gyn path- female Flashcards
what type of HSV typically involves genital mucosa and skin?
hsv 2
during acute infection of HSV virus migrates to
regional nerve ganglia to establish lastent infection
is candidiasis an STD
no
symptoms of candidiasis
severe itching, erythema, swelling and curdlike thick, white discharge
in HSV what can trigger reactivation of virus and recurrence of lesions
any decrease in immune system
symptomatic candidiasis is typically a result of what?
disturbance in the patients vaginal microbial ecosystem
coloscopic appearance of trichomonas vaginalis
strawberry cervix
what are the symptoms of trichomoniasis?
STD - pts may be asymptomatic or present with yellow frothy vaginal discharge, discomfort, dysuria, and painful intercourse
main cause of bacterial vaginosis is
gardnerella vaginalis
is gardnerella vaginalis an STD
no
symptom of gardnerella vaginalis
Thin, green-gray, malodorous (fishy) vaginal discharge
PID is
an infection that begins in the vulva or vagina and spreads upward
infections after abortions and deliveries spread ___ and are inflammation of ___
upward from uterus through lymphatics or veins
deeper layers
what cell do you see microscopically in a gardnerella vaginalis infection?
clear cell
what types of infections can cause PID?
gonorrhoeae
chlamydia
infections after abortions and deliveries
chronic complications of PID
Chronic salpingitis with scarring of the tubal lumen and fimbria Infertility Ectopic pregnancy Pelvic pain Intestinal obstruction due to adhesions
acute complications of PID
Bacteremia
Acute peritonitis
Endocarditis, meningitis, arthritis
bartholin cyst result from
obstruction of duct by inflammatory process
can be up to 5 cm
what is leukoplakia?
opaque, white plaque like epithelial lesions
itching and scaling
lichen sclerosis is most commonly seen in what population?
post-menopausal patients
what is lichen sclerosis?
gross: smooth white plaques resembling porcelain or parchment
micro: marked thinning of epidermis, degeneration of basal cells, hyperkeratosis, sclerotic changes of superficial dermis, bandlike lymphocytic infiltrate in underlying dermis
lichen sclerosis is slight increased risk of developing
squamous cell carcinoma
what is squamous cell hyperplasia?
nonspecific condition resulting from rubbing or scratching of the skin
micro: acanthosis thickening of epidermis and hyperkeratosis
**not considered premalignant
HPV types associated with benign genital warts (low risk)
6 and 11
most common
HPV types associated with carcinoma and its precursors
16, 18, 31, 33
high risk
what is a koilocyte?
an abnormal squamous cell that indicates HPV infection
perinuclear clearing
wrinkled, enlarged, and hyperchromatic nucleus
contains HPV DNA
what is condyloma acuminatum?
benign genital wart
HPV 6 & 11
papillary, exophytic cores of stroma covered by thickened squamous epithelium
koilocytosis
not precancerous lesion
what are the squamous neoplastic lesions of the vulva?
Vulvar Intraepithelial Neoplasia (VIN) and Vulvar Carcinoma
how do vulvar carcinomas appear grossly?
basaloid and warty carcinomas 30%
keratinizing SCC 70%
related to high risk HPV - most commonly 16
what are the risk factors for classic VIN?
young age at first intercourse
multiple sexual partners
grades high VIN 2-3
low VIN 1
Keratinizing squamous cell carcinomas occurs most often in individuals with
long-standing lichen sclerosus
Keratinizing squamous cell carcinomas arises from
differentiated VIN or VIN simplex
tp53 mutations; 8th decade
unrelated to HPV
differentiated VIN is
Marked atypia of the basal layer of the squamous epithelium and normal-appearing differentiation of the more superficial layers
what are the types of glandular neoplastic lesions?
papillary hidradenoma
extramammary pagets disease
is papillary hidradenoma benign or malignant?
and what does it look like
benign
small tumors of the tubular ducts (apocrine sweat gland tumors)
histologically identical to intraductal papilloma of the breast
what is extramammary paget disease?
itchy, red, crusted, sharply demarcated, maplike area
confined to the epidermis
typically seen in isolation
Ddx: melanoma in-situ
what is septate
double vagina that arises from failure of mullerian duct fusion
also double uterus
what effects were caused when women were exposed to diethylstilbestrol?
non-neoplastic and neoplastic changes (clear cell carcinoma) liked to in-utero exposure
what is VAIN?
vaginal intraepithelial neoplasia
what can VAIN lead to?
squamous cell carcinoma
virtually all primary carcinomas of the vagina are squamous cell carcinomas associated with high risk HPVs, arises from VAIN
what is the greatest risk factor for VAIN and squamous cell carcinoma?
previous carcinoma of the cervix or vulva
where do vaginal lesions metastasize to?
