uWISE Unit 5: Neoplasia

A 28-year-old G1P1 previously healthy woman is brought into the emergency department by her husband following a seizure at home. She had been complaining of a severe headache for two days prior to this, and had been feeling more and more fatigued and short of breath since the delivery of their child three months ago. She has been breastfeeding, and began to have vaginal spotting one month ago. Her neurologic and physical examinations are unremarkable and her pelvic exam reveals a normal uterus with no adnexal masses. Her work-up reveals multiple nodules on chest X-ray and within the brain and liver, suspicious for metastasis. Choriocarcinoma is highly suspected. Which of the following tests will confirm the diagnosis in this case? A. Quantitative Beta-hCG B. Serum CA-125 C. Transvaginal ultrasound D. Fine needle aspiration of the liver lesions E. Biopsy of a chest nodule

A. A diagnosis of choriocarcinoma is made once the presence of Beta-hCG is confirmed. Certainly, intrauterine pregnancy and ectopic pregnancy must be excluded, but this can easily be done depending on the quantitative level. In the presence of metastatic disease of unclear primary, the diagnosis of GTD (choriocarcinoma) must be considered. Ultrasound is useful in ruling out an intrauterine or ectopic pregnancy, but provides no information if the Beta-hCG is negative or below the discriminatory zone. Serum CA-125 is a tumor marker for most epithelial ovarian cancers, but, because it is non-specific, its possible elevation in this case is not diagnostic. Because metastatic choriocarcinoma is quite vascular, suspicious lesions should never be biopsied. Tissue diagnosis is the standard in establishing a diagnosis of almost all malignancies, with the exception of choriocarcinoma. Only a positive Beta-hCG in a reproductive-aged woman who has a history of a recent pregnancy (term, miscarriage, termination, mole) is necessary to establish the diagnosis.

A 72-year-old G3P3 presents to the emergency room complaining of abnormal vaginal discharge for the past two months. She has had two episodes of vaginal bleeding over the last year. She used combination hormone replacement therapy for 10 years when she went through menopause at age 58, but stopped once the Women's Health Initiative report came out. Her last gynecologic exam and Pap smear were two years ago and were normal. She has tried several over-the-counter antifungal creams for what she presumed was a yeast infection; however, she reports no change in the nature of the discharge. She does note that she has some mild lower abdominal discomfort. The only significant finding on exam is a mucopurulent discharge from a multiparous cervical os. She has a 10-week sized globular uterus. Which of the following findings is most concerning for presence of endometrial cancer? A. Vaginal bleeding B. Late menopause C. Abnormal vaginal discharge D. Enlarged uterus E. Hormone replacement therapy

A. Endometrial cancer is a disease that typically presents with symptoms and clinical findings that lead to an early diagnosis. The most common symptom is abnormal postmenopausal bleeding. However, other symptoms or clinical findings that may be seen include abnormal vaginal discharge and lower abdominal discomfort. Endometrial cancer can increase the size of the uterus as it grows, but is usually not the most common finding given the early diagnosis of this cancer. Unopposed estrogen replacement therapy does increase the risk, but not when taken in combination. Early menarche and late menopause are additional risk factors that may be related to endometrial cancer development.

A 20-year-old G0 woman presents requesting birth control pills. She received the HPV vaccine series last year, and had her first sexual encounter last month. Otherwise, she is in good health and is a non-smoker. Her pelvic examination reveals normal external genitalia, and a nulliparous cervix without discharge or mucosal lesions. A urine pregnancy test is negative. Which of the following is the appropriate screening recommendation for this patient? A. Return next year for a Pap test B. Return in three years for a Pap test C. Perform a Pap test now D. Perform HPV testing E. Perform colposcopy

A. In 2013, the American Congress of Obstetrics and Gynecology (ACOG) updated the following recommendations for cervical cancer screening: Cervical cancer screening should start at age 21 years. Women aged 21-29 years should have a Pap test every three years. Women aged 30-65 years should have a Pap test and an HPV test (co-testing) every five years (preferred). It is acceptable to have a Pap test alone every three years. Women should stop having cervical cancer screening after age 65 years if they do not have a history of moderate or severe dysplasia or cancer and they have had either three negative Pap test results in a row, or two negative co-test results in a row within the past 10 years, with the most recent test performed within the past five years. Women who have a history of cervical cancer, are infected with HIV, have a weakened immune system, or who were exposed to DES before birth should not follow these routine guidelines. ACOG recommends that women who have been vaccinated against HPV should follow the same screening guidelines as unvaccinated women.

A 28-year-old G2P0020 experienced her second miscarriage within 14 months. A recent ultrasound was notable for two uterine fibroids. The patient is worried that the fibroids may have caused her early pregnancy losses. She is otherwise healthy and has no previous surgeries. She presents to you for further consultation. Which type of fibroid is the most likely explanation of her miscarriages? A. Submucosal B. Intramural C. Subserosal D. Pedunculated E. Cervical

A. Leiomyomas are an infrequent cause of miscarriages and subfertility either by mechanical obstruction or distortion (and interference with implantation). When a mechanical obstruction of fallopian tubes, cervical canal or endometrial cavity is present and no other cause of infertility or recurrent miscarriage can be identified, myomectomy is usually followed by a prompt achievement of pregnancy. Submucosal or intracavitary myomas are most likely to cause lower pregnancy and implantation rates. Presumed mechanisms include: 1) focal endometrial vascular disturbance; 2) endometrial inflammation, and; 3) secretion of vasoactive substances. Submucosal fibroids are best treated by hysteroscopic resection.

A 25-year-old G1P1 woman comes in for her annual health maintenance examination. She has intermittent left lower quadrant discomfort. She has regular menses every 30 days and uses a diaphragm for birth control. Her last menstrual period was approximately three weeks ago. Her physical examination is notable for a 3 x 5 cm left adnexal mass. Ultrasound shows a unilocular simple cyst. Which of the following is the most likely diagnosis in this patient? A. Endometrioma B. Functional ovarian cyst C. Mucinous cystadenoma D. Serous cystadenoma E. Dermoid

B. Functional ovarian cysts are a result of normal ovulation. They may present as an asymptomatic adnexal mass or become symptomatic. Ultrasound characteristics include a unilocular simple cyst without evidence of blood, soft tissue elements or excrescences. An endometrioma is an isolated collection of endometriosis involving an ovary. This would not classically appear as a simple cyst on ultrasound. Serous cystadenomas are generally larger than functional cysts and patients may present with increasing abdominal girth. Mucinous cystadenomas tend to be multilocular and quite large. Dermoid tumors usually have solid components or appear echogenic on ultrasound, as they may contain teeth, cartilage, bone, fat and hair.

A 72-year-old woman presents to the office reporting a history of vulvar itching that has been worsening over the last six months. She has a long history of lichen sclerosus, for which she has not been receiving treatment. On exam, you find an irregular-shaped lesion which measures 3.5 cm in greatest dimension, suspicious for malignancy. You perform a punch biopsy at the edge of the lesion and send it for pathologic evaluation. The pathologist reports an invasive moderately differentiated squamous cell carcinoma. Which of the following is the most appropriate treatment for this patient? A. Treatment with a topical steroid B. Radical vulvectomy and groin node dissection C. Excisional biopsy D. Laser vaporization of the lesion E. Cryotherapy

B. Given the findings of obvious, moderately differentiated carcinoma, definitive treatment can be recommended with radical vulvectomy and groin node dissection. Only microinvasive squamous cell carcinoma of the vulva can be treated by wide local excision, but it is a diagnosis that is only made after pathology evaluation of a small (<2 cm), well-differentiated lesion, with invasion <1.0 mm. Excisional biopsy is not indicated given the larger lesion and confirmed finding of cancer. It would be inappropriate to laser a malignant lesion. Squamous cell carcinoma is the most common vulvar malignancy and may arise in the setting of chronic irritation from lichen sclerosus. Steroids would treat the lichen sclerosus, but would only result in needless delay in treatment of the malignancy. Cryotherapy is not an acceptable treatment for squamous cancer of the vulva.

A 44-year-old G0 woman returns to the office for a post operative check following tumor debulking for stage IIIB endometrioid adenocarcinoma of the ovary. Her medical history is significant for diabetes, hypertension, obesity, hypercholesterolemia and major depression. Which of the following is the most appropriate next step in the management of this patient? A. Hospice B. Chemotherapy C. Surveillance D. Pelvic radiation E. Second look laparotomy

B. In all patients with advanced ovarian cancer, post-operative chemotherapy with a combination of a taxane and platinum adjunct is considered standard of care in the United States. Women who undergo surgical cytoreduction, followed by chemotherapy, have a better overall survival rate than those who undergo surgery alone. The overall response rate in women with advanced ovarian cancer following surgery and 4-6 cycles of combination chemotherapy with a taxane and platinum adjunct is 60-80%. The overall five-year survival for women with stage III and IV disease is approximately 30%. Second look laparotomy is no longer considered standard of care.

A 44-year-old G1P1 woman was placed on three months of a GnRH agonist in order to diminish the size of a 5 cm submucosal myoma and allow it to be accessible to a hysteroscopic removal. About two weeks prior to surgery, she was no longer having severe menorrhagia although the drug side effects were becoming incapacitating especially the hot flashes. She decides to cancel the surgery and she stops the GnRH agonist. Which of the following is most likely to happen to the myoma? A. Continues to regress B. Resumes former growth potential C. Grows but to half of its original size D. Grows at a more rapid rate E. Becomes hemorrhagic

B. Maximal response is usually achieved by three months of GnRH agonist treatment. The reduction in size correlates with the estradiol level and with body weight. Hot flashes are experienced by >75% of patients, usually in three to four weeks after start of treatment, although they should not persist for longer than one to two months from end of treatment. After cessation of treatment, menses return in four to ten weeks, and myoma and uterine size return to pretreatment levels in three to four months. The regrowth is consistent with the fact that reduction in size is not due to a cytotoxic effect. However, it is not true that secondary to the GnRH agonist withdrawal they will grow at a more rapid rate.

