Female Genitalia Flashcards
Endometirum-
day 1-13 proliferative- estrogen- glands straight, epithelium cuboidal to tall, single to double layer, dense stroma, compact cells
day 14, ovulation
day 15-18 secretory(progesterone. - coiled glands, tall with vacuoles single layer epithelieum, edematous stroma, plump cells conspicous arterioles.
Examination of uterine diseases
Pelvic exam with speculum, colposcpy, ultrasund, CT scan
Pap smear for cervix, infection, CIN, neoplasia
Biopises- cervic, endometrium
Dilatation and curettage- (D&C)-
unopposed estrogen effect
anovulator cycles- persistent graffian follice, extremes of reproductive life- polycycstic ovaries, obesity, emotional stress, endocrine, excess physical activity
- etiology- estrogen producing neoplasms- granulosa cell tumor, ovary, adrenal cortical adenoma.
Pathogenesis- persistent proliferation- irregular breakdown, DUB
complication- endometrial hyperplasia, endometrial carcinoma.
Exogenous progesteron effect
pill endometrium, contraceptive pills with progesterone.
-abundant stroma, plump cells(pseudodecdiual., edema, gland small, atrophic (lack of priming estrogen.
Inadequate luteal phase
irregular ripening
etiology- lowered progesterone
Pathogenesis- poorly developed secretory endometerium, breask down irregularly (DUB
Morphology- poor and immature secretory glands,
Clinical: low progesterone, FSH, LH
PErsistent luteal phase
Etiology-normal menstruation is induced by abrupt cessation of progesteron secretion by CL,
If C.L. continues to secerete low levels of progesteron- protracted and irregular shedding. periods regular but bleeding is excessive and prolonged ( 10-14 days
Morphology- persistent secretory even after 5 days of menstruation.
Endometerious
Morphology- endometrial tissue in other places like ovary, tubes, parametrium, gut, serosa, umbillicus. can also appear at lapartomy or caesarian scars. Rarely in the lung, pleura or bones.
- have glands, stroma, and cyclical bleeding,
- discolored nodules: large, blood filled cysts, with adhesions. endometrial glans, endometrail stroma, hemosiderin.
Etiology- endometrosis interna- myometrium is more than 3 mm, diffuse focal adenomyoma
Clinical- hemosiderin, fibrosis, chocolate ovary cysts, tubal scars, infertitilty, happens during reproductive phase of life, asymptomatic, pain, dysmenorrhea, menorrhagia, infertility, cyclical bleeding, urinary tract, rectum umbillicus, surgical scars.
- higher risk of tubal pregnancy, urinary obstruction
- regression following pregnancy, oral contraception
Pathogenesis= metaplasi of celomic epithelium, retrograde flow through FT, also have the metastatic theory by vascular dissemination.
Endometritits
cyclical shedding of endometerium, no foothold
Etiology
Acute- postpartum (puerperal sepsis, offensive lochia
-ascending gonoccoal,
-pyometrum,-( obstrction of os by neoplasm, fibrosis)
Chronic- non specific, plasma cells, IUCD, retained products, TB
Endometrial hyperplasiia
Etiology- excess unopposed estrogen effect, perimenopausal metrorrhagia
Increased gland to stromal ration, more glands with less
simple cystic, complec with/without atypia
Reversible with progesterone tehrapy
Atypia, carcinoma in situ, endometrial carcinoma,
look for source of estrogen- (ovary, adrenals, HRT.)
Atypia hyperplasia
Simple no architectural complexity of glands but nuclear atypia, present in glands
complex marked archetectural complexcity of the glands and nuclear atypia present, progress to endometrial adenocarcinoma in 24%
Nuclear enlargment, pleomorphism, vesicular change, chromatin irrgularity, loss of polarity, prominent nucleoli, cellular stratification.
Simple hyper plasia
simple- no archtiecterual complexity of glands and no nucler atypia
complex- marked archetectural complexity of glands with no nuclear atypia.
Endometrial polyp
perimenopausal- .5 -3 cm
extrene response to hyperplasi, asymptomatic or metrorrhagia,
-malignant transformation very RARE.
Endometrial carcinoma
55- 65 years, if yong patients usually underlying cause. (cervical carcinoma in young patients.
