Endometrial Pathology — MCQs
What is the most common histological variety of uterine carcinoma?
This type of endometrial hyperplasia leads to an increased risk of endometrial cancer.
Which of the following statements about Asherman's syndrome is true?
An obese woman of 49 years of age, with a history of diabetes and hypertension, complains of heavy menstrual bleeding with delayed and irregular cycles. Which of the following is the most important cause that should be ruled out in this patient?
A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :
The gene most commonly involved in endometrial carcinoma is:
What is the first-line treatment for simple hyperplasia of the endometrium?
Most useful investigation in a 55-year-old postmenopausal woman with diabetes mellitus and hypertension who has presented with postmenopausal bleeding is:
A 39 year old nulliparous female has presented to Gynaecology OPD with complaint of post-coital bleeding for past six months. The first investigation to be offered to this female will be
A 60-year-old woman presents with postmenopausal bleeding per vaginum. Both per vaginum and per speculum examination reveal no abnormality, and the Pap smear is normal. What will be the most appropriate management?
Endometrial Pathology Indian Medical PG Practice Questions and MCQs
Question 1: What is the most common histological variety of uterine carcinoma?
- A. Mixed carcinoma
- B. Squamous cell carcinoma
- C. Serous carcinoma
- D. Adenocarcinoma (Correct Answer)
Explanation: ***Adenocarcinoma*** - **Endometrial adenocarcinoma** is by far the most common type of uterine carcinoma, accounting for about 80% of all cases [1]. - It arises from the **glandular epithelial cells** lining the endometrium and is typically associated with **estrogen exposure** [1]. *Squamous cell carcinoma* - **Squamous cell carcinoma** of the uterus is extremely rare and usually occurs in the cervix, not the uterine body. - While it can occur in the endometrium in specific circumstances (e.g., in association with pyometra), it is not the most common type. *Serous carcinoma* - **Uterine serous carcinoma** is a more aggressive, high-grade subtype that accounts for a smaller percentage (5-10%) of uterine cancers. - It is typically seen in older women and often presents at an advanced stage, but it is not the most common overall. *Mixed carcinoma* - **Mixed carcinoma** of the uterus contains elements of more than one histological type, typically adenocarcinoma and another more aggressive component. - These are uncommon and represent a smaller fraction of uterine cancers compared to pure adenocarcinoma. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1016-1018.
Question 2: This type of endometrial hyperplasia leads to an increased risk of endometrial cancer.
- A. Simple
- B. Atypical (Correct Answer)
- C. Complex
- D. Secretory
Explanation: ***Atypical*** - **Atypical endometrial hyperplasia** shows both glandular architectural abnormalities and features of cellular atypia, such as nuclear pleomorphism and prominent nucleoli [1]. - The presence of cellular atypia is the key differentiator and significantly increases the risk of progression to **endometrial adenocarcinoma**, with up to 30% progressing to cancer [2]. *Simple* - **Simple endometrial hyperplasia** involves an increase in the number of endometrial glands, which retain their normal shape and uniform distribution [1]. - While it represents abnormal proliferation, the risk of progression to **endometrial cancer** is very low (less than 1%) [2]. *Complex* - **Complex endometrial hyperplasia** shows architectural crowding and branching of glands, but without cellular atypia [2]. - The glands are no longer uniformly spaced, creating a more complex pattern, but the individual cells do not show features of malignancy; therefore, the risk of progression to **endometrial cancer** is low (around 3%) [2]. *Secretive* - **Secretory endometrium** is a normal physiological phase of the menstrual cycle, occurring after ovulation under the influence of progesterone. - This term describes the histological appearance of the endometrium, not a type of hyperplasia or a premalignant condition. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Female Genital Tract, pp. 1016-1018. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Female Genital Tract Disease, pp. 473-475.
Question 3: Which of the following statements about Asherman's syndrome is true?
