Bartholin glands in women are analogous to Cowper’s (bulbourethral) glands in men. They are also called greater vestibular glands. Inflamation or obstruction to the ducts of these glands can cause cyst formation.
The GREATER vestibular glands are located on the LOWER (posterior) wall of the vagina. The vestibular glands (NOT greater vestibular) are located on the UPPER (anterior) wall of the vagina.
This type of “lichenoid” disorder has HYPER-plastic epidermis, NOT atrophic. The “hyperplasia” is felt to be related to “itching” or mechanical epidermal irritation.
Yep, HPV again! (usually types 6 and 11)
VIN, CIN, PIN, VIN. (why a double “V”? (Vulvar,Vaginal too), all represent PRE-cancerous changes, vulva, cervix, prostate, vagina, respectively.
Very LOW grade VIN looks almost like normal skin, very HIGH grade VIN is regarded as carcinoma-in-situ, i.e., cancer, but hasn’t infiltrated yet. Identify the areas of VIN on this picture. Factures such as loss of maturation pattern, nuclear aberrations such as enlargement, hyperchromasia, pleomorphism, mitoses differentiate LOW fro HIGH.
INFILTRATING squamous cell carcinoma. Any doubt?
Any doubt? INFILTRATING squamous cell carcinoma!
Radical vulvectomy specimen? How do you know this is malignant melanoma? Where is the pigment? Would you order a S-100 and HMB-45 immunostain?
Atresia, double vagina, double uterus.
Bacteria, Candida, Trichomonas are the common causes of vaginitis
Note the trich’s flagella
Yep, you guessed it. Caused by HPV again.
Squamous metaplasia of cervical glands. Can you understand how this might be difficult to differentiate from infiltrating squamous cell carcinoma?
Cancer or metaplasia? Ans: Cancer Why?
Colposcopist’s view. Where is the squamocolumnar junction?
What is this?
What is this?
This is precisely the squamous metaplastic process? Where else might squamous metaplasia occur and why?
What is your diagnosis?
Note that the journey from noemal epithelium to carcinoma is a GRADUAL one, often many years too.
Which one is worse? Which one is more convincingly HPV? Why? (Ans: Koilocytosis)
Would you expect microinfiltration to originate from a carcinoma-in-situ appearing epithelium? Ans: YES
What is the difference between adenomyosis and endometriosis? Is adenomyosis also called endometriosis “interna”? Ans: YES
“ Chocolate” refers to the consistency of the hemorrhage, nothing more.
Endometrial “polyp”, colposcopist’s view and gross specimen.
Endometrial “polyp”, microscopic view. Because endometrial polyps are really excesses of estrogen targeted tissue, i.e., endometrium, are they related to estrogen excesses? Ans : YES Are they related to hyperplastic endometrium? Ans: YES Can they be confused with hyperplastic endometrium on a D&C specimen? Ans: YES
Just as NUCLEOLI differentiate benign from malignant prostate glands, what dofferentiate benign from malignant smooth muscle tumors? Ans: MITOSES per high power fields. NOT pleomorphism, NOT hyperchromasia, NOT nuclear size, ………………………………… ..But MITOSES!!!
INVASIVENESS is KEY feature to differentiate endometrial hyperplasia from endometrial carcinoma.
What are the usual glandular features of adenocarcinoma vs. “benign” glands?
These are merely adjectives, HOWEVER, some types are better than others, prognostically. HOWEVER, grading and staging are of utmost importance, independent of whatever of these “adjectives” you use.
Primary germ cells, male or female, first arise in the yolk sac and migrate to the genital ridge, which is in close proximity to the mesonephros. Eventually, retroperitoneal testes migrate through the inguinal canal to the scrotum, covered by peritoneum. Ovaries stay in the pelvis, and are covered by serosa, and are therefore intraperitoneal, by POSTERIOR to the fallopian tubes.
The CORTEX is the site of developing follicles. The MEDULLA is relatively free of developing follicles, and rich in connective tissue (stroma) and blood vessels.
Major internal female genitalia structures, landmarks, and interrelationships. In which ligament does the ovarian artery lie? Through which structure does the round ligament travel.
Major internal female genitalia structures, landmarks, and interrelationships.
GREAT whole mount to demonstrate overall cortex vs. medullary differentiation.
Zona pellucida, arrow, becomes “atretic” follicle. Is this a primary follicle? Ans: YES Why?
Secondary = Graffian = Antral follicle Where is the antrum?
Find the cumulus oophorus, liquor folliculi, and corona radiata
Granulosa and theca INTERNA cells make estrogen.
LUTEAL cells, under LUTEINIZING hormone and FSH too, make progesterone. LUTEUM means YELLOW. Why? Why is ANYTHING bright yellow? A corpus luteum of pregnancy is considerably larger than a regular, NON-pregnancy, corpus luteum.
Corpus albicans. ALBA means WHITE. Why is it white?
