DISORDERS OF THE VAGINA AND CERVIX

COMMON DISORDERS OF THE VAGINA

Congenital Anomalies Congenital absence of vagina

 Associated with anomalies of the uterus and urinary tract; structures arise from mullerian ducts
Septate vagina
 Failure of the embryonic Mullerian ducts to fuse
Vaginal atresia and imperforate hymen
 Prevent transformation of the lining of the embryonic vagina from a Mullerian to a squamous epithelium
In pubertal women, there might be a delay in the menstruation or menarche. It turns out that blood cannot go out of the vaginal tract because it is completely sealed by the
hymen
Vaginal Cysts May originate from Epithelial invaginations or Residual fetal structures
3 common types
 Epithelial inclusion cyst- Usually filled with keratin squames or debris; Lined by stratified squamous epithelium
 Mullerian cyst- Found in the upper vagina; Lined by tall columnar mucin-secreting cells
 Mesonephric cyst (Gartner duct cyst)- Usually found in the lateral walls of the vagina; Lined by low cuboidal clear cells that do not
secrete mucin
Atrophic Vaginitis  Thinning of vaginal epithelium that MATURATION INDEX INTERPRETATION
OF CERVICO-VAGINAL OF MATURATION INDEX
results from diminished estrogenic stimulation EPITHELIUM  Parabasal/intermediate/superficial (P/I/S%)
and superimposed infection  Microscopic evaluation
 Shift to the right (0/0/100%): Increase in superficial
 Thin epithelium is a poor barrier  Quantify estrogen status of vaginal
cells under the epithelium
effect of estrogen
to infections or abrasions.
 Menopause=decline is Shift to the left (100/0/0%): Indicate an atrophic effect
estrogen=atrophy
 Most common in postmenopausal women
Cell types: e.g. in post menopausal women
 Dyspareunia and vaginal
spotting are common symptoms.  Parabasal- low  Shift toofthe
concentration midzoneestrogens
circulating (0/100/0%):
if Progesterone-like
 Parabasal cells predominate (small cells effectcells
with absence of superficial e.g. secretory phase of endometrium, pregnancy
with small nuclei and very dense cytoplasm)  Intermediate- moderately mature
 Superficial- predominance=higher estrogen
concentration

Fibroepithelial Polyp  Benign growths composed of a fibrous connective tissue

 Usually single, gray-white, and less than 1.0 cm in diameter
 Simple excision is usually curative.
 Outward protrusions from the surface of the vaginal tract
 Core with fibroconnective tissue with small blood vessels with squamous lining epithelium
DISORDERS OF THE VAGINA AND CERVIX
Malignant Tumors  Compose 2% of genital
cancers (uncommon)
 80% represent extension
from the cervix and vulva
 Most common symptoms-
foul-smelling discharge,
postcoital bleeding
 Surgery is the main
treatment modality
SQUAMOUS CELL CARCINOMA CLEAR CELL CARCINOMA
 90% of primary vaginal malignancies  Occurs almost exclusively in
women exposed in utero to
 Peaks at 60-70 yrs
 Most commonly in the posterior wall as an exophytic mass diethylstilbestrol (synthetic
 Frequently in conjunction with VAIN estrogen)
 Dysplastic changes  Anterior wall of upper 3rd of
 Precursor lesions=SCC vagina
 Often silent in early stages  Peak: 17-22 years
 Pap smear for early detection  Tumor cells=clear
 Prognosis=spread of tumor at the time of discovery cytoplasm=↑glycogen;
 typical polygonal cells that exhibit large vesicular nucleus pleomorphic hyperchromatic
nucleus
and abundant eosinophilic cytoplasm
 May have hematogenous or
 differentiation=amount of keratin
lymphatic spread
 Alveolar pattern
EMBRYONAL
ADENOCARCINOMA
 Formerly called sarcoma
botryoides
 Appears as confluent polypoid
masses=bunch of grapes
 Peak: young children <4 years of
age
 Mesenchymal in origin
 Arises from the lamina propria of
the vaginal wall
 Composed of primitive/fetal
striated spindle cells called
rhabdomyoblasts