- A. May be secondary to TB
- B. Progesterone challenge test is positive
- C. Characterized by intrauterine adhesions (Correct Answer)
- D. Not associated with menstrual irregularities
Explanation: ***Characterized by intrauterine adhesions*** - **Asherman's syndrome** is fundamentally defined by the presence of **intrauterine adhesions** or scarring of the uterine cavity. - These adhesions develop following trauma to the basal layer of the endometrium, often from gynecological procedures like **dilation and curettage (D&C)**. - This is the **pathognomonic feature** that defines the syndrome. *Progesterone challenge test is positive* - The **progesterone challenge test** assesses the presence of an intact endometrium and adequate estrogen priming. - In Asherman's syndrome, due to the scarred endometrium, the response to progesterone is typically **absent or minimal**, leading to a **negative** result. - A negative progesterone challenge test indicates outflow obstruction or endometrial non-responsiveness. *May be secondary to TB* - While **genital tuberculosis** can cause intrauterine adhesions and is a recognized etiology, it represents a **small minority** of cases. - The primary etiology of Asherman's syndrome is usually **iatrogenic**, following uterine instrumentation such as D&C, particularly post-partum or post-abortion. - TB-related adhesions may have additional features like caseating granulomas. *Not associated with menstrual irregularities* - This is **false** - Asherman's syndrome is classically associated with **menstrual irregularities**. - Common presentations include **hypomenorrhea** (scanty periods), **amenorrhea** (absent periods), or oligomenorrhea. - These menstrual changes result from the reduced functional endometrium available for cyclical shedding due to intrauterine adhesions.
Question 4: An obese woman of 49 years of age, with a history of diabetes and hypertension, complains of heavy menstrual bleeding with delayed and irregular cycles. Which of the following is the most important cause that should be ruled out in this patient?
- A. Cancer cervix
- B. Endometrial cancer (Correct Answer)
- C. Fibroid uterus
- D. Polycystic ovaries
Explanation: ***Endometrial cancer*** - This patient has multiple risk factors for **endometrial cancer**, including **obesity**, **diabetes**, **hypertension**, and being in the **perimenopausal** age group (49 years old). - Her symptoms of heavy menstrual bleeding with delayed and irregular cycles are classic presentations of **endometrial hyperplasia** or **endometrial cancer**, warranting prompt investigation. *Cancer cervix* - While cervical cancer is a concern, its typical presentation often involves **post-coital bleeding** or **intermenstrual bleeding**, rather than heavy and irregular cycles, making other causes more likely in this specific scenario. - Risk factors for cervical cancer include **HPV infection**, early age of first intercourse, multiple sexual partners, and smoking, which are not mentioned here. *Fibroid uterus* - **Fibroids** can cause heavy menstrual bleeding, but the delayed and irregular cycles, combined with the patient's strong metabolic risk factors, make endometrial pathology a more urgent concern. - Fibroids are **benign tumors** and do not carry the same immediate malignancy risk as the presenting symptoms suggest for this patient profile. *Polycystic ovaries* - **PCOS** often presents with irregular or absent menstruation and infertility, usually in younger women, and is associated with obesity and insulin resistance. - While PCOS can lead to chronic anovulation and increased risk of **endometrial hyperplasia**, a 49-year-old with acute changes in bleeding pattern and metabolic syndrome points more directly to the need to rule out established endometrial malignancy.
Question 5: A postmenopausal diabetic woman presents with bleeding per vaginum. The most likely diagnosis is :
- A. Malignancy of the vulva
- B. Malignancy of the cervix
- C. Malignancy of the endometrium (Correct Answer)
- D. Malignancy of the ovary
Explanation: ***Malignancy of the endometrium*** - **Postmenopausal bleeding** is the classic presenting symptom of **endometrial cancer**, which must be ruled out in all such cases. - **Diabetes** is a known risk factor for endometrial cancer, along with obesity, hypertension, and unopposed estrogen exposure. *Malignancy of the vulva* - Vulvar cancer typically presents with a **pruritic lesion**, lump, or ulcer on the vulva, rather than solely with vaginal bleeding. - While bleeding can occur from an advanced vulvar lesion, it is not the primary or most common presentation for new onset postmenopausal bleeding. *Malignancy of the cervix* - Cervical cancer often presents with **postcoital bleeding** or irregular vaginal bleeding in premenopausal women, or less commonly, postmenopausal bleeding. - Screening with **Pap smears** typically detects precancerous changes or early cervical cancer, making it less likely to be the first presentation with postmenopausal bleeding in a well-screened population. *Malignancy of the ovary* - Ovarian cancer is often asymptomatic in its early stages and presents with non-specific symptoms like **abdominal distension**, bloating, or pelvic pain. - **Vaginal bleeding** is not a typical symptom of ovarian cancer, unless the tumor is very large, involves adjacent structures, or is a hormone-producing tumor.
