PATOLOGI SISTEM

REPRODUKSI WANITA

Sistem Genitalia Interna

Dr. Soekimin, SpPA ; dr. Jessy Chrestella, SpPA

Dept. Patologi Anatomi Fakultas Kedokteran
Universitas Sumatera Utara
Medan 2010
 Patologi Genitalia Interna

Todays lesson

Gestational
Cervix Endometrium Myometrium
diseases
GAMBARAN SERVIKS NORMAL
 Inflammatory Cervical Lesions
Acute Cervicitis
Common condition characterized by erythema, swelling,
neutrophil infiltration, and focal epithelial ulceration.
The endocervix is more frequently involved than the ectocervix.
Usually STD : gonococci, Chlamydia trachomatis, Candida
albicans, Trichomonas vaginalis, and Herpes simplex .
Non-sexually transmitted agents : Escherichia coli and
staphylococci may also be isolated from acutely inflamed
cervices.
Acute cervicitis also follows the trauma of childbirth and surgical
instrumentation.
Clinic : purulent vaginal discharge and pain.
Chronic Cervicitis
Histopath : moderate numbers of lymphocytes, plasma cells,
and histiocytes are present in the cervix in all females.
Most commonly seen at the external os and endocervical
canal.
May be associated with fibrous stenosis of gland ducts,
leading to retention (nabothian) cysts.
Clinic : chronic cervicitis is often an incidental finding.
May produce a vaginal discharge, and in a few cases
associated fibrosis of the endocervical canal may cause
stenosis, leading to infertility.
 NEOPLASMA
SERVIKS

Condyloma Acuminatum
 Nabothian Cyst
Retension cyst made of endocervical columnar cells and
resulting from closure of gland opening.
Normal feature of the adult cx.
Asymptomatic, white to yellow cyst on ectocervix.s
Mucus-filled cyst lines with columnar epithelium.
 Endocervical Polyp
Common benign tumors arise from the endocervical canal
cells (or can be ectocervix ectocx polyp).
Usually occurring at about the time of menopause (40-50
yrs old).
When large, a polyp may protrude out of the external os.
Micros :
polypoid growth contain hyperplastic endocervical glands
and a highly vascular stroma and may show marked
chronic inflammation. The surface epithelium made up of
columnar and commonly shows squamous metaplasia.
 Squamous Cell Carcinoma
7000 deaths /year ; 13,000 new cases / year (US).
Etiology : HPV (Human Papilloma Virus) serotype 16,18.
Predisposing factors : early onset of sexual activity, greater
number of sexual partners, multiparous women who have
married early .
Most arise in a stratified squamous epithelium that shows
precancerous change (dysplasia).
Sign & symptom :
abnormal uterine bleeding (commonly irregular and excessive menstrual
bleeding or postmenopausal bleeding)
vaginal discharge
obstruction of the cervical canal may cause blood to accumulate in the
uterine cavity and result in infection (pyometra).
 Sexual Exposure
Pathogenesis
HPV Infection

Cervical Transformation Zone

Squamous Ep Columnar Ep

High Risk
Types (16,18)

Smoking, Hormone, Oral contr. parity,

Low Risk-6,11 Altered immune response etc.

Squamous
Ca
Adeno Ca
 KANKER
SERVIKS

Reprinted with permission from Sellors JW, Sankaranarayanan R, eds. Colposcopy and Treatment of Cervical Intraepithelial Neoplasia.
A Beginners Manual. Lyon, France: International Agency for Research on Cancer; 2003.

Photos courtesy of Dr. J. Monsonego

 Dysplasia
Dysplasias are reversible lesions, but the more severe the
degree of dysplasia the less the tendency to reverse.
Dysplasia and carcinoma in situ produce no symptoms.
Changes in the mucosa on inspection are minimal, but some
lesions may be recognized by means of the magnified image
provided at colposcopy (eg, abnormal vascular pattern,
thickening, and white coloration).
Dysplasia commonly involves the region of the
squamocolumnar junction and the endocervical canal that has
undergone squamous metaplasia.
Dysplasia : presence of cytologic abnormalities in a cervical
(Pap) smear and confirmed by cervical biopsy.
 Dysplasia
The cytologic changes include increased nuclear size,
increased nuclear:cytoplasmic ratio, hyperchromatism,
abnormal chromatin distribution, and nuclear
membrane abnormalities.

