Transcript Vulva & Vagina

FEMALE
Reproductive System
Pathology
Embryology
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The mesoderm of the urogenital ridge gives rise to
the ovarian stroma, just as it does for the Sertoli
and Leydig cells of male embryos.
Primordial germ cells from the yolk sac migrate to
the ovarian (or testicular) stroma.
– Some of these end up in other midline structures,
explaining why "germ cell tumors" arise in the
retroperitoneum, pineal, and anterior mediastinum.
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In female embryos, the mullerian
(paramesonephric) ducts result from infolding of
the coelomic lining epithelium.
– They give rise to the surface epithelium of the
ovaries, and the lining of the oviducts and uterus.
– In male embryos, Mullerian inhibitory substance from
the testis makes the mullerian ducts regress.
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In female embryos, the wolffian (mesonephric)
ducts regress, persisting only as little bits of
epithelium along the whole female tract.
– These give rise to "Gardner's duct cysts" along the
cervix and vagina.
– In male embryos, the wolffian (mesonephric) ducts
become the epididymis and vas.
Anatomy and physiology
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The outer portion of the cervix ("portio
vaginalis") is covered with a thick,
nonkeratinizing, stratified squamous
epithelium.
The endocervical canal is lined by a simple
columnar mucus-producing epithelium.
The squamocolumnar junction usually is
located at the bottom of the endocervical
canal.
It's near this junction that cancers start
("the transformation zone“).
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In young adult women, the endocervical
cells may extend out onto the outer
surface of the cervix.
This is miscalled an "ectropion" or
"erosion"; actually it's normal.
The cervical os is almost entirely closed if
a woman has never given birth, and is
slightly widened and perhaps fishmouthed
if she has.
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Only the upper two thirds of the
endometrium ("the functionalis") cycles.
The basal third ("the basalis") does not
respond to a woman's steroid hormones
and stays in place, giving rise to next
month's endometrium.
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During reproductive life, every month several
follicles mature as graafian follicles.
One ovulates and suppresses the others, and
becomes a corpus luteum, which will regress
when the pregnancy ends or does not occur.
It will be recognizable for a few months,
gradually being replaced by scar tissue.
The oviduct's mucosa has ciliated cells, secretory
cells, and almost-no-cytoplasm "peg cells"
("intercalated cells").
The oviduct's mucosa is thrown up into
complicated folds ("plica", or "fimbria" at the
end).
Vulva & Vagina
Infectious Disease
of
Vulva & Vagina
Herpes Simplex II
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Vulva, vagina, cervix: Herpes blisters
Appear 3-7 days after exposure
– Pain
– Then the little blisters and the systemic syndrome
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fever, viral meningitis
– The blisters heal in a few weeks but are prone to
recur.
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Classic "herpes cell" seen on Tzanck preparation
or pap smears.
– Cells with multiple gigantic nuclei, usually bearing a
central inclusion, are diagnostic.
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If herpes is transmitted to the child during birth,
– severe sickness, brain damage, and even death are
likely to occur.
Human Papilloma Virus (HPV)
 Vulva:
– warts,
– intra-epithelial neoplasia,
– carcinoma
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Vagina and (especially) cervix:
– intra-epithelial neoplasia,
– carcinoma,
– less often warts.
Human Papilloma Virus (HPV)
Molluscum contagiosum
 Vulva: Molluscum lesions.
 This is not necessarily a sexually
transmitted disease.
Chlamydia trachomatis
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Vulva
– Bartholin gland abscess, bad strains can produce
lymphogranuloma venereum
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Cervix
– "Follicular cervicitis", with germinal centers.
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Endometrium
– "Chronic endometritis", with plasma cells.
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Oviduct
– Acute / chronic salpingitis ("pelvic inflammatory
disease").
Gonorrhea
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Vulva
– Inflammation and abscesses of Skene's or Bartholin's
glands
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Vagina
Cervix
– Purulent cervicitis.
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Endometrium
– Endometritis, either acute (with neutrophils) or
chronic (with plasma cells)
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Oviduct
– Acute/chronic salpingitis ("pelvic inflammatory
disease").
Hemophilus ducreyi
 Vulva
– Chancroid
Treponema pallidum (syphilis)
 Vulva, vagina, cervix
– Chancre (primary), condyloma latum
(secondary)
Mycobacterium tuberculosis
 Oviduct, endometrium TB
Calymmatobacterium – Klebsiella
granulomatis
 Vulva
– Donovoniasis, or "granuloma inguinale".
Gardnerella
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Vagina:
– Nonspecific vaginitis / "bacterial vaginosis"
– The bacterium is normal flora; it grows best in the
presence of semen but no woman is immune.
– You can make the diagnosis by observing that the
vaginal pH is more alkaline than the usual 4.5.
– And the bacteria cling to epithelial cells, creating the
fuzzy-looking "clue cell" in pap smear.
– Gardnerella is today's "usual suspect" for producing
many cases of premature rupture of the membranes,
premature labor, and premature birth.
Yeast infection
 Vulva, vagina, cervix
 red, itchy rash
 visible fungal colonies visible.
 Yeast infections are more likely when
there is more glucose in the area
– pregnancy,
– oral contraceptive pill, diabetes),
– when the normal bacteria are suppressed with
antibiotics.
