Question 1

A 33-year-old woman taking oral contraceptives for a year has noted vaginal bleeding that is not severe, but it occurs nearly every day over the past 5 weeks. On pelvic examination, there is a 0.7 cm polypoid mass noted to extend outward from the endocervical region. The ectocervix appears normal. The uterus is normal in size. The adnexa have no palpable masses. A biopsy of this lesion is performed. Which of the following microscopic findings is most likely to be found in this lesion?

A Endocervical adenocarcinoma

B Clear cell adenocarcinoma

C Microglandular hyperplasia

D Sarcoma botryoides

E Endocervical polyp

F Follicular cervicitis

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Question 2

A 48-year-old woman has noted a small amount of irregular vaginal bleeding for the past 2 months. She has a pelvic examination that reveals no cervical lesions, and a Pap smear that shows no abnormal cells. Next, an endometrial biopsy is performed, and there is microscopic evidence for endometrial hyperplasia. An abdominal ultrasound reveals a solid right ovarian mass. Which of the following neoplasms is this woman is most likely to have?

A Mature cystic teratoma

B Choriocarcinoma

C Sertoli-Leydig cell tumor

D Fibrothecoma

E Krukenberg tumor

F Cystadenocarcinoma

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Question 3

A 51-year-old perimenopausal woman has had vaginal bleeding for the past 6 months. On physical examination she has an enlarged, nodular uterus. A hysterectomy is performed. The surgeon notes several 0.2 to 1 cm translucent, smooth-surfaced, thin-walled, fluid-filled cysts near the fimbriated end of the right fallopian tube. Which of the following is the most likely diagnosis for these cysts?

A Gartner duct cysts

B Krukenberg tumors

C Parovarian cysts

D Pelvic inflammatory disease

E Mucinous cystadenomas

F Fibrocystic disease

G Omphalomesenteric duct cyst

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Question 4

A 36-year-old woman has had episodes of lower abdominal and pelvic pain for the past 10 years. A bimanual pelvic examination reveals no abnormalities. A Pap smear is negative. She has an abdominal ultrasound scan that reveals no abnormalities. She undergoes laparoscopy, and several 0.2 to 0.5 cm brown nodular lesions are seen on serosal surfaces of the uterus, fallopian tubes, and appendix. These lesions are excised. Which of the following microscopic findings is most likely to be present in these lesions?

A Endometrial stroma

B Mesothelial cells

C Metastatic adenocarcinoma

D Capillary proliferation

E Granulomatous inflammation

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Question 5

A 47-year-old woman has noted a pressure sensation, but no pain, in her pelvic region for the past 5 months. On physical examination there is a right adnexal mass. An ultrasound scan shows a 10 cm fluid-filled cystic mass in the right ovary, along with ascitic fluid. A fine needle aspirate of the mass is performed and cytologic examination of clear fluid aspirated from the mass reveals clusters of malignant epithelial cells surrounding psammoma bodies. Which of the following neoplasms is she most likely to have?

A Endometrioid carcinoma

B Serous cystadenocarcinoma

C Malignant mesothelioma

D Mature cystic teratoma

E Squamous cell carcinoma

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Question 6

A representative of the law firm of Flotsam, Flotsam & Jetsam enters your office and serves you with a subpoena that requires you to appear in regard to litigation by one of your former patients, a 31-year-old woman who is claiming that your malpractice led to medical expenses, pain, and suffering because she developed invasive cervical carcinoma. She was last seen in your office 10 years ago. She had been your patient for 5 years, receiving Pap smears in 4 of those 5 years. Your records indicate that she had no abnormal Pap smears. After discussion with your malpractice carrier's attorney, which of the following conclusions is most appropriate?

A The patient should have continued to return for yearly Pap smears

B You are at fault in this case and should avoid a trial

C The laboratory to which the Pap smears were sent is at fault for missing abnormal cells

D Nothing anyone could have done would have prevented this carcinoma

E The patient's health insurer is at fault for not covering the full cost of Pap smear testing

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Question 7

A quality assurance (QA) project is done by a group of physicians staffing an outpatient clinic to study rates of false negative Pap smears. The QA project reveals that one physician has accounted for half of all the false negative Pap smears collected by the group over the prior year, when compared to follow-up testing. The physician's collection techniques are analyzed, and of the following procedures practiced, which is the only one that is appropriate?

