Path of the Uterus (Gianani)

Question 1

Embriology and anatomy of the female genital tract.

Answer 1

Germ cells arise in the wall of the yolk sac by the fourth week of gestation.
By the fifth or sixth week - migrate into the urogenital ridge, induce proliferation of the mesodermal epithelium, –> epithelium and stroma of the ovary.
The lateral müllerian ducts form - 6th week of development through invagination and fusion of the coelomic lining epithelium.
- ducts progressively grow caudally into the pelvis, where they swing medially to fuse with the urogenital sinus at the müllerian tubercle .
- caudal growth brings these fused ducts into contact with the urogenital sinus.
- unfused upper portions of the müllerian ducts –> fallopian tubes,
- fused lower portion –> uterus, cervix and upper vagina.
- urogenital sinus develops when the cloaca is subdivided by the urorectal septum; –> lower part of the vagina and the vestibule of the external genitalia.
- mesonephric ducts normally regress in the female, but remnants may persist into adult life as epithelial inclusions adjacent to the ovaries, tubes, and uterus.
- In the cervix and vagina these rests may be cystic and are termed Gartner duct cysts

Question 2

A potential cause of second trimester abortion

Answer 2

Bicornuate uterus

Question 3

Chronic: Pain in in women for duration ≥ 6 months localized to the anatomic pelvis, anterior abdominal wall at or below umbilicus, lumbosacral back, or buttocks.

Answer 3

• intermittent or constant
• not exclusive to
• menstruation or intercourse, not associated with pregnancy
• severe enough to cause functional disability or require medical care
• considered a symptom, not a diagnosis
• No causes identified in up to 30% of cases.
• Common causes: Pelvic adhesions, Endometriosis.
• Less common causes: Leiomyomata, intrauterine device, symptomatic pelvic relaxation (genital prolapse) , cervical stenosis, tuberculous salpingitis, ovarian remnant syndrome
• 36% of women report chronic pelvic pain after diagnosis of acute pelvic inflammatory disease.

Question 4

Endometriosis

Answer 4

• presence of endometrial tissue outside the uterus.
• mostly in women of childbearing age.
• common symptoms : dysmenorrhea, dyspareunia, and low back pain that worsen during menses.
• associated with infertility.

The pathological diagnosis of endometriosis is made if endometrial glands and stroma (sometimes these findings are also associated with hemorrhage).

• pathogenesis unknown but several theories have been reported.
• Adenomyosis is a related (but not identical) disease in which endometrial tissue is present within the uterine wall but outside the endometrium.

Question 5

Pelvic Inflammatory disease

Answer 5

Pelvic inflammatory disease (PID) is an infection that begins in the vulva or vagina [typically STD] and spreads upward to involve most of the structures in the female genital system, resulting in pelvic pain, adnexal tenderness, fever, and vaginal discharge.
Long term consequence of PID include infertility and ectopic pregnancy.

Question 6

Infections involving the upper genital tract can result in

Answer 6

PELVIC INFLAMMATORY DISEASE.

Question 7

Haemophilus ducreyi

Answer 7

Chancroid - acute, sexually transmitted, ulcerative infection caused by Haemophilus ducreyi.

• most common in tropical and subtropical areas among lower socioeconomic groups.
• one of the most common causes of genital ulcers in Africa and Southeast Asia, ; cofactor in the trans­mission of HIV infection.
• uncommon in the United States,
• difficult to grow in culture and PCR-based tests are not widely available; likely underdiagnosed

Question 8

Infections of the lower and upper genital tract:Infections of the lower and upper genital tract:

Answer 8

Neisseria gonorrhoeae (STD).
Chlamydia trachomatis (STD).
Staphylococci, streptococci, coliforms and Clostridium perfrigens (infections after abortions or delivery)
Infections involving the upper genital tract can result in  PELVIC INFLAMMATORY DISEASE.

Question 9

Infections of the lower genital tract:

Answer 9

Herpes Virus.
Syphilis
Lymphogranuloma Venereum
Molluscum contagiosum.
Trichomonas vaginalis.
Gardnerella vaginalis.
Ureaplasma urealyticum and Mycoplasma hominis.
HPV

Question 10

Molluscum Contagiosum

Answer 10

Skin or mucosal lesion caused by poxvirus.
Four types: MCV-1 to 4.
Common in children between age 2-12 (can be transmitted through shared articles).
In adults typically sexually transmitted.
Pearly dome-shaped papules with a dimpled center (blue arrow) containing waxy material (see panel A).
Micrograph of low power appearance of dome shaped papule with dimple center (see panel B).
High power magnification reveals intracytoplasmic viral inclusions (see panel C, blue arrow) .

Question 11

Syphilis

Answer 11

• Treponema pallidum
• gram-negative spirochete that causes syphilis,
• primary, secondary, or tertiary stages of infections

Primary syphilis: painless ulcers, often in the genitalia and usually within the first 3 months of infection.