Most common PRE-menopausal cyst
Any EXTREMELY yellow cyst of a premenopausal ovary, is regarded as luteal in origin. Very common PRE-menopausal cyst
Although the cortical area of the normal ovary contains cysts, i.e., various stages of follicular development, true PCOD (PolyCystic Ovarian Disease, or Stein-Leventhall) ovaries are BIGGER (2x) than normal premenopaosal ovaries and have “true” cysts, NON-ovulatory, NOT just stages of follicular development. Is a “cyst” a “tumor” (i.e. swelling) in the classical sense of the word, like a bump on the head. Is a cyst usually a true neoplasm?
Always think of true ovarian tumors as following the normal anatomy/histology in these FOUR groups---mullerian, germ, sex-cord, metastatic. In contrast to the testicle, the ovary DOES occasionally get metastases.
Gross, microscopic, physiologic, behavioral classification factors for ovarian tumors.
The HUGEST tumors ever reported in human beings (50-100 lbs.?) are frequently benign mucinous ovarian tumors.
Q: What other adjective can we give to this tumor? Ans: Papillary
Close up of papillae
Why is this serous and NOT mucinous?
Less common M ü llerian carcinomas
Whether the teratomatous elements are “mature” or “immature” determine, greatly, the behavior of the teratoma, i.e., benign or malignant.
IMMATURE looking neural tissue. This is much more likely to behave badly (i.e., malignant) than a mature one. Often, you might see retinal tissue
Female dysgerminomas are IDENTICAL in appearance to male seminomas, i.e., germ cells + lymphocytes
Schiller-Duvall Body, just like in the testis yolk sac tumor!
EXACTLY the same as a malignant HCG producing testicular choriocarcinoma or a malignant HCG producing placental choriocarcinoma
“ Sex cord” = “stroma” MANY are functional, i.e., associated with hyper estrogenism (or androgenism)
Call-Exner bodies are virtually diagnostic of granulosa cell tumors. Q: Do they remind you of “rosettes”? Ans: YES
Q: Would a “thecoma” derived from theca INTERNA be more likely to be functional than a thecoma derived from theca EXTERNA? Ans: YES Why? Note the “theca” has both a vesicular and spindlt cell appearance. The juicy vesicular cells, theca interna, and tumors derived from them, can secrete estrogen. The spindly theca externa cells, usually do not, and may look simply like fibromas.
Many thecomas look white and fibrous, That is why the term fibrothecoma is often used? Is a fibrothecoma or fibroma less likely to be functional than a thecoma? Ans: YES Why?
Accessory placental lobe. An extreme lobe might be called a BI-partite placenta.
In a circumvallate placenta the amnionic, i.e., amniotic, membranes “thicken” or “double back”
And don’t forget placenta “abruptio” or premature separation of placenta with hemorrhage (i.e., hematoma)
Twin zygosity (mon- or di-) is related to the number of CHORIONS, NOT amnions or umbilical cords!
Toxemia of pregnancy occurs in an amazing 6% of all pregnancies. Toxemia is also called PRE-eclampsia. When PRE-eclampsia is particularly severe and associated with more serious systemic effects such as DIC or convulsions, it is called ECLAMPSIA.
What does TORCH stand for?
Syncytial cells are FUSED, CYTO-trophoblastic cells are deeper stem cells. Is this chorionic villus mature or IM-mature? Ans: mature Why? Ans: It has blood vessels in its core.
In COMPLETE moles, ALL the villi are swollen. They turn into choriocarcinomas 2% of the time. In PARTIAL moles, only some are. They NEVER turn into choriocarcinomas.
NOTE trophoblast looks NORMAL, i.e., NON-invasive and NON-proliferative, and NON atypical.
Choriocarcinoma. Note invasive trophoblast.
Choriocarcinoma. Note extreme pleomorphism of trophoblastic cells.
Diseases of female genital system
Female Reproductive System www.freelivedoctor.com
VULVA <ul><li>Synonymous with EXTERNAL genitalia </li></ul><ul><li>Everything ANTERIOR to the INTROITUS </li></ul><ul><li>Usual classification of Degen., Inflam., Neopl. </li></ul><ul><li>Common Diseases: </li></ul><ul><ul><li>BARTHOLIN Cyst </li></ul></ul><ul><ul><li>Vulvar Vestibulitis </li></ul></ul><ul><ul><li>Deg./Inflam. Epithelial: LICHEN diseases </li></ul></ul><ul><ul><li>BENIGN tumors: Condyloma(ta) </li></ul></ul><ul><ul><li>MALIGNANT tumors: VIN, SCC </li></ul></ul>www.freelivedoctor.com
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 www.freelivedoctor.com
VULVAR VESTIBULITIS, assoc. w. vulvodynia www.freelivedoctor.com
