9–1. Age has the greatest influence in the evaluation of a pelvic mass. Which of the following statements regarding demographic factors and pelvic masses is true?
a. Malignant ovarian tumors in children and adolescents are common.
b. Most gynecologic pelvic masses in prepubertal and adolescent girls involve the ovary.
c. Malignancy is a more frequent cause of pelvic masses in reproductive-aged women than in post-menopausal women.
d. None of the above
9–2. Which of the following statements regarding the pathology of leiomyomas is true as shown in part by these low-and high-power histologic images?
L = leiomyoma; M = myometrium. Photographs contributed by Dr. Kelley Carrick.
a. Each leiomyoma is derived from multiple progenitor myocytes.
b. Mitotic activity in their elongated smooth muscle bundles is common.
c. Leiomyomas possess a distinct autonomy from their surrounding myometrium.
d. Necrosis and degeneration develop infrequently in leiomyomas because of their abundant and well-organized blood supply.
9–3. Which of the following factors decreases the risk for development of leiomyomas?
a. Early menarche
b. Cigarette smoking
c. Elevated body mass index (BMI)
d. Polycystic ovarian syndrome (PCOS)
9–4. Mechanisms by which leiomyomas create a hyperestrogenic environment requisite for their growth and maintenance include which of the following?
a. Leiomyomas convert estradiol to estrone.
b. Leiomyoma cells contain a greater density of estrogen receptors compared with normal myometrium.
c. Leiomyomas contain higher levels of cytochrome P450 aromatase, which allows for conversion of androgens to estrogen.
d. All of the above
9–5. What type of leiomyoma is shown in this sonographic image?
a. Intramural
b. Subserosal
c. Submucosal, type 0
d. Submucosal, type I
9–6. Symptoms of leiomyomas have been correctly partnered with the appropriate pathophysiology in all EXCEPT which of the following pairs?
a. Asymptomatic—prolapsing fibroid
b. Menorrhagia—dilatation of endometrial venules
c. Pelvic pressure—mechanical compression
d. Acute pelvic pain—leiomyoma degeneration
9–7. Leiomyomas account for 2 to 3 percent of infertility cases. Which of the following describes the mechanisms by which leiomyomas may disrupt fertility?
a. Occlusion of tubal ostia
b. Distortion of normal uterine contractions
c. Disruption of implantation secondary to distortion of the endometrial cavity
d. All of the above
9–8. Rare complications of leiomyomas include all EXCEPT which of the following?
a. Leiomyomatosis
b. Cystic degeneration
c. Pseudo-Meigs syndrome
d. Myomatous erythrocytosis syndrome
9–9. As shown here, leiomyomas may commonly show which of the following sonographic features?
a. Cystic degeneration
b. Discrete borders with shadowing
c. Round hypoechoic myometrial mass
d. All of the above
9–10. Your 48-year-old patient presents with complaints of worsening menorrhagia. She has no other medical problems. Three-dimensional sonographic evaluation reveals the findings as shown below. All EXCEPT which of the following are suitable choices for medical treatment in this patient?
a. Combination oral contraceptives (COC)
b. Depot medroxyprogesterone acetate (DMPA)
c. Gonadotropin-releasing hormone (GnRH) agonist
d. Levonorgestrel-releasing intrauterine system (LNG-IUS)
9–11. Which of the following are proposed mechanisms of action of gonadotropin-releasing hormone (GnRH) agonists on leiomyomas?
a. GnRH agonists downregulate estrogen and progesterone receptors on the leiomyomas themselves.
b. GnRH agonists downregulate receptors on hypothalamic gonadotropes, thereby suppressing estrogen and progesterone levels.
c. GnRH agonists downregulate receptors on pituitary gonadotropes, thereby suppressing estrogen and progesterone levels.
d. None of the above
9–12. A 47-year-old woman presents to you with complaints of heavy menstrual bleeding and dysmenorrhea. She also is anemic, which you have determined from your evaluation to be secondary to leiomyoma-related bleeding. After thorough discussion of the various medical and surgical options, she wishes to proceed with a course of a gonadotropin-releasing hormone (GnRH) agonist. Which of the following statements is important to include in your counseling on this treatment?
a. Treatment can result in loss of trabecular bone, which may not be recouped following therapy discontinuation.
