Pathophysiology L 11 Female Genital System Prof Fakhir

Pathophysiology L 11 Female Genital System Prof. Fakhir Al-Ani fakeralani 2000@yahoo. com

Include ü Vulva ü Vagina ü Cervix ü Body of Uterus ü Fallopian Tubes ü Ovaries

Vulva Diseases of vulva: ü Vulvitis (Common but not serious). ü Painful bartholin cysts (obstruction of glands). ü Imperforate hymen. ü Non-Neoplastic epithelial disorders. ü Carcinomas (uncommon but life threatening).

Vulvitis 1. Most important forms is related to STDs: - ü HSV 1 or 2 (Herpes genitalis): Vesicular eruption. ü Gonococcal suppurative infection ü Syphilis: Primary chancre at site of inoculation. ü Candidal vulvitis.

Alergic Vulvitis 2. Contact dermatitis: Most common causes of vulvar pruritus. It is a reactive inflammation to an exogenous stimulus (Irritant or an allergen). - Contact irritant dermatitis: Erythema & crusting papules & plaques. May be a reaction to urine, sops, detergents, antiseptics, or alcohol. - Contact allergic dermatitis: Same gross appearance. Result from allergy to perfumes, additives in creams, lotions, soaps, chemical treatments on clothing.

Painful bartholin cysts Obstruction of glands: Pain when walking, sitting, or having sex. - It is rare for a Bartholin’s abscess to get better on its own. - Usually, the abscess needs to be drained through surgery.

Imperforate hymen It is a congenital disorder. The hymen without an opening. Primary amenorrhea

Non-Neoplasic epithelial disorders The epithelium of vulvar mucosa may undergo: 1. Atrophic thinning = Lichen sclerosus 2. Hyperplastic thickening = Lichen simplex chronicus Both: Exist in different areas in the same person. Appear as Leukoplakia (Depigmented white lesions).

Non-Neoplastic epithelial disorders Lichen Sclerosus: - Atrophic epithelium (with dermal fibrosis). - Pathogenesis is uncertain (may be autoimmune) - Carries risk of developing squamous cell carcinoma Lichen Simplex Chronicus: - Hyperplastic thickening, hyperkeratosis. - Pathogenesis chronic inflammatory reaction. - Not predisposing to cancer, but suspiciously present at margins of established cancer of the vulva.

Tumors Condylomas: - Two distinctive forms: - Condylomata lata: (not commonly seen today). moist, minimally elevated lesions. Occur in secondary syphilis - Condylomata accuminata: (more common) Papillary & distinctly elevated. Occur anywhere on the anogenital surface. Not pre-cancerous. Human papillomavirus (HPV) Carcinoma of the vuvla Rare; 3% of all genital tract cancers in women.

Vaginal diseases - It is usually secondary to infection or cancer arising in cervix, vulva, bladder, or rectum. - It is seldom the site of primary disease The secondary lesion due to: - Vaginitis. - Primary tumors. The primary disorders are: - Few congenital anomalies: Total absence of vagina Separate or double vagina

Vaginitis - Common, Often Transient & not serious. - Infection: Candida Albicans, Trichomonas, Gonococcus - Nonspecific atrophic vaginitis: - Postmenopausal women Atrophy & thinning of squamous vaginal mucosa. Candidal vaginitis 5% of normal women Asymptomatic Curdy white discharge Flashy meat bad smell Microscopic Exam. T. vaginalis 10% of normal Asymptomatic watery green Putrid odor often Microscopic Gonococcus Sexual transmited dis. Often are asymptomatic Mucopurulent discharge Pelvic inflammation Microscopic

Cervicitis - Extremely common - Associated with purulent vaginal discharge. The inflammation: 1. Infectious. 2. Noninfectious cervicitis. Microorganisms: 1. Aerobic. 2. Anaerobic. T. vaginlais (40%), Candida, Neisseria gonorrheae, herpes simplex genitalis, Streptococci, staphylococci, enterococci, E. coli, Chlamydia trachomatis, , HPV. Many of them are STDs.

Tumors of the cervix - Major causes of cancer-related deaths in women. - Pap smear reduces the incidence of cervical cancer. But The incidence of cervical intraepithelial neoplasia has increased > 50, 000 cases annually Because: - Precursor of cervical intraepithelial neoplasia is not diagnosed by Pap smear.

Invasive carcinoma of the cervix 75% = Sqamous cell carcinoma 20% =Adenocarcinoma & adenosquamous carcinoma. 5% = Small cell neuro-ednocrine carcinoma. - Adenocarcinoma has been increasing in recent years because glandular lesions are not detected well by Pap smear. - The only reliable way to monitor the course of the disease is with careful follow-up and repeat biopsies.

Body of Uterus - Common. - Chronic & recurrent & sometimes disastrous. The more frequent & significant are: ü Endometritis ü Adenomyosis ü Endometriosis ü Dysfunctional uterine bleeding & endometrial hyperplasia ü Tumors

Endometritis - Associated with: - pelvic inflammatory disease. Foreign bodies or retained tissue Miscarriage or delivery. They act as a nidus for infection: - removal= resolution Endometritis: - Acute or - chronic Depending on the predominant WBCs - Neutrophilic = Acute - Lymphoplasmacytic = Chronic endometritis Acute endometritis is frequently due to N. gonorrhoeae or C. trachomonus.

Endometritis S&S: - Fever. - Abdominal pain. - Menstrual abnormalities. - Infertility & ectopic pregnancy due to damage to the fallopian tubes. Granulomatous endometritis: Seen in immunocompromised individuals in U. S, and in other countries where T. B. is endemic.

