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USMLE > Reproductive - Female Pathology > Flashcards

Reproductive - Female Pathology Flashcards

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USMLE® Step 1 flashcards
1
Q

Bartholin cyst

A

P: unilateral, painful cystic lesion at lower vestibule adjacent to vaginal canal; in premenopausal women

M: inflammation and obstruction of gland -> cystic dilation

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2
Q

Condyloma

A

P: warty neoplasm of vulvar skin

M: HPV 6, 11 (condyloma acuminatum); secondary syphilis (condyloma latum)
Koilocytes (hallmark of HPV-infected cells)

Rarely progress to carcinoma

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3
Q

Lichen sclerosis

A

P: white patch (leukoplakia) with parchment-like (paper thin) valvular skin; post-menopausal women

M: thinning of epidermis and fibrosis (sclerosis) of dermis

Benign, slightly increased risk of squamous cell carcinoma

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4
Q

Lichen simplex chronicus

A

P: leukoplakia with thick, leathery vulvar skin

M: chronic irritation and scratching; hyperplasia of vulvar squamous epithelium

No increase risk of squamous cell carcinoma

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5
Q

Vulvular carcinoma

A

P: leukoplakia (biopsy to distinguish from other causes)

M: squamous epithelium lining vulva
1) HPV-related (type 16, 18) - vulvar intraepithelial neoplasia with koilocytic change, disordered cell maturation, nuclear atypia, mitotic activity

2) Non HPV-related - long-standing sclerosis (chronic inflammation/irritation); older women (> 70 yo)

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6
Q

Extramammary Paget Disease

A

P: erythematous, pruritic, ulcerated vulvar skin

M: malignant epithelial cells in epidermis of vulva

No underlying carcinoma (whereas in nipple there is underlying carcinoma)

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7
Q

Distinguishing Extramammary Paget Disease and Melanoma

A

Paget cells: PAS+, keratin+, S100-
Melanoma: PAS-, keratin-, S100+

PAS = mucous secreting
Keratin = epithelial
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8
Q

Adenosis

A

P: Focal persistence of columnar epithelium in upper 1/3 of vagina

(During development, squamous epithelium from lower 2/3 from urogenital sinus grows upward and replace columnar lining of upper 1/3 from Mullerian ducts)

Assoc. with exposure to diethystilbestrol in utero

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9
Q

Clear cell adenocarcinoma

A

M: malignant proliferation of glands with clear cytoplasm

Rare, but feared, complication of DES-associated vaginal adenosis

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10
Q

Embryonal rhabdomyosarcoma (Sarcoma botryoides)

A

P: bleeding and grape-like mass protruding from vagina or penis of child (usually < 5yo)

M: Malignant mesenchymal proliferation of immature skeletal muscles
Spindle-shaped tumor cells

Cytoplasmic cross-striations
Positive for desmin and myogenin

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11
Q

Vaginal carcinoma

A

Usually secondary to cervical squamous cell carcinoma

Squamous epithelium carcinoma lining vagina mucosa

Assoc. with high risk HPV (16, 18) -> vaginal intraepithelial neoplasia

Lower 2/3 of vaginal spreads to inguinal nodes
Upper 1/3 of vaginal spreads to regional iliac nodes

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12
Q

What is the histology of cervix?

A

Exocervix: nonkeratinizing squamous epithelium
Endocervix: single layer of columnar cells

Transformation zone = junction

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13
Q

HPV Infection

A

Sexually transmitted DNA virus that infects lower genital tracts, particularly cervical transformation zone

Persistent infection -> cervical dysplasia

High Risks: 16, 18, 31, 33
Low Risks: 6, 11

High risk HPV produce E6 (p53) and E7 (Rb) -> increase risk of CIN

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14
Q

Cervical intrapepithelial neoplasia

A

P: koilocytic change, disordered cellular maturation, nuclear atypia, increased mitotic activity

CIN I: < 1/3 thickness
CIN II: < 2/3 thickness
CIN: < 3/3 thickness
Carcinoma in situ: entire thickness

Progression not inevitable (CIN I often regress)

Higher grade more likely to progress to carcinoma and less likely to regress

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15
Q

Cervical carcinoma

A

P: middle-aged women with vaginal bleeding, postcoital bleeding, cervical discharge

M: invasive carcinoma from cervical epithelium; high-risk HPV infection
secondary factors: smoking, immunodeficiency (AIDS)

80% Squamous and 15% adenocarcinoma (both HPV related)

Can invade through anterior uterine wall into bladder -> blocks ureters -> hydronephrosis with postrenal failure common cause of death

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16
Q

What is the gold standard for screening cervical carcinoma?

