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Saturday, 7 July 2012

FEMALE GENITAL TRACT


THE FEMALE GENTAL TRACT PATHOLOGY MCQs
1.       During a routine health check examination a 26 year old female is found to have no abnormalities after a physical examination. Cells consistent with intraepithelial neoplasis are shown by a screening pap smear. Which of the following strongly relates to the Pap smear findings?
(A)   Multiple sexual partners
(B)   Vitamin B12 deficiency
(C)   Treated squamous cell carcinoma
(D)   Intake of oral contraceptives
Correct answer: A
(A)   Correct. Having multiple sexual partners or having a male partner who has many sexual partners increases the risk of developing CIN1. This is because of increased chances of contracting the HPV infection.
(B)   Incorrect. Vitamin B12 deficiency does not cause CIN1 although it may produce some megaloblastic epithelial changes.
(C)   Incorrect. Treated carcinoma pauses no threat in the development of CNI1.
(D)   Incorrect. There is no relationship between oral contraceptives intake and the development of CNI1.

2.       A 29 year old woman visits a physician with and complains of pain during coitus. There are no lesions on her external genitalia. A focal area of swelling on the left posterolateral inner labium is shown by a pelvic examination. The area is very tender and a cystic lesion that is 3cm and full of purulent exudates is excised. Which among the following is the lesion most likely to develop from?
(A)   Hair follicle
(B)   Vestibular bulb
(C)   Bartholins’s gland
(D)   Gartner duct
Correct answer: C
(A)   Incorrect. Hair follicles are absent in the inner labia
(B)    Incorrect. The vestibular bulb does not become cystic since it’s not glandular
(C)   Correct. The bartholin’s gland at times becomes obstructed, cystic and inflamed due to formation of abscess
(D)   Incorrect.  A Gartner duct cyst may form in the lateral vaginal wall. It is usually fluid filled but never inflamed

3.       The parents of a 3 year old girl noticed some vaginal bleeding from by their daughter. A physical examination shows polyploidy, grape-like masses protruding from her vagina. A biopsy specimen is examined under a microscope and small, round tumor cells (some of which show eosinophilic strap-like cytoplasm) are discovered. Desmin is also shown by immunohistochemical staining. Which of the following would be the most likely diagnosis?
(A)   Infiltrating squamous cell carcinoma
(B)   Condyloma acuminatum
(C)   Neuroblastoma
(D)   Sarcoma botryoides.
Correct answer: D
(A)   Incorrect. Squamous cell carcinoma is extremely rare in very young patients and if present it would show histological evidence of squamous epithelial differentiation.
(B)   Incorrect. Condyloma acuminate is caused by the human papilloma virus which is sexually transmitted and as such very rare in very young patients.
(C)   Incorrect. Neuroblastomas occur in the extra-adrenal sympathetic chain or adrenal gland. They are also small blue tumors.
(D)   Correct. Also called embryonal rhabdomyosarcoma and is found in young girls below the age of 5 years.  A microscopic examination shows small, round, blue cell tumors exhibiting skeletal muscle differentiation in presence of muscle specific proteins e.g. Desmin

4.       Over the past 3 years a sexually active 20 years old woman noticed multiple warty lesions on the perineum. A physical examination revealed slightly raised lesions which are pink to white in color. They measure about 0.2 – 1 cm in diameter. Necrosis or acute inflammation is absent. A scraping from one of the lesion produces cells which are cytologically consistent with koilocytotic atypia. Choose the infectious agent likely to produce the findings above.
(A)   Trichomonas vaginalis
(B)   Human papillomavirus
(C)   Neisseria gonorrhea
(D)   Chlamydia trachomatis
Correct answer: B
(A)   Incorrect. This organism causes cervicitis. A discharge containing inflammatory cells is produced
(B)   Correct. HPV causes squamous epithelial changes referred to as koilocytosis
(C)   Incorrect. Gonococcus cause acute cervicitis characterized by acute inflammatory infiltrate.
(D)   Incorrect. Like trichomonas vaginalis, this organism causes cervicitis and inflammatory cells are produced.

