Female Reproductive System

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Chapter 22 Female Reproductive System
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TOPICS

• TODAY (Part I)
• Vulva
• Vagina
• Cervix, uterus
• Body, uterus
• Tubes

• NEXT CLASS (Part II)
• Ovaries
• Placenta

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VULVA

• 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

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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
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VULVAR VESTIBULITIS, assoc. w. vulvodynia
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LICHEN DISORDERS
LICHEN Sclerosis (atrophic skin) LICHEN Simplex
Chronicus (hypertrophic skin) Common features
of FIBROSIS and INFLAMMATION
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Mucosal Atrophy Fibrosis (sclerosis) Inflammation
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LICHEN SIMPLEX CHRONICUS
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The types of lichen lesions which show
HYPER-plastic mucosal changes are often regarded
as being potentially malignant
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CONDYLOMA(TA)
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VIN, SCC

• Like condylomas, HIGHLY linked to HPV
• VINchanges leading to SCC-in-situ, look like
  plaques
• BEYOND VIN INFILTRATION

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VIN
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MALIGNANT MELANOMA
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VAGINA

• CONGENITAL Parallel Uterus
• INFLAMMATORY
• PRE-menopausal STD
• POST-menopausal ATROPHY
• BENIGN Hidradenoma, Condyloma
• MALIGNANT VIN, INFILTRATING SCC

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CONGENITAL

• Imperforate hymen (hematocolpos)
• Atresia
• Absence (agenesis)
• Septate
• Double (didelphys)

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Atresia, Double vagina, Double uterus.
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VAGINITIS

• 90?
• 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.

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VAGINAL NEOPLASIA

• VIN
• INFILTRATING SCC
• ADENOSIS (D.E.S.) ?
• ADENOCARCINOMA (Di-Ethyl-Stilbestrol)

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VIN
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NORMAL
VIN
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SCC
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CHILDHOOD EMBYRONAL RHABDOMYOSARCOMA
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CERVIX

• NORMAL
• METAPLASIA
• INFLAMMATION
• POLYPS
• DYSPLASIA
• CIN
• INFILTRATING SCC

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DYSPLASIA / CIN / SIL
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INFILTRATION
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How have we CURED Cervical Carcinoma?
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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

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MITOSES (Glandular and Stromal)
PRE-ovulatory VACUOLES/SECRETION
POST-ovulatory
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DYSFUNCTIONAL UTERINE BLEEDING (DUB)

• Anovulatory Cycle
• Inadequate Luteal Phase
• Oral Contraceptives
• Menopause
• Post-Menopause

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ENDOMETRITIS

• PID
• Post-partum Sepsis
• BCPs
• TB

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ADENOMYOSIS

• Defined as normal endometrial glands deep within
  the myometrium

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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
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CHOCOLATE CYST
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Adenocarcinoma of the Endometrium Carcinoma of
the Uterus
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ADENOCARCINOMAof the ENDOMETRIUM

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

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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

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Fallopian Tubes

• Inflammation
• Cysts
• Neoplasms

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SALPINGITIS/PID GC and CHLAMYDIA PYOSALPINX PERITO
NITIS TUBO-OVARIAN ADHESIONS STERILITY INFERTILITY
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Peritubal CYSTS

• Endometriosis
• Hydatid Cysts of Morgagni (Mullerian rests)
  Para-, Peri- tubal)

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TUBAL NEOPLASMS

• Adenocarcinomas
• Leiomyomas

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CHAPTER 22 DISEASES of OVARIES PREGNANCY PLACENTA
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DISEASES ofOVARIES

• DEGENERATIVE?
• INFLAMMATORY?
• CYSTS
• TUMORS
• Müllerian (Germinal)
• Germ Cell
• Sex Cord/Stromal
• Metastatic

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DISEASES ofPREGNANCY

• EARLY Pregnancy
• LATE Pregnancy

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DISEASES ofPLACENTA

• BENIGN tumors (MOLES)
• MALIGNANT tumors (CHORIOCARCINOMA)

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

• 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

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BGRANULOSA DTHECA INTERNA ETHECA EXTERNA
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ESTROGEN

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

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PROGESTERONE

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

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DISEASES ofOVARIES

• CYSTS
• Follicular
• Luteal

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FOLLICULAR CYST MOST COMMON
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CORPUS LUTEUM CYST
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POLY-Cystic Ovarian Disease(Stein-Leventhal
syndrome)
5 Prevalence Anovulation Oligomenorrhea Obesity
Hirsutism
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Polycystic Ovaries
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OVARIAN TUMORS

• MÜLLERIAN (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
• SEX-CORD/STROMAL
• METASTATIC

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OVARIAN TUMORS

• Solid vs. Cystic
• Functional vs. NON-functional
• Benign vs. Malignant
• First clinical presentation may be ascites
• 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.

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SEROUS, BENIGN
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MUCINOUS, BENIGN
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PSAMMOMA bodies are dried up papillae of
papillary adenocarcinomas, usually in the
thyroid, but in ANY papillary adenocarcinoma
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OTHER MÜLLERIAN

• ENDOMETRIOD, malignant
• (looks like endometrium)
• 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 Müllerian)

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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

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DysgerminomaFemaleSeminomaMale
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ENDODERMAL SINUS TUMOR, aka YOLK SAC TUMOR
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CHORIOCARCINOMA, Just like testis or placenta
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SEX-CORD/STROMALTUMORS

• Chiefly benign and NON-cystic, i.e., solid,
  often functional (hyper-estrogen-ism)
• Granulosa-Theca
• Fibroma-Theca
• Sertoli-Leydig (Androblastoma)

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CALL-EXNER BODIES
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BGRANULOSA DTHECA INTERNA ETHECA EXTERNA
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DISEASES ofPREGNANCY

• EARLY Pregnancy
• LATE Pregnancy

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EARLY PREGNANCY

• SPONTANEOUS ABORTION
• ECTOPIC PREGNANCY

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Spontaneous Abortion

• 15 - 35
• Fetal Causes
• Usually Genetic
• Maternal Causes (placental, uterus infections or
  trauma)
• Toxo, Mycoplasma, Listeria
• Trauma

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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

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LATE PREGNANCY

• PLACENTAL ANOMALIES
• TWIN PLACENTAS
• PLACENTAL INFLAMMATIONS
• TOXEMIA (ECLAMPSIA/PRE-ECLAMPSIA)
• INTRAUTERINE GROWTH RETARDATION

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PLACENTAL ANOMALIES

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

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CIRCUMVALLATE
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PLACENTA ACCRETA NO DECIDUA BETWEEN VILLI AND
MYOMETRIUM
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MRI of Placenta PREVIA, or LOW-LYING placenta,
usually anatomically normal, but just lies LOWER
than it should.
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MONOCHORIONIC MONOZYGOTIC
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TOXEMIA of PREGNANCY(PRE-eclampsia)

• Hypertension
• Proteinuria
• Edema
• Related to Placental Ischemia
• Risk for DIC, convulsions (eclampsia)

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Intrauterine Growth Retardation

• Fetal causes Genetic, malformations
• Maternal Causes, vascular diseases, toxemia,
  infections, placental diseases
• Placenta size (350-700g) Fetal size (7.5lb)

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Placental Infections

• Villitis vs. chorionamnionitis vs. funisitis
• ASCENDING vs. hematogenous
• ASCENDING are usually bacterial, and
  chorionamnionitis
• Hematogenous are often TORCH, and villitis

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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

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Hydatidiform 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

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The MAIN thing differentiating benign from
malignant from worrisome trophoblastic neoplasms
is INVASIVENESS of the trophoblast
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