A 22-year-old G1P0 woman who underwent dilation and curettage for a presumed missed abortion has a pathology report revealing a partial molar pregnancy. Compared to a complete mole, which of the following is true about a partial mole? A. Karyotype 69XXY, fetus present, higher risk of developing post-molar GTD B. Karyotype 69XXY, fetus present, lower risk of developing post-molar GTD C. Karyotype 46XX, fetus present, higher risk of developing post-molar GTD D. Karyotype 46XX, fetus present, lower risk of developing post-molar GTD E. Karyotype 46XX, fetus absent, lower risk of developing post-molar GTD

B. Molar pregnancies are classified as either complete or partial, depending on several histologic, pathologic and genetic characteristics. Partial moles may contain fetus/fetal parts, placenta/cord; complete moles do not. Partial moles are triploid karyotype (usually 69XXY, 69XXX, or 69XYY) resulting from fertilization of egg by dispermy; complete moles are diploid resulting from fertilization of "empty egg" by single sperm (46XX, 90%) or by two sperm (X & Y = 46XY 6-10%). Partial moles show marked villi swelling; complete moles show trophoblastic proliferation with hydropic degeneration. Clinically, partial moles present with lower Beta-hCG levels, affect older patients, have longer gestations, and are often diagnosed as missed or incomplete abortions. Complete moles usually present with larger uteri, preeclampsia and higher likelihood of developing into post-molar GTD.

A 62-year-old G0 postmenopausal woman is being referred to your gynecologic oncology colleague after an office endometrial sample demonstrated a FIGO grade 1 endometrioid adenocarcinoma. The patient has no significant medical, surgical or other gynecologic history. She does not smoke and drinks only occasionally at social events. She takes a multivitamin. Her physical exam is unremarkable. Which of the following additional tests is indicated for this patient? A. Pelvic ultrasound B. Chest x-ray C. Pelvic MRI D. CA-125 E. Serum estrogen level

B. Once a pathologic diagnosis is confirmed by biopsy, a basic clinical assessment should ensue in all patients to help define the extent of the disease. If a careful history and clinical gynecologic exam suggests that the carcinoma is likely of an early stage, minimal pre-treatment evaluation is necessary. Routine evaluation in this setting should include a chest x-ray as the lungs are the most common site of distant spread. A pelvic ultrasound is not indicated once a pathologic diagnosis has been established, although one may have been obtained as part of the initial evaluation of postmenopausal bleeding. When there is a low suspicion for advanced disease, a CT scan, MRI, PET scan, and other invasive and costly tests are not indicated. A CA-125 may be helpful in predicting those patients that may have extrauterine spread, but is not absolutely necessary.

An 81-year-old G3P3 presents to your office with a history of light vaginal spotting. She states this has occurred recently and in association with a thin yellow discharge. She never experienced any vaginal bleeding since menopause at the age of 52, and denies ever having been on hormone replacement therapy. She is otherwise reasonably healthy, except for osteoporosis, well-controlled hypertension, and diabetes. She is physically active and still drives to all her appointments. She is no longer sexually active since the death of her husband two years ago. On examination, she is noted to have severe atrophic changes affecting her vulva and vagina. A small Pederson speculum allows for visualization of a normal multiparous cervix, and the bimanual examination is notable for a small, mobile uterus. Rectovaginal exam confirms no suspicious adnexal masses or nodularity. Which of the following is the most appropriate management for this patient? A. Pelvic transvaginal ultrasound B. Office endometrial biopsy C. Reassurance and observation for further bleeding D. Vaginal estrogen therapy E. Clindamycin vaginal cream

B. Postmenopausal bleeding or discharge accounts for the presenting symptom in 80-90% of women with endometrial cancer. However, the most common causes of postmenopausal bleeding are atrophy of the endometrium (60-80%), hormone replacement therapy (15-25%), endometrial cancer (10-15%), polyps (2-12%), and hyperplasia (5-10%). Any history of vaginal bleeding requires a thorough history, physical/pelvic examination, and assessment of the endometrium. This is ideally done via office endometrial sampling as part of the initial work-up. The use of pelvic transvaginal ultrasound can provide useful information as to the presence of any structural changes (polyps, myomas, endometrial thickening), and for which a diagnosis of endometrial cancer would be less likely if the endometrial thickness is < 5 mm. Although this patient is likely to have atrophy as the cause of her spotting, a thin endometrial stripe does not exclude the possibility of a non-estrogen dependent carcinoma of the atrophic endometrium. Vaginal estrogen or clindamycin are not indicated.

A 68-year-old G5P5 woman presents for counseling following the diagnosis of cervical cancer. She has not seen a physician in 30 years since the birth of her last child. She has been widowed for three years and has only had sexual activity with her husband. The patient questions how she contracted this cancer as she practices excellent perineal hygiene including the use of talc. Which of the following most likely explains the pathogenesis of cervical cancer in this woman? A. New onset of sexual activity with another partner B. Past exposure to high risk HPV C. De novo cervical cancer development D. Genetic inheritance E. Exposure to talc

B. Sexual transmission of HPV is known to be a necessary event for the pathogenesis of cervical neoplasia (dysplasia and cancer). However, exposure to HPV is not sufficient, as other factors come into play in the ultimate development of cervical disease including smoking and immunologic factors. In this patient, exposure to HPV likely occurred earlier in her life, and because she never underwent screening, persistence of HPV infection ultimately resulted in the development of cervical cancer. This patient reports only one sexual partner, and although the risk of HPV correlates with the lifetime number of sexual partners, the risk is still relatively high even in those with one partner (up to 20%). At least 75 to 80% of sexually active women will have acquired a genital HPV infection by age 50. Cervical cancer is not genetically inherited. The use of talc does not increase risk of cervical cancer. Although nothing can be done to reverse the events that led to the development of this cancer in this individual, patient education in prevention and screening for cervical neoplasia should be practiced among all patients.

An 88-year-old woman is brought in for evaluation of blood found in her diapers. She is a nursing home resident and has a history of lichen sclerosus of the vulva, which was diagnosed fifteen years ago. She quit smoking in her fifties. Examination of the external genitalia reveals an elevated, firm, erythematous, ulcerated lesion arising from the left labia, measuring 2.5 cm in greatest dimension. What is the most likely diagnosis in this patient? A. Malignant melanoma B. Squamous cell carcinoma C. Lichen sclerosus D. Paget's disease E. Verrucous carcinoma

B. Squamous cell carcinoma accounts for approximately 90% of vulvar cancers. Patients commonly present with a lump and they commonly have a long-standing history of pruritus. The chronic itch-scratch cycle of untreated lichen sclerosus, or any other chronic pruritic vulvar disease, is thought to stimulate the development of squamous carcinoma. The mean age of squamous cell carcinoma is 65 years and smoking is known to increase the risk of development of vulvar cancer, especially in the setting of HPV infection. With lichen sclerosus, the skin appears thin, inelastic and white, with a "crinkled tissue paper" appearance. Paget's disease of the vulva is associated with white plaque-like lesions and poorly demarcated erythema, not a discrete mass. Verrucous carcinoma has cauliflower-like lesions. Melanoma typically presents as a pigmented lesion.

A 35-year-old African-American G0 woman has a family history of ovarian cancer. Her mother was diagnosed with ovarian cancer at age 50 and is in remission. The patient had onset of menarche at age 14. She has used oral contraceptives for a total of 10 years. She smokes one to two packs of cigarettes per week. The patient had a LEEP for treatment of cervical dysplasia. Which of the following places the patient at greatest risk for developing ovarian cancer? A. African American race B. Family history of ovarian cancer C. Gravidity D. Late age at menarche E. Smoking

B. The events leading to the development of ovarian cancer are unknown. Epidemiologic studies, however, have identified endocrine, environmental and genetic factors as important in the carcinogenesis of ovarian cancer. The established risk factors include nulliparity, family history, early menarche and late menopause, white race, increasing age and residence in North America and Northern Europe. Smoking has not been demonstrated to be associated with an increased risk of ovarian cancer.

A 61-year-old G3P3 woman is diagnosed with stage IIIA papillary serous adenocarcinoma of the ovary. She is concerned about her long-term prognosis. Which of the following factors would be most helpful in determining this patient's prognosis? A. Volume of residual disease B. Tumor stage C. Presence of non-malignant ascites D. Tumor grade E. Ovarian tumor diameter

B. The five-year survival of patients with epithelial ovarian cancer is directly correlated with the tumor stage. The volume of residual disease following cytoreductive surgery is also directly correlated with survival. Patients who have been optimally debulked (generally <2 cm or <1 cm maximal residual tumor diameter) have a significant improvement in median survival. Histologic grade of tumor is important. Women with poorly differentiated tumors or clear-cell carcinomas typically have a worse survival than those with well to moderately differentiated tumors. This is especially important in early-stage disease. Tumor size, bilaterality and ascites without cytologically positive cells, are not considered to be of prognostic importance.

