infiltrating endometriosis (DIE) of the rectovaginal septum desires fertility. Her AMH is 1.8 ng/mL. What is the MOST appropriate management approach according to current ESHRE guidelines?
A 40-year-old woman presents with heavy menstrual bleeding (pictorial blood assessment chart score 250), dysmenorrhea, and a uniformly enlarged 14-week size uterus. Transvaginal ultrasound shows heterogeneous myometrium, myometrial cysts, and increased vascularity within the myometrium. MRI shows junctional zone maximum thickness of 16 mm with islands of endometrial glands within the myometrium. Which criterion distinguishes adenomyosis from leiomyoma on MRI?
A 38-year-old woman with symptomatic uterine fibroids (largest 6 cm intramural) declines surgery and requests non-surgical options. She has completed her family. Uterine artery embolization (UAE) is proposed. Which fibroid characteristic is an ABSOLUTE contraindication to UAE?
A 34-year-old with deep infiltrating endometriosis involving the rectovaginal septum undergoes laparoscopy. A 4 cm nodule is found at the rectovaginal septum with involvement of the anterior rectal wall serosa. The revised ASRM (rASRM) endometriosis stage would be at least:
A 42-year-old with menorrhagia, dysmenorrhoea, and a uniformly enlarged 14-week-size uterus. MRI shows heterogeneous myometrium with junctional zone thickness >12 mm and small myometrial cysts. She has completed her family and wants definitive treatment. The diagnosis and best treatment are:
A 38-year-old with a single 5 cm submucosal fibroid (FIGO type 1 — less than 50% intramural) and primary infertility is referred for treatment. The most appropriate initial approach is:
A 32-year-old woman with severe endometriosis and a 4 cm left ovarian endometrioma desires fertility preservation. She has failed 6 months of GnRH agonist therapy. Laparoscopic cystectomy is planned. According to ESHRE 2022 endometriosis guidelines, the recommended surgical technique for the endometrioma to minimise impact on ovarian reserve is:
A 38-year-old woman is found to have multiple uterine fibroids (largest 6 cm intramural) with a uterine size of 14 weeks. She has menorrhagia, pressure symptoms, and secondary infertility. She wishes to conceive. She declines surgery. She enquires about medical management. Which drug reduces fibroid volume AND controls bleeding while maintaining fertility potential?
Adenomyosis on MRI is best characterised by which finding?
According to the revised ASRM 1997 staging system for endometriosis, a patient has superficial peritoneal endometriotic lesions totalling 3 cm (3 points), filmy unilateral adnexal adhesions (4 points), and no ovarian endometrioma. Cul-de-sac is partially obliterated (4 points). Total score is 11. What stage is this?
A 35-year-old with symptomatic uterine fibroids (multiple intramural fibroids, total uterine size 14-week equivalent) wishes to avoid surgery and preserve fertility. Which pharmacological agent is approved in India and Europe as long-term medical management for uterine fibroids?
On MRI, adenomyosis is best characterised by which finding?
The revised American Society of Reproductive Medicine (rASRM) staging of endometriosis classifies disease into 4 stages based on a points system. Which statement about the rASRM staging most accurately reflects its clinical utility?
A 38-year-old woman with symptomatic fibroids (heavy menstrual bleeding, bulk symptoms) desires uterine preservation. Uterine size is 18 weeks. She has a 7 cm intramural fibroid and two 3 cm submucosal fibroids. She is perimenopausal. The non-surgical medical option that reduces fibroid volume by 50% and controls bleeding via GnRH receptor antagonism for preoperative use is:
A 32-year-old woman with endometriosis and infertility undergoes laparoscopy. A 5 cm right ovarian endometrioma is found. She has been trying to conceive for 18 months. Which intervention best improves natural conception rates in this scenario?
The revised American Society for Reproductive Medicine (rASRM 1997) scoring system for endometriosis classifies disease based on findings at laparoscopy. Which score range defines Stage IV (severe) endometriosis?
In the FIGO PALM-COEIN leiomyoma classification, which statement correctly distinguishes a Type 2 (submucous) from a Type 3 (other) fibroid?