b. Side effects of GnRH agonists include vasomotor symptoms, libido changes, and vaginal dryness with accompanying dyspareunia.
c. Anticipated clinical benefits are reduced leiomyoma volume with diminished bleeding and pain. However, once therapy is stopped, leiomyomas regrow and regain pretreatment sizes within 3 to 4 months.
d. All of the above
9–13. Relative contraindications to uterine artery embolization (UAE) include all EXCEPT which of the following?
a. Desire for future fertility
b. Pedunculated subserosal or submucosal leiomyomas
c. Concurrent gonadotropin-releasing hormone (GnRH) agonist use
d. History of prior Neisseria gonorrhoeae or Chlamydia trachomatis infection
9–14. Compared with hysterectomy, uterine artery embolization (UAE) is associated with which of the following?
a. Longer hospitalization
b. Postembolization syndrome
c. Higher 24-hour postprocedural pain scores
d. Equivalent time frame for return to work
9–15. Your 35-year-old nulligravid patient comes to the office for counseling regarding uterine artery embolization (UAE) for treatment of her medically refractory menorrhagia secondary to leiomyomas. She desires future fertility. Which of the following complications of pregnancy is she at increased risk for after UAE?
a. Miscarriage
b. Cesarean delivery
c. Postpartum hemorrhage
d. All of the above
9–16. Frequent complications associated with uterine artery embolization include which of the following?
a. Groin hematoma
b. Leiomyoma tissue passage
c. Prolonged vaginal discharge
d. All of the above
9–17. All EXCEPT which of the following statements regarding magnetic resonance imaging-guided focused ultrasound therapy (MRgFUS) are true?
a. Long-term data regarding the duration of symptom relief are limited.
b. Less than 10 percent of women seek alternative treatments for their symptoms by 12 months following MRgFUS.
c. This technique focuses ultrasound energy to a degree that heats targeted leiomyomas to incite necrosis.
d. Contraindications include abdominal wall scars, contraindications to MR imaging, uterine size greater than 24 weeks, and desire for future fertility.
9–18. Advantages of laparoscopic versus open myomectomy include which of the following?
a. Equivalent febrile morbidity rates
b. Less adhesion formation
c. Improved pregnancy rates
d. Equivalent hospital stays
9–19. Which of the following surgical therapies does not have documented long-term effectiveness in the treatment of menorrhagia?
a. Myomectomy
b. Hysterectomy
c. Dilatation and curettage (D&C)
d. Hysteroscopic resection of submucous leiomyomas
9–20. A 32-year-old woman presents to the emergency department with complaints of progressively worsening midline lower pelvic pain during the last few months. She denies fever or vaginal discharge. Her last menstrual period (LMP) was 2 years ago. She states that she had a procedure done for heavy uterine bleeding, and after that, she “never had a period again.” Physical examination demonstrates a normal sized but tender uterus, her β-human chorionic gonadotropin (β-hCG) test is negative for pregnancy, and sonographic evaluation reveals the findings shown below. What is the most likely etiology for her condition?
a. Radiation treatment
b. Endometrial ablation
c. Congenital uterine anomaly
d. Prolonged hypoestrogenism with atrophy
9–21. Theories regarding the pathogenesis of adenomyosis include which of the following?
a. Metaplasia of pluripotent müllerian tissue
b. Invagination of the endometrial basalis layer into the myometrium
c. Myometrial weakness caused by pregnancy, uterine surgery, or compromised immunological activity at the endometrial–myometrial junction
d. All of the above
9–22. Which of the following symptoms of adenomyosis is correctly paired with its etiology?
a. Dysmenorrhea—increased prostaglandin production
b. Dysmenorrhea—hemorrhage within the ectopic glandular foci
c. Menorrhagia—increased and abnormal vascularization of the adenomyotic tissue
d. None of the above
9–23. Sonographic characteristics of diffuse adenomyosis may include which of the following?
a. Small myometrial hypoechoic cysts
b. Myometrial wall thickening with heterogeneous texture
c. Ill-defined endometrial echo with striated projections extending into the myometrium
d. All of the above
9–24. All EXCEPT which of the following are appropriate medical treatments for adenomyosis?