A 39-year-old G1P1 woman comes to see you because of increased bleeding due to her known uterine fibroids, especially during her menses. She reports that her bleeding is so heavy that she has to miss two days of work every month. She has been using oral contraceptives and NSAIDs. Her most recent hematocrit was 27%. She is undecided about having more children. You discuss with her short and long-term options to decrease her bleeding. What is the next best step in the management of this patient? A. Blood transfusion B. Gonadotropin-releasing hormone agonists C. Endometrial ablation D. Uterine artery embolization E. Hysterectomy

B. The goals of medical therapy are to temporarily reduce symptoms and to reduce myoma size. The therapy of choice is treatment with a GnRH agonist. The mean uterine size decreases 30-64% after three to six months of GnRH agonist treatment. Unfortunately, GnRH agonist therapy is recommended for only a short period of time (3-6 months) typically before a surgical procedure, or to bridge a woman who is close to menopause. In this case, it is the best short-term option. Even though she is anemic, she is asymptomatic and able to work so a blood transfusion will not be indicated. Although uterine artery embolization and endometrial ablation effectively reduce bleeding, pain and fibroid size, they are contraindicated in a patient who desires future fertility. The failure rate is about 10-15%. A hysterectomy would obviously take care of her bleeding but would not be performed if she desires future fertility.

A 50-year-old G2P2 woman has a history of menorrhagia, pelvic pain, dyspareunia, dysmenorrhea, constipation and occasional spotting in between periods. She has a three-year history of urinary urgency and frequency. The patient is concerned that she has fibroids, as her close friend was recently diagnosed with fibroids. What is the symptom most commonly associated with leiomyomas? A. Intermenstrual spotting B. Menorrhagia C. Dyspareunia D. Dysmenorrhea E. Urinary symptoms

B. The major symptom associated with myomas is menorrhagia, thought to be secondary to: 1) an increase in the uterine cavity size that leads to greater surface area for endometrial sloughing; and/or 2) an obstructive effect on uterine vasculature that leads to endometrial venule ectasia and proximal congestion in the myometrium/endometrium resulting in hypermenorrhea. Other relatively frequent symptoms include pain and pressure symptoms related to the size of the tumors filling the pelvic cavity, as well as causing pressure against the bladder, bowel and pelvic floor.

A 50-year-old G3P3 woman complains of menorrhagia. Physical examination is notable for a 14-week size irregularly shaped uterus. Her hematocrit is 35%. Which of the following is the next most appropriate step in this patient's management? A. Hysteroscopy B. Endometrial sampling C. Treatment with GnRH analogue D. Hysterectomy E. Myomectomy

B. The majority of patients with uterine fibroids do not require surgical treatment. If patients present with menstrual abnormalities, the endometrial cavity should be sampled to rule out endometrial hyperplasia or cancer. This is most important in patients in their late reproductive years or postmenopausal years. If the patient's bleeding is not heavy enough to cause iron deficiency anemia, reassurance and observation may be all that are necessary. Treatment with GnRH analogues to inhibit estrogen secretion may be used as a temporizing measure. This is helpful in premenopausal women who are likely to be anovulatory with relatively more endogenous estrogen. Treatment with GnRH analogues can be used for three to six months prior to a hysterectomy to decrease the uterine size and increase a patient's hematocrit. This may also lead to technically easier surgery and decreased intraoperative blood loss. Treatment with GnRH analogue can also be used in perimenopausal women as a temporary medical therapy until natural menopause occurs. Myomectomy may be an appropriate treatment for a younger patient who desires future fertility. Hysteroscopy is not indicated at this point prior to endometrial sampling. Hysterectomy is a definitive treatment for women who have completed childbearing. Particularly in a perimenopausal woman, it is important to first rule out an underlying endometrial malignancy with endometrial sampling.

A 56-year-old G2P2 post-menopausal woman presents with abnormal vaginal bleeding of four months duration. The bleeding initially was only light spotting, but has become heavier, longer and now with bleeding occurring almost daily. She also notes abdominal bloating. She is otherwise healthy and takes no medications. On physical examination, she has a mildly distended abdomen with fullness in the lower region. On pelvic examination, she has a multiparous cervix with dark blood in the vaginal vault. Bimanual and recto-vaginal examination confirms an eight-week uterus with a separate 10 cm right adnexal mobile mass. Endometrial biopsy confirms complex hyperplasia without atypia, and pelvic ultrasound reveals a 10 cm complex heterogenous mass with solid components and no ascites. What is the most likely etiology of the adnexal mass that would also explain the findings on endometrial biopsy? A. Dysgerminoma (Germ cell tumor) B. Granulosa cell tumor (Sex-cord stromal tumor) C. Papillary serous carcinoma (Epithelial ovarian tumor) D. Krukenberg tumor (Metastatic carcinoma) E. Endometrioma

B. The most likely diagnosis of the adnexal mass that would also explain the finding of endometrial hyperplasia would be a granulosa cell tumor (sex-cord stromal tumor). GCT are functional tumors that secrete high levels of estrogen, which can ultimately stimulate the endometrium to undergo hyperplastic changes and even lead to endometrial cancer. Approximately 25-50% of women with GCT will have endometrial hyperplasia on biopsy, and 5-10% will have endometrial cancer. Granulosa cell tumors represent 70% of sex-cord stromal tumors and typically affect women in their 50's (most common type is the adult GCT - 95%; the juvenile type affects females before puberty). The three main histologic sub-types of ovarian cancer include germ cell tumors (5%), sex-cord stromal tumors (1-2%), and epithelial tumors (90%). Germ cell tumors typically affect women of younger age groups (ages 10-30), comprise 20-25% of ovarian neoplasms overall (benign and malignant) and account for 70% of tumors in this age group. Epithelial ovarian tumors are the most common and can affect women of all ages, but typically the malignant types occur in women in their sixth decade of life.

A 30-year-old G3P1 woman undergoes an uncomplicated dilation and curettage for a first-trimester miscarriage. Pathology reveals a complete mole. The patient's medical history is significant for chronic hypertension. She has a history of a previous uncomplicated term pregnancy and a termination of a pregnancy at 16 weeks gestation with trisomy 18. What is the risk of her developing a recurrent molar pregnancy? A. No increase risk over general population B. Less than 2% C. 5% D. 10% E. More than 20%

B. The recurrent risk for molar pregnancies ranges from 1 to 2%, which is a 20-fold increase from background risk. The risk of recurrence after two molar pregnancies is 10%.

A 44-year-old G2P2 woman presents with six months of intermittent vulvar itching. She denies any bleeding, but does have a whitish discharge. She has not felt any obvious lumps or sores. She was diagnosed with lupus over 10 years ago and is on prednisone, mycophenolate mofetil (CellCept), and hydroxychloroquine (Plaquenil). Her periods are irregular and her Pap smears have been normal, and her last one was 5 years ago. She reports treatment in the past for warts when she was first diagnosed with lupus, but denies any other sexually transmitted infections. Examination of the vulva is notable for diffuse, erythematous labia, with a thin white filmy discharge. There appears to be subtle but multi-focal, flat, whitish lesions measuring 0.5 - 1 cm on the labia bilaterally. Her remaining pelvic exam is unremarkable. A saline and potassium hydroxide wet prep is performed and is negative. What is the most appropriate next step in the management of this patient? A. Treatment with oral fluconazole and a topical imidazole B. Biopsy of the vulvar lesions C. Treatment of the lesions with topical trichloroacetic acid D. Wide local excision of the vulva E. Adjustment of her immunosuppressive therapies

B. These lesions most likely represent an HPV-related condition such as condyloma or vulvar dysplasia. Women who are on immunosuppressive therapy are at higher risk of such conditions and require close surveillance. Although, her history of prior treatment for warts suggests these could be condyloma again, their flat, subtle appearance raises a concern that they may be dysplastic lesions, and biopsy is indicated. Treatment for presumed yeast infection is reasonable, given her susceptibility, but would not be the sole treatment in this setting of new clinically evident lesions especially in light of a negative wet prep. Wide excision is not indicated at this time without a diagnosis.

A 34-year-old healthy G3P3 woman presents for a health maintenance examination. She has not seen a gynecologist since she had a tubal ligation six years ago. She has been married for 12 years. She has no history of abnormal Pap tests or sexually transmitted infections. The patient's physical examination is normal, except for a small white plaque noted at the 12:00 o'clock position on her external cervical os. In addition to obtaining a Pap test, which of the following is the most appropriate next step in the management of this patient? A. Annual Pap tests B. Pap test in three years C. Biopsy the lesion D. Perform a wet mount E. Perform cervical conization

C. A white plaque found on the cervix is called leukoplakia and should be biopsied directly or under colposcopic guidance as soon as possible, regardless of Pap test outcome. Pap tests have a false-negative rate as high as 20-30%. If there is no evidence of dysplasia and her Pap test is normal, then routine screening can be resumed. A wet mount would be indicated if there was evidence of white discharge. Although cervical conization maybe necessary if high grade dysplasia is diagnosed, this is not the most appropriate step in the management of this patient.

An 18-year-old G0 woman presents to discuss contraception. Her best friend's mother was just diagnosed with ovarian cancer. The patient is healthy and does not have any significant medical history. She does not have a family history of ovarian, breast or any other malignancies. She uses condoms for birth control. She would like to know what she can do to minimize her risk for developing ovarian cancer. Which of the following recommendations is the most appropriate for this patient? A. Begin childbearing now B. Use an intrauterine device C. Use oral contraceptives until she is ready to have children D. Have a risk reducing salpingo-oophorectomy once childbearing is complete E. There are no proven means to reduce the risk of ovarian cancer

C. A woman's risk for development of ovarian cancer during her lifetime is approximately 1%. Factors associated with development of ovarian cancer include low parity and delayed childbearing. Long-term suppression of ovulation appears to be protective against the development of ovarian cancer. Oral contraceptives that cause anovulation appear to provide protection against the development of ovarian cancer. Five years cumulative use decreases the lifetime risk by one-half. Risk reducing salpingo-oophorectomy is not a practical choice for this patient with no family history, even once she completes childbearing. This option might be considered for a woman with a strong family history and the BRCA mutation.

