13 - gynaecology mcqs - 76 to 80

Question 76

A 28-year-old woman develops the sudden onset of severe lower abdominal pain. On physical examination there is tenderness to palpation of the right lower quadrant. Laboratory studies show her serum pregnancy test is positive. An ultrasound scan does not reveal a gestational sac in the uterus, but there is a right adnexal mass. The development of these findings is most closely related to past infection with which of the following organisms?

A Treponema pallidum
B Human papillomavirus
C Neisseria gonorrheae
D Candida albicans
E Group B Streptococcus
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(C) CORRECT. Many cases of pelvic inflammatory disease (PID) are due to gonorrhea. The tubal scarring from the inflammation leads to an increased risk for ectopic pregnancy(A) Incorrect. Syphilis can produce a chancre of the external genitalia or cervix.(B) Incorrect. HPV is associated with increased risk for squamous epithelial dysplasias.(D) Incorrect. Candida is the cause for vaginitis.(E) Incorrect. This organism presents the greatest risk as an intrauterine infection resulting in stillbirth in the third trimester.

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Question 77

A 45-year-old woman has had irregular menstrual periods for the past 9 months. On physical examination she has an enlarged uterus. An ultrasound scan shows a 9 cm solitary, solid mass in the uterus. A total abdominal hysterectomy is performed. Gross examination of the irregular reddish-tan mass located in the myometrium shows bundles of smooth muscle cells along with heterogenous elements of pleomorphic cartilaginous cells. There are also areas with poorly differentiated gland formation. Mitotic figures are frequent. Which of the following neoplasms is she most likely to have?

A Leiomyosarcoma
B Sarcoma botryoides
C Malignant mixed mullerian tumor
D Endolymphatic stromal myosis
E Leiomyoma
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(C) CORRECT. The malignant mixed mullerian tumor typically has malignant components that are both epithelial and stromal. The stromal component does not always resemble just smooth muscle but may have sarcomatous elements resembling other mesodermal tissues.(A) Incorrect. The leiomyosarcoma is distinguished from a leiomyoma by the cellularity and the mitotic rate, but it is composed only of cells resembling smooth muscle.(B) Incorrect. Sarcoma botryoides is a rare neoplasm most likely to occur in the vagina of a child. It is composed of primitive cells most resembling an embryonal rhabdomyosarcoma.(D) Incorrect. This rare condition consists of endometrial stromal cells extending into the body of uterus and beyond.(E) Incorrect. A leiomyoma should not have a significant mitotic rate.

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Question 78

A 72-year-old woman has been feeling tired for the past year. She has had episodes of vaginal bleeding during this time. On physical examination there are no abnormal findings. Laboratory studies show Hgb 9.1 g/dL, Hct 26.5%, MCV 72 fL, platelet count 158,000/microliter, and WBC count 7150/microliter. An endometrial biopsy is performed and on microscopic examination shows atypical adenomatous hyperplasia. Which of the following is the most likely risk factor for development of her disease?

A Human papillomavirus infection
B Long term use of an intrauterine contraceptive device
C Chronic endometritis
D Pelvic inflammatory disease
E Unopposed estrogenic stimulation

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(E) CORRECT. The unopposed estrogen drives the hyperplasia, which if atypical carries an increased risk for development of an endometrial adenocarcinoma.(A) Incorrect. HPV infection mainly produces lesions of squamous epithelium of external genitalia and cervix, such as dysplasias and carcinoma.(B) Incorrect. An IUD can cause endometritis, but not a preneoplastic lesion.(C) Incorrect. Chronic endometritis is not generally known as an antecedent to preneoplastic or neoplastic conditions.(D) Incorrect. PID can produce inflammation with scarring, mainly of tubes and ovaries.
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Question 79

A 56-year-old G0 P0 woman reports vaginal bleeding in the past 2 months. Her last menstrual period was 6 years ago. On physical examination there are no abnormal findings. Which of the following procedures is most appropriate to perform on this woman?

A Endometrial biopsy
B Pap smear
C Vaginal culture
D Colposcopy
E CT scan

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(A) CORRECT. This history points to a possible endometrial carcinoma, and nulliparity increases the risk.(B) Incorrect. CIN is less likely than an endometrial lesion in this setting.(C) Incorrect. An infection would be unlikely to cause bleeding.(D) Incorrect. This will show cervical lesions, not endometrial.(E) Incorrect. The possible causes of uterine bleeding cannot be distinguished by CT (or MRI) scan.