a. Copper intrauterine device
b. Combination oral contraceptives (COCs)
c. Nonsteroidal anti-inflammatory drugs (NSAIDS)
d. Levonorgestrel-releasing intrauterine system (LNG-IUS)
9–25. Which of the following tumor antigens is correctly paired with its ovarian tumor or malignancy?
a. Alpha-fetoprotein (AFP)—dysgerminoma
b. β-hCG—granulosa cell tumor
c. Cancer antigen 19-9 (CA19-9)—mucinous epithelial ovarian carcinoma
d. Lactate dehydrogenase (LDH)—yolk sac tumor and embryonal cell carcinoma
9–26. During the annual visit of a 56-year-old postmenopausal patient, you detect a right adnexal fullness during bimanual examination. Transvaginal sonography reveals a 3-cm thin-walled, unilocular cyst of the right ovary. She is asymptomatic. Which of the following is the most appropriate initial course of treatment?
a. Gynecologic oncology referral
b. Diagnostic laparoscopy with cystectomy
c. Expectant management with periodic surveillance if her CA125 level is normal
d. Prescription of combination oral contraceptive pills to hasten cyst resolution
9–27. Clinical criteria of a newly diagnosed pelvic mass in a premenopausal woman that should prompt referral to a gynecologic oncologist include all EXCEPT which of the following?
a. Ascites
b. CA125 level of 460 U/mL
c. Evidence of abdominal or distant metastasis
d. Family history of breast or ovarian cancer in a first-degree relative
9–28. All EXCEPT which of the following are risks factors for development of the ovarian lesion shown here?
a. Smoking
b. Tamoxifen
c. Combination oral contraceptives (COCs)
d. Levonorgestrel-releasing intrauterine device (LNGIUS)
9–29. A 25-year-old patient at 14 weeks’ gestation by last menstrual period presents to the emergency department with complaints of bilateral pelvic pain. Transabdominal sonography reveals these bilateral multilocular cystic ovarian masses. Which of the following commonly associated conditions must be excluded in pregnancies with this finding?
a. Fetal hydrops
b. Multifetal gestation
c. Gestational trophoblastic disease
d. All of the above
9–30. The sonographic “tip of the iceberg” sign corresponds to the site within a mature cystic teratoma where the most varied tissue types, such as hair and fatty secretions, are found. Pathologically, what is the name of this area?
a. Homunculus
b. Struma ovarii
c. Hydatid of Morgagni
d. Rokitansky protuberance
9–31. A 29-year-old G2P2 with a last menstrual period 3 weeks ago presents to the emergency department with complaints of worsening right pelvic pain. She states that she had the sudden onset of sharp pain after bending over to pick up one of her children. She experienced intense nausea with the pain. The pain did not respond to acetaminophen and has intermittently worsened during the past several hours. No adnexal masses were detected on physical examination, but the patient was guarding. Transvaginal sonography demonstrates an 8-cm enlarged right ovary without a dominant mass or cyst, high impedance arterial flow of the ovary on color Doppler interrogation, and no free fluid. These findings are most consistent with which of the following clinical diagnoses?
a. Appendicitis
b. Ovarian torsion
c. Hemorrhagic cyst
d. Ruptured corpus luteum cyst
9–32. Which of the following management plans is most appropriate for the patient in Question 9-31?
a. General surgery consultation
b. Laparoscopy with adnexectomy
c. Laparoscopy with detorsion of the ovary
d. Close observation with serial examinations
9–33. Which of the following statements regarding the pathology depicted here are true?
a. It can be associated with chronic pelvic pain.
b. It is the result of chronic swelling of the fallopian tube.
c. Women with this condition who undergo in vitro fertilization (IVF) have approximately half the pregnancy rate of other women.
d. All of the above
9–34. A 20-year-old nulligravida with a last menstrual period 5 days ago presents to the emergency department with generalized lower abdominal pain and fever. She reports a new sexual partner. Physical examination demonstrates guarding and bilateral adnexal fullness. Laboratory studies show leukocytosis, and transvaginal sonography reveals no visible ovaries but bilateral adnexal masses as shown here. The diagnosis most consistent with these findings is which of the following?
a. Endometriosis
b. Ovarian torsion
c. Tuboovarian abscess
d. Malignant ovarian neoplasm
Chapter 9 ANSWER KEY