A

Pap smear
Abnormal pap smear followed by confirmatory colposcopy (magnifying glass) and biopsy

Limitations: inadequate sampling, not for adenocarcinoma

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17
Q

Immunization for HPV infection

A

Quadrivalent: HPV 6, 11, 16, 18
Protection lasts 5 years

Pap smears still necessary due to limited number of HPV covered by vaccine

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18
Q

What are the layers of lining of uterine cavity? What hormones regulate the layers?

A

Myometrium: smooth muscle wall underlying endometrium

Endometrium: mucosal lining of uterine cavity
Hormone sensitive
- growth by estrogen, secretory phase by progesterone, shedding by loss of progesterone

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19
Q

Asherman syndrome

A

P: secondary amenorrhea after dilation and currettage (D&C)

M: overaggressive D&C -> loss of basalis (stem cell layer for regeneration of endometrium) and scarring

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20
Q

Anovulatory cycle

A

P: lack of ovulation, dysfunctional uterine bleeding during menarche and menopause

M: estrogen-driven proliferative phase without subsequent progesterone-driven secretory phase -> proliferative glands break down and shed

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21
Q

Acute endometritis

A

P: fever, abnormal uterine bleeding, pelvic pain

M: bacterial infection of endometrium; from retained products of conception (after delivery/miscarriage) -> acts as nidus for infection

Tx: gentamycin + clindamycin with or without ampicillin

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22
Q

Chronic endometritis

A

P: abnormal uterine bleeding, pain, infertility

M: chronic inflammation of endometrium (from products of contraception, chronic pelvic inflammatory - chlamydia, IUD, TB)

Lymphocytes and plasma cells (Plasma cells for diagnosis as lymphocytes are normally found in endometrium)

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23
Q

Endometrial polyp

A

P: abnormal uterine bleeding

M: hyperplastic protrusion of endometrium
Can arise from tamoxifen (pro-estrogenic on endometrium)

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24
Q

Endometriosis

A

P: dysmenorrhea (pain during menstruation), pelvic pain; may cause painful intercourse and infertility; cyclic bleeding from ectopic tissue

M: retrograde menstruation with implantation at ectopic site -> endometrial glands AND stroma outside of uterine endometrial lining -> cycle just like normal endometrium

Uterus is normal sized

Increased risk of carcinoma at site of endometriosis, especially the ovary

Tx: oral contraceptives, NSAIDs, leuprolide, danazol

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25
Q

Sites of Endometriosis

A 
Ovary (chocolate cysts)
Uterine ligaments (pelvic pain)
Pouch of douglas (pain with defecation)
Bladder wall (pain with urination)
Bowel serosa (abdominal pain and adhesions)
Fallopian tube mucosa (scarring increases risk for ectopic pregnancy) - "gun-powder" nodules
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26
Q

Adenomyosis

A

Endometriosis involving uterine myometrium
Uterus is enlarged

Tx: hysterectomy

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27
Q

Endometrial hyperplasia

A

P: postmenopausal uterine bleeding

M: Unopposed/excessive estrogen stimulation (obesity, polycystic ovary syndrome, estrogen replacement) -> hyperplasia of endometrial glands relative to stroma

Risks: anovulatory cycles, HRT, polycystic ovarian syndrome, granulosa cell tumor

Cellular atypia is the most important predictor for progression to carcinoma
Simple hyperplasia progresses 30%; Complex hyperplasia rarely

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28
Q

Endometrial carcinoma

A

P: postmenopausal bleeding at 55-65 yo

M: malignant proliferation of endometrial glands (most common invasive carcinoma of female genital tract)

2 pathways: hyperplasia and sporadic
Increased myometrial invasion -> lower prognosis

