pathoma female repro pathology Flashcards
what does the vulva include? lined by what type of epithelium?
the skin and mucosa of the female genitalia external to the hymen (labia majora, minora, mons pubis, and vestibule) lined by squamous epithelium
bartholin cyst
cystic dilation of the bartholin gland due to inflammation and obstruction of the gland presents as a unilateral, painful cyst at the lower vestibule adjacent to the vaginal canal
bartholin gland
one is present on each side of the vaginal canal and produces mucus-like fluid that drains via ducts into the lower vestibule
condyloma
sexually transmitted warty neoplasm of vulvar skin, often large either condyloma acuminatum (HPV 6 or 11) or secondary syphilis (condyloma latum) —HPV associated is characterized by koilocytes —low risk, rarely progresses to carcinoma
lichen sclerosis
thinning of the epidermis and fibrosis(sclerosis) of the dermis; presents as a white patch (leukoplakia) with parchment like vulvar skin usually in postmenopausal women benign but slight increased risk for sq. cell carcinoma
lichen simplex chronicus
hyperplasia of the vulvar squamous epithelium; presents as leukoplakia with thick leathery vulvar skin; associated with chronic irritation and scratching –benign
vulvar carcinoma
arises from vulva squamous epithelium; RARE; may be due to high risk HPV 16 or 17 or non-HPV cause(long standing lichen sclerosis) presents as leukoplakia **use biopsy to distinguish from other causes of leukoplakia
risk factors for vulvar carcinoma
HPV exposure, multiple partners, early first age of sex, women of reproductive age
VIN
vulvar intraepithelial neoplasia a dysplastic precursor lesion characterized by koilocytic change, disordered cellular maturation, nuclear atypia, and increased mitotic activity **leads to vulvar carcinoma
which type of vulvar carcinoma is seen in elderly women?
non-hpv related due to long standing lichen sclerosis (chronic inflammation and irritation)
extramammary paget disease
malignant epithelial cells in the vulva epidermis; presents as erythematous, pruritic, ulcerated vulvar skin **carcinoma in-situ (no underlying cancer) must distinguish from melanoma!! paget cells are PAS+, keratin +, and S100-
what type of paget disease DOES have underlying carcinoma?
paget disease of the nipple
melanoma vs paget disease
M = PAS -, keratin -, S100 + P = PAS +, keratin +, S100-
vagina mucosa is lined by…
non-keratinizing squamous epithelium
adenosis
focal persistence of columnar epithelium in the upper vagina mech: during development, sq. epithelium from the lower 1/3 vagina grows upward to replace the columnar epithelium lining the upper 2/3 **increased incidence in females who were xposed to DES (diethylstilbestrol) in utero
clear cell adenocarcinoma of vagina
malignant proliferation of glands with clear cytoplasm; RARE but FEARED complication of DES-associated vaginal adenosis
what can adenosis due to DES progress to?
clear cell adenocarcinoma
embryonal rhabdomyosarcoma
malignant mesenchymal proliferation of immature skeletal muscle -presents as bleeding and grape-like mass protruding from the vagina or penis of a child (
desmin + and myogenin +
characteristic of rhabdomyoblasts –> embryonal rhabdomyosarcoma
vaginal carcinoma
arises from sq. epithelium lining the vagina mucosa; usually related to high risk HPV precursor lesion is VAIN (vaginal intraepithelial neoplasia)
where does vaginal carcinoma spread when it spreads to regional lymph nodes?
lower 1/3 of vagina –> inguinal nodes upper 2/3 –> iliac nodes
exocervix vs endocervix epithelium
exo = nonkeratinizing sq epithelium endo = single layer of columnar cells
HPV
sexually transmitted DNA virus that infects the lower genital tract, especially the cervix in the transformation zone infection is usually eradicated by acute inflammation; persistence leads to risk for cervical dysplasia (CIN) high risk HPV = 16, 18, 31, 33 low risk = 6, 11
high risk hpv vs low risk hpv
high = 16, 18, 31, 33 low = 6, 11
CIN
cervical intraepithelial neoplasia caused by high risk HPV characterized by koilocytic change, disordered maturation, atypia, and mitoses –progresses stepwise through 4 different grades (1 –>2–>3–>CIS) to become invasive sq. cell carcinoma
high risk HPV produces….
