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Bien Ag Nina Ian John ͞G͟ 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 Tope

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Urogenital Sinus = Caudal growth & fusionr lower vagina


I. Introduction
Infections
a. Embryology
b. Lateral Mullerian Ducts  Candida
c. Pelvic Inflammatory  Trichomonas
II. Vulva  Gardnerella
a. Inflammatory Dermatologic Diseases  Gonorrhea
b. Bartholin Cyst  Chlamydia
c. Vestibular adenitis  Mycoplasma
d. Non neoplastic epithelial disorders  Human Papilloma Virus (HPV)
e. Tumors
III. Vagina Infections in the Lower Genital Tract
a. Congenital Anomalies: 1. Herpes Simplex
b. Gartner duct cysts  Vulva, vagina, cervix
c. Mucouc cysts  HSV-2
d. Endometriosis  Red painful papulesr Vesicles r Ulcers
e. Benign  Leukorrhea, fever, malaise, tender lymph nodes
f. Malignant  Heal spontaneously
IV. Cervix  Latent infectionsr region nerve ganglia
a. Inflammations  Neonatal transmission during delivery
b. Cancer
i. Cervical Intraepithelial Neoplasia 2. Mycotic & Yeast (ë  )
ii. Squamous cell carcinoma
 10%
iii. Cancer prevention and control
 DM, oral contraceptives, pregnancy
V. Body of the Uterus and Endometrium
a. Endometrial Hormonal Cycle  Small white surface patches
b. Organic abnormalities  Leukorrhea & pruritus
c. Functional Endometrial Disorders (Dysfunctional
Uterine Bleeding) 3. Ý  
 
d. Inflammation  Large flagellated ovoid protozoans
e. Endometriosis and Adenomyosis  15% STD
f. Endometrial Hyperplasia  Purulent vaginal discharge, discomfort
g. Malignant tumors  ³STRAWBERRY CERVIX´
h. Tumors of Endometrium with Stromal
Differentiation 4. x  
i. Tumors of Myometrium  Vaginitis & cervicitis
VI. Fallopian Tubes  Spontaneous abortion & chorioamnionitis
a. Inflammations
b. Tumors and cysts 5. P  
VII. Ovaries  Gram (-) small bacilli
a. Metastatic tumors
b. Non-neoplastic and Functional Cysts PELVIC INFLAMMATORY DISEASE (PID)
c. Inflammations  Pelvic pain, adnexal tenderness, fever, vaginal d/c
VIII. Gestaional and Placental Disorders  P ë    Enteric bacteria
a. Disorders of Early Pregnancy  Spontaneous or induced abortion
b. Disorders of Late Pregnancy  Puerpural infections: j   j  
c. Gestational Trophoblastic Disease ë   ë    
Introduction  P
p Bartholin & vestibular glands
Embryology p Periurethral glands
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4 week: primordial germ cells from yolk sac p Cervix
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5 week: migrate into urogenital ridge p Fallopian Tubes
Mesodermr epithelium & stroma p Acute suppurative reaction
Endodermr germ cells p Smears with intracellular gram (-) diplococci
Mesoderm + endoderm = OVARY p Culture
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6 week: invagination & fusion of coelomic epithelium r p Acute suppurative salpingitis, salpingoophoritis,
lateral mullerian ducts tubo-ovarian abscess pyosalpinx, follicular
salpingitis
 Non-gonococcal
LATERAL MULLERIAN DUCTS p S/P surgery
r fallopian tubes p Lymphatics or venous channels
r uterus & vagina  j   j  
p Less exudation
p Inflammation of deeper layers

