Female Genital System and Reproductive Pathology Flashcards
Bartholin Cyst
Bartholin gland normally secretes lubrication into vestibule.
Usually unilateral enlarged painful cystic lesion secondary to inflammation and plugging of the gland.
Located at lower vestibule adjacent to the vaginal canal.
Generally women of reproductive age (infections/STD’s)
Not uncommon
Can be accompanied by abscess.
Condyloma
Warty neoplasm of vulvar skin, often large
MC due to HPV 6 and 11. (low risk based on DNA sequencing)
Characterized by koilocytic change
Rarely progresses to carcinoma
Lichen sclerosis
Thinning of epidermis and fibrosis of dermis
Leukoplakia w/ parchment-like vulvar skin
MC in postmenopausal women
Benign, associated w/ slightly increased risk of SCC
Lichen simplex chronicus
Hyperplasia of vulvar squamous epithelium
Leukoplakia w/ thick, leathery skin
Associated w/ chronic irritation and scratching
Benign; no increased SCC risk
Vulvar carcinoma
Arises from squamous epithelium of vulva
Rare
Presents as leukoplakia (biopsy may be required to distinguish from lichen sclerosis)
Etiology: May be HPV –> VIN (High risk - 16, 18, 31, 33) = 40-50 years old; or non-HPV related (long standing lichen sclerosis) = 70+ years old.
Extramammary Paget Disease
Malignant epithelial cell in the epidermis of the vulva
Presents as erythemetous, pruritic, ulcerated skin
*Key ddx is carcinoma (PAS +; Keratin +; and S100-) vs. melanoma (PAS-, Keratin -, and S100+)
Represents as carcinoma in situ (no underlying malignancy which is not the case w/ Paget’s disease of the breast)
Adenosis
Focal persistence of columnar epithelium in upper 2/3rds of vagina
Increased incidence in females exposed to DES (drug used to be given to mothers to prevent miscarriage) in utero
Can lead to clear cell adenocarcinoma
Clear cell adenocarcinoma
Malignant proliferation of glands with clear cytoplasm
Rare complication of DES-associated vaginal adenosis
Discovery of this and other complications lead to cessation of DES usage
DES complications in DES mom
Slightly increased risk of breast CA (estrogen like compound)
DES complications in DES daughter
- ) Adenosis –> clear cell adenocarcinoma
2. ) Smooth muscle problems in tubes/uterus. Increased ectopic risk.
Embryonal rhabdomyosarcoma
Malignant mesenchymal proliferation of immature skeletal muscle
Rare
Presentation: Bleeding and grape-like mass protruding from vagina or penis of child usually
Vaginal carcinoma
Carcinoma arising from squamous epithelium lining the vaginal mucosa
Usually related to high-risk HPV (16,18,31,33)
Precursor lesion is vaginal intraepithelial neoplasia (VAIN)
Regional lymph node spread: Lower 1/3 goes to inguinal nodes; Upper 2/3 goes to regional iliac nodes (due to embryological differences)
HPV infection
Sexually transmitted DNA virus
Infects lower genital tract, esp. cervix in transformation zone (strat squamous to simple columnar of exo/endo cervical border)
Persistent infection leads to risk for CIN
High risk: 16,18,31,33
Low risk: 6 and 11
High risk proteins:
E6: increases destruction of p53
E7: increases destruction of Rb
CIN: characterized by koilocytic change, nuclear atypia, and increased mitotic activity. Divided into grades based on cells involved.
CIN 1 - bottom 1/3 portion has dysplasia (reverses 66%)
CIN 2 - middle 2/3 has dysplasia (33% reverse)
CIN 3 - Almost all have dysplasia (rare reversal)
Carcinoma in situ (cannot reverse)
CIN progresses stepwise, but is not inevitable
Cervical carcinoma
Invasive carcinoma that arises from cervical epithelium
MC in middle-aged women (40-50)
Presents as vaginal bleeding or post-coital bleeding
Key risk factor is high risk HPV infection. Secondary factors include smoking (cervical and pancreas are two non-logical smoking related cancers) and immunodeficiency. (usually clears HPV infection)
Most common subtypes:
Squamous cell carcinoma (most common) and adenocarcinoma (rarer, but also due to HPV)
Often invade through anterior uterine wall into bladder –> hydronephrosis.
Local invasion over metastasis
Screen to catch dysplasia before it devleops into carcinoma.
Pap smear is gold standard for screening. Most successful screening tests ever developed. Look at nucleus/cytoplasm ratio etc.
Abnormal papsmear –> followed by confirmatory coposcopy and biopsy
Limitations of Pap smear: 1.) Inadequate sampling of transition zone (false negative).
2.) Limited efficacy in screeing for adenocarcinoma
Immunization: Effective in preventing HPV infections (HPV 6,11,16, and 18). Protection lasts for 5 years and must still undergo pap smears (31,33 and other high risks not covered)
Asherman Syndrome
Secondary amenorrhea due to loss of *basalis (regenerative layer of stem cells) and scarring
Result of overaggressive dilation and curretage (D&C)
Anovulatory cycle
Lack of ovulation
Results in estrogen-driven proliferative phase w/o progesterone-driven secretory phase
Common cause of dysfunction uterine bleeding, especially during menarche and menopause
Acute endometritis
Bacterial infection of endometrium
Usually due to retained products of conception
Presents as fever, abnormal uterine bleeding, and pelvic pain
Chronic endometritis
Chronic inflammation of endometrium
Characterized by
*plasma cells (lymphocytes are always present)
Common causes: retained products of conception, chronic PID, IUD, and TB
Presents with abnormal uterine bleeding, pelvic pain, and infertility.
Endometrial polyp
Hyperplastic protrusion of endometrium
Presents as abnormal uterine bleeding
Can arise as a side effect of tamoxifen
Enodmetriosis
Abnormal placement of endometrial glands and stroma outside uterine endometrial lining
Presents with dysmenorrhea (tissue cycles as well) and pelvic pain; may cause infertility.
3 theories:
- Retrograde theory
- Metaplastic theory
- Lymphatic dissemination theory
Common sites of involvement:
- 1.) Ovary - chocolate cyst
2. ) Uterine ligaments - pelvic pain
3. ) Pouch of Douglas - pain with defecation
4. ) Bladder wall- pain with urination
5. ) Bowel serosa - abdominal pain and adhesions - 6.) Fallopian tube mucosa - scarring ( increased risk of infertility and ectopic)
“gunpowder” lesions in soft tissue.
Adenomyosis is endometriosis of myometrium
Increased risk of CA at site of endometriosis. Esp. at the ovary.
Adenomyosis
Endometriosis of the myometrium.
Endometrial hyperplasia
Increase in the amount of endometrium glands in comparison to the surrounding stroma.
*Consequence of unopposed estrogen.
Classically seen in postmenopausal obese women with uterine bleeding.
Classified histologically: Based on architectural growth and cellular atypia.
**Most important predictor for progression to CA is cellular atypia
Endometrial Carcinoma
Malignant proliferation of endometrial gland
Presents as postmenopausal bleeding
Arises via two distinct pathways:
1.) Hyperplasia pathway –> due to unopposed estrogen. Endometroid histology –> aged 50-60
2.) Sporadic pathway – cancer from an atrophic endometrium w/o precursor lesion. Serous/Papillary histology –> elderly. Driven by p53 mutations. Can get psammoma bodies. Very aggressive.
