[MEDICAL QUIZ] #2 Obstetry and Gynecology

A 29-year-old African-American woman with menometrorrhagia undergoes ultrasound of
the pelvis, which reveals uterine masses. Biopsy shows a whorled pattern of smooth muscle. A gross specimen from a patient with similar pathology is shown below. These masses are most commonly associated with which of the following conditions?(A) Enlargement during pregnancy
(B) Formation of chocolate cysts
(C) Malignant transformation
(D) Pelvic inflammatory disease
(E) Postmenopausal metastasis

The correct answer is A. Leiomyomas, or fibroids, are common smooth muscle tumors
that are most often seen in African-American  women and present with multiple masses. These tumors are benign and can be associated with dysmenorrhea (menstrual pain), menorrhagia/menometrorrhagia (heavy prolonged bleeding), infertility, and abnormal pelvic exams including palpable masses extending from the uterus. Because they are estrogen sensitive, they tend to increase in size during menses or pregnancy and decrease in size after menopause. Treatment of fibroids is solely dependent on the severity of symptoms and the desire of the woman to preserve or not preserve fertility. Myomectomy can be performed in a woman wishing to preserve fertility, whereas hysterectomy is used in women with severe symptoms not wishing to preserve fertility.
Medical therapy can be tried with monotherapy or combinations of GnRH analogs (leuprolide), combined oral contraceptives, progestins, and/or GnRH antagonists (centrorelix).
Answer B is incorrect. Chocolate cysts and “powder burns” are most often associated with
endometriosis (nonneoplastic ectopic endometrial tissue outside the uterus). Endometriosis is often associated with severe menstrualrelated pain and infertility, but this patient’s masses are confined to the uterus, and the biopsy shows smooth muscle proliferation rather than the glandular and stromal proliferation at
ectopic sites that would be expected with endometriosis.
Answer C is incorrect. Leiomyomas are benign tumors that are very rarely associated with
malignant transformation. Malignant leiomyosarcomas most typically arise de novo with areas of necrosis and hemorrhage, not from leiomyomas.
Answer D is incorrect. Leiomyomas are not the cause of PID, but rather occur independently of the development of PID.
PID is the end result of a polymicrobial infection of the genital tract, most commonly caused by untreated Neisseria gonorrhoeae and Chlamydia trachomatis. PID commonly presents with odiferous vaginal discharge,
pain with sexual intercourse, urinary symptoms, and dysmenorrhea as well as a history of multiple unprotected sexual encoun ters. However, PID can also be asymptomatic.
Treatment of PID is aimed at treating the most likely microbial pathogen(s). PID does not
cause proliferation of the smooth muscle cells leading to benign tumors.
Answer E is incorrect. Leiomyomas, or fibroids, are estrogen-sensitive benign tumors
and thus frequently regress in size after menopause. Also, they are not malignant nor do
they metastasize. A metastatic mass in a postmenopausal woman should warrant further
evaluation of a neoplastic process, and should lessen the suspicion of uterine fibroids.