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Flashcards in Female Pathology Deck (65):
1

Infections of lower gyn tract

don't miss chlamydia or gonococcus (intracellular gram (-) diplococci) -> can cause PID
- can be treated well, are commonest STDs in USA
Systemic -> HIV, syphilis, hepatits
Fetus/Newborns -> HSV, chlamydia, gonorrhea, syphilis, HIV, hep B/C

2

Obstetrical infections

staph, strep, gram (-), clostridia
- retained placenta = BAD
- colonization with sepsis risk to fetus = group B strep

3

Pelvic Inflammatory Disease

acute/frequent chronic infection of upper genital tract
- spectrum from mild to infertile
Exam = lower ab pain, discharge, dyrpareunia, tenderness with cervical motion
MANY cases are subclinical
- sexually active women with lower ab pain --> empiric Rx

4

Bacterial Vaginosis

commonest cause of vaginal discharge --> disturbed vaginal flora
- gardnerella vaginalis --> malodorous gray-white discharge --> clue cells (elevated pH)

5

Trichomoniasis

flagellated protozoa --> commonest curable STD

6

Candida

not STD --> usually a commensal, results from overgrowth after disturbed by Rx
- hyphae/yeast on wet mount
- cottage-cheese or curdled milk

7

Genital Herpes

HSV 2 - below the waist
- subclinical usually
- painful genital ulcers -> not curable
- can reactivate from DRG
- Tzanck smear --> multinucleated giant cells

8

Solitary genital ulcer/wart in sexually active young person

syphilis until proven otherwise

9

HPV

non-genital skin warts, genital warts, anogenital cancer
- lots of people infected and some don't know it (100s of serotypes)

10

Condyloma

warty neoplasm of vulvar skin --> HPV 6, 11 (low risk)
Hallmark Cells --> koilocytes
- rarely progress to carcinoma

11

Pre-invasive HPV terminology

ALL ARE SQUAMOUS TYPE
CIN - cervical intraepithelial neoplasia
VIN - vulvar intraepithelial neoplasia
VAIN - vaginal intraepithelial neoplasia
AIN - anal intraepithelial neoplasia
PAIN - perianal intraepithelial neoplasia

12

Low grade HPV vs High grade HPV

low grade is 6, 11 --> 90% regress
high grade is 16, 18 --> won't regress
vaccine --> 6, 11, 16, 18 --> very promising

13

Lichen sclerosis

thinning of epidermis and fibrosis of dermis
- presents as leukoplakia with parchment-like vulvar skin
- post-menopausal women
- increased risk of squamous cell cancer

14

Lichen Simplex Chronicus

hyperplasia of vulvar squamous epithelium
- presents as leukoplakia with thick leathery skin
- chronic irritation and scratching
- no increased risk of squamous cancer

15

Bartholin Cyst

cystic dilation of Bartholin gland -> due to inflammation and obstruction of gland
- unilateral, painful cystic lesion at lower vestibule adjacent to vaginal canal

16

Vulvar Carcinoma

arises from squamous epithelium lining the vulva
- presents as leukoplakia
HPV caused --> arises as VIN -> dysplastic precursor lesion characterized by koilocytic change
Non-HPV caused -> arises from long-standing lichen sclerosis (older women)

17

Vulvar non-squamous carcinoma

Melanoma - post-menopausal women, pigmented, fatal
- PAS (-), keratin (-), S100 (+)
Basal Cell - post-menopausal women, "rodent" ulceration, non-metastasizing

18

Extramammary Paget Disease

malignant epithelial cells in epidermis of vulva
- erythematous, pruritic, ulcerated vulvar skin
PAS (+), keratin (+), S100 (-)

19

Vaginal Carcinoma

carcinoma arising from squamous epithelium lining vaginal mucosa --> commonly due to HPV 16, 18, 31, 33
- precursor is VAIN
lower 1/3 of vagina --> inguinal nodes
upper 2/3 of vagina --> regional iliac nodes (para-aortic)

20

Embryonal Rhabdomyosarcoma

malignant mesenchymal proliferation of immature skeletal muscle
- bleeding and grape-like mass protruding from vagina
- rhabdomyoblasts --> characteristic cells
- cytoplasmic cross-striations and (+) stain for desmin and myogenin

21

Adenosis

focal persistance of columnar epithelium in upper vagina
- during development, lower 1/3 of vagina is from urogential sinus, but upper 2/3 is from mullerian ducts (columnar)
- increased incidence in women exposed to diethylstilbestrol

22

Cervical Carcinoma

invasive carcinoma --> ALMOST ALL HPV RELATED
- presents as postcoital bleeding, cervical discharge
- squamous cell carcinoma (85%) or adenocarcinoma (15%)
- advanced tumors can cause hydronephrosis with postrenal failure
- increased risk with smoking and immunodeficiency