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p Bacteremia è Sharply circumscribed nodule in labia majora
 Complications: or interlabial folds
p Peritonitis è HISTO: tubular ducts lined by single or
p Intestinal obstruction due to adhesions double layers of non ciliated columnar cells
p Bacteremia r endocarditis, meningitis, with myoepithelial cells
suppurative arthritis
p Infertility b. Benign raised or wart like conditions
b.1. Condyloma acuminatum
½ ½ è HPV 6& 11
è Venereal Wart
1. Inflammatory Dermatologic Diseases è HISTO: branching tree like proliferations of
 Psoriasis, eczema, allergic dermatitis stratified squamous epithelium, fibrous
 Blood dyscrasia, uremia, DM, malnutrition, stroma, acanthosis, parakeratosis,
avitaminoses hyperkeratosis, nuclear atypia & perinuclear
vacuolation ³koilocytosis´
2. Bartholin Cyst
 Obstruction & infection of Bartholin gland r abscess b.2. Mucosal Polyps
 Pain, local discomfort è Benign stroma proliferations
 Excised, ³marsupialization´ è Squamous epithelium

3. Vestibular adenitis b.3. Syphilitic Condyloma latum


 Posterior introitus è Elevated red brown spots, popular lesions 2-
 Vestibular glands 3cm
 Chronic recurrent, painful
 Malignant
 Unknown cause
p Carcinomas, malignant melanoma, sarcoma
 Surgery
a. Vulvar Carcinoma
è Uncommon, 3% of genital ca in females
4. Non neoplastic epithelial disorders
è 2/3 >60 years
 ³leukoplakia´
è 85% squamous cell carcinoma
 Vitiligo è Remainder: basal cell ca, melanoma,
 Inflammatory dermatosis adenocarcinoma
 Vulvar intraepithelial neoplasia, Paget disease, è Rare Variants: Verrucous CA & Basal Cell
invasive CA CA
 Unknown etiology
 Lichen sclerosus (Chronic Atrophic Vulvitis) b. Vulvar Intraepithelial Neoplasia (VIN)
p Pale gray skin, parchment-like è White pigmented plaques
p Atrophy of labia è Nuclear atypia
p Narrowed introitus è Increase mitosis
p Histology: è Lack of surface differentiation
ù Thinning of epidermis è Progress to CA depend on age (>45), extent
ù Disappearance of rete pegs of tumor, immune status
ù Dense collagenous fibrous tissue
ù Marked hyperkeratosis c. Extramammary Paget Disease
ù Mononuclear infiltrates about blood vessels è Rare
p Common after menopause è Vulva, perianal region
p All ages è Pruritic red crusted sharply demarcated
p Genetic predisposition, autoimmunity, hormonal map-like area
p 1-4% r cancer è Labia majora- palpable submucosal
 Lichen simplex chronicus thickening or tumors
p Acanthosis è Confined to epidermis & adjacent hair
p Hyperkeratosis follicles, sweat gland neoplasms
p Hyperplais of vulvar squamous epithelium è Histology:
p Increase mitotic activity > Large tumor cells, lying singly or small
p Variable WBC infiltration of dermis clusters, within epidermis & appendages
p May coexist with vulvar epithelial neoplasms > ³halo´
> Fairly granular cytoplasm (+) PAS,
5. Tumors alcian blue, mucopolysaccharide
 Benign
p Fibromas, neurofibroma, angiomas d. Malignant melanoma of vulva
a. Papillary Hidradenoma è Rare
è Modified apocrine sweat glands è <5% of vulvar ca¶s