A 33-year-old G3P1 woman presents to your office with a positive home pregnancy test. Her last menstrual period was 12 weeks ago. Obstetrical history is notable for a prior full term vaginal delivery and a miscarriage. Ultrasound reveals multiple internal echoes consistent with a "snow storm" appearance within the 20-week sized uterus, as well as bilateral 6 cm multicystic ovaries. Beta-hCG level is >200,000 mIU/mL. Dilation and curettage is performed and final pathology reveals a complete molar pregnancy. What is this patient's risk of developing persistent (post-molar) gestational trophoblastic disease? A. Not at risk B. Lower than that of a partial molar pregnancy C. Higher than that of a partial molar pregnancy D. Same as that of a partial molar pregnancy E. High enough to mandate prophylactic treatment with methotrexate

C. Although very effective in evacuating both complete and partial molar pregnancies, suction curettage provides definitive therapy in the vast majority of partial moles (>95%). For complete molar pregnancies, although Beta-hCG levels initially do drop following dilation and curettage, they can plateau and eventually rise in approximately 20% of cases. The risk following partial moles is much less (5%). The development of this post-molar GTD may be due to persistent (retained or invasive) disease in the uterus or metastatic disease (often to the lungs). The constellation of findings described in this patient (large uterus, theca lutein cysts, high Beta-hCG) increases the risk that this molar pregnancy will persist despite complete evacuation, hence the need for close follow-up with serial Beta-hCG levels. Persistent disease can easily be cured with chemotherapy, if it develops, and is therefore not routinely given prophylactically, except in high-risk situations (e.g. non-compliant patient who will be lost to follow-up).

A 25-year-old G0 woman presents for a refill on oral contraceptives. She has a history of recurrent ovarian cysts. She has no significant medical or surgical history. Her grandmother was recently diagnosed with ovarian cancer and her mother is undergoing treatment for metastatic breast cancer. The patient is interested in assessing her risk for ovarian cancer susceptibility. Which of the following is the most appropriate test to offer this patient? A. Annual CA125 levels B. Annual pelvic ultrasound C. Genetic testing of BRCA1 and BRCA2 mutations on the patient's mother D. Genetic testing of BRCA1 and BRCA2 mutations on the patient's grandmother E. Check the patient for p53 mutation

C. BRCA1 and BRCA2 mutations are typically seen in cases of hereditary ovarian cancers. Overall, it has been estimated that inherited BRCA1 and BRCA2 mutations account for 5 to 10 percent of breast cancers and 10 to 15 percent of ovarian cancers among white women in the United States. Given this family history, it is highly likely that a mutation is present, and the affected individual (proband) should be tested if still alive. Because breast cancers are part of the BRCA mutation, the affected mother should be tested. Routine screening for ovarian cancer has not been established.

A 32-year-old G3P3 woman had a Pap test that showed a high-grade squamous intraepithelial lesion (HSIL). She smokes one pack of cigarettes per day. She has a history of three vaginal deliveries and a tubal ligation. On colposcopic examination, at 12:00 there is an acetowhite lesion with punctations that extends into the endocervical canal. Endocervical speculum is unsuccessful at visualizing the entire lesion. Endocervical curettage and biopsy of this area is negative. Which of the following would be the most appropriate next step in the management of this patient? A. Repeat colposcopy in two months B. Cryotherapy ablation of the transformation zone C. Cervical conization D. HPV typing E. Repeat Pap test in six months

C. Because the entire lesion cannot be visualized, this colposcopy is unsatisfactory. Severe dysplasia and even invasive cancer cannot be ruled out. Endocervical curettage has a relatively low sensitivity (i.e. a high amount of false negatives) and, therefore, you cannot rule out endocervical disease. The endocervical canal must be histologically examined. A cervical conization should be performed to obtain a pathologic specimen. Alternatively co-testing can be repeated at 12 and 24 months. Cryotherapy may serve to ablate part of the canal, but will not provide a pathologic sample to assess for dysplasia or to rule out cancer.

A 17-year-old G0 female presents with vaginal spotting for the last three days. Her last menstrual period was six weeks ago. Vitals signs are normal. Abdominal and pelvic examination reveals a 10-week sized uterus. Beta-HCG is 80,000 mIU. What is the best next step in the management of this patient? A. Repeat Beta-HCG in 24 hours B. Repeat Beta-HCG in 48 hours C. Pelvic ultrasound D. Dilation and curettage E. Routine prenatal care

C. In the face of discrepancy between dates and uterine size, a pelvic ultrasound is indicated to confirm dates, exclude multiple gestation, uterine abnormalities, and molar pregnancy. There is no single Beta-hCG value that is diagnostic for a molar pregnancy. A quantitative Beta-hCG, though, is crucial at determining whether or not a pelvic (transvaginal) ultrasound will confirm a very early gestation. With a Beta-hCG above the discriminatory zone (>1500 mIU), an IUP should be easily identified on transvaginal ultrasound. If an IUP is not seen, the ultrasound findings (in conjunction with the Beta-hCG level) should identify a mole (multiple internal echoes) or an ectopic (absence of intra-uterine gestation). Additional Beta-HCG levels are not indicated at this time. Suction curettage will provide a pathologic specimen that can distinguish between a normal and molar pregnancy, but it is used only as a therapeutic intervention. Routine prenatal care would be appropriate only after establishing a normal pregnancy.

A 68-year-old woman with a history of breast cancer presents for evaluation of endometrial cancer risk. She was treated with lumpectomy and axillary node dissection and radiation therapy. She has been on tamoxifen therapy for the past year. She denies any vaginal bleeding or discharge. She is 5 feet 3 inches tall and weighs 140 pounds. Her pelvic examination is notable only for severe vulvovaginal atrophy. What is the next best step in the management of this patient? A. Endometrial biopsy now to obtain a baseline B. Annual endometrial biopsy C. Annual exams D. Annual pelvic ultrasound E. Endometrial biopsy upon completion of five years of tamoxifen therapy

C. Tamoxifen is known to increase the risk of endometrial cancer. However, diagnostic studies, such as endometrial biopsy, are reserved for when the patient develops symptoms of bleeding or abnormal vaginal discharge. Ultrasound is not helpful because Tamoxifen is known to cause changes to the endometrium, including thickening. Endometrial biopsy is not indicated as a screening tool for endometrial cancer.

A 21-year-old G0 woman presents for her first pelvic examination. She is completely asymptomatic, healthy, and reports having only one sexual partner. She uses condoms for contraception. On examination, the patient has a normal appearing cervix except for minimal, non-malodorous vaginal discharge. Chlamydia and gonorrhea screening is performed, as well as a Pap test. The Pap test is read as ASCUS (atypical squamous cells of undetermined significance), HPV negative, and her cultures are negative. Which of the following is the most appropriate management strategy for this patient? A. Repeat the Pap test in 4-6 weeks after antibiotic treatment for bacterial vaginosis B. Pap test in one year C. Pap test in three years D. Colposcopy with endocervical curettage and directed biopsies E. Cervical conization

C. The ASCCP (American Society of Colposcopy and Cervical Pathology) recommends that management options for ASCUS include performing HPV DNA testing or repeat cytology at 12 months following the abnormal Pap test result. If the HPV testing is negative (as was reported in this case), then routine screening can be resumed at three years. If HPV is positive, or if repeat cytology at 12 months reveals ASCUS or higher, then colposcopy should be performed. For women ages 21-24, if HPV is positive, then repeat cytology at 12 months is recommended with colposcopy performed only if the repeat cytology reveals ASC-H (atypical squamous cell - cannot rule out high grade squamous intraepithelial lesion), AGC (atypical glandular cells) or HSIL (high-grade squamous intraepithelial lesion). The presence of an underlying infection does not affect the triage of an abnormal Pap smear but may explain the presence of ASCUS. See ASCCP guidelines: http://www.asccp.org/Portals/9/docs/Algorithms%207.30.13.pdf

An obese 30-year-old G3P1 Asian woman undergoes an uncomplicated dilation and curettage for a first-trimester miscarriage. Pathology reveals a molar pregnancy. The patient's medical history is significant for chronic hypertension. She has a history of a previous uncomplicated term pregnancy, and termination of a pregnancy at 16 weeks gestation for trisomy 18. What aspect of the patient's history places her at increased risk for a molar pregnancy? A. Obesity B. Previous history of fetal aneuploidy C. Asian race D. Chronic hypertension E. Prior term pregnancy

C. The incidence of molar pregnancy is approximately 1 per 1,500-2,000 pregnancies among Caucasians in the United States. There is a much higher incidence among Asian women in the United States (1/800.) Molar pregnancy occurs more frequently in women less than 20 or older than 40 years of age. The incidence is higher in areas where people consume less beta-carotene and folic acid. There is no known association between molar pregnancy and obesity, a previous history of fetal aneuploidy, chronic hypertension and parity. The risk of having a molar pregnancy is increased in women with two or more miscarriages.