COMMON DISORDERS OF THE UTERINE CERVIX

Cervicitis  Inflammation of the cervix is very common due to constant

exposure to vaginal bacterial flora.
 Frequent etiologic agents: endogenous vaginal aerobes
and anaerobes: Staphylococcus, Streptococcus,
Enterococcus
 Acute or Chronic cervicitis
Endocervical Polyp  Most common cervical growth
 Appears as a single smooth or lobulated mass
 Often presents as vaginal bleeding
 Polypoid outgrowth in the endocervix
 Has a fibrous core that may show areas of erosion and
 granulation-type tissues with loose edematous stroma, scattered small blood vessels, inflammatory cells, benign endocervical glands; WATCH OUT FOR ATYPIA
 mucinous lining epithelium and benign endocervical glands with varying degrees of squamous metaplasia
Squamous Cell Neoplasia  Most well-known entity associated with malignancy in cervix.
 Cervical cancer remains as the 2nd most common cancer in women worldwide.
 Precursor lesions are termed cervical intraepithelial neoplasia (CIN); previously known as cervical dysplasia(similar to VIN in vulva and VAIN in vagina)
 Surveillance through Pap smear
 Cervical intraepithelial neoplasm (CIN)*
 Microinvasive SCC*
 Invasive SCC*
DISORDERS OF THE VAGINA AND CERVIX
Adenocarcinoma
 10% of cervical malignancies
 Most are endocervical cell (mucinous) type, followed by the endometrioid type
 Share epidemiological factors and clinical behavior with squamous cell carcinomas of the cervix
 Risk factors:
 Coitus at an early age
 Multiple sexual partners
 HPV infection (still operative)
 Invasive type=fungating, polyploid or papilla mass
 Spread=local invasion and lymphatic metastasis
 Exophytic tumors: papillary growth pattern
 Endophytic tumors: tubular or glandular pattern
 Poorly differentiated tumors: solid growth pattern
 Treated in the same manner as SCCA
 Has lesser survival rate than SCCA (resistant to radiotherapy)
 Small cell neuroendocrine carcinoma*

CERVICAL INTRAEPITHELIAL NEOPLASM
(CIN)
 Spectrum of epithelial changes that begins with
minimal cellular atypia→more marked
abnormalities→invasive squamous cell carcinoma.
 Dysplasia in the cervical epithelium=
alteration=potential for malignant transformation.
 Disease of the transformation zone of the cervix
(exocervix shift to endocervix);sample area for pap
smear
 Reversible
 Premalignant lesion
 May take several years to progress to squamous
cell carcinoma.
 Typically associated with HPV (considered as an
STD
Most important factors for development:
 Multiple sexual partners
 Early age of first sexual coitus
 Higher incidence in smokers
Bethesda classification: Pap smear findings of
squamous intraepithelial lesion (SIL)
 LSIL (low grade SIL)- Rarely progress in severity
MICROINVASIVE SCC INVASIVE SCC SMALL CELL NEUROENDOCRINE
CARCINOMA
 Result of progression from carcinoma in-situ  HPV 16 is the major causal agent for squamous  Rare: 1 to 5% of invasive cervical carcinomas
 early stage in the spectrum of frank cervical cancer cell carcinoma  Clinically aggressive with rapid metastases and
(stage 1A)  High risk HPV acts via E6 and E7 oncogenes poor prognosis
 Lesion is not grossly visible.  P16 immunohistochemistry is used as a surrogate  Women ages 25 to 87 years (median~42 years).
 Diagnosis rests on microscopic examination. marker for high risk HPV infection  Associated with HPV 18.
 Characterized by minimal invasion of stroma by  HPV vaccination of women 16-23 years of age  Mostly pure form, but may coexist with cervical
neoplastic cells offers protection for at least 12 years squamous cell carcinoma or adenocarcinoma
Diagnostic criteria:  Results from progression of microinvasive  Frequently presents with parametrial invasion and
 Invasion to a depth of <5mm below the basement squamous cell carcinoma pelvic lymph node metastases
membrane (microinvasion)  Frankly invasive
 Lack of vascular invasion  Most common type of cervical cancer
 No lymph node metastasis  Early stage
 Simple hysterectomy is generally sufficient for  Poorly defined granular eroded lesion
cure.  nodular exophytic mass
 If found in the endocervical canal
 Endophytic mass causes hardening of
 Cervix
 Microscopic types
 Large cell non-keratinizing (most common)
 Large cell keratinizing
 Small cell (least common and most aggressive
DISORDERS OF THE VAGINA AND CERVIX
and commonly disappear; more mature cells with pattern)
atypical nucleus and abundant cytoplasm;CIN I  Spread:
 HSIL (high grade SIL)- Tends to progress to SCC  Direct extension
and require treatment;CIN II and CIN III  Lymphatic vessels
 Higher grades of dysplasia=carcinoma in situ  Hematogenous route (rare)
 LSIL & HSIL- pap smear  Local extension=ureteral compression=renal
 CIN- biopsy failure
 Involvement of bladder & rectum=fistula
formation
 Postcoital bleeding
 Clinical stage is the best prognostic indicator
 Radical hysterectomy-early stage
 +radiation therapy- more advanced stage
 Staging