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è 2% of melanoma in women è Chronic: mononuclear, lymphocytes,
è 6-7th decade macrophages, plasma cells, necrosis,
è Same biological & histological characteristic granulation tissue
as melanoma elsewhere
è (+) S 100, (-) CEA, S100, b. Endocervical polyps
mucopolysaccharide è Innocuous tumors
è 2-5% adult women
½IN è Irregular vaginal spotting or bleeding
è Soft, almost mucoid, loose fibromyxomatous
 Primary disease uncommon stroma, dilated mucus secreting endocrine
1. Congenital Anomalies: glands
p Atresia
p Total absence 2. Cancer
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p Septate or double vagina  Ranks 8 leading cause of cancer mortality
2. Gartner duct cysts  4500 deaths annually
3. Mucouc cysts  High detection frequency of early cancers &
4. Endometriosis precancerous conditions- Papanicolao cytologic test
5. Benign: (PAPS)
p Rhabdomyoma, stromal polyps, leiomyomas,  Risks factors for cervical neoplasia
hemangiomas, mixed tumors p Early age at first intercourse
6. Malignant p Multiple sexual partners
p Carcinoma, embryonal rhabdomyosarcoma p Increased parity
a. Primary Cancer p Male partner with multiple previous sexual
è 1% malignant neoplasms partner
è 95% squamous cell CA p Cancer associated HPV (16, 18, 31, 33, 35, etc)
è Upper posterior vagina, junction with p Persistent detection of high risk HPV
ectocervix p Certain HLA & viral subtypes
a.1. Adenocarcinoma p Oral contraceptives & nicotine
è Rare p Genital infections (ë   )
è Increase frequency of young women whose a. Cervical Intraepithelial Neoplasia (CIN)
mothers had been treated with DES during è Precancerous stage
pregnancy (0.14% develop adenocarcinoma) è Continuum of morphologic changes with
è Anterior wall, upper 3rd indistinct boundaries
è 15-20 years old è Do not variably progress to cancer & may
è Vaginal adenosis- precursor spontaneously regress
è HISTO: gland epithelium either mucus è Associated with papillomaviruses & high risk
secreting, resembling endocervical mucosa HPV types are found in increase frequency
or tuboendometrial, with cilia in higher grade precursors
è Classification:
b. Embryonal rhabdomyosarcoma (sarcoma a.1. dysplasia/ carcinomain situ system
botyroides) a.2. cervical intraepithelial (CIN)
è Uncommon classification
è Infants & children <5 yo a.3. low grade & high grade intraepithelial
è (+) embryonal rhabdomyoblasts lesions
è Gross: polypoid, rounded, bulky masses, fill
& project out of vagina ³grape like clusters´ Cervical Intraepithelial Neoplasia
è Micro: small oval nuclei, ³tennis racket´, rare 1. CIN I
striations within cytoplasm, tumor cells in  Nuclear enlargement, hyperchromasia in superficial
cambium layer, loose fibromyxomatous cells
stroma  Koliocytotic atypia
è Invade locally  Raised lesions (acuminatum) & macular (flat
condyloma)
ëER½IX
2. CIN II
1. Inflammations  Atypical cells in lower layers of squamous epithelium
a. Acute & chronic cervicitis but with persistent differentiation toward the prickle
è Epithelial spongiosis and keratinizing cell layers
è Submucosal edema  Changes in NC ratio, variations in nuclear size, loss of
è Epithelial & stromal changes polarity, increase mitotic figures, abnormal mitosis,
è Acute: acute inflammatory cells, eriosion, hyperchromasia
reactive changes 3. CIN III

