Female Reproductive System- Fung Flashcards
What is the external female genitalia? what does it encompass? What kind of epithelium is it lined by?
vulva
- most hair-bearing skin and mucosa (external to the hymen)
i. e labia majora, labia minora, mons pubis, vestibule - squamos epithelium
What are the common disorders of the vulva?
inflammatory
- contact dermatitis
- eczymatous dermatitis
- infections
Where do you find bartholin glands and what does it do?
one on each side of the vaginal canal and produces mucus like fluid that drains via ducts into the lower vestibule.
What is bartholin cyst and what causes it? Who does it usually occur in?
cystic dilation of the bartholin gland, arises due to infammation and obstruction of gland
-women of reproductive age
How does a bartholin cyst present?
unilateral, painful cystic lesion at the lower vestibule adjacent to the vaginal canal
What is this:
Characterized by thinning of the epidermis and fibrosis (sclerosis) of the dermis.
What can it be caused by?
Is it benign or malignant?
Lichen sclerosis
autoimmune etiology
benign BUT CAN CAUSE increase risk of squamos cell carcinoma.
How does Lichen sclerosis present and who does it commonly present in?
Presents as a white patch (leukoplakia) with parchment-like vulvar skin
-Most commonly seen in postmenopausal women
What is this:
hyperplasia of the vulvar squamos epithelium
How does it present?
Lichen simplex chronicus
leukoplakia with thick, leathery vulvar skin
What is lichen simplex chronicus associated with?
Is it malignant or benign?
chronic irritation and scratching
benign; no increased risk of squamos cell carcinoma
What is this:
warty neoplasm of vulvar skin, often large.
Most commonly due to (blank) or (blank).
Condyloma HPV type 6 and 11 Secondary syphilis (less common) both are seually transmitted.
What do you call a condyloma if it is caused by HPV 6 and 11? What will you find histologically in this?
Condyloma acuminatum
-Koilocytes (hallmark of HPV infected cells)
What do you call a condyloma if it is caused by a secondary syphilis?
condyloma latum
Vulvar intraepithelial neoplasia has (Blank) levels of dysplasia?
VIN 1
VIN 2
VIN 3
A vulvar carcinoma arises from (blank) lining the vulva. Is this common or rare? How does it present?
Who is it most commonly seen in?
What is the etiology?
- squamos epithlium
- rare (accounts for only small percentage of female genital cancers)
- leukoplakia (biopsy required)
- HPV related or non-HPV related
HPV related vulvar carcinoma is due to high risk HPV types (blank and blank)
16 and 18
What are the risk factors for HPV related to carcinoma?
-mutiple partners, early first age of intercourse, generally occurs in women of reproductive age
Vulvar carcinoma arises from (blank), a dysplastic precursor lesions characterized by koilocytic change, disordered cellular maturation, nuclear atypic and increased mitotic activity
Vulvar intraeptihelial Neoplasia (VIN)
What are the 2 etiologies of vulvar carcinoma?
HPV-reated (VIN) Reactive changes (Lichen sclerosus)
What is pagets disease of the vulva characterized by? How does it present?
- malignant epithelial cells in the epidermis vulva
- erythematous, pruitic, ulcerated vulvar skin
(blank) represents carcinoma in situ, usually with no underlying carcinoma.
Pagets disease of the vulva
Paget disease of the nipple is also characterized by (blank) in the epidermis of the nipple but it is almost always associated with an underlying (blank)
malignant epithelial cells
carcinoma
How can you tell the difference between pagets and melanoma?