A Wrote the patient's name on the slides

B Air-dried the slides prior to shipping

C Used lubricant on the speculum during collection

D Scheduled the patient visit during the menstrual phase of her cycle

E Advised the patient to douche the day prior to the appointment

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Question 8

A 30-year-old infertile woman has had episodic lower abdominal and pelvic pain for 2 years. A physical examination, including pelvic exam, reveals no abnormalities. A Pap smear shows only a few trichomonads and no dysplastic cells. A laparoscopy is performed, and the gynecologist notes the presence of several blue to red 0.2 to 0.4 cm slighted raised lesions scattered on the pelvic peritoneum in the cul-de-sac and broad ligaments. Which of the following is the most likely diagnosis?

A Metastatic adenocarcinoma

B Neisseria gonorrheae infection

C Endometriosis

D Candidiasis

E Leiomyomata

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Question 9

A 43-year-old woman has noted menstrual periods that have been exceptionally heavy, lasting 6 to 8 days, for 4 months. She has also noted minor intermenstrual bleeding. On physical examination her uterine cervix appears normal, and a Pap smear shows no abnormal cells. Pelvic examination reveals that the uterus is enlarged to twice normal size and is nodular. There are no adnexal masses. Which of the following is the most likely diagnosis?

A Endometrial carcinoma

B Leiomyomata

C Ectopic pregnancy

D Endometriosis

E Secondary syphilis

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Question 10

A 43-year-old woman has noted increasing abdominal discomfort for the past year. On physical examination, there is no tenderness. Bowel sounds are present. She has no vaginal bleeding. An abdominal ultrasound reveals a 7 cm left adnexal mass. A total abdominal hysterectomy is performed. Pathologic examination of the ovarian mass reveals it is unilocular, filled with watery fluid, and lined with papillary excrescences. On microscopic examination there is no infiltration of the underlying stroma. Which of the following neoplasms is this woman most likely to have?

A Granulosa-theca cell tumors

B Mature cystic teratomas

C Fibrosarcoma with metastases

D Borderline serous tumor

E Clear cell carcinomas

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Question 11

A 28-year-old sexually active woman undergoes a routine examination. Pelvic examination reveals no abnormalities. A Pap smear is obtained. The cytopathology report indicates the presence of severely dysplastic cells (high grade squamous intraepithelial lesion, or HSIL). A biopsy of the cervix is performed, and on microscopic examination shows cervical intraepithelial neoplasia III (CIN III). Infection with which of the following organisms is most likely to cause her disease?

A Herpes simplex virus infection

B Epstein-Barr virus

C Candida albicans

D Human papillomavirus

E Trichomonas vaginalis

F Gardnerella vaginalis

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Question 12

A 23-year-old woman has a 1 day history of increasing obtundation. On physical examination her temperature is 37.3°C, pulse 96/minute, respirations 18/minute, and blood pressure 90/45 mm Hg. A culdocentesis yields no blood. Abdominal ultrasound shows an intrauterine gestational sac and 12 week fetus. Laboratory studies show a positive pregnancy test. She has a WBC count of 11,400/microliter, Hgb 10.6 g/dL, Hct 31.1%, MCV 95 fL, and platelet count 26,400/microliter. Schistocytes are noted on her peripheral blood smear. Her protime is 44 sec, partial thromboplastin time 61 sec, and D-Dimer 16 microgm/mL. A urinalysis dipstick examination shows no blood, protein, or glucose. Which of the following complications of pregnancy is most likely to explain her condition?

