Bien Ag Nina Ian John “G” Rachel Mark Jocelle Edo Gienah Jho Kath Aynz Je Glad Nickie

Ricobear Teacher Dadang Niňa Arlene Vivs Paul F. Rico F. Ren Mai Revs Mavis Jepay Yana Mayi Serge Hung

S3
S3 L7:
L7: The
The Female
Female Genital Tract by Dr. John Arnel Amata
Genital Tract January 8, 2011

I. Introduction  uterus & vagina

a. Embryology
b. Lateral Mullerian Ducts Urogenital Sinus = Caudal growth & fusion lower vagina
c. Pelvic Inflammatory Infections
II. Vulva  Candida
a. Inflammatory Dermatologic Diseases  Trichomonas
b. Bartholin Cyst  Gardnerella
c. Vestibular adenitis  Gonorrhea
d. Non neoplastic epithelial disorders  Chlamydia
e. Tumors  Mycoplasma
III. Vagina  Human Papilloma Virus (HPV)
a. Congenital Anomalies:
b. Gartner duct cysts Infections in the Lower Genital Tract
c. Mucouc cysts 1. Herpes Simplex
d. Endometriosis  Vulva, vagina, cervix
e. Benign  HSV-2
f. Malignant  Red painful papules Vesicles  Ulcers
IV. Cervix  Leukorrhea, fever, malaise, tender lymph nodes
a. Inflammations
 Heal spontaneously
b. Cancer
 Latent infections region nerve ganglia
i. Cervical Intraepithelial Neoplasia
ii. Squamous cell carcinoma  Neonatal transmission during delivery
iii. Cancer prevention and control
V. Body of the Uterus and Endometrium 2. Mycotic & Yeast (Candida)

Tope

a. Endometrial Hormonal Cycle 10%

b. Organic abnormalities  DM, oral contraceptives, pregnancy
c. Functional Endometrial Disorders (Dysfunctional  Small white surface patches
Uterine Bleeding)  Leukorrhea & pruritus
d. Inflammation
e. Endometriosis and Adenomyosis 3. Trichomonas vaginalis
f. Endometrial Hyperplasia  Large flagellated ovoid protozoans
g. Malignant tumors  15% STD
h. Tumors of Endometrium with Stromal Differentiation  Purulent vaginal discharge, discomfort
i. Tumors of Myometrium  “STRAWBERRY CERVIX”
VI. Fallopian Tubes
a. Inflammations 4. Mycoplasma
b. Tumors and cysts  Vaginitis & cervicitis
VII. Ovaries  Spontaneous abortion & chorioamnionitis
a. Metastatic tumors
b. Non-neoplastic and Functional Cysts 5. Gardnerella
c. Inflammations  Gram (-) small bacilli
VIII. Gestaional and Placental Disorders
a. Disorders of Early Pregnancy PELVIC INFLAMMATORY DISEASE (PID)
b. Disorders of Late Pregnancy  Pelvic pain, adnexal tenderness, fever, vaginal d/c
c. Gestational Trophoblastic Disease  Gonococcus, Chlamydia, Enteric bacteria
 Spontaneous or induced abortion
 Puerpural infections: Staphylococcus, Streptococcus,
Coliform, C. perfringens
Introduction  Gonococcal
o Bartholin & vestibular glands
Embryology o Periurethral glands
4th week: primordial germ cells from yolk sac o Cervix
5th week: migrate into urogenital ridge o Fallopian Tubes
Mesoderm epithelium & stroma o Acute suppurative reaction
Endoderm germ cells o Smears with intracellular gram (-) diplococci
Mesoderm + endoderm = OVARY
o Culture
6th week: invagination & fusion of coelomic epithelium  lateral
o Acute suppurative salpingitis, salpingoophoritis,
mullerian ducts
tubo-ovarian abscess pyosalpinx, follicular
salpingitis
LATERAL MULLERIAN DUCTS  Non-gonococcal
 fallopian tubes o S/P surgery

