Chapter 13 - Female Genital System Flashcards
Unilateral, painful cystic lesion at the lower vestibule adjacent to the vaginal canal (often in women of reproductive age)
Bartholin cyst
What infection is linked with condyloma’s and what is the characteristic finding on histology?
HPV types 6 or 11 (low risk)- more common than secondary syphilis. See koilocytes (crinkled nuclei like raisins).
Lichen Sclerosis + associations
Thinning of the epidermis and fibrosis of the dermis of the vulva often in women post-menopausal. Associated with an increased risk for squamous cell carcinoma of the vulva.
Leukoplakia of the vulva with parchment like skin = ???
Lichen Sclerosis
Lichen simplex chronicus + associations
Hyperplasia of the vulvar squamous epithelium associated with chronic irritation and scratching. BENIGN. No increased risk of vulvar carcinoma.
Leukoplakia with thick, leathery skin on the vulva = ???
Lichen simplex chronicus
How does vulvar carcinoma present? Ddx?
Leukoplakia of the vulva. Biopsy required to differentiate between carcinoma and lichen sclerosis/simplex chronicus.
Etiologies of vulvar carcinoma.
- HPV (types 16, 18) - from vulvar intraepithelial neoplasia
- Long-standing lichen sclerosis
Extramammary Paget Disease
Malignant epithelial cells in the epidermis of the vulva. Usually no underlying cancer.
Erythematous, pruritic, ulcerated skin of the vulva = ???
Extramammary paget disease
What is the Ddx for Extramammary Paget disease and how do you decide?
Carcinoma (paget cells) vs. Melanoma
Paget cells: PAS+, keratin+, S-100-
Melanoma: PAS-, keratin-, S-100+
What is Adenosis and what is it associated with?
Focal persistence of columnar epithelium in the upper 1/3 of the vagina. Associated with exposure to diethylstilbestrol (DES) in utero.
Why is adenosis bad?
Because of increased risk of Clear Cell Adenocarcinoma of the vagina. Other complications such as ectopic pregnancies due to malformed uterus/tubes also a problem.
Embryonal rhabdomyosarcoma
Rare malignant proliferation of immature skeletal muscle cells in vagina. (or penis).
How does embryonal rhabdomyosarcoma present and what stains are used?
Presents as bleeding with a grape-like mass protuding from the vagina or penis. See cytoplasmic cross-striations and desmin/myogenin staining.
Risk factor for vaginal carcinoma?
HPV 16, 18, 31, or 33. Precursor is vaginal intraepithelial neoplasia.
Where does vaginal carcinoma spread?
If lower 1/3 of vagina –> Superficial inguinal lymph nodes
If upper 2/3 of vagina –> regional iliac nodes.
What makes high risk HPV high risk???
Production of E6 and E7 proteins, which increase the destruction of p53 and Rb respectively. Carcinogenic!
Characteristics of cervical intraepithelial neoplasia (Dysplasia!) - CIN
Koilocytic change of nucleus, disordered cell maturation, nuclear atypia, and increased mitotic activity.
CIN I –> involves involves involves almost all of epithelium. Rarely reverses.
CIS (carcinoma in situ) –> entire thickness. Non-reversible.
Risk factors for SCC of cervix and Adenocarcinoma of cervix.
BOTH due to high risk HPV infection. Secondary risk factors include smoking and IMMUNODEFICIENCY.
Limitations of pap smears?
Does not detect adenocarcinoma, which makes up about 15% of cases.
What does the HPV vaccine protect against?
HPV 6, 11, 16, and 18. NOT 31 or 33, etc. Thus still need PAP smears.
What is Asherman Syndrome?
Secondary amenorrhea due to loss of the basalis layer of the endometrium (regenerative layer, ala stem cells of endometrium). Due to overaggressive dilation and curettage
Acute endometritis
Bacterial infection of endometrium often due to retained products of conception. Presents as fever, abnormal uterine bleeding, and pelvic pain.
Histological findings of Chronic Endometritis?
Lymphocytes (normal) and PLASMA CELLS!!!
Cause of chronic endometritis and presentation
Due to retained products of conception, Chronic pelvic inflammatory disease (Chlamydia), IUD, or Tb. Presents with abnormal uterine bleeding, pain, and infertility.
Common cause of endometrial polyp?
Tamoxifene (weakly pro-estrogenic effects on endometrium).
Definition of endometriosis?
Endometrial glands and stroma (BOTH) seen outside of the uterine endometrial lining.
