A 60-year-old woman comes to the office for evaluation of postmenopausal bleeding. The patient went through menopause at age 53 and did not use menopausal hormone therapy. Four months ago, she noticed some postcoital bleeding that resolved within a day. For the last 3 months, the patient has had daily vaginal spotting and sometimes has bleeding similar to the first day of her menstrual cycle. She has obstructive sleep apnea and hyperlipidemia. Pap test last year was normal. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 68/min. BMI is 34 kg/m². The abdomen is soft and nontender. Speculum examination shows a small amount of blood in the vaginal vault and a normal cervix. Bimanual examination reveals right adnexal fullness and a slightly enlarged uterus. Hemoglobin is 11.8 g/dL. Pelvic ultrasound shows an 11-cm solid ovarian mass and no free fluid in the pelvis. Endometrial biopsy shows complex hyperplasia without atypia. Which of the following is the most likely diagnosis in this patient?

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11ec25c8_d9d4_edfb_bc81_b3640b902373_MD0003_00 This patient's postmenopausal bleeding and large ovarian mass are most likely due to a granulosa cell tumor, an ovarian sex cord-stromal tumor. The ovarian stroma, which is primarily composed of granulosa cells, produces the ovarian estrogen supply. Granulosa cells convert testosterone to estradiol (via aromatase) and secrete inhibin (which typically inhibits FSH); therefore, uncontrolled proliferation of these cells, as seen in a granulosa cell tumor, results in high estradiol and inhibin levels. Women with an adult subtype granulosa cell tumor have chronic, unopposed estrogen exposure that can result in endometrial hyperplasia or cancer (eg, postmenopausal bleeding). Additional clinical features may include breast tenderness and mass-effect symptoms (eg, abdominal distension, ovarian torsion). Due to the association of granulosa cell tumors with endometrial cancer, patients with a suspected granulosa cell tumor require an endometrial biopsy prior to surgical staging to help guide management. After surgical management, inhibin levels can be monitored to evaluate for disease progression or recurrence. (Choice A) Brenner tumors are a rare, benign subtype of epithelial ovarian tumor that is typically found incidentally in asymptomatic patients. There is no association with endometrial hyperplasia. (Choice B) Embryonal carcinoma is a type of ovarian germ cell tumor that occurs typically in young women. Embryonal carcinoma secretes alpha-fetoprotein and hCG rather than estradiol and therefore is not associated with endometrial hyperplasia. (Choice D) Mature teratomas (dermoid cysts) are benign germ cell tumors that are more common in younger women (age 10-30). Mature teratomas do not secrete estrogen; however, some can secrete thyroid hormone (eg, struma ovarii). (Choice E) Metastatic gastric carcinoma can affect the ovary (ie, Krukenberg tumor) and cause a nontender adnexal mass. Patients with gastric cancer typically present with weight loss and persistent abdominal pain rather than postmenopausal bleeding. (Choice F) Yolk sac tumors are germ cell tumors that are more common in young women and secrete alpha-fetoprotein. Because yolk sac tumors grow rapidly, patients typically have an acute onset of pelvic pain rather than abnormal uterine or postmenopausal bleeding. Educational objective: Granulosa cell tumors are malignant sex cord-stromal tumors of the ovary that secrete estradiol. Patients typically present with a large ovarian mass and postmenopausal bleeding (due to associated endometrial hyperplasia from chronic unopposed estrogen exposure). References: Recent advances in granulosa cell tumor ovary: a review. (http://www.ncbi.nlm.nih.gov/pubmed/24426698) Granulosa cell tumor of the ovary: tumor review. (http://www.ncbi.nlm.nih.gov/pubmed/18815151) Ovarian sex-cord stromal tumours and small cell tumours: pathological, genetic and management aspects. (http://www.ncbi.nlm.nih.gov/pubmed/29198337)

A 60-Year-Old Woman Comes to the Office for Evaluation of Postmenopausal