A 49-year-old G5P5 woman presents for her first health maintenance examination since she had her last child 10 years ago. She has no health complaints. She has had two sexual partners. She smokes three to five cigarettes per day, and has been smoking for the past 15 years. Last month, her mother underwent a radical hysterectomy for Stage 1B cervical carcinoma. Her pelvic examination is normal, except for mucopurulent discharge and vaginal condyloma. Which of the following is the patient's greatest risk for developing cervical cancer? A. Family history of cervical cancer B. Smoking history C. Vaginal condyloma D. Multiparity E. Age

C. The majority of risk factors for cervical cancer are related to HPV exposure and include early-onset sexual activity, multiple sexual partners, a sexual partner with multiple partners, history of HPV or other sexually transmitted diseases, immunosuppression, smoking, low socioeconomic status and a lack of regular Pap tests. In this patient with multiple risk factors, the presence of an HPV-related condition (vaginal condyloma) already indicates infection with HPV. Although the HPV type associated with condyloma is typically a low risk strain (e.g. types 6 and 11), she is also at risk of having been exposed to high-risk types that are typically associated with high-grade dysplasia and cervical cancer (e.g. types 16 and 18).

An 88-year-old G2P2 woman is brought in for evaluation of blood found in her diapers. She is a nursing home resident and has a long-standing history of incontinence. This is the first time that her caregivers have noted blood. They describe it as "quarter size." Her nurses think that she may have been itching, as they frequently find her scratching through the diaper. On review of her medical record, biopsy-documented lichen sclerosus of the vulva was diagnosed fifteen years ago. She has not been on any therapy for this condition for years. Examination of the external genitalia reveals an elevated, white, firm irregular lesion arising from the upper middle left labia. The lesion measures 2.5 cm in greatest dimension. The remainder of the external genitalia shows evidence of excoriation of thin, white skin with a wrinkled parchment appearance. The vagina and cervix are atrophic. No masses are noted on bimanual or rectovaginal exam and a sample of her stool is negative for blood. No adenopathy is noted in her groin. Which of the following is the most appropriate next step in the management of this patient? A. Begin topical steroids B. Begin topical benadryl C. Biopsy the lesion D. Obtain cultures of the lesion E. Complete vulvectomy and lymph node dissection

C. The most important step is to first biopsy the lesion. It would be inappropriate to treat the lichen sclerosus first with steroids, as the lesion is suspicious for malignancy. Treatment with benadryl would also be inappropriate given the suspicious nature of the lesion. Diagnostic studies such as cultures and cytology of such a lesion are not appropriate given the exophytic, nodular lesion seen on examination. A biopsy should be performed to make a definitive diagnosis and rule out malignancy. It would also be inappropriate to treat the patient with a vulvectomy and lymph node dissection before obtaining a clear diagnosis.

A 72-year-old G3P2 postmenopausal woman is referred by her internist after work-up for abdominal bloating revealed a large pelvic mass on transvaginal ultrasound and an elevated CA-125. The patient had a normal colonoscopy and mammography two months ago. The patient's greatest complaint is early satiety and upper abdominal discomfort. Her physical exam is notable for moderate abdominal distension and a significant fluid wave. Pelvic examination confirms a smooth, but fixed pelvic mass filling the cul de sac and extending to the umbilicus. Which of the following tests would be most helpful in assessing the extent of disease? A. Barium enema B. PET scan C. CT scan of abdomen and pelvis D. Chest X-ray E. Intravenous pyelogram

C. The most useful radiologic tool for evaluating the entire peritoneal cavity and the retroperitoneum is computerized tomography. Specifically in this patient, it would be important to look for significant involvement of the omentum. A chest x-ray provides adequate evaluation of the chest, unless it is abnormal. If there is a suspicion for chest involvement on the chest film, then a chest CT is necessary. With a normal colonoscopy and no symptoms suggestive of colonic obstruction, a barium enema would not be useful. PET scan, to date, has not been shown to play a role in the initial evaluation of women with a suspected ovarian malignancy. However, PET scan may play a role in evaluating women with a known diagnosis of ovarian cancer who have a suspected recurrence. An IVP would be useful if there was suspected ureteral obstruction, but otherwise is quite limited in assessing the entire abdominal/pelvic cavity.

A 47-year-old G2P2 woman comes to see you because she is concerned that she has uterine fibroids, as she recently gained about 20 pounds. Her mother had a hysterectomy for large fibroids that "made her look like she was 40 weeks pregnant." She has smoked one pack of cigarettes a day for the last 35 years and reports no other medical problems. She has normal menstrual cycles. Her weight is 216 pounds and she is 5 feet 4 inches tall (BMI 37). Her exam is extremely limited by her body habitus. A Beta-hCG is negative. A pelvic ultrasound shows a 4 cm intramural fibroid. What is the next best step in the management of this patient? A. Obtain a pelvic MRI B. Perform laparoscopic myomectomy C. Counsel her on diet and exercise D. Perform a hysterectomy E. Recommend bariatric surgery

C. The mostly likely cause of this patient's weight gain is excessive dietary intake and lack of exercise. She should be counseled on healthy habits and quitting smoking. The treatment of asymptomatic relatively small fibroids is not indicated. She does not qualify for bariatric surgery based on her BMI. Bariatric surgery may be considered when BMI is greater than 40, or is between 35 to 39.9 accompanied by a serious weight-related health problem, such as type 2 diabetes, high blood pressure or severe sleep apnea.

A 48-year-old G2P2 woman complains of progressively heavier and longer menstrual periods over the last year. Prior to this year the patient had normal periods. She denies any symptoms other than fatigue over the last few months. Physical examination is unremarkable except for the pelvic examination. The patient is noted to have an irregularly shaped 16-week size uterus. The patient's hematocrit is 28%. What is this patient's most likely diagnosis? A. Endometrial hyperplasia B. Endometrial carcinoma C. Uterine fibroids D. Uterine leiomyosarcoma E. Adenomyosis

C. The patient's history and physical examination is typical for a perimenopausal woman with probable uterine fibroids. Although it is possible that she could have underlying endometrial hyperplasia, the most likely diagnosis is uterine fibroids. Uterine leiomyosarcoma should be considered in a postmenopausal woman with bleeding, pelvic pain coupled with uterine enlargement, and vaginal discharge, but it is exceedingly rare. Endometrial hyperplasia is more common in perimenopausal women who do not ovulate regularly and postmenopausal women. Endometrial carcinoma is typically a disease of postmenopausal women, although 5-10% of cases occur in women who are menstruating and 10-15% of cases occur in perimenopausal women. For this reason, she should still undergo an endometrial biopsy. Adenomyosis may result in a symmetrically enlarged "boggy" uterus, but usually presents with dysmenorrhea in addition to menorrhagia.

A 45-year-old G5P5 premenopausal woman was initially seen in your office for work-up and evaluation of a FIGO grade 3 endometrial cancer that was diagnosed by her gynecologist. Which of the following is the most appropriate treatment for this patient? A. Chemotherapy B. Radiation treatment C. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, bilateral pelvic and para-aortic lymphadenectomy D. Supracervical abdominal hysterectomy with ovarian preservation E. Medroxprogesterone (Megace)

C. The recommended components of the surgical approach to an early endometrial cancer are the extrafascial total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy. Alternative surgical approaches to early endometrial cancer include a total vaginal hysterectomy with or without a bilateral salpingo-oophorectomy in women who are medically unstable or have contraindications to major abdominal surgery. Ideally, this approach would only be utilized in patients with well-differentiated endometrioid adenocarcinomas and avoided in patients with high-grade lesions or aggressive cell types, such as clear cell or papillary serous carcinomas. A total laparoscopic hysterectomy, BSO, with or without staging is being utilized more and more in lieu of the traditional open approach for select patients in many centers, and is a reasonable alternative. Although chemotherapy, radiation, and hormonal therapy may be utilized, it is usually in an adjuvant setting.

A 42-year-old G2P2 woman presents to the office because she recently noticed a pigmented lesion on her vulva. She does not know how long it has been there and it doesn't bother her except that she is worried that she may have warts. Her screening Paps have been negative. Her prior exams have been reported as normal. She is a nonsmoker. Examination of her vulva reveals a pigmented, flat lesion, approximately 1.5 cm in largest diameter at the base of the right labia. It is non-tender. No induration is present. Her groin examination reveals no adenopathy. Her vagina and cervix are well estrogenized and without obvious lesions. Which of the following is the most likely diagnosis? A. Vulvar condyloma B. Squamous cell carcinoma C. Melanoma in situ D. Paget's disease E. Lichen sclerosus

C. This lesion may be melanoma and a biopsy must be done to exclude this diagnosis. The concerning features are the size and irregularity of the lesion. Melanoma represents 5% of vulvar cancer, which is not insignificant given the lack of sun exposure and the relatively small surface area. There is no variability in the coloration, ulceration or thickening of the lesion to suggest malignancy at this time. Squamous cell carcinoma is typically not pigmented. Paget's disease is usually erythematous with a lacy white mottling of the surface. Condyloma lesions have a characteristic verrucous appearance. With lichen sclerosus, the skin appears thin, inelastic and white, with a "crinkled tissue paper" appearance. Although not listed as an option, the most likely diagnosis is high-grade vulvar intraepithelial neoplasia, which can have the same clinical appearance.