A Placental infarction

B Eclampsia

C Amniotic fluid embolus

D Retained dead fetus

E Ruptured tubal ectopic

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Question 13

A 22-year-old woman passes grape-like masses of tissue per vagina in the 16th week of her first pregnancy. She had not felt any fetal movement at any time. On physical examination she measures 18 weeks in size. A D&C is performed, yielding 1000 cc of 0.5 to 1.5 cm fluid-filled vesicles. Microscopic examination of this tissue shows large avascular villi along with trophoblastic proliferation. Which of the following is the best method to employ for her follow-up care?

A Chest radiograph

B Serum beta-HCG

C Endometrial biopsy

D Pelvic ultrasound

E Pap smear

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Question 14

A 23-year-old woman has the sudden onset of lower abdominal pain. Pelvic examination reveals a normal sized uterus and normal appearing cervix and vagina. However, there is marked tenderness upon palpation of the left adnexal region. A transvaginal ultrasound shows no intrauterine gestational sac, but there is a 2 cm left adnexal mass. Culdoscocentesis yields bloody fluid. Which of the following is most useful procedure to aid in diagnosis?

A Serum complement determination

B Microscopic urinalysis

C Pap smear

D Serum beta-HCG

E Endometrial biopsy

F WBC count

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Question 15

A 20-year-old woman has had irregular menstrual bleeding for the past 6 months. On physical examination there are no abnormal findings. Laboratory studies show a negative pregnancy test. A D&C is performed and microscopic examination shows dyssynchronous endometrial glands and stroma of anovulatory cycles. Following the procedure she ceases to have menstrual bleeding. Which of the following is the most likely diagnosis?

A Endometriosis

B Asherman syndrome

C Prolactinoma

D Ovarian failure

E Oral contraceptive use

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Question 16

A 14-year-old girl has had pelvic pain for the past 3 months. She has not yet noted passing menstrual blood. She has not had any sexual activity. She refuses physical examination, but an abdominal ultrasound shows fluid distending the vagina. Which of the following is the most likely diagnosis?

A Cervical condyloma

B Endometriosis

C Cervical gonorrhea

D Imperforate hymen

E Ruptured Bartholin cyst

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Question 17

A 64-year-old woman has had itching with irritation of the vulvar region, along with vaginal dryness, for the past 8 months. On physical examination she has pale grey patches from 1 to 2 cm in size on the vulva. Biopsy of one lesion is performed and on microscopic examination shows epithelial thinning, dermal fibrosis, and perivascular chronic inflammation. Which of the following is the most likely diagnosis?

A Squamous cell carcinoma

B Lichen sclerosus

C Condyloma acuminatum

D Adenosis

E Extramammary Paget disease

F Dermatophyte infection

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Question 18

For the past year, a 50-year-old woman has noted that her menstrual periods have been exceptionally heavy and last 7 to 9 days. She has noted occasional minor intermenstrual bleeding. For the past 3 months, she has been taking supplemental dietary iron for iron deficiency anemia. On pelvic examination, the uterine cervix appears normal, but the uterus is enlarged to twice normal size. Transvaginal ultrasound reveals the presence of a 9 cm solid mass in the uterus. A hysterectomy is performed, and on gross inspection with sectioning the uterus a reddish-tan mass is found with a fleshy cut surface. Microscopically the mass is highly cellular, with spindle cells having hyperchromatic nuclei and 10 to 20 mitoses per high power field. Which of the following is the most likely diagnosis?

A Endometrial polyp

B Adenomyosis

C Embryonal rhabdomyosarcoma

D Atypical hyperplasia

E Leiomyosarcoma

F Malignant mixed mullerian tumor

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Question 19

A 31-year-old G3 P2 woman is at 14 weeks gestation, but has noted a small amount of vaginal bleeding for the past 2 weeks. Laboratory studies show an HCG level of 650,000 U/L. An ultrasound shows a "snowstorm" for intrauterine contents but no identifiable fetus. A D&C is performed with evacuation of 500 mL of grape-like vesicles. A month later her vaginal bleeding persists and her serum beta-HCG is 35,000 U/L. Which of the following pathologic abnormalities is most likely to be present in this woman?

