Reproductive Pathology: Female 2 Flashcards
Congenital Uterine Abnormalities
- The uterus, tubes, and upper vagina develop from the Mullerian ducts in the absence of Anti-Mullerian Hormone. The development requires the prior existence of mesonephric ducts that will give rise to the renal system. The fusion of the Mullerian ducts will form the tubes, uterus, and upper vagina around the 10th week of gestation. Subsequent canalisation will form the cavity, and the absorption of the dividing septum will result in the final, normal anatomy by mid gestation.
- Congenital uterine anomalies can be detected in about 5% of women. The rate is lower in the general population, higher among infertile women, and highest in women with recurrent pregnancy loss (10%).
- Uterus didelphys (2 cervix each leading to one fallopian tube, no body of uterus), uterus bicornis bicollis (1 cervix with two openings which lead to a fallopian tube each, no body of uterus), uterus bicornis unicollis (thin body of uterus), uterus unicornis (one fallopian tube), uterus unicornis with rudimentary horn (2 fallopian tubes present but one is not attached to uterus), uterus septus (septum did not disappear).
Mullerian Malformations
Frequently associated with abnormalities of the renal and axial skeletal systems, and they are oten first encountered when patients are examined for associated conditions. Most mullerian duct anomalies are associated with functioning ovaries and age-appropriate external genitalia. These abnormalities are often recognised after the onset of puberty. In the prepubertal period, normal external genitalia and age-appropriate developmental milestones often mask abnormalities of the internal reproductive organs. After the onset of puberty, young women often present to the gynaecologist with menstrual disorders. Late presentations include infertility and obstetric complications.
Vulval Cancers
The vulva is essentially epithelial skin; therefore the main tumours that affect the vulva are skin-related cancers. About 90% of vulval cancers are squamous cell carcinomas, which typically develop at the edges of labia majora/minora or in the vagina. As with vaginal squamous cell carcinomas, vulval squamous cell cancers are slow growing and usually develop from “precancerous”, pre-invasive areas called vulval intraepithelial neoplasia (VIN). There are two subtypes of squamous cell vulval cancer: one is more common in younger women and is associated with HPC; the other occurs in older women and is not associated with HPV but is associated with chronic vulval skin changes called vulval dystrophy, including lichen sclerosis.
Squamous Hyperplasia
Hyperkeratosis, irregular thickening of ridges, some neoplastic potential.
Lichen Sclerosus
Hyperkeratosis, flattening of ridges, oedema in connective tissue with chronic inflammation. Some neoplastic potential. Sometimes white patches - leukoplakia. Causes pruritis. Excoriation makes things worse. Treated with potent corticosteroids.
Endometrial Cancer
- Endometrial cancer accounts for 5% of cancers in UK women (around 8000 cases per year). It is the fourth most common cancer and causes 2.5% of cancer deaths (about 2000 per year). There is a lifetime risk of 2.35%, or in 1/43, for women in the UK.
- Usually affects women in their 50-70s and is rare in those aged under 40. The incidence is increasing, probably due to increasing population age, obesity and use of HRT. It is most commonly diagnosed gynaecological cancer in developed countries, cervical cancer more prevalent in developing cancers.
- Endometrial cancer is a common oestrogen-dependent gynaecological cancer which tends to affect older women. It is not screened for in the UK and therefore doctors must maintain a high level of suspicion in order to pick it up as early as possible. POSTMENOPAUSAL BLEEDING IS DUE TO MALIGNANCY UNTIL PROVEN OTHERWISE.
Adenomyosis
Benign disease of the uterus due to the presence of ectopic endometrial glands and stroma deep within the myometrium with adjacent reactive myometrial hyperplasia. The disease can be diffuse or focal (adenomyoma). Causes menorrhagia and dysmenorrhoea.
Smooth Muscle Tumours of Myometrium
- Leiomyoma (fibroid) - very common and associated with menorrhagia and infertility. Very common cause of uterine enlargement. May undergo degeneration. Intramural, submucosal (can be pedunculated appearing in the form of an endometrial polyp) and subserosal (could compress bladder or rectum).
- Leiomyosarcoma
Endometriosis
- Endometrial glands and stroma outside the uterine body. May cause pelvic inflammation, infertility, pain. Sites include ovary (‘chocolate’ cyst), pouch of douglas, peritoneal surfaces including uterus, cervix, vulva, vagina, bladder, bowel, etc.