A 38-year-old G3P3 woman presents to the office because she has noted dark spots on her vulva. She states that the lesions have been present for at least two years and are occasionally itchy. She has a history of laser therapy for cervical intraepithelial neoplasia ten years ago, and has not had a pelvic exam since then. She has had multiple partners and uses condoms. Her menses are regular and she had a tubal ligation. She has a history of genital herpes, but has only one or two recurrences a year. She has smoked since age 14. On examination, multicentric brown-pigmented papules are noted on the perineum, perianal region and labia minora. No induration or groin adenopathy is noted. The vagina and cervix are normal in appearance. Which of the following is the most likely diagnosis? A. Hidradenitis suppurativa B. Molluscum contagiosum C. Vulvar intraepithelial neoplasia D. Melanoma E. Paget's disease

C. This presentation is classic for human papilloma virus (HPV) related vulvar intraepithelial neoplasia. Melanoma would be unlikely to be multifocal and warts have a characteristic verrucous appearance, although pigmentation can occur. Molluscum, a poxvirus, is characterized by multiple shiny non-pigmented papules with a central umbilication. Paget's disease, although multicentric, does not have brown pigmentation. Hidradenitis is a chronic, unrelenting skin infection causing deep, painful scars and foul discharge.

A 45-year-old G3P3 woman presents to the office because of a large dark spot on her vulva. She states that the lesion has been present for at least two years and is occasionally itchy. She has smoked since age 20. She has a history of genital herpes, but only has one or two recurrences a year. On examination, a 2.5 cm lesion is noted. No induration or groin lymphadenopathy is noted. The vagina and cervix appear normal. There are no additional lesions noted on colposcopic examination of the vulva. A biopsy of the lesion returns as vulvar intraepithelial neoplasia grade 3 (VIN 3). What is the most appropriate next step in the management of this patient? A. Imiquimod (Aldara) treatment B. Trichloroacetic acid (TCA) treatment C. Wide local excision D. Cryotherapy E. Radical vulvectomy

C. VIN III should be treated with local superficial excision. Even with complete removal of all gross disease, recurrence is still possible and the patient will need close surveillance. It is inappropriate to do radical surgery in this setting as cancer has not been diagnosed. Treatment with TCA and Aldara are reserved for condyloma, although some studies have shown utility in the use of Aldara in treating low grade VIN. Cryotherapy is primarily used to treat cervical dysplasia.

A 20-year-old G0 previously healthy woman presents to the emergency department with painless vaginal bleeding. Her last menstrual period was 16 weeks ago. On physical exam, her vital signs are: temperature 98.6°F (37.0°C); heart rate 120 beats/minute; and blood pressure 140/90. Abdominal and pelvic examination confirms a 20-week sized uterus with a small amount of blood in the vagina. Beta-hCG is 68,000 mIU/mL. Fetal doppler tones are not auscultated. Which of the following findings would you expect to see on a pelvic ultrasound of this patient? A. Fetus with no cardiac activity C. Multifetal gestation D. Uterus with a snowstorm appearance E. Empty uterus with an enlarged, complex adnexal mass

D. A complete mole has a characteristic "snowstorm" appearance on ultrasound. This is due to the presence of multiple hydropic villi. This patient has a classic presentation for a molar pregnancy. Vaginal bleeding is universal in molar pregnancies. Uterine size greater than dates (weeks from LMP) can be seen in 25-50% of moles, although size less than dates can be seen in 14-33% of moles. There is no fetus seen in cases of a complete mole. There can be a fetus, which is usually grossly abnormal, in cases of a partial mole. There is detectable Beta-hCG in molar pregnancies. The Beta-hCG values are generally higher than the values observed in normal pregnancy. Caution should be taken against the use of a single-value of Beta-hCG to rule in or out a molar pregnancy. However, when combined with the findings of an enlarged uterus and vaginal bleeding, a Beta-hCG value >1,000,000 mIU/mL may be diagnostic. Tachycardia from hyperthyroidism (10% serum diagnosis; 1% clinical diagnosis) and hypertension from preeclampsia (12-25%) can occur in molar pregnancy.

A 17-year-old G0 sexually active female presents to the emergency room with acute right lower quadrant pain and nausea for 12 hours. Her periods have always been irregular, with her last one six weeks ago. She is otherwise completely healthy. She appears in mild distress. Physical examination: temperature 100.2°F (37.9°C); blood pressure 110/60; heart rate 108 beats/min. She has moderate abdominal tenderness with right greater than left pelvic tenderness. Pelvic examination reveals normal external genitalia and pink-tinged discharge is noted on speculum examination. Bimanual/rectovaginal examination confirms mild cervical motion tenderness and fullness in the right adnexa with moderate tenderness and some voluntary guarding. What is the single most important test to obtain? A. Pelvic ultrasound B. CT scan of the abdomen and pelvis C. GC and chlamydia DNA probe D. Beta-hCG E. CBC with differential

D. Although all of the tests listed above may be considered, it is imperative to obtain a Beta-HCG to rule out an ectopic pregnancy.

A 65-year-old G2P2 postmenopausal woman with a remote history of stage I, grade 1 endometrial cancer treated with surgery 15 years ago returns to your office for a health maintenance examination. During a review of systems, the patient reports several months of a dry cough, progressive dyspnea on exertion, and swelling in her legs. She is a non-smoker, but her now deceased husband smoked heavily. She saw her family physician, who initially treated her with a short course of antibiotics; however, because of persistent symptoms a chest x-ray was obtained and revealed a bilateral pleural effusion and a suspicious pulmonary nodule. Her examination is notable for decreased breath sounds at the lung bases, a normal abdominal exam, and a pelvic exam without any suspicious masses or nodularity. She has pitting edema in both of her lower extremities. What is the most appropriate next step in the management of this patient? A. Obtain a Doppler of her lower extremities B. Refer to oncologist C. Refer to palliative care D. Refer to pulmonologist E. Repeat chest x-ray in three months

D. Although recurrent endometrial cancer can present as multiple pulmonary nodules, this patient is unlikely to have a recurrence of her endometrial cancer given the initial early stage and remote timing of her cancer diagnosis. The most appropriate next step is to refer her to a pulmonologist (or cardiologist) for a thorough work-up. The finding of pleural effusions and lower extremity edema point towards a cardiopulmonary etiology; however, the finding of a solitary lung nodule in a patient exposed to second hand smoke certainly suggests the possibility of a primary lung cancer. Referral to palliative care would be premature at this point. A Doppler ultrasound to rule out a deep venous thrombosis is reasonable, but typically of more utility in the setting of unilateral edema, and still would not address the need to evaluate her lung findings

A 28-year-old G0 woman with a low-grade squamous intraepithelial lesion (LSIL) on a Pap test presents for evaluation. A colposcopy is performed and is satisfactory. A lesion is seen at 3:00 that turns white with acetic acid, has punctations and mosaicism, and is friable. This lesion is biopsied with a pathology report of CIN 1. The patient's endocervical curettage (ECC) is positive for a high-grade lesion. Which of the following is the most appropriate next step in the management of this patient? A. Follow up Pap test in six months B. Repeat colposcopy in six months C. Cryotherapy D. Cervical conization E. Hysterectomy

D. Cervical conization is indicated in this patient who has a positive ECC. Hysterectomy is the treatment for invasive cancer. Waiting six months can potentially be harmful, as the lesion can progress or a higher-grade lesion might already be present. Cryotherapy will not provide a pathologic specimen to rule out invasive cancer, but can be used to treat cervical dysplasia once cancer has been completely ruled out and the entire lesion can be visualized.

A 34-year-old G2P2 woman presents with biopsy-proven vulvar intraepithelial neoplasia, grade 2 (VIN 2). She had undergone routine examination by her primary physician, who performed a Pap smear (normal) and noted multiple warty-type lesions on the labia. The patient describes some mild itching that she self-treated for a yeast infection, with minimal relief. Otherwise, she is completely healthy, except for smoking a half-pack of cigarettes per day. She is sexually active, and is concerned about the impact this will have on her sex life. Examination confirms multiple, whitish raised 0.5 - 1.5 cm papules throughout her labial minora, majora, clitoral hood and perineum. Which of the following is the most appropriate treatment option for this patient? A. Trichloroacetic acid (TCA) B. Skinning vulvectomy C. Observation and expectant management D. CO2 laser ablation of the lesions E. Smoking cessation

D. Given the multifocality of the vulvar dysplasia (VIN 2), laser treatment is the best choice. In order to adequately treat these lesions, a complete (skinning) vulvectomy would be the other choice, but would be disfiguring and require removal of the clitoris which would have detrimental effects on her sexual function. Treatment with TCA is recommended for treatment of warts and not VIN. Smoking cessation is strongly recommended regardless, but would not be the sole means of addressing these lesions. Observation is not ideal, given her mild symptoms, moderate grade, and diffuse nature of the lesions.

A 49-year-old G0 woman reports that her periods have become heavier over the last year. The patient's physical exam is notable for a slightly enlarged, irregularly shaped uterus, measuring approximately eight weeks in size. A pelvic ultrasound confirms the presence of two 2 x 2 cm intramural uterine fibroids. Her endometrial biopsy reveals proliferative endometrium. The patient's friend recently had a hysterectomy due to uterine fibroids and menorrhagia, but she would like to avoid having surgery. She is interested in the medical options for treating symptomatic uterine fibroids, but has tried NSAIDs which did not seem to help much. What is the next best step in the management of this patient? A. Aspirin B. Methotrexate C. Estrogen D. Gonadotropin-releasing hormone agonists E. Indomethacin

D. Growth of uterine fibroids is stimulated by estrogen. Gonadotropin-releasing hormone agonists inhibit endogenous estrogen production by suppressing the hypothalamic-pituitary-ovarian axis. They can result in a 40-60% reduction in uterine size. This treatment is commonly used for three to six months before a planned hysterectomy in an attempt to decrease the size of the uterus, which may lead to a technically easier surgery and decreased intraoperative blood loss. In patients who are not yet menopausal, once the gonadotropin-releasing hormone agonist therapy is discontinued, the fibroids may grow again with re-exposure to endogenous estrogen. Thus, this therapy may be most useful for women who are close to menopause, as this patient is at age 49. Aspirin and methotrexate are not effective treatments for fibroids. Methotrexate is used in ectopic pregnancies. Aspirin and indomethacin will likely not help, as she did not respond to NSAIDs.