23

Cervical Intraepithelial Neoplasia

KOILOCYTIC CHANGE --> stepwise fashion through stages (higher risk HPV more likely to progress)
CIN 1 - < 1/3 of thickness
CIN 2 - < 2/3 of thickness
CIN 3 - almost entire thickness
CIS - entire thickness

24

Pap Smears

goal = catch dysplasia before it develops into carcinoma
- progression take 10-20 years (start at 21 y.o. every 3 years)
- GOLD STANDARD -> cells scraped from SCJ and analyzed under microscope
High grade dysplasia = hyperchromatic nuclei and high nuclear to cytoplasm ratio
- abnormal pap smear followed by colposcopy
- pap smear doesn't pick up adenocarcinoma

25

Asherman Syndrome

secondary amenorrhea due to loss of basalis and scarring
- due to overaggressive D&C

26

Anovulatory Cycle

Lack of ovulation --> estrogen-driven proliferative phase without subsequent progesterone driven secretory phase
- can lead to hyperplasia of endometrium

27

Endometrial Polyps

hyperplastic protrusion of endometrium -> presents as abnormal bleeding
- can be due to tamoxifen (agonistic effect on uterus)

28

Endometrial Hyperplasia

hyperplasia of endometrial glands relative to stroma
- unopposed estrogen (obesity, PCOS, replacement)
- classified histologically based on architectural growth and if there is cellular atypia
Cellular Atypia - most important predictor for progression to carcinoma

29

Endometrial Carcinoma

commonest form of GYN carcinoma
1. Hyperplasia pathway (60s) - from endometrial hyperplasia -> unopposed estrogen therapy
- endometrioid histology
2. Sporadic pathway (older women) - from atrophic endometrium
- serous histology (papillary structures with psammoma bodies) -- p53 mutation is common

30

Endometriosis

endometrial glands and stroma outside uterine endometrial lining --> retrograde menstruation --> cycles just like normal endometrium!!!
- presents as dysmenorrhea and pelvic pain
- most common site = ovary (chocolate cyst)
- increased risk of carcinoma at site of endometriosis

31

Adenomyosis

endometriosis involving uterine myometrium

32

Leiomyomas (fibroids)

benign neoplastic proliferation of smooth muscle arising from myometrium --> related to estrogen exposure
- PREmenopausal women, multiple, enlarge during pregnancy
- multiple, well-defined, white, whorled masses
- asymptomatic --> can cause abnormal uterine bleeding, infertility, pelvic mass

33

Lieomyosarcoma

malignant proliferation of smooth muscle arising from myometrium --> arises de novo
- no risk of leiomyoma causing leiomyosarcoma
- POSTmenopausal women, single lesion with necrosis and hemorrhage
histologically - necrosis, mitotic activity, cellular atypia

34

Fallopian tube pathology

generally non-neoplastic --> more PID
- salpingitis --> PID bugs
- endometriosis
- tubal infertility and ectopic pregnancies

35

Tubal Neoplasia

adenomatoid tumor --> benign mesothelioma
tubal carcinoma - historically rare, BRCA 1 or 2 mutations

36

Polycystic Ovarian Syndrome

multiple ovarian follicular cysts due to hormonal imbalance
- increased LH -> excess androgen production resulting in hirtuism
- androgens converted to estrone in adipose tissue
- estrone feedback decreases FSH --> cystic degeneration of follicles
- increased risk of endometrial carcinoma
- highly associated with obesity and diabetes

37

Surface Epithelial Tumors

most common type of ovarian tumor - derived from coelomic epithelium that lines ovary
2 subtypes - can be benign or malignant or borderline
1. Serous - watery fluid
- BRCA-1 mutation carry higher risk -> may elect to have prophylactic oophorectomy and mastectomy
2. Mucinous - mucus like fluid (HUGE!)

38

Benign surface epithelial tumors

cystadenomas -> composed of single cyst with simple, flat lining (premenopausal women)

39

Malignant surface epithelial tumors

cystadenocarcinoma -> complex cysts with thick, shaggy lining (postmenopausal women)

40

Borderline surface epithelial tumors

features of both benign and malignant
- better prognosis than malignant but carry metastatic potential

41

Clinical Diagnosis of Ovarian Neoplasm

1. Incidental adnexal mass
2. Chronic pelvic/ab compression
3. Acute/subacute presentations
4. Signs of chronic sex steroids
5. Atypical glandular cells

42

Ovarian Germ Cell Tumors

usually occur in women of reproductive age
Fetal tissue - cystic teratoma and embryonal carcinoma
Oocytes - dysgerminoma
Yolk Sac - endodermal sinus tumor
Placental Tissue - choriocarcinoma

43

Cystic teratoma

cystic tumor composed of fetal tissue dervied from 2 or 3 embryologic layers (skin, hair, bone)
- most common germ cell tumor in females (99% benign)
- struma ovarii - teratoma composed of thyroid tissue

