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Endometriosis Multiple Choice Questions for Vol. 18, No. 2 1. Resistance to progesterone in endometriosis may be due to: a. To the presence of PR in eutopic tissue but the absence in ectopic tissue. b. To the presence of the inhibitory PR isoform PR-A and the absence of the stimulatory isoform PR-B in the endometriotic tissue. c. To the absence of both PR isoforms in the endometriotic tissue. d. To the increased levels of estrogen receptors in the endometriotic tissue. 2. Evidence for the pathogenesis of deep rectovaginal endometriosis as the natural evolution of peritoneal endometriosis of Douglas pouch as consequence of its secondary infiltration are. a. patients with endometriosis of the rectovaginal septum have about a one- third reduction in the depth of the pouch of Douglas b. a smooth muscle component is present in all types of endometriotic lesions c. other forms of the disease are infrequently associated with the presence of deep peritoneal endometriotic nodules d. the absence of evolution of the rectal lesion after removal of the endometriotic glands 3. With regard to risk factors for endometriosis: a. Recent studies have shown that the frequency of endometriosis increases with age until the menopause. b. The younger tha age at diagnosis, the more severe the symptoms of endometriosis. c. There is strong evidence for a racial bias in the incidence of endometriosis, being more common in black than white women in the USA. d. Women with early menarche, short and heavy menstrual cycles are at higher risk of endometriosis. e. Parity is inversely associated with the risk of endometriosis. 4. The younger a girl or woman is at onset of pelvic endometriosis symptoms, a. The more likely she is to experience a long delay in diagnosis. b. The more doctors a girl or woman had to see. c. The most likely they were to have mild disease. d. More likely to become pregnant. e. Most likely to be disabled. 1521-6934/$ - see front matter Best Practice & Research Clinical Obstetrics and Gynaecology Vol. 18, No. 2, pp. A1–A6, 2004 doi:10.1016/j.bpobgyn.2004.04.003 available online at http://www.sciencedirect.com

EndometriosisMultiple Choice Questionsfor Vol. 18, No. 2

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Endometriosis

Multiple Choice Questions

for Vol. 18, No. 2

1. Resistance to progesterone in endometriosis may be due to:a. To the presence of PR in eutopic tissue but the absence in ectopic tissue.b. To the presence of the inhibitory PR isoform PR-A and the absence of the

stimulatory isoform PR-B in the endometriotic tissue.c. To the absence of both PR isoforms in the endometriotic tissue.d. To the increased levels of estrogen receptors in the endometriotic tissue.

2. Evidence for the pathogenesis of deep rectovaginal endometriosis as the naturalevolution of peritoneal endometriosis of Douglas pouch as consequence of itssecondary infiltration are.

a. patients with endometriosis of the rectovaginal septum have about a one-third reduction in the depth of the pouch of Douglas

b. a smooth muscle component is present in all types of endometriotic lesionsc. other forms of the disease are infrequently associated with the presence of

deep peritoneal endometriotic nodulesd. the absence of evolution of the rectal lesion after removal of the

endometriotic glands

3. With regard to risk factors for endometriosis:a. Recent studies have shown that the frequency of endometriosis increases

with age until the menopause.b. The younger tha age at diagnosis, the more severe the symptoms of

endometriosis.c. There is strong evidence for a racial bias in the incidence of endometriosis,

being more common in black than white women in the USA.d. Women with early menarche, short and heavy menstrual cycles are at higher

risk of endometriosis.e. Parity is inversely associated with the risk of endometriosis.

4. The younger a girl or woman is at onset of pelvic endometriosis symptoms,a. The more likely she is to experience a long delay in diagnosis.b. The more doctors a girl or woman had to see.c. The most likely they were to have mild disease.d. More likely to become pregnant.e. Most likely to be disabled.

1521-6934/$ - see front matter

Best Practice & Research Clinical Obstetrics and GynaecologyVol. 18, No. 2, pp. A1–A6, 2004doi:10.1016/j.bpobgyn.2004.04.003

available online at http://www.sciencedirect.com

5. The “big picture” of endometriosis includes:a. Traditional gynecological symptoms.b. Immunological symptoms.c. Gastrointestinal symptoms.d. Systemic treatment approaches are useless for endometriosis.e. An allergic background was especially likely in comorbid diseases.

6. Barriers to diagnosis and proper treatment of endometriosis include:a. Gynecologists.b. Onset of symptoms in the patient’s 30s.c. Early age of pelvic symptom onset.d. Family practitioners.e. Cultural attitudes about women’s pain.

7. Familial tendency and polygenic/multi-factorial mode of inheritance for endome-triosis has been shown through the following studies:

a. Population-based studies using questionnaires and review of patient medicalrecords.

b. Linkage analysis.c. Molecular cytogenetic analysis using fluorescent in situ hybridisation.d. Tissue microarrays.

