vulva + vagina + cervix + uterine + ovarian Flashcards
round ligament of uterus terminates here
labia majora
skene glands are located around the
urethra
bartholin glands located
near vagina opening
ducts at 5 o’clock and 7 o’clock
obstruction of duct → cyst → infected cyst = abscess (I & D)
provide lubrication for intercourse
part of cervix in vagina
ectocervix
part of cervix closer to uterus is
endocervix
histology of vulva
stratified squamous epithelium labia majora (exposed): keratinized labia minor (moist): non-keratinized
histology of vagina
stratified squamous epithelium (non-keratinized)
histology of ectocervix
stratified squamous epithelium (non-keratinized)
histology of endocervix
simple columnar epithelium (mucous-secreting cells prevent infection to uterus)
where does most cervical cancers occur
squamocolumnar junction of the transformation zone (transitions between ectocervix and endocervix)
HPV can infect and replicate well here
squmocolumnar junction is located in
transformation zone
metaplastic cells transform from columnar (endocervix) → squamous epithelium (ectocervix) here
depends on age + hormonal status of women
transformation zone
histology of body of uterus
simple columnar epithelium (ciliated or secretory, long tubular glands)
histology of fallopian tube
simple columnar epithelium (mostly ciliated, some secretory (peg) cells - nutrition to egg)
histology of ovary
simple cuboidal epithelium (germinal epithelium)
most ovarian cancer come from what epithelium
simple cuboidal epithelium
most common type of vulvar cancer
squamous cell carcinoma of vulva
pre-pubertal or post-menopausal female benign, inflammatory lesion of vulva thinning of epidermis smooth, white plaques pruritic, pain, dyspareunia
lichen sclerosus
treatment of lichen sclerosus
topical corticosteroids
vulvar lesion associated with increased risk of squamous cell carcinoma of vulva
lichen sclerosus
most common type of vulvar cancer
squamous cell carcinoma of vulva
increased risk of squamous cell carcinoma of vulva if:
HPV infection (koilocytes present) -30% cases chronic inflammation (most cases) - like lichen sclerosus
HPV infection (oncogenic strains: 16, 18, 31) can cause
squamous cell carcinoma of: (vulvar and vaginal cancer are secondary to cervical SCC - have same risk factors) cervical cancer vulvar cancer vaginal cancer
koilocytosis (enlarged nuclei, white cytoplasmic clearing)
squamous cells infected with HPV (viral replication occurring here)
intraepithelial cancer of vulva (occurs in skin)
can be associated with underlying malignancy of vulva or non-vulvar (breast, GI)
red, well-demarcated lesion
pruritic (like eczema)
Paget disease of vulva
intraepithelial cancer of vulva (occurs in skin)
can be associated with underlying malignancy
Paget disease of breast
types of vaginal cancers
squamous cell carcinoma
clear cell adenocarcinoma
sarcoma botryoides
vaginal cancer associated with high-risk HPV strains (16, 18, 31)
squamous cell carcinoma
vaginal cancer associated with in utero
diethylstilbestrol (DES) exposure
clear cell adenocarcinoma of women in utero during exposure:
DES was given in 40/50’s to prevent miscarriage
SE of DES exposure
clear cell adenocarcinoma of vagina of women in utero during exposure
mullerian duct anomalies: T-shaped uterus
vaginal adenosis (patches of columnar epithelium on ectocervix + vagina)
vaginal cancer in infants and children
sarcoma botryoides (embryonal rhabdomyosarcoma)
progression of cervical cancer
infection of squamocolumnar junction of the transformation zone with high-risk HPV 16 and 18 have oncogenes E6 + E7 → mutated cells → cervical dyplasia (screen for this) → cervical cancer
risk factors for cervical dysplasia + cancer
persistent infection with high-risk HPV strain (16 + 18 = 70% of cervical cancers)
early coitarche: ↑ risk of exposure to HPV
multiple sexual partners
immunosuppression (HIV): can’t clear infection
smoking: impairs immunity
OCP use: don’t protect against HPV infection
history of STDs
Rb is a tumor suppressor that
G1 → S checkpoint
binds to and inactivates E2F TF (transcribes genes for DNA replication)
at G1→S
E7 protein
binds and inactivates Rb → activated E2F TF → DNA replication (G1 →S)