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 o Lymphatics or venous channels - Sharply circumscribed nodule in labia majora
 Staphylococcus, Streptococcus or interlabial folds
o Less exudation - HISTO: tubular ducts lined by single or
o Inflammation of deeper layers double layers of non ciliated columnar cells
o Bacteremia with myoepithelial cells
 Complications:
o Peritonitis b. Benign raised or wart like conditions
o Intestinal obstruction due to adhesions b.1. Condyloma acuminatum
- HPV 6& 11
o Bacteremia  endocarditis, meningitis,
- Venereal Wart
suppurative arthritis
o Infertility - HISTO: branching tree like proliferations of
stratified squamous epithelium, fibrous
stroma, acanthosis, parakeratosis,
VULVA
hyperkeratosis, nuclear atypia & perinuclear
vacuolation “koilocytosis”
1. Inflammatory Dermatologic Diseases
 Psoriasis, eczema, allergic dermatitis
b.2. Mucosal Polyps
 Blood dyscrasia, uremia, DM, malnutrition,
- Benign stroma proliferations
avitaminoses
- Squamous epithelium
2. Bartholin Cyst
b.3. Syphilitic Condyloma latum
 Obstruction & infection of Bartholin gland  abscess
- Elevated red brown spots, popular lesions 2-
 Pain, local discomfort
3cm
 Excised, “marsupialization”
 Malignant
3. Vestibular adenitis
o Carcinomas, malignant melanoma, sarcoma
 Posterior introitus
a. Vulvar Carcinoma
 Vestibular glands
- Uncommon, 3% of genital ca in females
 Chronic recurrent, painful
- 2/3 >60 years
 Unknown cause
- 85% squamous cell carcinoma
 Surgery
- Remainder: basal cell ca, melanoma,
adenocarcinoma
4. Non neoplastic epithelial disorders
- Rare Variants: Verrucous CA & Basal Cell
 “leukoplakia”
CA
 Vitiligo
 Inflammatory dermatosis b. Vulvar Intraepithelial Neoplasia (VIN)
 Vulvar intraepithelial neoplasia, Paget disease, - White pigmented plaques
invasive CA - Nuclear atypia
 Unknown etiology - Increase mitosis
 Lichen sclerosus (Chronic Atrophic Vulvitis) - Lack of surface differentiation
o Pale gray skin, parchment-like - Progress to CA depend on age (>45), extent
o Atrophy of labia of tumor, immune status
o Narrowed introitus
o Histology: c. Extramammary Paget Disease
 Thinning of epidermis - Rare
 Disappearance of rete pegs - Vulva, perianal region
 Dense collagenous fibrous tissue - Pruritic red crusted sharply demarcated
 Marked hyperkeratosis map-like area
 Mononuclear infiltrates about blood vessels - Labia majora- palpable submucosal
o Common after menopause thickening or tumors
o All ages - Confined to epidermis & adjacent hair
o Genetic predisposition, autoimmunity, hormonal follicles, sweat gland neoplasms
o 1-4%  cancer - Histology:
 Lichen simplex chronicus  Large tumor cells, lying singly or small
o Acanthosis clusters, within epidermis & appendages
o Hyperkeratosis  “halo”
o Hyperplais of vulvar squamous epithelium  Fairly granular cytoplasm (+) PAS,
o Increase mitotic activity alcian blue, mucopolysaccharide
o Variable WBC infiltration of dermis
o May coexist with vulvar epithelial neoplasms d. Malignant melanoma of vulva
- Rare
5. Tumors - <5% of vulvar ca’s
 Benign - 2% of melanoma in women
o Fibromas, neurofibroma, angiomas - 6-7th decade
a. Papillary Hidradenoma - Same biological & histological characteristic
- Modified apocrine sweat glands as melanoma elsewhere

