Gyn and Breast Flashcards
Diseases of the vulva and vagina are most often
inflammatory, rendering them more uncomfortable than serious. Malignant neoplasia is uncommon.
Vulvitis, inflammation of the vulva, can be caused by
infection, contact irritant, allergic reaction, or traumatic injury.
Vulvitis
A variety of pathogens has been associated and often
sexually transmitted.
Vulvitis
In addition, the moist environment supports
fungal infections (Candida albicans).
Vulvitis
Contact irritation or allergic reaction may be related to a number of
agents, including soaps, perfumes, deodorants, clothing textiles, etc.
Vulvitis
Scratching-induced trauma secondary to
associated pruritus (itching) may exacerbate the primary condition.
Vaginitis, inflammation of the vagina, is relatively common and results in production of
vaginal discharge (leukorrhea).
Vaginitis
A variety of organisms have been associated, including
bacteria, fungi, and parasites.
Vaginitis
Many associated orgs are normal commensal organisms that become
pathogenic under certain circumstances, such diabetes, systemic antibiotic therapy (which disrupts normal microbial flora), or immunodeficiency.
Vaginitis
Candida albicans and Trichomonas vaginalis are
frequent offenders.
The cervix must act as a
barrier to prevent entrance of air and microflora into the uterus but at the same time permit escape of menstrual flow and be capable of dilation to accommodate childbirth. This location represents the site of one of the most common cancers in women.
Cervicitis is inflammation of the
cervix, is extremely common and is associated with purulent vaginal discharge.
Cervicitis
The process may be secondary to
specific infections such as candida, trichomonas, chlamydia, gonorrhea, syphilis, HPV, or herpes; but more commonly, it arises from nonspecific infections and is seen in virtually every multiparous woman.
Cervicitis
It may be
acute or chronic.
Cervicitis
In severe lesions, it is difficult to
clinically distinguish from carcinoma and biopsy is required for diagnosis.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
At one time, this cancer was the
leading cause of cancer deaths in women; but currently, it ranks 14th (12,820 cases and 4,200 deaths predicted in the US in 2017).
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
In contrast, the discovery of preinvasive intraepithelial cervical neoplasia has
increased significantly.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
The Papanicolaou cytologic test (Pap smear, 1940) is responsible for the
increased discovery of these earlier lesions, most of which are cured by effective therapy.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Exfoliated cells collected from the cervix are processed with a
special stain (Papanicolaou stain). This allows identification of precancerous (dysplastic) cytological features. This test is inexpensive, however, false positives/negatives are recognized and additional HPV testing is now standard with abnormal Pap tests.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Several factors tend to increase the prevalence; the four most important are
early onset of coitus, multiple sexual partners, a male partner with multiple previous sexual partners, and persistent infection with “high-risk” HPV (16, 18).
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
HPV is present in
85-90% of cervical neoplasia.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
In spite of this correlation, research has shown that
something more than viral action must be involved in the evolution of invasive cervical carcinoma.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Approximately 75-95% of cervical cancers present as
squamous cell carcinoma.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Most (perhaps all) invasive cervical carcinomas arise from
precursor lesions termed cervical intraepithelial neoplasia (CIN).
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Not all CIN progress to
cancer.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
The cancer is now known to be the end stage of a continuum of
progressively more dysplastic changes in which one slowly progresses on to the next stage; this progression evolves slowly over the course of many years.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Cervical intraepithelial neoplasia is
graded I (Mild) – III (Carcinoma in situ); the higher the grade, the greater the likelihood of progression to carcinoma.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Although probable in many instances, progression to
carcinoma is not inevitable, even in higher-grade lesions.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Screening for cervical neoplasia via cytology (Pap smear) and cervical examination (colposcopy) remaining the
standard approach.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Abnormalities revealed during a
colposcopy examination following application of acetic acid appear as white patches.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Upon discovery of a high-grade lesion,
biopsy always is necessary to confirm the cytologic findings and to evaluate for invasion.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
CIN typically is
asymptomatic.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Once invasive, the main symptoms of the carcinoma are
irregular vaginal bleeding, leukorrhea, painful coitus and dysuria.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Treatment of cervical carcinoma is
surgery and/or radiation and chemotherapy; in situ lesions have a 100% survival rate, while the prognosis of invasive lesions correlates directly with the stage.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Deeply invasive stage 4 carcinomas have only a
10% survival.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Recent reports indicate that chemotherapy may
improve survival in advanced cases.
