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Diseases of the female genital system and breast. Anatomy of female genital system. Diseases of female genital system. Diseases of the cervix Diseases of body of uterus Diseases of pregnancy Tumors of the ovary Diseases of the breast. Normal cervix. Normal cervix.

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Diseases of the female genital system and breast

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Diseases of the female genital system and breast


Anatomy of female genital system


Diseases of female genital system

  • Diseases of the cervix

  • Diseases of body of uterus

  • Diseases of pregnancy

  • Tumors of the ovary

  • Diseases of the breast


Normal cervix


Normal cervix

Squamocoluminar junction is the seat of most of the epithelial diseases that occur in the cervix


Diseases of the cervix

  • Chronic cervicitis

  • Neoplasia of the cervix


Chronic cervicitis

Erosion of cervix


Chronic cervicitis

Nabothian cyst


Cervical polyps


Chronic cervicitis


Diseases of the cervix

  • Chronic cervicitis

  • Neoplasia of the cervix


Cervical intraepithelial neoplasia(CIN)

Invasive carcinoma of the cervix

Neoplasia of the cervix


CIN

CIN I

CIN II

CIN III


Normal cervical squamous epithelium

CIN I


CIN II


CIN III


Risk factors for CIN and invasive carcinoma

  • Sexual intercourse

  • Early age at first intercourse(≤ 17 years old)

  • Smoking

  • Human papillomavirus (HPV 16, 18, 33)

  • HIV infection

  • Male factors


Cervical intraepithelial neoplasia(CIN)

Invasive carcinoma of the cervix

Neoplasia of the cervix


Invasive carcinoma of the cervix

  • Vast majority are squamous cell carcinomas

  • Arise from transformation zone

  • Preceded by CIN

  • Average is 50 years


Cervical carcinoma (early microinvasion)


Cervical carcinoma (early stage)

Abnormal hardness of the cervix


Cervical carcinoma ( late stage)

Fungating ulcerated areas destroy the cervix


Pap smear ( diagnostic cervical cytology)


Invasive carcinoma of the cervix


Clinical feature

  • Unscheduled vaginal bleeding

  • Leukorrhea

  • Painful coitus (dyspareunia)

  • Dysuria (advanced stage)


The size and depth of invasion of the primary tumor

The prescence and the extent of lymph node metastasis

Prognosis


Outline of female genital system

  • Diseases of the cervix

  • Diseases of body of uterus

  • Diseases of pregnancy

  • Tumors of the ovary

  • Diseases of the breast


Diseases of body of uterus

  • Adenomyosis

  • Endometriosis

  • Endometrial hyperplasia

  • Tumors of the endometrium and myometrium


Adenomyosis: growth of endometrium down into the myometrium

Endometriosis: growth of endometrium outside the uterus

Adenomyosis and endometriosis

ovaries

fallopian tubes

round ligaments

pelvic peritoneum


Adenomyosis and endometriosis


Adenomyosis


Endometriosis (uterine serosa)


“Chocolate” cyst of the ovary


Menstrual abnormalities

dysmenorrhea

Cyclic pelvic pain

Dysmenorrhea

Dyspareunia (painful intercourse)

Infertility(30% of cases)

Clinical feature

Adenomyosis

Endometriosis


Diseases of body of uterus

  • Adenomyosis

  • Endometriosis

  • Endometrial hyperplasia

  • Tumors of the endometrium and myometrium


Endometrial hyperplasia

  • Occurs in the third and fourth decades

  • In response to estrogen stimulation

  • Functional uterine bleeding


Endometrial hyperplasia


Diseases of body of uterus

  • Adenomyosis

  • Endometriosis

  • Endometrial hyperplasia

  • Tumors of the endometrium and myometrium


Tumors of the endometrium

Tumors of the myometrium

  • Endometrial carcinoma

  • Leiomyoma and leiomyosarcoma


Endometrial carcinoma

  • The most common cancer of the female genital tract

  • Mean age : 56 years (80% of women are postmenopausal)


Hyperestrogenic state

Obesity

Diabetes

Late menopause

Prolonged use of estrogen

Estrogen-secreting tumors

Risk factors

  • Previous pelvic irradiation

  • Lower parity


Endometrial carcinoma (early stage)


Endometrial carcinoma


Endometrial adenocarcinoma


Clinical feature

  • Irregular bleeding

  • Postmenopausal bleeding

  • Blood-stained discharge


Diagnosis of endometrial disease

  • Transvaginal ultrasonography

  • Hysteroscopy

  • Endometrial biopsy


Tumors of myometrium

  • Leiomyoma and leiomyosarcoma


Leiomyoma

  • Commonest tumor of all pelvic tumors (affect over half of all women over the age of 30)

  • Benign tumor

  • Arise from the smooth muscle cells in the myometrium


Risk factors

  • Age: rare under 30 years.

