FEMALE 

GENITAL TRACT
Developmental Disorders (Congenital)
• Mullerian Duct Anomalies
- Embryologic fusion anomalies Æ organ agenesis,
abnormal septation,
organ duplication : double vag/uterus (didelphys), etc.
• Gardner’Duct Cyst
- arise in women from remnants of the degenerated
mesonephric/wolffian duct
- Submucosa of anterolateral vaginal wall, 1-2 cm in size
• Imperforate Hymen
- May not be recognized until puberty Æ complain of
failure to menstruate
Æ retain blood: hematocolpos, hematometria,
hematosalpinx
Atresia,
Double vagina,
Double uterus.
 VULVA
• Synonymous with EXTERNAL genitalia
• Everything ANTERIOR to the INTROITUS
• Usual classification of Degen., Inflam., Neopl.
• Common Diseases:
– BARTHOLIN Cyst
– Vulvar Vestibulitis
– Deg./Inflam. Epithelial: LICHEN diseases
– BENIGN tumors: Condyloma(ta)
– MALIGNANT tumors: VIN, SCC
Result from
Inflammation/Obstruction
of the Bartholin glands
(i.e., greater vestibular
glands)
Often result in abscesses
Surgical removal is
curative when local
procedures are
inadequate or often
recurrent
NEVER become
malignant
VULVAR VESTIBULITIS, assoc. w. vulvodynia
 “LICHEN” DISORDERS
LICHEN Sclerosu(i)s (atrophic skin)
LICHEN Simplex Chronicus (hypertrophic skin)

Common features of
FIBROSIS and INFLAMMATION
Mucosal Atrophy
Fibrosis (sclerosis)
Inflammation
 LICHEN SIMPLEX CHRONICUS
show HYPER-plastic mucosal changes are often regarded as being potentially
pre-malignant
 Condylomas

A vulva chancre and condylomata Condyloma accuminata

-Condylomata lata: (not commonly seen today), are flat, moist, minimally
elevated lesions that occur in secondary syphilis
-Condylomata accuminata: (more common) may be papillary and distinctly
elevated, occur anywhere on the anogenital surface. Significant characteristic
cellular morphology is: perinuclear cytoplasim vacuolization. Vulvar cndylomas
are not pre-cancerous but may coexist with foci of intraepithelial neoplasia in
vulva (VIN grade 1) and cervix.
CONDYLOMA(TA)
 VIN, SCC
• Like condylomas, HIGHLY linked to 
HPV
• VIN=changes leading to SCC‐in‐situ, 
look like “plaques”
• BEYOND VIN = INFILTRATION
VIN
EXTRAMAMMARY PAGET’S DISEASE
MALIGNANT
MELANOMA
 VAGINA
• CONGENITAL: Parallel uterus anomalies
• INFLAMMATORY
– PRE‐menopausal: STD
– POST‐menopausal: ATROPHY
• BENIGN: Hidradenoma, Condyloma
• MALIGNANT: VIN, INFILTRATING SCC
 VAGINITIS
• 90% Æbacterial vaginitis, candida, T. vaginalis

• Bacterial Vaginitis
• the most common cause of vaginitis, 
accounting for 50% of vaginitis cases. 
• caused by an overgrowth of organisms such as 
Gardnerella vaginalis (gram‐variable 
coccobacillus), Mobiluncus species, 
Mycoplasma hominis, and Peptostreptococcus
species. 
• Risk factors include pregnancy, intrauterine 
device (IUD) use, and frequent douching.
 Candida
• Candida species (C albicans, C tropicalis, and 
C glabrata) are airborne fungi that are 
natural inhabitants of the vagina in as many 
as 50% of women, 
• vaginal candidiasis is the second most 
common cause of vaginitis. 
• Risk factors include oral contraceptive use, 
IUD use, young age at first intercourse, 
increased frequency of intercourse, receptive 
cunnilingus, diabetes, HIV or other 
immunocompromised states, chronic 
antibiotic use, and pregnancy.
 T. vaginalis
• the third most common cause of vaginitis, is caused 
by trichomonads. 
• These organisms are flagellated protozoans. 
Trichomonads primarily infect vaginal epithelium, 
and they less commonly infect the endocervix, 
urethra, and Bartholin and Skene glands. 
• Trichomonads are transmitted sexually and can be 
identified in as many as 80% of male partners of 
infected women. 
• Risk factors include tobacco use, unprotected 
intercourse with multiple sexual partners, and the 
use of an IUD.
 VAGINAL NEOPLASIA
• VIN
• INFILTRATING SCC
• ADENOSIS (D.E.S.) Æ
• ADENOCARCINOMA (Di‐
Ethyl‐Stilbestrol)
NORMAL VIN
SCC
CHILDHOOD EMBYRONAL
RHABDOMYOSARCOMA
 CERVIX
• NORMAL
• METAPLASIA
• INFLAMMATION
• POLYPS
• DYSPLASIA
• CIN
• INFILTRATING SCC
DYSPLASIA / CIN / SIL
INFILTRATION
How have we “CURED” Cervical Carcinoma?
 ENDOMETRIUM
• FUNCTIONAL HISTOLOGY
• D.U.B. (Dysfunctional Uterine Bleeding)
• INFLAMMATION
• ADENOMYOSIS/ENDOMETRIOSIS
• POLYPS/HYPERPLASIA
• ADENOCARCINOMA and/or STROMAL
• LEIOMYOMYOMAS, ‐SARCOMAS
• MITOSES differentiate benign from malignant
MITOSES (Glandular and Stromal) = PRE-ovulatory