Cervical Intraepithelial Neoplasia and Carcinoma of the Cervix
Introduction of HPV vaccines (now available: Gardasil-9: 6, 11, 16, 18, 31, 33, 45, 52, 58) have been shown effective in decreasing the frequency of genital warts, condylomas (low-risk HPV types 6, 11) and CIN and are expected to decrease cancers associated with these
HPV serotypes, possibly including oropharyngeal/tonsillar cancers in both men and women.
• Uterine corpus is responsible for majority of female
reproductive tract diseases
Uterine • Disorders often
chronic and recurrent
Structure of Uterus
• Myometrium o Muscular wall of the uterus o Composed of interlacing bundles of smooth muscle • Endometrium o Glandular lining of the uterus o Changes under hormonal influence
• Myometrium
o Muscular wall of the uterus
o Composed of interlacing bundles of smooth muscle
• Endometrium
o Glandular lining of the uterus
o Changes under hormonal influence
By far, the most common complaints related to disorders of the uterus are
pelvic pain and abnormalities in menstrual function: menorrhagia (profuse or prolonged bleeding), metrorrhagia (irregular bleeding between periods), and dysmenorrhea (unusually painful menstrual bleeding).
Uterine disorders;
Common causes include, but are not restricted to
endometriosis, endometrial hyperplasia, leiomyomas, and endometrial carcinoma.
Endometriosis is the presence of endometrial glands and/or stroma in locations
other than the uterine lining (10% women in reproductive years, 50% of women with infertility).
Endometriosis
The most common site is in the
pelvis (ovaries, uterine ligaments, tubes and rectovaginal septum).
Endometriosis
Less common sites include the
peritoneal cavity, umbilicus, lymph nodes, lungs and even heart or bone.
Endometriosis
Although the causation is unknown, the most accepted
“regurgitation” theory proposes that menstrual endometrium backflows through the fallopian tubes and also somehow enters the local venous and lymphatic systems.
Endometriosis
Sites of endometriosis are
functional and undergo cyclic bleeding.
Endometriosis
With long-standing disease,
seepage and organization of the blood leads to widespread fibrosis and adherence of pelvic structures; severe dysmenorrhea (painful menstruation), dyspareunia (painful intercourse), dysuria, pain upon defecation, and pelvic pain may occur secondary to intrapelvic bleeding and periuterine adhesions.
Endometriosis
Large blood-filled cysts on the ovaries transform to
“chocolate” cysts as the blood ages.
Endometriosis;
Involvement of the oviducts and ovaries may result in
sterility.
Endometrial hyperplasia refers to
hyperplasia of the epithelial lining of the uterus that is thought secondary to an excess of estrogen.
Endometrial hyperplasia
The process often arises in
perimenopausal women from obesity (estrogen synthesis in fat deposits), failure of ovulation, administration of estrogen or from estrogen-secreting tumors.
Endometrial hyperplasia
Endometrial hyperplasia produces
abnormal bleeding; but more importantly, it is a forerunner to endometrial carcinoma.
Endometrial hyperplasia
It progresses through stages of
mild, moderate and atypical hyperplasia which often then progresses to carcinoma.
Endometrial hyperplasia
D & C is required to control the
bleeding and to rule out carcinomatous transformation.
Endometrial hyperplasia
In addition, any correctable underlying
causation should be resolved.
Uterine Tumors
• May arise from
endometrium or myometrium
Uterine Tumors
• All produce
abnormal uterine bleeding
Uterine Tumors
• Most common:
o Endometrial polyps
o Smooth muscle tumors
o Carcinomas
Leiomyomas are benign tumors of
myometrial smooth muscle origin.
Leiomyomas
When arising in the uterus, these neoplasms historically have been called
fibroids.
Leiomyomas
These arise from the ——— in 30-50% of women during active reproductive life; this makes leiomyoma the most common benign tumor in females.
myometrium
Leiomyomas
Although the cause is unknown, they seem to be
estrogen dependent, as evidenced by their rapid growth during pregnancy and the tendency to regress after menopause.
Leiomyomas
Uterine leiomyomas are often
asymptomatic and discovered during routine pelvic exams.
Leiomyomas
Occasionally, they produce
menorrhagia.
Leiomyomas
Multiple leiomyomas are
not rare.
Endometrial Carcinoma:
Carcinoma of the endometrium arises from the
uterine lining and is the most frequent cancer of the female genital tract in the Western world (due to decreased prevalence of cervical carcinoma secondary to PAP test).
