Module 3: Gentials: Cervix and Vagina

Question 1

Now these cards are about pathologies of the cervix. First what is the endo and ectocervix lined by?

Answer 1

Ectocervix: lined by hormonally responsive stratified squamous epithelium
Endocervix: lined by simple columnar epithelium

Question 2

Next just a quick review: What is acute cervicitis?

Answer 2

Endocervix:

• -gonococcal, chlamydia, trichomonas, herpes
• postpartum, post D and C
• -purulent vaginal discharge

Question 3

What is chronic cervicitis?

Answer 3

Non-specific and incidental

• -lymphocytes and plasma cells normally present in wall
• -granularity, thickening
• -retention (nabothian cysts)

Question 4

What is squamous metaplasia? slide 5

Answer 4

Irritation at puberty by lactic acid

• -conversion from columnar to stratified squamous
• -physiological
• -no HPV
• forms the transformation zone: squamocolumnar junction

Question 5

Moving on to carcinoma in situ of the cervix. What are the HPV strains of concern?

Answer 5

HPV 16 and 18

–E6 and E7 inactivating p53 and Rb

Question 6

What is the histology for carcinoma in situ?

Answer 6

Both still have koilocytes
CIN I: lower 1/3rd dysplasia
CIN II: lower 2/3rd dyplasia
CIN III: dysplasia throughout without koilocytes but BM in tact – this is actually carcinoma in situ
–note on cytology II and III are group together as HSIL and I is LSIL

Question 7

Increased dysplasia shows what on histology?

Answer 7

High nuclear: cytoplasmic ratio

more basophilic nucleus (hyperchromatism)

Question 8

What is the best diagnostic test for cervical carcinoma in situ?

Answer 8

Colposcopy and biopsy to look for BM intact

Question 9

What are the futures of micro invasive cervical cancer?

Answer 9

Microinvasive: 5mm deep and 7mm wide
no invasion of blood vessels or lymphatics
Cone Biopsy: taking out the total squamocolumnar junction for tx

Question 10

What are the features of fully invasive cervical cancer?

Answer 10

Fully Invasive: greater than 5mm deep and 7mm wide; invasion of lymph and blood vessels

Question 11

What is the most important predisposing factor for invasive cervical cancer?

Answer 11

multiple sexual partners
multi party
early age at first sexual intercourse
immunodeficient

Question 12

What is the presentation for invasive cervical cancer?

Answer 12

Postcoital bleeding most common
Leukoria:
Dyspareunia: painful intercourse

Question 13

What does histology show for invasive cervical cancer?

Answer 13

Keratin pearls abundant for well differentiated: better dx

note there is moderate and poorly differentiated

Question 14

What are the complications for invasive cervical cancer?

Answer 14

Most common cause of death is renal failure as a result of bilateral hydronephrosis as a result of invasion of the bladder
Constipation from rectal invasion
Invasion of vagina
Metastasis to inguinal lymph nodes

Question 15

What does a pap cytology show?

Answer 15

Naturally in the cervix, squamous cells mature from bottom to top as they accumulate glycogen

• -Smaller Nucleus: most mature/largest = superficial cells (pap smear)
• Biggest nucleus/mitotically active = least mature = parabasal cells

Question 16

What is the Schiller’s Test?

Answer 16

test for non-glycogen/highly mitotic areas — site of carcinoma
–paint cervix with iodine and look for unstained pale patches

Question 17

What is the P16 stain in regards to cervical cancer ?

Answer 17

if completely negative than not CIN

–marker of staining for high risk HPV

Question 18

Moving on to the low risk HPV strains 6 and 11. What are features? what do they cause?

Answer 18

No dysplasia: due to lack of insertion into the host genome

–raised painless warts around the vagina called Condyloma acuminatum

Question 19

What are the gross and histology features, slide 8, of Condyloma Acuminatum?

Answer 19

Gential Warts: cauliflower shaped that is raised, dry and scaly
Histology: Koilocytes with epidermal hyperplasia and hyperkeratosis (thickening of the stratum corneum) and parakeratosis (Stratum spinosum). no dysplasia (acathosis)

Question 20

What are symptoms of Condyloma Acuminatum?