p53 is a tumor suppressor that controls
senses DNA damage at G1→S or G2→M
stop cell-cycle for DNA repair
if no repair possible: p53 induces apoptosis of cell
E6 protein
binds to p53 →degradation of p53 →DNA damage → cancer
types of cervical cancer
squamous cell carcinoma (most common)
adenocarcinoma
CIN describes
how far dysplastic cells extend
CIN: bottom 1/3 of epithelium
CIN II: 2/3 or full thickness involvement
invasive cervical carcinoma
invasion through BM
more common grading scheme
low grade and high grade SIL
(squamous intraepithelial lesions)
LSIL: = CIN I (mild dysplasia) HSIL = CIN II (moderate dysplasia) /III (severe or CIS)
most LSIL’s
regress
tx: just monitor
most HSIL’s
are precancerous
tx: need excision
cervical cancer screening
Pap smear: catches cervical dysplasia (koilocytes, darkening of nuclei, ↑N/C) before progressive to invasive carcinoma
if >30 yo: HPV DNA test + Pap smear allows to space out the screening interval
HPV vaccines
prevent HPV infection and cervical dysplasia
bivalent: 16 + 18
quadravalent: 16 + 18, 6 + 11 (90% of genital warts)
abnormal vaginal bleeding (poist-coital) due to friable tissue in cervix
nonspecific vaginal discharge
pelvic or low back pain
bowel or bladder symptoms
ureteral obstruction → pyelonoephritis, uremia, renal failure
cervical cancer
staging and treatment of cervical cancer
staged clinically (not surgically) treatment depends on stage: surgery +/- chemoradiation
3 layers of uterus
perimetrium: outer serosal
myometrium: smooth muscle
endometrium: glandular, grows via estrogen
4 layers of endometrium
stratum spongiosum + stratum compactum: sheds every month (due to low estrogen/progesterone) stratum basale (base layer): doesn't shed with menstruation
estrogen causes the endometrium to
proliferate and become thicker during 1st have of cycle
excess estrogen can cause
endometrial hyperplasia and carcinoma
risk factors for endometrial hyperplasia
unopposed estrogen state:
anovulation (PCOS): no CL forms (source of progesterone)
↑ estrogen production: granulosa cell tumor (secretes estrogen), obesity (estrone)
↑ exogenous estrogen with uterus (HRT without progesterone)
most common gyn cancer in US
endometrial carcinoma
55-65 yo women (post-menopausal)
irregular bleeding or post-menopausal bleeding
endometrial carcinoma
diagnosis of endometrial cancer
endometrial biopsy
inflammation of endometrium
caused by ascending vaginal infection (most common)
acute: postpartum (Csection), retained products of conception
chronic: due to PID, retained foreign bodies
endometritis
plasma cell in endometrium
CHRONIC endometritis
treatment of endometritis
broad spectrum antibiotic
post-partum endometritis: getamicin + clindamycin
endometrial tissue outside uterus
tissue bleeds every month → irritation, pain → inflammation → fibrosis + adhesions
endometriosis
possible causes of endometriosis
retrograde menstrual flow through fallopian tubes
metaplasia of coelomic epithelium (germinal epithelium)
vascular or lymphatic spread
common areas of endometriosis
ovaries (most common) → large ovarian cysts with blood → chocolate cyst uterine ligaments bowel, bladder lungs bone heart
childbearing women with dysmenorrhea CYCLIC pelvic pain dsypareunia dysuria dyschezia - pain with BM NORMAL-SIZED uterus
endometriosis
diagnosis of endometriosis
laparoscopy: biopsy + therapeutic (remove implants)
treatment of endometriosis
laparoscopy - remove lesions NSAIDs OCPs progestins: inhibit growth of endometrial tissue leuprolide: continous GnRH agonist danazol
hypeplasia of basalis layer of endometrium → endometrial tissue extends into myometrium (smooth muscle layer) → hypertrophy (thickened) uterine wall
adenomyosis
menorrhagia dysmenorrhea dyspareunia pelvic pain UNIFORMLY ENLARGED, SOFT globular uterus uterus TENDER upon palpation
adenomyosis
treatment of adenomyosis
hysterectomy
benign tumor of smooth muscle of the myometrium
monoclonal (each arises from one cell)
hormone sensitive to estrogen/progesterone (bigger with pregnancy, ↓ in size with menopause)
leiomyoma
most common benign tumor in women
leiomyoma
round, firm, well-circumscribed tumors