The Schiller test, which consists of painting the cervix

with aqueous iodine, is helpful in locating areas of
dysplasia, since dysplastic epithelium lacks glycogen
and will appear as a pale area whereas normal
epithelium stains dark brown with iodine.
PAPS SMEAR

The mortality rate from cervical

carcinoma has been falling, partly
due to early detection of
premalignant epithelial dysplasia by
routine cytologic screening of
cervical smears (Pap smears); many
cases are detected and treated in
the preinvasive stage.
Pap Smear Results:
Figure 22-20 A, Histology of CIN I (flat condyloma), illustrating the prominent koilocytotic atypia in the upper epithelial cells, as evidenced by
the prominent perinuclear halos. B, Nucleic acid in situ hybridization of the same lesion for HPV nucleic acids. The blue staining denotes HPV
DNA, which is typically most abundant in the koilocytes. C, Diffuse immunostaining of CIN II for Ki-67, illustrating widespread deregulation of cell
cycle controls. D, Up-regulation of p161NK4 (seen as intense immunostaining) characterizes high-risk HPV infections.
 Invasive Squamous Carcinoma
Defined as carcinoma infiltrating to a depth of greater than 5
mm from the basement membrane.
It occurs most frequently in the age group from 30 to 50 years.
Grossly : exophytic, fungating, necrotic mass (common) or as
a malignant ulcer; or as a diffusely infiltrative lesion with only
minimal surface ulceration or nodularity (uncommon).
Microscopically : three different types:
(1) nonkeratinizing squamous carcinomathe most common
type, with the best prognosis;
(2) keratinizing squamous carcinomanext most common,
with an intermediate prognosis;
(3) small cell carcinomarare, with a poor prognosis.
 Endocervical Adenocarcinoma
Accounts for 10-15% of malignant cervical tumors.
Most tumors are of the endocervical cell (mucinous) type.
The tumors are often associated with HPV types 16 and 18.
Manifestation : fungating polypoid or papillary mass.
Microscopically :
exophytic tumors often have a papillary pattern, whereas
endophytic ones display tubular or glandular patterns. Poorly
differentiated tumors are predominantly composed of solid
sheets of cells.
Overall survival is worse than squamous carcinoma.
The tumor is treated similarly to squamous carcinoma.
UTERUS
 DISEASES O/T UTERUS

Congenital
Prolapse Perforation
anomalies

Laceration
Stricture
 DISEASES O/T UTERUS

Endometrial
Polyps hyperplasia

Tumors Endometritis
 Congenital anomalies
Uterus Duplex Separatus (didelphys)
U.Duplex bicornus (septus)
U. Bicornis unicollis
U. Septus, subseptus
U. Unicornis
 Manifestations of Uterine Disease
Abnormal uterine bleeding (most common) :
menorrhagia or metrorrhagia.
Pain associated with menstruation
(dysmenorrhea).
Infertility & spontaneous abortion
Uterine masses
Uterine enlargement neoplasm
Causes of Abnormal Uterine Bleeding (Including Uterine and Extrauterine Causes)
Newborn Maternal estrogen
Childhood Iatrogenic (trauma, foreign body, infection of vagina)
Vaginal neoplasms (sarcoma botryoides)
Ovarian tumors (functional)
Adolescence Hypothalamic immaturity
Psychogenic and nutritional problems
Inadequate luteal function
Reproductive age Anovulatory
Central: psychogenic, stress
Systemic: nutritional and endocrine
disease
Gonadal: functional tumors
End-organ: benign endometrial hyperplasia
Pregnancy: ectopic, retained placenta, abortion, mole
Ovulatory
Organic: neoplasia, infections (PID), leiomyomas
Polymenorrhea: short follicular or luteal phases
Iatrogenic: anticoagulants, IUD
Irregular shedding