5.       A 20 year old lady goes to a physician complaining of pelvic pain for the last 1 week. Mild erythema of the pelvis is discovered after a pelvic examination. Many neutrophils are seen from a pap smear but no dysplastic cells are present. Neisseria gonorrhea grows from a cervical culture. Which of the following complications would the patient suffer from if the infection is not adequately treated?
(A)   Ectopic pregnancy
(B)   Placenta previa
(C)   Endometriosis
(D)   Cervical carcinoma
Correct answer: A
(A)   Correct. Pelvic inflammatory disease and salphingitis predisposes an individual to ectopic pregnancy. The two are caused by gonorrheal infections. No dysfunctional bleeding is caused by gonorrhea and other GTI infection.
(B)   Incorrect. It is related to sexually transmitted infections. It results from low lying implantation of the placenta.
(C)   Incorrect. Its actual cause is unknown
(D)   Incorrect. Carcinoma would lead to dysplasia

6.       The pelvic examination of a 32 year old woman who has had a whitish, globular vaginal discharge for the past five days reveals a cervix which appears erythematous. Erosions and masses are absent. A pap smear shows presence of budding cells and pseudohyphae. No dysplastic cells are present. Which among the following is likely to produce such findings?
(A)   Chlamydia trichomonas
(B)   Human papilloma virus
(C)   Candida albicans
(D)   Neisseria gonorrhea  
Correct answer: C
(A)   Incorrect. Produces pus-like vaginal discharge but hyphae is not produced since these are protozoa.
(B)   Incorrect. Bacteria that produces cervicitis.
(C)    Correct. Presence of pseudohyphae indicates a fungal infection. Candida vaginalis is very common and produces superficial inflammation.
(D)   Incorrect. This is a bacteria that causes gonorrhea

7.       After an abdominal ultrasound, a 7cm solid right adnexal mass is detected.  The patient is a 40 year old woman who has reached menopause and has menometrorrhagia for the past two months. Never before has she had irregular menstrual bleeding. Endometrial biopsy reveals hyperplastic endometrium but no cellar atypia. What would be the most appropriate diagnosis?
(A)   Granulosa-theca cell tumor
(B)   Metastasia
(C)   Endometrioma
(D)   Stroma ovarii
Correct answer: A
(A)   Correct. Endometrial hyperplasia indicates presence of estrogen producing tumors of the ovary. Granulosa-theca is such a tumor.
(B)   Incorrect. Ovary metastases does not necessarily cause increase in estrogen production.
(C)   Incorrect. Endometrioma is produced by endometriosis. Although hormonally sensitive, endometrial glands do not produce estrogen.
(D)   Incorrect. Strom ovarii causes hyperthyroidism when thyroid tissue which is present on the mass becomes functional.

8.       What would be the most likely diagnosis for a 49 year old woman who presents with vaginal bleeding? She reached menopause 4 years ago. A physical examination shows no abnormality. Endometrial adenocarcinoma is discovered from an endometrial biopsy and total abdominal hysterectomy follows. She has a normal sized uterus, but a sectioning shows a single 1.5cm firm, tan white, circumscribed subarerosal nodule.
(A)   Endometrioma
(B)   Choriocarcinoma
(C)   Leiomyoma
(D)   Metastasis
Correct answer: C
(A)   Incorrect. Develops due to recurrent hemorrhage and is mostly a cystic lesion with its centre filled by brown sludge.
(B)   Incorrect. Choriocarcinoma is rare in women who have reached menopause.
(C)   Correct. It is also called fibroids and is present in 30 – 50% of all women. They cease growing after menopause and do not show symptoms.
(D)   Incorrect. Solitary metastasis to the serosa is usually rare.

