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Female Reproductive System
Monserrat S. Chichioco, MD, FPSP

Infections of the lower genital tract:
- Most are sexually transmitted
- Candida (curdlike extremely pruritic), Trichomonas (fishy
odor), Gardnerella (thin, green-gray, fishy odor) are extremely
common causes significant discomfort, no serious sequelae
- Neisseria gonorrhoea and chlamydia are major causes of
infertility
- Ureaplasma, mycoplasma are implicated in pre-term deliveries

PID
- Ascending infection originates from vulva or vagina and
spread upward
- Pelvic pain, adnexal tenderness, fever, vaginal discharge
- Gonococcus and chlamydia are common causes, spread
upward from mucosal surfaces to involve fallopian tubes
and tubo-ovarian region
- Puerperal infections are polymicrobial staph, strep,
coliforms, Clostridium perfringens, spread from the uterus
upward through the lymphatics or venous channels
complication of deliveries, abortion septicaemia
Morphology
- Acute suppurative salpingitis formation of lymphoid
follicles
- Salpingooophoritis
- Tubo-ovarian abscesses
- Pyosalpinx
- Chronic follicular salpingitis
- Hydrosalpinx
Complications
- Acute complications:
- Sequelae:
o Infertility
o Tubal obstruction
o Inc risk of ectopic pregnancy
o Pelvic pain
o Intestinal obstruction due to adhesion serositis
of the bowel

VULVA
- Bartholin cyst most common lesion, result from
obstruction of duct
- Cyst may reach 3-5 cm
- Lining epithelium is squamous metaplastic ductal
epithelium
- May produce pain and local discomfort
- May be excised or opened permanently marsupialization
Non-neoplastic Epithelial disorders
- Lesions may present w/ opaque, white, plaquelike-
mucosal thickening
- May produce itching and scaling
- Lesions include:
o Inflammatory dermatosis psoriasis, chronic
dermatitis
o Lichen sclerosus and squamous cell hyperplasia
are disorders of unknown etiology
o VIN is a pre-malignant lesion (vulvar
intraepithelial neoplasia)
Lichen Sclerosus
- Thinning of epidermis
- Disappearance of rete pegs
- Hydrophic degeneration of basal cells
- Superficial hyperkeratosis
- Dermal fibrosis
- Scant perivascular, mononuclear infiltrates
- Common in post-menopausal women
- Gross lesion
o Smooth, white plaques or papules that may
extend or coalesce
o Atrophied and stiffened labia
o Constriction of vaginal orifice
- Consequence:
o Inc chance of developing Ca

Squamous cell hyperplasia
- Lichen simplex chronicus
- Results from rubbing or scratching of the skin to relieve
pruritus
- Appears clinically as an area of luekoplakia
- Epithelial thickening
- Expansion of stratum granulosum
- Surface hyperkeratosis
- Leukocytic infiltration in the dermin
- No predisposition to cancer

Condyloma acuminatum
- Sexually transmitted
- Verrucous or warty appearance
- Papillary cores of stroma covered by hyperplastic
epithelium
- With viral cytopathic effect referred to as koilocytotic
atypia
- Not a precancerous lesion
- Associated w/ HPV 6 and 11

VIN and Vulvar Ca
- Basaloid and wart vulvar Cas develop from pre-cancerous
in situ lesion VIN (analogous to cervix SIL)
- VIN nuclear atypia, increased mitosis, lack of cellular
maturation, frequently multicentric
- HPV 16, less frequently HPV 18 or 31
- Risk of developing ca is related to age, extent and immune
status
- Dysplastic epithelium pare-parehong mukhang basal
cells

Extramammary Pagets disease
- Pruritic, red, crusted sharply demarcated, map-like lesion
usually on the labia majora
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- Hallmark: Intraepithelial proliferation of malignant cells
w/c are PAS positive
- Treated w/ wide local excision
- Has high recurrence rate, rarely invasive, may persist for
so many years

Pre-malignant and malignant lesions of vagina
- Vaginal intraepithelial neoplasia is similar to cervical SIL
- SCCa arise from premalignant lesion vagina intraepithelial
neoplasia
o Affects upper post part of vagina at the junction
w/ the ectocervix
- Embryonal rhabdomyosarcoma is an uncommon vaginal
tumor frequently found in infant and children below 5 y/o:
MC sarcoma w/c involves vagina
o Polypoid bulky masses that projects out of the
vagina
o Small round tumor cells w/ oval nuclei and
racket shaped cytoplasm w/c crowd beneath
epithelium forming a cambium layer
o Death is caused by penetration into peritoneal
cavity or obstruction of urinary tract