  • Parity: more common in nulliparous and women with low fertility.

  • Genetic: often with a family history


Features of leiomyoma

  • Estrogen sensitive

  • Fast growing in pregnancy

  • Shrink at menopause


Submucosal leiomyoma


Submucosal, intramural, subserosal leiomyomas


Leiomyoma


Clinical features

  • Abnormal menstrual bleeding

  • Dysmenorrhea

  • Infertility

  • Compression


Leiomyosarcoma


Leiomyosarcoma


Outline of female genital system

  • Diseases of the cervix

  • Diseases of body of uterus

  • Diseases of pregnancy

  • Tumors of the ovary

  • Diseases of the breast


Gestational trophoblastic tumors

Hydatidiform mole

Invasive mole

Diseases of pregnancy

  • Choriocarcinoma


Hydatidiform mole

  • Chracterised by swollen chorionic villi and trophoblastic hyperplasia

  • Associated with high HCG levels

  • Complete mole: no fetus

  • Partial mole: fetus or placenta may be present

  • May be complicated by chriocarcinoma


Complete mole


Hydatidiform mole


Doppler scan


Partial mole


Clinical feature

  • Amenorrhea followed by continuous or intermittent vaginal bleeding

  • Other symptoms of pregnancy: vomoting

  • Human chorionic gonadotropian (HCG)

  • Enlarged soft uterus (often larger than dates would suggest)


Invasive mole

Hemorrhage


Choriocarcinoma

  • Malignant tumor of trophoblastic tissue

  • With a propensity for invading vessel walls

  • Blood-borne metastasis occur early to many sites (lung, brain…)


Etiology

  • 50% develop from a hydatidiform mole

  • 20% arise after a normal pregnancy


Choriocarcinoma

Hemorrhagic necrotic masses


Choriocarcinoma

Villi are not present

Proliferation of bizarre trophoblastic cells

Highly aggressive


Choriocarcinoma

Dissemination to lung


Prognosis

  • Excellent as the tumors respond well to cytotoxic chemotherapy


Outline of female genital system

  • Diseases of the cervix

  • Diseases of body of uterus

  • Diseases of pregnancy

  • Tumors of the ovary

  • Diseases of the breast


Classification of ovarian tumor


Tumors of the ovary

  • Responsible for more deaths than any other gynaecological malignancy


Serous cystadenoma


Serous papillary cystadenoma


Serous adenocarcinoma


Mucinous cystadenoma


Mucinous adenocarcinoma


Krukenberg tumor (metastatic carcinoma from gastrointestinal tract)


Krukenberg tumor (metastatic carcinoma from gastrointestinal tract)


Outline of female genital system

  • Diseases of the cervix

  • Diseases of body of uterus

  • Diseases of pregnancy

  • Tumors of the ovary

  • Diseases of the breast


Normal breast


Key facts forproliferative conditions of the breast

  • Present as diffuse granularity, ill-defined lump or discrete swelling

  • Increased in frequency towards menopause, then rapid decrease

  • Variety of histological changes


Fibrocystic changes


Fibrocystic changes


Key facts Fibrocystic disease

  • Increased risk of subsequent development of carcinoma is related to the presence of epithelial hyperplasia, particularly atypical hyperplasia

  • Sclerosing adenosis can be clinically and radiologically confused with carcinoma


Predisposing factors for breast carcinoma

  • Atypical epithelial proliferation

  • Mutations of BRCA 1 and 2 genes

  • Long interval between menarche and menopause

  • Older age at first pregnancy

  • Obesity

  • High-fat diet

  • Lonizing radiation


Breast carcinoma


Carcinoma

Fibroadenoma


Paget’s disease


Prognosis

  • Tumor grade and type

  • Size of the tumor

  • Lymph node status

  • Estrogen receptor status


Estrogen receptror staining


Progesterone receptor staining


Cerb-B2 staining


Diagnostic methods

  • Fine-needle aspiration cytology

  • Tru-cut biopsy

  • Examination of frozen section

  • Mammography and ultrasound


Fine Needle Aspiration


Fine needle aspiration under control of mammography


Diagnostic methods

  • Fine-needle aspiration cytology

  • Tru-cut biopsy

  • Examination of frozen section

  • Mammography and ultrasound


Case study

  • A 35-year-old sales assistant at a discount frozen-food warehouse, attends her doctor for a routine cervical smear. She is asymptomatic and well, but has not visited her doctor for the previous five years and has not had a smear in that time.