Menopause Carcinoma, EIN, benign hyperplasias, polyps, leiomyomata

Postmenopause Carcinoma, EIN, polyps, leiomyomata
 Endometriosis
Presence of endometrial glands and stroma within the
myometrium and other site out of endometrium.
Symptoms : asymptomatic, dysfunctional uterine
bleeding, dysmenorrhea, and dyspareunia, infertility.
Pathologic : the glands are located at least 3 mm or
more beneath the endometrial myometrial junction.
Adenomyosis is more likely to be symptomatic the more
deeply it penetrates the myometrium.
One fifth of all uteri removed at surgery show some
adenomyosis.
 Endometriosis
Pathologic finding :
foci of endometriosis appear as cysts that contain
areas of new and old hemorrhage (chocolate cysts),
due to cyclic bleeding that occurs during
menstruation.
foci are characterized by the presence of endometrial
glands surrounded by stroma .
Evidence of hemorrhage, hemosiderin deposition, and
fibrosis are common.
Endometriosis of the uterine tube is a common cause of
infertility because of luminal obliteration by fibrosis.
Endometriosis, showing sites of involvement.
Fig. 8A, B. Focal adenomyosis. A Sagittal T2-weighted SE image. Focal thickening (arrow) of the junctional
zone of the uterus. B Histologic specimen (H&E staining, not taken from this case) with ectopic endometrial
tissue in the myometrium
Endometrial Hyperplasia
Endometrial hyperplasia : premalignant lesion
that is caused by unopposed estrogen
stimulation.
It usually occurs around or after menopause
and is associated with excessive and irregular
uterine bleeding.
The risk of malignancy correlates with the
severity of the hyperplasia.
Classified as follows:
Simple hyperplasia (mild hyperplasia)
Increased number of proliferative glands without cytologic atypia.
The glands, although crowded, are separated by densely cellular
stroma and are of varying sizes. In some cases, cystically dilated
glands predominate (cystic hyperplasia).
Complex hyperplasia without atypia (moderate hyperplasia) :
Greater increase in gland number with crowding. The lining cells
maintain normal polarity and do not show pleomorphism or
cytologic atypia. Densely cellular stroma is still present between
glands.
Complex hyperplasia with atypia (severe hyperplasia) :
Gland crowding with back-to-back glands and marked cytologic
atypia characterized by pleomorphism, hyperchromatism, and
abnormal nuclear chromatin pattern. It carries a high risk of
endometrial carcinoma.
Endometrial Polyps
Common, particularly around menopause.
Vary in size from 0.5 to 3 cm and are covered
by endometrial epithelium.
Clinical : asymptomatic or may cause excessive
uterine bleeding.
Microscopical : composed of endometrial
glandswhich may or may not show cyclic
changes, and a fibrovascular stroma. Very
rarely undergo carcinomatous transformation.
Fig. 9A, B. Endometrial polyp. A Sagittal T2-weighted SE image. The endometrial polyp is of slightly lower signal intensity compared to the endometrium.
MR imaging does not permit distinction of an endometrial polyp from a polypous endometrial carcinoma. Regular and intact junctional zone of the
myometrium. B . Gross specimen
 Leiomyoma (Fibroid)
Benign neoplasm of uterine smooth muscle.
The most common neoplasms in females, 1 in every 4 women in the
reproductive years.
Between 20 and 40 years of age ; stop growing actively or regress
after menopause.
Growth appears to be dependent on estrogens and may be rapid
during pregnancy.
Grossly : circumscribed, firm, grayish-white masses with a
characteristic whorled appearance on cut section, can reach large
size. Solitary or multiple and may be located anywhere in the
uterine smooth muscle.
Histologically : composed of a uniform proliferation of spindle-
shaped smooth muscle cells. Cytologic atypia is sometimes present,
but mitotic figures are scarce.
Fig. Multiple leiomyomas of the uterus
 Uterine leiomyoma, showing interlacing
fascicles of cytologically uniform smooth
muscle cells

Leiomyomas of the uterus, showing different locations where

these neoplasms are found in the uterus.
 Endometrial Carcinoma
About 10% of cancers in women.
90% of cases occur in postmenopausal women, the
most common age being 5565 years.
Etiology and risk factors :
Prolonged unopposed estrogen stimulation of the
endometrium
Endometrial hyperplasia.
Obesity, diabetes mellitus, and hypertension.
Pregnancy protective effect ;probably by opposing
estrogenic stimulation; there is a decreased incidence in
multiparous as compared with nulliparous women.
 Endometrial Carcinoma
Gross :
polypoid fungating masses in the endometrial cavity. The
uterus is often asymmetrically enlarged. Invasion into the
myometrium occurs early.
Microscopically :
endometrial carcinoma is an adenocarcinoma, with
irregular glands lined by malignant columnar epithelial
cells.
Degree of histologic differentiation :
Well-differentiated carcinomas.
Moderately differentiated
Poor differentiation.
Karsinoma Endometrium :
- massa menonjol ke kavum uteri
- invasi ke lapisan myometrium
 Carcinoma of Body (Corpus) Carcinoma of Cervix

Incidence in United States 34,000/yr 13,000/yr

Deaths 3000/yr 7000/yr

Site Body of uterus Cervix

Age 50 plus 40 plus

Etiologic factors Nulliparity, obesity, Multiparity, human papilloma

hypertension, diabetes virus, herpes simplex virus;
multiple sexual partners

Fiveyear survival rate (overall) 80% 60%

Histology Adenocarcinoma (occasionally Squamous carcinoma (except

with squamous metaplasia) endocervical carcinoma which
is adenocarcinoma)
Endometrioid adenocarcinoma
Endometrioid adenocarcinoma
 Leiomyosarcoma
Leiomyosarcoma is a rare uterine neoplasm, accounting for
3% of uterine malignant neoplasms.
Leiomyosarcoma is most common in older women,
presenting as postmenopausal bleeding or a uterine mass.
Arises from smooth muscle of the myometrium, usually de
novo rather than from a preexisting leiomyoma.
Leiomyosarcomas appear as bulky, fleshy masses that show
hemorrhage and necrosis.
Marked cytologic pleomorphism and atypia are usually
present. The most important diagnostic criterion is a high
rate of mitotic figures (over 10 mitoses per 10 high-power
fields).
Local recurrence and hematogenous metastases are
frequent. The 5-year survival rate is about 40%.
Terima Kasih