Female Reproductive System Flashcards
What is endometriosis and how does it present histologically?
presence of endometrial glands and stroma outside the uterus
There are scattered endometrial type glands with surrounding endometrial type stroma.
What are the common sites of endometriosis?
1) Ovaries
2) uterine ligaments
3) rectovaginal septum
4) cul de sac
5) pelvic peritoneum
6) serosa of the large and small bowel and appendix
7) mucosa of the cervix, vagina, and fallopian tubes, and
8) laparotomy scar
What are the clinical features of endometriosis?
• Dysmenorrhea (painful menstruation)
• Dyspareunia (pain with intercourse)
• Pelvic pain - intrapelvic bleeding and periuterine adhesions.
• Menstrual irregularities
• Infertility - 30% to 40% of women
What is the pathogenesis of endometriosis?
1) Regurgitation theory ( Retrograde menstruation)
2) “Benign” metastasis theory – spread through blood vessels and lymphatic channels
3) Metaplastic theory – coelomic epithelium (Mesothelium) – Mullerian ducts
4) Extrauterine stem/progenitor cell theory -stem/progenitor cells from the bone marrow differentiate into endometrial tissue
What are the complications and risks of endometriosis?
• Periodic/cyclical bleeding - extrinsic cyclic (ovarian) + intrinsic hormonal stimulation - red-blue to yellow-brown appearance beneath the mucosal and/or serosal surfaces
• organizing hemorrhage -> extensive fibrous adhesions in tubes, ovaries, obliteration of pouch of Douglas.
• Ovaries - large cystic masses - contain brown fluid from previous
hemorrhage (chocolate cysts or endometriomas)
• Risk of malignancy – commonly endometrioid and clear cell carcinoma
What is adenomyosis and how would it present histologically?
the presence of endometrial tissue within the uterine wall (myometrium)
Scattered islands of endometrial glands and stroma are seen scattered in the myometrium.
What is the treatment of endometriosis?
• Hormonal treatments – supress oestrogen
(OCP/Progesterone/GNRH agonists)
• Surgery -preserve fertility – laproscopic diathermy/laser ablation
• Surgery – completed family – hysterectomy and bilateral salpingo-oophorectomy
What is the cervical cancer screening programme, when is it offered and what are the steps?
NHS Cervical Screening Programme (NHSCSP)- available to women and people with a cervix aged 25 to 64 in England
25-49 years – every 3 years
50-64 years – every 5 years
STEP 1
Cervical Smear taking- detects changes in the squamous and glandular cells
STEP 2
HR HPV testing (PCR)
STEP 3
Cervical cytology- smear assess under microscope if positive for HR HPV
STEP 4
Colposcopy with biopsy +/- cervical loop
What is the role of HPV?
• Human papilloma virus – DNA oncogenic virus - 99% of cervical cancers – strongest risk factor
• High risk HPV (HR HPV) subtypes -15 subtypes – HPV 16 accounts for 60% of the cervical carcinoma cases, HPV 18 another 10% of cases
• HR HPV – can cause cancers at other sites - vagina, vulva, penis, anus, tonsil, and other oropharyngeal locations.
• low oncogenic risk HPVs - sexually transmitted ano-genital warts (condyloma acuminatum)
What is the transformation zone?
What is colposcopy?
- binocular microscope
- acetic acid coagulates protein and the abnormal cells, which have more protein, appear ‘aceto-white’
What is cervical intraepithelial neoplasia (CIN)?
• Squamous cervical precursor lesion/ Carcinoma in situ – precursor lesion to squamous cell carcinoma
• In UK 3 grades
CIN 1 (mild dysplasia)
CIN 2 (moderate dysplasia)
CIN 3 (severe dysplasia)
• CIN 2 and CIN 3 – high grade – risk of progression to invasive carcinoma – therefore require treatment
Image:
1- normal squamous epithelium
2- CIN1 nuclei enlarged, hyperchromatic nucleus, koilocytes
3- CIN2
4- CIN3
What is the treatment of CIN?
• CIN 1 (low grade) – surveillance as low grade lesions can spontaneously resolve
• CIN 2 and CIN 3 – Large loop excision of the transformation zone (LLETZ)
• Followed up post LLETZ – “Test of cure” – HR HPV
What is cervical glandular intraepithelial neoplasia (GCIN)
• Precursor lesion to cervical adenocarcinoma
• High grade by definition and requires treatment
What is the HPV vaccine for?
HPV vaccine protects against
• cervical cancer
• some mouth and throat cancers
• some cancers of the anus and genital areas
• In UK, Gardasil vaccine offered to all girls and boys in year 8
What are the key histological features of squamous cell carcinoma?
High grade CIN which cases basement membrane invasion
Type 1 vs type 2 endometrial cancers (age, clinical setting, morphology, precursor lesions and behaviour)
What are the stages in development of type 1 endometrial cancers?
What is endometrioid endometrial Adenocarcinoma?
• Closely resemble normal endometrium
• Gland forming tumour
• Usually express Oestrogen and progesterone receptors
• Grade 1 and 2 endometrioid adenocarcinoma generally have mild to moderate cytological atypia – low grade
• Grade 3 endometrioid adenocarcinoma is considered high grade
What is serous endometrial Adenocarcinoma?
• Papillary architecture (may have glandular architecture)
• Display high grade cytological atypia
• Tumours have mutations in TP53 genes
What is clear cell endometrial Adenocarcinoma?
• Can have solid, papillary and glandular architecture
• Characterised by the presence of “clear cells”
• Oestrogen receptor negative (ER-)
• High grade aggressive tumour
What is the link between endometrial cancer and lynch syndrome?
• 2% to 5% of endometrial cancers - inherited susceptibility
• Lynch syndrome/hereditary nonpolyposis colorectal cancer (HNPCC) syndrome
• Autosomal-dominant inheritance -> germline mutation in one of the DNA mismatch repair genes
• Lynch syndrome – lifetime risk of developing endometrial cancer – 40-60%
• Other sites - colorectal, gastric, ovarian, pancreas, ureter, renal pelvis, biliary tract
What is the treatment of endometrial cancer?
• Standard surgery - total hysterectomy with bilateral salpingo-oophorectomy
• High grade serous carcinoma – omentectomy
• High grade carcinomas – Sentinel lymph node biopsy/pelvic, para-aortic lymphadenectomy
• Post surgery – adjuvant radiotherapy or chemotherapy
What are the 3 cell types in a normal ovary?
Three cell types in the normal ovary:
(1) EPITHELIAL majority of ovarian tumors (90% of ovarian cancers)
(2) GERM CELLS pluripotent germ cells
(3) SEX CORD STROMAL CELLS
