Reproductive System Content Content Female disease

Content
Reproductive System
Ratirath Samol, MD
• Female disease
- genital tract : infection (PID), vulva,
vagina, cervix, body of uterus with
endometrium, ovaries
- breast disease
- gestational disorders
Content
• Male disease
- gynecomastia
- penis
- testis
- prostate gland
Female disease
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Pelvic inflammatory disease (PID)
• Ascending infection begins in vulva or
vagina and spreads upward to involve
most structure in female genital tract
• Clinical : pelvic pain, fever, vaginal
discharge
Pelvic inflammatory disease (PID)
Pelvic inflammatory disease (PID)
• Organisms :
- Neisseria gonorrhoaea
- Chlamydia spp.
- Staphylococcus spp.
- Streptococcus spp.
- Coliform bacteria
Vulva
• Bartholin cyst and abscess
• Codyloma acuminatum
• Vulva carcinoma
Bartholin cyst and abscess
• Acute infection of Bartholin gland
produces cyst or abscess
• Cyst result from obstruction of Bartholin
duct, usually by preceding infection
• Cyst may become large, up to 3-5 cm.
• Clinical : pain, mass at labia
• Rx: excision
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Bartholin cyst and abscess
Condyloma acuminatum
• Sexual transmitted, benign lesion
• Frequent multiple lesions involve vulva,
perianal region and vagina
• Caused by HPV type 6, 11
• Frequent regress spontaneously
• No precancerous lesion
Condyloma acuminatum
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Squamous cell carcinoma (SCCA) of Vulva
• Cancer-related HPV infection type
16, 18
• May be genetic cause
• Tumor metastasis to any organs
Verrucous nodules
Koilocytosis
Squamous cell carcinoma (SCCA) of Vulva
Vagina
• Squamous cell carcinoma (SCCA)
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SCCA of vagina
SCCA of vagina
• Uncommon primary SCCA of vagina
• 95% SCCA associated with HPV
• Greatest risk factor is previous SCCA of
cervix or vulva
Squamous cell carcinoma
• Clinical course
- insidious tumor growth
- irregular spotting or frank vaginal
discharge (leukorrhea)
- may be silent and become present with
urinary or rectal fistulas
Cervix
• Cervicitis
• Intraepithelial and invasive squamous
neoplasia
- Cervical Intraepithelial Neoplasia (CIN)
- Squamous cell carcinoma (SCCA)
Cervix
Cervicitis
• Acute and chronic inflammation of cervix
• Caused by bleeding, sexual intercourse,
vaginal douching resulting lactobacilli
decrease H2O2 production Æ alkaline
vaginal pH Æ pathogenic organisms
overgrowth Æ cervicitis
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CIN and Invasive squamous neoplasia
• Risk factors for cervical neoplasm
- early age at first intercourse
- multiple sexual partners
- increased parity
- a male partner with multiple previous
sexual partners
- HPV infection
CIN and Invasive squamous neoplasia
• Specific HPV types associated with
- Cervical cancers : high-risk HPV type
16,18,31,33
- Condyloma : low-risk HPV type 6,11,
CIN and Invasive squamous neoplasia
• Risk factors for cervical neoplasm
- exposure to oral contraceptive
- smoking
- genital infections (chlamydia)
Cervical Intraepithelial Neoplasia (CIN)
• Occurs in transformation zone
• Precancerous lesion of cervix, classified in
a variety of ways
- mild dysplasia (lower 1/3) = CIN I
- moderate dysplasia (lower 2/3) = CIN II
- severe dysplasia (nearly thickness) = CIN III
- carcinoma in situ (CIS) (full thickness)=CIN III
Cervical Intraepithelial Neoplasia (CIN)
Cervical Intraepithelial Neoplasia (CIN)
• Clinical course
- CIN I: most likely no progress to carcinoma
- CIN III and CIS most frequent associated
with invasive SCCA
- often no symptom
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Squamous cell carcinoma (SCCA)
• Occurs at any age from second decade of
life to senility
• Gross : 3 patterns
- fungating (exophytic) mass
- ulcerating mass
- infiltrative mass
Squamous cell carcinoma (SCCA)
• Clinical course
- advanced carcinoma direct spread to any
structure eg.urinary bladder,ureter, rectum,
vagina, liver, lungs
- no symptom, vaginal bleeding, contact
bleeding, pain during sexual intercourse,
swollen leg
Body of uterus and Endometrium
Squamous cell carcinoma (SCCA)
• Fig micro
Prevention and control of carcinoma of cervix
• Papanicolaou (PAP) smear screening
• Vaccines for preventing HPV infection
Uterus and Endometrium
• Endometrial carcinoma
• Endometriosis/Adenomyosis
• Leiomyoma (myoma uteri)
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Endometrial carcinoma
Endometrial carcinoma
• Malignant endometrial epithelial tumor
• Arise mainly in postmenopausal women,
causing abnormal postmenopausal
bleeding
• Peak incidence 55-65 yrs
• High frequent in obesity, diabetes,
hypertension, infertility
• Most develops on background of prolong
estrogen stimulation
• Most endometrial adenocarcinoma
Endometrial carcinoma
