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Flashcards in Female Genitalia Deck (44):
1

Endometirum-

day 1-13 proliferative- estrogen- glands straight, epithelium cuboidal to tall, single to double layer, dense stroma, compact cells
day 14, ovulation
day 15-18 secretory(progesterone. - coiled glands, tall with vacuoles single layer epithelieum, edematous stroma, plump cells conspicous arterioles.

2

Examination of uterine diseases

Pelvic exam with speculum, colposcpy, ultrasund, CT scan
Pap smear for cervix, infection, CIN, neoplasia
Biopises- cervic, endometrium
Dilatation and curettage- (D&C)-

3

unopposed estrogen effect

anovulator cycles- persistent graffian follice, extremes of reproductive life- polycycstic ovaries, obesity, emotional stress, endocrine, excess physical activity

- etiology- estrogen producing neoplasms- granulosa cell tumor, ovary, adrenal cortical adenoma.

Pathogenesis- persistent proliferation- irregular breakdown, DUB

complication- endometrial hyperplasia, endometrial carcinoma.

4

Exogenous progesteron effect

pill endometrium, contraceptive pills with progesterone.
-abundant stroma, plump cells(pseudodecdiual., edema, gland small, atrophic (lack of priming estrogen.

5

Inadequate luteal phase

irregular ripening

etiology- lowered progesterone

Pathogenesis- poorly developed secretory endometerium, breask down irregularly (DUB

Morphology- poor and immature secretory glands,

Clinical: low progesterone, FSH, LH

6

PErsistent luteal phase

Etiology-normal menstruation is induced by abrupt cessation of progesteron secretion by CL,

If C.L. continues to secerete low levels of progesteron- protracted and irregular shedding. periods regular but bleeding is excessive and prolonged ( 10-14 days

Morphology- persistent secretory even after 5 days of menstruation.

7

Endometerious

Morphology- endometrial tissue in other places like ovary, tubes, parametrium, gut, serosa, umbillicus. can also appear at lapartomy or caesarian scars. Rarely in the lung, pleura or bones.
-have glands, stroma, and cyclical bleeding,
-discolored nodules: large, blood filled cysts, with adhesions. endometrial glans, endometrail stroma, hemosiderin.

Etiology- endometrosis interna- myometrium is more than 3 mm, diffuse focal adenomyoma

Clinical- hemosiderin, fibrosis, chocolate ovary cysts, tubal scars, infertitilty, happens during reproductive phase of life, asymptomatic, pain, dysmenorrhea, menorrhagia, infertility, cyclical bleeding, urinary tract, rectum umbillicus, surgical scars.
-higher risk of tubal pregnancy, urinary obstruction
- regression following pregnancy, oral contraception

Pathogenesis= metaplasi of celomic epithelium, retrograde flow through FT, also have the metastatic theory by vascular dissemination.

8

Endometritits

cyclical shedding of endometerium, no foothold

Etiology
Acute- postpartum (puerperal sepsis, offensive lochia
-ascending gonoccoal,
-pyometrum,-( obstrction of os by neoplasm, fibrosis)
Chronic- non specific, plasma cells, IUCD, retained products, TB

9

Endometrial hyperplasiia

Etiology- excess unopposed estrogen effect, perimenopausal metrorrhagia

Increased gland to stromal ration, more glands with less

simple cystic, complec with/without atypia

Reversible with progesterone tehrapy

Atypia, carcinoma in situ, endometrial carcinoma,

look for source of estrogen- (ovary, adrenals, HRT.)

10

Atypia hyperplasia

Simple no architectural complexity of glands but nuclear atypia, present in glands

complex marked archetectural complexcity of the glands and nuclear atypia present, progress to endometrial adenocarcinoma in 24%

Nuclear enlargment, pleomorphism, vesicular change, chromatin irrgularity, loss of polarity, prominent nucleoli, cellular stratification.

11

Simple hyper plasia

simple- no archtiecterual complexity of glands and no nucler atypia
complex- marked archetectural complexity of glands with no nuclear atypia.

12

Endometrial polyp

perimenopausal- .5 -3 cm
extrene response to hyperplasi, asymptomatic or metrorrhagia,
-malignant transformation very RARE.

13

Endometrial carcinoma

55- 65 years, if yong patients usually underlying cause. (cervical carcinoma in young patients.