Question 6: The gene most commonly involved in endometrial carcinoma is:
- A. PTEN (Correct Answer)
- B. BRAF
- C. KRAS
- D. Mismatch repair genes
Explanation: ***PTEN*** - **PTEN** (phosphatase and tensin homolog) is a **tumor suppressor gene** frequently inactivated in **endometrial carcinoma**, particularly in cases of **endometrioid histology**. - Loss of PTEN function leads to uncontrolled cell proliferation and survival by activating the **PI3K/Akt signaling pathway**, contributing to tumor development. *BRAF* - **BRAF mutations** are most commonly associated with **melanoma** and certain types of **thyroid cancer**, specifically papillary thyroid carcinoma. - While BRAF mutations can be found in a small subset of other cancers, they are not a primary driver or common gene in endometrial carcinoma. *KRAS* - **KRAS mutations** are frequently observed in **colorectal cancer**, **pancreatic cancer**, and **non-small cell lung cancer**. - Though KRAS can be mutated in various cancers, it is not the most commonly involved gene in endometrial carcinoma. *Mismatch repair genes* - Mutations in **mismatch repair (MMR) genes** (e.g., MLH1, MSH2, MSH6, PMS2) are characteristic of **Lynch syndrome** and lead to **microsatellite instability (MSI)**. - While MSI is observed in a significant subset of endometrial cancers (especially those associated with Lynch syndrome), PTEN mutations are more broadly common across all types of endometrial carcinoma.
Question 7: What is the first-line treatment for simple hyperplasia of the endometrium?
- A. Endometrial ablation (surgical procedure)
- B. Estrogen therapy (e.g., Estradiol)
- C. Total abdominal hysterectomy (surgical removal of the uterus)
- D. Progestin therapy (e.g., Medroxyprogesterone acetate) (Correct Answer)
Explanation: ***Progestin therapy (e.g., Medroxyprogesterone acetate)*** - **Progestin therapy** is the first-line treatment for simple endometrial hyperplasia because it counteracts the unopposed estrogen effect causing the hyperplasia. - **Progestins** lead to endometrial atrophy and shedding, helping to reverse the hyperplastic changes and prevent progression to cancer. *Estrogen therapy (e.g., Estradiol)* - **Estrogen therapy** without concomitant progestins would exacerbate endometrial hyperplasia by further stimulating endometrial growth. - This treatment is contraindicated in cases of endometrial hyperplasia unless carefully balanced with progestins. *Endometrial ablation (surgical procedure)* - **Endometrial ablation** is a destructive procedure to remove the endometrial lining and is typically considered for persistent abnormal uterine bleeding, not as a primary treatment for simple hyperplasia. - It is often reserved for patients who have completed childbearing and fail medical management. *Total abdominal hysterectomy (surgical removal of the uterus)* - A **total abdominal hysterectomy** is an invasive surgical procedure that is generally reserved for complex or atypical endometrial hyperplasia, or hyperplasia that is recurrent and unresponsive to medical management. - It is not the first-line treatment for simple hyperplasia, especially in patients who may desire future fertility or wish to avoid major surgery.
Question 8: Most useful investigation in a 55-year-old postmenopausal woman with diabetes mellitus and hypertension who has presented with postmenopausal bleeding is:
- A. Pap test
- B. Endometrial biopsy (Correct Answer)
- C. Transvaginal ultrasound examination
- D. CA-125 blood test
Explanation: ***Endometrial biopsy*** - This is the **most crucial investigation** for postmenopausal bleeding to rule out **endometrial cancer** or **hyperplasia**, especially in a patient with risk factors like diabetes and hypertension. - An endometrial biopsy directly samples the **uterine lining** for histological examination, providing a definitive diagnosis of any abnormal tissue changes. *Pap test* - A Pap test, or **Papanicolaou test**, primarily screens for **cervical cancer** by examining cells from the cervix. - It is **not effective** for detecting uterine (endometrial) abnormalities or cancer, which is the main concern with postmenopausal bleeding. *Transvaginal ultrasound examination* - While useful for assessing **endometrial thickness** and identifying structural abnormalities like polyps or fibroids, it is **not diagnostic** on its own. - An abnormal ultrasound finding, such as a thickened endometrium (usually >4-5mm in postmenopausal women), would typically prompt an endometrial biopsy for definitive diagnosis. *CA-125 blood test* - **CA-125** is a tumor marker primarily used for monitoring the response to treatment in **ovarian cancer** and can be elevated in other conditions like endometriosis or fibroids. - It is **not a screening tool** for endometrial cancer and is **not specific or sensitive enough** to be the primary investigation for postmenopausal bleeding.