Paget cells are PAS+, Keratin+, and S100-
Melanoma is PAS-, Keratin-, and S100+
The vagina is a canal leading to the cervix. Mucosa is lined by (blank)
non-keratizing squamos epithelium
What is a clear cell caricnoma of the vagina? What can cause this?
malignant proliferation of glands with clear cytoplasms
DES (diethylstilbestrol)- associated vaginal adenosis
Vaginal carcinoma arises frorm (blank) epithelium lining the vaginal mucosa. Usually related to high risk (blank). Precursor lesion is (blank)
squamos
HPV
Vaginal intraepithelial neoplasia (VIN)
When squamos cell carcinoma of the vagina spreads to regional lymph nodes, cancer from the lower 1/3rd of the vagina goes to (blank) nodes
inguinal
When squamos cell carcinoma of the vagina spreads to regional lymph nodes, cancer from the upper 2/3rd of the vagina goes to (blank) nodes
iliac nodes
What is this:
focal persistence of columnar epithelium in the upper vagina.
NOTE: During development, squamos epithelium from the lower 1/3 of the vagina (derived from the urogenital sinus) grows upward to replace the columnar epithelium linng of the upper 2/3 of the vagina (derived from Mullerian ducts)
Who has increased incidence of this?
Adenosis
females exposed to diethylstilbestrol (DES) in utero
What is this:
malignant mesenchymal proliferation of immature skeletal muscle; rare.
Presents as bleeding and a grape-like mass protruding from the vagina or penis of a child (usually less than 5) also known as a sarcoma botyroides
Embryonal Rhabdomyosarcoma
(blank), the characteristic cell of embryonal rhabomyosarcoma, exhibits cytoplasmic cross striations and positive immunohistochemical staining for desmin and myogenin
Rhabdomyoblast
(blank) anatomicaly comprises the “neck” of the uterus. The cervix is divided into the (blank and blank). The (blank) is lined by non keratinizing squamos epithelium. The (blank) is lined by a single layer of columnar cells. The junction b/w exocervix and endocervix is called the (blank)
cervix
exocervix and endocervix
Exocervix
Endocervix
transformation zone
(blank) is a circular double-stranded DNA virus. Over 200 known types which are specific and tissue specific, Causes epithelial proliferations; warts to carcinoma
HPV (human papilloma virus)
HPV is sexually transmitted DNA virus that infects the (Blank) especially the (blank) in the transformation zone
lower genital tract
cervix
HPV iis usually eradied by acute (blank); persistent infection leads to an increased risk for (blank)
inflammation cervical dysplasia (cervical intraepithelial neoplasia,CIN)
Risk of cervical intraepithelial neoplasia (CIN), risk of CIN depends on HPV type, which is determined by DNA sequencing. High risk HPV types are (blank x 4) What are the low risk strands?
16, 18, 31, 33
6, 11
High risk HPV produces (blank and blank) proteins which results in increased destruction of p53 and Rb, respectively. Loss of tumor suppressor proteins increases the risk of (blank)
E6 and E7
CIN
Low risk HPV?
High risk HPV?
low risk: 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81
high risk: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, 82
What genes of HPV cause cancer?
E6 and E7
(blank) is characterized by koilocytic change, disordered cellular maturation, cellular atypia and increased mitotic activity within the cervical epithelium. CIN is divided into graders based on the extent of (bank) involvement by immature dysplastic cells,
Cervical Intraepithelial neoplasia (CIN)
epithelial involvement
CIN I involves (blank) of the thickness of the epithelium
CIN II involves (blank) of the thickness of the epithelium
CIN III involves (blank) than the entire thickness of the epithelium
(blank) involves the entire thickness of the epithelium
How does CIN classically progress? Is this progression inevitable?
in a stepwise fashion through CIN I, CIN II, CIN III, CIN IV and CIS to become invasive squamos cell carcinoma
no, the higher the grade of dysplasia the less likely it is to regess to normal. (CIN I often regresses)
What is this:
invasive carcinoma that arises from the cervical epithelium. Who is it most commonly seen in? How does it commonly present?
cervical carcinoma
Middle-aged women (40-50 y/o)
-vaginal bleeding, postcoital bleeding, cervical discharge
What is the key risk factor for cervical carcinoma?