Etiology- unopposed estrogen effect, preceded by hyperplasia,
Risk factors- obesity, diabetes, hypertension, nulliparous,

Pathogenesis- polypoid fungating mass in the cavity asymmetric enlargment of uterus. Back to back glands.

Grading I, II, III, staging

Spread- local, myometrium, cervix, vagina, rectum, peritoneal,
-lymphatic-liac, paraaortic,
-blood-lung liver.

Clinical-Post menopausal bleeding, endometerial biopsy for diagnosis.

14

Malignant mixed Mullerian tumor ( mixed mesodermal tumor

older than 55 years,

Etiology- from residual Mullerian msodermal cells in endometrium

Morphology
Large fleshy mass, hemorrhage, necrosis
-epithelial and mesenchymal (leio, rhabdo, chondro, osteo,

Poor prognosis.

15

Smooth muscle tumors of the uterus algorithm

nuclear atypia--> tumor necrosis?
-Yes--> MI greater than 10?--> leimyosarcoma
- NO No need to mitotic count- Leiomyoma

16

Leiomyoma

Common(25 % benign smooth muscle tumor- 20-40 years old, estrogen dependant growth, regress, with menopause.

morphology0 subserous intramural, submucous, circumscribed, whorled nodules, resemble normal smooth muscle fibrosis (fibroid

Asymptomatic, menorrhagia, mettrohagia, infertility, mass effect

Acute pain, red degeneration- necrosis specially in pregnancy- no malignant potential.

Laparoscopic resection, hysterectomy

17

Leiomyosarcoma

Etiology-Rare, denovo and not from leiomyoma

Morphology- large bulky, hemorrhage, necrosis

hypercellular with atypia, greater than 10 mitosis, poor prognosis.

clinical- older women, post menopausal bleed

18

Uterine bleeding differential

abortion, dUB, endometriosis, Chronic endometritits, endometrial hyperplasia, polyp, carcinoma, leiomyoma

19

Ectocervix

lined by hormonally responsive stratified squamous epithelium, noncornified: post puberty, mature cells, store glycogen which support the growth of normal flora.

20

endocervix

lined by simple columnar epithelium, lined by simple columnar epithelium, endocervical glands are crypt like spaced lined by the same epithelium

21

acute cervicitis

endocervix- no erosion
extocervix- erosion

etiology- Goncoccal, chlamydia, candida, trichomonas, herpes, Post partum, Post D&C,

clinical- purulent vaginal discharge

22

Chronic cerviciits

non specified incidental, lympohcytes and plasma cellsnormally present in wall, granularity, thickening, retention, Nabothian cysts.

23

Squamous metaplasia

Non-specific response to irritation, no malignant potential. no loss of polarity, no hyperchromasia

24

Endo cervical polyp

Pre- menopausal- hyperplastic glands, vascularity, edema, inflammation, no malignant potential.

25

Condyloma accuminatum

Etiology-STD Papillomatous, koilocytes, HPV 6, 11, no malignatn potentation
-flat- HPV 16, 19,31, 32- risk of carcinoma

-inactivated tumor supressor genes, Tp53, RB1 and activate cyclin E leading to uncontrolled proliferation,

26

Cerviacl Intraepithelial Neoplasia

Risk factors- HPV 16, 18, 31, 33, 35, 45 -high risk
-HPV 6, 11, 40, 54- low risk, not associated with invasive carcinoma
- sexual activity at a young age
- multiple sex partners
-parity greater than 7
-Chymdal infection
-smoking
- high viral load
-persistent SIL/HPV

CIN1- mild dysplasia, increased N:C ratio, pleomorphic, hyper chromatic nuclei
CIN3(severe dysplasia, carcinoma in situ) 22, 72% invasive carcinoma.

treatment- cryosurgery, electrocoagulation, laser, cone biopsy,(total squamocolumnar junction( stage 1A carcinomas (depth of invasion 5 mm and lateral extent 7mm-microinvasive.

27

Normal maturation of cervical cells

in normal cervical squamous epithelium, basal cells are small and cuboidal or columnar, with relatively high N:C ratio. Mitoses are rare and limited to the basal layer. As the cells rise in the epithelium, the cells rise in the epithelium, the nuclei shrink, the cytoplasm increases and becomes flat, the cells store glycogen.

28

Loss of maturation of cervical cells

orderly sequenc of maturation from bottom to top is lost beginning at the basal layer and progressing until the entir thickness of the peithelium is involved, nuclei remain large, cells remain cuboidal, glycogen is not stored, mitoses above basement membrane.