The ESHRE revised #ENZIAN classification of deep endometriosis characterises lesions in which dimension?
A 35-year-old woman with fibroid uterus desires fertility preservation. Uterine artery embolisation (UAE) was offered but she declined. She has a 6 cm intramural fibroid. Which medical treatment specifically approved for fibroid management that reduces fibroid volume by blocking GnRH receptors and can be used as a bridge to surgery?
In the LOKI trial and subsequent evidence, which medical therapy for adenomyosis-associated dysmenorrhoea and heavy bleeding demonstrated the most sustained symptom relief with reduced uterine volume?
A 32-year-old woman with a 5 cm endometrioma of the left ovary is planning IVF. Regarding pre-IVF surgical cystectomy, which statement best reflects current evidence?
A 36-year-old woman has a posterior wall intramural fibroid of 4 cm causing menorrhagia and dysmenorrhoea. She desires future fertility. Which medical treatment reduces fibroid volume through anti-progestogenic and anti-angiogenic mechanisms?
A 40-year-old woman is diagnosed with adenomyosis on MRI (heterogeneous enlarged uterus, junction zone thickness 14 mm). She has completed her family and has refractory menorrhagia. Which is the definitive treatment?
A 32-year-old woman with Stage IV endometriosis (revised ASRM scoring, dense posterior cul-de-sac adhesions, bilateral endometriomas) undergoes IVF. Which finding has the highest evidence for impairing IVF outcomes in endometriosis?
A 42-year-old woman presents with heavy menstrual bleeding (HMB) and a 14-week-sized uterus with multiple intramural fibroids, largest 6 cm. She declines surgery. She is treated with ulipristal acetate (UPA). The PEARL III trial showed UPA is effective in controlling HMB; however, which key safety concern led to CHMP (European Medicines Agency) restricting its use?
On histology, adenomyosis is defined by endometrial glands and stroma within the myometrium. The minimum depth required from the endometrial-myometrial junction (EMJ) for histological diagnosis of adenomyosis is:
A 32-year-old woman with stage IV endometriosis (deep infiltrating endometriosis, bilateral endometriomas) and infertility is counselled regarding treatment. The ESHRE 2022 guideline recommends which FIRST-LINE approach for endometriosis-associated infertility?
Which of the following MRI features is MOST specific for adenomyosis (not fibroid)?
A 38-year-old woman with a 6 cm posterior intramural fibroid and recurrent pregnancy loss (3 consecutive first-trimester miscarriages) with no other identified cause. Her uterine cavity is not distorted on hysteroscopy. What is the MOST evidence-based management for the fibroid?
The ESHRE revised endometriosis classification (2023 #Endo) differs from the revised ASRM (rASRM) scoring in that it:
A 36-year-old woman with confirmed adenomyosis and menorrhagia is referred for MRI. Which MRI finding is MOST specific for adenomyosis?
Regarding uterine artery embolisation (UAE) for symptomatic uterine fibroids, which outcome parameter is BEST supported by current evidence compared to surgical myomectomy?
A 35-year-old nulliparous woman with severe endometriosis (rASRM Stage IV) desires fertility. Diagnostic laparoscopy confirms bilateral endometriomas and deep infiltrating endometriosis of the uterosacral ligaments. The most fertility-enhancing surgical approach is:
Adenomyosis differs from endometriosis histologically in that adenomyosis is defined by:
Uterine artery embolization (UAE) for fibroids is contraindicated in which of the following situations?
The revised American Society for Reproductive Medicine (rASRM) classification of endometriosis is based on findings at laparoscopy. Which factor is weighted MOST HEAVILY in the scoring system?
Regarding adenomyosis, which MRI feature is MOST specific for diagnosis?
GnRH antagonist (relugolix) for uterine fibroids is combined with low-dose estradiol and norethindrone acetate add-back therapy. The purpose of add-back therapy is:
The ESHRE PAIN II guideline on endometriosis recommends which approach as first-line medical treatment for pain in confirmed endometriosis?