9.       A woman in her early 30s experiences cyclic abdominal pains that coincides with her menses. She has unsuccessfully tried conceiving for the last 5 years. A physical examination yields no findings. Numerous hemorrhagic 0.2 – 0.5 lesions over the peritoneal surface of the ovaries uterus are shown by a laparoscopic examination. Of the following ovarian lesion, which is most likely to be visualized during the laparoscopic procedure?
(A)   Mature cyst teratoma
(B)   Fibroma
(C)   Brenner tumor
(D)   Endometriotic tumor.
Correct answer: D
(A)   Incorrect. The woman is suffering from endometriosis which has no relationship with mature cyst teratoma.
(B)   Incorrect. Fibroma is not associated with endometriosis
(C)   Incorrect. Brenner tumor has no association with endometriosis
(D)   Correct. In the event of endometriosis, functional endometrial glands are located outside the uterus. This could be uterine ligaments or ovaries. Abdominal pain occurs as a result of these glands responding to ovarian hormones. Recurrent hemorrhage cause scaring and distortion of fallopian tubes and ovaries. This leads to infertility.

10.   A woman in her mid thirties who experienced menarche at the age of 11 has experienced bleeding after coitus for the last 6 months. She has had 10 sexual partners in her life. Her menstrual cycle is regular with no abnormal inter-menstrual bleeding. Pelvic examination reveals a focal area of erythema at the 5 o’clock position of the cervix. A pap smear confirms CIN3 and presence of human papillomavirus is discovered after performing in situ hybridization. Which of the following malignancies is she likely to develop if the cervical lesion is not treated?
(A)   Krokeberg tumor
(B)   Immature teratoma
(C)   Clear cell carcinoma
(D)   Squamous cell carcinoma
Correct answer: D
(A)   Incorrect. A Krokeberg tumor is just a form of metastasis to the ovary
(B)   Incorrect. An immature teratoma also arises from the ovary
(C)   Incorrect. Clear cell carcinoma of the cervix is fairly uncommon with some of them being associated with maternal use of diethylstilbestrol in pregnancy
(D)   Correct. Multiple sexual partners, HPV type 16 and high grade squamous intraepithelial neoplasm predispose a woman to squamous cell carcinoma

11.   Which of the following tumor has the highest degree of bilateral involvement?
(A)   Serous cystadenocarcinoma
(B)   Endometroid carcinoma
(C)   Serous cystadenoma
(D)   Mucinous cystadenoma
Correct answer: A
(A)   Correct. Serous cystadenocarcinoma has a bilaterarity of about 70%
(B)   Incorrect: this one has a bilaterarity rate of about 45%
(C)   Incorrect. Serous cystadenocarcinoma has a bilaterarity rate of about 30%
(D)   Incorrect. Mucinous cystadenocarcinoma has the lowest rate of bilaterarity rate which is 5%

12.   Following pelvic discomfort a 19 year old woman goes to a hospital and after a pelvic examination a 10 cm right adrenal mass is discovered. Abdominal CT scan reveals the mass to be solid and circumscribed. The solid mass is surgically removed and it appears white and contains small areas of necrosis. A microscopic examination shows primitive mesenchymal cells, cartilage, muscle and foci of neuroepithelial differentiation. Which of the following is the most likely diagnosis?
(A)   Sarcoma botryoides
(B)   Brener tumor
(C)   Granulosa cell tumor
(D)   Immature teratoma
Correct answer: D
(A)   Incorrect. This tumor is common in young girls. It resembles embryonal rhabdomyosarcoma
(B)   Incorrect. These tumors affect the ovaries. They contain epithelial nests resembling transitional cells of the urinary tract
(C)   Incorrect. The cells in this kind of tumor resemble those in the ovarian follicles. At times they may secrete estrogens
(D)   Correct. These are not cyclic and different tissues from different germ cell layers are present. Neuroectodermal tissue are present in these immature taratomas

13.   A 60 year old notices a pale discolored area on her labia. She is subjected to a pelvic examination and a 0.7cm flat white area on the right labia majora is discovered. 50% of the squamous epithelium is occupied by dysplastic cells where there is minimal underlying chronic inflammation. In situ hybridization reveals human papillomavirus type 6 DNA in the epithelial cell. Which of the following is the most likely diagnosis?
(A)   Squamous hyperplasia
(B)   Vulvar intraepithelial neuplasia
(C)   Lichens sclerosus
(D)   Condyloma acuminatum
Correct answer: B
(A)   Incorrect. This is a form of vulvar dystrophy which appears as an area of leukoplakia. Dysplastic changes are absent.
(B)   Correct. VIN presents with dysplastic cells occupying half the thickness of the epithelium. HPV infection increases incidence of these lesions. Some VIN lesions may progress into invasive cancer
(C)   Incorrect. This is another form of vulvar dystrophy. It causes thinning of the squamous epithelium and sclerosis of the dermis.
(D)   Incorrect. A condyloma is a nodular lesion caused by HPV-6 and HPV-11. The lesion is usually raised.

