Cervix, Vagina, Vulva Flashcards
What are the structures that provide vaginal lubrication?
Transudate from BVs
Secretions of the Bartholin’s & Skene’s glands
WHat are the 5 congenital anomlies of the vagina & vulva?
- Imperforate hymen (Hematocolpos)
- Vaginal atresia
- Vaginal agenesis
- Septate vagina
- Double uterus didelphys
What congenital anomaly of the uterus has double uterus with 2 separate cervices & possibly double vagina?
Double uterus (Didelphys)
What is the cause of Didelphys?
Embyronic fusion of the Mullerian ducts fail to occr
What is the most common and most distal form of vaginal outflow obstruction that is a congenital anomaly w/ hymen completely obstructing the vaginal opening?
Imperforate. Hymen/Hematocolpos
When is Hematocolpos diagnosed in adolescent girls?
When menstrual blood accumulated in the vagina & can backflow in the uterus
What congenital anomaly has total absence of the vaginal canal?
Vaginal agenesis
What other conditions are associated with vaginal agenesis?
assoc w/ renal hypoplasia or agenesis & middle ear abnormalities in px w/ Winter syndrome
What congenital anomaly of the vagina is found at the lower portion of the vagina replaced by 2-3cm of fibrous tissue?
Vaginal atresia
Whaat is the cause of Vaginal atresia?
Failure of urogenital sinus to contribute to the formation of the caudal portion of the vagina -> ABsence of Mullerian derivatives
What is a rare congenital anomaly of the vagina where it is divided to create a double vagina?
Septate vagina
What is the cause of septate vagina? What other structures are doubled?
incomplete fusion of the lower parts of the 2 Mullerian ducts
Doubled: cervix, uterine septum
What are the diff causative agents of lower genital tract infections in females?
Gardnerella vaginalis
Trichomonas vaginalis
Candidasis albicans, C. Glabiata,, C tropicales
HSV type 2
HPV
Molloscum Contagiosum
Syphilis
What structures are affected in the upper & lower reproductive tract of females in cases of infections?
URT: Fallopian tube, ovary, uterus
LRT: Vagina cervix, and vulva
What are the diff types of repro tract infectionss?
Endogenous infections
Iatrogenic infections
STIs
What are the S/Sx & Dx of Gardnerella vaginalis?
S/Sx: thin, milky, Malodorous (FISHY) ginal discharge, pH >4.5
Dx: Clue cells in PAP smear —> Shaggy coat of coccobacilli in cytoplasm
What are the risk factors in developing bacterial vaginosis?
Higher incidence of preterm labor
PID
Concomitant HIV, HSV, GC, and chlamydial infection & transmission
Premature rupture of membranou & chorioamnionitis
What are the risk factors in developing Candidiasis?
recent antibiotic use
Uncontrolled DM
HIV/AIDS
Other immunocompromised states
What are the S/Sx & Dx of Candidiasis?
Dx: Pap smear, KOH mount: spaghetti & balls
S/Sx:
Pruritus
Thick, white, curd-like cervical discharge
Edema
Dysuria
Vulvovaginal erythema
What are the S/Sx & Dx of Trichomoniasis ?
S/Sx:
- strawberry spot cervix
- yellow, frothy, foul smelling vaignal discharge
- duspareunia (painful intercourse)
- dysuria, vulvovaginal discomfort
Dx:
- Oval, flagellated single-celled organisms w/ v small round nucleus
What is the leading cause of genital ulcer dis that has an INC risk of HIV acquisition & neonatal herpes?
HSV-2
What reproductive tract structures of females are affected in HSV-2 infections?
Cervix
Vagina
VUlva
Sacral nerves
What is produced by nerve involvement during acute, latent, chronic phase of HSV-2 to allow persistence of infection?
Retrograde axonal transport
What are complications of HSV-2?
Neonatal transmission
Malignant transformation
What are the gross features & histologic features of HSV-2?