Adenomyosis Ø Growth of basal layer of the endometrium down into the myometrium. - Endometrial stroma, glands are found in uterine wall. - So uterine wall becomes thickened & enlarged uterus Adenomyosis do not undergo cyclical bleeding: Because they are derived from stratum basalis of the endometrium, . But may produce menorrhagia, dysmenorrhea, & pelvic pain before the onset of menstruation.

Endometriosis Patho. Ø Characterized by: Endometrial glands & stroma in a located outside the endomyometrium. In pelvis cause mass filled with blood. Most accepted theory of endometriosis is: Regurgitation theory: - Menstrual backflow through the fallopian tubes with subsequent implantation. - Because menstural endometrium is viable & survives even when injected into the anterior abdominal wall.

Endometriosis Clinical Manifestations: Depend on the distribution of the lesions. - Sterility due to extensive scaring of the oviducts & ovaries produces. - Discomfort in the lower abdominal quadrants. - Pain on defecation reflects rectal wall involvement. - Dyspareunia (painful intercourse). - Dysuria reflect involvement of the bladder serosa. - Almost in all cases, there is severe dysmenorrhea & pelvic pain as a result of intra-pelvic bleeding and periuterine adhesions.

Dysfunctional uterine bleeding Ø Abnormal bleeding in the absence of a well-defined organic lesion in the uterus. Various causes segregated into 4 groups depending on the age of women: 1. Failure of ovulation: Estrogen relative to progesterone. 2. Inadequate luteal phase: Prgesterone due to failure of corpus maturation. 3. Contraceptive-induced bleeding: 4. Endomyometrial disorders: After menopause

Endometrial hyperplasia Estrogen relative to progestin hyperplasia, Classification: - Simple hyperplasia. - Complex hyperplasia. - Atypical hyperplasia. Endometrial hyperplasia is pre-neoplastic. The risk dependent on: - The severity hyperplesia. - Failure of ovulation. - Prolonged administration of estrogen. - Polycystic ovaries - Obesity.

Tumors Endometrial polyps: - Composed of endometrium resembling the basalis, frequently with small muscular arteries. - More often they have cystic dilated glands, glands but some have normal endometrial architecture. - They may occur at any age, age but more commonly at time of menopause. Clinical significance: - Production of abnormal uterine bleeding. - Risk of giving rise to a cancer (rare).

Tumors Leiomyoma: - The most common benign tumor in females. - Found in 30% to 50% of women during reproductive life. - In Blacks > than in Whites. - They are firm. - Estrogens & oral contraceptives stimulate their growth; conversely, so shrink postmenopausally. - They may be asymptomatic, discovered on routine pelvic examination. - Frequently manifested as menorrrhagia with or without metrorrhagia.

Tumors Liomyosarcomas: - Almost always solitary tumors. - They are frequently soft, hemorrhagic & necrotic. - Diagnostic features include tumor necrosis & mitotic activity. - They present a wide range of differentiation - Recurrence after removal is common with these cancers. - Many metastasize, typically to the lungs. Yielding a 5 years survival rate of about 40%.

Tumors § Endometrial carcinoma: - Most frequent cancer. - Appears mostly between the ages of 55 & 65 years. There are 2 clinical stetting's: - In peri-menopausal women with estrogen excess. - In older women with endometrial atrophy. Risk factors: - Obesity - Diabetes. - Hypertension. - Infertility All are associated with increased estrogen stimulation.

Fallopian tubes Salpingitis: Most common disease of the fallopian tubes. Always a component of pelvic inflammatory disease. It is almost always microbial in origin. Non-gonococcal infections are more invasive: - Salpingitis risk of tubal ectopic pregnancy. All forms of salpingitis may produce: - Fever. - Lower abdominal. - Pelvic pain. - Pelvic masses. - They may result in tubo-ovarian abscess.

Fallopian tubes Primary adenocarcinomas: may be of: - Papillary serous - Endometrioid type.

Ovaries Follicle and luteal cysts Polycystic ovaries Tumors of the ovary Surface epithelial-stromal tumors - Serous tumors - Mucinous tumors - Endometrioid tumors - Brenner tumor Other tumors - Teratomas *Benign (mature) cystic teratomas *Immature malignant teratomas

Ovaries Follicle & luteal cysts: Ø Originate from un-ruptured graafian follicles. Ø Or from immediately sealed ruptured follicles. - Produce pelvic pain. - Variable size, they may become palpable masses when they achieve diameters of 4 -5 cm - Sometimes these cysts rupture, producing intraperitoneal bleeding & acute abdomin. - When small they are lined by granulosa lining cells or luteal cells, but as the fluid accumulates, Pr. may cause atrophy of these cells.

Ovaries Polycystic ovaries: Excessive high concentration of androgens, LH, and low concentration of FSH. Causing: - Multiple cystic follicles in the ovaries. - Oligomenorrhea, hirsutism, infertility. - Sometimes obesity appears in girls after menarche - Ovaries usually increase in size (twice normal size).

Tumors of the ovary Ovarian cancer: - Common: (5 th most common cancer in US women). (5 th leading cause of cancer death in women). - 90 % of ovarian cancers are originated from the surface epithelial.

Tumors of the ovary Risk factors: - Nulliparity. - Family history. - Prolonged use of oral contraceptives reduce the risk. - Mutations in: BRCA 1 & BRCA 2 genes. P 53 in 50% of all ovarian cancers.

Teratomas • • Neoplasms of germ-cell origin. Constitute 15 -20% of ovarian tumors. They arise in the first two decades of life. More than 90% of these germ-cell are benign mature cystic teratomas. • The immature malignant variant is rare.