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 - (+) S 100, (-) CEA, S100, - Soft, almost mucoid, loose fibromyxomatous
mucopolysaccharide stroma, dilated mucus secreting endocrine
glands
VAGINA
2. Cancer
 Primary disease uncommon  Ranks 8th leading cause of cancer mortality
1. Congenital Anomalies:  4500 deaths annually
o Atresia  High detection frequency of early cancers &
o Total absence precancerous conditions- Papanicolao cytologic test
o Septate or double vagina (PAPS)
2. Gartner duct cysts  Risks factors for cervical neoplasia
3. Mucouc cysts o Early age at first intercourse
4. Endometriosis o Multiple sexual partners
5. Benign: o Increased parity
o Rhabdomyoma, stromal polyps, leiomyomas, o Male partner with multiple previous sexual
hemangiomas, mixed tumors partner
6. Malignant o Cancer associated HPV (16, 18, 31, 33, 35, etc)
o Carcinoma, embryonal rhabdomyosarcoma o Persistent detection of high risk HPV
a. Primary Cancer o Certain HLA & viral subtypes
- 1% malignant neoplasms o Oral contraceptives & nicotine
- 95% squamous cell CA o Genital infections (Chlamydia)
- Upper posterior vagina, junction with a. Cervical Intraepithelial Neoplasia (CIN)
ectocervix - Precancerous stage
a.1. Adenocarcinoma - Continuum of morphologic changes with
- Rare indistinct boundaries
- Increase frequency of young women whose - Do not variably progress to cancer & may
mothers had been treated with DES during spontaneously regress
pregnancy (0.14% develop adenocarcinoma) - Associated with papillomaviruses & high risk
- Anterior wall, upper 3rd HPV types are found in increase frequency
- 15-20 years old in higher grade precursors
- Vaginal adenosis- precursor - Classification:
- HISTO: gland epithelium either mucus a.1. dysplasia/ carcinomain situ system
secreting, resembling endocervical mucosa a.2. cervical intraepithelial (CIN)
or tuboendometrial, with cilia classification
a.3. low grade & high grade intraepithelial
b. Embryonal rhabdomyosarcoma (sarcoma lesions
botyroides)
- Uncommon Cervical Intraepithelial Neoplasia
- Infants & children <5 yo 1. CIN I
- (+) embryonal rhabdomyoblasts  Nuclear enlargement, hyperchromasia in superficial
- Gross: polypoid, rounded, bulky masses, fill cells
& project out of vagina “grape like clusters”  Koliocytotic atypia
- Micro: small oval nuclei, “tennis racket”, rare  Raised lesions (acuminatum) & macular (flat
striations within cytoplasm, tumor cells in condyloma)
cambium layer, loose fibromyxomatous
stroma 2. CIN II
- Invade locally  Atypical cells in lower layers of squamous epithelium
but with persistent differentiation toward the prickle
CERVIX and keratinizing cell layers
 Changes in NC ratio, variations in nuclear size, loss of
1. Inflammations polarity, increase mitotic figures, abnormal mitosis,
a. Acute & chronic cervicitis hyperchromasia
- Epithelial spongiosis 3. CIN III
- Submucosal edema  Loss of differentiation and greater atypia in more
- Epithelial & stromal changes layers of epithelium
- Acute: acute inflammatory cells, eriosion,  Totally replaced by immature atypical cells, exhibiting
reactive changes no surface differentiation
- Chronic: mononuclear, lymphocytes,
macrophages, plasma cells, necrosis, Squamous cell carcinoma
granulation tissue
 Peak incidence: 40-45 years
b. Endocervical polyps  3 distinct patterns
- Innocuous tumors o Fungating (exophytic) – most common
- 2-5% adult women o Ulcerating
- Irregular vaginal spotting or bleeding o Infiltrative
 Extend by direct spread
 Local and distant lymph node metastasis