Answer 20

Itching and burning of the vulva but no vaginal discharge and no pain

Question 21

What is used to visualize the warts in Condyloma Acuminatum?

Answer 21

Acetic Acid

Question 22

What are the complications of Condyloma Acuminatum?

Answer 22

No chance of malignant transformation

–papillomas in the larynx (benign) if baby comes through the birth canal

Question 23

Finally genital herpes is caused by which HSV strains?

Answer 23

HSV2 mainly but can be caused by HSV1 (oral sex)

• -latent in the sacral nerve ganglion
• -primary infection is worse than the reactivation

Question 24

What is the main mode of transmission of genital herpes?

Answer 24

Genital Fluids

–sexually and vertically transmitted (placenta or vaginal birth)

Question 25

Why is vaginal birth contraindicated in patients with genital herpes?

Answer 25

Baby get conjunctivitis and temporal lobe encephalitis so must do a C -section

Question 26

What is the presentation for patients with genital herpes?

Answer 26

Initial painful filled vesicles that ruptures to become ulcers in the vulvar region
–can become latent in sacral neurons and reactivate when stressed

Question 27

What is seen on Tzank smear for patients with genital herpes?

Answer 27

Intracellular cowdry type A bodies and multinucleated syncytial giant cells
–note PCR most accurate (b/c this is a virus)
can also do serology for IgG and IgM

Question 28

What are complications of genital herpes?

Answer 28

Immunocompetent = pain 
Immunocompromised = temporal lobe encephalitis and in babies vertical transmission

Question 29

What are the three M’s for any herpes?

Answer 29

Multinucleation
Margination of the chromatin pushed to the periphery
Molding of the cells

Question 30

The next vaginal issue to be discussed are Gartner’s Duct Cysts. What are some general features?

Answer 30

Benign 
Remnants of mesonephric ducts 
Anterolateral wall of vagina 
1-2cm
Mimics carcinoma clinically

Question 31

Next is vaginal adenosis, what are some features?

Answer 31

Seen in young girls (10yrs) whose mother got diethyl stilbesterol (DES) during pregnancy to prevent abortion

Question 32

What are histological features of vaginal adenosis?

Answer 32

Cells forming endocervical glands in vaginal wall

• -may progress to clear cell adenocarcinoma years later
• -benign and clinically mimics carcinoma

Question 33

Next is Sarcoma Botryoides (Embryonal Rhabdomyosarcoma). What are the features?

Answer 33

Girls less than 5 years old

• –polypoid friable mass (bunch of grapes) hanging in the vagina
• -highly malignant, malignant rhabdomyoblasts, cambium layer, fibromyxomatous stroma

Question 34

What is the histology for Sarcoma Botryoides?

Answer 34

Rhabdomyoblasts (precursors of skeletal muscle)

–requires surgery and chemotherapy

Question 35

Next is squamous carcinoma of the vagina, what are the features?

Answer 35

Primary is super rare

• -usually due to a secondary cause of carcinoma from other parts of the female genital tract
• -poor prognosis for either
• -pelvic and inguinal nodes are based on location

Question 36

Finally the last topic of this card deck is Bartholinitis. What are the features?

Answer 36

Acute inflammation on inferior part of labium major – bartholin glands (which open into vaginal introitus)

Question 37

How does an abscess formation happen with Bartholinitis?

Answer 37

Blocking due to inflammation — abscess formation

• -strep, staph, gonococci and e.coli
• -drainage and marsupialization

Question 38

How do patients with Bartholinitis present?

Answer 38

Severe discomfort during intercourse

Question 39

How often should a women get a pap smear? what if it is abnormal?

Answer 39

once every 3 years if normal

and every 6 months if abnormal

Question 40

What are the two type of cervical cancer?

Answer 40

Endocervical (dysplastic glands)
Ectocervical (keratin pearls)
both HPV 16 and 18

Question 41

Besides cervical cancer, what other cancers can HPV 16 and 18 cause?

Answer 41

Anal
Penile
Vulva
Oral