FEMALE GENITAL TRACT

Part II: Uterus to Trophoblastic

Diseases
Uterus
Proliferative Secretory
Acute endometritis
CHRONIC ENDOMETRITIS
Chronic endometritis.
• Presence of plasma cells in the endometrium is diagnostic.
• Maturation of the endometrium is irregular making histologic dating difficult.
• The stromal cells become spindled and swirl around the glands.
• Endometriosis
- (from endo, "inside", and
metra, "womb")
- endometrial-like cells appear
and flourish in areas outside
the uterine cavity
- most commonly → ovaries
(R picture)

• Adenomyosis
- the presence of ectopic
glandular tissue found in
muscle
• Endometrial polyps
(uterine polyp )
- mass in the inner lining of the
uterus
- Assoc. to the effect of
estrogen than from
progesterone → hyperplasia
- Tamoxifen (Breast CA)
- Pedunculated > sessile
 Endometrial Hyperplasia
• Simple non-atypical hyperplasia
- cystic/mild hyperplasia
- various sizes, irregular gland shape
- responsive to estrogen

• Complex atypical hyperplasia

- increase in size & number of gland
- crowding
- (+) mitotic figures
- increased cell stratification and nuclear enlargement
- (+) scalloped or tufted surface
A, Lower-grade hyperplasias of the endometrium show principally architectural
glandular changes with cystic glandular dilatation and are synonymous with
anovulatory changes. B, Atypical hyperplasias (endometrial intraepithelial neoplasia)
exhibit increased gland/stroma ratio (gland crowding) and epithelial stratification
(arrows). C, Loss of PTEN gene expression in intraepithelial neoplasia, seen here as
absence of staining. Compare to normal glands (arrows), which express the gene D,
Endometrial hyperplasia with squamous metaplasia.
Simple Complex
- Atypia + atypia
- Atypia + atypia
Uterus adenocarcinoma
 Uterus tumors

• Endometrial carcinoma
- most common invasive cancer
- arise mainly on
postmenopausal women →
abnormal bleeding
- Links: obesity, estrogen
therapy, estrogen-secreting
tumors
(Unopposed Estrogen →
inactivates PTEN tumor
suppresor gene)
Classification of Endometrial
Carcinoma
Type I

Type II
Adenocarcinoma
Well diff poorly diff
Endometrioid Adenocarcinoma
Endometrioid Adenocarcinoma with
squamous differentiation
• Adenocarcinomas
Staging of endometrial adenocarcinoma is as
follows:
Stage I. Carcinoma is confined to the corpus uteri
itself.
Stage II. Carcinoma has involved the corpus and
the cervix.
Stage III. Carcinoma has extended outside the
uterus but not outside the true pelvis.
Stage IV. Carcinoma has extended outside the
true pelvis or has obviously involved the mucosa
of the bladder or the rectum.
• Leiomyoma
- Benign
Micro: whorled bundles of smooth
muscle cells
Cells →uniform in size and shape
and have the characteristic oval
nucleus and long, slender bipolar
cytoplasmic processes
Mitotic figures are scarce.
• Leiomyosarcoma
- Malignant
Gross: Large hemorrhagic tumor
mass
Micro: wide range of atypia,
Irreglular size, hyperchomatic nuclei
Mitotic index & zonal necrosis
• Carcinosarcoma
- malignant mixed mullerian tumor
- metastatic, highly malignant

Gross: Fleshy, bulky, polypoid,

may protrude at cervical os
Micro: has epithelial and
mesenchymal component,
mimics extrauterine tissues.
 Fallopian Tubes
• Where egg and sperm meet
• Most common disorders → Inflammatory
 Inflammatory conditions
• Acute salpingitis
- Suppurative salpingitis → pyogenic (Chlamydia)
Gross: there is a pyosalpinx (pus), hematosalpinx;
enlarged, erythematous, edematous; may have
fibrinous exudate; tubo-ovarian abscess
common
Micro: (+) marked neutrophilic infiltrate, congestion
and edema; mucosal ulceration; reactive
epithelial changes
• Chronic salpingitis
Tuberculous salpingitis → more common, may cause
infertitlity
Gross: enlarged distorted tube adherent to ovary;
may be associated with hydrosalpinx or
pyosalpinx that transforms to a tubo-ovarian
cyst
Micro: there is a blunted, shortened, fibrotic plica
contain chronic inflammatory cells; fused plica
may produce a pseudoglandular pattern
(chronic follicular salpingitis) that resembles
malignancy
 Adenocarcinoma