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  Liver, lungs, bone marrow and other structures
 95% composed of large cells, either keratinizing or
non keratinizing patterns
 5% poorly differentiated small cell cacinomas
 Stage 0 – IV
 10-25%: adenocarcinomas, adenosquamous
carcinomas, undifferentiated carcinomas
 Arise in endocervical glands
Cancer prevention and control
 Cytologic screening and management of PAP smear
abnormality
 Histologic diagnosis and removal of precancers
 Surgical removal of invasive cancers, with adjunctive
radiation and chemotherapy
 Use of vaccines under investigation
BODY OF THE UTERUS AND ENDOMETRIUM
Disorders
 Endocrine imbalances
 Complications of pregnancy
 Neoplastic proliferations
oAfter delivery, miscarriage, retained products
of conception
o Interstitium inflammation
 Chronic endometritis
o Chronic PID
o Postpartal or postabortal endometrial cavities
o Intrauterine contraceptive devices
o TB patients: drain TB salpingitis
o 15%: no primary cause – nonspecific chronic
endometritis
o Chlamydia may be involved
5. Endometriosis and Adenomyosis
 3 theories
1. Regurgitation/implantation theory: retrograde
menstruation
2. Metaplastic theory: arise from coelomic
epithelium
3. Vascular or lymphatic dissemination theory:
disseminated through pelvic veins and lymphatics
 Red-blue to yellow brown nodules on or just beneath
the serosal surface
 Extensive organizing hemorrhage, fibrous adhesions
between tubes and ovaries
 Obliteration of pouch of Douglas

1. Endometrial Hormonal Cycle Endometriosis

 Proliferative – early, mid, late  Endometrial glands or stroma in abnormal locations
 Secretory outside the uterus
 Menstrual o Ovaries
o Uterine ligaments
2. Organic abnormalities o Rectovaginal septum
 Chronic endometritis o Pelvic peritoneum
 Submucosal leiomyomas o Laparotomy scars
 Endometrial polyp o Umbilicus
 Endometrial neoplasm o Vagina
o Vulva
3. Functional Endometrial Disorders (Dysfunctional Uterine o Appendix
Bleeding)  Manifestations: infertility, dysmenorrhea, pelvic pain
 Anovulatory cycle  due to excess estrogen
stimulation Adenomyosis
o Result of:  Endometrial tissue in uterine wall
- Endocrine disorders: thyroid disease, adrenal  20% of uteri
disease or pituitary tumors
 Shedding of endometrium: colicky dysmenorrhea,
- Primary lesions of the ovary: granulosa-theca
dysparenunia and pelvic pain during premenstrual
cell tumors or polycystic ovaries
period
- Generalized metabolic disturbance: obesity,
malnutrition, chronic system disease
6. Endometrial polyps
 Subtle hormonal imbalances: most unexplained
 Single or multiple, 0.5 to 3 cm, large, pedunculated
 Inadequate Luteal Phase
 Asymptomatic or cause abnormal bleeding
o Inadequate corpus luteum function
 Functional endometrium or hyperplastic and cystic
o Low progesterone output
o Irregular ovulatory cycle
7. Endometrial Hyperplasia
o Manifestations: infertility with eithr increase Endometrial intraepithelial neoplasia
bleeding or amenorrhea  Increase gland to stroma ratio
 Endometrial changes induced by oral contraceptives  Abnormalities in epithelial growth
o Common response pattern: discordant
 Prolonged estrogen stimulation by anovulation or
appearance between glands and stroma, usually increase estrogen production
with inactive glands amid a stroma showing large o Menopause, polycystic ovarian disease,
cells with abundant cytoplasm reminiscent of the
functioning granulosa cell tumors of ovary,
decidua of pregnancy
cortical stromal hyperplasia, prolonged
 Menopausal and Postmenopausal changes administration of estrogenic substance
o Atrophy o Inactivation of PTEN tumor suppresor gene
o Mild hyperplasias with cystic dilatation
 Simple non-atypical hyperplasia
o Cystic, mild hyperplasia
4. Inflammation
 Complex atypical hyperplasia (endometrial
 Acute endometritis
intraepithelial neoplasia)