The ASRM revised classification (1996) for endometriosis is based on laparoscopic findings. Stage IV (severe) endometriosis is defined by a total score of:
Dienogest, a fourth-generation progestogen used for endometriosis, acts by which primary mechanism?
Uterine artery embolization (UAE) for symptomatic fibroids is RELATIVELY contraindicated in which situation?
The American Society for Reproductive Medicine (ASRM) revised classification of endometriosis uses a scoring system (rAFS/rASRM) based on peritoneal implants, ovarian endometriomas, and adhesions. A score of 16–40 corresponds to which stage?
A 38-year-old woman with a 4 cm intramural fibroid presents with menorrhagia. She declines surgery and medical therapy has failed. Which minimally invasive option preserves the uterus while directly occluding uterine blood supply to the fibroid?
On transvaginal ultrasound, which finding is MOST specific for adenomyosis?
Which selective progesterone receptor modulator is approved in Europe for pre-operative treatment of uterine fibroids and has been associated with progesterone receptor modulator-associated endometrial changes (PAEC)?
A 35-year-old woman with deeply infiltrating endometriosis and a 3 cm chocolate cyst (endometrioma) presents with 18 months of primary infertility. Which management approach has the strongest evidence for improving natural conception rates?
A 38-year-old woman with adenomyosis on MRI presents with menorrhagia and dysmenorrhoea, declining hysterectomy. The non-surgical treatment with the strongest evidence for reducing menstrual blood loss in adenomyosis is:
A 34-year-old woman with deep infiltrating endometriosis of the rectovaginal septum is planned for surgical excision. The ENDOCARE classification describes which extent of disease?
A 38-year-old woman with symptomatic uterine fibroids (heaviest fibroid 8 cm, intramural, no submucosal component) seeks non-surgical management. She declines surgery. The MOST appropriate pharmacological long-term management is:
On MRI, adenomyosis is characterized by which of the following features?
A 28-year-old woman with surgically confirmed stage III endometriosis (revised ASRM) has dysmenorrhea and dyspareunia. She has completed childbearing plans for 2 years. The MOST appropriate medical treatment to suppress endometriosis pain long-term is:
A 34-year-old woman with stage IV endometriosis (American Society for Reproductive Medicine) and primary infertility has bilateral endometriomas (right 4 cm, left 3 cm) and a small amount of residual normal ovarian tissue. She is about to undergo IVF. What is the recommended approach to the endometriomas before IVF?
Adenomyosis on MRI is characterised by which of the following findings?
A 38-year-old woman with a 12 cm intramural fibroid causing menorrhagia and pressure symptoms refuses hysterectomy and wants to preserve her uterus. She is perimenopausal and has no desire for fertility. Which non-surgical uterus-conserving treatment is most appropriate?
Regarding the depth classification of endometriosis per ASRM revised scoring, which type of lesion contributes the most points to the total score?
The revised American Society for Reproductive Medicine (rASRM) staging of endometriosis assigns additional points for which ovarian endometrioma feature compared to a peritoneal implant of the same size?
A 38-year-old woman with symptomatic uterine fibroids (multiple, largest 5 cm, normal uterine cavity) desires future fertility. She is interested in a non-surgical option. Which treatment most consistently reduces fibroid volume while preserving fertility potential?
Which MRI finding is pathognomonic of adenomyosis and distinguishes it reliably from uterine fibroids?
The ENDOCAN-1 trial evaluated which surgical approach for Stage III–IV endometriosis before IVF?
The ESHRE 2022 Endometriosis Guideline recommends empirical medical treatment for suspected endometriosis in women with chronic pelvic pain before diagnostic laparoscopy. Which medical treatment is specifically NOT recommended as first-line empirical therapy because it lacks evidence for suppressing endometriosis-associated pain?
A 29-year-old woman with Stage III endometriosis has her endometriosis scored using the rASRM classification. She scores 48 points. The rASRM Stage IV threshold is >40 points. Which finding in the classification contributes MOST points?
On MRI, the junctional zone (JZ) thickness is the most reliable parameter for diagnosing adenomyosis. What maximum JZ thickness on MRI is considered diagnostic of adenomyosis?

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