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MD3002 Week 11 > 4. Reproductive pathology/ female 2 > Flashcards

4. Reproductive pathology/ female 2 Flashcards

1
Q

Outline the congenital development of the female reproductive anatomy?

A

The uterus, tubes and upper vagina develop from the Mullerian ducts (due to no AMH)
Requires existence of mesonephric ducts ( give rise to the renal system)
The fusion of the Mullerian ducts will form the tubes, uterus and upper vagina around week 10 of gestation.
Subsequent canalization will form the cavity
Absorption of the dividing septum

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2
Q

What is associated with Mullerian malformations?

A

Renal and axial skeleton systems

However have functioning ovaries and age-appropriate external genitalia

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3
Q

Changes to presentation of mullerian malformations due to puberty onset?

A

Puberty: Menstrual disorders

Later presentation: Infertility and obstetric complications

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4
Q

Internal reproductive anomalies due to mullerian malformation?

A

Hysterosalpingogram shows: Open fallopian tubes and bicornuate uterus

MRI and hysteroscope shows: Septate uterus

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5
Q

Most common vulval cancer?

A

Squamous cell carcinoma at edges of labia majora/minora or in the vagina

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6
Q

Early development of vulvar cancers?

A

Slow growing

Usually develop from “precancerous”, pre-invasive areas called Vulvar Intraepithelial Neoplasia (VIN)

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7
Q

Two examples of vulval non-neoplastic epithelial disorders?

A
  1. Squamous hyperplasia
    - Hyperkeratosisis
    - Irregular thickening of ridges
    - Some neoplastic potential
  2. Lichen sclerosus
    - Hyperketatosis
    - Flattening of ridges
    - Oedema in connective tissue with chronic inflammation
    - Some neoplastic potential
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8
Q

Features of vulval dystrophy?

A

Presents as Lichen Sclerosus

  1. Hyperkeratosis: Flattening of ridges, oedema in connective tissue
  2. White patches of leukoplakia
  3. Prurits
  4. Excoriation worsens symptoms

Treated with potent topical corticosteroids

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9
Q

Two main constituents of the endometrium?

A

Endometrial glands

Endometrial stroma

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10
Q

What are the two clinico-pathological endometrial adenocarcinomas?

A

Endometrioid:

  • Related to unopposed oestrogen
  • Associated with atypical hyperplasia
  • Associated with polycystic ovary syndrome

Non-endometrioid:

  • Not associated with unopposed oestrogen
  • Affects elderly post-menopausal women
  • p53 often mutated
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11
Q

Infiltration process of endometrial adenocarcinoma?

A

Infiltrates endometrium then myometrium

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12
Q

Typical presentation of endometrial cancer?

A

Post menopausal bleeding (due to malignancy until proven otherwise!)

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13
Q

Epidemiology of endometrial cancer?

A

Women 50-70

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14
Q

Reasons of for increased incidence of endometrial cancer?

A

Increased population age
Obesity
Use of HRT

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15
Q

What is endometrial stromal sarcoma?

A

Tumour arising from endometrial stroma

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16
Q

What is malignant mixed mullerian tumour?

A

Mixed tumour with malignancy epithelial and stromal elements (Carcinosarcoma)
Poor diagnosis

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17
Q

What is endometriosis?

A

Endometrial glands and stroma outside the uterine body

Sites: Ovary, pouch of douglas, peritoneal surfaces, all pelvic viscera

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18
Q

Symptoms of endometriosis?

A

Pelvic inflammation
Infertility
Pain

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19
Q

What is adenomyosis?

A

Adenomyosis is a benign disease of the uterus due to the presence of ectopic endometrial glands and stroma, deep within the myometrium with adjacent reactive myometrial hyperplasia. The disease can be diffuse or focal (adenomyoma).
I.e. Endometrial glands and stroma within the myometrium
Causes menorrhagia/dysmenorrhoea

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20
Q

Tumours of the myometrium?

A

Smooth muscle tumours

  1. Leiomyoma (fibroid)
    - Very common
    - Associated with menorrhagia, infertility
    - Benign
    - Common cause of uterine enlargement
  2. Leiomyosarcoma
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21
Q

Different forms of leiomyomas of the uterus?

A

Intramural
Submucosal (a pedunculated one appearing in the form of an endometrial polyp)
Subserosal (one compressing the bladder or rectum)

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22
Q

What is an UAE?

