Diseases of the Lower Female Genital Tract

Question 1

What inflammation is the hallmark of gonorrhea infection?

Answer 1

Exudative purulent reaction (FACULTATIVE intracellular inside neutrophils) followed by plasma cell infiltration + granulation tissue / scarring

Question 2

What are the sequellae of gonococcal cervicitis vs salpingitis?

Answer 2

Cervicitis - few sequelae

Salpingitis - sealing of tube with distension by pus (pyosalpinx), can form tuboovarian abscess. May subsequently scar -> infertility

Question 3

What neonatal complication is associated with gonorrhea infection of the mother and how is it prevented / treated?

Answer 3

Neonatal ophthalmitis (neonatal conjunctivitis)

Prevent / treat with erythromycin eye ointment or silver nitrate (AgNO3)

Question 4

What are the acute conditions caused by Chlamydia, how does it grow? and how is it diagnosed?

Answer 4

1. Venereal urethritis / cervicitis which can ascend to cause PID
2. Lymphogranuloma venereum
3. Trachoma (follicular conjunctivitis of eye), also neonatal conjunctivitis

Grows obligate intracellularly inside mucosal cells

Question 5

How is Chlamydia diagnosed?

Answer 5

1. Giemsa stain
2. Fluorescent anti-chlamydial antibodies
3. PCR, nucleic acid amplification tests

Question 6

What inflammation is seen in Lymphogranuloma venereum?

Answer 6

Vesicle at site ofinfection ulcers and has purulent exudate.

base will have granulomatous inflammation
-> both suppurative and granulomatous inflammation

Swollen inguinal, pelvic, and rectal nodes will be seen

Question 7

What do herpes virus inclusions look like on histological stain and what stain do you use?

Answer 7

Tzank smear from bottom of ulcer

IntraNUCLEAR eosinophilic ground glass inclusions with peripheral chromatin clumping. Often have multinucleated giant cells and moulding (nuclei fit together like puzzle pieces)

Question 8

Where are molluscum bodies?

Answer 8

These will be large, eosinophilic intraCYTOPLASMIC bodies
-> only DNA virus family to replicate in the cytoplasm

See pg 159

Question 9

Does HPV cause squamous cell carcinoma or adenocarcinoma? Which strain is responsible?

Answer 9

HPV causes BOTH

-> adenocarcinoma mostly caused by HPV 16 & 18

Question 10

What are the symptoms of trichomoniasis and how is it transmitted? How is it visualized?

Answer 10

It is an anerobic, flagellated protozoan which does NOT form cysts so it is sexually transmitted

Symptoms:
Pruritis with foul-smelling greenish discharge
Inflamed cervix: “Strawberry cervix”

Visualize via wet mounts.

Question 11

What conditions are associated with vaginal candida infection?

Answer 11

Think of sketchy

Candy jar - diabetes
Pill bottle - antibiotic use
Birth control - OCP use (high estrogen levels)

Question 12

What is chronic atrophic dermatitis also called and who tends to get it?

Answer 12

Lichen sclerosis (et atrophicus)
-> commonly seen in postmenopausal women, with possible autoimmune etiology

Question 13

What does Lichen sclerosis look / feel like?

Answer 13

Presents as a white patch (leukoplakia) in a butterfly distribution (symmetric)
-> skin surrounding vulva will be “parchment-like” -> very thin

Question 14

What are the histologic features of lichen sclerosis?

Answer 14

Atrophy of epidermis with absence of epidermal ridges

Replacement of underlying dermis with dense fibrotic collagenous connective tissue

Dense, bandlike (lichenoid) inflammation under epidermis

Question 15

What is the primary worry with lichen sclerosis?

Answer 15

Development of carcinoma of vulva

• > longstanding diseases can progress to non-HPV related vulvar carcinoma related to a p53 mutation
• > generally occurs in elderly women

Question 16

What is VIN / what is it analogous to? What is VIN-1 and VIN-3? What is the cause usually?

Answer 16

Vulvar intraepithelial neoplasia, analogous to CIN (cervical)

VIN-1 = mild, dysplasia limited to lower 1/3
VIN-3 = full thickness dysplasia

Cause is usually high risk HPV strains

Question 17

What is extramammary Paget disease and how does it present grossly / microscopically?

Answer 17

Malignant epidermal cells in the epidermis of the vulva (skin around vagina)

Presents an an erythematous, pruritic, ulcerated lesion around vulva

Microscopically - large clear tumor cells in epidermis

Question 18

How is extramammary Paget disease told apart from melanoma (which can sometimes occur on vulva)?

Answer 18

Extramammary Paget disease: PAS+ (stains positive for mucin = carcinoma)
Keratin +, S100-

Melanoma: PAS-, keratin-, S100+ (marker for neural crest derivation)

Question 19

Is there an underlying carcinoma in extramammary Paget disease?

Answer 19

NO -> cancer is limited to epidermis

This is in contrast to Paget disease of the nipple, in which this is a sign of underlying breast carcinoma

Question 20

Where does cervical intraepithelial neoplasia tend to arise and why?

Answer 20

Arises in the transformation zone (zone between ectocervix (squamous epithelium) and endocervix (glandular epithelium)

Transformation zone is delicate and may have rips / tears which allow HPV to enter and infect the BASAL layer -> required for HPV replication

Question 21

Why are Pap smears so effective and where should they be done?

Answer 21

So effective because it takes many years for CIN-1 to progress to CIN-3 and then invasive carcinoma. Typically takes 10+ years for this to arise.

They should be done at the transformation zone for reasons explained before

Question 22

What are the risk factors for CIN and is persistent infection common?

Answer 22

Persistent infection is actually relatively rare, and is required to develop CIN

Risk factors: Smoking! Important one
Immunodeficiency -> squamous cell carcinoma of anus or cervix is actually an AIDS-defining illness (CD4 < 500, pg 173)

Question 23

What is seen on histology of condyloma acuminatum?

Answer 23

Hyperkeratosis, parakeratosis, and mild dysplasia with koilocytic change (raisinoid, hyperchromatic, perivaculolar clearing)

Warty exophytic structure

Question 24

Where does HPV-related adenocarcinoma arise?

Answer 24

Arises in endocervical glandular epithelium

Question 25

What is the hallmark of invasive cervical carcinoma and a feared complication?

Answer 25

Invasion of the stroma.

Often, it can invade anteriorly into the bladder wall, leading to ureteral obstruction
-> post-renal azotemia is a common cause of death in advanced carcinoma

Question 26

Other than adenocarcinoma and squamous cell carcinoma, what is one cancer type that HPV can rarely cause?

Answer 26

Small cell carcinoma -> tumor of neuroendocrine differentiation which may show rosette formation. High grade necrosis (like small cell cancer of the lungs)

Question 27

How does the treatment of CIN and invasive carcinoma differ and why?

Answer 27

CIN - oftentimes very conservative management with followup Pap smear, or cryosurgery / lazer therapy, or removal of the small area.

This is because CIN is still reversible (though less likely from CIN-1 to CIN-3)

Invasive carcinoma - aggressive management -> hysterectomy and lymph node dissection with radiation therapy.

This is because invasive carcinoma is IRREVERSIBLE.