A 69-year-old G3P3 comes in for a health maintenance examination. Her younger sister was recently diagnosed with endometrial cancer and she is concerned about her risk. Your patient experienced her last menstrual period at age 49, and she has not had any bleeding since. Her medications include only a multivitamin and supplemental calcium. She has no other significant family history. Her physical examination including a pelvic examination is normal. She is 5 feet 5 inches tall and weighs 120 pounds. What is the most appropriate management for this patient? A. Endometrial biopsy B. CA125 level C. Ultrasound with measurement of the endometrial lining D. Annual exams E. Refer to genetic counselor for risk assessment

D. Less than 5% of women diagnosed with endometrial cancer are asymptomatic. Approximately 80-90% of women with endometrial carcinoma present with vaginal bleeding or discharge as their only presenting symptom. Since this patient does not have any symptoms or risk factors for endometrial cancer, she does not need to have any diagnostic testing. Risk factors for endometrial cancer include late menopause, unopposed estrogen therapy, nulliparity, obesity, Tamoxifen therapy and diabetes mellitus. Although sometimes associated with Hereditary Non-polyposis Colorectal Cancer Syndrome (HNPCC, or Lynch II), endometrial cancer is typically not a genetically-inherited malignancy, and so genetic counseling for risk assessment would not be recommended unless a more significant family history existed. Endometrial cancer ranks as the fourth most common cancer detected in women in the US. In 2010, according to the American Cancer Society, there will be an estimated 43,470 new endometrial cancer cases. It is the most common gynecologic malignancy. Top Five Cancers Detected in Women: • Breast 28% • Lung 14% • Colon 10% • Uterine 6% • Ovary 3% Gynecologic Cancers: • Uterine 52% • Ovary 26% • Cervix 14% • Vulva 5% • Vagina 3%

A 38-year-old G1P0 woman undergoes dilation and curettage for a partial molar pregnancy. The patient and her husband are very devastated by the loss of this much-desired pregnancy. Because she feels that her "reproductive clock" is ticking away, the patient would like to get pregnant as soon as possible. How long should she wait before attempting pregnancy? A. After recovery from the dilation and curettage B. After the Beta-hCG normalizes C. After she has one normal menstrual cycle D. Six months after negative Beta-hCG levels E. Two years

D. Once evacuation has been accomplished, patients must be followed regularly with serial Beta-hCG levels to insure spontaneous regression. Pregnancy should be avoided during this follow-up period, and for the following six months. Effective contraception (OCP or other hormonal contraception) is strongly recommended to prevent confusion in interpreting a rising Beta-hCG as a post-molar recurrence/progression versus a new, spontaneous pregnancy. Given this patient's age and desire for a pregnancy, waiting two years decreases her fertility and increases her risks of pregnancy complications.

A 39-year-old G4P3 woman with an ultrasound report suggestive of a molar pregnancy is referred for evaluation. She is asymptomatic. Her uterus is 16-weeks size and her Beta-hCG is >200,000 mIU/mL. What is the recommended treatment for this patient? A. Expectant management B. Induction with oxytocin C. Methotrexate D. Suction curettage E. Hysterectomy

D. Suction curettage is the standard management for molar pregnancies. Hysterectomy can be considered in women who have completed childbearing, however, the morbidity of a hysterectomy is still considered greater than suction curettage. Induction with oxytocin would result in severe bleeding once cervical dilation and contractions developed, and expectant management would risk increased growth and progression of the mole (as well as the similar unnecessary risk of bleeding.) Methotrexate may become necessary if she develops post-molar GTD, but not as a sole means of primary treatment.

A 47-year-old G3P3 presents with a several month history of progressive abdominal bloating. She has had regular menses her entire life, but recently notes her bleeding to be heavier and occurring "twice a month." She is otherwise healthy and does not smoke or drink. On examination, she is 5 feet 5 inches tall and weighs 130 pounds. Her abdominal exam is notable for some mild distension, but no palpable masses. Her pelvic examination is notable for a normal appearing cervix, a deviated, but non-enlarged uterus, and a 10 cm mobile, non-tender right adnexal mass. An office endometrial biopsy reveals complex endometrial hyperplasia without atypia. What is the most likely explanation for the adnexal mass and the findings seen on the endometrial biopsy? A. Fibroid uterus B. Endometrioma C. Metastatic endometrial cancer D. Granulosa cell tumor E. Theca lutein cyst

D. The finding of an adnexal mass in a perimenopausal woman raises the suspicion of a neoplastic process. Because of the new onset of irregular bleeding and the finding of hyperplasia, the most likely explanation would be that of a granulosa cell tumor, an estrogen-secreting tumor. A theca lutein cyst is typically seen in the setting of pregnancy (molar pregnancy) and is often bilateral. A fibroid uterus may present with heavy irregular bleeding, but a pedunculated fibroid mimicking an adnexal mass is unlikely to present with such a bleeding pattern and has no correlation with hyperplasia. Severe endometriosis often presents with dysmenorrhea and is unlikely to develop in the perimenopause.

A 30-year-old G1P1 woman presents to the emergency department with left-sided abdominal pain. Physical examination is notable for a 5 x 6 cm mobile left adnexal mass. An ultrasound is performed, which shows a left ovarian mass with cystic and solid components. Which of the following is the most likely diagnosis in this patient? A. Serous cystadenoma B. Mucinous cystadenoma C. Endometrioid tumor D. Dermoid tumor E. Brenner tumor

D. The most common tumor found in women of all ages is the dermoid. The median age of occurrence is 30 years, and 80% occur during the reproductive years. Dermoids may contain differentiated tissue from all three embryonic germ layers. Dermoid tumors can contain teeth, hair, sweat and sebaceous glands, cartilage, bone, and fat.

A 52-year-old G3P2 woman reports vaginal spotting and bleeding after intercourse for the past 18 months. She stopped having menses at the age of 48 and has not been on hormone replacement therapy. She also notes new onset low back pain. She has smoked two packs a day for the past thirty years. Her last gynecologic exam was 10 years ago. On physical examination, she is a thin female who appears older than her stated age. She weighs 120 pounds and is 5 feet 6 inches tall. Her pelvic examination reveals atrophy of the external genitalia and vagina, a minimal amount of dark brown blood in the vault, and a large parous cervix with a friable lesion on the anterior lip of the cervix. The uterus is normal size, non-mobile and fixed in a retroverted position. There are no palpable adnexal masses, but there is firm nodularity in the posterior cul-de-sac on rectal examination. Which of the following is the most appropriate next step in the management of this patient? A. Computerized tomography of the lower spine and pelvis B. Pap test C. Colposcopy D. Cervical biopsy E. Pelvic ultrasound

D. This patient is at high-risk for cervical cancer. Her risk factors include tobacco use and a poor screening history. The symptoms of postmenopausal and postcoital bleeding should be taken seriously, and a cervical biopsy of the suspicious cervical lesion performed. Her physical examination with fixation of the uterus and thickening of the rectovaginal septum and back pain suggests involvement of the parametria (Stage II) and possible extension to the sidewall (Stage III). A Pap test should not be used to exclude cervical cancer, as it is a screening test and not a diagnostic test, and colposcopy would not be useful since a clinically visible lesion is already present. Although a CT scan may ultimately be needed as part of the evaluation of cervical cancer, a diagnosis must first be made by biopsy. Ultrasonography may be helpful in the diagnostic evaluation of post-menopausal bleeding, but not in the setting of an obvious cervical lesion.

A 26-year-old G2P1 woman presents with early pregnancy and vaginal spotting. Her last normal menstrual period was three months ago, and she had a positive home pregnancy test two weeks ago. She has been experiencing severe morning sickness. She denies any pelvic cramping or abdominal pain. She is otherwise healthy. On physical examination, she has a palpable uterus just above the symphysis. Pelvic examination is notable for a 2 cm fleshy friable nodular lesion along the left lateral vaginal sidewall, the cervix is multiparous, with a small amount of blood in the vault. Bimanual examination confirms a 10-week sized uterus. A pelvic ultrasound confirms a snowstorm pattern, and Beta-hCG is 52,000 mIU. What is the next step in the management of this patient? A. Chest X-Ray B. Biopsy the vaginal lesion C. PET scan D. CT scan of the chest/abdomen/pelvis E. Evacuation of the uterus

D. This patient most likely has metastatic GTD given the constellation of findings, and elevated Beta-hCG with no evidence of an intrauterine pregnancy. Although evacuation is likely necessary, the finding of a vaginal nodule raises the suspicion of metastasis and further warrants a full staging evaluation with a CT scan of the chest, abdomen and pelvis. A brain MRI is also likely. A simple CXR would not be sufficient since she already has evidence of metastasis to the vagina. Since metastatic GTD is known to be quite vascular, suspicious lesions should not be biopsied. A PET scan has not been shown to be a preferred method of evaluation at this time.

