Female genital system

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Female genital system

• Dr. Amitabha Basu MD

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Topic of this Lecture

• Disease of Cervix, Vagina, Vulva
• Disease of endometrium
• Disease of uterus
• Disease of fallopian tube

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Disease of Cervix

1. T-zone
2. Cervicitis
3. CIN
4. Malignancy of cervix

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Normal cervix
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Histology T zone
T zone Junction between squamous and columnar
epithelium. Most malignancy begin here.
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Cervicitis

• Types
• Etiology
• Morphology
• Clinical

1. Acute
2. Chronic Cervicitis

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Etiology

• Mostly non specific Cervicitis
• Specific form
• C. trachomatis.
• Trichomonous and Candida infection.

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Chronic Cervicitis Morphological features

1. Chronic inflammatory cells
2. Nabothian cyst.
3. Squamous metaplasia

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C. Trachomatis Cervicitis

• It produce follicular Cervicitis ( Plenty
  lymphocytes form FOLLICLES)

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Clinical Cervicitis

• It can produce temporary Female infertility.
• It provide a fertile soil for malignancy.

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Next topic CIN Types
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CIN SIL

• CIN Cervical intraepithelial neoplasia
• Or,
• SIN Squamous intraepithelial neoplasia

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CIN cervical intraepithelial neoplasia

• Etiology Humane papilloma virus ( 16,18), or
  inflammation.
• CIN III Carcinoma in situ severe dysplasia
  irreversible progress to invasive squamous
  cell carcinoma

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CIN I Flat Condyloma will show koilocytic
change
CIN I lower 1/3 rd of the epithelium is
Dysplastic
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Koilocyte Evidence of HPV infections
HIGH POWER
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CIN II lower 2/3 rd is dysplastic
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Carcinoma In Situ CIN III Entire epithelium
is involved.
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Carcinoma in situ intact basement membrane
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Screening of dysplasia PAP smear of the
exfoliated cell from the cervix Most important
cause of reduced mortality in west.
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Time for carcinoma of cervix
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Etiopathogenesis- CA cervix

• Etiology HPV type 16,18
• Age Peak incidence 45 years
• High risk group-
• Multiple sex partner
• Early age of 1st intercourse.
• Persistent infection with HIGH RISK HPV infection
• A male partner with multiple previous sex partner.

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Cervical carcinoma and HPV

• Squamous cell carcinoma MOST COMMON by this
  infection.
• Viral Oncogenes of HPV are
• E6 (bind to TP53) and E7 ( bind to RB)
• Cause inactivation of these two tumor suppressor
  genes.

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Cervical carcinoma

1. Squamous cell carcinoma HPV 16, 18- MOST
   COMMON
2. Clear cell carcinoma exposure to
   diethylstilbestrol (DES) .
3. Adenocarcinoma ( RARE)

Rare thing Think rarely
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Squamous cells carcinoma gross Exophytic growth
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Squamous cells carcinoma of cervix
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Clear cell carcinoma microscopy Recall etiology
Exposure to diethylstilbestrol (DES)
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Clinical features of squamous cell carcinoma
cervix

• Dyspareunia.
• Post coital bleeding.
• Leucorrhoea.

Diagnosis Papanicolaou smear Biopsy
(cone) Colposcopy.
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Staging of carcinoma cervix with prognosis
Stage 0. Carcinoma in situ (CIN III)
Stage I. Carcinoma confined to the cervix 1A. Micro invasive carcinoma (Stromal invasion no greater than 3 mm) 1B. Histologically invasive carcinoma gt 3 mm invasion.
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Micro invasive carcinoma
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Stage II. Carcinoma involves the vagina (upper 2/3rd).
Stage III. Carcinoma has extended onto pelvic wall and beyond it. The tumor involves entire vagina.
Stage IV. Involve the mucosa of the bladder or rectum. Present with metastatic dissemination.
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Prognosis 5 year survival

1. Stage 0 ( ca-in situ) 100
2. Stage 1( tumor confined to cervix) 90
3. Stage 2 82
4. Stage 3 35
5. Stage 4 ( tumor with distant metastasis)10

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Disease of vagina

1. Sarcoma botroid
2. Effect of diethylstilbestrol (DES) during
   pregnancy.
3. Vaginal adenosis
4. Clear cell carcinoma of vagina

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Sarcoma botroid

• Age 0-5 years
• Type of malignancy Embryonal rhabdomyosarcoma

Rare form of Primary vaginal malignancy
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Clear cell carcinoma of vagina

• Common in the young girls whose mother took
  diethylstilbestrol (DES) during pregnancy.

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Now vulval diseases
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Vulval disease

• Extra mammary pagets disease
• Gross crushed rash
• Micro intraepithelial malignant cells and
  intraepithelial spread.
• Condyloma acuminatum
• Wart like, HPV 6, 11
• Micro koilocytic change, hyperkeratois.

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Vulval disease

• Lichen atrophicus
• Thinning of the epidermis , dermal fibrosis,
  scant lymphocytes.
• Pre-cancerous lesion.

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Disease of the uterus Relax for a few minutes
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Disease of uterus

• Endometritis
• Adenomyosis
• Endometriosis
• Endometrial Hyperplasia.

