A 42-year-old, nulliparous woman comes to the office due to abnormal uterine bleeding. The patient previously had regular monthly menses but, for the last 8 months, has had irregular episodes of bleeding and spotting that last 1-5 days. She initially attributed this irregular bleeding to stress but is now having abdominal bloating and daily breast tenderness. The patient has no chronic medical conditions and her Pap test 2 years ago was normal. She does not use tobacco, alcohol, or illicit drugs. The patient recently married and is hoping to conceive within the next several months. Vital signs are normal. BMI is 30 kg/m². Breast examination shows bilateral diffuse tenderness and no masses. There is fullness in the left lower quadrant of the abdomen with no rebound or guarding. Pelvic examination shows a large, nontender left adnexal mass. A urine pregnancy test is negative. Pelvic ultrasound reveals a 10-cm, complex left ovarian mass and an irregular endometrial stripe. Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_d9d1_e0b7_bc81_8d42a3fefb75_MD0003_00 This patient's abnormal uterine bleeding and complex ovarian mass are suggestive of a granulosa cell tumor-an estradiol-secreting sex cord-stromal tumor. Other clinical features may include breast tenderness (caused by estrogen-stimulated breast tissue proliferation) and abdominal bloating/pain (eg, mass effect, ascites). Granulosa cell tumors secrete high levels of estradiol that cause uncontrolled endometrial proliferation; therefore, patients often have abnormal uterine bleeding (eg, irregular menses) due to the subsequent development of endometrial hyperplasia/cancer. Granulosa cell tumors are typically diagnosed at an early cancer stage and treated surgically; however, due to the possibility of concomitant endometrial hyperplasia/cancer from excessive estrogen, the best next step is an endometrial biopsy. Premenopausal women desiring future fertility (such as this patient) who have a granulosa cell tumor and no endometrial cancer can undergo a uterus-sparing procedure (eg, unilateral salpingo-oophorectomy). In contrast, patients with both a granulosa cell tumor and endometrial cancer require a hysterectomy and bilateral salpingo-oophorectomy. Additionally, postoperative management with chemotherapy or radiation depends on the stage of both the granulosa cell tumor and the endometrial cancer, as regimens differ. (Choices A and E) Both oral contraceptives and the progestin-containing intrauterine device are treatment options for patients with abnormal uterine bleeding. However, patients with risk factors for endometrial cancer (eg, obesity, chronic anovulation) require endometrial biopsy prior to treatment initiation as side effects from these treatments may mask symptoms. (Choice B) Endometrial ablation (surgical destruction of the endometrial lining) is typically used for premenopausal patients with heavy, regular menses. An endometrial biopsy is required prior to an endometrial ablation because it is contraindicated in patients with endometrial cancer. (Choice D) A hysterosalpingogram is used to evaluate the uterine cavity and fallopian tubes in patients with infertility (eg, hydrosalpinx) or uterine anomalies (eg, septate uterus). Hysterosalpingogram is not used in the evaluation of adnexal masses because it does not further define the mass or affect management. Educational objective: Granulosa cell tumors are an estradiol-secreting ovarian sex-cord stromal tumor which can cause a concomitant endometrial hyperplasia/cancer. Management of patients with granulosa cell tumors depends upon possible concomitant endometrial cancer (eg, uterine-sparing surgery, chemoradiation); therefore, the best next step in these patients is an endometrial biopsy. References: Is the endometrial evaluation routinely required in patients with adult granulosa cell tumors of the ovary? (http://www.ncbi.nlm.nih.gov/pubmed/25527364) Recent advances in granulosa cell tumor ovary: a review. (http://www.ncbi.nlm.nih.gov/pubmed/24426698) The incidence of endometrial hyperplasia and cancer in 1,031 patients with a granulosa cell tumor of the ovary: long-term follow-up in a population-based cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/24257556)

A 42-Year-Old, Nulliparous Woman Comes to the Office Due to Abnormal