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Question 80

A 50-year-old woman has experienced mild pelvic discomfort for 3 months. On physical examination there are bilateral adnexal masses. A pelvic CT scan reveals irregular unilocular cystic, bilateral mass lesions in the region of the ovaries. One is 10 cm and the other is 8 cm in size. Which of the following types of neoplasm is most likely to be present in this woman?

A Mature cystic teratoma
B Serous cystadenocarcinoma
C Endometrioid carcinoma
D Fibrothecoma
E Mucinous cystadenoma

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(B) CORRECT. Ovarian serous tumors are bilateral more often than other ovarian tumors. Serous cystadenocarcinomas are bilateral in about 2/3 of cases.(A) Incorrect. Teratomas of the ovary are bilateral in about 10 to 15% of cases.(C) Incorrect. These are bilateral in about 40% of cases; however, they tend to be solid masses.(D) Incorrect. These are unlikely to be bilateral; they are solid masses(E) Incorrect. Benign mucinous ovarian tumors are bilateral in about 5% of cases. Malignant mucinous ovarian tumors are bilateral about 20% of the time. They tend to be multilocular.

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6 - gynaecology mcqs - 41 to 45

Question 41
A 33-year-old woman has been on oral contraceptives for a year. She has noted vaginal bleeding for the past 5 weeks. The bleeding is not severe, but it occurs nearly every day. On pelvic examination, there is a 0.7 cm polypoid mass noted to extend outward from the endocervical region. The ectocervix appears normal. The uterus is normal in size. The adnexa have no palpable masses. A biopsy of this lesion is performed. Which of the following pathologic findings is most likely to be found on microscopic examination of this lesion?
A Endocervical adenocarcinoma
B Clear cell adenocarcinoma
C Microglandular hyperplasia
D Sarcoma botryoides
E Endocervical polyp
F Follicular cervicitis
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(C) CORRECT. This lesion occurs secondary to oral contraceptive use (those containing progestagens) and must be distinguished from adenocarcinoma histologically.
(A) Incorrect. This is an uncommon lesion that is unlikely to be present at this age.
(B) Incorrect. This unusual lesion is more likely to occur in the vagina of women who were exposed to diethylstilbestrol in utero when their mothers took this drug.
(D) Incorrect. This rare tumor, a form of embryonal rhabdomyosarcoma, is seen in the vagina of young girls.
(E) Incorrect. Endocervical polyps occur in about 2 to 5% of women but is not specifically related to oral contraceptive use.
(F) Incorrect. Follicular cervicitis appears grossly as erythema and irregular surface features of the cervix, but not a mass.
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Question 42
A 48-year-old woman has noted a small amount of irregular vaginal bleeding for the past 2 months. She has a pelvic examination that reveals no cervical lesions, and a Pap smear that shows no abnormal cells. Next, an endometrial biopsy is performed, and there is microscopic evidence for endometrial hyperplasia. An abdominal ultrasound reveals a solid right ovarian mass. Which of the following neoplasms is this woman is most likely to have?
A Mature cystic teratoma
B Choriocarcinoma
C Sertoli-Leydig cell tumor
D Fibrothecoma
E Krukenberg tumor
F Cystadenocarcinoma
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(D) CORRECT. Fibrothecomas and granulosa cell tumors can be estrogen producing. The excessive estrogen drives endometrial hyperplasia, which can progress to atypical adenomatous hyperplasia, which can progress to carcinoma.
(A) Incorrect. Struma ovarii is the most common variant of a 'dermoid' that secretes significant amounts of a hormone. Such benign teratomas are invariably cystic, usually filled with hair and sebum from a prominent ectodermal component.
(B) Incorrect. However, theca-lutein cysts of the ovary may occur with molar pregnancy.
(C) Incorrect. However, Sertoli-Leydig cell tumor can produce virilizing symptoms.
(E) Incorrect. This tumor represents a metastatic adenocarcinoma (usually from a gastric primary).
(F) Incorrect. Though cystadenocarcinoma is one of the more common ovarian neoplasms, it is not likely to be a source of steroid hormone secretion. Cystadenocarcinomas are likely to be cystic and not solid.