14.   A 57 year old woman has been experiencing dull lower abdominal pain for the past 7 months. She has had three incidences of vaginal bleeding. A pelvic examination is carried out and a right adnexal mass is discovered. The uterus appears normal in size. A 7cm solid mass is shown by an abdominal ultrasound. After a hysterectomy, it is concluded that the mass is an ovarian-granulosa theca. Which of the following is also most likely to be found in the excised specimen?
(A)   Endometrial hyperplasia
(B)   Condyloma acuminata of the cervix
(C)   Chronic salphingitis
(D)   Partial mole of the uterus
Correct answer: A
(A)   Correct. Most granulosa-theca cells are estrogen producing and lead to carcinoma or hyperplasia. Most of them do not metastasize.
(B)   Incorrect. Condyloma mostly affects young women who are sexually active. It is linked to HPV infections
(C)   Incorrect. Chronic salphingitis is linked to STIs like gonorrhea
(D)   Incorrect. A partial mole occurs only in women in the reproductive age

15.   A 64 year old woman who has never had a child noticed a bloody vaginal discharge twice last month. She reached menopause 16 years ago. Neither abnormality in the size of the uterus nor palpable adnexal masses are detected during a physical examination. No cervical erosion or masses are present. She has had type 2 diabetes mellitus and hypertension for the last 30 years. Her BMI stands at 33. What is likely to be shown by an endometrial biopsy?
(A)   Choriocarcinoma
(B)   Leiomyosarcoma
(C)   Adenocarcinoma
(D)   Adenomyosis
Correct answer: C
(A)   Incorrect. Although choriocarcinomas produce the same findings as above, they are of gestational origin
(B)   Incorrect. This disorder produces vaginal bleeding but it also causes enlargement of the uterus
(C)   Correct. Postmenopausal bleeding is a strong indicator of endometrial carcinoma. Risk factors include; obesity, type 2 diabetes mellitus, hypertension and infertility
(D)   Incorrect. In adenomyosis the stroma and endometrial glands protrude into the myometrium. This leads to symmetrical uterine enlargement

16.   A physical examination carried out on a 26 year old sexually active woman shows no abnormalities. She has been on oral contraceptives for the past 8 years. Moderate dysplasia is shown by a pap smear. Which of the following is of major significance in these findings?
(A)   The patient has increased risk of cervical carcinoma
(B)   Condyloma acuminata might be present
(C)   Treatment of cervicitis needs to be treated
(D)   Excision of an endocervical polyp is needed
Correct answer: A
(A)   Correct. Naturally dysplasias progress to more severe dysplasias and eventually to invasive carcinoma. There is a strong relationship between dysplasias and HPV
(B)   Incorrect. Although condyloma acuminatum is strongly linked to HPV the type is usually the low risk type
(C)   Incorrect. Cervicitis is due to fungal or bacterial infection and does not pause a risk of carcinoma or dysplasia
(D)   Incorrect. Although endocervical polyps produce bleeding they do not show dysplasia

17.   A 64 year old woman with a BMI of 33 experiences vaginal bleeding. About 6 mm of blood is produced. No uterus enlargement is shown by a physical examination. A pap smear reveals cells consistent with adenocarcinoma. Which of the following might have been a risk factor in the development of the malignancy?
(A)   Chronic endometritis
(B)   Endometrial hyperplasia
(C)   Human papillomavirus
(D)   Adenomyosis
Correct answer: B
(A)   Incorrect. Chronic endometritis does not give rise to cancer
(B)   Correct. Endometrial hyperplasia results from estrogenic stimulation from obesity, nulliparity, anovulatory cycles etc. it can progress into endometrial carcinoma if the estrogenic stimulation persists.
(C)   Incorrect. HPV does not give rise to cancer
(D)   Incorrect. Adenomyosis enlarges the uterus but does not pause a risk in development of endometrial carcinoma.

