Vulva/Vagina Flashcards
Development
Around 7 weeks - indifferent stage
Male – MESONEPHROS (Wolffian Ducts) develop into the male genitals – in the female they regress in the fetus with the remnants becoming the broad ligament and the lateral walls of the cervix/vagina
PARAMESONEPHROS = MULLERIAN DUCTS = Become the FEMALE GENITALS
By week 9, they start to fuse, forming the uterine corpus, cervix and upper 2/3 of vagina
Urogenital ridge forms the lower 1/3 of the vagina
By week 12, the uterus structure is complete with fallopian tubes, and the ovaries are visible
Congenital Abnormalities of the Vagina/Vulva
FAILURE OF MULLERIAN DUCT FUSION – no fusion; can lead to DUPLICATION OF THE WHOLE EXTERNAL GENITALIA as well as duplication of the ureters, vagina, cervix, uterus
IMPERFORATE HYMEN –> hymen membrane remains solid; with menstrual shedding, blood accumulates in the vagina
VAGINAL ATRESIA –> failure of the vaginal plate to become hollow, or the vagina might not form at all………cool
Vulvar CYSTS
Normal vulva has a vestibule with Bartholin Ducts coming out at the bottom of the genitals –> since the external vulva is on the outside of the body, it is covered by SQUAMOUS epithelium (like skin!) so it can have any skin abnormality
CYSTS may develop in and around the specialized structures
BARTHOLIN
VESTIBULAR
These cysts are BENIGN, but can be uncomfortable so they can be excised
Complications include infection or abscess –> pain, redness, bulbous
Lichen Sclerosus
A condition in which the epidermis is THINNED with hyperkeratosis on the surface (thick surface layer of anucleate squamous cells)
When the entire vulva is affected, the labia becomes somewhat atrophic and stiffened, and the vaginal orifice is constricted
Most commonly in POSTMENOPAUSAL WOMEN
Responds to TOPICAL STEROIDS
LIFELONG INFLAMMATORY SKIN DISEASE; itching, irritation
Somewhat increases risk of developing SQUAMOUS CELL CARCINOMA (1-4%)
Squamous Hyperplasia
Thickening/hardening (lichenification) of the squamous epithelium
Dermis is in a CHRONIC INFLAMMATORY STATE
Appears as a pink-white lesion
Presents as ITCHING
THICKENED SQUAMOUS EPITHELIUM and an INCREASED KERATIN LAYER above
Biopsy needed to rule out neoplasm
CONDYLOMAS
Vulvar Tumors –> usually associated with HPV6 and HPV11, resulting in CONDYLOMA ACUMINATUM (genital warts)
Koilocytic changes –> nuclear enlargement, irregularity of the nuclear membrane, darker staining pattern, clear area around nucleus (PERINUCLEAR HALO)
Papillary, exophytic raised lesions, sometimes dark
Lesions are CONTAGIOUS and may persist in immunocompromised individuals; if healthy, the lesion will regress
HPV 16 or 18 will mean INCREASED RISK FOR DYSPLASIA/CANCER
Treat - excision, cautery, lasers, topical agents, HPV vaccine is PREVENTATIVE
Vulvar Intraepithelial Neoplasia
Related to condyloma, and is also related to HPV INFECTION
Present as MULTIFOCAL raised lesions, pigmented 25% of the time
Microscopic transition to a THICKENED DYSPLASTIC EPITHELIUM; nuclear abnormalities seen
3 grades (1 = low level dysplasia, 2 = moderate, 3 = SEVERE CARCINOMA IN SITU)
Associated with vulvar carcinoma, typically SQUAMOUS
1/3 of these patients ALSO have Cervical Intraepithelial neoplasia (CIN)
HPV Vaccine! Even to those affected, can decrease size of lesions
SQUAMOUS CARCINOMA of the vulva
Two types
KERATINIZING –> seen in older, post-menopausal women; NOT HPV ASSOCIATED
Associated with LICHEN SCLEROSUS and differentiated VIN; 60% of squamous carcinomas of the vulva
CLASSIC VIN ASSOCIATED –> Younger women, HPV RELATED, Basaloid, WARTY appearance; 40% of the vulva squamous carcinomas
Looks like a RAISED vulvar lesion
Hyperchromatic nuclei, with a high N/C ratio, Keratin pearls!
Undifferentiated vs. Differentiated (just in general)
Normal cells of an organ ARE differentiated
When tumors become present, they can closely resemble that organ’s cells (well-differentiated) or not really (poorly differentiated) or not at all (undifferentiated)
Poorly/undifferentiated TEND TO BE WORSE and MORE INVASIVE
Paget’s Disease OF THE VULVA!!!
Similar to that seen in the breast –> red, scaly patch
Adenocarcinoma in situ that involves vulvar skin
Stains positive for MUCIN and CEA
May be underlying invasive carcinoma
CARCINOMA IS ALWAYS INVASIVE IN THE VULVA –> can lead to urinary tract malignancy or adenocarcinoma of the rectum
14% have CONCURRENT breast carcinoma! oh no!!!
Malignant Melanoma of the VULVA
Occurs VERY RARELY in the vulva
9% of vulvar abnormalities are melanoma –> appear in SUN-damaged skin; pigmented lesions in the vulvar area, and can occur in ANY skin layer; Dark colored (blood or melanoma pigment)
Lesion is NOT COMPLETELY UNIFORM
POOR PROGNOSIS
Benign counterpart = NEVUS –> usually small, uniform in color, regular; formed from melanocytes of the skin
Diff Dx of Melanomas/classification
If you suspect melanoma, CANT RULE OUT PAGET’s or SQUAMOUS CELL CARCINOMA –> they all look very similar grossly AND microscopically
Melanomas can be classified by SKIN LAYER INVADED or by the THICKNESS OF THE TUMOR (little metastatic potential if less than .75 mm)
Non-neoplastic vaginal disorders
Vaginal CYSTS –> can arise from the MESONEPHRIC ducts (Gartner’s)
Lined by a single layer of GLANDULAR TISSUE; they can have epithelial inclusions when the ducts are obstructed; can also be lined with SQUAMOUS epithelium; anytime there is an obstruction, an abscess or infection is formed
Atrophic Vaginitis –> inflammation secondary to the LACK OF ESTROGEN
Benign Tumors of the Vagina
SQUAMOUS PAPILLOMA – because squamous cells are part of the epithelium, squamous papillomas may arise from the epithelium of the vagina
These MAY or MAY NOT be associated with HPV
LEIOMYOMA – underneath the epithelium lies SMOOTH MUSCLE (these are smooth muscle tumors)
SQUAMOUS CELL CANCER of the vagina
These are OFTEN HPV RELATED, termed VAGINAL INTRAEPITHELIAL NEOPLASIA (VAIN)
Account for LESS THAN 2% of female genital tract malignancies
20% have had PRIOR CERVICAL NEOPLASMS
Found mostly in post-menopausal women in their 60s-80s