E6 and E7 proteins that result in increased destruction of p53 (by E6) and Rb (by E7), respectively loss of these tumor suppressor genes increases the risk for CIN
CIN1 CIN2 CIN3 CIS
1 - involves less than 1/3 of epithelium thickness; often regresses 2 - involves less than 2/3 of epi thickness 3 - slightly less than the entire thickness Carcinoma in situ - involved entire epithelial thickness
cervical carcinoma
invasive; arises in cervical epithelium; common in middle aged women (40-50) presents as vaginal bleeding, especially postcoital bleeding, or cervical discharge squamous cell is 80% of cases; adenocarcinoma is less common
risk factors for cervical carcinoma
high risk HPV, smoking, immunodeficiency (Cervical carcinoma is AIDS defining)
advanced cervical carcinoma often…
invades through the anterior uterine wall into the bladder, blocking the ureters –> hydronephrosis with postrenal failure can cause death
screening and prevention of cervical carcinoma
catch CIN before It progresses –> usually takes 10-20 yrs so screening begins at 21, every 3 years pap smear is gold standard (cells from transformation zone) abnormal pap smear is followed by confirmatory colonoscopy and biopsy immunization with quadrivalent HPV vaccine (for 6, 11, 16, 18)
asherman syndrome
secondary amenorrhea due to loss of the basalis and scarring; due to overaggressive D&C (dilation and curettage)
anovulatory cycle
lack of ovulation; results in estrogen-driven proliferatory phase without a subsequent progesterone driven secretory phase –proliferative glands break down and shed resulting in uterine bleeding
acute endometritis
bacterial infection of the endometrium; due to retained products of contraception (after delivery or miscarriage) presents as fever, abnormal uterine bleeding and pelvic pain
chronic endometritis
chronic inflammation of the endometrium; characterized by lymphocytes and plasma cells —since lymphocytes are normal in the endometrium, plasma cells are necessary for diagnosis causes: IUD, TB, contraception products, chronic disease (chlamydia) presents as abnormal uterine bleeding, pain, and infertility
endometrial polyp
hyperplastic protrusion of endometrium; presents as abnormal uterine bleeding can be a side effect of tamoxifen, which has an anti-estrogenic effect of breast but pro-estrogenic effects on endometrium
drug that can cause endometrial polyp?
tamoxifen (pro estrogen on endometrium; anti estrogenic on breasts)
endometriosis
endometrial glands and stroma outside of the uterine endometrial lining due to retrograde menstruation with implantation at ectopic site ***common site is the ovary (“chocolate cyst”) presents as dysmenorrhea(pain during menstruation) and pelvic pain; can cause infertility endometriosis cycles just like normal endometrium risk of carcinoma
“chocolate cyst”
endometriosis of the ovary
“gunpowder nodules”
endometriosis
adenomyosis
endometriosis with involvement of the uterine myometrium
endometrial hyperplasia
hyperplasia of endometrial glands relative to stroma; due to unopposed estrogen (obesity, polycystic ovary syndrome, estrogen replacement) presents as postmenopausal uterine bleeding most important predictor for carcinoma progression is the presence of cellular atypia!