Etiology- unopposed estrogen effect, preceded by hyperplasia,
Risk factors- obesity, diabetes, hypertension, nulliparous,
Pathogenesis- polypoid fungating mass in the cavity asymmetric enlargment of uterus. Back to back glands.
Grading I, II, III, staging
Spread- local, myometrium, cervix, vagina, rectum, peritoneal,
- lymphatic-liac, paraaortic,
- blood-lung liver.
Clinical-Post menopausal bleeding, endometerial biopsy for diagnosis.
Malignant mixed Mullerian tumor ( mixed mesodermal tumor
older than 55 years,
Etiology- from residual Mullerian msodermal cells in endometrium
Morphology
Large fleshy mass, hemorrhage, necrosis
-epithelial and mesenchymal (leio, rhabdo, chondro, osteo,
Poor prognosis.
Smooth muscle tumors of the uterus algorithm
nuclear atypia–> tumor necrosis?
- Yes–> MI greater than 10?–> leimyosarcoma
- NO No need to mitotic count- Leiomyoma
Leiomyoma
Common(25 % benign smooth muscle tumor- 20-40 years old, estrogen dependant growth, regress, with menopause.
morphology0 subserous intramural, submucous, circumscribed, whorled nodules, resemble normal smooth muscle fibrosis (fibroid
Asymptomatic, menorrhagia, mettrohagia, infertility, mass effect
Acute pain, red degeneration- necrosis specially in pregnancy- no malignant potential.
Laparoscopic resection, hysterectomy
Leiomyosarcoma
Etiology-Rare, denovo and not from leiomyoma
Morphology- large bulky, hemorrhage, necrosis
hypercellular with atypia, greater than 10 mitosis, poor prognosis.
clinical- older women, post menopausal bleed
Uterine bleeding differential
abortion, dUB, endometriosis, Chronic endometritits, endometrial hyperplasia, polyp, carcinoma, leiomyoma
Ectocervix
lined by hormonally responsive stratified squamous epithelium, noncornified: post puberty, mature cells, store glycogen which support the growth of normal flora.
endocervix
lined by simple columnar epithelium, lined by simple columnar epithelium, endocervical glands are crypt like spaced lined by the same epithelium
acute cervicitis
endocervix- no erosion
extocervix- erosion
etiology- Goncoccal, chlamydia, candida, trichomonas, herpes, Post partum, Post D&C,
clinical- purulent vaginal discharge
Chronic cerviciits
non specified incidental, lympohcytes and plasma cellsnormally present in wall, granularity, thickening, retention, Nabothian cysts.
Squamous metaplasia
Non-specific response to irritation, no malignant potential. no loss of polarity, no hyperchromasia
Endo cervical polyp
Pre- menopausal- hyperplastic glands, vascularity, edema, inflammation, no malignant potential.
Condyloma accuminatum
Etiology-STD Papillomatous, koilocytes, HPV 6, 11, no malignatn potentation
-flat- HPV 16, 19,31, 32- risk of carcinoma
-inactivated tumor supressor genes, Tp53, RB1 and activate cyclin E leading to uncontrolled proliferation,
Cerviacl Intraepithelial Neoplasia
Risk factors- HPV 16, 18, 31, 33, 35, 45 -high risk
- HPV 6, 11, 40, 54- low risk, not associated with invasive carcinoma
- sexual activity at a young age
- multiple sex partners
- parity greater than 7
- Chymdal infection
- smoking
- high viral load
- persistent SIL/HPV
CIN1- mild dysplasia, increased N:C ratio, pleomorphic, hyper chromatic nuclei
CIN3(severe dysplasia, carcinoma in situ) 22, 72% invasive carcinoma.
treatment- cryosurgery, electrocoagulation, laser, cone biopsy,(total squamocolumnar junction( stage 1A carcinomas (depth of invasion 5 mm and lateral extent 7mm-microinvasive.
Normal maturation of cervical cells
in normal cervical squamous epithelium, basal cells are small and cuboidal or columnar, with relatively high N:C ratio. Mitoses are rare and limited to the basal layer. As the cells rise in the epithelium, the cells rise in the epithelium, the nuclei shrink, the cytoplasm increases and becomes flat, the cells store glycogen.
Loss of maturation of cervical cells
orderly sequenc of maturation from bottom to top is lost beginning at the basal layer and progressing until the entir thickness of the peithelium is involved, nuclei remain large, cells remain cuboidal, glycogen is not stored, mitoses above basement membrane.