VACUOLES/SECRETION = POST-ovulatory
DYSFUNCTIONAL UTERINE BLEEDING 
(DUB)
• Anovulatory Cycle
• Inadequate Luteal Phase
• Oral Contraceptives
• Menopause
• Post‐Menopause
 INFLAMMATORY DISEASE
A. Acute endometritis
• Post‐abortion, post‐partum states with retaind 
placental parts
• Suppurative inflammation + microabscess Æ
pyometra Æ obstruction of endocervical canal
B. Chronic endometritis
• Contination of acute endometritis, could be 
associated with IUD, 15% with unknown etiology
• Pelvic pain, abnormal bleeding, infertility
• Characteristic: infiltration by plasma cells
 ADENOMYOSIS
• Defined as normal endometrial glands deep 
within the myometrium
 Endometriosis
• Presence of endometrial tissue outside uterus 
(ectopic)
– Found on ovaries, ligaments, colon, sometimes lungs
• Responds to cyclic hormonal variations
– Grows and secretes then degenerates, sheds and bleeds
– Blood irritating to tissues = inflammation and pain
• Recurs with every cycle with eventual fibrous tissue
– Causes adhesions and obstruction
• Diagnosis confirmed with laparoscopy
 Endometriosis
• Infertility results from 
– Adhesions pulling uterus out of normal position
– Blockage of fallopian tubes
• “chocolate cyst” develops on ovary
– Fibrous sac containing old brown blood
• Primary manifestations
– Dysmenorrhea
• More severe every month
– Painful intercourse if vagina and supporting ligaments 
affected by adhesions
Endometriosis
“CHOCOLATE” CYST
ENDOMETRIAL POLYPS

-Often pedunculated, may be solitary

or multiple

-Commonly composed of hyperplastic

endometrium with cystically dilated
glands, cellular stroma, and thick
walled vessels

-May cause intermittent bleeding, 3%

harbor adenocarcinoma
 ENDOMETRIAL HYPERPLASIA

• Mostly occur in post-menarchal or peri-menopausal Æ

associated to prolonged or excessive estrogen stimulation

LOW GRADE HYPERPLASIA

• Simple low grade hyperplasia Æ Swiss cheese
• Complex low grade hyperplasia
• Low to moderate risk of developing carinoma
HIGH GRADE (ATYPICAL) HYPERPLASIA
• High risk to develop carcinoma
ENDOMETRIAL HYPERPLASIA