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29
Q

Hyperplasic endometrial carcinoma

A

Estrogen exposure risks -> hyperplasia
Histology: endometrioid (normal endometrium-like)

60 yo

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30
Q

Sporadic endometrial carcinoma

A

Arise in atrophic endometrium with no evident precursor lesion
Histology: papillary structures, psammoma bodies, p53 mutation

70 yo, aggressive tumor

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31
Q

Leiomyoma (Fibroids)

A

P: Asymptomatic; can include abnormal uterine bleeding (iron deficiency), infertility, pelvic mass. Premenopausal (20-40yo); African american

M: benign neoplastic proliferation of smooth muscle from myometrium; most common tumor in females

Estrogen associated (premenopausal, multiple, enlarges during pregnancy, shrinks after menopause)

Multiple well-defined, white, whorled masses

32
Q

Leiomyosarcoma

A

P: postmenopausal (middle age) women, African American

M: malignant proliferation of smooth muscle from myometrium

De novo (NOT from leiomyoma), single lesion with necrosis, hemorrhage, mitotic activity and cellular atypia. May protrude from cervix and bleed

Highly aggressive; tend to recur

33
Q

Basic histology and function of ovary

A

Functional unit = follicle
Oocyte surrounded by granulosa and theca cells

1) LH induces androgen production from theca
2) FSH stimulates granulosa to convert androgen to estradiol
3) Estradiol surge induces LH surge leading to ovulation

4) After ovulation, residual follicle becomes corpus luteum and secretes progesterone (drives secretory phase)

34
Q

Hemorrhagic corpus luteal cyst

A

Hemorrhage into corpus luteum; early pregnancy

Degeneration of follicles results in follicular cysts - small number are common

35
Q

Polycystic ovarian disease

A

P: obese woman, amennorhea, infertility, hirsutism; 5% of women

M: hormone inmbalance

1) high LH induces androgen production in theta cells (hirsutism)
2) Androgens converted to estrone in adipose
3) Estrone inhibits FSH
4) Decreased FSH results in cystic degeneration of follicles

High LH, low FSH, high T, high E (from aromatization)

Assoc. with insulin resistance (type 2 diabetes 10-15 years later) and endometrial carcinoma (high circulating estrone)

Tx: weight reduction, low dose OCP or medroxyprogesterone (decreases LH/androgenesis), spironolactone (acne/hirsutism), clomiphene (for those who want pregnancy), metformin (diabetes/metabolic syndrome)

36
Q

What are the 3 cell types of ovary?

A

Surface epithelium
Germ cells
Sex cord stroma

37
Q

Surface epithelial tumors

A

Most common types of ovarian tumors (70%)

Coelomic epithelium (embryologically produces epithelial lining of fallopian tube (serous), endometrium, and endocervix (mucinous cells)

2 most common subtypes: serous and mucus (both cystic)

Present late with vague abdominal symptoms or compression (urinary frequency)
Poor prognosis (worst of genital tract cancers)

Spread locally (peritoneum); CA-125 for monitoring treatment and recurrence; not for diagnosis

38
Q

Serous cystadenoma

A

Surface epithelial tumor of ovary (45% of ovarian tumors); Benign
Premenopausal (30-40 yo)

Histology: fallopian tube-like epithelium; single cyst (often bilateral) with simple, flat lining

39
Q

Mucinous cystadenoma

A

Surface epithelial tumor of ovary; Benign

Histology: intestine-like tissue

Multilocular cyst lined by mucus-secreting epithelium

40
Q

Serous cystadenocarcinoma

A 
Surface epithelial tumor of ovary (45% of ovarian tumors; Malignant and bilateral
Postmenopausal women (60-70 yo)

Histology: complex cysts with thick, shaggy lining; psammoma bodies

Assoc. with BRCA1 (serous carcinoma of ovary and fallopian tube - prophylactic salpingo-oophorectomy)

41
Q

Mucinous cystadenocarcinoma

A

Surface epithelial tumor of ovary; malignant

Pseudomyxoma peritonei - intraperitoneal accumulation of mucinous material from ovarian or apendiceal tumor

42
Q

Endometrioid tumor

A

Surface epithelial tumor of ovary; malignant

Endometrial-like glands
May arise from endometriosis

15% associated with independent endometrial carcinoma (endometrioid type)