29

Pap Smears

annually until 3 consecutive negative PAP smears
-colposcopy vascular pattern, thickening
-schiller test- paint cervix with iodine, look for unstained pale patches
-5% acetic acid applied to surface of servix and examed before and after application

follow up biopsy if smear abnormal.

30

Koilocytotic atypia

enlarged hyperchromatic, irregular nuclei, pernuclear halo.

31

Carcinoma cervix

majority squamous cell- rarely adenocarcinoma
gradual decline due to pap screening- CIN squamous intraepithelial lesion cytology

risk factors- HPV 16, 18 HSV-2 promoter

Associations- frequent coitus, increased sexual partners, prostitutes, multiparity, sexual partners formerly married to women with cancer cervix,

Rare in nuns, jews, moslems

clincical features- 30-50 years, irregular vaginal bleeding, postcoital bleeding, vaginal discharge, pyometron due to obstruction, colposcopic biopsy, surgery and radiation.

Morphology- invasive- exophytic, necrotic fungating mass, ulcerative, infiltrative.

32

Microinvasive carcinoma stage 1A

Depth- less than 5 mm from basement membrane of the epithelium and width no more than 7 mm, no lymphatics or blood vessels invasion, surgical excision is curative with a cone biopsy or hysterectomy

Stage Ia tumours can only be diagnosed in cone biopsies or hysterectomy specimens.

Morphology- squamous cell carcinoma with keratin perals, spread: confined to uterus, beyond uterus in pelvis or lower 1/3 of vagina, parametrium bladder, rectum , distant metastsis

33

Adenocarcinoma.

fourth decade mean- 20% history of CIN- asymptomatic, visible lesion- absent or rare. Multifocal 15 %
associated lesion- CIN- 50%-70%
Associated with HPV 16-18

Rare- 10-15%, HPV 16-18
endocervical canal- adenocarcinmoa in situ
obstruction- pyometron, hysterectomy.

34

Vagina- gartner's duct cyst

remnants of mesonephric ducts- anterolateral wall of vagina

35

vaginal adenosis

girls 10 years whose mother's received DES during pregnancy to prevent abortion endocervical ype glands in vaginal wall, inhibition of transformation of mullerian epithelium into squamous epithelium- some girls develop clear cell adenocarcinoma (10-35 years)

36

Squamous carcinoma

exophytic polypoidal fungating mass, pelvic or inguinal nodes based on location, poor prognosis.

37

Sarcoma botryoides

embryonal rhabdomyosarcoma- less than 5 years, bunch of grapes hanging in the vagina, highly malignant.

38

Bartholinitis

Acute inflammation on the inferior part of the labium major- bartholin gland- blocking due to inflammation.
-Abscess formation- strep, staph, gonococci, e. Coli

39

Condyloma accuminatum

Bulky, warty growth, may be multiple: hyperplasia, koilocytosis.

40

Leukoplakia- non-neoplastic epithelial disorders (NNED)

white patch- look for neoplastic potential
-lichen sclerosus- kraurosis vulvae postmenopausal- scaly plaques, think parchment like, dense collagen, very low malignant potential, autoimmune nature
- hyperplastic dystrophy- (Lichen simplex chronicus)- post menopausal, localized, hyperplastic epidermis, no malignant potential

41

VINIII Bowen's disease

carcinoma in situ- old terminology in vulva
-leukoplakia
-reddish brown plaque
-needs surgical excision

42

Vulva intra epithelial neoplasia- VIN

flat, erythema, papule gray-white or reddish brown plaque, needs surgical excision.
- risk factors: HPV mainly 16, 18, 31, 33, age: mean 40 years, smoking, immunosuppressed patients,
-multifocal- 50-60% have synchronous lesions in the cervix, vagina, urethra, anus
-35-50% recur after local treatment
- some patients regress(younger age)
progression in invastion
- progression to invasion in 4-7% after treatment
- grade I, II, III, high risk HPV related may be associated with cervical carinoma

43

Carcinoma vulva

greater than 60 years old, plaque, nodule ulcer
-anterior 2/3 of labia majora
-squamous cell carcinoma
-inguinal and pelvic nodes.

44

Squamous cell carcinoma

- invasive
-- ulcer with rased edges base of right labium minorum