OVARY

clinical pic: -Asymptomatic! -palpable abd mass -sudden abd pain

CERVIX 1. CERVICITIS

UTERUS 1. ENDOMETRIAL POLYP

- solitary polypoidal lesion in uterine cavity covered by endometrial surface epithelium - formed of cystic endometrial glands +cellular fibrocytic stroma - pic : intermenstrual/postmenopausal bleeding (ulcerated polyp)

1. OVARIAN CYSTS
from ovarian follicles that becomes abnormally cystic during their development

Muco-purulent cervicitis (endocervix)

- STD! - Chlamydia trachomatis, Neisseria Gonorrhea - spread upwards PIDinfertility

-Numerous follicle cysts -Superficial cortical fibrosis

FUNCTIONAL CYST Follicular cyst : non ruptured follicles *lined by granulosa cells Corpus luteum cyst : CL that fails to collapse & resolve POLYCYSTIC OVARY (Stein Leventhal )SYNDROME
- pathogenesis : overproduction of androgens! impaired maturation of developing follicles & failure of ovulation - pic : menst.irregularities, obesity, hirsutism, anovulation

Chronic persistent/recurrent infection of squamous epithelium of exocervix

- HPV / HSV 2

2. ENDOMETRIAL HYPERPLASIA
- number of glands relative to endometrial stroma - dt : prolonged unopposed estrogen stimulation of endometrium - pic : menorrhagia, irregular uterine bleeding -types:

Mild non-specific inflammation of endocervix

- vaginal bacteria

ENDOMETROITIC (chocolate) CYST 2. TUMORS OF OVARY - PRIMARY SURFACE EPITHELIAL TUMORS Serous tumors Mucinous tumors mucinous deposits in peritoneum with implantation Endometrioid tumors
*Pseudomyxo peritonei

2. CERVICAL POLYP
- non-neoplastic lesion dt overgrowth of endocervical mucosa that protrudes as a polyp in the endocervical canal cause intermittent uterine bleeding - X associated with malignancy

1. Simple endometrial hyperplasia 2. Complex endometrial hyperplasia 3.Complex endometrial hyperplasia with atypia
risk of endometrial carcinoma -risk factors: Anovulatory cycles, exo.E2, polycystic ovary, nulliparity, obesity, E2 producing tumors

3. ENDOMETRIAL CARCINOMA
- risk : endometrial hyperplasia (precursor) + its risk factors - gross : fungating, infiltrating mass - micro type : 1. Endometrioid adenocarcinoma : post menopausal women, related to hyperestrenism, better prognosis 2. Papillary serous carcinoma : older women, X relatn with hyperestrenism, endometrial atrophy, worse prognosis

Brenners tumors

of tumor cells in peritoneum & production of large amount of mucin dt rupture of tumor

3. CERVICAL INTRAEPITHELIAL NEOPLASIA

- dysplastic changes of squamous epithelium of cervix at transformation zone - recognized as the precursor of squamous cell carcinoma CIN 1 CIN 2 CIN 3 incidence 25 years 30-40 years 30-40 years lower 1/3 of lower 2/3 of all layers of atypical cells involve epithelium epithelium epithelium type of HPV low risk hi risk hi risk 85% regress > risk to >25% of 10% - CIN 3 cervical untreated case fate 2-3% - risk to carcinoma cervical cerv.carcinoma than CIN 1 carcinoma treatment follow up conization conization -risk factors - infection of hi risk HPV (16,18) CIN - multiparity - sexual activity at early age - immunosupression - multiple hi risk sexual partners - cigarette smoking

GERM CELL TUMORS Teratoma (dermoid cyst) in women <25 yrs old! Mature (benign) cystic teratoma - cystic !
- with hair & greasy yellowish sebaceous material

Immature (malignant) solid teratoma

- with immature tissue, behaves like malignant tumor

4. ENDOMETRIOSIS -red brown nodules !

- presence of functional endometrial tissue outside the uterus - pathogenesis : implantation/metaplastic/metastatic theories - pic : dysmenorrhea, infertility, constipation, rectal pain

Teratoma with malignant transformation Monodermal (highly specialized) teratoma

- Struma ovarii! + Ovarian carcinoid!
thyroid tissue!