Cervix
- Acute and chronic cervicitis
o Gonococci, chlamydiae, mycoplasma, HSV
- Endocervical polyps
o Exophytic growth arising within the endocervical
canal
o Soft, mucoid lesions, may cause vaginal spotting
o Excision or curettage effect cure
- Pre-malignant lesion CIN/SIL
o Associated w/ 15 high oncogenic risk viruses, 16
and 18 are most important
o Virurses infect only immature squamous cells
but replication occur in maturing cells
koilocyotic atypia
- Cervical ca
o SCC is the MC histologic type of cervical ca
o Keratinizing and non-keratinizing types
- SIL 1 low grade
- SIL 2, 3, 4 high grade

Staging Cervical CA
- Stage 0 CA in situ, CIN III, HSIL no tendency for
metastasis
- Stage 1 Confined to cervix
o Pre-clinical dxed by microscopy
o Stromal invasion no deeper than 3 mm and not
wider than 7 mm (microinvasive CA)
o Invasion beyond 3 mm but not deeper than 5 mm
o Invasive CA confined to cervix greater than 1a2
- Stage II extend beyond cervix but not pelvic wall, involve
vagina but not lower 3
rd

- Stage III extend beyond pelvic wall, no cancer free space
between tumor and pelvic wall, involves lower 3
rd
vagina
- Stage IV beyond true pelvis, involve mucosa of bladder
or rectum, metastasis to other organs
- Pelvic LN external iliac, internal iliac, obturator

Endometrium
- Functional endometrial disorders
- Inflammation
- endometrial hyperplasia
- Endometrial polyps
*MC symptom uterine bleeding

Dysfunctional uterine bleeding
- Not caused by any underlying organic abnormally
- Most common causes:
o Anovulatory cycles metabolic disorder
Prolonged estrogenic stimulation
Endocrine disorder
Functioning ovarian disorder
Generalized metabo0lic
disorder
o Inadequate luteal phase
Low progesterone output
o Menopausal and post menopausal changes
Anovulatory cycles
- Granulosa cell tumor secrete estrogen
- Obesity inc steroid hormones

** Several Patterns of Bleeding (Read)

Endometrial hyperplasia
- Thickened endometrial mucosal folds
- Inc gland to stromal ration
- Associated w/ prolonged estrogen stimulation
(endogenous or exogenous)
- MC pattern: cystic hyperplasia
- Divided into: simple and complex; w/ or w/out atypia
(Read)
- Simple tubular or cystic
- Complex budding of glands, back to back pattern of
glands, intraluminal spiking
Endometrial carcinoma
- Type 1 ca endometrioid pattern
o G1 well diff CA less than 5% solid growth
o G2 mod diff CA with less than 50% solid growth
o G3 predominantly solid pattern of growth (>50%)
- 20% contain squamous differentiation
- Type 2 tumors less common
- Serous pattern is the MC subtype

Uterine corpus (body)
- Leiomyomas stroma tumor composed of smooth muscle
cells
- Spherical
o Intramural
o Subserosal
o Submucosal
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- Never develop into malignancy, very rare
- Multiple: leiomyomatosis

Leiomyosarcoma
- Well-circumscribed w/ characteristic areas of hemorrhages
- Spindle shaped tumors since derived from muscles
- Abnormal giant cells, very pleomorphic
- Hematogenous -- sarcoma

Ovary
- Tumor of surface epithelium
o Serous lining epithelium is cuboidal cells
cauliflower growth of inner lining
o Mucinous - MC lined by columnar cells usu
malignant
o Endometrioid resemble endometrial ca

Germ Cell Tumor
- Teratoma derived from all 3 germ cell layers: MC
malignant component is squamous
- Dysgerminoma infiltrates of lymphocytes

Endometroma/endommetriotic cyst
- Endometrial cysts found elsewhere
- Cystic: chocolate cysts cavity contains old blood
- Not a tumor
- Results from accumulation of menstrual material