Endometrial Carcinoma
Most cases are diagnosed between the ages of
55-65 and are very uncommon prior to the age of 40.
Endometrial Carcinoma
The cancer tends to arise in
two clinical settings, each associated with a specific type of endometrial carcinoma: perimenopausal women with evidence of estrogen excess (endometrioid carcinoma, more common type) and in older women with endometrial atrophy (serous carcinoma).
Endometrial Carcinoma
The majority of these cancers appear to be associated with
increased estrogen stimulation with similar risk factors as endometrial hyperplasia.
Endometrial Carcinoma
The most common early symptoms are
leukorrhea and irregular bleeding, a red flag in postmenopausal women.
Endometrial Carcinoma
Fortunately, these are
late-metastasizing cancers, but dissemination can occur to regional nodes and more distant sites like the liver and lungs.
Endometrial Carcinoma
Radiotherapy and surgery are the
standard of care with the addition of antiestrogen chemotherapy for disseminated cases.
Endometrial Carcinoma
If localized to the body of the uterus, 5-year survival is
90%, but this drops to 20% once it has spread outside of the uterus (Stage III and IV).
DISORDERS OF THE OVARIES
Solitary non-neoplastic cysts of the ovaries are common, but generally
not serious.
Disorders of the ovaries
polycystic ovarian disease causes
significant problems for many women.
Polycystic ovarian disease is a common
hormonal disorder affecting 5-10% of females of reproductive age.
Polycystic ovarian disease
It is generally diagnosed after
menarche in teenage girls or young adults.
Polycystic ovarian disease
The condition was named due to the presence of
multiple cystic follicles in ovaries, resulting in increased size of ovaries and excess production of androgens and estrogens.
Polycystic ovarian disease
While there seems to be a genetic influence, the cause of this disorder is
incompletely understood.
Polycystic ovarian disease
Patients may present with
delayed or absent menstruation, oligomenorrhea, hirsutism (increased body hair), acne, fertility problems, and obesity.
Polycystic ovarian disease
These women are also at increased risk fo
r type II diabetes and cardiovascular disease.
Polycystic ovarian disease
——– is the most significant disease with carcinoma of the ovaries accounting for more deaths than cancers of the cervix and endometrium combined. This is the fifth leading cause of cancer deaths in women
Neoplasia
Ovarian Carcinoma
Ovarian cancers come in a wide variety of
histogenic types.
Ovarian Carcinoma
The surface epithelial variants account for
90% of ovarian cancers, with less common varieties also produced by the germ cells and sex-cord stroma.
Ovarian Carcinoma
Several risk factors for ovarian cancer have been recognized, with the two most prominent being
nulliparity and family history (5-10% of cases → Mutations of BRCA genes (BRCA1, BRCA2 = increase risk for breast and ovarian cancer).
Ovarian Carcinoma
Use of oral contraceptives appears to
reduce the risk somewhat.
Ovarian Carcinoma
The clinical presentation of these tumors is remarkably similar. Most are
asymptomatic until they become large enough to cause local pressure symptoms.
Ovarian Carcinoma
The prognosis of invasive ovarian tumors depends heavily on the
stage of the disease at the time of diagnosis.
Ovarian Carcinoma
For those cancers that have penetrated the capsule, the 10-year survival is less than
15%.
Ovarian Carcinoma
Approximately 22K new cases of ovarian cancer will be diagnosed in the US
in 2017; of these patients, close to 14K will die of their disease.
Teratomas of the ovary are tumors which develop from
differentiation of totipotential germ cells into mature tissues which represent all three germ layers: ectoderm, mesoderm, and endoderm.
Teratomas
These tumors have a tendency to arise in the
first two decades of life, and the earlier onset the greater the likelihood of malignancy.
Teratomas
Fortunately, at least 90% of these germ cell neoplasms are
benign mature cystic teratomas.
Teratomas
Usually, these cysts contain an
epidermal appearing cyst lining with adnexal skin appendages (hair follicles, sebaceous glands, sweat glands), hence the common designation of dermoid cysts.
Teratomas
Most are discovered incidentally in young women on
abdominal scans or radiography.
Teratomas
These tumors often contain
hair, bone, cartilage, bronchial or gastrointestinal epithelium, and even teeth!