lesions in the lower 2/3 metastasize to the inguinal nodes
lesions in the upper vagina spread to regional iliac nodes
what is embryonal rhabdomyosarcoma?
who is it frequent in
how do you treat it
bulky polypoid mass that can project out of vagina
composed of malignant embryonal rhabdomyoblasts
most frequently in children under age five
tx with surgery and adjuvant chemotherapy
what types of cells are found in the cervix?
exocervix - mature squamous epithelium
endocervix - columnar, mucus-secreting epithelium
transformation zone: area where the columnar epithelium abuts the squamous epithelium (HPV tends to affect this area)
what causes acute and chronic cervicitis?
bacteria - primarily lactobacilli
estrogen stimulates glycogenation of vaginal and cervical squamous cells
shedding provides glycogen substrate for endogenous bacteria
lactobacilli produce lactic acid which maintains the vaginal pH below 4.5 suppressing growth of other organisms
what are endocervical polyps?
Benign exophytic growth of fibromyxomatous stroma covered by mucus-secreting endocervical glands
Irregular vaginal bleeding
what are the most important factors in the development of cervical cancer?
high risk HPVs (16 and 18)
most HPV infections are transient and eliminated by
immune response
the ability of HPV to act as a carcinogen depends on what viral proteins?
E6 and E7
E7 binds to what and promotes its degradation?
Rb
E6 binds to what and promotes its degradation?
p53
what is HSIL and LSIL
High grade intraepithelial lesion and low grade
LSILS are how many times more common than HSILs?
10 times
all HSILS are considered to be what?
at high risk for progression to carcinoma
almost all cervical carcinomas caused by
high risk HPV
what is the treatment for cervical carcinoma?
most invasive cancers managed by hysterectomy with lymph node dissection and radiation and chemotherapy
what do most patients with advanced cervical cancer die of?
the consequences of local tumor invasion rather than distant metastases
when should a woman get her first pap smear?
at age 21 or within 3 years of onset of sexual activity and every 3 years after
after age 30 every 5 years if negative for HPV
what is the uterine endometrium?
glands embedded in a cellular stroma
glands embedded in a cellular stroma
bundles of smooth muscle that form the wall of the uterus
proliferative phase in endometrium
estrogen driven endometrium grows
secretory phase in endometrium
progesterone driven endometrium prepares for implantation
menstrual phase phase in endometrium
endometrium falls due to loss of progesterone
what can cause abnormal uterine bleeding?
lesions of endometrium or uterus (leiomyoma, adenomyosis, polyps, endometrial hyperplasia, endometrial carcinoma)
complications of pregnancy (ectopic, abortion trophoblastic disease)
what is dysfunctional uterine bleeding (DUB)?
due to hormonal disturbances, no morphologic cause
the most frequent cause of DUB is anovulation results in excessive endomentrial stimulation by estrogens that is unopposed to progesterone
why are the myometrium and endometrium relatively resistance to infections?
because of cervical barrier
what is acute endometritis
Uncommcon
Bacterial infection occurring after delivery, abortion or miscarriage
Often related to retained products of conception
what is chronic endometritis
and what causes it
plasma cells in stroma
Pelvic inflammatory disease Intrauterine devices Retained gestational tissue Tuberculosis (very rare) Idiopathic (about 15% of cases)
what is endometriosis
presence of ectopic endometrial tissue at a site outside of the uterus
most common sites endometriosis found
within the abdominal cavity (ovary), but occasionally it is found at distant sites
endometriosis is associated with which types of ovarian cancers?
endometrioid and clear cell types
how do you identify endometriosis grossly?
ovarian chocolate cysts (endometriomas)
subseroal and/or submucosal red-blue to yellow brown nodules
fibrous adhesions
need to see: endometrial glands, stroma, and hemosiderin
adenomyosis is
presence of endometrial tissue within uterine wall (myometrium)
can coexist with endometriosis
what are endometrial polyps?
masses of endometrium protruding into the endometrial cavity
may cause abnormal uterine bleeding
may contain functional or hyperplastic endometrium
endometrial carcinoma can arise within a polyp
what is endometrial hyperplasia and what can it lead to?
defined as an increased proliferation of the endometrial glands relative to the stroma
increased gland to stroma ratio
most commonly caused by unopposed estrogen stimulation
precursor to most common type of endometrial carcinoma
hyperplasia with and without atypia
what is the most common invasive cancer of female genital tract
carcinoma of endometrium
what are the two types of carcinoma of the endometrium?
type 1 - endometrioid
type 2 - serious, clear cell, MMMT - malignant mixed mullerian tumor
what are the characteristics of a type I endometrial carcinoma
endometrioid
80% of cases
55-65
unopposed estrogen stimulation obesity, diabetes, HTN, infertility
indolent, spreads via lymphatics
what are the characteristics of a type II endometrial carcinoma?
serous, clear cell, MMMT
65-75
endometrial atrophy
aggressive, intraperitoneal and lymphatic spread
endometrial carcinoma is often preceded by atypical hyperplasia and commonly has mutations in what genes?