• direct extension or metastasis from

tumors arising elsewhere.
• Primary adenocarcinoma → rare
• Has dominant tubal mass lumen and
mucosal involvement
Ovaries
 Ovary
• NON-NEOPLASTIC AND FUNCTIONAL
CYST
A. Cystic follicles → are common &physiologic → from an
unruptured graafian follicles or in follicles that have
ruptured and immediately sealed
→ Assoc.to hyperestrenism
→ multiple, 2 cm in diameter, filled with a clear serous fluid,
and are lined by a gray, glistening membrane

B. Chocolate cyst - blood containing cyst

resulting from ovarian endometriosis with
hemorrhage
Polycystic ovarian disease (PCOD / Stein-Leventhal
syndrome)

- numerous cystic follicles or follicle cysts, often associated with

oligomenorrhea

- anovulation, obesity (40%), hirsutism (50%), virilism

- Increased secretion of luteinizing hormone → stimulate the theca-
lutein cells of the follicles →excessive production of androgen
(androstenedione)
Ovarian Tumors
 A. Surface Epithelial Origin

• Serous
- bilateral
- 75% benign and borderline
Serous cystadenocarcinomas →
40% of all cancers of the ovary &
the most common malignant
ovarian tumors

Gross: cystic lesion in which the

papillary epithelium is contained within
a few fibrous walled cysts (intracystic)
Micro: lined by tall, columnar, ciliated
epithelial cells, filled with clear serous
fluid

L cystadenoma
R cystadenocarcinoma
• Mucinous
- Less bilateral
- 80% benign & borderline
Gross: larger cystic masses, weighs > than 25
kgs; multiloculated tumors filled with
sticky, gelatinous fluid rich in glycoproteins
Micro: lining of tall columnar epithelial cells
with apical mucin & absence of cilia

Cystadenocarcinomas → solid growth +

epithelial cell atypia & stratification, loss of
gland architecture, and necrosis, complex
glands in the stroma, clear-cut stromal
invasion
• Clear cell
- uncommon
- characterized by large epithelial cells with abundant
clear cytoplasm
- Solid → arranged in sheets or tubules
- cystic → neoplastic cells line the spaces

• Endometroid
- mostly Malignant
- distinguished → (+) tubular glands bearing a close
resemblance to benign or malignant endometrium
Gross: combination of solid and cystic areas, similar to
other cystadenocarcinomas
Brenner
- uncommon
- consists of nests of transitional cells
resembling those lining the urinary
bladder, in a background of fibrous
stroma

- benign or malignant, depending on

invasion of the surrounding tissue

Brenner tumor showing the characteristic

coffee bean nuclei.
 B. Germ cell Origin
• TERATOMA
A. Mature / Benign
- derived from the ectodermal totipotential cells
- unilocular cysts with hair & sebaceous material
reveal a thin wall lined by an opaque, gray-white, wrinkled, apparent epidermis. From this epidermis,
hair shafts frequently protrude. Within the wall, it is common to find tooth structures and areas of
calcification

B. Immature
- rare
- found chiefly in prepubertal adolescents and young women
- grows rapidly & has local spread or metastaseare
Gross: bulky and have a smooth external surface
Micro: solid (or predominantly solid) structure, with areas of necrosis and hemorrhage, Hair, grumous
material, cartilage, bone, and calcification may be present

C. Monodermal / specialized
-unilateral
- rare group of tumors
Struma ovarii → entirely of mature thyroid tissue. May hyperfunction, causing hyperthyroidism.
Ovarian carcinoid →from intestinal epithelium large (greater than 7 cm) tumors, producing 5-
hydroxytryptamine and the carcinoid syndrome.
• Endodermal sinus (yolk sac) tumor
- rare
- 2nd most common malignant tumor of germ
cell origin
- rich in α-fetoprotein and α1-antitrypsin
Micro: (+) glomerulus-like structure composed of a
central blood vessel enveloped by germ cells
within a space lined by germ cells (Schiller-
Duval body)

• Dysgerminoma
- malignant
- unilateral
Gross: has yellow-white to gray-pink appearanc,
soft and fleshy
Micro: dispersed in sheets or cords separated by
scant fibrous stroma ,the fibrous stroma is
infiltrated with mature lymphocytes and Dysgerminoma showing polyhedral tumor
occasional granulomas cells with round nuclei and adjacent
inflammation .
 C. Sex-cord – Stromal origin

• GRANULOSA
- composed of varying proportions of granulosa and
theca cell differentiation

- importance: (1) their potential elaboration of large

amounts of estrogen and (2) the small but distinct
hazard of malignancy in the granulosa cell forms
(assoc with endometrial hyperplasia, cystic disease
of the breast, and endometrial carcinoma)

