Week 2

Question 1

Question: Which of these statements is true about the phases of the uterine mucosa?

1. During the menstrual phase, the stratum functionale and stratum basale are shed and then rebuild during the estrogen-induced proliferative phase
2. During the progesterone-induced secretory phase, glands of the endometrium are coiled, wavy, and filled with glycogen-rich fluid
3. Secretion of FSH from the hypothalamus induces development of follicles and subsequent estrogen secretion
4. The hormonal trigger for ovulation is the secretion of LH from the mature follicle
5. In the absence of pregnancy, secretion of estrogen from the corpus luteum inhibits the release of LH from the pituitary, which leads to the eventual degeneration of the corpus luteum

Answer 1

Answer: B is correct.

Incorrect explanations: A is wrong because only the stratum functionale (and not the stratum basale) is sloughed off during the menstrual phase. C is wrong because FSH is secreted from the anterior pituitary and not the hypothalamus. D is wrong because the hormonal trigger for ovulation is the secretion of LH from the anterior pituitary, not the follicle. E is wrong because it is the secretion of progesterone (not estrogen) that inhibits LH, leading to the degeneration of the corpus luteum.

Learning objective: SM 206 (Identify the menstrual, proliferative, and secretory phases of the uterine mucosa (endometrium) and the hormonal basis for changes in the uterine lining. Describe the histological differences between cervix and body)

Question 2

Question: Name these non-neoplastic causes of abnormal uterine bleeding based on their findings on histology.

1. Presence of stroma and glands in the endometrium + hemosiderin-laden macrophages
2. Presence of glands and stroma in the myometrium
3. Proliferative glands with stromal breakdown
4. Stromal changes including spindling, along with presence of plasma cells
5. Rounded shape with epithelium on 3 sides, with fibrotic stroma and prominent blood vessels

Answer 2

Answer:

1. Endometriosis: Histology: Endometrial glands + stroma + hemorrhage (at least 2 of 3)
2. Adenomyosis: similar to endometriosis but confined to myometrium
3. Anovulatory cycles
4. Chronic endometritis
5. Endometrial polyps: also have fibrotic stroma

Learning objective: SM 210 (List three non-neoplastic causes of abnormal uterine bleeding)

Question 3

Question: Which of these contraceptives is associated with increased risk of thromboembolic complications?

1. Vaginal ring releasing estrogen and progestin
2. Combined estrogen and progestin oral contraceptive pills
3. Long-acting progestin only depots or implants
4. Progestin-only mini pill
5. Transdermal patch releasing estrogen and progestin

Answer 3

Answer: B. Combined oral contraceptives are associated with an increased risk of venous thrombosis due to the estrogen component of the pill causing increased hepatic production of certain clotting factors. Vaginal or transdermal administration of combination estrogen + progestin avoids first pass GI and hepatic metabolism, leading to less hepatic stimulation via estrogen (A and E are incorrect). This increased hepatic production of clotting factors is due to estrogen, not progestin (C and D are incorrect).

Learning objective: SM 215 (Explain, using the concept of first pass metabolism, why oral combined hormonal contraception is associated with increased risk of thromboembolic complications compared to trans-dermal and vaginal combined hormonal formulations.)

Question 4

Question: What are the analytes/components of maternal serum screening in the first versus the second trimesters?

What can these components tell you?

Answer 4

Answer:

First trimester:

PAPP-A (pregnancy associated plasma protein-A): reduced in aneuploid pregnancies

Total or free b-HCG: elevated in Down syndrome, decreased in trisomy 18

Nuchal translucency: ultrasound-based assessment of fluid space between skin and soft tissue of the fetal neck

Second trimester:

AFP: decreased in DS and trisomy 18, increased in neural tube defects

uE3 (unconjugated estriol): decreased in DS and trisomy 18

HCG: increased in DS, decreased in trisomy 18

Inhibin: increased in DS

Based on these results and calculated risks, patients may then choose to undergo CVS or amniocentesis.

Learning objective: SM 208 (List indications for prenatal genetic diagnostic testing)

Question 5

Question: Name the mechanism of action of the following agents used during medically induced abortion.

Mifepristone

Misoprostol

Laminaria

Answer 5

Answer:

Mifepristone: anti-progestin and abortifacient that causes cervical dilation, decidual necrosis, increased endogenous prostaglandin production and sensitivity to exogenous prostaglandin, and gap junction formation in the myometrium

Misoprostol: prostaglandin analogue and expulsion agent

Laminaria (also Lamicel and Dilapan): osmotic dilators used during D&E procedures

Learning objective: SM 219 (Describe in layman’s terms to a classmate medical options for uterine evacuation during the first trimester)

Question 6

Question: ­­­­­­­­­­­­­­Fill in the blanks

__Older/younger_____ women are more likely to develop vulvar squamous cell carcinoma that is associated with lichen _____ and mutations in the _____ gene.

The other type of vulvar squamous cell carcinoma is HPV-related and occurs in __older/younger_____ women.

Answer 6

Answer:

__Older____ women are more likely to develop vulvar squamous cell carcinoma that is associated with lichen _sclerosis____ and mutations in the __p53___ gene.

The other type of vulvar squamous cell carcinoma is HPV-related and occurs in __younger_____ women.

Learning objective: SM 209 (Describe the two pathways of squamous carcinogenesis in the vulva 1) HPV related, 2) related to lichen sclerosus)

Question 7

Question: Which of the following is true about leiomyomas?