Gross: crops of vesicles, pustules, and painful shallow ulcers
Histo:
1. Synctial multinucleated giant cells containing ground glass nuclei
2. Nuclear MOLDING
3. MARGINATION of chromatin at the periphery of the nculear membrane
What are inclusion bodies pathognomonic for HSV-2? WHat test is done to detect the virus?
Cowdry A inclusion bodies
Tzanck test
WHat strains of HOV are low risk and high risk?
High risk HPV: 16, 18, 31, 33
Low risk HPV 6, 11, 42, 44
What HPV serological type causes Condylomata acuminatum?
HPV type 6
What are the gross & histo featuers of Condylomata acuminatum?
Gross: Verrucuous papillary exophytic outgrowth (flat on the perineal surface of the vagina & vulva)
Histo: Acanthosis, hyperkeratosis, parakeratosis, papillomatosis & koilocytosis (perinuclear halo)
WHat is an intermediate cell w/ perinuclear halo associated with COndylomata acuminatum?
Koilocytes
What are the 4 serologic types of Molloscul contagiosum?
MCV 1, 2, 3, 4
What strain of Molloscum contagiosum is the most common and which one is assoc with STI?
MCV 1 = most common
MCV 2 = STI
What are the gross & histo features of Molloscum contagiosum?
Gross: multiple, umbilicated, highly pruritic, small papular lesions (dome-shaped) found on the trunk & anogenital areas
Histo:
- Molloscum contagiosum lesion = dome-shaped lesion of the skin with a central umbilicated crater
- Molloscum bodies = shows densely eosinophilic, round intracytoplasmic inclusion bodies
WHat are the lesions seen in primary & secondary syphilis?
Primary syphilis - chancre
SEcondary syphilis - condylomata lata
What kind of infection begins in the vulva/vagina & spreads upwards to involve the uterus, fallopian tubes, ovaries, and pelvic peritoneum?
Pelvic inflammatory disease
What are the most common sites of PID (pelvic inflammatory dis)? WHat are the causative agents?
Fallopian tubes & ovaries
CAs: N gonorrheae, Chlamydia, Enteric bacte, polymicrobial orgnanisms
But most common is Neisseira gonorrhoeae
What are acute & chronic complications of PID?
Acute: Peritonitis, Bacteremia
Chronic: Salpingitis, Tubo-ovarian abscess, Intestinal osbtructions, Infertility
What are the 3 benign cystic lesions of the vulva?
Epidermoid cyst of the vulva
Bartholin’s duct cyst
Epithelial tumors of the vulva
What benign cystic lesion of the vulva is lined by stratified squamous epithelium that contains keratin of amorphous material in the lumen?
Epidermoid cyst of the vulva
What benign cystic lesion is found in the posterior wall of the vulva and causes “fist formation” where there is inflammation/obstruction of Bartholin’s gland?
Bartholin’s duct cyst
What is the cause of Bartholin’s duct cyst?
Scaring & obstruction of the duct & eventual cystic dilations of the duct
How do u tx Bartholin’s duct cyst?
Marsupialization: surgery to remove the cyst
What are the 2 types of epitheliam tumors of the vulva?
- Fibro-epithalial polyp
- Papillary/nodular hidradenoma
What are the gross & histo features of Acrochordon/Fibro-Epithelial polyp?
Gross: Papillomatous pedunculated outgrowth of the mucosa of the vulva & vagina
Histo:
- Elevated, dome-shaped, pedunculated, polypod outgrowth
What are the gross & histo features of Papillary/Nodular Hidradenoma?
Gross: Small brown nodules on vulva
Histo: Benign proliferative glands that have Aprocirin features lined by columnar/cuboidal pink cytoplasm
What are groups of non-neoplatic disorders of the mucosa of the vulva and the skin seen in post-menopausal women?
Vulvar dystrophies
What are the common presentations of Vulvar dystrophies?