A Pulmonary metastases

B Tubal ectopic pregnancy

C Endometritis

D Placental site trophoblastic tumor

E Invasive mole

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Question 20

A 33-year-old woman and her husband have wanted a child, but she has been unable to conceive for the past 10 years. She has mild pelvic pain, but regular menstrual cycles. On physical examination the cervix and vagina appear normal. The uterus and adnexal regions are normal on palpation. A pelvic ultrasound shows no lesions. A Pap smear is normal. Her husband's sperm count is normal. Which of the following is most likely to be the cause for her infertility?

A Adenomyosis

B Adenohypophyseal prolactinoma

C Pelvic inflammatory disease

D Mature cystic teratoma

E Chronic cervicitis

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Question 21

A 38-year-old woman has noted intermenstrual spotting of blood for the past 3 months. On pelvic examination, she has a nodular 2 x 3 cm mass in the upper vagina. Biopsy of the mass is performed and on microscopic examination shows a clear cell carcinoma. Which of the following risk factors probably preceded development of this carcinoma?

A Human papilloma virus infection

B Endometriosis

C Irregular menstrual cycles

D Diethylstilbestrol exposure

E Precocious pseudopuberty

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Question 22

A 19-year-old woman has noted increasing size and number of warty lesions on her external genitalia for the past 5 years. On physical examination she has several pink-tan rounded 1 to 2 cm slightly raised, rough lesions on the perineum and vulva. Biopsy of one lesion is performed and on microscopic examination shows acanthosis of squamous epithelium along with koilocytosis. Which of the following is the most likely risk factor for these lesions?

A Irritant chemical exposure

B Oral contraceptive use

C Candida vulvovaginitis

D Multiple sexual partners

E Turner syndrome

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Question 23

A 40-year-old woman has experienced pelvic discomfort for over a month, along with a 4 kg weight loss, nervousness, and diaphoresis. A pelvic examination reveals a large left adnexal mass that, on transvaginal ultrasound, appears as a discrete 10 cm cystic and solid mass. The uterus appears normal in size. A Pap smear is normal. The mass is removed and on gross pathologic examination is filled with hair and sebum, along with solid tan areas next to the smooth-surfaced outer wall. Which of the following laboratory test findings is most likely to have been present just prior to her surgery?

A Thyroxine of 11.3 microgm/dL

B HCG of 45,000 IU/L

C Potassium of 2.9 mmol/L

D Estradiol of 1700 pg/mL

E Cancer antigen 125 of 540 U/mL

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Question 24

A 32-year-old G3 P2 woman goes for a routine prenatal check at 12 weeks gestation. On physical examination she is found to be large for dates, and no fetal heart tones are audible. An ultrasound is performed and revealed that no fetus was present, only many echogenic cystic areas within the uterus. Which of the following is the most likely diagnosis?

A Invasive mole

B Partial hydatidiform mole

C Placental site trophoblastic tumor

D Choriocarcinoma

E Complete hydatidiform mole

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Question 25

A 37-year-old woman goes to her physician for a routine checkup. On physical examination there are no abnormal findings. A Pap smear is taken and cytologically there are dysplastic cells present. A cervical biopsy is performed. Microscopic examination shows dysplasia involving the full thickness of the cervical epithelium. Which of the following is the most likely diagnosis?

A High grade squamous intraepithelial lesion (HSIL)

B Severe chronic cervicitis with herpes simplex virus (HSV)

C Diethylstilbestrol (DES) exposure

D Endocervical adenocarcinoma

E Extramammary Paget disease

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Question 26

Two weeks after delivery of a normal healthy term infant boy following an uncomplicated pregnancy, a 25-year-old woman still has a vaginal discharge consisting of dark brown, foul-smelling material. Her temperature is 37.4°C. On pelvic examination, the uterus is slightly enlarged and she has pelvic tenderness. Laboratory studies show her serum beta-HCG is negative. Which of the following conditions is she most likely to have?