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 Loss of differentiation and greater atypia in more ù Subtle hormonal imbalances: most unexplained
layers of epithelium  Inadequate Luteal Phase
 Totally replaced by immature atypical cells, exhibiting p Inadequate corpus luteum function
no surface differentiation p Low progesterone output
p Irregular ovulatory cycle
Squamous cell carcinoma p Manifestations: infertility with eithr increase
bleeding or amenorrhea
 Peak incidence: 40-45 years  Endometrial changes induced by oral contraceptives
 3 distinct patterns p Common response pattern: discordant
p Fungating (exophytic) ± most common appearance between glands and stroma, usually
p Ulcerating with inactive glands amid a stroma showing large
p Infiltrative cells with abundant cytoplasm reminiscent of the
 Extend by direct spread decidua of pregnancy
 Local and distant lymph node metastasis  Menopausal and Postmenopausal changes
 Liver, lungs, bone marrow and other structures p Atrophy
 95% composed of large cells, either keratinizing or p Mild hyperplasias with cystic dilatation
non keratinizing patterns
 5% poorly differentiated small cell cacinomas 4. Inflammation
 Stage 0 ± IV  Acute endometritis
 10-25%: adenocarcinomas, adenosquamous p After delivery, miscarriage, retained products
carcinomas, undifferentiated carcinomas of conception
p Interstitium inflammation
 Arise in endocervical glands
 Chronic endometritis
Cancer prevention and control p Chronic PID
p Postpartal or postabortal endometrial cavities
p Intrauterine contraceptive devices
 Cytologic screening and management of PAP smear
p TB patients: drain TB salpingitis
abnormality
p 15%: no primary cause ± nonspecific chronic
 Histologic diagnosis and removal of precancers
endometritis
 Surgical removal of invasive cancers, with adjunctive p Chlamydia may be involved
radiation and chemotherapy 5. Endometriosis and Adenomyosis
 Use of vaccines under investigation  3 theories
1. Regurgitation/implantation theory: retrograde
BODY OF THE TER  ND ENDOMETRI M menstruation
2. Metaplastic theory: arise from coelomic
Disorders epithelium
 Endocrine imbalances 3. Vascular or lymphatic dissemination theory:
 Complications of pregnancy disseminated through pelvic veins and lymphatics
 Neoplastic proliferations  Red-blue to yellow brown nodules on or just beneath
the serosal surface
1. Endometrial Hormonal Cycle  Extensive organizing hemorrhage, fibrous adhesions
 Proliferative ± early, mid, late between tubes and ovaries
 Secretory  Obliteration of pouch of Douglas
 Menstrual
Endometriosis
2. Organic abnormalities  Endometrial glands or stroma in abnormal locations
 Chronic endometritis outside the uterus
 Submucosal leiomyomas p Ovaries
 Endometrial polyp p Uterine ligaments
 Endometrial neoplasm p Rectovaginal septum
p Pelvic peritoneum
3. Functional Endometrial Disorders (Dysfunctional Uterine p Laparotomy scars
Bleeding) p Umbilicus
 Anovulatory cycle r due to excess estrogen p Vagina
stimulation p Vulva
p Result of: p Appendix
- Endocrine disorders: thyroid disease, adrenal  Manifestations: infertility, dysmenorrhea, pelvic pain
disease or pituitary tumors
- Primary lesions of the ovary: granulosa-theca Adenomyosis
cell tumors or polycystic ovaries  Endometrial tissue in uterine wall
- Generalized metabolic disturbance: obesity,  20% of uteri
malnutrition, chronic system disease

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 Shedding of endometrium: colicky dysmenorrhea, p Peak at 40-60
dysparenunia and pelvic pain during premenstrual
period FOPIN T BE