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 o Increase number, size, crowding glands,  Similar effects as PCOD although virilization may be
enlagement and irregular shape common mitotic striking
figures  Theca lutein hyperplasia of pregnancy – mimick
o Treatment: hysterectomy  Classification 1993 WHO
o Surface epithelial (mullerian) stromal tumors
8. Malignant tumors  Serous – 30%
 Endometrial carcinoma - Tall columnar ciliated epithelial cells
o Most common invasive cance of female genital - Clear serous fluid
tract - Psammoma bodies
o 7% of invasive cancers in women  Mucinous – 25%
o Pak age: 55-65 - Associated with pseudomyxoma peritonei
o Higher frequency in obesity, diabetes, HPN,  Endometrioid
infertility  Epithelial stromal
o Gross: localized polypoid tumor or diffuse  Clear cell tumors
involving entire endometrial surface  Clear cell adenocarcinoma
o 85% adenocarcinomas: endometrioid type;  Cystadenofibroma
 Transitional tumors
others: seous type (grade 3)
- Brenner tumors: transitional cells
o 3 step grading system: grade 1, 2, 3
o Sex cord-stromal tumors
 Granulosa-theca cell tumors
9. Tumors of Endometrium with Stromal Differentiation
- Call-Exner bodies
 Carcinosarcomas (malignant mixed mullerian tumors)
 Fibro-thecomas
 Adenosarcomas: benign glands, malignant stroma
 Sertoli-Leydig cell tumors (androblastomas)
 Stromal tumors
 Others
o Benign stromal nodules
o Germ cell tumors
o Endometrial stromal sarcomas
 Teratomas
 Dysgerminoma
10. Tumors of Myometrium
 Endodermal sinus (Yolk Sac) tumor
 Leiomyomas (fibroids)
 Choriocarcinoma
- 75% of femaled of reproductive age
 Others
o Gross: sharply circumscribed, discrete, round,
o Malignant, NOS (not otherwise specified)
firm, gray white tumors
o Metastatic Non-ovarian Cancer
o Microscopic: whorled bundles of smooth muscle
cells
3. Metastatic tumors
 Leiomyosarcomas
 Uterus, fallopian tubes, contralateral ovary, pelvic
o Bulky fleshy or polypoid masses
peritoneum
o Nuclear atypia, mitotic index, zonal necrosis
 Krukenberg tumor: gastric CA
o 10 or more mitosis/10 hpf w/o atypia; 5/10 hpf
w/ atypia GESTATIONAL AND PLACENTAL DISORDERS
o Peak at 40-60
1. Disorders of Early Pregnancy
FALLOPIAN TUBES  Spontanoues abortions
o 10-15% of recognized pregnancies
1. Inflammations o Fetal and maternal causes
 Suppurative salpingitis: 60% gonococcus
 Ectopic pregnancy
 Tuberculous salpingitis o 90% tubal
2. Tumors and cysts
o 35-50%: PID w/ chronic salpingitis
 Paratubal cysts: hyatids of Morgagni
2. Disorders of Late Pregnancy
 Adenomatoid tumors (mesotheliomas)
 Placental abnormalities and twin placentas
 Primary adenocarcinoma: rare
 Placental inflammations and infections
OVARIES  Toxemia of pregnancy (preeclampsia and eclampsia)
o Hypertension, proteinuria, edema + convulsions
1. Inflammations o DIC
 Oophorits: uncommon 3. Gestational Trophoblastic Disease
2. Non-neoplastic and Functional Cysts  Hyatidiform Mole
 Follicular and luteal cysts  Invasive Mole
 Polycystic Ovarian Disease (PCOD, Stein-Leventhal  Choriocarcinoma
syndrome) o Cytotrophoblasts and syncytiotrophoblasts
 3-6% of reproductive women  Placental site trophoblastic tumor (PSTT)
 Numerous cystic follicles or follicle cysts o Intermediate trophoblasts
 Associated with oligomenorrhea, persistent anovulation,
obesity, hirsutism and rarely virilism
 Stromal hyperthecosis (cortical stromal hyperplasia)
 Post menopausal women
 Uniform enlargement, bilateral
 Hypercellular stromal with luteinization of stromal cells

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