Assoc with Pruritus
Presents w/ white, scaly, plaque-like mucosal thickening
What are 2 types of vulvar dystrophies?
Lichen sclerosus
Squamou hyperplasia
what type of vulvar dystophy is aka Hyperplastic hystrophy or LIchen simplex chronicus?
Squamous hyperplasia
What is the cause of squamous hyperplasia or LIchen simplex Chornicus?
Rubbing/scratching/chronic irritation of the skin to relive pruritus
What is the clinical presentation of Hyperplastic dystrophy?
Leukoplakic lesion
What are the histo & gross features of Lichen Simplex Chronicus?
Gross:
- irregular map-like white thickeing of the vulva
Histo:
- Thickening of the epidermis (Acanthosis), Hyperkeratosis and dermal inflammation
- Lymphocytic infitlration of the dermis
What type of vulvar dystrophy is aka Chronic Atrophic Vulvitis caused by an autoimmune rxn of activated T cells in the sub-epithelium?
Lichen Sclerosus
What is the clinical presetation of LIchen Sclerosus? IN what age grp does this commonly seen?
Porcelain or parchment surface of the vulva
Age grp: Post-menopausawomen
What are the histo & gross features of Lichen Sclerosis?
Gross:
- everted labia majora with white patchent-like smooth thickening of the mucosa
- vaginal introitus is narrowd & obliterated
(Trisha mukha siyang loob ng oyster)
Histo:
- Rete pegs are lost
- marked thinning & hypoplasia of the pidermis + hyperkeratosis
- scattered mononuclear inflammaotry responses
What are the 3 categories of vulvar intraepithelial neoplasia (VIN)?
VIN I - mild dysplasia
VIN II - moderate dysplasia
VIN III - Severe dysplasia
Are px w/ VIN lesions less susceptible to HPV sero type 16?
No, they are MORE susceptible
What are the gross & histo features of VIN lesions?
Gross; Irregular map-like white parchment leukoplakic lesion
(Mukha ngang parchment paper)
Microscopic:
- R side affected (w/ VIN lesion)
- irregular thickening, acanthosis, papillomatosis of strat squamous mucosa
What type of VIN has 1/3 epithelial thickness from the basement membrane up to the surface?
VIN I - Mild dyplasia
What are the causes of VIN I?
Disordered maturation
Nuclear enlargement
Hyperchromasia
Mitosis
What VIN has atypical proliferation exceeding 1/3 of the epithelium but does not exceed 2/3 of it?
VIN II = moderate dysplasia
WHat VIN type exceeds 2/3 of the epithelial thickness but does not involve the full thickness of the epithelium?
VIN III - severe dysplasia`
What are the caues of ViN II?
Disordered maturation of squamosu cells
Hyperchromatic large nuclei
Mitotic figures
What is an important sign of maturation in VIN III?
Top of the epidermis that appear longitudinally parallel to the basement membrane
What are the most common type of vulvar carcinoma?
Squamous cell carcinoma:
- Keratinizing SCCA
- Warty basaloid SCCA
What are the causes of vulvar carcinoma?
- Lichen sclerosus
- VIN lesions or VIN simplex: carried a high risk of cancer devt
- HPV-associated warty and basaloid carcinoma
What are the gross features of Vulvar carcinoma?
Exophytic, ulcerative, infiltrative
Slow growing mass w/ surface extension to contiguous skin, vagina, and rectum
What are the 2 grps of vulvar carcinoma?
Assoc w/ HPV
Assoc w/ VIN, Squamous cell hyperplasia, Lichen sclerosus
What type of vulvar carcinoma represents the tumor that has invaded the underlying connective tissue trauma?
Invasive SCCA vulva
What are the gross & histo features of Invasive SCCA vulva?