Endometrial carcinoma
• Clinical course
- irregular vaginal bleeding with excessive
leukorrhea
- diagnosis by curettage and histology
- prognosis depend on clinical staging
Endometriosis
Chocolate cyst
• Endometrium locate outer site eg. cervix,
myometrium, ovary
• Endometrium invade in myometrium =
adenomyosis
• Endometrium locate in ovary forming cyst
= endometriotic cyst or chocolate cyst
• Clinical : dysmenorrhea
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Leiomyoma (myoma uteri)
• Most common benign tumor of smooth
muscle cells (myometrium)
• Present in 75% of female reproductive age
• Malignant change in leiomyoma is
extremely rare
Leiomyoma (myoma uteri)
Leiomyoma (myoma uteri)
• Gross finding
- well circumscribed, gray white mass
with whorled, trabeculation cut section
- variable in size
Leiomyoma (myoma uteri)
• Clinical course : may asymptomatic or symptoms
• Most important symptoms
- abnormal uterine bleeding (submucosal)
- compress bladder (urinary frequency)
- sudden pain if disruption of blood supply
- impaired fertility
- myoma in pregnancy increase frequency of
spontaneous abortion, fetal malpresentation,
postpartum hemorrhage
circumscribed gray-white mass
with whorled trabeculation
Interlacing fascicles of spindle
cells
Ovaries
• Functional cysts
- Follicular cysts
- Corpus luteum (luteal) cysts
• Ovarian tumor
- mucinous tumor
- serous tumor
- germ cell tumor (teratoma)
- krukenberg tumor
Follicular cysts
• Cysts >2 cm, originate in unruptured
graafian follicles or in follicles
• Usually no symptom
• May be pain from rupture, rapid growth,
bleeding into cyst, or twisting of cyst
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Corpus luteum cysts
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Occurs when an egg is released from follicle
Variable in size of cyst
Usually no symptom
May be pain from rupture, rapid growth,
bleeding into cyst, or twisting of cyst
Ovarian tumors
• 80% are benign and occurs in young
women (20-45 yrs)
• Malignant tumor common in old women
(40-65 yrs)
• High frequent in unmarried and in married
with low parity
Ovarian tumors
• Clinical features
- abdominal mass, pain and distension
- ascites with peritoneal seeding
- urinary and GI tract symptom due to
compression or invasion by tumor
Surface-epithelial stromal tumor
• Most primary neoplasm in ovary
• Gross finding
- cysts : most benign
- risk of malignancy increase as :
solid growth
thick cystic wall
necrotic friable tissues
Serous tumors
• Classified 3 types
- Benign (serous cystadenoma)
- Borderline serous tumor
- Malignant (serous cystadenocarcinoma) :
most common malignant ovarian tumors
• Common in 20-50 yrs
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Serous cystadenoma
• Gross finding : single or multiple, smooth
cysts filled with clear fluid
Serous cystadenocarcinoma
• Gross finding : large amounts of solid or
papillary tumor mass
Mucinous tumors
• Less frequency of bilateral
• If bilateral mucinous ovarian tumors,
must exclusion of non-ovarian origin
tumor eg. appendix, GI tract
Borderline serous tumor
• Gross finding : cysts with increase number
of papillary projection
Mucinous tumors
• Common in middle age women
• Classified 3 types
- Benign (mucinous cystadenoma)
- Borderline mucinous tumor
- Malignant (mucinous cystadenocarcinoma) :
10% of malignant ovarian tumors
Mucinous cystadenoma
• Gross finding : single or multiple, smooth
cysts filled with sticky, gelatinous fluid
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Borderline mucinous tumor
• Gross finding : single or multiple, smooth
cysts filled with sticky, gelatinous fluid,
hemorrhage, necrosis, some solid area
Germ cell tumor
• Occurs in children and young adult
women
• Most are mature teratoma
Mucinous cystadenocarcinoma
• Gross finding : single or multiple cysts
filled with scant sticky, gelatinous fluid, but
predominate hemorrhage, necrosis and
solid mass
Teratoma
• Germ cell tumor derived from pluripotential
cells and made up of elements of different
types of tissue from one or more of the
three germ cell layers (endoderm,
mesoderm, ectoderm)
• Endoderm : GI tract
• Mesoderm : bone, muscle, fat, cartilage
• Ectoderm : skin and appendage, brain
Teratoma
Mature teratoma
• Divided to 3 categories
- mature teratoma (benign)
- immature teratoma (malignant)
- monodermal or specialized teratoma
• Most are cystic and known as
“Dermoid cyst” or “Mature cystic teratoma”
• Bilateral 10-15% of cases
• 1% of dermoid cyst have malignant
change of any components
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Dermoid cyst
Dermoid cyst
• Gross : unilocular cyst contains hair, tooth,
and cheesy sebaceous materials
Dermoid cyst
• Microscopic :
- cyst wall is squamous epithelium with
sebaceous glands, hair shafts
- other germ layers : cartilage, bone, brain,
fat, thyroid tissue, GI epithelium etc.