A 48-year-old G3P3 woman recently had an abnormal Pap test with high grade squamous intraepithelial lesion (HSIL). Colposcopically-directed biopsy revealed cervical intraepithelial neoplasia 3 (CIN 3). A loop electrosurgical excision procedure (LEEP) is subsequently performed. In reviewing the pathologic specimen with the pathologist, abnormal squamous cells are seen extending 2 mm beyond the basement membrane. What is the patient's diagnosis? A. CIN 1 B. CIN 2 C. CIN 3 D. Carcinoma in situ E. Microinvasive cervical cancer

E. Cervical dysplasia is graded based on extent of involvement of the epithelial layer but does not extend below the basement membrane. Carcinoma in situ (CIS) represents abnormal cells involving the entire epithelium to the basement membrane. In cancer, the cells invade beyond the basement membrane. In microinvasive cancer, they invade less than 3 mm.

A 57-year-old G0 postmenopausal woman presents to her gynecologist with a complaint of vaginal bleeding for one week. The patient reports the cessation of normal menses approximately four years ago. She has had no previous episodes of irregular bleeding except when she took hormonal replacement therapy for six months. She saw her nurse practitioner five months ago and reports having a normal gynecologic evaluation and a normal Pap smear. Her past medical history is significant for hypercholesterolemia and diet-controlled diabetes mellitus. Physical exam reveals a 5 feet 3 inches tall, 275-pound woman in no acute distress. Pelvic exam demonstrated a normal vulva, urethra, vagina and cervix. Bimanual exam was normal. An endometrial biopsy was obtained and demonstrated complex atypical hyperplasia. Which of the following is this patient's greatest risk factor for developing endometrial cancer? A. Nulliparity B. Obesity C. Postmenopausal status D. Use of hormone replacement therapy E. Complex atypical hyperplasia

E. Endometrial cancer is a gynecologic malignancy that has easily identifiable risk factors and typically presents with symptoms that lead to an early diagnosis. Risk factors include nulliparity, obesity, late menopause, hypertension and exposure to unopposed estrogens. Of these risk factors, obesity confers the greatest risk of developing endometrial carcinoma, especially when the patient is more than 50 pounds over ideal body weight (10-fold increase). However, in this case, the patient's greatest risk for developing an endometrial cancer is the presence of complex atypical hyperplasia (CAH) on endometrial biopsy. If left untreated, this process has approximately a 28% chance of progressing to an invasive cancer. More importantly, approximately 30% of women with a diagnosis of CAH will be found to have an invasive endometrial cancer on final pathology. Most women who develop endometrial cancer are postmenopausal, but this is less of an issue because of the finding of CAH.

A 65-year-old G2P1 woman has been referred to you for further evaluation of postmenopausal bleeding. She initially was seen by her internist after two weeks of intermittent vaginal spotting. She reports a similar episode approximately two months ago. A recent exam and Pap smear were normal. A transvaginal ultrasound showed a homogeneous endometrial lining measuring 5.0 mm. A subsequent office endometrial sample was obtained and returned with rare atypical cells. What is the most appropriate next step in the management of this patient? A. Repeat office endometrial sample B. Follow-up ultrasound in eight to twelve weeks C. Return visit in three to six months D. Abdominopelvic CT scan E. Dilation and curettage

E. Enough to think it was endometrial cancer

A 31-year-old G0 woman has been diagnosed with uterine fibroids. An ultrasound confirmed the presence of two intramural fibroids measuring 5 x 6 cm and 2 x 3 cm that appear to be distorting the patient's uterine cavity. The patient has a two-year history of infertility. She has had a thorough infertility work up. No etiology for her infertility has been identified. Which of the following treatments is most appropriate for this patient? A. Hysteroscopy B. Uterine curettage C. Gonadotropin-releasing hormone agonist D. Uterine artery embolization E. Myomectomy

E. Myomectomy is warranted in younger patients whose fertility is compromised by the presence of fibroids that cause significant distortion of the uterine cavity. A myomectomy may be indicated in infertility patients when the fibroids are of sufficient size or location to be a probable cause of infertility and when no more likely explanation exists for the failure to conceive. Hysteroscopy is a procedure that involves placing a scope through the cervical os to assess the endometrial cavity. The patient has already been diagnosed with uterine fibroids that are distorting her cavity and she has already had a fluid contrast ultrasound, so it is unnecessary to perform hysteroscopy on this patient. Treatment with GnRH agonists can be useful to shrink fibroids in anticipation of surgery, or if menopause is expected soon. This patient desires future childbearing, therefore, its use would not be an appropriate option. Uterine artery embolization can be recommended for women who have completed child-bearing because of the unclear long-term effects on fertility.

A 28-year-old G0 woman has a high-grade squamous intraepithelial lesion (HSIL) on a Pap test. She has no complaints. She smokes one pack of cigarettes per day. Her pelvic exam is normal. Colposcopy is performed. The cervix is noted to have an ectropion and there is abundant acetowhite epithelium. Mosaicism, punctations and several disorderly atypical vessels are noted. Three biopsies are obtained and sent to pathology. Which of the findings on this patient's colposcopy is most concerning? A. Ectropion B. Acetowhite epithelium C. Mosaicism D. Punctations E. Disorderly atypical vessels

E. Punctations and mosaicism represent new blood vessels on end and on their sides, respectively. Atypical vessels usually represent a greater degree of angiogenesis and, thus, usually a more concerning lesion. An ectropion is an area of columnar epithelium that has not yet undergone squamous metaplasia. It appears as a reddish ring of tissue surrounding the external os. Acetowhite epithelium can represent dysplasia but, in most cases, is less concerning than the above vascular changes.

A 74-year-old G2P2 post-menopausal woman presents for a health maintenance examination. She notes the new onset of a lump in her vagina, but denies any pain, abnormal bleeding or vaginal discharge. She has well-controlled diabetes mellitus and hypertension. She is recently sexually active with a new partner since the death of her husband three years ago. She smokes a half-pack per day, and has done so since age 18. On examination, she is noted to have a somewhat firm and fixed non-tender 4 cm mass in her labia majora at the level of the Bartholin gland on the right. There is no associated erythema or discharge, and the remaining vulvar exam and pelvic exam are unremarkable. Her groin examination reveals no adenopathy. What is the most likely diagnosis? A. Lipoma B. Fibroma C. Bartholin gland cyst D. Bartholin gland abscess E. Bartholin gland malignancy

E. The finding of a mass in the Bartholin gland is highly suspicious for malignancy and requires excision/biopsy, especially in a post-menopausal women. Primary vulvar adenocarcinomas most likely arise from the Bartholin gland, but other histologies such as squamous cell, transitional, adenosquamous, and adenoid cystic carcinomas can also arise from this location. This is unlikely to be a fibroma or lipoma given the recent onset and fixed nature of the mass. A benign Bartholin gland cyst is also unlikely given the patient's age and rather abrupt onset, and any finding of a new Bartholin gland cyst in a post-menopausal woman should be further investigated. For any woman over the age of 40 with a mass in this area, a biopsy should be obtained. This is not an abscess given the absence of signs and symptoms of cellulitis or infection.

A 58-year-old G2P2 woman presents to your office complaining of two years of a vulvar rash. She has seen multiple physicians without a clear definitive diagnosis. The patient has experienced intermittent pruritus for one year. She has been prescribed "every yeast medication known" and has also used multiple over-the-counter products. She was recently given topical steroid cream, which did not alleviate her symptoms. She is a breast cancer survivor and was diagnosed and treated one year ago. She is presently on tamoxifen. No vaginal bleeding has occurred since her menopause. On examination, her vulva is fiery red mottled background with whitish hyperkeratotic areas. A distinct lesion is not seen. No nodularity or tenderness is noted. With the exception of vaginal atrophy, the rest of her pelvic exam is normal. What is the most likely diagnosis in this patient? A. Lichen sclerosus of the vulva B. Contact dermatitis C. Yeast vulvitis D. Psoriasis of the vulva E. Paget's disease of the vulva

E. This is a typical description of Paget's disease of the vulva. Paget's is an in situ carcinoma of the vulva. The association with breast cancer is significant, but not as high as Paget's disease of the nipple. It would be unlikely for psoriasis to present this late in life. Contact dermatitis is unlikely to last for years and this woman has had therapy for yeast. Lichen sclerosus is possible and more common, but does not have the hyperkeratotic overlay and would have more likely responded to steroid use.

A 25-year-old G1 is at 18 weeks gestation. A 2 cm subserosal fibroid was noted on the anterior fundal wall of her uterus at the time of her obstetric ultrasound at 17 weeks gestation. Which of the following treatment options for the uterine fibroid is most appropriate? A. Obtain a follow up ultrasound every six weeks to follow growth of the fibroid B. Laparoscopy now to remove the fibroid C. Perform delivery by Cesarean section at term D. Perform delivery by Cesarean section at term with removal of the fibroid after delivery of the baby and placenta E. No further treatment is necessary

E. Uterine fibroids are the most common solid pelvic tumors in women. On postmortem examination, fibroids can be detected in as high as 80% of women. Most uterine fibroids are asymptomatic and do not require any treatment. Pregnant patients with fibroids usually are asymptomatic and do not have any complications related to the fibroids. Fibroids may grow or become symptomatic in pregnancy due to hemorrhagic changes associated with rapid growth, known as red or carneous degeneration. However, this is uncommon for smaller fibroids. Uncommonly, fibroids can be located below the fetus, in the lower uterine segment, or cervix, causing a soft tissue dystocia, necessitating delivery by Cesarean section. In this case, it is not indicated given the location of the fibroid. Myomectomy (removal of the fibroid) during pregnancy is contraindicated. Myomectomy at the time of Cesarean section should be avoided, if possible, secondary to the risk for increased blood loss. It is not necessary to follow the growth of fibroids during pregnancy, except for the rare cases when the fibroid is causing symptoms (primarily pain) or appear to be located in a position likely to cause dystocia.