Gross:
- large, whitish, exophytic, fungating mass
- endophytic ulcerating lesion
Histo
- Nests and islands of malignant squamous cells
- Keratinizing and intracellular bridges –> Keratin pearls
What is aka Extramammary Paget Disease where it is assoc with carcinoma of the skin adnexa?
Paget’s disease of the vulva
What are the gross & histo features of Extramammary Paget dis?
Gross:
- Large, red, moist, sharply demarcated encrusted lesion in the labia
Histo
- Piaget cell: + Mucopolysaccharide stain
What are the 3 pathologies of the vagina?
Mesonephric cyst/Gartner’s duct cyst
Squamous papilloma
Vagina intraepithelial Neoplasia
Where is Gartner’s duct cyst located?
Anterolateral wall of the vagina, ff the route of mesonephric duct
What is the histologic feature of Gartner’s duct cyst?
Simple cuboidal, non-mucin-secreting cells that is reminiscent from mullerian cell derivative
What benign lesion of the vagina is commonly seen in reproductive-age women and includes Stromal tumors, Leiomyomas, and Hemangiomas?
Squamous papilloma
What are the gross & histo features of squamous papilloma?
Gross: Shows exophytic small, pedunculated lesions
Histo:
- benign squamous epithelium arranged in complex papillary frond
- single papillary front around a central fibrovascular core
What is the location of squamous papilloma?
near the hymenal ring
What are the group of spectrum epithelium lesions of atypia involving the vaginal mucosa?
Vaginal intraepithelial neoplasia
What is the Bethesda system of vaginal intraepithelial neoplasia?
Low grade squamous epithelial lesion: VaIN 1 (Mild dysplasia)
High grade squamous epithelia lesion: VaIN 2 and VaIN3
What are the gross & histo features of Vaginal Intraepithelial neoplasia?
Gross: raised, flat white or pink, eroded
Histo:
- loss of normal maturation
- nuclear atypia
- INC mitotic activity
- abnormal mitotic figures
- acanthosis & dyskeratosis
What are the characteristics of Bethesda system?
LG SQEL: N I).
- Atypical changes are confined within the inner 1/3 of vaginal mucosa.
- hyperchromasia of the nuclei, presence of abnormal mitotic figures, disordered
maturation.
HGSEL: atypia > 2/3 of epithelial linings -> full thickness in carcinoma situ
What are the risk factors of vaginal carcinoma?
- high risk HPV: detected via vaginal testing
- premalignant lesion
- assoc with cervical and vulvar carcinoma
What is the pattern of spread of vaginal carcinoma?
Upper vaginal tumor -> Iliac lymph node
Lower vaginal tumor -> inguinal lymph node
What is an important histo feature of vaginal carcinoma?
keratinization forming laminated pink keratin pearls
What are the 2 types of vaginal adenocarcinoma?
Clear cell adenocarcinoma
Embryonal rhabdomyosarcoma
What are histological features of clear cell adenocarcinoma?
- Hobnail = cell pattern that presents a nucleus protruding out of their lumen
- Solid, Tubulocystic pattern
- Clear cells due to glycogen
What is the risk factor of developing vaginal adenocarcioma?
Vaginal adenosis (precursor lesion)
What is the most common malignant tumor of the vagina in infants & children?
Embryonal rhabdomyosarcoma/Sarcoma botryoides
What are the gross & histo features of Embryonal Rhabdomyosarcoma?
Gross:
“bunch of grapes” - large, soft, polypoid mass
Microscopic:
- Rhabdomyoblasts = racket-shaped. tadpole-shaped cells
- Cambium layer = condensed layer beneath the benign squamous epithelium of the vagina
What condition presents with inflammation of the cervical mucosa and stroma?
Cervicitis
What are the histological features of Cervicitis?
- Glycogenated squamopus cells
- inflammation of the stroma
What is the common cause of Cervicitis?
Chlamydial infection
What are the clinical features of Cervicitis?