Question 9: A 39 year old nulliparous female has presented to Gynaecology OPD with complaint of post-coital bleeding for past six months. The first investigation to be offered to this female will be
- A. Pap smear (Correct Answer)
- B. Hysteroscopy
- C. Ultrasound
- D. Endometrial biopsy
Explanation: ***Pap smear*** - **Post-coital bleeding** is a classic symptom of **cervical pathology**, including **cervical cancer**, which a Pap smear is designed to detect. - As a **screening tool**, a Pap smear is the appropriate initial investigation to broadly assess for abnormal cervical cells. *Hysteroscopy* - Hysteroscopy is an invasive procedure primarily used to visualize the **uterine cavity** and would be considered if concerns about intrauterine pathology arise after initial screening. - It's not the first-line investigation for post-coital bleeding, which typically points to a **cervical or vaginal source**. *Ultrasound* - **Pelvic ultrasound** is useful for evaluating uterine, ovarian, and adnexal pathologies but is less effective for directly visualizing the **cervical surface** where post-coital bleeding often originates. - It would be considered if there are other symptoms suggesting uterine or ovarian issues that aren't typically associated with post-coital bleeding alone. *Endometrial biopsy* - An **endometrial biopsy** is indicated for investigating **abnormal uterine bleeding** originating from the endometrium, such as in cases of suspected **endometrial hyperplasia** or cancer. - Post-coital bleeding is generally not an indication for an initial endometrial biopsy unless other findings suggest an endometrial origin.
Question 10: A 60-year-old woman presents with postmenopausal bleeding per vaginum. Both per vaginum and per speculum examination reveal no abnormality, and the Pap smear is normal. What will be the most appropriate management?
- A. Keep her under observation
- B. Administer haemostatics
- C. Measure endometrial thickness with ultrasound (Correct Answer)
- D. Hysterectomy
Explanation: ***Measure endometrial thickness with ultrasound*** - **Postmenopausal bleeding (PMB)** is a significant symptom that requires thorough evaluation to rule out **endometrial hyperplasia** or **carcinoma**, even with normal clinical exams and Pap smear. - Measuring **endometrial thickness with transvaginal ultrasound (TVS)** is the **first-line investigation** for PMB to assess for abnormalities. - **Endometrial thickness >4-5mm** warrants further evaluation with **endometrial biopsy** to rule out malignancy. - This is a non-invasive, cost-effective screening tool with high sensitivity for detecting endometrial pathology. *Keep her under observation* - This approach is inappropriate for PMB, as **10-15% of cases** can indicate underlying serious pathology like **endometrial cancer**. - **Prompt investigation** is necessary to ensure timely diagnosis and treatment. - Observation without investigation can lead to dangerous delays in cancer diagnosis. *Administer haemostatics* - Administering haemostatics addresses the symptom (bleeding) but does not identify or treat the underlying cause, which could be malignant. - This would delay crucial diagnostic evaluation and potentially worsen the prognosis if a **malignant condition** is present. - **PMB always requires investigation**, not symptomatic treatment alone. *Hysterectomy* - Hysterectomy is an invasive surgical procedure and is considered a definitive treatment, not a diagnostic step in this initial presentation. - It would only be contemplated after a definitive diagnosis of a serious condition, such as **endometrial cancer**, is made via less invasive means (e.g., endometrial biopsy). - Diagnostic workup should proceed stepwise: **TVS → endometrial biopsy → treatment decision**.
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