8. Strategies used for finding genes responsible for endometriosis include all of thefollowing EXCEPT:

a. cDNA microarrays.b. Quantitative linkage analysis.c. Gene expression profiling.d. DNA sequence analysis.

9. In surveying candidate genes, which of the following approaches has not beenutilized to identify a causative gene in endometriosis:

a. Association studies that demonstrate a role of GSTM1 null genotypes.b. Linkage analysis that prove role of ras oncogene activation.c. Molecular cytogenetic techniques that detect loss of p53.d. Loss of heterozygosity that indicate inactivation of a tumor suppressor gene.

10. Endometriosisa. Has a clear pathogenesis.b. Is a phenomenon which can be explained by dysfunctioning endometrium only.c. Is a polygenically inherited disease with a complex, multifactorial etiology.d. Can be looked upon as a phenomenon which is present in a majority of

women, and as a disease in some women.e. May present with different signs and symptoms, except dyspareunia.

11. The peritoneal environmenta. Peritoneal fluid may be of pivotal importance in the defense against

endometriosis.b. Peritoneal fluid may be of pivotal importance in inducing endometriosis.

A2 Appendix

c. The presence of activated macrophages in peritoneal fluid of women withendometriosis can only be explained as a cause of endometriosis.

d. The mesothelium itself is not involved in the pathogenesis of endometriosis.e. Menstrual effluent may induce morphological changes in the mesothelium.

12. Early endometriosis lesion formationa. Endometriosis and malignancies share molecular mechanisms of invasion

and metastasis.b. The collagenase subfamily of matrix metalloproteinases (MMPs) is the

predominantly involved subfamily in early lesion formation.c. MMP activity is mainly oestrogen-regulated.d. Proliferation is an essential step in early lesion formation.e. Inhibiting angiogenesis may be a promising future treatment option for

endometriosis.

13. The following immunological functions are suppressed in women with endometriosis:a. NK function.b. Cytokine synthesis.c. Antibody synthesis.d. Phagocytosis.e. Leukocyte chemotaxis.

14. The following features of endometrial cells favor the establishment ofendometriosis:

a. Resistance to spontaneous apoptosis.b. Resistance to macrophage-mediated killing.c. Capacity to synthesize proinflammatory cytokines.d. Capacity to inhibit chemokine synthesis.e. Capacity to stimulate COX-2 metabolism.

15. In women with endometriosis, the following changes in the immune responsehave been documented:

a. Decreased NK-cell cytotoxicity to autologous endometrial cells.b. Increased autoantibody production.c. Increased synthesis of pro-inflammatory cytokines by peritoneal macro-

phages.d. Increased synthesis of pro-inflammatory cytokines byperipheral bloodmonocytes.e. Decreased mobilization of macrophages into the peritoneal cavity.

16. The following statements on superficial endometriosis are true:a. The reproducibility of the laparoscopic staging of endometriosis is high.b. Peritoneal implants are too small to be diagnosed by imaging techniques.c. The current staging system reflects the natural progression of the disease.d. Endometriosis is like cancer a progressive, invasive disease.e. One-third of peritoneal implants may disappear spontaneously.

17. The following statements on ovarian endometriosis are false:a. Ovarian endometriomas occur more frequently on the left than the right

side.

Appendix A3

b. Most endometriomas occur as an intraovarian cyst.c. Transvaginal sonography is a useful tool to make and to exclude an ovarian

endometrioma.d. Small ovarian endometriomas are easily detected at laparoscopy.e. Complete excision of a large endometriotic cyst garantees that all

endometriotic tissue has been removed.

18. The following statements on posterior pelvis endometriosis are true:a. Posterior pelvic endometriosis can be diagnosed by laparoscopy.b. Transvaginal sonography is useless to detect bowel involvement.c. Magnetic resonance imaging is of no use for the diagnosis of posterior pelvis

endometriosis.d. Posterior pelvis endometriosis should be explored for the presence of

obstructive uropathy.e. Rectovaginal endometriosis involves the rectovaginal septum.

19. The following descriptions are true for endometriosis:a. Based on the behavior of the endometriosis, ectopic endometrium acts like

the tumorous tissue and the level of growth factor is positively correlatedwith the degree of endometriosis.

b. Serum IL-6 could discriminate between patients with endometriosis andthose without.

c. MMPs and their inhibitors, TIMPs are involved in matrix turnover that playsa key role in the pathogenesis of endometriosis.

d. Endometriosis is an autoimmune disease.e. Environmental contaminant residues such as dioxin may contribute to the

etiology of endometriosis. Therefore, the serum level of dioxin mayassociate with the incidence and severity of endometriosis.

