female genital tract pathology Flashcards
what is the epidemiology of endometriosis?
6-10% of women aged 30-40 years old
what is the presentation of endometriosis?
25% are asymptomatic, if symptomatic then pain passing stool, pelvic pain, subfertility, dysparenuria and dysmenorrhoea
what are the investigations for endometriosis?
laparoscopy
what is the treatment for endometriosis?
medical - progesterone antagonist or GnRH agonists or antagonists or COCP
surgical - ablation or TAH-BSO
what are the associations with endometriosis?
ectopic pregnancy, ovarian cancer and IBD
what is the result and how is this reached for endometriosis?
ectopic endometrium (regurgitation/metaplasia/stem cell/metastasis theory) leading to bleeding into tissues and then fibrosis ultimately
what is inflammation of the endometrium?
chronic endometriosis with a predominant picture of lymphocytes and plasma cells in histology and is caused by foreign bodies or chronic retained products or infection
where is there increasing prevalence of inflammation of the endometrium?
with increasing chlamydia
what is the cause of inflammation of the endometrium?
retained gestational tissue, endometrial TB, IUCD infection
what is the presentation of inflammation of the endometrium?
abdo pain or pelvic pain, dysuria, discharge, abnormal vaginal bleeding and pyrexia
what is the investigations for inflammation of the endometrium?
biochemistry, microbiology or USS
what are the treatments for inflammation of the endometrium?
medical such as analgesia or ANX or removing the cause
what are endometrial polyps?
they are sessile/polypoid E2 dependent uterine overgrowths of which <1% are malignant. They are in less than 10% of women and this is in their 40-50s
what is the presentation of endometrial polyps?
often asymptomatic but can present with intermenstrual or post menopausal bleeding, menorrhagia or dysmenorrhoea
what are the investigations for endometrial polyps?
USS or hysteroscopy
what are the treatments for endometrial polyps?
medical (P4/GnRH agonists) or surgical (curettage)
what are leiyomyomas?
they are uterine fibroids - benign myometrial tumours with E2/P4 dependent growth that affect around 20% of women in the 30-50s and can result in menopausal regression and have a malignancy risk of 0.01%
what are the risk factors for leiyomyomas?
genetics, nullparity, obesity, PCOS and HTN
what is the history of leiyomyomas?
often asymptomatic, menorrhagia (leading to Fe deficienct anaemia), subfertility and pregnancy problems and pressure
what are the investigations for leiyomyomas?
bimanual examination or USS
what are the treatments for leiyomyomas?
medical or non medial
medical - NSAIDs, IUS, OCP, P4 or Fe2+
non medical - artery embolisation or ablation or TAH
what is endometrial hyperplasia?
it is excessive endometrial proliferation where E2 increases and P4 decreases and has a risk of progression to endometrial adenocarcinoma or regression
what are the types of endometrial hyperplasia?
there is simple: atypical or non atypical or complex: atypical or non atypical
what are the risk factors for endometrial hyperplasia?
obestiy, exogenous E2, PCOS, E2 producing tumours, tamoxifen, HNPCC (PTEN mutation)
what are the investigations for endometrial hyperplasia?
USS, hysteroscopy, biopsy
what are the presentations for endometrial hyperplasia?
abnormal bleeding - IMB, PCB, PMB
what are the treatments for endometrial hyperplasia?
medical - IUS or P4 or surgical TAH
how can endometrial hyperplasia produce cancer?
nedometrial hyperplasia to endometriod carcinoma is progression from simple hyperplasia through to complex atypical hyperplasia and invasive carcinoma. Simple is common and carcinoma is less frequent - the chances of progression through the pathway increase the farther down the pathway a woman is
what is the cause of simple hyperplasia and what is seen?
it is caused by excess oestrogens from a variety of possible sources and it shows an overgrowth of the whole epithelium therefore a thick endometrium on USS
what happens in complex hyperplasia?
the glandular epithelium increases and the epithelium can be folded into complex architectural structures
what happens in atypical/intraepithelial neoplasia?
the cells show architectural changes of neoplasia with increased nuclear cytoplasm ratio - larger nucleus and less cytoplasm and there are irregular shapes, increased number of mitoses and some of these are abnormal
what is the malignant progression of hyperplasia?
when there is normal to non atypical hyperplasia which resembles normal proliferative endometrium, then atypical hyperplasia/endometrial intraepithelial neoplasia - presence of cytological abnormalitiy and then endometriod adenocarcinoma which shows invasion into the myometrium
what is the presentation and investigations for endometrial adenocarcinoma?
the presentation is IMB or PMB or pain if late, and the investigations are USS biopsy and hysteroscopy
what is the staging and treatment used for endometrial adenocarcinoma?
FIGO staging 1-4
medical P4, surgery TAH-BSO or adjuvnant therapy such as chemo or radiotherapy
what is the prognosis of endometrial adenomcarcinoma?