MC mutations act to increase signaling through the PI3K/AKT pathway
PTEN
PIK3CA
KRAS
ARID1A
what are the most common mutations seen in serous carcinoma of the endometrium?
TP53
what is MMMT
malignant mixed mullerian tumor
carcinosarcoma
endometrial adenocarcinomas with a malignant mesenchymal component biphasic
clinically aggressive, 5 year survival 25-30%
what is true of both low and high grade stromal sarcomas of the endometrium?
both prone to late recurrences
low grade stromal sarcomas associated with what genes
JAZF1 and SUZ12
what is leiomyoma of the endometrium?
fibroids
benign smooth muscle neoplasn that can occur anywhere smooth muscle is normally found
about 25% of women of repro age have them
what is leiomyosarcoma?
malignant tumor of the endometrial smooth muscle
uncommon
40-60 y/o
mets to lungs bone brain
malignant neoplasms of fallopian tubes are metastases from
ovarian or uterine primaries
what is STIC?
serous tubal intraepithelial carcinoma
(tubal carcinoma in situ - p53)
precursor of ovarian high grade serous carcinoma
what are the most common lesions of the ovarian?
benign follicular cysts
what are follicular cysts?
unruptured graafian follicles or follicles that have ruptured and immediately sealed
what do luteal cysts look like?
bright yellow/orange luteal tissue, hemorrhage and fibrin in the center (may be confused with endometriosis)
what is PCOS?
complex endocrine disorder characterized by hyperandrogenism, menstrual abnormalities, polycystic ovaries, chronic anovulation, and decreased fertility
**dysregulation of enzymes involved in androgen biosynthesis and excessive androgen production
why is there a disproportionate number of deaths from cancer of female genital tract?
bc most ovarian cancers have spread beyond the ovary by the time of diagnosis
fifth most common cause of cancer death in women
what are the different classifications of ovarian tumors?
surface epithelial tumors
germ cell tumors
sex cord stromal tumors
metastatic tumors
what are the three major types of surface epithelial tumors in women?
serous
mucinous
endometrioid
(classified as benign, borderline, and malignant)
what determines the stage of ovarian tumors?
extent of spread outside the ovary
ovarian tumors associated with BRCA1 and 2 mutations are almost always associated with what?
serous carcinoma and TP53 mutations
low and borderline serous tumors have associations with what mutations?
high grade serous tumors have associations with what mutation?
low and borderline - KRAS, BRAF, HER2
high - TP53
serous carcinomas have a spread where?
peritoneal surfaces and omentum
ascites
5 year survival does not mean cure
what is the consistent genetic alteration in mucinous tumors?
KRAS
what does mucinous tumors look like
Large cystic masses; multiloculated filled with sticky, gelatinous fluid
only ___ of primary mucinous cystadenomas and mucinous are bilateral
5% *****
what is pseudomyxoma peritonei?
extensive mucinous ascites, cystic epithelial implants on the peritoneal surfaces, adhesions, frequent involvement of ovaries
(related to mucinous ovarian tumors)
endometrioud ovarian tumors resemble
endometrious adenocarcinoma of endometrium
clear cell carcinoma
rare
aggressive, extremely poor diagnosis
in association with endometriosis
brenner tumor
uncommon
neoplastic epithelial cells resembling urothelium
the majority of female germ cell tumors are of what type?
mature cystic teratomas in women of reproductive age
what are the three catagories of teratomas?
mature (benign)
immature (malignant)
monodermal or highly specialized
what is another name for a mature teratoma?
dermoid cyst (almost always lined by skin-like structures)
in mature teratomas you see unilocular cyst containing
hair, sebaceous debris, teeth, and mature brain tissue
immature malignant teratomas is presence of
immature elements, most often consisting of primitive neuroepithelium
struma ovarii and carcinoid in
immature elements, most often consisting of primitive neuroepithelium
struma ovarii compossed entirely of
mature thyroid tissue that may be functional (hyperthyroidism)
carcinoid may arise from
intestinal epithelium in a teratoma, can also be functional (carcinoid syndrome)
dysgerminoma is ovarian counterpart of
testicular seminoma
is dysgerminoma response to chemo
yes
yolk sac tumor affects
children and young adults
tumor cells in yolk sac tumor produce
AFP
yolk sac tumor feature
shiller duval bodies
sex cord stromal tumors are derived from
ovarian stroma which is derived from sex cords of embryonic gonad
granulosa cell tumors are mostly in which women
post menopausal
granulosa cell tumors are composed of cells that resemble granulosa cells of
developing ovarian follicle
granulosa cell tumors associated with elevated tissue and serum levels of
inhibin
Mutations of the ___ gene in 97% of adult granulosa cell tumors
FOXL2
granulosa cell tumors unilateral or bilateral
unilateral
histological features of granulosa cell tumors
call exner bodies
grooved (coffee bean) nuclei
what are fibromas, thecomas, and fibrothecomas?