“whorled pattern” of smooth muscle cells
leiomyoma
most asymptomatic menorrhagia (most common sx) dysmenorrhea pelvic pressure/discomfort acute pelvic pain (fibroid on stalk and twists itself → cuts of its blood supply) or (outgrow blood supply → becomes necrotic) infertility, miscarriages urinary frequency: compress bladder non-tender, ENLARGED uterus with IRREGULAR contours
leiomyoma
diagnosis of leiomyoma
physical exam followed by US (confirmation)
treatment of leiomyoma
hysterectomy
myomectomy (only remove fibroid - can result in ↑ number of leiomyomas after surgery)
leuprolide pre-op: shrink fibroid
can leiomyomas progress to leiomyosarcomas
no
malignant tumor arising from myometrium de novo
leiomyosarcoma
women with rapidly enlarging uterus and/or
vaginal bleeding
leiomyosarcoma
SE of drug used to shrink leiomyoma pre-op and endometriosis
bone loss (produces a menopausal-like state)
dominant (graafian) follicle fails to rupture at ovulation (after LH surge) → follicle continues to grow
regresses spontaneously
follicular cyst (type of functional cyst)
corpus luteum does not degenerate (should involute after 2 weeks with no fertilization or after 6 wks if pregnancy ocrurs)
usually hemorrhagic cyst (broken blood vessel at time of ovulation)
regresses spontaneously
corpus luteum cyst
ovarian cyst due to high hCG levels (multiple gestations, molar pregnancy, gestational trophoblastic disease, assisted reproductive techniques)
bilateral, multiples usually
theca-lutein cyst
ovarian cyst with multiple tissue types from all 3 germ layers (endoderm, mesoderm, ectoderm)
benign: mature tissue
malignant: immature tissue (neuroectoderm)
teratoma (dermoid cyst)
ovarian cyst that contains blood
hemorrhagic cyst
endometriosis inside the ovary →cyclic bleeding in the ovary
endometriod cyst or
“chocolate cyst” or endometrioma
twisting of supportive ligaments of ovary →↓ blood supply → ischemia, necrosis
ovarian torsion
greatest risk if >5 cm
acute onset of severe (sharp, stabbing) pelvic pain with possible radiation to back or groin
+/- nausea and vomiting
ovarian torsion
treatment for infertility
leuprolide: GnRH agonist (continuous - act like antagonist)
clomiphene: estrogen antagonist effect, induces ovulation
inability to conceive after 1 year of unprotected intercourse
infertility
85% successful after 1 year
female causes of infertility
PCOS: anovulation
endometriosis: affects tubes
uterine fibroids
PID: ascending infection of female reproductive tract, scar tubes
chromosomal abnormalities: turner syndrome (streak ovaries)
Ashermann syndrome: (intrauterine adhesions) after D&C
work up for infertility
ovulating (cyclic menses, mittleschmertz - mid-cycle pelvic pain at ovulation, LH surge predictor kit, biphasic basal body temp (1 day after ovulation)?
reproductive anatomy (hysterosalpingography - see dye leave fallopian tubes)?
semen or sperm (get semen analysis)?
symptoms of ovarian cancer
usually symptoms once mets: ascites ab distention ab pain → nausea, early satiety vaginal bleeding urinary sx (mets to bladder, ureter)
ascites in otherwise healthy women
ovarian cancer
risk factor of ovarian cancer
family history:
BRCA 1 or 2 mutation (associated with breast and ovarian cancer)
Lynch syndrome/hereditary nonpolyposis colon cancer (associated with colon, endometrial, ovarian cancer)
uninterrupted ovulatory cycles (nulliparity, infertility, early menarche, late menopause)
protective against ovarian cancer
interrupt ovoluatory cycles
increase in parity
breastfeeding
OCP use
CA-125 tumor marker
ovarian cancer
used to monitor disease progression and response to therapy
not used for screening: nonspecific (esp reproductive age, ↑ with peritoneal irritation)
4 types of ovarian tumors
epithelial tumors (benign or malignant)
sex-cord stromal tumors
germ cell tumors
metastatic tumors
most common type of ovarian neoplasm (majority of ovarian tumors, majority of malignant tumors)
epithelial tumor
40-60 yo female
bilateral ovarian mass
poor prognosis if malignant (found late)
epithelial ovarian tumor
types of serous epithelial ovarian tumors (most common type of epithelial tumor):
cystic, serous fluid-filled
ciliated columnar epithelium (fallopian tube-like)