Trichomonas
 Vulva, vagina, cervix
 Trichomonas vulvovaginitis
 a bad-smelling, red ("strawberry")
inflammation with a thin discharge.
 The protozoan is easily seen in wet
mounts, looking like a bouncing pear
moving about with flagella.
NON-NEOPLASTIC DISORDERS
of
VULVA
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Ectopic breast tissue is fairly common on the
vulva. It can enlarge during pregnancy and
lactation.
Bartholin glands on either side of the vaginal
introitus are prone to acute infection by ordinary
bacteria, chlamydia, or gonorrhea.
– Abscess formation may appear,
– They can resolve, leaving the duct obstructed, and a
cyst can form.
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Skene's glands, on either side of the
urethra, can also become inflamed,
especially by gonorrhea.
Vestibular adenitis is a poorly-understood
inflammatory process at the entry to the
vagina. The glands are inflamed and very
painful.
They may be excised surgically for a cure.
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Skin diseases including psoriasis, lichen
planus, vitiligo, and familial pemphigoid,
are very familiar on the vulva.
Vulvar hyperplasia: Sometimes the
epidermis simply undergoes hyperplasia
without anaplasia.
It thickens ("acanthosis"), and becomes
develops extra keratin ("hyperkeratosis").
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Lichen sclerosus: ("chronic atrophic
vulvitis") is a mysterious process in which a
band of dense, homogeneous, hyaline
collagen forms underneath the epidermis,
which is thinned.
The skin turns gray and parchment-like and
becomes itchy.
It can occur at any age.
Although there is no anaplasia, a few
percent turn malignant.
BENIGN TUMORS
of
VULVA
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Papillary hidradenoma is an intraductal papilloma
of the breast, only in the vulva along the
embryonic milk like.
Mucosal polyps are skin tags, fibrous nodules
covered with normal epithelium.
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Condyloma acuminatum is the large, usually
multiple warts that can occur on the vulva, perianal
region, and (less often) the vagina and cervix.
– HPV strains 6 and 11 as causes of condyloma acuminatum
– Microscopically, a branching fibrous stalk with a thickened
epithelium exhibiting these features of HPV infection:
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hyperkeratosis
parakeratosis
koilocytes :cells with dark, wrinkled nuclei (from all those
extra copies of the viral genome)
a perinuclear clear zone.
Koilocytes
Vulvar intraepithelial neoplasia
(VIN)
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Epithelial dysplasia (macule, papule,
plaque)
Atypia  CIS
Etiology
HPV (16, 6, 11)
Histology:
– VIN I, II, III (CIS).
CARCINOMA
of the
VULVA
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3% of the Gyn cancers.
Exophytic (2/3), ulcerative, infiltrative.
Metastases:
– ingiunal and femoral lymph nodes.
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Most vulvar cancers are:
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squamous cell carcinomas (most common),
adenocarcinomas,
melanomas,
basal cell carcinoma (less common).
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Squamous cell carcinoma
Most squamous carcinomas are caused by
HPV:
– Preceded by dysplasia and carcinoma in situ
("vulvar intraepithelial neoplasia“; VIN),
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which is analogous to the lesions in the cervix.
– A physician may notice the premalignant
lesions and excise them before cancer
develops.
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Squamous cell carcinomas not caused by
HPV:
– usually arise in lichen sclerosus or idiopathic
hyperkeratosis.
– These are more aggressive.
Verrucous carcinoma
Squamous cell carcinoma
Extramammary Paget's disease
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Mucin-rich cancer cells growing within the
epidermis of the vulva or perineum
– a red, itchy rash on Labium major.
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Histology:
– Tumor cells present clear cytoplasm which will
stain for some sort of mucin (Paget cells).
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Local excision should be curative.
The pathologist will do frozen sections to
help see if the margins are free.
Even without excision, the lesion is likely
to remain stable for a long time.
Paget’s disease:
Cancer cells growing within the epidermis
NON-NEOPLASTIC DISORDERS
of
VAGINA
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DES bumps
– Baby-girls exposed in utero to diethylstilbestrol (DES)
often have glands in the upper vagina.
– These appear as red bumps against the normally-pink
mucosa.
– These turn cancerous in fewer than 1% of affected
girls.
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Septate vagina
– The only common non-iatrogenic birth defect is a
septate vagina, from failure of the mullerian ducts to
fuse.
– There will also be a double uterus.
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Gartner duct cyst
– The only non-infectious, non-neoplastic lesion of the
vagina
– develops from the Wolffian duct remnants.
CANCER of the VAGINA
Squamous cell carcinoma
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Disease of old age.
Caused by HPV.
Good prgonosis in Localized lesions.
Adenocarcinoma
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Arises from the glands of girls exposed
to DES, usually in their teens.
Only one in about 1000 of girls
exposed in this way get cancer,
devastating.
The cells are glycogen-rich, hence the
name "clear cell carcinoma".
Clear cell carcinoma
Embryonal rhabdomyosarcoma
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“Sarcoma botryoides", is a common
malignant tumor of young children
Polypoid tumor (a bunch of grapes)
– botryoidgrape-like.
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The sarcoma contains cross-striated
rhabdomyoblastic cells,
They are locally destructive and can
metastasize late.