tumors of ovarian stroma composed of fibroblasts (fibromas) or spindle cells with lipid droplets (thecomas)
tumors that contain a mixture of these cells are termed fibrothecomas
***the thecoma portion can produce estrogen
fibromas, thecomas, and fibrothecomas as associated with what two syndromes?
meigs syndrome (ovarian tumor, hydrothorax - R, ascites)
basal cell nevus syndrome (Gorlin syndrome)
what is meigs syndrome?
ovarian tumor, hydrothorax (R side), ascites
sertoli-leydig cell tumor is ovarian tumor that resembles cell of
male testis: capable of androgen production
Unilateral solid tumors
Histologically, Sertoli-like tubules and interspersed large Leydig-like cells
most common metastatic ovarian tumor
Müllerian origin most common
-Uterus, contralateral ovary, fallopian tube, pelvic peritoneum
Extra-Müllerian metastatic ovarian tumors
- Breast
- Gastrointestinal tract (stomach, colon, biliary tract, pancreas, appendix)
what is a krukenberg tumor?
bilateral mets composed of mucin producing signet ring cancer cells, most often gastric origin
spontaneous abortion/ miscarriage is
pregnancy loss before 20 weeks of gestation
About 50% show fetal chromosomal abnormalities
ectopic pregnany is
Implantation of fetus outside of the uterus including fallopian tube (90%), ovary, abdominal cavity, intrauterine portion of the tube (cornual pregnancy)
what is the predisposing condition of ectopic pregnancy?
previous PID with chronic salpingitis
scarring & adhesions from appendicitis, endometriosis, prior surgery
IUD
Placenta previa is
placenta implants to low uterine segment or cervix
serious 3rd trimester bleeding
what percentage of spontaneous abortions show fetal chromosomal abnormalities?
50%
what is placenta acreta?
partial or complete absence of the decidua - the placental villous tissue adhere directly to the myometrium
(failure of placental separation can cause severe postpartum bleeding)
what is chorioamnionitis
inflammation of fetal membrane
what is funisitis
inflammation of umbilical cord
hematogenous (transplacental) infection examples
TORCH group (toxoplasmosis and others [syphilis, TB, listeriosis], rubella, cytomegalovirus, herpes simplex): chronic villitis, congenital anomalies
what are ascending infections through birth canal caused by
bacteria
what is preeclampsa
widespread maternal endothelial dysfunction that presents with hypertension, edema and proteinuria
eclampsia: if convulsions occur
what is HELLP syndrome?
microangiopathic hemolytic anemia
elevated liver enzymes
low platelets
management of preeclampsia depends on
gestational age and severity of disease
definitive treatment is delivery
what type of disease is caused by a hydatidiform mole?
gestational trophoblastic disease
cystic swelling of the chorionic villi, accompanied by variable trophoblastic proliferation
abnormal vaginal bleeding sometimes with passage of bits of tissue
how do you measure hydatidiform mole?
** measure B-hCG for diagnosis
persistently elevated beta-hCG may be indicative of persistent or invasive mole
treatment of hydatidiform mole?
curettage of hysterectomy
complete mole is fertilization of an egg that __
has lost its female chromosomes
46 chromosomes
is there edema in complete mole
almost all villi are edematous
are there fetal parts in complete mole
no
partial mole is fertilization of egg with
two sperm
69 chromosomes
is there edema in partial mole
mixture of edematous villi and normal sized villi
which mole has more risk for choriocarcinoma
complete
what are the differences between a complete and partial hydatidiform mole?
complete: fertilization of egg that has lost its female diploid all villi edematous diffuse trophoblastic hyperplasia no fetal parts serum B-hCG markedly elevated
partial: triploid edematous villi and normal-sized villi focal trophoblastic proliferation fetal parts often present serum b-hCG less elevated than with complete mole
what is invasive mole
a mole that penetrates or even perforates the uterine wall
what is a choriocarcinoma in females?
gestational malignant neoplasm of trophoblastic cells derived from a previously normal or abnormal pregnancy
clinical symptoms of choriocarcinoma in females
presentation: irregular spotting of bloody brown fluid hCG markedly elevated proliferation sync and cytotrophoblasts widespread metastasis nearly 100% remission with chemo