endometrial carcinoma
malignant proliferation of endometrial glands; most common invasive carcinoma of the female genital tract presents as postmenopausal bleeding arises through two different pathways: hyperplasia (most cases) and sporadic
hyperplasia pathway for endometrial carcinoma
arises from hyperplasia; average age is 60 risk factors: related to estrogen exposure, early menarche/late menopause, nulliparity, anovulatory cycles, obesity histology is endometrioid (normal endometrial like)
sporadic pathway for endometrial carcinoma
carcinoma arises in an atrophic endometrium with no precursor lesion; aggressive! average age is 70; p53 mutation is common histology is serous with papillary structures and psammoma body formation
leiomyoma (fibroids)
benign; smooth muscle proliferation arising from myometrium; related to estrogen exposure common in premenopausal women, often multiple, enlarge during pregnancy and shrink after menopause multiple, well defined white whorled masses that may distort the area; usually asymptomatic, but can present with bleeding, infertility, and a pelvic mass
leiomyosarcoma
malignant proliferation of smooth muscle arising from myometrium; de novo (DO NOT arise from leiomyoma) usually in postmenopausal women a single lesion with areas of necrosis and hemorrhage; histology shows necrosis, mitotic activity and cellular atypia
PCOD (polycystic ovarian disease)
-multiple ovarian follicular cysts due to hormone imbalance; women of reproductive age -characterized by increased LH and low FSH (LH:FSH>2) –increased LH induces excess androgen from theca cells –> hirsutism (excess hair in male distribution) –androgen is converted to estrone in adipose tissue –> estrone feedback decreases FSH –> cystic degeneration of follicles **high circulating estrone increases risk of endometrial carcinoma
classic presentation of PCOD
obese young woman with infertility, oligomenhorrhea, and hirsutism; sometimes have insulin resistance and may develop diabetes 10-15 years later
small number of follicular cysts are…
common and have no clinical significance
ovarian tumor: surface epithelial tumor
most common type; derived from the coelomic epithelium that lines the ovary –serous tumors are full of watery fluid –mucinous tumors are full of mucus-like fluid both can be benign, borderline, or malignant present late with vague abdominal pain and fullness, and urinary frequency (sign of compression) POOR prognosis; ca125 is a serum marker
what is a benign surface epithelial tumor called? describe?
cystadenoma single cyst with a simple flat lining; usually in premenopausal women (30-40)
what is a malignant surface epithelial ovarian tumor called?
cystadenocarcinoma complex cysts with thick shaggy lining; usually in postmenopausal women (60-70)
BRCA1 mutation has increase risk for what? what can they opt for?
risk of serous carcinoma of the ovary and fallopian tube and breast cancer prophylactic salpingo-oophorectomy and mastectomy
endometrioid tumor
tumor of endometrial-like glands; usually malignant may arise from endometriosis
Brenner tumor
composed of bladder like epithelium and are usually benign
ca125
serum marker for surface epithelial tumors
ovarian tumors: germ cell tumor
women of reproductive age; tumor subtypes mimic tissues produced by germ cells normally –cystic teratoma and embryonal carcinoma = fetal tissue –dysgerminoma = oocytes –endodermal sinus tumor = yolk sac –chariocarcinoma = placental tissue
cystic teratoma
germ cell tumor composed of fetal tissue derived from 2 or 3 embryologic layers; can be uni or bilateral benign but malignant potential if there is immature/neural tissue or somatic malignancy (sq cell carcinoma of skin)
struma ovarii
a teratoma composed of thyroid tissue
dysgerminoma
germ cell tumor composed of large cells with clear cytoplasm and central nuclei (resemble oocytes) —if testicular, call a seminoma good prognosis; responds to radiotherapy
endodermal sinus tumor
germ cell tumor that is malignant and resembles the yolk sac; common in children serum AFP is elevated histology shows schiller-duval bodies
schiller-duval bodies
glomerulus like structures seen in endodermal sinus tumors
choriocarcinoma
malignant germ cell tumor composed of cytotrophoblasts and syncytiotrophoblasts; mimics placental tissue but villi are absent small hemorrhagic tumor with early hematogenous spread high B-hCG (made by syncytiotrophoblasts)
poor response to chemo
embryonal carcinoma
malignant germ cell tumor composed of large primitive cells; aggressive with early metastasis
sex cord-stromal tumors (3)
tumors that resemble sex cord-stromal tissues of the ovary