5. ADENOMYOSIS
- presence of non-functional endometrial tissue within the uterus - menorrhagia, dysmenorrhea

Dysgerminoma = seminoma Yolk sac tumor : young age! fetoprotein Choriocarcinoma HCG SEX CORD-STROMAL Granulosa cell tumor : E2 secreting! Granulosa-theca cell tumor : E2 secreting! Fibrothecoma tumor Fibroma : Meigs syndrome! *non-functioning Thecoma E2 secreting Sertoli-Leydig cell tumor : androgen secreting!
at any age! Steroid hormone-secreting! TUMORS (10% of all ovarian tumor)

6. TUMORS OF UTERUS Uterine leimyoma/fibroids

- benign smooth muscle tumors of myometrium - X malignant association - gross: multiple, well-defined, non-capsulated, diff.sizes, greyish-white, whorly appearance - subserosal/intramural/submucosal - pic : infertility, abn.uterine bleeding, obstruct of delivery, abortion, twisted & necrotic, some are Asymptomatic!

4. INVASINE CERVICAL CARCINOMA

- arise from CIN ( dt infection of HPV! ) - 50 years old - gross : fungating, ulcerating, infiltrating mass! - micro type : 1. squamous cell carcinoma(85%) 2. adenocarcinoma (10%) - pic : Asymptomatic, abnormal uterine bleeding, malodorous vaginal discharge

Leiomyosarcoma (malignant) Malignant mixed mullerian tumor (carcinosarcoma)

TUMORS OF THE UTERUS

GRAVID UTERUS NON-GRAVID UTERUS

BENIGN VESICULAR MOLE

INVASIVE MOLE

MALIGNANT CHORIOCARCINOMA

CERVIX CERVICAL CARCINOMA

BODY OF UTEURS

ENDOMETRIUM ENDOMETRIAL CARCINOMA

MYOMETRIUM

BENIGN LEIOMYOMA

MALIGNANT LEIOMYOSARCOMA

DISEASES OF PREGNANCY
ECTOPIC PREGNANCY BENIGN VESICULAR MOLE GESTATIONAL TROPHOBLASTIC DISEASE LOCALLY INVASIVE MOLE PRE-ECLAMPSIA & ECLAMPSIA

MALIGNANT CHORIOCARCINOMA

SURFACE EPITHELIAL TUMORS - arise from small mesothelial lined cysts which become incorporated into the substance of ovary following rupture & repair of ovulation site. - peritoneal mesothelium + epithelial lining all female genital tract = derived from ceolomic epithelium of the embryo - mesothelial cell lining the inclusion cysts of the ovary may become neoplastic & differentiate into epithelial cells which resembles the lining of endocervix, endometrium & FT Benign (cystadenoma) - 60% -usually cystic -30-40 yrs - 20% are bilateral - unilocular smooth-lined cyst filled with clear serous fluid - cyst wall lined by single layer of columnar ciliated cells Malignant (cystadenocarcinoma) -25% -partly cystic -34-60 yrs - 66% are bilateral -complex multilocular cyst with focal solid areas & nodular irregularities - stratified tumor cells, showing atypical nuclear features - tufting & papillary structures - psammoma bodies - stromal invasion detected! -spread by seeding of peritoneal cavity -lymphatic spread to regional LN -secretes tumor marker : CA125! - 10% - 20% are bilateral - better prognosis than serous carcinoma

SEROUS tumors

-resemble FT epithelium -most commonly bilateral

MUCINOUS -resemble endocervical tumors epithelium *rupture of tumors may result in pseudomyxoma ENDOMETRIOID tumors -resemble endometrial epithelium