High risk HPV infection
Secondary factors-smoking, and immunodeficiency (e.g cervical carcinoma is an AIDS-defining illness)
What are the most common subtypes of cervical carcinoma? Both types are related to (blank)
squamos cell carcinoma ( 80% of cases)
adenocarcinoma (15% of cases)
HPV
Advanced tumors often invade through the (blank) wall into the bladder, blocking the (blank). (blank) with postrenal failure is a common cause of death in advanced cervical carcinoma
anterior uterine
ureters
Hydronephrosis
When do you start screening and prevention of cervical carcinoma? How long does it take for CIN to become carcinoma? Dysplastic cells are classified as low grade (blank) or high grade (Blank).
21-29, every 3 years
10-20 years
CIN I
CIN II or CIN III
High grade dysplasia is chracterized by cells with (blank) nuclei and high (blank) ratio
hyperchromatic
nuclear to cyotplasmic ratios
An abnormal pap smear is followed by a confirmatory (blank)
colposcopy and biopsy
Does a pap smear reduce adenocarcinoma?
no
Immunizations are effective in preventing HPV infections.
The quadrivalent vaccine cover (blank x 4)
6,11,16,18
Antibodies generated against types 6 and 11 protect against (blank)
Antibodies generated against 16 adn 18 protect against (blank)
condylomas
CIN and carcinoma
B/w the ages of 30-65 how do you screen women for cervical cancer?
>65 ?
HPV and cytology “cotesting” every 5 years
no screening following adequate negative prior screening
(blank) is the mucosal lining of the uterine cavity
(blank) is the SM wall underlying the endometrium
Endometrium
Myometrium
Endometrium is (blank) sensitive. Growth of the endometrium is (blank) driven i.e the prolierative phase. Preparation of the endometrium for implantation is (blank) driven i.e secretory phase
hormonally
estrogen
progesterone
What is this:
secondary amenorrhea due to loss of the basalis and scarring
-result of overaggressive dilation and curettage (D & C)
Asherman syndrome
What is this: lack of ovulation
Results in an (blank) phase without a (blank) phase. Proliferative glands break down and shed resulting in (blank). Represents a common cause of dysfunctinal uterine bleeding, especially during (blank and blank)
Anovulatory Cycle
Estrogen driven proliferative
progesterone driven secretory
uterine bleeding
menarche and menopause
What causes acute endometriosis?
What is it usually do to?
How does it present?
bacterial infection of endometrium
retained products of conception (after delivery or miscarriages) cause bacterial collection
fever, abnormal uterine bleeding and pelvic pain
What is the chronic inflammation of the endometrium?
What is it characterized by?
Chronic endometritis
lymphocytes and plasma cells (PLASMA CELLS are necessary for diagnosis)
What are the causes of chronic endometritis?
retained products of conception
Chronic pevic inflammatory disease (chlamydia)
IUD
TB
How does chronic endometritis present?
abnormal uterine bleding, pain and infertility
What is this:
hyperplastic protrusion of endometrium
presents as abnormal uterine bleeding
What can it arise as a side effect form?
Endometrial polyp
Tamoxifen (has anti-estrogenic effects on the breast but weak pro-estrogenic effects on the endometrium)
What are the uterine causes of abnormal bleeding?
anovulatory cycles
polyps
hyperplasia
carcinoma
What is this:
endometrial glands and stroma outside of the uterine endometrial lining
What causes this?
Endometriosis
Retrogade menstruation with implantation at an ectopic site
What are the symptoms of endometriosis?
What do the nodules look lik?
dysmenorrhea (pain during menstruation) and pelvic pain; may cause infertility (endometriosis cycles just like normal endometrium)
-yellow-brown gun-powder nodules!
What is the most common site of endometriosis and what do you call it when it presents here? What can this lead to?
Ovaries
Chocolate cyst
Cancer
What is endometriosis also involving the uterine myometrium?
adenomyosis
What are all the places that endometriosis can effect?