BREAST DISORDERS
Disorders of the female breast are extremely common. In a large study of patients with breast complaints, 30% had no breast disease, 40% had fibrocystic disease, 10% had carcinoma, 7% had fibroadenomas and the remainder had a
miscellany of benign lesions. The discussion will be limited to the three most frequent abnormalities of the breast.
BREAST DISORDERS
Fibrocystic changes apply to
breast alterations which arise as an exaggeration and distortion of the cyclic breast changes that occur normally in the menstrual cycle.
BREAST DISORDERS
Fibrocystic changes consist of
overgrowths of the fibrous stroma, the epithelial elements or a proliferation of both.
BREAST DISORDERS
All tend to arise during
reproductive life but may persist after menopause.
BREAST DISORDERS
The lesions frequently are
bilateral and/or multiple.
BREAST DISORDERS
They sometimes produce masses requiring
differentiation from cancer.
BREAST DISORDERS
The great majority of these lesions do not
predispose to cancer.
BREAST DISORDERS
However, there is a slightly increased risk with
florid ductal hyperplasia; and if the hyperplasia is atypical, there is a significant increased risk.
BREAST DISORDERS
Fibroadenoma is the most common
benign tumor of the female breast and usually appears in prepubertal girls and young women, with the peak prevalence in the third decade.
BREAST DISORDERS
They result from increased
estrogen.
BREAST DISORDERS
These tumors are
encapsulated and comprised of both glandular epithelium and fibrous tissue.
BREAST DISORDERS
They usually appear as a
solitary, discrete, freely movable nodule (1-10 cm in diameter).
BREAST DISORDERS
Biopsy is mandatory to verify its
benign nature.
Carcinoma of the breast:
Carcinoma of the breast arises from the
glandular (and ductal) structures of the breast, and many histologic variants are seen.
Carcinoma of the breast
Breast carcinoma was the number one cause of cancer deaths in women until
1986, when the increased prevalence of smoking caught up with females and lung cancer became number 1.
Carcinoma of the breast
Of those women that develop breast cancer (253,00 US cases in 2017), approximately
one fourth will die of their disease.
Carcinoma of the breast
It is the 2nd leading cause of
cancer related death in women (41,000 deaths in US for 2017).
Carcinoma of the breast
Genetic factors, environmental influences (e.g. Exposure to ionizing radiation, diet, reproductive patterns, nursing habits, etc.) and hormonal influences (e.g. Prolonged exposure to exogenous estrogens) have been i
mplicated in the etiology.
Carcinoma of the breast
About 10% of breast cancers are thought to be related to
specific inherited mutations.
Carcinoma of the breast
In those cases related to specific inherited mutations (Majority seen with BRCA1, BRCA2 genes), the cancers appear in women under
40 years of age and more often are bilateral.
Carcinoma of the breast
The lifetime risk of female breast cancer is
one in eight with 75% occurring in individuals over the age of 50
Carcinoma of the breast
Early lesions are
freely movable, discrete, non-tender masses and most are found by self-examination.
Carcinoma of the breast
Much less often, an occult lesion is detected by a
routine mammogram (Calcification or soft tissue density).
Carcinoma of the breast
Most are identified in the
upper outer quadrant but lower inner quadrant and central lesions have lowest 5 yr survival (tumors tend to be larger by the time of detection).
Carcinoma of the breast
The tumor has a tendency to become adherent to the body wall with
fixation of the lesion.
Carcinoma of the breast
Adherence to the overlying skin results in
retraction or dimpling of the nipple (often the first indication of a lesion).
Carcinoma of the breast
Tumor blockage of the lymphatics can result in
thickened skin which resembles the surface of an orange (peau d’orange).
Carcinoma of the breast can be classified as
ductal carcinoma (arising from ductal epithelium) or lobular carcinoma (arising from glandular acini).
Carcinoma of the breast
Both have noninvasive precursor stages, termed ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS), in which the
neoplasm has not penetrated the basement membrane and thus has not invaded or infiltrated the connective tissue stroma.
Carcinoma of the breast
Current therapeutic approaches include combinations of
simple mastectomy or segmental resection of the mass (lumpectomy) with or without lymph node dissection, postoperative irradiation and/or chemotherapy.
Carcinoma of the breast
The prognosis is
variable and dependent on several factors, including tumor stage.
Carcinoma of the breast
While metastases may occur many years after apparent therapeutic control of the primary lesion, the prognosis
improves with each passing year free of disease.
Carcinoma of the breast
Overall, the 10-year survival is
still no more than 50%.
