22 The Female Genital Tract
1 A 24-year-old woman experiences sudden onset of severe lower abdominal pain. Physical examination shows no masses, but there is severe tenderness in the right lower quadrant. A pelvic examination shows no lesions of the cervix or vagina. Bowel sounds are detected. An abdominal ultrasound scan shows a 4-cm focal enlargement of the proximal right fallopian tube. A dilation and curettage procedure shows only decidua from the endometrial cavity. Which of the following laboratory findings is most likely to be reported for this patient?
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(E) 2 A 30-year-old, sexually active woman has had a mucopurulent vaginal discharge for 1 week. On pelvic examination, the cervix appears reddened around the os, but no erosions or mass lesions are present. A Pap smear shows numerous neutrophils, but no dysplastic cells. A cervical biopsy specimen shows marked follicular cervicitis. Which of the following infectious agents is most likely to produce these findings?
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(G) 3 A 36-year-old woman has had menorrhagia and pelvic pain for several months. She had a normal, uncomplicated pregnancy 10 years ago. She has been sexually active with one partner for the past 20 years and has had no dyspareunia. On physical examination, she is afebrile. A pelvic examination shows a symmetrically enlarged uterus, with no apparent nodularity or palpable mass. A serum pregnancy test result is negative. What is the most likely diagnosis?
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(E) 4 A 45-year-old woman has had menometrorrhagia for the past 3 months. On physical examination, there are no remarkable findings. The microscopic appearance of an endometrial biopsy specimen is shown in the figure. The patient undergoes a dilation and curettage, and the bleeding stops, with no further problems. What condition is most likely to produce these findings?
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5 A 31-year-old woman has had dull, constant abdominal pain for 6 months. On physical examination, the only finding is a right adnexal mass. CT scan of the pelvis shows a 7-cm circumscribed mass that involves the right ovary and contains irregular calcifications. The right fallopian tube and ovary are surgically excised. The gross appearance of the ovary, which has been opened, is shown in the figure. What is the most likely diagnosis?
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6 A healthy 52-year-old woman has had a feeling of pelvic heaviness for the past 11 months. There is no history of abnormal bleeding, and her last menstrual period was 8 years ago. Her physician palpates an enlarged nodular uterus on bimanual pelvic examination. A Pap smear shows no abnormalities. Pelvic CT scan shows multiple solid uterine masses; there is no evidence of necrosis or hemorrhage. A total abdominal hysterectomy is performed. Based on the gross appearance of the mass shown in the figure, what is the most likely diagnosis?
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(E) 7 A 33-year-old woman comes to the physician for a routine health maintenance examination. On physical examination, there are no abnormal findings. A Pap smear shows abnormalities; colposcopy and a biopsy are performed. The figure shows the microscopic appearance of the biopsy specimen. Which of the following factors is likely to have contributed most to the development of this lesion?
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(E) 8 A 62-year-old, obese, nulliparous woman had an episode of vaginal bleeding, which produced only about 5 mL of blood. On pelvic examination, there appears to be no enlargement of the uterus, and the cervix appears normal. A Pap smear shows cells consistent with adenocarcinoma. Which of the following conditions is most likely to have contributed to the development of this malignancy?
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(E) 9 A 36-year-old primigravida developed peripheral edema late in the second trimester. On physical examination, her blood pressure was 155/95 mm Hg. Urinalysis showed 2+ proteinuria, but no blood, glucose, or ketones. At 36 weeks, the patient gives birth to a normal viable, but low-birth-weight, infant. Her blood pressure returns to normal, and she no longer has proteinuria. Which of the following is most likely to be found on examination of the placenta?
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(E) 10 A 22-year-old woman, G2, P1, is in the early second trimester. She has noted a small amount of vaginal bleeding for the past week and has had marked nausea and vomiting for several weeks. On physical examination, the uterus measures large for dates. Ultrasound shows intrauterine contents with a “snowstorm appearance,” and no fetus is identified. The gross appearance of tissue obtained by dilation and curettage is shown in the figure. Which of the following substances is most likely to be increased in the serum?
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(G) 11 A 46-year-old perimenopausal woman has had pelvic discomfort for 5 months. On physical examination, the uterus appears slightly enlarged, and there are no adnexal masses. The cervix and vagina appear normal. A total abdominal hysterectomy is performed. The figure shows the gross (A) and microscopic (B) features of the uterus. Which of the following is most likely prevented by the hysterectomy performed on this patient?
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(F) 12 A 62-year-old childless woman noticed a blood-tinged vaginal discharge twice during the past month. Her last menstrual period was 14 years ago. Bimanual pelvic examination shows that the uterus is normal in size, with no palpable adnexal masses. There are no cervical erosions or masses. Her body mass index is 33. Her medical history indicates that for the past 30 years she has had hypertension and type 2 diabetes mellitus. An endometrial biopsy specimen is most likely to show which of the following?
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(F) 13 A 23-year-old woman, G3, P2, has a spontaneous abortion at 15 weeks’ gestation. The male fetus is small for gestational age and is malformed and has syndactyly of the third and fourth digits of each hand. The placenta also is small, and shows 0.5-cm grapelike villi scattered among morphologically normal villi. Chromosomal analysis of placental tissue is most likely to show which of the following karyotypes?