- 80% - 5% are bilateral - large multilocularcystic masses filled with mucinous material - tumor cell is mucin secreting

TERATOMA (dermoid cyst) cystic ! - formed of elements from all 3 germ layers Ectoderm : skin hair, neural tissue Mesoderm : bone, cartilage, fat Endoderm : bronchial & gastrointestinal mucosal lining -complication : torsion of the ovary! SEX CORD STROMAL TUMOR FIBROMA - benign non-functioning tumor formed of fibroblasts! - benign THECOMA

*MALIGNANT TERATOMA = teratocarcinoma (1%) - Usually squamous cell carcinoma

GRANULOSA CELL TUMOR - may occur at any age -most are benign *25% may recur / metastasize during 10 years following diagnosis considered potentially malignant! solid, yellowish with cystic element

SERTOLI-LEYDIG CELL TUMOR biphasic tumor that contains cells resembling -testicular sertoli cells -leydig cells

C.S: solid, grey-white in colour firm consistency Microscopic:

solid, firm, with yellow cut surface dt high steroid content of tumor cells formed of spindle cells that contain fat

- may be associated with right pleural effusion & ascites (Meigs syndrome)

- secrete estrogen endometrial hyperplasia + uterine bleeding

formed of granulosa cells that may form Call-Exner bodies, like the normal granulosa cells in the ovarian follicles - often produce excess estrogen clinical presentation : * depends on age! -prepubertal precocious puberty -reproductive age irregular menses -postmenopausal post menopausal uterine bleeding

-secrete androgens cause virilization

KRUKENBERG TUMORS (secondary!) : bilateral ovarian metastasis of mucin-secreting gastrointestinal adenocarcinoma, most of gastric origin

incidence precursor lesion cause risk factor

INVASIVE CERVICAL CARCINOMA 50 years Cervical Intraepithelial lesion (CIN) Infection of HPV - infection of hi risk HPV (16,18) CIN - multiparity - sexual activity at early age - immunosupression - multiple hi risk sexual partners - cigarette smoking

ENDOMETRIAL CARCINOMA 50 60 years Endometrial hyperplasia Hyperestrenemia - obesity - DM & hypertension - infertility & nulliparity - anovulatory cycle - polycystic ovary - early menarche & late menopause - estrogen-producing tumor - estrogen replacement therapy - endometrial hyperplasia - exophytic polypoidal (fungating) mass projecting into uterine cavity - invasive infiltrating lesion extending into myometrium - diffuse thickening on endometrium Endometrioid Papillary serous adenocarcinoma carcinoma - post menopausal - older women - related to - X related to hyperestrenism hyperestrenism *develops against the background of endometrial atrophy -better prognosis -worse prognosis

gross

- ulcerative - exophytic fungating mass - endophytic invasive (infiltrating)lesion causing induration/deformities of the cervix (barrel-shaped cervix)

microscopic types

1. Squamous cell carcinoma(85%) 2. Adenocarcinoma originating from endocervical glands(10%) 3. Small cell carcinoma/Undiff. Carcinoma (5%)

clinical picture

spread

- Asymptomatic - abnormal uterine bleeding (intermittent/post-coidal) - malodorous vaginal discharge - local vagina, parametria, rectum, UB (obstructing ureters leading to renal failure the most common cause of death) - meastatis LN & lungs

- local myometrium, cervix & surrounding organs - lymphatics regional LN - hematogenous distant sites commonly the lung!