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Question 43
A 49-year-old perimenopausal woman has had vaginal bleeding for the past 6 months. On physical examination she has an enlarged, nodular uterus. A hysterectomy is performed. The surgeon notes several 0.2 to 1 cm translucent, smooth-surfaced, thin-walled, fluid-filled cysts near the fimbriated end of the right fallopian tube. Which of the following is the most likely diagnosis for these cysts?
A Gartner duct cysts
B Krukenberg tumors
C Parovarian cysts
D Pelvic inflammatory disease
E Mucinous cystadenomas
F Fibrocystic disease
G Omphalomesenteric duct cyst
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(C) CORRECT. Also called paratubal cysts, these are common incidental findings. They are embryologic remnants of the wolffian duct. They are not related to neoplasia. This woman had leiomyomas of the uterus which led to the hysterectomy.
(A) Incorrect. Such cysts are found in the anterolateral vaginal wall. They are derived from embryologic wolffian duct rests.
(B) Incorrect. These are metastatic adenocarcinomas, typically from the stomach.
(D) Incorrect. PID leads to inflammation with fibrosis, which may result in tubo-ovarian abscess.
(E) Incorrect. These are usually solitary large bulky tumors of the ovary.
(F) Incorrect. Fibrocystic disease (or fibrocystic changes) is a diagnosis applied to the breast.
(G) Incorrect. A remnant of the embryologic omphalomesenteric duct may be found from umbilicus to small bowel; the most common remnant is a Meckel diverticulum.
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Question 44
A 36-year-old woman has had episodes of lower abdominal and pelvic pain for the past 10 years. A bimanual pelvic examination reveals no abnormalities. A Pap smear is negative. She has an abdominal ultrasound scan that reveals no abnormalities. Finally, she undergoes laparoscopy, and her physician notes the presence of several 0.2 to 0.5 cm brown lesions located over the serosal surfaces of the uterus, fallopian tubes, and appendix. These lesions are excised. Which of the following microscopic findings is most likely to be present in these lesions?
A Endometrial glands and stroma
B Mesothelioma
C Metastatic carcinoma
D Small capillary proliferation
E Caseating granulomas
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(A) CORRECT. Pain is a major feature of endometriosis. The foci of endometriosis are most often found on serosal surfaces in the pelvis, but can be found in other locations such as the surface of the bowel.
(B) Incorrect. Endometriosis does not undergo malignant transformation and it is not associated with mesothelial lesions.
(C) Incorrect. Endometriosis (which has glands) is a benign process and not neoplastic.
(D) Incorrect. Though hemangiomas can be found at a variety of lcoations and can be multiple, they are not typically associated with pain.
(E) Incorrect. Granulomatous inflammation of the pelvis is uncommon; it is unlikely to be hemorrhagic.
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Question 45
A 47-year-old woman has noted a pressure sensation, but no pain, in her pelvic region for the past 5 months. On physical examination there is a right adnexal mass. An ultrasound scan shows a 10 cm fluid-filled cystic mass in the right ovary. A fine needle aspirate of the mass is performed and cytologic examination of clear fluid aspirated from the mass reveals clusters of malignant epithelial cells surrounding psammoma bodies. Which of the following neoplasms is she most likely to have?
A Endometrial adenocarcinoma
B Ovarian serous cystadenocarcinoma
C Mesothelioma
D Ovarian mature cystic teratoma
E Adenocarcinoma of fallopian tube
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(B) CORRECT. Ovarian carcinomas are often associated with ascites, because they seed throughout the peritoneal cavity. Psammoma body formation is common to malignant serous tumors of the ovary.
(A) Incorrect. Cells from such a carcinoma are usually shed into the endometrial cavity and psammoma body formation does not occur.
(C) Incorrect. Though clusters of mesothelioma cells might be difficult to distinguish from adenocarcinoma, mesotheliomas are quite rare and they do not make psammoma bodies.
(D) Incorrect. A mature cystic teratoma would not have malignant elements.
(E) Incorrect. An adenocarcinoma at this site is extremely rare.
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