Female Genital System and Gestational Pathology Flashcards
Bartholian Cyst
unilateral dilation of <b>lower vestibule</b> due to obstruction and consequential inflammation (caused by infection or STD)
<b>*gland abscess is often causes by N. gonorrhoeae</b>
Condyloma
warty neoplasm of vulvar skin due to HPV (6, 11) causing koilocytic change
*rarely progresses to carcinoma
HPV categories
<b>low risk</b>: 6, 11; condyloma
<b>high risk</b>: 16, 18, 31, 33; dysplasia–> carcinoma
Lichen Sclerosis
benign thinning of epidermis and fibrosis or dermis causing leukoplakia with <b>parchment-like</b> vulvar skin
- occurs in postmenopausal women
- slighly increases risk for squamous cell carcinoma
Lichen Simplex Chronicus
benign squamous cell hyperplasia causing leukoplakia with <b>leathery</b> vulvar skin
- <b>chronic irritation and scratching</b>
- no increased risk of squamous cell carcinoma
Vulvar Carcinoma etiology
<b>HPV-related</b>: high risk HPV 16 and 18 in 40-50 year olds; from vulvar intraepithelial neoplasia (VIN)
<b>non-HPV-related</b>: long-standing Lichen Sclerosis in >70 year olds
*keratin squamous pearls on histology
Extramammary Paget Disease
malignant epithelial cells in epidermis causing erythematous, pruritic (itchy) and ulcerated skin <b>without underlying carcinoma</b> (unlike Paget Disease of the breast)
Vulvar Carcinoma vs. Vulvar Melanoma
<b>Carcinoma</b>: PAS +, keratin +, S100 -
<b>Melanoma</b>: PAS -, ketain -, S100 +
Adenosis
when upper 2/3 of vaginal canal remains columnar when it should actually transition to squamous (<b>residual columnar cells</b>)
- related to DES in utero
- <b>Complication= Clear Cell Adenocarcinoma</b>
Clear Cell Adenocarcinoma
malignant proliferation of glands with clear carinoma
- complication of DES-associated Adenosis
- DES inhibits Mullerian differentiation
Embryonal Rhabdomyosarcoma
malignant mesenchymal proliferation of immature skeletal muscle causing <b> grape-like mass</b> protrusion in children
Rhabdomyoblast
has cytoplasmic cross-striations and + IHC staining for desmin and myogenin
Vaginal Carcinoma (& lymph node spread)
related to high risk HPV with vaginal intraepithelial neoplasia (VAIN) as the precursor lesion
lower 1/3–> spreads to inguinal nodes
upper 2/3–> spreads to regional iliac nodes
Cervix anatomy
endocervix (mucus-secreting columnar cells), transformation zone, exocervix (squamous)
proteins made by high-risk HPV
<b>E6</b>- increased destruction of p53
<b>E7</b>- increased destruction of Rb
Cervical Intraepithelial Neoplasia: CIN (definition and grades)
koilocytic change, nuclear atypia and increased mitotic activity
<b>Grades</b>:
- CIN 1 (lower 1/3 of epithelium), 2 (lower 2/3 of epithelium), 3 (full thickness of the epithelium) are reversible
- CIN in situ is irreversible (involves full thickness of epithelium)
- progression from CIN 1 to CIN 3 takes ~10 years
- progression from CIN 3 to invasive cancer ~10 years
Cervical Carcinoma (definition, risk factors, types)
invades basement membrane in women aged 40-50 years old presenting as <b>vaginal bleeding</b>
<b>Risk factors</b>: high-risk HPV, smoking, immunodeficiency (since majority of the time, HPV is eliminated by the immune system)
<b>Types</b>: squamous cell and adenocarcinoma
**postrenal azotemia leading to renal failure is a common cause of death
Limitations of Pap smears
- inadequate transformation zone sampling
2. limited efficacy in screening adenocarcinoma
Asherman Syndrome
secondary amenorrhea due to loss of basalis (regenerative layer of endometrium) <b>from overaggressive dilation and curettage</b>
Anovulatory Cycle
estrogen proliferative phase <b> without progesterone-driven secretory phase</b> causing dysfunctional uterine bleeding
Endometritis (Acute and Chronic)
<b>Acute</b>: bacterial infection fro retained products of conception causing <b>fever</b>, uterine bleeding and pelvic pain
<b>Chronic</b>: inflammation of endometrium from placenta retention characterized by plasma cells causing uterine bleeding, pelvic pain and <b>infertility</b>
Endometriosis
glands and stroma outside of the uterine endometrial lining from retrograde menstruation commonly involving <b>ovary (chocolate cyst)</b>
Adenomyosis
endometriosis involving the myometrium increasing risk for carcinoma
- uterus becomes enlarged, menorrhagia, dysmenorrhea, pelvic pain
- <b>treatment: hysterectomy</b>
Endometrial Hyperplasia
hyperplasia of glands due to unopposed estrogen causing postmenopausal bleeding
<b>Simple</b>: increased number of cystically dilated glands without glandular crowding
<b>Complex</b>: increased number of dilated glands with branching and glandular crowding
<b>Atypical</b>: glandular crowding and dysplastic epithelium
*atypia is an important predictor for progression to carcinoma
Endometrial Carcinoma (pathways)