ENDOMETRIAL HYPERPLASIA Types: (according to extends of increase of the number of glands & presence of atypia) Simple endometrial hyperplasia Complex endometrial hyperplasia Complex endometrial hyperplasia with atypia - increase number of endometrial glands, some are cystically dilated with intervening cellular stroma - glands are crowded & branching - stroma is relatively scanty - endometrial glands appear crowded & irregular - lining epithelial cells show nuclear atypia

ENDOMETRIOSIS Common site : OVARY, OVARIAN & UTERINE ligaments, DOUGLAS pouch, serosa of bowel & urinary bladder, peritoneal cavity Pathogenesis: IMPLANTATION theory endometrial deposits arise when endometrial glands are regurgitated into peritoneal cavity thru FT during menstruation, then implant in peritoneal surface. METAPLASTIC theory arise due to metaplasia of peritoneal surface epithelium into endometrial type epithelium, * both arise from the same embryonic cell ( ceolomic epithelium) METASTATIC theory hematogenous spread if endometrial tissue which enter the circulation at menstruation *explains cases if endometriosis affecting organs such as lungs ADENOMYOSIS : presence of non-functional endometrial tissue within the uterus - surrounding myometrial smooth muscle cells undergo HYPERTROPHY and result in enlargement of uterus

Pathogenesis/Etiology 1. Follicular cyst : unruptured follicles 2. Luteal cyst : CL that fails to collapse & resolve 3. Polycystic ovary : overproduction of androgen by ovaries (defect in hypothalamic control of pituitary secretion) 4. Chocolate (endometriotic) cyst : endometriosis of the ovary 5. Surface epithelial tumor : - arise from small mesothelial lined cysts which become incorporated into the substance of ovary following rupture & repair of ovulation site. *peritoneal mesothelium + epithelial lining all female genital tract = derived from ceolomic epithelium of the embryo - mesothelial cell lining the inclusion cysts of the ovary may become neoplastic & differentiate into epithelial cells which resembles the lining of endocervix, endometrium & FT 6. Mucopurulent cervicitis : Chlamydia Trachomatis, Neisseria gonorrhoea 7. Chronic persistent/recurrent infection of squamous epith of exocervic : HPV, HSV 8. Cervical polyp : non-neoplastic lesion dt overgrowth of endocervical mucosa that protrudes as a polyp in the endocervical canal 9. CIN : dysplastic changes of squamous epithelium of cervix at transformation zone 10. Invasive cervical carcinoma : - arise from CIN ( dt infection of HPV!) 11.Endometrial polyp : solitary polypoidal lesion in uterine cavity covered by endometrial surface epithelium 12. Endometrial Hyperplasia & Endometrial carcinoma : prolonged unopposed estrogen stimulation of endometrium 13. Endometriosis : - presence of functional endometrial tissue outside the uterus 14. Adenomyosis : presence of non-functional endometrial tissue within the uterus Ages! 1. Functional cysts : most common in women in the reproductive age 2. Follicular cyst : most common ovarian mass 3. Corpus luteal cyst : most common ovarian mass in pregnancy * Ovarian tumor : 80% are benign, occurs mostly in young women aged 20-45 years : 2nd most common group of tumors in female genital tract : malignant ovarian tumors are seen inolder women aged 45-65 years! 1. Surface epithelial tumors : most common tumors of the ovary 2. Serous tumors : most frequent ovarian tumors & most commonly bilateral! - Benign serous tumor : most common benign ovarian tumor - Serous cystadenocarcinoma : most common malignant ovarian tumor 3. Teratoma : most common germ cell tumor in women younger than 25 years old , most common benign germ cell tumor of ovary 4. Fibroma : most common sex cordal stromal tumor! 1. Invasive cervical carcinoma : least common gynaecologic cancer 2. Leiyomyoma/fibroids : most common benign tumor of female genital system 3. Leiomyosarcoma : most common sarcoma of uterus Hormone-secreting diseases Follicular cyst Polycystic ovary Struma Ovarii Thecoma & Granulosatheca cell tumor Sertoli-leydig tumor Yolk sac carcinoma Choriocarcinoma Surface epithelial tumor estrogen androgen endometrial hyperplasia impaired maturation of developing follicles & fsilure of ovulation oligomenorrhea, hirsutism, infertility hyperthyroidism endometrial hyperplasia & uterine bleeding virilization

estrogen androgens feto protein HCG glycoprotein CA-125