Question 66
Two weeks after delivery of a term infant boy following an uncomplicated pregnancy, a 25-year-old woman still has a vaginal discharge consisting of dark brown, foul-smelling material. Her temperature is 37.4 C. On pelvic examination, the uterus is slightly enlarged and she has pelvic tenderness. Laboratory studies show her serum beta-HCG is negative. Which of the following conditions is she most likely to have?
A Invasive mole
B Degenerating leiomyoma
C Sheehan syndrome
D Endometriosis
E Retained products of conception
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(E) CORRECT. The retained placental fragements are a source for infection producing an acute endometritis. A D&C must be done to remove the fragments. At the time of delivery, the placenta should be checked for completeness; a missing cotyledon suggests incomplete placental delivery.(A) Incorrect. Her beta-HCG is negative, so molar pregnancy is ruled out.(B) Incorrect. A leiomyoma may degenerate and abort following delivery, but this is a rare event.(C) Incorrect. Anterior pituitary necrosis leads to lack of lactation and other evidence for hypopituitarism which are signs of Sheehan's syndrome.(D) Incorrect. Endometriosis is the presence of endometrial glands and stroma outside the endometrium, producing pain but no discharge.----------------------------------------------------------------
Question 67
A 39-year-old woman has had dysmenorrhea for 7 months. On pelvic examination, there are no adnexal masses, and the cervix appears normal, but the uterus is three times normal size. The uterus appears to be symmetrically enlarged on abdominal ultrasound, with no masses present and an endometrial cavity that is nearly normal in size. A Pap smear is normal. Her serum pregnancy test is negative. A total abdominal hysterectomy is performed. Which of the following microscopic findings is most likely to be present in her uterus?
A Atypical glands invading through the uterine wall
B Large avascular villi with trophoblastic proliferation
C Hyperchromatic and pleomorphic smooth muscle cells
D Extensive acute inflammation
E Endometrial glands and stroma in the myometrium
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(E) CORRECT. Adenomyosis can produce diffuse uterine enlargement.(A) Incorrect. An endometrial adenocarcinoma is most likely to occur at a postmenopausal age, and it is not likely to greatly enlarge the uterus.(B) Incorrect. The avascular villi with trophoblastic proliferation are features of a molar pregnancy.(C) Incorrect. A leiomyosarcoma is usually a large, solitary mass.(D) Incorrect. Endometritis does not typically enlarge the uterus.
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Question 68
A 15-year-old girl has had irregular menstrual cycles for 5 months. She had menarche at age 13. There are no abnormal physical examination findings. An endometrial biopsy is taken on post-ovulatory day 9 and shows proliferative phase endometrium. Which of the following is the most likely diagnosis?
A Adenomyosis
B Anovulatory cycles
C Endometrial adenocarcinoma
D Leiomyomata
E Oral contraceptive use
F Ovarian thecoma
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(B) CORRECT. Anovulatory cycles occur most often at the time of menarche, menopause, or with ovarian dysfunction such as in polycystic ovarian disease.(A) Incorrect. Adenomyosis is uncommon at this age. It could produce irregular bleeding. The uterus is usually enlarged.(C) Incorrect. Endometrial adenocarcinoma is rare at this age.(D) Incorrect. Leiomyomas may produce irregular bleeding. It would be rare to have leiomyomas of sufficient size to produce problems at her age.(E) Incorrect. Oral contraceptive use produces regular menstrual cycles.(F) Incorrect. Ovarian thecomas could produce estrogens and cause endometrial hyperplasia and bleeding. An ovarian tumor is rare at her age, and it would produce a mass lesion.
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Question 69
A 29-year-old woman has had dyspareunia for the past 2 months. She has had only one sexual partner--her husband. She is G2 P2. On physical examination there are no abnormal findings except for a small but slightly tender 1.5 cm mass located in the right lateral wall of her vagina. The lesion is excised. On gross examination this mass is cystic and fluid filled. On microscopic examination the cyst is lined by a cuboidal epithelium. Which of the following is the most likely etiology for this lesion?
A Diethylstilbestrol exposure
B Embryologic remnant
C Gonoccocal infection
D Metastatic adenocarcinoma
E Oral contraceptive use
F Foreign body
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(B) CORRECT. This is a Gartner duct cyst, which is a remnant of the mesonephric duct in the lateral vaginal wall. They can be multiple. There is no risk for malignancy.(A) Incorrect. DES exposure leads to vaginal adenosis and to clear cell carcinomas.(C) Incorrect. Gonorrhea is more likely to produce a urethritis, cervicitis, or pelvic inflammatory disease. It is unlikely to produce a mass lesion of the vagina.(D) Incorrect. Carcinomas are uncommon at her age. The vagina is an uncommon site for metastases.(E) Incorrect. Oral contraceptive use does not lead to vaginal mass lesions.(F) Incorrect. Objects inserted are likely to be large and smooth-surfaced, though local trauma with abrasion or contusion is possible.
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Question 70
A 55-year-old woman has had lower abdominal pain for the past 6 months. She had a simple hysterectomy performed 25 years before. On pelvic examination, she has a vagina that ends in a blind pouch, and a large non-tender left adnexal mass is palpable. At laparotomy, there is a 9 cm mass involving the left ovary. Microscopic examination reveals malignant glands resembling endometrial glands. What pathologic abnormality was her hysterectomy specimen most likely to have shown?
A Endometriosis
B Adenomyosis
C Malignant mixed mullerian tumor
D Chronic endometritis
E Endometrial hyperplasia
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(A) CORRECT. An endometrioid carcinoma can develop in the setting of endometriosis. These processes can occur decades apart.(B) Incorrect. Adenomyosis does not carry a risk for development of any epithelial or stromal neoplasm.(C) Incorrect. A 3M tumor may have an epithelial component, but it is not related to ovarian endometroid carcinoma.(D) Incorrect. Chronic endometritis is not associated with malignancies, but the uterine bleeding that could occur must be distinguished from that caused by a carcinoma.(E) Incorrect. Atypical endometrial hyperplasia is a precursor to endometrial carcinoma.
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