Female

Reproductive
System

TOPICS
TODAY (Part I) NEXT CLASS (Part II)
Vulva Vagina Cervix, uterus Body, uterus Tubes Ovaries Placenta

 Synonymous with EXTERNAL genitalia Everything ANTERIOR to the INTROITUS Usual classification of Degen., Inflam., Neopl. Common Diseases:
BARTHOLIN Cyst Vulvar Vestibulitis Deg./Inflam. Epithelial: LICHEN diseases BENIGN tumors: Condyloma(ta) MALIGNANT tumors: VIN, SCC

VULVA

Result from Inflammation/Obstruction of the Bartholin glands (i.e., greater vestibular glands)

Often result in abscesses

Surgical removal is curative when local procedures are inadequate or often recurrent NEVER become malignant

VULVAR VESTIBULITIS, assoc. w. vulvodynia

LICHEN DISORDERS
LICHEN Sclerosu(i)s (atrophic skin)

LICHEN Simplex Chronicus (hypertrophic skin)

Common features of FIBROSIS and INFLAMMATION

Mucosal Atrophy
Fibrosis (sclerosis) Inflammation

LICHEN SIMPLEX CHRONICUS

The types of lichen lesions which show HYPER-plastic mucosal changes are often regarded as being potentially pre-malignant

CONDYLOMA(TA)

 Like condylomas, HIGHLY linked to HPV VIN=changes leading to SCCin-situ, look like plaques BEYOND VIN = INFILTRATION

VIN, SCC

VIN

MALIGNANT MELANOMA

VAGINA
CONGENITAL: Parallel uterus anomalies INFLAMMATORY
PRE-menopausal: STD POST-menopausal: ATROPHY

BENIGN: Hidradenoma, Condyloma MALIGNANT: VIN, INFILTRATING SCC

CONGENITAL
Imperforate hymen (hematocolpos) Atresia Absence (agenesis) Septate Double vag/uterus (didelphys)

Atresia, Double vagina, Double uterus.

 90%

VAGINITIS

Bacterial Vaginitis is the most common cause of vaginitis,

accounting for 50% of vaginitis cases. As previously mentioned, BV is caused by an overgrowth of organisms such as Gardnerella vaginalis (gram-variable coccobacillus), Mobiluncus species, Mycoplasma hominis, and Peptostreptococcus species. Risk factors include pregnancy, intrauterine device (IUD) use, and frequent douching. Candida species (C albicans, C tropicalis, and C glabrata) are airborne fungi that are natural inhabitants of the vagina in as many as 50% of women, and vaginal candidiasis is the second most common cause of vaginitis. Risk factors include oral contraceptive use, IUD use, young age at first intercourse, increased frequency of intercourse, receptive cunnilingus, diabetes, HIV or other immunocompromised states, chronic antibiotic use, and pregnancy. T. vaginalis infection, the third most common cause of vaginitis, is caused by trichomonads. These organisms are flagellated protozoans. Trichomonads primarily infect vaginal epithelium, and they less commonly infect the endocervix, urethra, and Bartholin and Skene glands. Trichomonads are transmitted sexually and can be identified in as many as 80% of male partners of infected women. Risk factors include tobacco use, unprotected intercourse with multiple sexual partners, and the use of an IUD.

VAGINAL NEOPLASIA
VIN INFILTRATING SCC ADENOSIS (D.E.S.) ADENOCARCINOMA
(Di-Ethyl-Stilbestrol)

VIN

NORMAL

VIN

SCC

CHILDHOOD EMBYRONAL RHABDOMYOSARCOMA

CERVIX
NORMAL METAPLASIA INFLAMMATION POLYPS DYSPLASIA CIN INFILTRATING SCC

DYSPLASIA / CIN / SIL

INFILTRATION

How have we CURED Cervical Carcinoma?