  • The cervical cytological report shows severe dyskarosis.


  • She is recalled and has colposcopy performed which demonstrates the abnormal area of the cervical squamous epithelium which is biopsied. The changes seen colposcopically extend up the endocervical canal, and the upper margin of the abnormality can not be seen.

  • Histology shows that this is indeed an area of CIN (cervical intraepithelial neoplasia) grade 3, at the transformation zone, with atypical cells extending through the full thickness of the epithelium and showing no maturation towards the surface.


  • Mitotic figures, including abnormal forms, are present through all layers. There is no evidence of invasion in the biopsy.

  • She then has a cone biopsy performed. This confirms that CIN 3 is present at the transformation zone. There is no evidence of invasive squamous-cell carcinoma, no glandular atypia and the sever atypia is completely excised at both ecto- and endocervical margins.


Questions

  • If she had not had the disease identified by screening what would have been her risk of developing invasive cervical carcinoma?


Questions

  • What are the risk factors for developing cervical carcinoma?


Diseases of reproductive system

  • Diseases of male reproductive system

  • Sexually transmitted disease (STD)

  • Diseases of female reproductive system


Male reproductive system


Normal prostate


Normal prostate


Normal adult prostate


Diseases of prostate gland

  • Prostatitis

  • Nodular hyperplasia of the prostate

  • Carcinoma of the prostate


Chronic prostatis


Nodular hyperplasia of the prostate

  • The most common disorder of the prostate

  • A common non-neoplastic lesion

  • Often involves peri-urethral zone


Nodular hyperplasia of the prostate

  • Nodular hyperplasia affects most males over the age of 70 years

  • Nodular hyperplasia is termed glandular and stromal hyperplasia


Etiology

  • Androgen-estrogen imblance

  • Dehydrotesterone (DHT) is the main stimulator

  • DHT binds to nuclear receptors on both stromal and epithelial cells

  • Other factors


Affected lobes

  • Arises most commonly in the inner, periurethral glands of the prostate

  • Arises particularly from those that lie above the seminal vesicles


Gross feature

  • Nodular pattern of hyperplastic glandular acini separated by fibrous stroma

  • Some nodules are cystically dilated and contain a milky fluid

  • Other nodules contain numerous calcific concretions(corpora amylacea)


Nodular prostatic hyperplasia

Normal prostate gland


Nodular prostatic hyperplasia


Histological feature

  • Reveals two components: hyperplasia of both glands and of stroma

  • The acini are larger than normal


Prostatic hyperplasia


Prostatic hyperplasia


Clinical presentation

  • Compression of the urethra difficulties with micturition

  • Complications- prolonged prostatic obstruction can lead to outflow diseases


Acute cystitis


Trabeculation of the bladder

Stone formation

Enlarged prostate gland


Treatment

  • Anti-androgens

  • Surgical treatment


Prostate gland

  • Prostatitis

  • Nodular hyperplasia of the prostate

  • Carcinoma of the prostate


PIN (prostatic intraepithelial neoplasia) low grade


PIN (high grade)


Prostatic carcinoma

  • Adenocarcinoma occurring in males usually > 50 years (peak incidence: 60-85 years)

  • Metastasis mainly to bone (osteosclerotic metastasis)

  • Obstructs bladder outflow

  • Many are hormone(androgen)-dependent

  • Genetic and environmental factors may play a role in pathogenesis


Types of prostatic carcinoma

  • Latent- small foci of well-differentiated carcinoma, remain confined to prostate for a long period

  • Invasive- invade locally and metastasize

  • Occult- not clinically apparent in primary site but present as metastatic disease


Prostatic carcinoma


Adenocarcinoma of the prostate

Well differentiated

Poorly differentiated


Prostatic adenocarcinomawithprominent nucleoli


Carcinoma of the prostate


PSA staining of prostate carcinoma


Clinical feature

  • Often clinically silent

  • Urinary symptoms (delay in starting to pass urine, poor stream, terminal dribbling)