A Invasive mole

B Degenerating uterine leiomyoma

C Postpartum pituitary necrosis

D Endometriosis

E Retained products of conception

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Question 27

A 39-year-old woman has had dysmenorrhea for 7 months. On pelvic examination, there are no adnexal masses, and the cervix appears normal, but the uterus is three times normal size. The uterus appears to be symmetrically enlarged on abdominal ultrasound, with no masses present and an endometrial cavity that is nearly normal in size. A Pap smear is normal. Her serum pregnancy test is negative. A total abdominal hysterectomy is performed. Which of the following microscopic findings is most likely to be present in her uterus?

A Atypical glands invading through the uterine wall

B Large avascular villi with trophoblastic proliferation

C Hyperchromatic and pleomorphic smooth muscle cells

D Extensive acute inflammation

E Endometrial glands and stroma in the myometrium

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Question 28

A 15-year-old girl has had irregular menstrual cycles for 5 months. She had menarche at age 13. There are no abnormal physical examination findings. An endometrial biopsy is taken on post-ovulatory day 9 and shows proliferative phase endometrium. Which of the following is the most likely diagnosis?

A Adenomyosis

B Anovulatory cycles

C Endometrial adenocarcinoma

D Leiomyomata

E Oral contraceptive use

F Ovarian thecoma

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Question 29

A 29-year-old woman has had dyspareunia for the past 2 months. She has had only one sexual partner--her husband. She is G2 P2. On physical examination there are no abnormal findings except for a small but slightly tender 1.5 cm mass located in the right lateral wall of her vagina. The lesion is excised. On gross examination this mass is cystic and fluid filled. On microscopic examination the cyst is lined by a cuboidal epithelium. Which of the following is the most likely etiology for this lesion?

A Bacterial vaginosis

B Embryologic remnant

C Gonoccocal infection

D Metastatic adenocarcinoma

E Oral contraceptive use

F Foreign body

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Question 30

A 33-year-old woman has an infertility workup. Her BMI is 32. Hirsutims is noted. On pelvic examination, bilateral adnexal masses are palpated. Transvaginal ultrasound examination shows a normal sized uterus, but the ovaries are enlarged and have a dozen peripheral echogeni follicles. Laboratory studies show hyperglycemia and increased androgenic steroids. For which of the following conditions is she at greatest risk?

A Endometrial hyperplasia

B Adenomyosis

C Malignant mixed mullerian tumor

D Chronic endometritis

E Borderline mucinous tumor

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Question 31

A 24-year-old woman is G2 P1. Her first pregnancy resulted in a normal term birth. Now at 15 weeks gestation, a prenatal checkup reveals that she has a blood pressure of 140/90 mm Hg. An ultrasound is performed that reveals no fetal cardiac motion. Misoprostol induction is performed for termination of the pregnancy. Examination of the malformed stillborn fetus reveals that it is small for gestational age and has 3,4 syndactyly bilaterally, an indented nasal bridge, and a two vessel cord. The placenta is small for gestation and has scattered 0.5 cm grape-like villi. A chromosome analysis performed on the placental tissue will most likely demonstrate which of the following karyotypes?

A 46, XX

B 69, XXY

C 45, X

D 47, XX, +18

E 23, X

F 47, XYY

G 47, XXX

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Question 32

A 16-year-old girl has not begun menstruation. Physical examination reveals that she has breast development, but a short vagina and no palpable uterus or adnexa, only bilateral inguinal masses. She appears otherwise normally developed. Which of the following laboratory tests would be most appropriate to order on this girl?

A Chromosome analysis

B Serum estrogen

C Assay for luteinizing hormone

D Serum cortisol

E Serum testosterone

F Magnetic resonance imaging of brain

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Question 33

A 38-year-old healthy woman has had a white, curd-like vaginal discharge for the past week. There is no bleeding. A Pap smear demonstrates normal appearing squamous epithelial cells along with scattered neutrophils and budding cells with pseudohyphae. Which of the following infectious agents is most likely to be present in this woman?