ENDOMETRIUM
FUNCTIONAL HISTOLOGY D.U.B. (Dysfunctional Uterine Bleeding) INFLAMMATION ADENOMYOSIS/ENDOMETRIOSIS POLYPS/HYPERPLASIA ADENOCARCINOMA and/or STROMAL LEIOMYOMYOMAS, -SARCOMAS
MITOSES differentiate benign from malignant

MITOSES (Glandular and Stromal) =

PRE-ovulatory

VACUOLES/SECRETION =

POST-ovulatory

DYSFUNCTIONAL UTERINE BLEEDING (DUB)

Anovulatory Cycle Inadequate Luteal Phase Oral Contraceptives Menopause Post-Menopause

 PID Post-partum Sepsis BCPs TB IUDs

ENDOMETRITIS

ADENOMYOSIS
Defined as normal endometrial glands deep within the myometrium

ENDOMETRIOSIS
Defined as normal endometrial glands OUTSIDE the confines of the myometrium Reverse menstruation vs. Embryologic rest theories EXTREMELY common cause of cyclical abdominal/pelvic pain Broad Ligament, Ovary (chocolate cysts), Peritoneum, Bowel, Umbilicus

CHOCOLATE CYST

Adenocarcinoma of the Endometrium

= Carcinoma of the Uterus

ADENOCARCINOMA of the ENDOMETRIUM

Papillary, Polypoid Clear Cell Adeno-Squamous Mucinous Serous Preceded by hyperplasia, dysplasia (EIN) Estrogenic, DES effects Ass. w.: obesity, diabetes, hypertension, infertility Stromal sarcomatous conditions can co-exist, i.e., adenosarcoma

GRADING and STAGING

GRADING
1, 2, 3 Well, Moderate, Poor

STAGING
(I) Corpus (II) Corpus + Cervix (III) Beyond uterus, but inside true pelvis (IV) Outside true pelvis or involving bladder or rectal mucosa

Fallopian Tubes
Inflammation Cysts Neoplasms

SALPINGITIS/PID
GC and CHLAMYDIA PYOSALPINX PERITONITIS TUBO-OVARIAN ADHESIONS STERILITY INFERTILITY

Peritubal CYSTS
Endometriosis Hydatid Cysts of Morgagni (Mullerian rests) Para-, Peritubal)

TUBAL NEOPLASMS
Adenocarcinomas

Leiomyo(sarco)mas

CHAPTER 22

DISEASES of OVARIES PREGNANCY PLACENTA

DISEASES of OVARIES DEGENERATIVE?

INFLAMMATORY? CYSTS TUMORS
Mllerian (Germinal) Germ Cell Sex Cord/Stromal Metastatic

DISEASES of PREGNANCY
EARLY Pregnancy LATE Pregnancy

DISEASES of PLACENTA
ANOMALIES

BENIGN tumors (MOLES)

MALIGNANT tumors (CHORIOCARCINOMA)

6 WEEKS

GENITAL RIDGE

Everything you can see or feel is lined by serosa (i.e., mesothelial cells, visceral and parietal

Germinal Epithelium (Mesothelium) Ovum (Oocyte) Tunica Albuginea Primordial Follicle Primary Follicle Mature Graffian follicle (antral or secondary) Granulosa cells ( Estrogen) Thecal cells ( Estrogen) Corpus luteum ( Progesterone) Atretic follicle Corpus Albicans Stroma

TERMS

B=GRANULOSA

D=THECA INTERNA E=THECA EXTERNA

ESTROGEN
Controlled by FSH and LH Develop, Lactate Breast Lobules Proliferate Endometrial Glands Cardioprotective Bone Mass protective

PROGESTERONE
Controlled by FSH and LH SECRETE Endometrial Glands IMPLANTATION of the blastocyst Lactation

 CYSTS:

DISEASES of OVARIES

Follicular Luteal

FOLLICULAR CYST

MOST COMMON

CORPUS LUTEUM CYST

POLY-Cystic Ovarian Disease

(Stein-Leventhal syndrome)
5% Prevalence

Anovulation
Oligomenorrhea Obesity Hirsutism

Polycystic Ovaries

OVARIAN TUMORS
MLLERIAN (MAJORITY)
Serous (Benign, Borderline, Malignant) Mucinous (Benign, Borderline, Malignant) Endometroid (Benign, Borderline, Malignant) Adenosarcoma (Carcinoma AND Sarcoma) Mesodermal Mixed (MULTIPHASIC Sarcoma) Clear Cell Brenner (almost always benign) Transitional (almost always look like Brenner)

Germ Cell (Not surprisingly, like males) SEX-CORD/STROMAL METASTATIC

OVARIAN TUMORS
Solid vs. Cystic Functional vs. NON-functional Benign vs. Malignant First clinical presentation may be ascites, in carcinomas. Malignant ascites in a woman is ovarian cancer until proven otherwise CA-125 is THE important tumor marker in ovarian cancer, especially as a follow up.