malignant proliferation of endometrial glands causing postmenopausal bleeding
<b>Hyperplasia</b>–> CA–> Endometrioid
- 50 year-olds
- related to estrogen exposure
<b>Sporatic p53 mutation</b>–> Serous–> Papillary
- elderly
- no evident precursor lesion
*lungs are a common site of metastasis
Leiomyoma/Fibroids (definition, possible symptoms, what happens to the tumors)
benign proliferation of smooth muscle (myometrium) due to estrogen exposure causing <b>multiple, well-defined white whorled masses</b>
- usually asymptomatic or cause uterine bleeding, infertility and pelvic mass
- <b>never</b> leads to Leiomyosarcoma
*tumors undergo degeneration, dystrophic calcification and hyalinization
Leiomyosarcoma
malignant proliferation of smooth muscle (myometrium) arising <b>denovo</b> in postmenopausal women causing <b>single lesion with necrosis and hemorrhage</b>
Hormone flow in oocytes:
LH stimulates Theca cells to produce androgens which then in the Granulosa cells they can turn into estradiol with the help of FSH allowing for maturation of the oocyte
Polycystic Ovarian Disease: PCOD
hormone imbalance (<b>high LH and low FSH</b>) leading to multiple follicular cysts (hyperplasia of ovarian theca cells around ovarian follicles)
high LH causes increased androgen synthesis leading to <b>infertility, oligomenorrhea and hirtuism</b>
Cell types that make up the ovary:
- Surface epithelium
- Germ cells
- Sex-cord stroma
Surface Epithelial Tumors of the Ovary
presents late with vague abdominal symptoms and urinary frequency and tend to spread locally with poor prognosis
- <b>Cystadenoma</b>: benign, simple cyst with flat lining, premenopausal (30-40 years old)
- <b>Cystadenocarcinoma</b>: malignant, complex cyst with thick shaggy lining, postmenopausal, presence of psammoma bodies (60-70 years old)
- <b>Borderline</b>: still carries metastatic potential
- <b>Endometrioid</b>
- <b>Brenner</b>: urothelium; contains Walthard cell rests
Germ Cell Tumors of the Ovary
occurs in women of reproductive age
- <b>Cystic Teratoma</b>: benign, composed of 2-3 embryonic layers of fetal tissue, bilateral in 10% of cases
- <b>Struma Ovarii</b>: cystic teratoma composed of thyroid tissue
- <b> Dysgerminoma</b>: malignant, large cells with clear cytoplasm and central nuclei with elevated LDH but a good prognosis
- <b>Endodermal Sinus Tumor</b>: malignant, resembles yolk sac, elevated seum AFP, Schillar-Duval bodies
- <b>Choriocarcinoma</b>: composed of trophoblasts and syncytiotrophoblasts, early hematogenous spread, high beta hCG, chorionic villi are not present
- <b>Embryonal Carcinoma</b>: large primitive cells, aggressive with early metastasis
Sex Chord Stromal Tumors of the Ovary
- <b>Granulosa-Theca Cell Tumor</b>: produces estrogen, contains Call-Exner bodies
- <b>Sertoli-Leydig Cell Tumor </b>: Sertoli cells form tubules and Leydig cells contain Reinke crystals; production of androgens thus associated with hirtuism or virulization
- <b>Fibroma</b>: benign fibroblast tumor associated with pleural effusion and ascites (Meigs Syndrome)
- <b>Metastasis</b>: Kruckenberg tumor (hematogenous spread of gastric cancer) and Pseudomyxoma peritonei
Ectopic Pregnancy risk factor
scarring
What are spontaneous abortions usually due to?
chromosomal anomalies, congenital infections, exposure to teratogens or hypercoaguable states
Placenta Previa
implantation of placenta in lower uterine segment <b>overlying cervical Os</b>
*presents as painless 3rd trimester bleeding without fetal distress
Placenta Abruption
separation of placenta from decidua due to <b>retroplacental clot</b> cutting off O2 supply
*presents as painful 3rd trimester bleeding and <b>fetal insufficiency</b>
Placenta Accreta
improper implantation of placenta into <b>myometrium without intervening decidua</b> requiring a hysterectomy since it cannot be properly removed
Preeclampsia and Ecclampsia
<b>Preeclampsia</b>: pregnancy-induced hypertension, proteinuria and edema (and placental hypoperfusion) due to abnormality of <b>maternal-fetal vascular interface</b> and increase in vasoconstrictors and sensitivity to ANGII
<b>Ecclampsia</b>: Preeclampsia + Seizures
HELLP
Hemolysis, Elevated Liver enzymes, Low Platelets
*preeclampsia with thrombotic microangiopathy involving liver
Hyaditidiform Mole
- <b>benign tumors of the chorionic villus</b>
- abnormal conception
- <b>swollen and edematous villi with trophoblast proliferation</b>
- passage of grape-like masses
- complete vs. partial
- <b>high beta hCG</b>
- <b>risk of Choriocarcinoma</b>
- snow storm appearance on ultrasound</b>
<b>Treatment</b>= dilatation and curettage
Gardnerella vaginalis
gram negative rod that adheres to squamous cells thus producing <b>“clue cells”</b>
- due to alteration in the microenvironment of the vagina
- <b>treatment: metronidazole</b>
What happens to cells when they undergo koilocytic change?