1) granulosa-theca cell tumor
2) sertoli-leydig cell tumor
3) fibroma
granulosa-theca cell tumor
malignant proliferation of granulosa and theca cells
often produces estrogen -> signs of estrogen excess like:
- precocious puberty (pre-puberty)
- menorrhagia or metrorrhagia (reproductive age)
- endometrial hyperplasia with postmenopausal uterine bleeding (postmenopause)**most common
sertoli-leydig cell tumor
composed of sertoli cells that form tubules and leydig cells between the tubules with characteristic Reinke crystals
may produce androgen; associated with hirsutism and virilization
fibroma
benign tumor of fibroblasts; associated with pleural effusions and ascites (Meigs syndrome); syndrome resolves with removal of tumor
krukenberg tumor
metastatic mucinous tumor that involves BOTH ovaries; most commonly due to metastatic gastric carcinoma (diffuse type)
**bilateral - helps distinguish it from a primary mucinous carcinoma of the ovary which is usually unilateral
pseudomyxoma peritonei
massive amount of mucus in the peritoneum due to a mucinous tumor of the appendix; usually with metastasis to ovary
ectopic pregnancy
implantation of fertilized ovum anywhere else than uterine wall; common in the lumen of the fallopian tube
risk factor is scarring
presents as lower quadrant abdominal pain a few weeks after a missed period – SURGICAL EMERGENCY – major complications are bleeding into fallopian tube (hematosalpinx) and rupture
spontaneous abortion
miscarriage of fetus occuring before 20 weeks gestation
presents as vaginal bleeding, crampy pain, and passage of fetal tissues
usually due to chromosomal anomalies (trisomy 16) or hypercoagulable states, congenital infection, or exposure to teratogens
effects of teratogens in
1- first two weeks of gestation
2-weeks 3-8
3 - months 3-9
1 - spontaneous abortion
2 - organ malformation
3 - organ hypoplasia
placenta previa
implantation of the placenta in the lower uterine segment; placenta overlies cervical os (opening)
presents as third trimester bleeding and requires C-section
placental abruption
separation of the placenta from the decidua prior to delivery of the fetus; causes still birth
presents with third trimester bleeding and fetal insufficiency
placenta accreta
improper implantation of placenta into the myometrium with little or no intervening decidua
presents with difficult delivery of the placenta and postpartum bleeding
often requires hysterectomy
effects of these teratogens?
1 - alcohol
2- cocaine
3- thalidomide
4 - cigarette smoke
5- isotretinoin
6- tetracycline
7- warfarin
8- phenytoin
1 - mental retardation, facial abnormalities, microcephaly
2 - intrauterine growth retardation and placental abruption
3 - limb defects
4 - intrauterine growth retardation
5 - spontaneous abortion, hearing/visual impairment
6 - discolored teeth
7 - fetal bleeding
8 - digit hypoplasia and cleft lip/palate
preeclampsia
pregnancy induced hypertension, proteinuria, and edema in third trimester; if HTN is severe it can cause headaches and visual abnormalities
-due to abnormal maternal-fetal vascular interface in the placenta; resolves with delivery
eclampsia
preeclampsia with seizures
warrants immediate delivery
HELLP
preeclampsia with thrombotic microangiopathy involving the liver; characterized by Hemolysis, Elevated Liver enzymes, and Low Platelets
warrants immediate delivery
sudden infant death syndrome
death without obvious cause (1 month to 1 year old); usually during sleep
risk factors: sleeping on stomach, exposure to cigarette smoke, and prematurity
hydatidiform mole
abnormal conception characterized by swollen and edematous villi with proliferation of trophoblasts
- uterus expands as if normal pregnancy, but the uterus is much larger and B-hCG is higher than expected
- classically presents in 2nd trimester as passage of grape like masses through vaginal canal (diagnosed by routine ultrasound–> no fetal heart sounds and “snowstorm” appearance)
- either partial or complete
- treat with suction curettage
partial mole
genetics?
fetal tissue?
villous edema?
trophoblastic proliferation?
risk for choriocarcinoma?
normal ovum fertilized by two sperm (or one that duplicates chromosomes); 69 ch
fetal tissue is present
some villi are hydropic, some are normal
focal proliferation present around hydropic villi
minimal risk
complete mole
genetics?
fetal tissue?
villous edema?
trophoblastic proliferation?
risk for choriocarcinoma?
- empty ovum fertilized by two sperm (or one sperm that duplicates chromosomes); 46 ch
- fetal tissue absent
- most villi are hydropic (grapelike)
- diffuse circumferential proliferation around hydropic villi
- 2-3% risk for choriocarcinoma