Most common site of endometriosis?
Ovary, resulting in formation of Chocolate cyst.
What is Adenomyosis?
Involvement of the uterine myometrium in endometriosis.
What risks go along with endometriosis?
Increased risk of carcinoma at site of endometriosis (esp. ovary)
How does endometriosis present?
Dysmenorrhea and pelvic pain (may cause infertility).
Cause of endometrial hyperplasia?
Unopposed estrogen stimulation (eg. obesity, PCOD, and estrogen replacement)
Histologic classification of endometrial hyperplasia?
Architecture: simple or complex
Presence or absence of cellular atypia –> THIS IS THE MOST IMPORTANT PREDICTOR FOR PROGRESSION TO CARCINOMA. Not complex vs. simple
How does endometrial carcinoma arise and what histological findings are seen? (2)
- From endometrial hyperplasia (75%). Histology is endometrioid (looks like endometrium).
- Sporatic pathway (25%), with NO EVIDENT PRECURSOR LESION. Histology is serous w/papillary structures and psammoma bodies. p53 mutation common.
Cancers that you see Psammoma bodies? (4)
- Papillary carcinoma of thyroid
- Meningioma
- Mesothelioma
- Serous papillary endometrial carcinoma
Muliple well-defined, white, whorled masses in uterus = ???
Leiomyoma (benign).
Cause of leiomyoma and usual presentation
Related to estrogen exposure (disappear post-menopause, worse during pregnancy, etc.) Usually asymptomatic, but can present with abnormal uterine bleeding, infertility, and a pelvic mass.
Cause of leiomyosarcoma, common patient population, and histologic findings?
Arises de novo - NOT related to prior leiomyomas.
Usually in postmenopausal women.
Single lesion with areas of necrosis and hemorrhage. (increased mitotic activity and cellular atypia).
Normal female hormone production axis
GnRH stimulates LH and FSH release.
- LH acts on theca cells to induce androgen production
- FSH acts on granulosa cells to convert androgen to estradiol
- Estradiol drives proliferative phase of endometrial cycle, and then surge induces an LH surge leading to ovulation.
- Post-ovulation the corpus luteum produces progesterone, driving secretory phase of endometrium (preparatory).
Polycystic Ovarian Disease (PCOD)
Multiple ovarian follicular cyst due to hormone imbalance. Characterized by increased LH and decreased FSH (LH:FSH>2).
How to understand PCOD?
Increased LH causes excess androgen production, leading to hirsutism.
Androgen converted to estrone in adipose, feedback inhibiting FSH. Low FSH results in cystic degeneration of follicles.
Obese young women with infertility, oligomenorrhea, and hirsutism = ???
Polycystic Ovarian Disease
Associations with PCOD?
Increased risk of endometrial carcinoma (due to increased estrogen leading to endometrial hyperplasia) as well as DM type II!
What are the main types of Surface Epithelial tumors of the ovary?
- Serous or Mucinous tumors (benign, malignant, or borderline)
- Endometrioid
- Brenner tumors
Single ovarian cysts with simple, flat lining filled with either watery fluid or mucus like fluid = ???
Benign cystadenoma (serous or mucus)– surface epithelial tumor!. More common in premenopausal women 30-40 years old.
Complex ovarian cysts with a thick, shaggy lining = ???
Malignant cstadenocarcinoma (serous or mucus)– surface epithelial tumor!. More common in post menopausal women 60-70 years old.
BRCA1 carriers have an increased risk of what type of ovarian cancer?
Serous carcinoma of the ovary and fallopian tubes (cystadenocarcinoma). Surface epithelial tumor.
What are endometrioid tumors associated with and what type of cancer are they?
Surface epithelial tumor of the ovary that arise from endometriosis often and are usually malignant. Associated with independent endometrial carcinoma…
What is a Brenner tumor?
Benign, urothelial tumor of the surface epithelium of the ovary. (bladder like)
How to screen for treatment response/recurrence of Surface Epithelial tumors of the ovary?
CA-125
Types of Germ Cell Tumors of the Ovary? (5)
- Cystic teratoma
- Embryonal carcinoma
- Dysgerminoma
- Endodermal sinus tumor
- Choriocarcinoma
Cystic teratoma
Type of Germ Cell Tumor of the ovary. Benign tumor composed of fetal tissue derived from two or three embryologic layers.