Krukenberg tumor
• Metastatic GI tumor to ovary, most
often from stomach
• Often bilateral metastasis
Krukenberg tumor
• Gross: multiple masses in both ovaries
• Micro: mucin-producing signet ring cells
Female breast disease
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Acute mastitis
Fibrocystic change
Fibroadenoma
Invasive ductal carcinoma
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Female breast
Normal breast
• Ducts and lobules lined by two cell types
• Myoepithelial cells lies on basement
membrane and luminal epithelial cells lines
lumens
• Luminal epithelial cells produce milk
Acute mastitis
Clinical presentations of breast disease
• Pain
• Palpable mass
• Nipple discharge or skin discharge
Fibrocystic change
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Occur during lactation
Cracks and fissures in nipples
Usually Staphylococcus aureus
Erythematous painful breast, usually
accompanied by fever
• If not treated, infection may spread to
entire breast
Fibrocystic changes
• Related hormonal fluctuation
• Clinical : breast pain, lump with firm breast
• There are three principal patterns of
morphologic change:
1. Cyst formation, often apocrine cyst
2. Fibrosis
3. Adenosis
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Fibrosis
• Cysts frequently rupture, with release of
secretory material into adjacent stroma
• Resulting chronic inflammation and fibrous
scarring contribute to palpable firmness of
breast
Fibroadenoma
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Most common benign tumor of breast
More common before age 30
Frequently multiple mass and bilateral
Cure by excision
Rare carcinoma arising in it
Fibroadenoma
Adenosis
• Increase in number of acini per lobule
• Often enlarged acini
• May be calcifications
Fibroadenoma
• Gross: well-circumscribed, rubbery, gray
white mass, variable in size
Carcinoma of breast
• Risk factors
– Age
– Age at menarche
– Age at first live birth
– First-degree relatives with breast cancer
– Estrogen exposure
– Breast-feeding
– Environment toxins
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Carcinoma of breast
• Risk factors
– Breast density
– Radiation exposure
– Carcinoma of contralateral breast or
endometrium
– Diet
– Obesity
– Exercise
– Genetic
Invasive ductal carcinoma
Invasive ductal carcinoma
• Almost presents as a palpable mass
• More 50% of case have axillary lymph
node metastases
• Larger carcinomas may be fixed to chest
wall or cause dimpling of the skin
Prognosis and predictive factors
• Major prognostic factors
firm to hard, gray-white mass
with irregular border
– Invasive carcinoma
– Distant metastases
– Lymph node metastases
– Tumor size
– Locally advanced disease
– Inflammatory carcinoma
Ectopic pregnancy
• การตั้งครรภนอกมดลูก
• พบบอยที่ทอนําไข “Tubal pregnancy”
• ปจจัยเสี่ยง
- PID
- การใสหวงคุมกําเนิด (intrauterine device)
• มักมีการแทงภายในอายุครรภ 3 เดือน
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Hydatidiform mole
• Classified 2 type
- complete hydatidiform mole
- partial hydatidiform mole
Partial hydatidiform mole
• Triploid karyotype from egg and sperm
• Presence of fetal part
Complete hydatidiform mole
• Diploid karyotype from only sperm
• No fetal part
Feature
Complete Mole
Partial Mole
Karyotype
Diploid
Triploid
(46XX, 46XY)
(69xxx, 69xxy)
Villous edema
All villi
Some villi
Trophoblast
Diffuse;
Focal; slight
proliferation
circumferential
Atypia
Often present
Absent
Serum hCG
Elevated
Less elevated
HCG in tissue
++++
+
Behavior
2%
Rare
choriocarcinoma
choriocarcinoma
Gynecomastia
Male disease
• Enlargement of male breast
• Presents as a subareolar enlargement
• Imbalance between estrogen, which
stimulate breast tissue, and androgens
• Condition of elevated estrogen :
- cirrhosis of the liver
- increase in adrenal estrogen
- drugs : alcohol, heroin, steroid
- functioning testicular tumor
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Gynecomastia
Gynecomastia
Normal
Paraffinoma of penis
• Injection foreign body (paraffin) to penis
result as enlarged penis
• Inflammation or abscess of penis
Carcinoma of penis
Carcinoma of penis
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Most of squamous cell carcinoma
Occurs in 40-70 years
Clinical : mass, ulcer at penis
Risk factor : smoking and HPV infection
(type 16, 18)
Seminoma
• Germ cell tumor of testis
• Occurs in 20-30 years
• Predisposing factors:
- cryptorchidism (undescended testis)
- genetic factor
• Clinical : testicular mass
• Radiosensitive
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Seminoma
Benign prostate hyperplasia (BPH)
• Common in > 50 year
• Hyperplasia of prostate gland result as
enlarged prostate Æ compress urethra
cause to obstruction
• Clinical : urinary retention, frequency, flow
dribbling, dysuria, urinary infection
Benign prostate hyperplasia (BPH)
Prostate carcinoma
• Most of adenocarcinoma
• Common in old men
• Increase level of serum PSA (prostate
specific antigen)
• Localized cancer : no symptom
• Advance cancer : dysuria, hematuria,
back pain (bone metastasis)
Prostate carcinoma
THE END
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