Gynecology 4

The most common site for uterine fibroids (leiomyomas) is the intramural location, where the fibroid is situated within the myometrium. Intramural fibroids account for approximately 70% of all fibroids. They can distort the uterine cavity if large and may cause symptoms like menorrhagia, dysmenorrhea, and infertility. Submucous fibroids are less common but more likely to cause heavy menstrual bleeding, while subserous fibroids project outward from the uterus. Cervical fibroids are rare.

In carcinoma cervix, the most common cause of death is renal failure, usually due to ureteric obstruction from advanced disease. Tumor infiltration or external compression by pelvic lymph nodes can cause bilateral ureteric obstruction, leading to hydronephrosis and chronic renal failure. Septicemia, hemorrhage, and cachexia can occur in late stages, but they are less frequent causes of mortality compared to obstructive uropathy and its sequelae.

In childhood, most ovarian tumors are benign, but the proportion of malignancy is relatively higher compared to adults. Approximately 10% of ovarian tumors in children are malignant. The most common malignant ovarian tumors in this age group are germ cell tumors (e.g., dysgerminoma, yolk sac tumor), rather than epithelial tumors which predominate in adults.

Cystic glandular hyperplasia refers to endometrial hyperplasia with cystic dilation of glands, usually caused by prolonged unopposed estrogen stimulation. Among the tumors listed, theca cell tumors are estrogen-secreting ovarian stromal tumors. The excess estrogen they produce can lead to cystoglandular hyperplasia and even endometrial carcinoma if prolonged.

Endometrial cancer is strongly linked to conditions causing prolonged unopposed estrogen exposure.

Metropathica haemorrhagica → Chronic anovulation (often seen in perimenopausal women) leads to unopposed estrogen stimulation and endometrial hyperplasia, a known precursor of endometrial carcinoma.

Fibroid (leiomyoma) itself is not premalignant, but women with fibroids may have anovulatory cycles or estrogen excess, indirectly increasing risk.

Dysgerminoma is a germ cell tumor, not hormonally active, and generally not associated with endometrial carcinoma.

Endometrial carcinoma is most common in postmenopausal women and is strongly associated with obesity, diabetes mellitus, and hypertension (the “corpus cancer triad”). The most common histological type is endometrioid adenocarcinoma, not adenosquamous. It is rarely associated with carcinoma of the cervix, as the two have different etiologies. Peak incidence occurs between 55–65 years, not 20–40 years.

Squamous cell carcinoma of the cervix most commonly arises at the squamocolumnar junction (transformation zone), and HPV types 16 and 18 are indeed strongly associated with high-risk carcinogenesis. Postcoital bleeding is a common presenting symptom due to friable cervical tissue.

The false statement is that CT scan is mandatory for staging — FIGO staging of cervical cancer is clinical, based on pelvic examination, colposcopy, cystoscopy, proctoscopy, and chest X-ray. Imaging modalities like CT or MRI may be used for treatment planning, but they are not mandatory or included in official staging criteria.

In a woman with postcoital bleeding and foul-smelling discharge, the most likely suspicion is carcinoma of the cervix. The gold standard for diagnosis is histopathological confirmation from the lesion itself.
Among the options, cervical biopsy (preferably colposcopy-directed) is the most important investigation to confirm the diagnosis.

Procedures like endometrial aspiration, dilatation & curettage, or endometrial biopsy are indicated for uterine/endometrial pathologies and not primary for suspected cervical malignancy.

Among endometrial carcinomas, clear cell carcinoma is considered the most malignant. It belongs to Type II endometrial cancers, which are estrogen-independent, high-grade tumors often occurring in atrophic endometrium of postmenopausal women. These tumors have a higher propensity for early myometrial invasion, lymphovascular spread, and poor prognosis compared to endometrioid adenocarcinoma (Type I).

Other options:

Adenocarcinoma (endometrioid type): Most common but relatively less aggressive.

Adenoacanthoma: Variant with benign squamous differentiation, often better prognosis.

Mixed adenosquamous carcinoma: More aggressive than pure adenocarcinoma but still less malignant than clear cell carcinoma.

Granulosa-theca cell tumor is not a germ cell tumor — it is a sex cord–stromal tumor arising from ovarian stroma, often estrogen-producing, and associated with endometrial hyperplasia or carcinoma.

Other options:

Dysgerminoma: Malignant germ cell tumor, ovarian counterpart of seminoma.

Teratoma: Germ cell tumor containing elements from all three germ layers (can be benign or malignant).

Embryonal carcinoma: Rare malignant germ cell tumor.

Long-term complications of PCOS include type II diabetes mellitus, cardiovascular disease (due to metabolic syndrome, dyslipidemia, and insulin resistance), and endometrial cancer (from prolonged unopposed estrogen exposure leading to endometrial hyperplasia).
Ovarian cancer is not a recognized long-term complication of PCOS — current evidence does not show a significant increase in ovarian cancer risk in PCOS patients.

Call–Exner bodies are small, eosinophilic, fluid-filled spaces between granulosa cells, resembling immature follicles. They are characteristic of granulosa cell tumors, a type of sex cord–stromal tumor of the ovary. These tumors often produce estrogen, leading to symptoms such as precocious puberty in children or abnormal uterine bleeding in adults.
They are not seen in yolk sac tumor (which shows Schiller–Duval bodies), choriocarcinoma (which shows cytotrophoblasts and syncytiotrophoblasts without villi), or dysgerminoma (which shows large clear cells with central nuclei, “fried-egg” appearance).

Endodermal sinus tumor (also called yolk sac tumor) is a malignant germ cell tumor of the ovary (or testis) that is highly aggressive and occurs most commonly in children and young women.
The characteristic tumor marker is α-fetoprotein (AFP), which is elevated in serum and can be used both for diagnosis and follow-up after treatment.

a) α-fetoprotein → Correct; produced by tumor cells mimicking yolk sac elements.

b) hCG → Marker for choriocarcinoma and some germ cell tumors like embryonal carcinoma.

c) LDH → Marker for dysgerminoma.

d) CA-125 → Marker for epithelial ovarian cancers.

In India, the most common cause of postmenopausal bleeding is cancer cervix, whereas in many Western countries, endometrial carcinoma is more common.
This difference is due to the higher prevalence of cervical cancer in India, related to lower screening rates and higher HPV infection burden.