Immature teratoma
Same as cystic teratoma, but with potential to spread. Includes immature tissue (most often neural) or somatic malignancy (most often squamous cell carcinoma of skin).
What is a Struma ovarii?
Teratoma composed primarily of thyroid tissue in ovary. Can present with symptoms of hyperthyroidism.
Dysgerminoma
Malignant germ cell tumor of the ovary composed of large cells with clear cytoplasm and central nuclei. Good prognosis (responds to radiotherapy).
Marker for dysgerminoma?
Elevated serum LDH
Endodermal sinus tumor
Malignant germ cell tumor of the ovary that mimics the yolk sac. MOST COMMON GERM CELL TUMOR IN CHILDREN.
Findings in Endodermal sinus tumors?
Elevated AFP as well as Schiller-Duval bodies (glomeruli like structures) on histology.
Choriocarcinoma
Malignant germ cell tumor of the ovary composed of trophoblasts and syncytiotrophoblasts. Villi absent. Often small, hemorrhagic tumor with EARLY hematogenous spread. Poor response to chemo.
Marker for choriocarcinoma?
Elevated b-hCG
Embryonal carcinoma
Malignant germ cell tumor composed of large, primitive cells that is aggressive with early metastasis.
What are the Sex Cord-Stromal tumors of the ovary?
- Granulosa-theca cell tumor
- Sertoli-Leydic cell tumor (in OVARY)
- Fibroma
How do granulosa-theca cell tumors present?
With symptoms of excessive estrogen (varies on age of woman).
How do Sertoli-Leydig cell tumors present?
With Hirsutism and virilization in a women due to excess androgen production.
Tubule forming cells with interspersed pink cells and Reinke crystals = ???
Sertoli Leydig cell tumor of the Ovary.
What is Meigs syndrome?
Ovarian fibroma with pleural effusions and ascites.
What is a Krukenberg tumor?
Metastatic mucinous tumor involving both ovaries, most commonly due to metastatic gastric carcinoma (diffuse type).
What is Pseudomyxoma peritonei?
Massive amounts of mucus in the peritoneum due to mucinous tumor of the appendix that often metastasizes to the ovary.
Causes of spontaneous abortions?
Most often due to chromosomal abnormalities. Also hypercoagulable states (think SLE), congenital infections, and exposure to teratogens.
Placenta previa
Implantation of placenta in lower uterine segment. Presents as third trimester bleeding, and requires C-section
Placental abruption
Separation of placenta from decidua prior to delivery. Common cause of still birth. Presents as third trimester bleeding and fetal insufficiency.
Placenta accreta
Improper implantation of placenta into myometrium. Presents with difficult delivery of placenta and postpartum bleeding. Often requires a hysterectomy.
Alcohol effect on fetus
Mental retardation (most common cause of this), also facial abnormalities and microcephaly.
Cocaine effect on fetus
Intrauterine growth retardation and placenta abruption
Thalidomide effect on fetus
Limb deformities
Cigarette smoke effect on fetus
Intrauterine growth retardation
Isotretinoin effect on fetus
Spontaneous abortion, hearing and visual impairment
Tetracycline effect on fetus
Discolored teeth
Warfarin effect on fetus
Fetal bleeding
Phenytoin effect on fetus
Digit hypoplasia and cleft lip/palate
What is Preeclampsia?
Pregnancy induced hypertension, proteinuria, and edema, usually arising in third trimester. Due to abnormality of maternal-fetal vascular interface in the placenta.
What is Eclampsia?
Preeclampsia with SEIZURES. Must deliver to get rid of placenta…
What is HELLP?
Preeclampsia with thrombotic microangiopathy of the liver.
Hemolysis
Elevated Liver enzymes
Low Platelets
Risk factors for SIDS?
Sleeping on stomach, exposure to cigarette smoke, and prematurity.
What is a partial hydatidiform Mole?
Normal ovum fertilized by two sperm (69X).
What is a complete hydatidiform mole?
Empty ovum fertilized by two sperm (46X)
What is a hydatidiform mole?
Abnormal conception characterized by swollen and edematous villi of placenta with proliferation of trophoblasts.
Findings with hydatidiform mole?
Uterus larger than expected and b-hCG much higher than expected. Also passage of grape-like masses through the vaginal canal during second trimester.
How to treat hydatidiform mole and feared complication?
Treat with dilatation and curettage. Fear choriocarcinoma. However, gestational choriocarcinoma responds well to chemo, unlike germ cell choriocarcinomas.