they have wrinkled pyknotic nuclei surrounded by a clear halo
Klebsiella granulomatis
STD; gram negative coccobacillus causing granuloma inguinale in which the organism is phagocytized by macrophages (<b>Donovan bodies</b>)
- <b>creeping, raised sore</b>
- treatment: doxycycline
Trichomonas vaginalis
produces vaginitis, cervicitis, urethritis, green-frothy discharge
*treatment: metronidazole
Rokitansky-Kuster-Hauser (RKH) Syndrome
underdeveloped or absent vagina and uterus
*ovaries are usually present and functional
Gartner Duct Cyst
remnant of wolffian/mesonephric duct presenting as cyst on lateral wall of vagina
Nabothian cysts
obstruction of the outflow of mucus due to blockage by metaplastic squamous cells
Cervicitis (Acute, Chronic, Follicular)
<b>Acute</b>: Chlamydia, Gonorrhea, Trichomonas vaginalis, Candida or HPV will cause discharge, pain during sex (dyspareunia) and pelvic pain
<b>Chronic</b>: when acute cervicitis persists
<b>Follicular</b>: Chlamydia infects metaplastic squamous cells causing profound lymphoid infiltrate with germinal centers
Different cells that are noticed on Pap smear
<b>Superficial squamous cell</b>: estrogen
<b>Intermediate squamous cells</b>: progesterone
<b>Parabasal cells</b>: lack of estrogen and progesterone
hCG
made by the syncytiotrophoblast lining the chorionic villus in the plascenta acting as LH by maintaining the corpus luteum so it can produce progesterone to keep the pregnancy
Estradiol vs. Estrone vs. Estriol
Estradiol: made by ovaries and present primarily in non-pregnant women allowing for development of reproductive system
Estrone: weak estrogen made during menopause
Estriol: primary estrogen of pregnancy
Androgen origins that cause hirtuism
- Ovarian origin–> testosterone
2. Adrenal origin–> DHEA-S and testosterone
Types of Dysfunctional Uterine Bleeding (DUB)
<b>Menorrhagia</b>: regular but excessive flow
<b>Hypomenorrhea</b>: regular but decreased flow
<b>Metrorrhagia</b>: irregular with excessive flow
<b>Menometrorrhagia</b>: irregular or excessive between periods
rectal pouch of Douglas (lol such a royal sounding name)
area anterior to rectum but posterior to uterus that can be palpated
*<b>common site for blood, malignant cells, pus and endometrial implants</b>
CA-125
- excellent sensitivity, poor specificity (increased false positive results)
- increased in surface-derived ovarian cancers
- <b>useful in excluding endometriosis when it returns negative</b>
What causes an endometrial polyp to enlarge?
estrogen stimulation
2 common causes of PID
N. gonorrhoeae and C. trachomatis causing pus filled fallopian tube lumen
Salpingitis Isthmica Nodosa (SIN)
invagination of the mucosa into the muscle of fallopian tubes producing nodules
Most common risk factor for ectopic pregnancy
scarring from previous PID
Stromal Hyperthecosis
hypercellular ovarian stroma causing <b>bilateral ovarian enlargement</b>
- vacuolated/lutenized stromal hilar cells synthesize extra androgens
- <b>hirsutism or virilization</b>
What decreases the risk for surface-derived ovarian cancers?
Pregnancies since this would mean a decreased number of ovulatory cycles
Two sides of the placenta (and layers of the chorionic villi)
<b>Baby’s view</b>: chorion covered by aminon (chorionic villi vessels converge with the umbilical cord)
*chorionic villi are lined by trophoblastic tissue: outside layer is syncytiotrophoblast and inside layer is cytotrophoblast
<b>Mother’s view</b>: decidua basalis
Funisitis, Placentitis and Chorioamnionitis
<b>Funisitis</b>: infection of umbilical cord
<b>Placentitis</b>: infection of placenta
<b>Chorioamnionitis</b>: infection of fetal membranes (danger of neonatal sepsis and meningitis
Velamentous insertion
umbilical cord inserts away from placental edge causing increased risk for hemorrhage
*<b>vessels pass through the membranes between amnion and chorion</b>
What can lead to the development of an enlarged placenta?
DM, Rh hemolytic disease, congenital syphilis
amniotic fluid (and disorders where it is increased or decreased)
-made of fetal urine that is recycled
<b>Polyhydramnios</b>: excess
<b>Oligohydramnios</b>: decreased
alpha-fetoprotein
increased–> open neural tube defect or folic acid deficiency
decreased–> Down syndrome (would also show decreased urine estriol and increased B-hCG)