20. The following statements are true:a. Oestrogen appears to be an essential requirement for continued growth of

endometriosis.b. Aromatase is a cytochrome P450 enzyme that catalyzes the rate limiting

step in estrogen biosynthesis.c. PGE2 is a potent inducer of aromatase activity in endometriotic cells.d. Oestrogen antagonizes the effects of PGE2 on endometriotic cells. in turn,

was found to up-regulate PGE2 formation by stimulating cyclo-oxygenasetype 2 enzyme.

e. Endometriotic cysts and extraovarian endometriotic implants express lowor undetectable levels of aromatase.

21. The following statements are true:a. Progesterone mediates its effects via cell surface receptors.b. There is only one identified progesterone receptor to date.c. MMPs are enzymes thought to mediate peritoneal inavsion by endometrial

tissue.d. MMPs are regulated by oestrogen and progesterone.e. TIMPs act synergistically with MMPs in tissue remodeling.

A4 Appendix

22. The method by which selective progesterone receptor modulators are believedto treat endometriosis is:

a. A direct anti-proliferative effect upon endometrium.b. Inhibition of endometrial vascular supply.c. Hypothalamic suppression.d. Pituitary suppression.

23. Aromatase inhibitors would be a potential drug of choice for which woman withendometriosis-associated pain?

a. Premenopausal, cycles regularly.b. Postmenopausal, atrophic endometrium, no estrogen replacement therapy.c. Postmenopausal, proliferative endometrium, no hormone replacement

therapy.d. Postmenopausal, proliferative endometrium, oral estrogen replacement

therapy.

24. The only new drug tested to treat endometriosis-associated infertility is:a. Pentoxifylline.b. Mifepristone.c. TBP-1.d. Anastrazole.

25. What are the concepts to bear in mind when endometriosis therapy is discussed(one is false)

a. Peritoneal endometriosis, ovarian endometriosis and rectovaginal adeno-myotic lesions must be considered as three different entities.

b. Patients with endometriosis-associated pain must be differentiated fromthose with endometriosis-associated infertility.

c. Obtaining a consensus on the therapy is a totally impossible task.d. Medical therapy alone is efficacious in the eradication of endometriosis.

26. In young women, unilateral ovarian endometriomas of more than 10 cm in sizeshould be treated:

a. By a three-step procedure: puncture, GnRH agonist, and laser vaporization.b. By cystectomy.c. By oophorectomy.

27. Ovarian endometriosis is caused by metaplasia of invaginated celomic epithelium.The arguments are as follows (one is false):

a. Multilocular endometriomas cannot be explained by the adhesions theory.b. Common epithelial tumors of the ovary are considered to be derived from

the surface epithelium covering the ovary and from the underlying stroma.c. Endometriomas have been described in patients with Rokitansky–Kuster–

Hauser syndrome who do not have a uterus and, therefore, do not haveretrograde menstruation.

d. The fibrotic capsule surrounding the endometrioma is endometriotictissue.

e. The epithelium covering the ovary, which is the mesothelium, can invaginateinto the ovarian cortex.

Appendix A5

28. The following statements about the prevalence of endometriosis and ovariancancer are true:

a. Almost 20% of all serous papillary ovarian tumours contain a focus ofendometriosis.

b. The prevalence of malignant tumours in endometriosis is as high as 2.5%,if one accepts the co-existence (without proven transition) of endometriosisand the malignant tumour in the same ovary as a sufficient criterion.

c. Endometrioid carcinomas are the most frequent encountered malignanttumours in ovarian endometriosis.

d. Adenosarcomas are thought to be the second most common neoplasmarising in ovarian endometriosis.

e. Mucinous ovarian tumours rarely contain a focus of endometriosis.

29. A 53-year old healthy postmenopausal woman is diagnosed with severeendometriosis during a diagnostic laparoscopy for pelvic pain. Which of thefollowing treatment options are acceptable:

a. Wait and see.b. Laser vaporisation of the existing endometriosis.c. Marsupialisation of an existing endometrioma.d. Extensive sampling of the endometriosis before destruction of the

endometriosis.e. Complete excision of the endometriosis.

30. Which of the following statements is true?a. Mild atypism in endometriotic lesions is considered as potentially pre-

neoplastic.b. The frequency of severe atypical lesions in endometriosis is considered to

be 8.0%.c. Unopposed estrogens do not influence the transition from normal

endometriosis to atypical endometriosis, and from the latter to malignanttumours.

d. The mean age to develop a malignant tumour in an endometriotic lesion is56 year.

e. Endometriosis associated ovarian cancer appears to have a seem to occur inyounger and nulliparous patients and are well-differentiated and low-stagecarcinomas resulting in a better survival.

A6 Appendix