18.   A 15 year old girl who experienced menarche at the age of 13 experiences abnormal uterine bleeding. Menstrual period lasts 2-7 days and is 2-6 weeks apart. Considerable variation in the amount of bleeding is observed; sometimes minimum spotting and at times heavy flow. A physical examination yields no remarkable findings. No abnormality is detected via an ultra sound. Which of the following is the most likely to produce these findings?
(A)   Ectopic pregnancy
(B)   Endometrial polyps
(C)   Endometrial carcinoma
(D)   Anovulatory cycles
Correct answer: D
(A)   Incorrect. An ectopic pregnancy lacks a prolonged course and would produce acute findings
(B)   Incorrect. Polyps are uncommon in young girls
(C)   Incorrect. Endometrial carcinomas are rare in young girls
(D)   Correct. Young women who are just beginning menstruation and older women approaching menopause usually experience dysfunctional uterine bleeding due to anovulatory cycles

19.   After experiencing shortness of breath and producing a bloody brown vaginal discharge, a 21 year old woman sees a physician. A physical examination shows a brown mass on the lateral wall of her vagina. The mass measures 3cm. numerous 2 to 5cm nodules are also discovered in both lungs after chest radiography.  A Biopsy specimen of the vaginal mass reveals malignant cells consistent with those of synctiotrophoblast. Which proteins might have increased in the serum?
(A)   Testosterone
(B)   Human chorionic gonadotropin
(C)   Carcinoembryonic antigen
(D)   Alpha fetoprotein.
Correct answer: B
(A)   Incorrect. Testosterone is usually elevated in case of leydig cell tumors.
(B)   Correct. This patient is suffering from choriocarcinoma which causes metastasis in the vaginal wall and lungs. Synctiotrophoblastic cells produce human chorionic gonadotropin.
(C)   Incorrect. Carcinoembryonic antigen is characteristics of visceral malignancies.
(D)   Incorrect. Alpha fetoprotein is elevated in presence of yolk sac tumors.

20.   A 29 year old female experiences pelvic pain, fever and pelvic heaviness for the past 1week. She visits her physician and undergoes a pelvic examination and laparoscopy. A palpable left adnexal mass is shown by a pelvic examination. The laparoscopy shows an indistinct right fallopian tube that is part of a 6 cm circumscribed tan mass involving the right adnexal region. Of the following infections which is most likely to produce such findings?
(A)   Trepanoma pallidum
(B)   Candida albicans
(C)   Chlamydia trachomatis
(D)   Herpes simples virus
Correct answer: C
(A)   Incorrect. Trepanoma pallidum results into syphilis which does not produce florid inflammation with mass effect
(B)   Incorrect. Candida infections mostly affect the vagina and the cervix. These infections are fairly superficial.
(C)   Correct. The lady is suffering from salphingitis which is caused by increase in mycoplasma and Chlamydia.
(D)   Incorrect. The herpes simplex virus mostly affect the external genitalia and at times produces lesions on the cervix or vagina but does not proceed further

21.   A 19 year old woman who had her first menstrual period 5 years ago visits a physician. For several years her menstrual cycle has been fairly regular but during the past 1 year she gets oligomenorrhea and develops hirsutism. In the past 1 month she has gained 10 kg. A pelvic examination yields no significant abnormal findings. Ultrasound of the pelvis shows that each ovary has enlarged to twice their normal size. Which of the following is the most likely diagnosis?
(A)   Polycystic ovaries
(B)   Krukenberge tumor
(C)   Tubo-ovarian abcesses
(D)    Cytodenocarcinoma
Correct answer: A
(A)   Correct. The origin of polycystic disease is unclear but it is associated with oligomenorrhea, hirsutism and obesity
(B)   Incorrect. These tumors are rare in young patients
(C)   Incorrect. Abscesses are mostly unilateral and do not cause hormonal changes seen in this patient
(D)   Incorrect. Although cystadenocarcinoma can be bilateral, production of androgens by the ovarian tumor is rare