- freq asymptomatic
- mucosal changes: erosion, superficial ulceration
- vaginal discharge
What are the 3 important hallmarks of Chronic Cervicitis?
- Squamous metaplasia of the endocervix
- Nabothian cysts
- Endocervical polyp
What are the histo findings of Nabothian cysts?
- cystic dilation of endocervical glands w/ accumulation of secretory material in the lumen
- scarring, securitization
What cells line the Endocervical polyp
Mucous columnar cells
Squamous metaplastic cells
What sero typeof HPV is assoc w/ higher risk of LSIL?
What viral oncogene interferes with tumor suppressor proteins and DNA repair mechanisms?
sero type: HPV-16
Viral oncogene E6&E7
What structures are affected in Cervical intraepithlial lesion & invasive squamous neoplasia?
Intraepithelial atypia to invasive squamous cell carcioma
What are the risk factors of Cervical Intraepithelial lesion & invasive squamous neoplasia?
- early age of 1st intercourse
- multiple sexual partners (HIGHER in males)
- immunosuppression
- HPV 16, 18, 31, 33
What are atypical changes in the cervix causing Cervical Intraepithelial Neoplasia?
Atypical changes:
- dyskeratosis
- nuclear pleomorphism
- mitoses
- koilocytosis
Where does Cervical Intraepithelial Neoplasia commonly occur?
Squamo-columnar junction
what are the 3 significant biomarkers of squmaous intraepithelial lesions?
p16, Ki67 & high-risk HPV
what biomarker distinguishes from benign mimics? What is indicated if it is negative for thsi biomarker?
P16
Neg P16 - focal positivity that are patchy & distributed all throughout epithelium
What biomarker is expresses in SIL and correlates with the extend of disordered maturation?
Ki-67
What are the clinical presentation of Cervical carcinoma?
- Nodular, infiltrative & fungating lesions
- advanced spread & metastasis
- vagina bleeding/discharge
What are the gross & histo features of Cervical caricnoma?
Gross:
- fungating or exophytic, ulcerating & infiltrative/endophytic
histo
- SCC, adenocarcinoma, adenosquamous carcinoma & neuroendocrine carcinoma
What are the 5 types of cervical carcinoma?
Cervical squamous cell carcinoma
Cervical adenocarcinoma
Cervical adenosquamous carcinoma
Clear cell adenocarcinoma
Neuroendocrine carcinoma
At what age should males & females have their HPV vax?
11-12yr - 26 y/o
When should the 1st screening for cervical cancer be? How often should px 21-29 yo undergo cytologic testing?
21 yrs or 3 yrs after onset of sex
Cyto test: every 3 yrs
What is px 30-65 yo test negative for HPV, when should they have their next test?
After 5 yrs
If a px is + for HPV, what should be advised to the px?
Cotesting every 6-12 mons
What should we do if there is a + abnormal pap smear?
Colposcopoc biopsy
What are the 3 morphologic variants of Cervical SCC/
Large cell keratinizing
Large cell non-keratiniizing
Small cell
WHat are the morphological clues of squamous differentiation?
Keratin pearls
Intracellular bridges
Intracytoplasmic keratin
What are the most common morphological var of cervical SCC?
Large Cell, Nonkeratinizing - presence of iNTRACELLULAR BRIDGES
What are clues of Large Cell Keratinizing variant?
Sheaths, islands & nests of malignant polygonal cells w/ KERATIN PEARLS
What are clues of small cell var of cervical SCC?
NO KERATINIZATION
NO INTRACELLULAR BRIDGES
What are the gradings of cervical SCC?
G1 = well-diff
G2 = moderately diff
G3 = poorly diff
What type of cervical carcinoma may present w/ Cushings & Carcinoid syndromes?
What are its histological features?
Neuroendocrine carcinoma
Histo features:
- fine chromatin pattern
- nuclear molding
- signs of apoptosis positive for Chromogranin & Synaptophysin