Pap Smears
annually until 3 consecutive negative PAP smears
- colposcopy vascular pattern, thickening
- schiller test- paint cervix with iodine, look for unstained pale patches
- 5% acetic acid applied to surface of servix and examed before and after application
follow up biopsy if smear abnormal.
Koilocytotic atypia
enlarged hyperchromatic, irregular nuclei, pernuclear halo.
Carcinoma cervix
majority squamous cell- rarely adenocarcinoma
gradual decline due to pap screening- CIN squamous intraepithelial lesion cytology
risk factors- HPV 16, 18 HSV-2 promoter
Associations- frequent coitus, increased sexual partners, prostitutes, multiparity, sexual partners formerly married to women with cancer cervix,
Rare in nuns, jews, moslems
clincical features- 30-50 years, irregular vaginal bleeding, postcoital bleeding, vaginal discharge, pyometron due to obstruction, colposcopic biopsy, surgery and radiation.
Morphology- invasive- exophytic, necrotic fungating mass, ulcerative, infiltrative.
Microinvasive carcinoma stage 1A
Depth- less than 5 mm from basement membrane of the epithelium and width no more than 7 mm, no lymphatics or blood vessels invasion, surgical excision is curative with a cone biopsy or hysterectomy
Stage Ia tumours can only be diagnosed in cone biopsies or hysterectomy specimens.
Morphology- squamous cell carcinoma with keratin perals, spread: confined to uterus, beyond uterus in pelvis or lower 1/3 of vagina, parametrium bladder, rectum , distant metastsis
Adenocarcinoma.
fourth decade mean- 20% history of CIN- asymptomatic, visible lesion- absent or rare. Multifocal 15 %
associated lesion- CIN- 50%-70%
Associated with HPV 16-18
Rare- 10-15%, HPV 16-18
endocervical canal- adenocarcinmoa in situ
obstruction- pyometron, hysterectomy.
Vagina- gartner’s duct cyst
remnants of mesonephric ducts- anterolateral wall of vagina
vaginal adenosis
girls 10 years whose mother’s received DES during pregnancy to prevent abortion endocervical ype glands in vaginal wall, inhibition of transformation of mullerian epithelium into squamous epithelium- some girls develop clear cell adenocarcinoma (10-35 years)
Squamous carcinoma
exophytic polypoidal fungating mass, pelvic or inguinal nodes based on location, poor prognosis.
Sarcoma botryoides
embryonal rhabdomyosarcoma- less than 5 years, bunch of grapes hanging in the vagina, highly malignant.
Bartholinitis
Acute inflammation on the inferior part of the labium major- bartholin gland- blocking due to inflammation.
-Abscess formation- strep, staph, gonococci, e. Coli
Condyloma accuminatum
Bulky, warty growth, may be multiple: hyperplasia, koilocytosis.
Leukoplakia- non-neoplastic epithelial disorders (NNED)
white patch- look for neoplastic potential
- lichen sclerosus- kraurosis vulvae postmenopausal- scaly plaques, think parchment like, dense collagen, very low malignant potential, autoimmune nature
- hyperplastic dystrophy- (Lichen simplex chronicus)- post menopausal, localized, hyperplastic epidermis, no malignant potential
VINIII Bowen’s disease
carcinoma in situ- old terminology in vulva
- leukoplakia
- reddish brown plaque
- needs surgical excision
Vulva intra epithelial neoplasia- VIN
flat, erythema, papule gray-white or reddish brown plaque, needs surgical excision.
- risk factors: HPV mainly 16, 18, 31, 33, age: mean 40 years, smoking, immunosuppressed patients,
-multifocal- 50-60% have synchronous lesions in the cervix, vagina, urethra, anus
-35-50% recur after local treatment
- some patients regress(younger age)
progression in invastion
- progression to invasion in 4-7% after treatment
- grade I, II, III, high risk HPV related may be associated with cervical carinoma
Carcinoma vulva
greater than 60 years old, plaque, nodule ulcer
- anterior 2/3 of labia majora
- squamous cell carcinoma
- inguinal and pelvic nodes.
Squamous cell carcinoma
- invasive
- - ulcer with rased edges base of right labium minorum