1. 70% are associated with mutations in B-catenin
2. Parity is associated with increased risk of leiomyomas
3. Myomectomy is only preferred for fertility preservation
4. ECM breakdown and loss is necessary for leiomyoma expansion

Answer 7

Answer: C. Myomectomy is only preferred for fertility preservation, while hysterectomy is a definitive surgical treatment.

Others: 70% are associated with mutations in MED12 on the X chromosome (a is incorrect). MED12 binds b-catenin and regulates the WNT pathway. Parity is associated with decreased risk of leiomyomas (b is incorrect). ECM formation contributes substantially to leiomyoma expansion.

Learning objective: SM 211 (Describe the etiology, pathophysiology, epidemiology and clinical presentation of the most common benign uterine conditions: leiomyomata, endometriosis, uterine polyps, and adenomyosis.)

Question 8

Question: Which of the following structures is in the superficial perineal compartment?

1. External urethral sphincter
2. Bulbospongiosus muscle
3. Membranous urethra
4. Male bulbourethral gland
5. Scarpa’s fascia

Answer 8

Answer: B (bulbospongiosus muscle)

The external urethral sphincter (A), membranous urethra (C), and the male bulbourethral gland (D) are all in the deep perineal compartment. Scarpa’s fascia is of the abdominal wall and is continuous with Colles’ fascia which encloses the superficial perineal compartment in the male.

Learning objective: SM 217 (Define the superficial and deep perineal pouches and identify their contents. Describe Colles’ fascia and its attachments and relations.)

Question 9

Question: Which of these is the primary structure cut during a medio-lateral episiotomy?

1. Ischiocavernosus muscles
2. Perineal body
3. Urogenital diaphragm
4. Vestibular bulb

Answer 9

Answer: C (UG diaphragm)

Episiotomy—enlargement of the distal birth canal to facilitate a difficult birth. Median: cut the skin, vaginal wall, and perineal body. Medio-lateral: skin, vaginal wall, bulbospongiosus, superficial transverse perinei, UG diaphragm.

Learning objective: SM 218 (Describe the structures cut in a median and mediolateral episiotomy, the muscular cause of uterine prolapse, the location and effects of nerve blocks, and the clinical significance of the rectouterine pouch. Identify the location of highest risk for urethral puncture via catheter insertion in the male.)

Question 10

Question: Fill in these blanks regarding innervation of the pelvis.

Somatic innervation of the pelvis is mostly from the __________ nerve.

Sympathetic innervation is primarily from the ________ nerve (T_ to L_)

Neurotransmitter for preganglionic neurons: ________

Neurotransmitter for postganglionic neurons: ________

Parasympathetic innervation is primarily via the _______ nerve (S_ to S_)

Neurotransmitter for preganglionic neurons: ________

Neurotransmitter for postganglionic neurons: ________

Inhibitory neurotransmitter: ______

Answer 10

Answer:

Somatic innervation of the pelvis is mostly from the pudendal nerve.

Sympathetic innervation is primarily from the hypogastric nerve (T11 to L2)

Neurotransmitter for preganglionic neurons: ACh

Neurotransmitter for postganglionic neurons: NE

Parasympathetic innervation is primarily via the pelvic nerve (S2 to S4)

Neurotransmitter for preganglionic neurons: ACh

Neurotransmitter for postganglionic neurons: ACh

Inhibitory neurotransmitter: nitric oxide

Learning objective: SM 207 (Be able to outline, in general terms, the somatic (pudendal), sympathetic, and parasympathetic innervation underlying pelvic functions.)

Question 11

Question: What type and frequency of cervical cancer screening would you recommend to the following female patients?

1. A 20 year old
2. A 29 year old
3. A 45 year old
4. A 55 year old post-hysterectomy
5. A 66 year old with no history of HGSIL

Answer 11

Answer:

1. A 20 year old: none
2. A 29 year old: pap only, every 3 years
3. A 45 year old: pap and HPV cotesting every 5 years OR pap only every 3 years
4. A 55 year old post-hysterectomy: stop testing
5. A 66 year old with no history of HGSIL: none

Learning objective: SM 212 (Define the criteria that make the pap smear a successful screening tool for cervical cancer; Apply risk benchmarking to contemporary pap smear/HPV results when presented with a clinical scenario)

Question 12

Question: What structure/cells/tissues/source could each of the following ovarian neoplasms come from?

Epithelial tumors

Sex-cord stromal tumors

Germ cell tumors

Metastases

Answer 12

Answer:

Epithelial tumors: fallopian tubes, endometriosis, other (not understood)

Sex-cord stromal tumors: sex cords (supporting cells of oocytes), ovarian stroma

Germ cell tumors: oocytes (germ cells)

Metastases: other organs

Learning objective: SM 213 (List the three major categories of primary ovarian tumors)

Question 13

Question: Which of these is true of epithelial ovarian cancer?

1. Risk increases with early menopause
2. Screening for the CA125 marker is recommended for “high risk” women
3. Fibroademonas are the most common epithelial neoplasm
4. Epithelial ovarian cancer is the most lethal gynecologic cancer

Answer 13

Answer: D is true.

Others: Risk increases with more #s of ovulatory cycles, so risk increases with later menopause (A is incorrect). CA125 is the tumor marker associated with epithelial ovarian cancer but is not a screening marker (B is incorrect). Fibroadenomas are not epithelial tumors; serous cysteadenomas are the most common epithelial neoplasm (C is incorrect).

Learning objective: SM 214 (Discuss the pathogenesis of ovarian cancer and the role of BRCA gene mutations in carcinogenesis, 3. Use the three anatomic layers of the ovary to create a differential diagnosis of benign and malignant ovarian masses)