Download
1 / 81
820 likes | 868 Views
The Female Genital System. TOPICS. Vulva Cervix Endometrium Uterus Tubes Ovaries. Vulva. Non-Neoplastic Epithelial DISORDERS. LICHEN Sclerosis (atrophic skin) LICHEN Simplex Chronicus (hypertrophic skin). LICHEN Sclerosis <Thined epidermis, Sclerotic stroma>.
E N D
TOPICS • Vulva • Cervix • Endometrium • Uterus • Tubes • Ovaries
Non-Neoplastic Epithelial DISORDERS • LICHEN Sclerosis (atrophic skin) • LICHEN Simplex Chronicus (hypertrophic skin)
LICHEN Sclerosis <Thined epidermis, Sclerotic stroma>
LICHEN Simplex Chronicus < Hyperkeratosis , Thikened epidermis
The normal adult vaginal mucosa with a wrinkled appearance that is seen in women of reproductive years appears at the left. The cervix has been opened to reveal an endocervical canal leading to the lower uterine segment at the right that has an erythematous appearance extending to the cervical os consistent with chronic inflammation.
Here is a normal cervix with a smooth, glistening mucosal surface. There is a small rim of vaginal cuff from this hysterectomy specimen. The cervical os is small and round, typical for a nulliparous woman. The os will have a fish-mouth shape after one or more pregnancies.
This is normal cervical non-keratinizing squamous epithelium. The squamous cells show maturation from basal layer to surface.
The normal cervical squamous epithelium at the left transforms to dysplastic changes on the right.
Cervical squamous dysplasia is seen at medium magnification, extending from the center to the right. The epithelium is normal at the left. Note how the dysplastic cell nuclei at the right are larger and darker, and the dysplastic cells have a disorderly arrangement. This dysplastic process involves the full thickness of the epithelium, but the basal lamina is intact, so this is a high grade squamous intraepithelial lesion (HSIL) that can also be termed cervical intraepithelial neoplasia (CIN) III.
This is a Pap smear. The cytologic features of normal squamous epithelial cells can be seen at the center top and bottom, with orange to pale blue plate-like squamous cells that have small pyknotic nuclei. The dysplastic cells in the center extending to upper right are smaller overall with darker, more irregular nuclei.
This is why you do Pap smears--to prevent invasive squamous cell carcinomas from occurring. With Pap smears, pre-neoplastic and neoplastic cervical lesions can be detected when small and treated. Nests ofsquamous cell carcinomahave invaded underlying stroma at the center and left.
This is the gross appearance of a cervical squamous cell carcinoma that is still limited to the cervix (stage I). The tumor is a fungating red to tan to yellow mass.
Here is another cervical squamous cell carcinoma. Note the IUD string protruding from the cervix.
This is a larger cervical squamous cell carcinoma which spread to the vagina. A total abdominal hysterectomy with bilateral salpingo-oopherectomy (TAH-BSO) was performed.
This is the microscopic appearance of normal proliferative endometrium in the menstrual cycle. In this phase, tubular glands with columnar cells and surrounding dense stroma are proliferating to build up the endometrium following shedding with previous menstruation.
Here is early secretory endometrium. The appearance with prominent subnuclear vacuoles in cells forming the glands is consistent with post-ovulatory day 2. The histologic changes following ovulation are quite constant over the 14 days to menstruation and can be utilized to date the endometrium.
This is normal secretory phase endometrium. Note the larger tortuous glands with secretions. The secretory phase follows a set 14 day course leading to either implantation of a fertilized ovum or menstruation.
The endometrial cavity is opened to reveal lush fronds of hyperplastic endometrium. Endometrial hyperplasia usually results with conditions of prolonged estrogen excess and can lead to metrorrhagia (uterine bleeding at irregular intervals), menorrhagia (excessive bleeding with menstrual periods), or menometrorrhagia.
This is endometrial cystic hyperplasia in which the amount of endometrium is abnormally increased and not cycling as it should. The glands are enlarged and irregular with columnar cells that have some atypia. Simple endometrial hyperplasias can cause bleeding, but are not thought to be premalignant.
This uterus has been opened anteriorly through cervix and into the endometrial cavity. High in the fundus and projecting into the endometrial cavity is a small endometrial polyp. Such benign polyps may cause uterine bleeding.
This uterus is not enlarged, but there is an irregular mass in the upper fundus that proved to be endometrial adenocarcinoma on biopsy. Such carcinomas are more likely to occur in postmenopausal women. Thus, any postmenopausal bleeding should make you suspect that this lesion may be present.
This adenocarcinoma of the endometrium is more obvious. Irregular masses of white tumor are seen over the surface of this uterus that has been opened anteriorly. The cervix is at the bottom of the picture. This enlarged uterus was no doubt palpable on physical examination. Such a neoplasm often present with abnormal bleeding.