Simple/Swiss cheese Complex hyperplasia

Atypical hyperplasia Squamous metaplasia

Adenocarcinoma of the Endometrium
=
Carcinoma of the Uterus
 ADENOCARCINOMA
of the ENDOMETRIUM
• Papillary, Polypoid
• Clear Cell
• Adeno‐Squamous
• Mucinous
• Serous
• Preceded by hyperplasia, dysplasiaÆ (EIN)
• Estrogenic, DES effects
• Ass. w.: obesity, diabetes, hypertension, infertility
• Stromal “sarcomatous” conditions can co‐exist, i.e., 
“adenosarcoma”
 GRADING and STAGING
• GRADING • STAGING
– 1, 2, 3 – (I) Corpus
– Well, Moderate, Poor – (II) Corpus + Cervix
– (III) Beyond uterus, but 
inside true pelvis
– (IV) Outside true pelvis 
or involving bladder or 
rectal mucosa
 ENDOMETRIAL STROMAL TUMORS
• BENIGN STROMAL NODULES, appear as expanding
nodules of endometrial stroma burried within the
endometrium
• ENDOLYMPHATIC STROMAL MYOSIS, this represents a
low-grade sarcoma Æ invade the myometrium tend to
invade lymphatics and blood vessels
• ENDOMETRIAL STROMAL SARCOMA, this usually
arises high in the fundus Æ fills the endometrial cavity Æ
grows into myometrium Æ extensive vascular invasion
• 5yr survival : 25%
 MALIGNANT MIXED MULLERIAN
TUMORS
• Elderly postmenopausal patients and present with bleeding
• Derived from muellerian mesoderm, consists of malignant
stromal and glandular component
• The stromal component may be homologous (stromal
sarcoma, leiomyosarcoma) or heterologous
(chondrosarcoma, rhabdomyosarcoma, etc.)
• 5 yr survival : 25%
• Other name: Carcinosarcoma
 MYOMETRIAL TUMORS
LEIOMYOMA
• Most common neoplasm in women during reproductive life (25%), 3rd
to 4th decade, tending to decrease in size in menopause
• Malignancy is extremely unusual (<0.1%)
• Symptom: pain of degeneration, bleeding, symptom related to size
Æ pressure on rectum and bladder, sensation of heaviness
LEIOMYOSARCOMA
• Uncommon, as fleshy mass invading into uterine wall, or polypoid
• Arising de novo rather than from a pre-existing leiomyoma
• 5 yr survival is 40 – 50 %
MYOMETRIAL TUMORS
Leiomyoma
 LEIOMYOSARCOMA

Large hemorrhagic tumor mass

distends to the lower corpus and
flanked by two leiomyomas
The tumor cells are irregular in size &
shape, with hyperchromatic nuclei
 Fallopian Tubes
Inflammatory disease
• Specific: Tbc Æ infertility
• Non-specific Æ suppurative salpingitis Æ pyosalpinx Æ
hydrosalpinx Æ infertility
Salpingitis isthmica nodosa
• The process and morphology similar to adenomyosis
Cyst
• Embryologic remnants of the muellerian and wolffian
Ectopic pregnancy
Tumors
• Very rare, mostly secondary
SALPINGITIS/PID
GC and CHLAMYDIA
PYOSALPINX
PERITONITIS
TUBO-OVARIAN
ADHESIONS
STERILITY
INFERTILITY
 ECTOPIC  PREGNANCY

- Most ectopic pregnancies involve the fallopian tube (90%)

- Predisposing factors include that inhibit tubal transport: chronic salpingitis,
peritubal adhesion, large cyst, tumors, etc.
- After 2-6 weeks growing Æ rupture Æ hematosalpinx (in tube), 12 weeks in
isthmus
 Peritubal CYSTS
• Endometriosis
• Hydatid Cysts of Morgagni (Mullerian 
rests)  Para‐, Peri‐ tubal)
 DISEASES of OVARIES
• DEGENERATIVE?
• INFLAMMATORY?
• CYSTS
• TUMORS
– Müllerian (“Germinal”)
– Germ Cell
– Sex Cord/Stromal
– Metastatic
B=GRANULOSA D=THECA INTERNA E=THECA EXTERNA
• ESTROGEN : Controlled by FSH and LH
Develop, Lactate Breast
Lobules
Proliferate Endometrial Glands
“Bone Mass” protective
“Cardioprotective”
• PROGESTERON : Controlled by FSH and LH
SECRETE Endometrial Glands
IMPLANTATION of the
blastocyst
Lactation
FOLLICULAR CYST
MOST COMMON
CORPUS LUTEUM
CYST
POLY‐Cystic Ovarian Disease
(Stein‐Leventhal syndrome)