43
Q

Brenner tumor

A

Surface epithelial tumor of ovary; benign
Solid tumor that is pale yellow-tan in color and appears encapsulated. “Coffee bean” nuclei on H&E staining

Histology: bladder-like epithelium

44
Q

Germ cell tumors

A

2nd most common ovarian tumor (15%)
Reproductive age; mimics tissues normally produced by germ cells

  1. Fetal tissue - cystic terotoma, embryonal carcinoma
  2. Oocytes - dysgerminoma
  3. Yolk sac - endodermal sinus tumor
  4. Placental tissue - choriocarcinoma
45
Q

Cystic teratoma

A

Germ cell tumor of ovary, most common germ cell tumor in females; 10% bilateral
Fetal tissue from two or three embryologic layers (skin, hair, bone, cartilage, gut, and thyroid)

Mature teratoma (“Dermoid cyst”): benign

Immature teratoma - aggressively malignant (usually neural ectoderm) or somatic malignancy (squamous cell carcinoma of skin) indicates malignant potential

46
Q

Strauma ovarii

A

Cystic teratoma of ovary with thyroid tissue

Can present as hyperthyroidism

47
Q

Dysgerminoma

A

Germ cell tumor of ovary

Large cells with clear cytoplasm and central nuclei (oocytes); uniform cells. Most common malignant germ cell tumor (testicular seminoma)

Elevated LDH, hCG
Assoc. with Turner syndrome
Good prognosis; responds to radiotherapy

48
Q

Endodermal sinus tumor

A

Cystic termatoma of ovary (testes in boys)
Yolk sac; most common in children (sacrococcygeal area)

Yellow, friable, solid mass

Elevated AFP
Schiller-Duval bodies (glomerulus-like structures)

49
Q

Choriocarcinoma

A

Germ cell tumor of ovary; malignant
Trophoblasts and syncytiotrophoblasts; mimics placental tissue, but absent chorionic villi

Can develop during or after pregnancy in mother or baby

Small, hemorrhagic tumor with early hematogenous spread (genetically programed to invade blood vessels) - to lungs

High beta-HCG (produced by synctiotrophoblasts)
May lead to theca-lutein cysts in ovary

Poor response to chemotherapy

50
Q

Embryonal carcinoma

A

Germ cell tumor of ovary
Malignant tumor of large primitive cells (able to move and spread)

Aggressive with early metastasis

51
Q

Granulosa-theca cell tumor

A

Sex cord-stromal tumor of ovary; malignant but minimal risk for metastasis

Neoplastic proliferation of granulosa and theca cells
Produces estrogens

Signs of estrogen excess (precocious puberty; menorrhagia/metrorrhagia; endometrial hyperplasia with postmenopausal uterine bleed)

Call-Exner bodies - small follicles filled with eosinophilic secretions

52
Q

Sertoli-Leydig cell tumor

A

Sex cord-stromal tumor of ovary

Sertoli cells that form tubules and Leydig cells (between tubules) with characteristic Reinke crystals (pink cells with crystals)

Signs of androgen excess: hirsutism, virilization

53
Q

Fibroma

A

Sex cord-stromal tumor of ovary

Benign tumor of fibroblasts; bundles of spindle-shaped fibroblasts

54
Q

Meigs syndrome

A

Fibroma with pleural effusions (hydrothorax) and ascites
Pulling sensation in groin

Syndrome resolves with removal of tumor

55
Q

Krukenberg tumor

A

Metastatic tumor of both ovaries
Most commonly from metastatic gastric carcinoma (diffuse type - secretes mucous)

Bilaterality distinguish metastases from primary mucinous carcinoma

Mucin=secreting signet cell adenocarinoma

56
Q

Pseudomyxoma peritonei

A

Massive amoung of mucus in peritoneum
“jelly belly”

Mucinous tumor of appendix; usually with metastasis to the ovary

57
Q

Ectopic pregnancy

A

P: lower quadrant abdominal pain a few weeks after missed period; lower than expected increased hCG

Implantation of fertilized ovum at site other than uterine wall; most common is lumen of fallopian tube

Key risk: scarring - salpingitis from PID, endometriosis, ruptured appendix, prior tubal surgery, history of infertility)