22.   A 30 year old woman visits a physician and complains of abdominal enlargement. She takes a pregnancy test and the results are negative. A physical examination reveals abdominal distention with a fluid wave. Presence of bilateral cystic ovarian masses is detected via an ultrasound. One is located on the right and measures 8 cm while the other is located on the left and measures 11 cm. These masses are removed surgically and examined. They appear as fluid filled unilocular cysts with papillary projections that extend into the central lumen of the cyst. Atypical cuboidal cells cover the papillae and are invading underlying stroma. Psammoma bodies are present. Which of the following is the most likely diagnosis?
(A)   Dysgerminoma
(B)   Clear cell carcinoma
(C)   Sertoli-leydig carcinoma
(D)   Cystadenocarcinoma
Correct answer: D
(A)   Incorrect. These are solid tumors of germ line origin
(B)   Incorrect. These are malignancies of the vagina and cervix which are uncommon
(C)   Incorrect. These are solid brown masses that at times secrete androgens or estrogen. They are uncommon
(D)   Correct. These are common ovarian tumors that are bilateral. The serous type is much more common than the mucinous type. These tumors can be benign, malignant or borderline

23.   A sexually active woman aged 30 experiences a mucopulurent vaginal discharge for 1 week. A pelvic examination shows a cervix that is reddened around the os region. Neither mass lesions nor erosions are present. A pap smear shows numerous microphages but no dysplastic cells. A biopsy of the cervix reveals follicular cervicitis. Which of the following is likely to produce such findings?
(A)   Chlamydia trachomatis
(B)   Human papillomavirus
(C)   Trichomonas vaginalis
(D)   Candida albicans
Correct answer: A
(A)   Correct.  The most common cause of cervicitis in sexually active women is Chlamydia trachomatis. The red inflamed cervix indicates cervicitis
(B)   Incorrect. A HPV infection is always associated with carcinoma, condyloma and dysplasias
(C)   Incorrect. Trichomonas infection would produce homogenous, frothy and sticky green vaginal discharge.
(D)   Incorrect. Candidiasis produces a scant, white curd-like vaginal discharge.

24.   Dysplastic cells are present in a pap smear from a 34 year old woman. The lesion is consistent with CIN 3. Colposcopy and several other biopsies confirm CIN 3. A focus of the microinvasion is shown by conization of the cervix. Which of the following would be the next course of action in treatment of the patient based on the findings above?
(A)   No further therapy
(B)   Radiation therapy
(C)   Hysterectomy
(D)   Bone scan

Correct answer: A
(A)   Correct. Stage 1 lesions have a rate of survival similar to that one of in situ lesions with minimal likelihood of metastasizing and as such do not call for aggressive therapies.
(B)   Refer to A
(C)   Refer to A
(D)   Refer to A

25.   Following severe abdominal pain, a 23 year old female visits a physician. Although masses are not shown by a physical examination, the right lower quadrant is severely tender. A pelvic examination follows and no vaginal or cervical lesions are discovered. Bowel sounds are present. An ultrasound of the abdomen shows a 4 cm focal enlargement of the proximal right fallopian tube. Curettage and dilation procedures only show deciduas from the endometrial cavity. Which one of the following is the most likely laboratory finding?
(A)   Positive result for serum pregnancy test
(B)   Candida present from a pap smear
(C)   Positive result for the serological test for syphilis
(D)   Cervical culture positive for Neisseria gonorrhoeae
Correct answer: A
(A)   Correct. This lady has an ectopic pregnancy. The predisposing factors for ectopic pregnancy are, chronic salphingitis, intrauterine tumor and endometriosis
(B)   Incorrect. Candida produces vaginitis and cervicitis. It is rarely invasive unless in the case of immunocompromised patients
(C)   Incorrect. It is unlikely for syphilis produce a tubal mass with acute symptoms
(D)   Incorrect. Though gonorrhea causes salphingitis which is a predisposing factor for ectopic pregnancy a culture would only be positive in the case of acute infection


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