- Pelvic examination: Physical examination of pelvis for any abnormalities, such as cysts or scars behind the uterus. Ultrasound: To detect cysts associated with endometriosis. Laparoscopy: To identify the location, extent and size of the endometriosis. It is also removed in the same procedure.
Ovarian Cysts
- Arise from several elements of ovary - mesothelial, epithelial, follicular, luteal and endometriotic.
- Commonly encountered in gynaecological imaging and vary widely in aetiology, from physiologic, to complex benign, to neoplastic.
- Small cystic ovarian structures should be considered normal ovarian follicles unless patient is prepubertal, postmenopausal, pregnant or mena diameter is >3cm.
Polycystic Ovary Syndrome
- One of the most common endocrine disorders affecting women of reproductive age. Heterogenous condition whose pathophysiology appears to be multifactorial and polygenic. Women may initially present with symptoms of hyperandrogenism (hirsutism, acne, alopecia), menstrual disturbance, infertility or obesity. Possible long term associations include T2DM, dyslipidaemia, hypertension, CVD, and endometrial carcinoma.
- Signs and symptoms can vary considerably. It is familial and various aspects of the syndrome can be inherited. Can originally be asymptomatic and then become expressed overtime e.g. with weight gain.
- Combined oral contraceptive pill may be prescribed for a variety of reasons including contraception, protection against the development of endometrial hyperplasia and cancer, and to suppress excessive androgen secretion to control acne and hirsutism.
- At risk of endometrial hyperplasia or adenocarcinoma due to unopposed action of oestrogen in absence of progesterone, 3x higher risk of endometrial cancer.
- Transvaginal ultrasound should be considered in the absence of withdrawal bleeds or in the presence of abnormal uterine bleeding. Normal endometrial thickness varies in pre-menopausal women. Normal endometrial thickness varies in pre-menopausal women. Endometrial thickness of less than 7mm or an intermenstrual interval of less than 3 months are associated with normal proliferative endometrium only.
- A thickened endometrium in an amenorrhoeic/oligomenorrhoeic woman, or the presence of an endometrial polyp, should be prompt consideration of an endometrial biopsy and/or hysteroscopy.
Ovarian Neoplasms
- Solid vs Cystic
- Benign vs Malignant
- Classification - epithelial (90%), germ cell, sex cord/stromal, metastatic, miscellaneous.
Epithelial Ovarian Tumours
- Benign
- Borderline - cytological abnormalities - no stromal invasion
- Malignant - stromal invasion
Ovarian Cancer Symptoms
- Insidious onset means that up to 75% of patients present with symptoms of advanced disease due to the mass effects of the tumour.
- Non-specific GI symptoms include bloating and indigestion (often misdiagnosed as IBS). Gradually increasing abdominal distension (often misdiagnosed as “middle-aged spread”).
- Increasing tumour size results in pressure effects causing chronic abdominal, pelvic or back pain, urinary frequency/urgency (pressure on bladder), constipation/altered bowel habit/bowel obstruction (pressure on bowel), leg swelling and DVT/PE (pressure on pelvic veins).
- Abnormal vaginal bleeding can also be a symptom.
- Symptoms of metastatic disease include pleural effusion, ascites, weight loss and fatigue.
- Less commonly, sudden torsion, rupture or infection of the tumour in early disease can present as acute abdominal or pelvic pain (blessing in disguise as can lead to early diagnosis).
Management of Ovarian Cancer
- Surgical management is generally the mainstay of treatment: exploratory laparotomy for tumour debulking and formal surgical staging. This is a major procedure which generally comprises total abdominal hysterectomy (TAH) and bilateral salpingo-oopherectomy (BSO), infracolic omenectomy, pelvic and para-aortic lymph node sampling, peritoneal biopsies, multiple pelvic washings and sampling of ascites.
- Adjuvant chemotherapy is given to all patients past stage 1c.
- Response to treatment can be monitored using CA-125 levels, which decrease if treatment is effective and increase if there is a relapse.
- Intraperitoneal chemotherapy has been shown to improve survival in recent trials.
- Radiotherapy is nto really used in the management of ovarian cancer as the tumours tend to be very radioresistant.
- Biological immunotherapy is emerging as a potential new treatment - specifically monoclonal antibodies.
- Advanced metastatic cancer (unfortunately very common) requires individualised palliative treatment.