This is endometrial adenocarcinoma which can be seen invading into the smooth muscle bundles of the myometrial wall of the uterus. This neoplasm has a higher stage than a neoplasm that is just confined to the endometrium or is superficially invasive.
The thickened and spongy appearing myometrial wall of this sectioned uterus is typical of adenomyosis. There is also a small white leiomyoma at the lower left.
Adenomyosis occurs when endometrial glands and stroma are found in the myometrium, not just in the endometrium where they belong. This condition leads to uterine enlargement and irregular bleeding.
When endometrial glands and stroma are found outside the uterus, the condition is known as endometriosis. Up to 10% of women may have this condition. It can be very disabling and painful, even when just a few foci are present. Diagrammed here are typical locations for foci of endometriosis. Sometimes the old dark brown blood collects over time from repeated hemorrhage in a cystic space in the ovary and produces a so-called "chocolate cyst".
Here, a small cluster of endometrial glands and stroma with hemorrhage are seen at the left near the surface of the fallopian tube. The lumen of the tube is at the right. This is a focus of endometriosis.
Endometrial glands and stroma are seen at high magnification in the wall of the colon. Endometriosis is symptomatic during reproductive years when patients may present with dysmenorrhea, pelvic pain, and infertility.
Grossly, in areas of endometriosis the blood is darker and gives the small foci of endometriosis the gross appearance of "powder burns". Small foci are seen here just under the serosa of the posterior uterus in the pouch of Douglas. Such areas of endometriosis can be seen and obliterated by cauterization via laparoscopy.
Upon closer view, these five small areas of endometriosis have a reddish-brown to bluish appearance. Typical locations for endometriosis may include: ovaries, uterine ligaments, rectovaginal septum, pelvic peritoneum, and laparotomy scars. Endometriosis may even be found at more distant locations such as appendix and vagina.
This is a section through an enlarnged 12 cm ovary to demonstrate a cystic cavity filled with old blood typical for endometriosis with formation of an endometriotic, or "chocolate", cyst. The hemorrhage from endometriosis into the ovary may give rise to a large "chocolate cyst" so named because the old blood in the cystic space formed by the hemorrhage is broken down to produce much hemosiderin and a brown to black color.
In the upper fundus of the uterus protruding into the endometrial cavity is a nodule that proved to be a leiomyoma. Thus, this is a submucosal leiomyoma. Such benign smooth muscle tumors of the myometrium are very common, perhaps 1 in 5 women has one. They may be the cause of irregular bleeding if placed submucosally, as seen here, or if large.
Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the uterus.
Here is a very large leiomyoma of the uterus that has undergone degenerative change and is red (so-called "red degeneration"). Such an appearance might make you think that it could be malignant. Remember that malignant tumors do not generally arise from benign tumors, which is a good thing, because leiomyomas are so common (20% of women will have at least one). Postmenopausally, leiomyomas tend to regress in size and become fibrotic.
Here is the microscopic appearance of a benign leiomyoma. Normal myometrium is at the left, and the neoplasm is well-differentiated so that the leiomyoma at the right hardly appears different. Bundles of smooth muscle are interlacing in the tumor mass.
This is a leiomyosarcoma protruding from myometrium into the endometrial cavity of this uterus that has been opened laterally so that the halves of the cervix appear at right and left. Fallopian tubes and ovaries project from top and bottom. The irregular nature of this mass suggests that is not just an ordinary leiomyoma.
Here is the microscopic appearance of a leiomyosarcoma. It is much more cellular and the cells have much more pleomorphism and hyperchromatism than the benign leiomyoma. An irregular mitosis is seen in the center.
As with sarcomas in general, leiomyosarcomas have spindle cells. Several mitoses are seen here, just in this one high power field.
Sarcomas, including leiomyosarcomas, often have very large bizarre giant cells along with the spindle cells. A couple of mitotic figures appear at the left and lower left.
Here is a bifid (septate) uterus. Sometimes even the cervix and/or vagina may be double as well. This is of no major consequence except that in pregnancy a bifid uterus may not enlarge normally and lead to fetal loss, or a normal vaginal delivery may not be possible with a double cervix or vagina. Note that there is also a small intramural leiomyoma on the septum at the left.
Ovulation releases an egg from an ovarian follicle. The egg is swept into the fallopian tube and begins to descend. Spermatozoa (millions are represented here by one) begin ascending. Fertilization of the egg by a single sperm occurs in the ampullary portion of the fallopian tube about a day after ovulation. The fertilized egg begins to develop into the blastocyt on descent into the endometrial cavity, where implantation occurs on the wall of the fundus about a week after ovulation.