6. Endometrial polyps 1. Inflammations


 Single or multiple, 0.5 to 3 cm, large, pedunculated  Suppurative salpingitis: 60% gonococcus
 Asymptomatic or cause abnormal bleeding  Tuberculous salpingitis
 Functional endometrium or hyperplastic and cystic 2. Tumors and cysts
 Paratubal cysts: hyatids of Morgagni
7. Endometrial Hyperplasia  Adenomatoid tumors (mesotheliomas)
Endometrial intraepithelial neoplasia  Primary adenocarcinoma: rare
 Increase gland to stroma ratio
 Abnormalities in epithelial growth O½RIE
 Prolonged estrogen stimulation by anovulation or
increase estrogen production 1. Inflammations
p Menopause, polycystic ovarian disease,  Oophorits: uncommon
functioning granulosa cell tumors of ovary, 2. Non-neoplastic and Functional Cysts
cortical stromal hyperplasia, prolonged  Follicular and luteal cysts
administration of estrogenic substance  Polycystic Ovarian Disease (PCOD, Stein-Leventhal
p Inactivation of PTEN tumor suppresor gene syndrome)
 Simple non-atypical hyperplasia ù 3-6% of reproductive women
p Cystic, mild hyperplasia ù Numerous cystic follicles or follicle cysts
 Complex atypical hyperplasia (endometrial ù Associated with oligomenorrhea, persistent anovulation,
intraepithelial neoplasia) obesity, hirsutism and rarely virilism
p Increase number, size, crowding glands,  Stromal hyperthecosis (cortical stromal hyperplasia)
enlagement and irregular shape common mitotic ù Post menopausal women
figures ù Uniform enlargement, bilateral
p Treatment: hysterectomy ù Hypercellular stromal with luteinization of stromal cells
ù Similar effects as PCOD although virilization may be
8. Malignant tumors striking
 Endometrial carcinoma  Theca lutein hyperplasia of pregnancy ± mimick
p Most common invasive cance of female genital  Classification 1993 WHO
tract p Surface epithelial (mullerian) stromal tumors
p 7% of invasive cancers in women ù Serous ± 30%
p Pak age: 55-65 - Tall columnar ciliated epithelial cells
p Higher frequency in obesity, diabetes, HPN, - Clear serous fluid
infertility - Psammoma bodies
p Gross: localized polypoid tumor or diffuse ù Mucinous ± 25%
involving entire endometrial surface - Associated with pseudomyxoma peritonei
p 85% adenocarcinomas: endometrioid type; ù Endometrioid
others: seous type (grade 3) ù Epithelial stromal
p 3 step grading system: grade 1, 2, 3 ù Clear cell tumors
ù Clear cell adenocarcinoma
9. Tumors of Endometrium with Stromal Differentiation ù Cystadenofibroma
ù Carcinosarcomas (malignant mixed mullerian tumors) ù Transitional tumors
ù Adenosarcomas: benign glands, malignant stroma - Brenner tumors: transitional cells
ù Stromal tumors p Sex cord-stromal tumors
p Benign stromal nodules ù Granulosa-theca cell tumors
p Endometrial stromal sarcomas - Call-Exner bodies
ù Fibro-thecomas
10. Tumors of Myometrium ù Sertoli-Leydig cell tumors (androblastomas)
ù Leiomyomas (fibroids) ù Others
- 75% of femaled of reproductive age p Germ cell tumors
p Gross: sharply circumscribed, discrete, round, ù Teratomas
firm, gray white tumors ù Dysgerminoma
p Microscopic: whorled bundles of smooth muscle ù Endodermal sinus (Yolk Sac) tumor
cells ù Choriocarcinoma
ù Leiomyosarcomas ù Others
p Bulky fleshy or polypoid masses p Malignant, NOS (not otherwise specified)
p Nuclear atypia, mitotic index, zonal necrosis p Metastatic Non-ovarian Cancer
p 10 or more mitosis/10 hpf w/o atypia; 5/10 hpf
w/ atypia

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3. Metastatic tumors
 Uterus, fallopian tubes, contralateral ovary, pelvic
peritoneum
 Krukenberg tumor: gastric CA

ETTION ND PëENT DIORDER

1. Disorders of Early Pregnancy


 Spontanoues abortions
p 10-15% of recognized pregnancies
p Fetal and maternal causes
 Ectopic pregnancy
p 90% tubal
p 35-50%: PID w/ chronic salpingitis
2. Disorders of Late Pregnancy
 Placental abnormalities and twin placentas
 Placental inflammations and infections
 Toxemia of pregnancy (preeclampsia and eclampsia)
p Hypertension, proteinuria, edema + convulsions
p DIC
3. Gestational Trophoblastic Disease
 Hyatidiform Mole
 Invasive Mole
 Choriocarcinoma
p Cytotrophoblasts and syncytiotrophoblasts
 Placental site trophoblastic tumor (PSTT)
p Intermediate trophoblasts

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