SEROUS, BENIGN

MUCINOUS, BENIGN

PSAMMOMA bodies are dried up papillae of papillary adenocarcinomas, usually in the thyroid, but in ANY papillary adenocarcinoma

 ENDOMETRIOD, malignant
(looks like endometrium)

OTHER MLLERIAN

CLEAR CELL, malignant

(clear cells, reminiscent of renal clear cell ca.)

CYSTADENOFIBROMA, benign
(BENIGN FIBROUS COMPONENT)

BRENNER TUMOR, benign

(transitional cell nests)

CARCINOMA with SARCOMA

(adenosarcoma, mixed Mllerian)

GERM CELL Tumors

Teratomas (usually benign in ovary), i.e.,
mature cystic teratoma or dermoid cyst Immature teratomas are regarded as malignant Dysgerminoma (look exactly like the testicular seminoma), malignant

Endodermal Sinus (Yolk Sac),

malignant, Just like testicular Choriocarcinoma, malignant, just like testicular

Dysgerminoma:Female::Seminoma:Male

ENDODERMAL SINUS TUMOR, aka

YOLK SAC TUMOR

CHORIOCARCINOMA,
Just like testis or placenta

 Chiefly benign and NON-cystic, i.e., solid, often functional (hyper-estrogen-ism)

SEX-CORD/STROMAL TUMORS

Granulosa-Theca Fibroma-Theca Sertoli-Leydig (Androblastoma)

CALL-EXNER BODIES

B=GRANULOSA

D=THECA INTERNA E=THECA EXTERNA

DISEASES of PREGNANCY
EARLY Pregnancy LATE Pregnancy

EARLY PREGNANCY
SPONTANEOUS ABORTION ECTOPIC PREGNANCY

Spontaneous Abortion
15% - 35% Fetal Causes
Usually Genetic

Maternal Causes (placental, uterus infections or trauma)

Toxo, Mycoplasma, Listeria Trauma

Ectopic Pregnancy
Chiefly TUBAL, but ovarian or abdominal rare

1% OF NORMAL WOMEN 35%-50% OF WOMEN with

previous SALPINGITIS/PID + HCG, Abdominal pain, 1st trimester, ultrasound

LATE PREGNANCY
PLACENTAL ANOMALIES TWIN PLACENTAS PLACENTAL INFLAMMATIONS TOXEMIA (ECLAMPSIA/PREECLAMPSIA) INTRAUTERINE GROWTH RETARDATION

PLACENTAL ANOMALIES
Accessory Lobes Bipartite Placenta Circumvallate Placenta Placenta Accreta, chorion going DIRECTLY to the myometrium

CIRCUMVALLATE

PLACENTA ACCRETA NO DECIDUA BETWEEN VILLI AND MYOMETRIUM

MRI of Placenta PREVIA, or LOW-LYING placenta, usually anatomically normal, but just lies LOWER than it should.

MONOCHORIONIC = MONOZYGOTIC

TOXEMIA of PREGNANCY (PRE-eclampsia)

Hypertension Proteinuria Edema
Related to Placental Ischemia, but MANY theories Risk for DIC, convulsions (eclampsia)

Intrauterine Growth Retardation

Fetal causes: Genetic, malformations Maternal Causes, vascular diseases, toxemia, infections, placental diseases

Placenta size (350-700g) ~ Fetal size (7.5 lb)

 Villitis vs. chorionamnionitis vs. funisitis

Placental Infections

ASCENDING vs. hematogenous ASCENDING are usually bacterial,

and chorionamnionitis

HEMATOGENOUS
are often TORCH, and villitis

Placental Neoplasms,
i.e. gestational trophoblastic disease Benign: MOLES (Hydatidiform moles) Malignant: CHORIOCARCINOMA BOTH are associated with increased or persistent levels of the placental hormone HCG

(Hydatid)-iform Mole
1/1000 in USA 1% in Indonesia Also called NON-invasive mole in its most common benign variant, but can also be invasive Complete (2% chorioCA incidence) or partial (0% incidence) Grapelike clusters, i.e., swollen villi

The MAIN thing differentiating benign from malignant from worrisome trophoblastic neoplasms is

INVASIVENESS
of the trophoblast