A

Uterine artery embolism

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23
Q

Abnormalities that can occur in the ovary?

A

Cysts
Endometriosis
Tumours

May cause… Pain, swelling or endocrine effects

24
Q

Where do ovarian cysts arise from?

A 
Mesothelial
Epithelial
Follicle
Luteal
Endometriotic
25
Q

What factor make small ovarian cysts NOT normal?

A

Pre-pubertal patient
Post menopausal patient
Pregnant
Mean diameter more than 3cm

26
Q

Initial presentation of polycystic ovary syndrome?

A

Hypergonadism symptoms e.g. hirsutism, acne, alopecia
Menstrual disturbance
Infertility
Obesity

27
Q

Long term associations of polycystic ovary syndrome…

A 
Type 2 diabetes
Mellitus
Dyslipidaemia
Hypertension
CVD
Endometrial carcinoma
28
Q

What factor can lead to presentation of previously absent polycystic ovary syndrome?

A

Weight gain

29
Q

PCOS treatment/management?

A

Combined oral contraceptive pill for..

  • Contraception
  • Protection against the development of endometrial hyperplasia
  • Cancer
  • Suppress excessive androgen secretion to control acne and hirsutism

Alternatives: Mirena intrauterine system (IUS)

30
Q

Risks associated with PCOS?

A

Endometrial hyperplasia
Adenocarcinoma
Due to the unopposed actions of oestrogen in the absence of progesterone that is normally released after ovulation

31
Q

PCOS investigations?

A

Transvaginal ultrasound is the absence of withdrawal bleed or in the presence of abnormal uterine bleeding

32
Q

How to recognise a normal proliferative endometrium?

A

An endometrial thickness of less than 7 mm, or an intermenstrual interval of less than three months

33
Q

Which is better, transvaginal or abdominal U/S?

A

Transvaginal.

Better delineate the endometrium, internal os and character of the myometrium

34
Q

A thickened endometrium in an amenorrhoeic / oligomenorrhoeic woman, or the presence of an endometrial polyp, should prompt consideration of an….

A

Endometrial biopsy and/or hysteroscopy.

35
Q

Ovarian neoplasms, features and classifications?

A

Features: Solid

Classification: Epithelial, germ cell, sex-cord/stromal, metastatic, miscellaneous

36
Q

Different malignant stages of epithelial ovarian tumours?

A

Benign
Borderline: Cytological abnormalities with no stromal invasion
Malignant: Stromal invasion

37
Q

Ovarian cancer symptoms?

A

Insidious onset

  1. GI symptoms: Bloating or indigestion (often misdiagnosed as IBS)
  2. Gradually increased abdominal distension (often misdiagnosed as “middle-aged spread”
  3. increasing tumour size –> Pressure effects:
    - Chronic abdominal, pelvic or back pain
    - Urinary frequency/urgency
    - Constipation/altered bowel habits/bowel obstruction
    - Leg swelling
    - DVT/PE
  4. Abnormal vaginal bleeding
38
Q

Symptoms of metastatic ovarian cancer?

A

Pleural effusion
Ascites
Weight loss
Fatigue

39
Q

Less common ovarian cancer symptoms due to sudden torsion/rupture/infection of tumour…

A

Acute abdominal or pelvic pain

Blessing in disguise as it can lead to earlier diagnosis

40
Q

Staging of ovarian cancer

A

slide 48

41
Q

Management/treatment of ovarian cancer?

A

• Surgical management is generally the mainstay of treatment: exploratory laparotomy for tumour debulking and formal surgical staging.
• This is a major procedure which generally comprises total abdominal hysterectomy (TAH) and bilateral salpingo- oophorectomy (BSO), infracolic omentectomy, pelvic and para- aortic lymph node sampling, peritoneal biopsies, multiple pelvic washings, sampling of ascites.
• Adjuvant chemotherapy is given to all patients >stage Ic.
• Response to treatment can be monitored using CA-125 levels,
which decrease if treatment is effective and increase if there is a relapse.

42
Q

Examples of germ cell tumours of the ovary?

A

Dysgerminoma:

  • Undifferentiated tumour
  • Young women
  • Counterpart of male seminoma

Teratoma:

  • Contains elements from all three embryonic germ cell layers
  • Mature cystic teratoma is common (Dermoid cyst).
43
Q

Components of mature cystic teratoma (Dermoid cyst)

A

(Contains elements from all three embryonic germ cell layers)
Endoderm: Respiratory epithelium
Ectoderm: Sebaceous gland
Mesoderm: Fat

44
Q

Extraembryonic germ cell tumours?