- uterine ligaments (pelvic pain)
- pouch of douglas (pain w/ defecation)
- bladder wall (pain with urination)
- bowel serosa (ab pain and adhesions)
- fallopian tube mucosa (scarring increase, risk for ectopic tubal pregnancy)
What is hyperplasia of endometrial glands relative to stroma? What causes this?
Endometrial hyperplasia
-> unopposed estrogen (e.g. obesity, PCOS, estrogen replacement)
What are the symptoms of endometrial hyperplasia?
How do you classify it histologically?
postmenopausal uterine bleeding
based on architectural growth pattern (simple or complex) and the presence or abscence of cellular atypia
If you have endometrial hyperplasia what is the most important predictor for progression to carcinoma?
presence of cellular atypia
-simple hyperplasia with atypia results in progression to cancer (blank) of the time.
30%
-Complex hyperplasia with atypia results in progression to cancer (blank) percent of the time
<5%
What is the most common invasive carcinoma of the female genital tract? What does it do?
What are the symptoms?
What are the 2 distinct pathways that it arises from?
Endometrial carcinoma-
malignant proliferation of endometrial glands
- postmenopausal bleeding
- hyperplasia (75%) and sporadic (25%)
What is the most common cause of endometrial carcinoma?
What are the risk factors for this?
What is the average age of presentation?
What is histology like?
endometrial hyperplasia
- estrogen exposure
- early menarche/late menopause
- nulliparity
- infertility with anovulatory cycles
- obesity
60
endometroid
In the sporadic pathway of endometrial carcinoma, carcinoma arises in an (blank) with no evident precursor lesion
What is the average age of presentation?
What does histology look like?
atrophic endometrium
70 years
usually serous and is characterized by papillary structures with psammoma body formation; p53 mutation is ommon and the tumor exhibits aggressive behavior
An endometrioid cacrinoma is related to (blank). How is it graded? What are the mutations associated with endometrioid carcinoma?
- precursor hyperplasia
- FIGO
- PTEN and DNA mismatch repair gene mutations
T or F
Serous carcinoma is related to endometrial hyperplasia
F
Where does serous carcinoma occur?
What is the gene mutation associated with it?
in the fallopian tube and
p53 gene mutations
What are the pathologies associated with the myometrium?
adenomyosis
leiomyoma
leiomyosarcoma
What is this:
benign neoplastic proliferation of SM arising from myometrium; most common tumor in females
Leiomyoma (fibroids)
What are leiomyomas related to exposure of? Who are leiomyomas ommon in?
estrogen
premenopausal women
How do leiomyomas present?
multiple
enlarge during pregnany, shrink after menopause
-multiple well defined, white, whorled masses that may distort the uterus and impinge on pelvic structures
(blank) is usually asymptomatic; when present, symptoms include abnormal uterine bleding, infertility, and a pelvic mass
Leiomyoma (fibroids)
What is this:
malignant proliferation of SM arising from the myometrium
ARises de novo, DO NOT ARISE FROM LEIOMYOMAS
Who does it present in?
Leiomyosarcoma
postmenopausal women
Gross exam of a leiomyosarcoma shows a (blank) lesion with areas of (blank) and (Blank) histological features include (blank x 3)
single
nerosis and hemorrhage
-necrosis, mitotic activity, and cellular atypia
What causes salpingitis?
- Chlamydia
- Gonorrhea
- Pelvic inflammatory disease
What is this:
implantation of fertilized ovum at a site other than the uterine wall; most ommon site is the lumen of the fallopian tube.
What is the key risk factor?
Ectopic pregnancy
scarring (secondary to pelvic inflammatory disease or endometriosis)
What is the classic presentation of ectopic pregnancy?
Is this an emergency?
- lower quadrant abdominal pain a few weeks after a missed period
- yes, a surgical emergency; major complications are bleeding into fallopian tube (hematosalpinx) and rupture
What is the function unit of the ovary?