“ LICHEN” DISORDERS LICHEN Sclerosis (atrophic skin) LICHEN Simplex Chronicus (hypertrophic skin) Common features of FIBROSIS and INFLAMMATION www.freelivedoctor.com
VAGINITIS <ul><li>90% </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>www.freelivedoctor.com
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 www.freelivedoctor.com
ESTROGEN <ul><li>Controlled by FSH and LH </li></ul><ul><li>Develop, Lactate Breast Lobules </li></ul><ul><li>Proliferate Endometrial Glands </li></ul><ul><li>“ Cardioprotective” </li></ul><ul><li>“ Bone Mass” protective </li></ul>www.freelivedoctor.com
PROGESTERONE <ul><li>Controlled by FSH and LH </li></ul><ul><li>SECRETE Endometrial Glands </li></ul><ul><li>IMPLANTATION of the blastocyst </li></ul><ul><li>Lactation </li></ul>www.freelivedoctor.com
DISEASES of OVARIES <ul><li>CYSTS: </li></ul><ul><ul><li>Follicular </li></ul></ul><ul><ul><li>Luteal </li></ul></ul>www.freelivedoctor.com
FOLLICULAR CYST MOST COMMON www.freelivedoctor.com
OVARIAN TUMORS <ul><li>Solid vs. Cystic </li></ul><ul><li>Functional vs. NON-functional </li></ul><ul><li>Benign vs. Malignant </li></ul><ul><li>First clinical presentation may be ascites </li></ul><ul><li>Malignant ascites in a woman is ovarian cancer until proven otherwise </li></ul><ul><li>CA-125 is THE important tumor marker in ovarian cancer, especially as a follow up. </li></ul>www.freelivedoctor.com
OTHER M Ü LLERIAN <ul><li>ENDOMETRIOD, malignant </li></ul><ul><ul><li>(looks like endometrium) </li></ul></ul><ul><li>CLEAR CELL, malignant </li></ul><ul><ul><li>(clear cells, reminiscent of renal clear cell ca.) </li></ul></ul><ul><li>CYSTADENOFIBROMA, benign </li></ul><ul><ul><li>(BENIGN “FIBROUS” COMPONENT) </li></ul></ul><ul><li>BRENNER TUMOR, benign </li></ul><ul><ul><li>(transitional cell nests) </li></ul></ul><ul><li>CARCINOMA with SARCOMA </li></ul><ul><ul><li>(adenosarcoma, mixed M ü llerian) </li></ul></ul>www.freelivedoctor.com
“ GERM CELL” Tumors <ul><li>Teratomas (usually benign in ovary), i.e., “mature” cystic teratoma or dermoid cyst </li></ul><ul><li>“ Immature” teratomas are regarded as malignant </li></ul><ul><li>Dysgerminoma (look exactly like the testicular seminoma), malignant </li></ul><ul><li>Endodermal Sinus (Yolk Sac), malignant, Just like testicular </li></ul><ul><li>Choriocarcinoma, malignant, just like testicular </li></ul>www.freelivedoctor.com
www.freelivedoctor.com Many thecomas look white and fibrous, That is why the term fibrothecoma is often used? Is a fibrothecoma or fibroma less likely to be functional than a thecoma? Ans: YES Why?
DISEASES of PREGNANCY <ul><li>EARLY Pregnancy </li></ul><ul><li>LATE Pregnancy </li></ul>www.freelivedoctor.com
EARLY PREGNANCY <ul><li>SPONTANEOUS ABORTION </li></ul><ul><li>ECTOPIC PREGNANCY </li></ul>www.freelivedoctor.com
Ectopic Pregnancy <ul><li>Chiefly TUBAL, but ovarian or abdominal rare </li></ul><ul><li>1% OF NORMAL WOMEN </li></ul><ul><li>35%-50% OF WOMEN with previous SALPINGITIS/PID </li></ul><ul><li>+ HCG, Abdominal pain, 1 st trimester, ultrasound </li></ul>www.freelivedoctor.com
TOXEMIA of PREGNANCY (PRE-eclampsia ) <ul><li>Hypertension </li></ul><ul><li>Proteinuria </li></ul><ul><li>Edema </li></ul><ul><li>Related to Placental Ischemia </li></ul><ul><li>Risk for DIC, convulsions (eclampsia ) </li></ul>www.freelivedoctor.com
I ntrauterine G rowth R etardation <ul><li>Fetal causes: Genetic, malformations </li></ul><ul><li>Maternal Causes, vascular diseases, toxemia, infections, placental diseases </li></ul><ul><li>Placenta size (350-700g) ~ Fetal size (7.5lb) </li></ul>www.freelivedoctor.com
Placental Infections <ul><li>Villitis vs. chorionamnionitis vs. funisitis </li></ul><ul><li>ASCENDING vs. hematogenous </li></ul><ul><li>ASCENDING are usually bacterial, and chorionamnionitis </li></ul><ul><li>Hematogenous are often TORCH, and villitis </li></ul>www.freelivedoctor.com
Placental Neoplasms, i.e. gestational trophoblastic disease <ul><li>Benign: MOLES (Hydatidiform moles) </li></ul><ul><li>Malignant: CHORIOCARCINOMA </li></ul><ul><li>BOTH are associated with increased or persistent levels of the placental hormone HCG </li></ul>www.freelivedoctor.com
Hydatidiform Mole <ul><li>1/1000 in USA </li></ul><ul><li>1% in Indonesia </li></ul><ul><li>Also called NON-invasive mole in its most common benign variant, but can also be “invasive” </li></ul><ul><li>Complete (2% chorioCA incidence) or partial (0% incidence) </li></ul><ul><li>Grapelike clusters, i.e., swollen villi </li></ul>www.freelivedoctor.com