Secondary syphilis: 2 months after the resolution of the ulcers; non-specific clinical features such as pharyngitis, fever, and mucocutaneous lesions.

Tertiary syphilis: years to decades after the initial infection; cardiac, neurological, and dermatological features.

Question 12

Granuloma Inguinale

Answer 12

Granuloma inguinale, or donovanosis, is a sexually transmitted chronic inflammatory disease caused by Klebsiella granulomatis. Untreated cases are characterized by the development of extensive scarring, often associated with lymphatic obstruction and lymphedema (elephantiasis) of the external genitalia.

Question 13

Acute HIV Infection

Answer 13

Please remember that not all STD have “genital signs and symptoms”.

Acute HIV infection- two to four weeks after someone is infected with HIV.

= primary HIV infection or acute retroviral syndrome.

It is the primary stage of infection and lasts until the body has created antibodies against HIV.  
rash
fever
chills
headache
fatigue
sore throat
night sweats
loss of appetite
swollen lymph nodes
muscle aches

Remember, however, that genital lesions make HIV infection more likely during sexual contact with an infected individual

Question 14

Causes of acute gynecological abdominal pain in adults

Answer 14

Ectopic pregnancy
Ovarian mass
Ovarian  torsion 
Pelvic inflammatory disease
Leiomyomata

Question 15

Ectopic Pregnancy

Answer 15

Approximately 85-90% occur in multigravida women
Rates are nearly twice as high for women of other ethnicities as Caucasian women

Any woman with functioning ovaries (menarche to menopause) can potentially have an ectopic pregnancy;

most common site: ampulla

Occurs in women of all ages, often with a history of infertility, usually secondary to prior tubal damage
Often results in rupture of maternal vessels at week 8 into gestational sac

Risk Factors:Tubal damage:
Infections (PID) or salpingitis (may not be documented)
Abdominal/pelvic surgery or tubal ligation
Congenital abnormality (DES)
History of previous ectopic pregnancy
Smoking identified in 1/3 of ectopic pregnancies; smoking may contribute to decreased tubal motility by damaging ciliated cells
Altered tubal motility: due to smoking or hormonal contraception; progesterone-only contraception and progesterone intrauterine devices (IUDs) have been associated with increased risk of ectopic pregnancy
History of 2+ years of infertility (whether treated or not): women using assisted reproduction have 2x risk of ectopic pregnancy, although this is mostly due to the underlying infertility (related associations are fertility drugs and treatments, such as in vitro fertilization)
History of multiple sexual partners
Use of an intrauterine device (IUD) inserted at the time of conception
Maternal age: not an independent risk factor

Question 16

Ovarian Torsion

Answer 16

• infrequent but significant cause of acutelower abdominal pain;
• associated with reduced venous return from the ovary as a result of stromal edema, internal hemorrhage, or a mass. The ovary and fallopian tube are typically involved.
• present with the sudden onset (commonly during exercise or other agitating movement) of severe, unilateral lower abdominal pain that worsens intermittently over many hours.
• A minority of patients, however, complain of mild pain that follows a more prolonged time course. The pain usually is localized over the involved side, often radiating to the back, pelvis, or thigh. Approximately 25% of patients experience bilateral lower quadrant pain. It may be described as sharp and stabbing or, less frequently, crampy.

Question 17

leiomyoma genetics

Answer 17

= fibroids
most common tumor in women.

They are benign smooth muscle neoplasms that may occur singly, but more often are multiple.

Most leiomyomas have normal karyotypes

40% have a simple chromosomal abnormality:

• HMGIC and HMGIY gene mutations– encode closely related DNA-binding factors that regulate chromatin structure.
• MED12 gene have been identified in up to 70% of uterine leiomyomas. encodes a component of Mediator, a multiprotein complex that stimulates gene expression by serving as a bridge between long-range DNA regulatory elements (so-called enhancers) and gene promoters.

Question 18

Leiomyoma in general

Answer 18

• bundles of smooth muscle cells that resemble the uninvolved myometrium.
• muscle cells are uniform in size and shape and have the characteristic oval nucleus and long, slender bipolar cytoplasmic processes.
• Mitotic figures are scarce.

Benign variants of leiomyoma include atypical or bizarre (symplastic) tumors with nuclear atypia and giant cells, and cellular leiomyomas. Both have a low mitotic index, helping to distinguish these benign tumors from leiomyosarcomas. An extremely rare variant, benign metastasizing leiomyoma, is a uterine leiomyoma that extends into vessels and spreads hematogenously to other sites, most commonly the lung. Another variant, disseminated peritoneal leiomyomatosis, presents as multiple small peritoneal nodules. Both are considered benign despite their unusual

Question 19

leiomyota most likely to cause vaginal bleeding if

Answer 19

submucosal