44

Dysgerminoma

tumor composed of large cells with clear cytoplasm and central nuclei (oocytes)
- same as seminoma in males
- responds to radiotherapy - good prognosis
LDH may be elevated

45

Endodermanl Sinus Tumor

malignant tumor that mimics yolk sac -> most common in children
- serum AFP elevated, Schiller-Duval bodies

46

Choriocarcinoma

malignant tumor composed of cytotrophoblasts and syncytiotrophoblasts --> mimics placental tissue
- small, hemorrhagic tumor with early hematogeneous spread
- high beta-hCG
- poorly responsive to chemo --> worst prognosis

47

Embronal Carcinoma

malignant tumor composed of large primitive cells
- aggressive with early metastasis

48

Sex-cord Stromal Tumors

resemble sex-cord-stromal tissue
Granulosa-Theca cells - produces estrogen (malignant but low metastasis)
- precocious puberty, menorrhagia, or postmenopausal bleeding
Sertoli-Leydig cell - composed of sertoli cells that form tubules and leydig cells with Reinke crystals
Fibroma - benign tumor of fibroblasts (pleural effusions and ascites)

49

Kruckenberg tumor

metastatic mucinous tumor that involves both ovaries
- most commonly with metastatic gastric carcinoma
- bilaterally = distinguish from metastases of primary mucinous carcinoma of ovary (unilateral)

50

Pseudomyxoma peritonei

massive amounts of mucus in peritoneum
- due to mucinous tumor of appendix --> usually with metastasis to ovary

51

Spontaneous Abortion

miscarriage of fetus before 20 weeks gestation
- presents as ab pain, vaginal bleeding, passage of fetal tissues
- chromosomal abnormalities, uterine abnormalities, previous PID
- retained dead fetus = high risk for DIC (rich in thromboplastin)

52

Ectopic Pregnancy

implantation of fertilized ovum at site other than uterine wall (most common in tubes)
- key risk factor = previous PID
presents with = lower quandrant pain - after missed period (6-8 weeks)
- diagnose with hCG (less than 50% increase) and transvaginal ultrasound
-surgical emergency

53

Preeclampsia

pregnancy induce HTN, proteinuria, edema (3rd trimester)
- HTN can be severe and lead to symptoms (fibrinoid necrosis of placental vessels)
- abnormal maternal-fetal vascular interface (maternal endothelium malfunction)
- primary risk factor = 1st pregnancy
HELLP syndrome
- hemolysis, elevated liver enzymes, low platelets

54

Eclampsia

preeclampsia with new onset seizures
- CNS hemorrhage, acute renal failure, pulmonary edema, DIC, hepatic failure, death

55

Placenta previa

implantation of placenta in lower quandrant of uterus -> overlies the cervical os (marignal, partial, complete)
- often requires c-section
- associated with placenta accreta

56

Placental abruption

separation of placenta from decidua prior to delivery of fetus
- 1% maternal mortality....12% fetal mortality
- vaginal bleeding, contractions, and fetal insufficiency

57

Placental accreta

improper implantation of placenta into myometrium
- difficulty delivering the placenta -> postpartum bleeding
- often require hysterectomy
RISK FACTOR - placenta previa w/ prior c-section

58

Postpartum hemorrhage

most commonly due to uterine atony
- retained placenta
- defined as causing hypovolemic symptoms
- can be delayed

59

Acute DIC in pregnancy

avalanche of systemic coagulation factors
TRIGGERS:
- preeclampsia/abruption, retained dead fetus, amniotic fluid embolus, massive hemorrhage
Corollary fact - unprovoked DVT/PE = underlying coag disorder

60

Placental/maternal infections

ascending infections = bacterial, polymicrobial
- can cause premature rupture of membranes

61

Infections from mom->fetus

Toxoplasmosis/TB
Rubella
CMV
Herpes/HIV/HBV
Syphilis

62

Infections from birth canal

HSV
Group B strep
Chlamydia/Gonococcus

63

Hydatiform Mole

abnormal conception characterized by swollen and edematous villi with proliferation of trophoblasts (abnormal placental tissue)
- higher beta-hCG than expected
- passage of grape-like mass through vaginal canal
- "snow-storm" appearance on ultrasound

64

Complete hydatiform mole

- empty ovum fertilized by 2 sperm (46 chromos)
- absent fetal tissue (completely dad)
- most villi are hydropic
- lots of trophoblastic proliferation (high beta-hCG)
- risk of choriocarcinoma (use beta-hCG as serum marker)

65

Partial hydatiform mole

- normal ovum fertilized by 2 sperm (69 chromos - triploid)
- present fetal tissue
- some villi are hydropic
- low trophoblastic proliferation
- low risk of choriocarcinoma