Surgical emergency; major complications: bleeding into fallopian tube (hematosalpinx) and rupture

58
Q

Spontaneous abortion

A

P: vaginal bleeding, cramp-like pain, passage of fetal tissue

Miscarriage before 20 weeks (usually first trimester)

Chromosomal anomalies (trisomy 16), hypercoagulable states (antiphospholipid syndromes), congenital infections, exposure to teratogens (first 2 weeks)

59
Q

Teratogen: Alcohol

A

Mental retardation, facial abnormalities, microencephaly

60
Q

Teratogen: Cocaine

A

Intrauterine growth retardation, placental abruption

61
Q

Teratogen: thalidomide

A

limb defects

62
Q

Teratogen: Cigarette smoke

A

intrauterine growth retardation

63
Q

Teratogen: isotretinoin

A

spontaneous abortion, hearing/visual impairment

64
Q

Teratogen: tetracycline

A

discolored teeth

65
Q

Teratogen: warfarin

A

fetal bleeding

66
Q

Teratogen: phenytoin

A

digit hypoplasia, cleft lip/palate

67
Q

Preeclampsia

A

P: pregnancy-induced hypertension, proteinuria, edema, particularly in 3rd trimester (5% of pregnancies)

Headaches, visual abnormalities

M: abnormality of maternal-fetal vascular interface in placenta; resolves with delivery
placental ischemia from impaired vasodilation of spiral arteries, resulting increased vascular tone

Eclampsia - seizures (IV magnesium sulfate to prevent/treat seizures)

Risks: preexisting hypertension, diabetes, chronic renal, autoimmune disorders

Mortality: cerebral hemorrhage, ARDS

68
Q

HELLP (preeclampsia)

A

Thrombotic microangiopathy involving liver

Hemolysis
Elevated liver enzymes
Low platelets

69
Q

Sudden infant death syndrome

A

P: infant expires during sleep

M: death of infant (1m-1y) without obvious cause

Risk factors: cigarette smoke exposure, sleeping on stomach, prematurity

70
Q

Hydatidiform mole

A

P: grape-like masses (“clusters of grapes”, “honeycombed uterus”) through vaginal canal in 2nd trimester/
or absent fetal heart sound; snowstorm appearance on ultrasound

abnormally large uterus, increased beta-hCG

Abnormal conception characterized by swollen and edematous villi with proliferation of trophoblasts

Tx: dilatation and curettage
Subsequent beta-HCG monitoring for adequate mole removal and screen for choriocarcinoma

71
Q

Partial hydatidiform mole

A

Normal ovum fertilized by two sperms (or one sperm duplicates)
69 chromosomes

Present fetal tissue
Some normal villi, focal proliferation

Minimal risk for choriocarcinoma

72
Q

Complete hydatidiform mole

A

Empty ovum fertilized by 2 sperm (or 1 that duplicates)
46 chromosomes

Absent fetal tissue
Most villi are hydropic

Diffuse, circumferential proliferation around hydropic villi

2-3% risk for choriocarcinoma

73
Q

2 Forms of Choriocarcinoma and Differences

A

Complication of gestation (spontaneous abortion, normal pregnancy, hydatidiform mole) or spontaneous germ cell tumor

Arising from gestation pathway responds well to chemotherapy.

Germ cell pathway does not respond well to chemotherapy.

74
Q

Placenta previa

A

P: third-trimester bleeding (painless)

M: Implantation of placenta in lower uterine segment; placenta overlies cervical os (opening)

Often requires delivery by c-section (compress blood supply)

Risks: multiparity, prior C-section

75
Q

Placental abruption (abruptio placentae)

A

P: third-trimester bleeding and fetal insufficiency; common cause of still birth

M: separation of placenta from decidua prior to delivery of fetus

May be associated with DIC
Risks: smoking, HTN, cocaine use

Life-threatening for both mother and fetus

76
Q

Placenta accreta

A

P: difficult delivery of placenta and massive postpartum bleeding

M: Improper implantation of placenta into myometrium with little or no intervening decidua

Risks: prior C-sectio, inflammation, placenta previa

“accreta” = encased

USMLE (13 decks)

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