  • Hard, craggy prostate on rectal examination


Spread of prostatic carcinoma

  • Direct

  • Lymphatic

  • Hematogenic: most commonly to bone


Bone metastasis of prostatic carcinoma


Treatment

  • Radical prostatectomy

  • Reduce androgen levels

  • Orchidectomy

  • Treatment with estrogenic drugs


Squamous carcinoma of the penis


Squamous carcinoma of the penis


Germ cell neoplasms

  • Most common types of testicular neoplasm

  • Most common in the 15 to 34 age range

  • Types:

  • Seminoma (malignant)

  • Embryonal carcinoma (malignant)

  • Teratoma (benign and malignant)

  • Yolk sac tumor (malignant)


Seminoma of the testis


Seminoma


Embryonal carcinoma


Teratoma


Yolk sac tumor


Outline

  • Diseases of male reproductive system

  • Sexually transmitted disease(STD)


Classical veneral diseases

  • Syphilis

  • Gonorrhea

  • Chancroid

  • Lymphogranuloma venereum

  • Granuloma inguinale


Sexually transmitted diseases (STD)

  • Spectrum has broadened

  • Transmitted by sexual contact

  • Transmitted by other means


Classification of important STDs


Sexually transmitted disease(STD)

  • Gonorrhea

  • Syphilis

  • Condylomata acuminata


Gonorrhea

  • Causative organism: Neisseria gonorrheae

  • Almost always acqiured during sexual intercourse

  • Morphology: intense suppurative inflammation


Neisseria gonorrheae


Gonorrhea

Purulent urethral discharge


Abscess of epididymitis


Gonorrhea

Purulent infection of eye


Clinical feature

  • Presence of dysuria

  • Urinary frequency

  • Mucopurulent urethral or vaginal exudate


Complication

  • Disseminated infection

  • Chronic stricture

  • Chronic scarring of fallopian tubes (salpingitis)

  • Chronic urethral stricture

  • Male sterility

  • Female infertility


Neonatal gonorrhea

Transmitted to infants

Ophthalmia neonatorum

Blindness


Standard for diagnosis

  • Detection of gonococci

Bacterial culture


Syphilis

  • Causative organism:Treponema pallidum, a kind of spirochete

  • Almost always acqiured during sexual intercourse


Pathological change

  • Infiltration of lymphocytes and plasma cells

  • Endoarteritis

  • Gumma ( a kind of granuloma)


Histological feature


Clinicopathological feature

  • Acquired syphilis

  • Congenital syphilis


Acquired syphilis

  • Primary stage

  • Secondary stage

  • Tertiary stage


Primary stage

Chancre


Secondary stage

Lymphode enlargement

Syphilid


Systemic involement in tertiary syphilis

Gumma formation


Tertiary stage

Gumma


Clinicopathological feature

  • Acquired syphilis

  • Congenital syphilis


Congenital syphilis

  • Syphilitic hepatitis

  • Syphilitic pneumonia

  • Desquamation of skin

Early death

  • Osteochondritis

  • Perichondritis

Bone deformities


Malformation of the teeth

Saddle nose


Sexually transmitted disease(STD)

  • Gonorrhea

  • Syphilis

  • Condylomata acuminata


Condylomata acuminata (veneral warts)

  • Causative organism:Human papillomavirus(HPV)6,11

  • Spread of infection

Sexal intercourse

Indirect contact


Condylomata acuminata


Condylomata acuminata

Koliocytosis


Gold criteria for diagnosis

In situhybridization (ISH)

Electronmicroscopy


Suggested reading


Case study

  • A 74-year-old retired fruit-farm labourer says that he has been feeling unusually tired and has lost his appetite. Initial blood tests show that he is anemic, with an Hb of 9.8g/dl and has renal failure with a blood urea of 26mmol/l and a creatinine of 280mmol/l.On further enquiry, you find out that he has had a poor urinary system, with some frequency, nocturia and a post-micturitional dribble.


Physical examination

  • Rectal examination reveals a rubbery, firm, smooth enlargement of the prostate gland. Further investigations include an intravenous urogram (IVU) which showed both kidneys to be functioning but also showed bilateral hydronephrosis with hydroureter.


Questions

  • what is the most likely diagnosis?


Questions

  • what further tests may be helpful?


Questions

  • what abnormality is seen in the bladder?


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