Gross: unilateral and vary from microscopic foci to large,

solid, and cystic encapsulated masses, yellow Granulosa cell tumor. A, The tumor cells are
coloration with lipids arranged in sheets punctuated by small follicle-like
structures (Call-Exner bodies).
Micro: small, cuboidal to polygonal cells may grow in
anastomosing cords, sheets, or strands, glandlike
structures filled with an acidophilic material recall
immature follicles (Call-Exner bodies)
• Fibroma-Thecomas
- Arising in the ovarian stroma that are
composed of either fibroblasts (fibromas)
or more plump spindle cells with lipid
droplets

Gross: unilateral, solid, spherical or slightly

lobulated, encapsulated, hard, gray-white
masses covered by glistening, intact
ovarian serosa
Micro: well-differentiated fibroblasts with a
more or less scant collagenous
connective tissue interspersed

- Meigs syndrome →combination of

Thecoma-fibroma composed of plump, differentiated
findings (ovarian tumor, hydrothorax, and stromal cells with thecal appearance.
ascites)
• SERTOLI – LEYDIG TUMOR
CELLS
- produce masculinization or at least defeminization
- block normal female sexual development in
children and may cause defeminization of women,
manifested by atrophy of the breasts, amenorrhea,
sterility, and loss of hair

Gross: solid and varies from gray to golden brown

Micro:
The well-differentiated tumors → tubules composed of
Sertoli cells or Leydig cells interspersed with stroma
The intermediate forms → outlines of immature tubules
and large eosinophilic Leydig cell
The poorly differentiate→ have a sarcomatous pattern
with a disorderly disposition of epithelial cell cords
Sertoli cell tumor. well-differentiated
Sertoli cell tubules.
 D. Metastatic to Ovaries
- Most common "metastatic" tumors of the ovary are probably derived
from tumors of müllerian origin: the uterus, fallopian tube,
contralateral ovary, or pelvic peritoneum.
- Extramüllerian primaries → breast & GIT
- Krukenberg tumor →bilateral metastases composed of mucin-
producing, signet-ring cancer cells
Gestational and Placental Disorders
 Gestational and Placental Disorders

• Spontaneous Abortion • Ectopic Pregnancy

- maternal influences, - implantation of the fetus in any
inflammatory (Listeria, site other than a normal uterine
Toxoplasmosis, Mycoplasma), location.
trauma, uterine abnormalities - 35% to 50% → PID with chronic
salpingitis (cause)
Histo: focal areas of decidual - Tubal pregnancy →
necrosis with intense neutrophilic hematosalpinx
infiltration, thrombi within
decidual blood vessels, and
considerable amounts of
hemorrhage, both recent and old,
within the necrotic decidua.
Placental villi may be markedly
edematous and devoid of blood
vessels
 Placental Disorders
– Abruptio placenta
• premature separation of the placenta
• cause of antepartum bleeding & fetal death
• Assoc. with disseminated intravascular coagulation.

– Placenta accreta/increta/percreta
• Attachment/invasion/penetration of the placenta to the myometrium from which
the decicual layer is defective
• Predisposed: endometrial inflammation &old scars from surgery

– Placenta previa
• attachment of the placenta to the lower uterine segment and may partially or
completely cover the cervical os
 Gestational and Placental Disorders

• Toxemia in pregnancy
- TRIAD: hypertension, proteinuria, & edema (preeclampsia)
- 6% last trimester –
- primiparas > multupara
- more seriously ill + convulsions → eclampsia

The main features:

(1) decreased uteroplacental perfusion;
(2) increased vasoconstrictors and decreased vasodilators,
resulting in local and systemic vasoconstriction;
(3) disseminated intravascular coagulation (DIC)
 Gestational and Placental Disorders

• Hydatidiform mole
- cystic swelling of the chorionic villi, accompanied by variable
trophoblastic proliferation
- they may precede choriocarcinoma
• Complete • Incomplete/ Partial
- uterine cavity filled with a delicate, friable
mass of thin-walled, translucent, cystic,
- villous hydrops and architectural
grapelike structures consisting of swollen disturbances in only a proportion of
edematous (hydropic) villi villi. The trophoblastic proliferation is
- hydropic swelling of most chorionic villi minimal and limited to the
and virtual absence or inadequate syncitiotrophoblast
development of vascularization of villi
- Extensive trophoblastic proliferation
Choriocarcinoma
• epithelial malignant neoplasm of
trophoblastic cells
• rapidly invasive widely metastasizing
malignant neoplasm
• responds well to chemotherapy

Gross: a soft, fleshy, yellow-white tumor

with a marked tendency to form large
pale areas of ischemic necrosis, foci of
cystic softening, and extensive
hemorrhage
Micro: a purely epithelial tumor that does
not produce chorionic villi & abnormal
proliferation of both cytotrophoblast
and syncytiotrophoblast;
anaplasia within such abnormal
proliferation, replete with abnormal
mitoses
 END

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