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(F) 14 A 54-year-old woman has had weight loss accompanied by abdominal enlargement for the past 6 months. She is concerned because of a family history of ovarian carcinoma. On physical examination, there are no lesions of the cervix, and the uterus is normal in size, but there is a left adnexal mass. An abdominal ultrasound scan shows a 10-cm cystic mass in the left adnexal region, with scattered 1-cm peritoneal nodules. Cytologic studies of peritoneal fluid show malignant cells consistent with a cystadenocarcinoma. Which of the following mutated genes is most likely a factor in the development of this neoplasm?
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(E) 15 A 4-year-old girl is brought to the physician by her parents, who noticed blood-stained underwear and “something” protruding from her external genitalia. On physical examination, there are polypoid, grapelike masses projecting from the vagina. Histologic examination of a biopsy specimen from the lesion shows small, round tumor cells, some of which have eosinophilic straplike cytoplasm. Immunohistochemical staining shows desmin in these cells. What is the most likely diagnosis?
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(E) 16 A 42-year-old woman has had menometrorrhagia for the past 2 months. She has no history of irregular menstrual bleeding, and she has not yet reached menopause. On physical examination, there are no vaginal or cervical lesions, and the uterus appears normal in size, but there is a right adnexal mass. An abdominal ultrasound scan shows the presence of a 7-cm solid right adnexal mass. Endometrial biopsy shows hyperplastic endometrium, but no cellular atypia. What is the most likely diagnosis?
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(F) 17 A 19-year-old woman has had pelvic pain for 1 week. A pelvic examination shows mild erythema of the ectocervix. A Pap smear shows many neutrophils, but no dysplastic cells. A cervical culture grows Neisseria gonorrhoeae. If the infection is not adequately treated, the patient will be at increased risk for which of the following complications?
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(F) 18 A 28-year-old, sexually active woman comes to her physician for a routine health maintenance examination. There are no abnormal findings on physical examination. The patient has been taking oral contraceptives for the past 10 years. A Pap smear shows a moderate dysplasia, or cervical intraepithelial neoplasia (CIN) II. What is the major significance of this finding?
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(E) 19 A 40-year-old, G5, P5 woman has noticed lower abdominal pain with fever for the past 2 days. She delivered a normal term infant 1 week ago. On examination, she has a temperature of 37.4°C. There is a foul-smelling vaginal discharge. Which of the following pathologic findings is she most likely to have?
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(F) 20 A 25-year-old woman has experienced discomfort during sexual intercourse for the past month. On physical examination, there are no lesions of the external genitalia. Pelvic examination shows a focal area of swelling on the left posterolateral inner labium that is very tender on palpation. A 3-cm cystic lesion filled with purulent exudate is excised. In which of the following structures is this lesion most likely to develop?
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(E) 21 A 58-year-old woman has had dull pain in the lower abdomen for the past 6 months and minimal vaginal bleeding on three occasions. Her last menstrual period was 14 years ago. Pelvic examination shows a right adnexal mass, and the uterus appears normal in size. An abdominal ultrasound scan shows an 8-cm solid mass. A total abdominal hysterectomy is performed, and the mass is diagnosed as an ovarian granulosa-theca cell tumor. Which of the following additional lesions is most likely to be found in the excised specimen?
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(E) 22 A 43-year-old woman has had postcoital bleeding for 6 months. She experienced menarche at age 11 and has had 12 sexual partners during her life. She continues to have regular menstrual cycles without abnormal intermenstrual bleeding. Pelvic examination shows a focal, slightly raised area of erythema on the cervix at the 5 o’clock position. A Pap smear shows high-grade cervical intraepithelial neoplasia (CIN III). In situ hybridization performed on cells from the cervix shows the presence of human papillomavirus type 16. If the cervical lesion is not treated, which of the following malignancies is she at greatest risk of developing?
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(G) 23 An 18-year-old woman has had pelvic discomfort for several months. On pelvic examination, there is a 10-cm right adnexal mass. An abdominal CT scan shows the mass to be solid and circumscribed. On surgical removal, the mass is solid and white, with small areas of necrosis. Microscopically, it contains mostly primitive mesenchymal cells along with some cartilage, muscle, and foci of neuroepithelial differentiation. What is the most likely diagnosis?
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(G) 24 A 32-year-old woman has cyclic abdominal pain that coincides with her menses. Attempts to become pregnant have failed over the past 5 years. There are no abnormal findings on physical examination. Laparoscopic examination shows numerous hemorrhagic 0.2- to 0.5-cm lesions over the peritoneal surfaces of the uterus and ovaries. Which of the following ovarian lesions is most likely to be seen during the laparoscopic procedure?
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(F) 25 A 37-year-old woman has noted increasing size of a red, pruritic lesion on her left labium over the past 7 months. On examination, this rough, scaly lesion is 0.4 × 0.9 cm. On physical examination, the lesions are slightly raised, soft pink to white in color, and 0.2 to 1 cm in diameter. The perineum appears normal; there is no lymphadenopathy, and there are no rectal lesions. A Pap smear shows no abnormal findings. The lesion is excised; on microscopic examination, there is infiltration of the lower dermis by large cells having pale blue to granular cytoplasm. What is the most likely diagnosis?
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