Psammoma bodies (concentric calcifications)
benign: serous cystadenoma
malignant: serous cystadenocarcinoma
psammoma bodies in ovary
concentric calcifications
found in serous epithelial tumors:
benign: serous cystadenoma
malignant: serous cystadenocarcinoma
types of mucinous epithelial ovarian tumors
multi-loculated filled with mucin can get up to 50 lbs histology similar to GI tissue benign: mucinous cystadenoma malignant: mucinous cystadenocarcinoma
abundant mucinous ascites (abdomen filled with gelatinous substance) caused by primary appendiceal cancer (not mucinous ovarian tumor as originally thought)
pseudomyxoma peritonei
MALIGNANT epithelial ovarian tumor
look like endometrium (tubular glands)
some associated with endometriosis
30% coexist with endometrial cancer (cancers arise independently)
endometriod tumor
variant of endometroid tumor (epithelial ovarian tumor)
cells with clear cytoplasm
clear cell ovarian tumor
BENIGN epithelial ovarian tumor
epithelium is urinary tract-like
Brenner tumors
germ cell tumors in female analagous to
testicular cancers in males
unilateral usually
teens to 20 yo female
good prognosis (responsive to chemo)
germ cell ovarian tumor
types of ovarian epithelial tumors
Serious Epithelial Malignancies are Clearly Bad Serous (most common type) Endometroid Mucinous Clear cell Brenner tumor
types of ovarian germ cell tumors
teratomas (includes struma ovarii)
dysgerminoma (seminoma in males)
yolk sac tumor
ovarian choriocarcinoma
ovarian mass with hyperthyroidism
struma ovarii: teratoma containing functional thyroid tissue → hyperthyroidism
malignant ovarian tumor that produces hCG and LDH
sheets of large cells with clear cytoplasm + central nuclei (“fried egg cells”)
dysgerminoma ovarian tumor
malignant ovarian tumor that produces AFP (tumor marker) Shiller-Duval bodies (primitive glomeruli - central vessel surrounded by tumor cells)
yolk sac tumors (endodermal sinus tumors)
malignant ovarian tumor that produces hCG
mets to LUNG (shortness of breath, hemoptysis)
not responsive to chemo (fatal)
ovarian
choriocarcinoma
–identical histology to choriocarcinoma that arise from placental tissue during or after pregnancy (but responsive to chemo)
types of sex cords stromal tumors
granulosa cell tumors
sertoli-leydig tumors
fibroma
thecoma
unilateral ovarian mass
women of any age
produce hormones
good prognosis (detected early due to hormonal changes)
sex-cord stromal tumors (hormones located in the stroma)
potentially malignant ovarian tumor
produce ESTROGEN
child: precocious puberty
postmenopausal women (more common): abnormal vaginal bleeding, postmenopausal bleeding, endometrial hyperplasia/cancer
yellow: contain cholesterol needed for estrogen synthesis
call-exner body
granulosa cell tumors
call-exner body in ovary
granulosa cell tumor
granulosa cells are trying to make ovarian follicles to surround the oocyte (make rosettes of tumor cells around eosinophilic lumen)
Shiller-Duval bodies in ovary
yolk sac tumor
primitive glomeruli - central vessel surrounded by tumor cells in cystic space lined by tumor cells
ovarian tumor that can resemble seminiferous tubules
possibly malignant (but detected early)
good prognosis
produce ANDROGENS → virilization (hirsutism, deepening of voice, clitoromegaly)
yellow: contain cholesterol
sertoli-leydig tumors
sertoli cells line the seminiferous tubules in males
ovarian tumor that arise from fibroblast
form encapsulated, solid
NO HORMONES
associated with Meigs syndrome
fibroma
ovarian tumor + ascites + hydrothorax (pleural effusion)
Meigs syndrome: associated with fibroma (ovarian tumor)
ovarian tumor that arises from spindle cells
can be mixed with estrogen-producing cells →
CAN PRODUCE ESTROGEN: precocious puberty, postmenopausal bleeding, endometrial carcinoma (like granulosa cell tumors)
thecoma
bilateral ovarian masses think of
metastasis to ovaries
common causes of ovarian mets
uterus fallopian tube other ovary GI (krukenberg tumor) breast
metastatic gastroadenocarcinoma travels to the
bilateral ovaries
called Krukenberg tumor
signet ring cells filled with mucin (nuclei pushed to side) in ovary
Krukenberg tumor (met gastroadenocarcinoma)