A

Yolk sac tumour:

  • Young people (less than 30yrs)
  • Produces alpha fetoprotein
  • Highly malignant but treatable

Choriocarcinoma:

  • Pure variety is rare
  • Usually seen as part of teratoma
  • Different from gestational choriocarcinoma
45
Q

Examples of sex cord/ stromal tumours?

A

Fibroma/ Thecoma
– Benign
– May produce oestrogen, causing uterine bleeding

Granulosa cell tumour
– All are potentially malignant
– May be associated with oestrogenic manifestations

 Sertoli-Leydig cell tumours
– Rare
– May produce androgens

46
Q

Where are the commonest metastatic tumours?

A

Stomach
Colon
Breast
Pancreas

47
Q

Abnormal Pregnancy due to Gestational trophoblastic disease, signs?

A
  • Hydatidiform mole (complete or partial)
  • Invasive mole
  • Choriocarcinoma
  • Placental-site trophoblastic tumour
  • Epithelioid trophoblastic tumour
48
Q

Spectrum of gestational trophoblastic disease?

A

A. Normal chorionic villus of 8-week fetus, with blood vessel containing nucleated red blood cells.
B.Hydatidiform mole with hydropic villi. The villi are enlarged by an oedematous stroma devoid of blood vessels. The trophoblastic epithelium is hyperplastic and exhibits variable atypia.
C. Choriocarcinoma that has arisen in a molar pregnancy invades the myometrium and consists of admixed syncytiotrophoblastic and cytotrophoblastic elements.
D. Common sites of metastasis from choriocarcinoma.

49
Q

What normally causes a complete hydatidiform mole to form?

A

A complete hydatidiform mole most often develops when either 1 or 2 sperm cells fertilize an egg cell that contains no nucleus or DNA (an “empty” egg cell). All the genetic material comes from the father’s sperm cell. Therefore, there is no foetal tissue.

50
Q

What normally causes a partial hydatidiform mole to form?

A

A partial hydatidiform mole develops when 2 sperm fertilize a normal egg. These tumours contain some foetal tissue, but this is often mixed in with the trophoblastic tissue. It is important to know that a viable foetus is not being formed.

51
Q

What is an invasive hydatidiform mole?

A
  • An invasive mole is a hydatidiform mole that has grown into the muscle layer of the uterus.
  • Invasive moles can develop from either complete or partial moles, but complete moles become invasive much more often than do partial moles.
  • Invasive moles develop in a little less than 1 out of 5 women who have had a complete mole removed.
52
Q

What is a moral pregnancy?

A

Molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term.
A molar pregnancy is a gestational trophoblastic disease which grows into a mass in the uterus that has swollen chorionic villi. These villi grow in clusters that resemble grapes.
A molar pregnancy can develop when a fertilized egg does not contain an original maternal nucleus. The products of conception may or may not contain fetal tissue.
It is characterized by the presence of a hydatidiform mole. Molar pregnancies are categorized as partial moles or complete moles, with the word mole being used to denote simply a clump of growing tissue, or a growth.

53
Q

The risk of developing an invasive mole in these women increases if….

A
  • there is a long time (more than 4 months) between the last menstrual period and treatment.
  • the uterus has become very large.
  • the woman is older than 40 years.
  • the woman has had gestational trophoblastic disease in the past.
54
Q

What is choriocarcinoma?

A

A malignant form of gestational trophoblastic disease (GTD)
1/2 starts as molar pregnancies
1/4 in women who have has a miscarriage, intentional abortion or tubal pregnancy

55
Q

Non-gestational choriocarcinoma?

A

In ovaries, testicles, chest or abdomen.
Mixed with other types o cancer formed a MIXED GERM CELL TUMOUR
Less responsive to chemo and less favourable prognosis

56
Q

Features and issues of ectopic preganncy?

A

Implantation of a conceptus outside the endometrial cavity

Commonest sit: Fallopian tube, on ovary, peritoneum

Often ruptures and causes fatal haemorrhage

57
Q

Female of reproductive age with amenorrhoea and acute hypotension or an acute abdomen…. think?

A

Ectopic pregnancy

MD3002 Week 11 (6 decks)

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