5% Prevalence

Anovulation
Oligomenorrhea
Obesity
Hirsutism
Polycystic Ovaries
 OVARY

12/04/2013 tums‐pafkugm 91
 OVARIAN TUMORS
• MÜLLERIAN (MAJORITY)
– Serous (Benign, Borderline, Malignant)
– Mucinous (Benign, Borderline, Malignant)
– Endometroid (Benign, Borderline, Malignant)
– Adenosarcoma (Carcinoma AND Sarcoma)
– Mesodermal Mixed  (MULTIPHASIC Sarcoma)
– Clear Cell
– Brenner  (almost always benign)
– Transitional  (almost always look like Brenner)
• Germ Cell
• SEX‐CORD/STROMAL
• METASTATIC
 OVARIAN TUMORS
• Solid vs. Cystic
• Functional vs. NON‐functional
• Benign vs. Malignant
• First clinical presentation may be ascites
• Malignant ascites in a woman is ovarian cancer 
until proven otherwise
• CA‐125 is THE important tumor marker in ovarian 
cancer, especially as a follow up.
SEROUS, BENIGN
MUCINOUS, BENIGN
PSAMMOMA bodies are dried up papillae of papillary adenocarcinomas, usually in
the thyroid, but in ANY papillary adenocarcinoma
 OTHER MÜLLERIAN
• ENDOMETRIOD, malignant
– (looks like endometrium)
• CLEAR CELL, malignant
– (clear cells, reminiscent of renal clear cell ca.)
• CYSTADENOFIBROMA, benign
– (BENIGN “FIBROUS” COMPONENT)
• BRENNER TUMOR, benign
– (transitional cell nests)
• CARCINOMA with SARCOMA
– (adenosarcoma, mixed Müllerian)
Histogenesis and inter‐relationship of 
tumors of germ cell origin
 “GERM CELL” Tumors
• Teratomas (usually benign in ovary), i.e., 
“mature” cystic teratoma or dermoid cyst
• “Immature” teratomas are regarded as 
malignant
• Dysgerminoma (look exactly like the testicular 
seminoma), malignant
• Endodermal Sinus (Yolk Sac), malignant, Just 
like testicular
• Choriocarcinoma, malignant, just like 
testicular or placenta
Dysgerminoma:Female::Seminoma:Male
ENDODERMAL SINUS TUMOR
(YOLK SAC TUMOR)
CHORIOCARCINOMA,
Just like testis or placenta
 SEX‐CORD/STROMAL TUMORS
• Chiefly benign and NON‐cystic, i.e., 
“solid”, often functional (hyper‐
estrogen‐ism)

• Granulosa‐Theca
• Fibroma‐Theca
• Sertoli‐Leydig (Androblastoma)
CALL-EXNER
BODIES
Krukenberg Tumor
DISEASES of PREGNANCY
• EARLY Pregnancy
• SPONTANEOUS ABORTION
• ECTOPIC PREGNANCY

• LATE Pregnancy
 Spontaneous Abortion
• 15% ‐ 35%
• Fetal Causes
–Usually Genetic
• Maternal Causes (placental, uterus 
infections or trauma)
–Toxo, Mycoplasma, Listeria
–Trauma
 Ectopic Pregnancy
• Chiefly TUBAL, but ovarian or abdominal 
rare
• 1% OF NORMAL WOMEN
• 35%‐50% OF WOMEN with previous 
SALPINGITIS/PID
• + HCG, Abdominal pain, 1st trimester, 
ultrasound
 LATE PREGNANCY
• PLACENTAL ANOMALIES
• TWIN PLACENTAS
• PLACENTAL INFLAMMATIONS
• TOXEMIA (ECLAMPSIA/PRE‐ECLAMPSIA)
• INTRAUTERINE GROWTH RETARDATION
 PLACENTAL ANOMALIES
• Accessory Lobes
• Bipartite Placenta
• Circumvallate Placenta
• Placenta Accreta, chorion going 
DIRECTLY to the myometrium
CIRCUMVALLATE
 PLACENTA ACCRETA
NO DECIDUA BETWEEN VILLI AND MYOMETRIUM
MONOCHORIONIC = MONOZYGOTIC
 (PRE‐eclampsia)
• Hypertension
• Proteinuria
• Edema

• Related to Placental Ischemia

• Risk for DIC, convulsions (eclampsia)
 Intrauterine Growth Retardation
• Fetal causes: Genetic, malformations
• Maternal Causes, vascular diseases, 
toxemia, infections, placental diseases

• Placenta size (350‐700g) ~ Fetal size
 Placental Infections
• Villitis vs. chorionamnionitis vs. funisitis
• ASCENDING vs. hematogenous
• ASCENDING are usually bacterial, and 
chorionamnionitis

• HEMATOGENOUS  are often 
TORCH, and villitis
 Placental Neoplasms,
i.e. gestational trophoblastic disease

• Benign: MOLES (Hydatidiform moles)
• Malignant: CHORIOCARCINOMA

• BOTH are associated with increased or 
persistent levels of the placental hormone 
HCG
 Hydatidiform Mole
• 1/1000 in USA
• 1% in Indonesia
• Also called NON‐invasive mole in its 
most common benign variant, but can 
also be “invasive”
• Complete (2% chorioCA incidence) or 
partial (0% incidence)
• Grapelike clusters, i.e., swollen villi
The MAIN thing differentiating benign from malignant
from worrisome trophoblastic neoplasms is
INVASIVENESS of the trophoblast
Terima kasih