A Treponema pallidum

B Neisseria gonorrhea

C Chlamydia trachomatis

D Herpes simplex virus

E Escherichia coli

F Gardnerella vaginalis

G Trichomonas vaginalis

H Candida albicans

I Human papillomavirus

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Question 34

A 35-year-old woman has had dull pelvic pain for 4 months. A pelvic examination reveals a normal appearing cervix, a normal sized uterus, and a large tender right adnexal mass. Ultrasound reveals an 8 cm cystic, fluid-filled mass involving the right adnexal region. At laparotomy, there are many filmy fibrous adhesions in the pelvis. The mass is excised and on gross examination is found to have a thin wall and is filled with purulent exudate. Microscopically, there are thin remnants of fallopian tube and ovary comprising the wall of the mass, with numerous neutrophils filling the lumen. Which of the following infectious agents is most likely to have produced these findings?

A Human papillomavirus

B Mycobacterium tuberculosis

C Trichomonas vaginalis

D Candida albicans

E Neisseria gonorrheae

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Question 35

Abnormal bleeding per vagina for the past 5 months prompts a 62-year-old woman to see her physician. She has never been pregnant and went through menopause 10 years previously. On physical examination her BMI is 33. There are no abnormal findings on physical examination. An endometrial biopsy is performed and on microscopic examination shows a well-differentiated endometrial adenocarcinoma. Which of the following ovarian neoplasms is she most likely to have?

A Papillary serous cystadenocarcinoma

B Krukenberg tumor

C Mucinous cystadenoma

D Granulosa cell tumor

E Immature teratoma

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Question 36

A 28-year-old woman develops the sudden onset of severe lower abdominal pain. On physical examination there is tenderness to palpation of the right lower quadrant. Laboratory studies show her serum pregnancy test is positive. An ultrasound scan does not reveal a gestational sac in the uterus, but there is a right adnexal mass. The development of these findings is most closely related to past infection with which of the following organisms?

A Treponema pallidum

B Human papillomavirus

C Neisseria gonorrheae

D Candida albicans

E Group B Streptococcus

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Question 37

A 44-year-old woman has had irregular menstrual periods for the past 9 months. On physical examination she has an enlarged uterus. An ultrasound scan shows a 9 cm solitary, solid mass in the uterus. A total abdominal hysterectomy is performed. Gross examination of the irregular reddish-tan mass located in the myometrium shows bundles of smooth muscle cells along with heterogenous elements of pleomorphic cartilaginous cells. There are also areas with poorly differentiated gland formation. Mitotic figures are frequent. Which of the following neoplasms is she most likely to have?

A Leiomyosarcoma

B Sarcoma botryoides

C Malignant mixed mullerian tumor

D Endolymphatic stromal myosis

E Leiomyoma with focal degeneration

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Question 38

A 72-year-old woman has had fatigue for the past year, along with episodes of vaginal bleeding. On physical examination there are no abnormal findings. Laboratory studies show Hgb 9.1 g/dL, Hct 26.5%, MCV 72 fL, platelet count 158,000/microliter, and WBC count 7150/microliter. An endometrial biopsy is performed and on microscopic examination shows atypical adenomatous hyperplasia. Which of the following is the most likely risk factor for development of her disease?

A Human papillomavirus infection

B Long term intrauterine contraceptive device use

C Chronic endometritis

D Pelvic inflammatory disease

E Unopposed estrogenic stimulation

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Question 39

A 56-year-old G0 P0 woman reports vaginal bleeding in the past 2 months. Her last menstrual period was 6 years ago. On physical examination there are no abnormal findings. Which of the following procedures is most appropriate to perform on this woman?

A Endometrial biopsy

B Pap smear

C Vaginal culture

D Colposcopy

E CT scan

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Question 40

A 50-year-old woman has experienced mild pelvic discomfort for 3 months. On physical examination there are bilateral adnexal masses. A pelvic CT scan reveals irregular unilocular cystic, bilateral mass lesions in the region of the ovaries. One is 10 cm and the other is 8 cm in size. Which of the following types of neoplasm is most likely to be present in this woman?

A Mature cystic teratoma

B Serous cystadenocarcinoma

C Endometrioid carcinoma

D Fibrothecoma

E Mucinous cystadenoma

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