A follicle consists of an oocyte surrounded by (blank and blank) cells
follicle
granulosa and theca cells
(blank) acts on theca cells to induce androgen production.
(blank) stimulates granulosa cells to convert androgen to estradiol (drives the proliferative phase of the endometrial cycle).
After ovulation, the residual follicle becomes a (blank), which primarily secretes (blank) (drives the secretory phase which prepares the endometrium for a possible pregnancy)
LH
FSH
corpus luteum
progesterone
Hemorrhage into a corpus luteum can result in a (blank) cyst especially during early pregnancy
hemorrhagic corpus luteal cyst
What are three types of ovarian cysts?
follicular cysts
luteal cysts
polycstic ovaries
What is this:
benign tumors composed of a single cyst with a simple, flat lining; most commonly arise in premenopausal women (30-40 y/o)
cystadenomas
What are broderline tumors?
have features in between benign and malignant tumors- better prognosis than clearly malignant tumors, but still carry metastatic potential
What is the most common type of ovarian tumor? What are the 2 most common subtypes?
surface epithelial tumors
- serous tumors (watery fluid)
- mucinous tumors (mucus-like fluid)
Mucinous and serous tumors can be benign, borderline or malignant.
Benign tumors are called (blank), what do these look like?
Malignant tumors are called (blank)
cystadenomas-single cyst with a simple, flat lining
cystadenocarcinomas-composed of complex cysts with a thick shaggy lining: most commonly arise in postmenopasal women 60-70 years old
What is this:
composed of bladder-like epithelium and are usually benign
Brenner tumor
(blank) mutation carriers have an increased risk for serous carcinoma of the ovary and fallopian tube.
BRCA1
-BRCA1 carriers often elect to have a prophylactic salpingo-oophorectomy (along with prophylatic mastectomy due to increased risk for breast cancer)
(blank) tumors are composed of endometrial-like glands and are usually malignant. May arise from endometriosis. 15% of endometrioid carcinomas of the ovary are associated with an independent endometrial carcinoma (endometrioid type).
Endometrioid tumor
What are complications of the placenta?
-infections Trophoblastic Disease -complete mole -incomplete mole -choriocarcinoma
What is this:
neoplastic proliferation of granulose and theca cells. Often produces estrogen; presents with signs of estrogen excess.
granulosa cell tumor
If you get a granulosa cell tumor before puberty what will you get?
If you get a granulosa tumor during reproductive age what will you get?
If you get a granulosa cell tumor during postmenopause what will this cause?
precocious puberty
menorrhagic or metrorrhagia
Postmenopause (most common setting for granulosa cell tumors)-> endometrial hyperplasia with postmenopausal uterine bleeding
Are granulosa cell tumors malignant?
yes but minimal risk for metastasis
What does the gardasil shot cover and what ages and sex should get this?
Types 6, 11, 16, 18
Ages 9-26
Females and males
What oes the cervarix shot cover and what ages and sex should get this?
Types 16 and 18
Ages 9-25
Females only
What makes up 90% of malignant ovarian tumors? What age group is affected by this? What are the types of this?
surface epithelial cells
20+ years
-serous tumor, mucinous tumor, endometroid tumor, clear cell tumor, brenner tumor, cystadenofibroma
What ovarian tumor type makes up to 3-5% of malignant ovarian tumors and affects 0-25+ year olds? What are the types?
Germ cell
-teratoma, dysgerminoma, endodermal sinus tumor, choriocarcinoma
What ovarian tumor type makes up to 2-3% of malignant tumors and 5-10% overall ovarian tumors. It affects all ages. What are the types?
Sex-cord stroma tumor
-fibroma, granulosa-theca cell tumor, sertoli leydig cell tumor
What percent of tumors of the ovary are metastasese?
5%
What are the three main types of ovarian surface epithelial tumors?
- serous (adenoma, borderline, carcinoma)
- mucinous (adenoma, borderline, carcinoma)
- endometrioid (adenoma, borderline, carcinoma)