5YSR for stage 1 is 90%
for stages 2-3 is less than 50%
what is the prevalence of endometrial adenocarcinoma?
it is the most common cancer of the female genital tract with 9200 cases per year and 2500 deaths in the UK
what are the types, incidence of these and age of onset for the endometrial adenocarcinomas?
there are two types
type 1 is endometriod and it is around 7% of cases at pre or perimenopausal age
type 2 is serous which is around 25% of cases at postmenopausal age
what are the precursors to the types of endometrial adenocarcinoma?
type 1 - endometrial hyperplasia
type 2 - endometrial atrophy
what are the mutations and E status of endometriod and serious adenocarcinomas?
endometrioid - PTEN and KRAS mutations with a positive E2 status
serous - P53 mutation and E2 negative
what are the grades for endometrioid and serous adenocarcinomas?
grade 1,2,3 for endometrioid and grade 3 only for serous
what is polycystic ovary syndome?
it is an endocrine disorder with hyperandrogenism, menstrual abnormalities and polycystic ovaries. 6-10% of women have this but 20-30% have polycystic ovaries.
what is the diagnosis for POS?
rotterdam criteria - 2/3 of the following:
polycystic ovaries, irregular periods of over 35 days and hyperandrogenism resulting in hirsutism or biochemical
what are the investigations for POS?
USS< fasting biochemical screen with drop is FSH and a rise in LH, testosterone and DHEAS, or OGTT
what are the treatments of POS?
lifestyle weight loss, medical - metformin, OCP or clomiphene or surgical - ovarian drilling
what are the links with POS?
inferility, endometrial hyperplasia and adenocarcinoma
what are epithelial tumours?
they are the most common group of ovarian neoplasms representing 90% and there are three major carcinoma histologic types which are serous - tubal, endometriod - endometrium and mucinous - endocervical. Each type contains benign/borderline/malignant variatns
how are benign tumours classified?
based on their components - cystic are cystadenomas, fibrous are adenofibromas and both are cystadenofibromas
what are cystadenocarcinomas?
they are malignant epithelial tumours
what are the origins of ovarian neoplasms?
they are surface epithelial tumours, sex cord stromal tumours or germ cell tumours
what are serous cystadenocarcinomas?
they are characterised by complex, branching, papillae and glands incorporating slit like spaces - there is destructive stromal invasion is identified most conspicuously within the confluent solid growth pattern exhibited within the ovarian cortex
what are germ cell tumours?
they are 15-20% of all ovarian tumours and are germinatous or non germinatous
what is the main germinatous tumour?
it is a dysgerminoma which is malignant and chemosensitive
what are the main types of non germinatous tumours?
teratomas which show differentiation towards multiple germ layers, yolk sac tumours and choriocarcinomas
what differentiation is shown in choriocarcinomas and yolk sac tumours?
in YS there is differentiation towards extraembryonic yolk sac, malignant and chemosensitive
chorio show differentiation to the placenta, malignant and are often unresponsive
what are sex cord stromal tumours?
they are rare and arise from ovarian stroma which was derived from sec cord of embyronic gonad - they can generate cells from the opposite sex and can be sertoli leydig cell tumours, granulosa cell tumours or thecomas/fibromas or fibrothecomas
what are fibrothecomas etc?
they are benign and thecomas and fibrothecomas produce E2 - also rarely androgens - fibromas are hormonally active
comprised of spindle cells - plump spindle cells with lipid droplets gives the thecoma appearance
meigs syndrome - ovarian tumour, right sided hydrothroax and ascites
what are sertoli leydig?
sex cell stromal tumours that produce androgens and 10-25% are malignant
what are granulosa cell tumours?
they are low grade malignant and produce E2
what is the prevalence of ovarian cancer?
it is the second most common gynae cancer with over 7000 women in the UK diagnosed and over 4000 deaths per year. 80% are over 50y/o and 80-90% are epithelial
what are the risk factors for ovarian cancer?
FH, increased age, PMH opf breast cancer, smoking, E2 only HRT, Lynch II syndrome, obestiy and nulliparity
what are protective factors for ovarian cancer?
OCP, breast feeding and hysterectomy
what are the presentations of ovarian cancer?
they are non specific symptoms - urinary frequency, pain, bloating, weight loss, PV bleeding, anorexia
what is the staging of ovarian cancer?
FIGO 1-4
what is the treatment of ovarian cancer?
for less than stage 1C is TAH, BSO omentectomy, appendectomy, lymphadenectomy and adjuvant chemo - this is only in sensitive GCTs
what is the prognoses for ovarian cancer?
43% 5YSR
what are the types of ovarian metastatic tumours?
mullerian and non mullerian tumours
what is a mullerian tumour?
it is the most common ovarian metastatic tumour that is in the uterus, fallopian tubes, pelvic peritoneum, contralateral ovary
what is a non mullerian tumour?
it is spread through lymphatic spread or haematogenous and goes to the GIT, breast - lobular, melanoma and the kidney and lung and directly to the bladder and rectum
what is endometriosis and what is endometritis?
endometriosis is ectopic endometrial tissue and endometritis is chronic inflammation of the endometrium
what is leiyomyomata?
it is benign tumour of the smooth muscle of the myometrium
what are the features of PCOS?
common, multiple follicular cysts, hyperandrogenism and menstrual irregularity