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Endometritis
Acute Bacterial infection after delivery (parturition). Miscarriage. Neutrophils cells in the endometrial biopsy
Chronic Etiology Tuberculosis, With IUD, PID. Caseating granuloma and or plasma cells
Clinical Feature infertility and dysmenorrhea
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Adenomyosis

• Endometrial tissue deep in the myometrium of
  uterus.
• Gross enlargement of uterus
• Clinical
• irregular profuse menstruation
• Dysmenorrhea , menorrhagia

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Adenomyosis
Normal Endo-myometrium reaction
Adenomyosis Uterus enlarged
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Adenomyosis Enlarged Uterus
Clinical d/d Fibroid C/F irregular profuse
menstruation (Dysmenorrhea , menorrhagia )
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Endometriosis

1. Location
2. Pathogenesis
3. Pathophysiology
4. Chocolate cyst ( endometriosis of Ovary)
5. Clinical Features

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Endometriosis

• Endometrial tissue ( BOTH GLAND AND STROMA ) in
  any place out side the uterus.

Ovary or other tissue
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Endometriosis location
And Laparoscopic Scar ( during caesarian
section).
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Endometriosis pathogenesis

• Metapalstic Differentiation of
• Celomic Epithelium.
• Lymphatic dissemination.
• Regurgitation of endometrial fluid to ovary.
• Dissemination through pelvic vein.

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Endometriosis Pathophysiology

• In this case Endometrial glands respond to the
  cyclical change of Hormone.
• So, it bleeds along with menstruation.
• And produce hemorrhage at the site of
  endometriosis.

Uterus
Ovary
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Gross

• Red blue nodule at the site of implant.
• Ovary
• Produce chocolate cyst
• (hemosiderin)
• In ovary it occurs due to regurgitation of
  endometrial fluid in fallopian tube.

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Chocolate cyst of the ovary endometriosis of
ovary Regurgitation of endometrial fluid to
ovary.
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Why it is called chocolate cysts ?

• It is the color of altered blood in the cyst.
• This color is due to Hemosiderin pigments.

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Clinical Features Endometriosis

• Generalized pelvic pain
• Dysmenorrhea
• Dyspareunia
• Infertility

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Endometrial Hyperplasia
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Endometrial Hyperplasia

1. Etiology
2. Types
3. Clinical Features

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Endometrial Hyperplasia

• Etiology Prolonged , elevated level of Estrogen.
• Clinical Examples
• Polycystic Ovary ( stein Leventhal syndrome).
• Functional Granulosa Theca cell Tumor

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Types

1. Simple cystic Hyperplasia
2. Complex Hyperplasia
3. Atypical Hyperplasia

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Simple cystic Hyperplasia cystically dilated
glands and adequate compact stroma
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Complex Hyperplasia more glands less stroma
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Atypical Hyperplasia Atypical glands 20 -25
risk of progression to adenocarcinoma.
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Clinical features

• Irregular Bleeding
• Menometrorrhagia

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Tumor of the Uterus
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Tumors of the Uterus

• Leiomyoma (fibroids)
• Malignant mixed möllerian tumor
• Endometrial adenocarcinoma

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We shall discuss about-

1. Leiomyoma
2. Endometrial carcinoma

1. Etiology
2. Types
3. Complications

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Leiomyoma( Fibroid)

• Estrogen , OCP stimulate their growth.
• Increases in size as the pregnancy progress ( if
  present in a pregnant lady).

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Leiomyoma- types

• Sub Mucosal
• Intra mural
• Sub serosal

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Leiomyoma A benign tumor of the smooth muscles
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Leiomyoma complication

1. Bleeding
2. Infertility
3. Abortion ( in a pregnant lady).
4. Pain due to red degeneration( Ischemic
   necrosis) within a large Leiomyoma.

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Leiomyosarcoma

• Malignant tumor of the smooth muscle. often have
  very large bizarre giant cells along with the
  spindle cells.

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Prognosis Bad
Recurrence after removal is common. Metastasize
widely.
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Endometrial carcinoma

• Etiology
• Atypical endometrial Hyperplasia.
• Prolonged estrogenic stimulation.
• Tumor of ovary
• ERT

• Risk factors
• Obesity
• Diabetes
• Hypertension
• Infertility
• Lynch syndrome colon, endometrial and ovarian
  cancer

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C/F Abnormal excessive Bleeding Age 55-65
years
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Morphology and Clinical

• Morphology
• Gross early case no significant change in size
  of uterus.
• Later invasion occur and produce a polypoid
  mass.
• Micro Endometroid adenocarcinoma
• Clinical Post menopausal women with irregular
  Bleeding.

Red Flag sign
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Fallopian tube

• Inflammation of the Tube ( may be associated with
  pelvic inflammatory disease).
• Chlamydia
• Neisseria gonorrheae
• Streptococci ( postpartum period)
• Tuberculosis
• Ectopic Pregnancy

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Gross Bilateral tuboovarian abscess
.(asymmetric Involvement)
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Micro Acute salpingitis by Neisseria gonorrheae.
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Salpingitis clinical Features

1. Fever
2. Lower abdominal pain
3. Pelvic masses ( if tube contain exudates, and
   inflammatory debris, even fibrosis)

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Tubal Ectopic Pregnancy 1 in 500 pregnancies
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Tubal pregnancy
Risk factors Pelvic inflammatory disease (PID
Progesterone-bearing IUD's.
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Micro Tubal Pregnancy
Villi
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Clinical

• Vaginal spotting
• Mild Lower abdominal pain

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Complication of Tubal pregnancy

• Rupture and hemoperitoneum
• Hemorrhagic shock.

It is an absolute emergency requiring immediate
surgical correction
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Thank you!