4. VULVA
• Synonymous with EXTERNAL genitalia
• Everything ANTERIOR to the INTROITUS
• Usual classification of Degen., Inflam.,
Neopl.
• Common Diseases:
– BARTHOLIN Cyst
– Vulvar Vestibulitis
– Deg./Inflam. Epithelial: LICHEN diseases
– BENIGN tumors: Condyloma(ta)
– MALIGNANT tumors: VIN, SCC 4
4
5. Result from
Inflammation/Obstruction
of the Bartholin glands
(i.e., greater vestibular
glands)
Often result in abscesses
Surgical removal is
curative when local
procedures are
inadequate or often
recurrent
NEVER become
malignant
5
5
21. VAGINITIS
• 90%
• Bacterial Vaginitis is the most common cause of vaginitis,
accounting for 50% of vaginitis cases. As previously mentioned, BV is
caused by an overgrowth of organisms such as Gardnerella vaginalis
(gram-variable coccobacillus), Mobiluncus species, Mycoplasma
hominis, and Peptostreptococcus species. Risk factors include
pregnancy, intrauterine device (IUD) use, and frequent douching.
• Candida species (C albicans, C tropicalis, and C glabrata) are
airborne fungi that are natural inhabitants of the vagina in as many as
50% of women, and vaginal candidiasis is the second most common
cause of vaginitis. Risk factors include oral contraceptive use, IUD use,
young age at first intercourse, increased frequency of intercourse,
receptive cunnilingus, diabetes, HIV or other immunocompromised
states, chronic antibiotic use, and pregnancy.
• T. vaginalis infection, the third most common cause of vaginitis, is
caused by trichomonads. These organisms are flagellated protozoans.
Trichomonads primarily infect vaginal epithelium, and they less
commonly infect the endocervix, urethra, and Bartholin and Skene
glands. Trichomonads are transmitted sexually and can be identified in
as many as 80% of male partners of infected women. Risk factors
include tobacco use, unprotected intercourse with multiple sexual
partners, and the use of an IUD.
21
21
49. Cervical Intraepithelial Neoplasia (CIN)
• Precursor to carcinoma
• Almost all carcinomas arise in CIN; but not all cases
of CIN progress to carcinoma!
• Three grades:
• CIN I: mild dysplasia (half regress, 20% progress)
• CIN II: moderate dysplasia
• CIN III: severe dysplasia (30% regress, 70% progress)
• The higher the grade, the more likely the lesion will
progress to carcinoma
49
49
51. Cervical Carcinoma
• Once the most common cancer in women –
now not even in top 10.
• Decrease due to Pap test!
• At the same time, precursor lesions are
increasing (early detection)
51
51
52. Invasive Cervical Carcinoma
• Most cases are squamous, arising from CIN
• Small number are adenocarcinomas
• Peak age: 45 (10-15 years after CIN develops!)
• Spreads slowly
• Most cases are diagnosed early
• Mortality is related to stage:
• stage 0 (preinvasive): 100% 5 year survival
• stage 4: 10% 5 year survival
52
52
56. Cervical Carcinoma Risk Factors
• Early age at first intercourse
• Multiple sexual partners
• A male partner with multiple previous partners
• Persistent infection with “high-risk” HPV
• Smoking
• Immunodeficiency
56
56
57. Cervical Carcinoma and HPV
• HPV is detectable in almost all CIN and cancer.
• “High-risk” types:
• 16, 18, 45, 31
• Found in carcinomas
• Integrate into genome, inactivate p53, RB
• “Low-risk” types:
• 6,11
• Found in condylomas (benign lesions)
• Do not integrate into genome
57
57
66. ENDOMETRIOSIS
Defined as normal endometrial glands OUTSIDE
the confines of the myometrium
Reverse menstruation vs. Embryologic “rest”
theories
EXTREMELY common cause of cyclical
abdominal/pelvic pain
Broad Ligament, Ovary (“chocolate cysts”),
Peritoneum, Bowel, Umbilicus
66
66
71. Endometrial Hyperplasia
• Proliferation of endometrium due to estrogen excess
• Risk factors: anovulatory cycles, obesity, estrogen-
producing ovarian tumors, exogenous hormone use
• Three categories: simple, complex, and atypical
• The more severe the hyperplasia, the greater the
chance that it will evolve into carcinoma
71
71
80. Leiomyosarcoma
• Malignant tumor of smooth muscle
• Necrotic, with atypical cells and lots of mitoses
• Often recur after surgery
• Many metastasize, especially to lungs
• 5 year survival = 40%
80
80
128. Ovarian Cancer
• 23,000 new cases / 15,000 deaths in 2007
• 5th commonest, 5th most deadly cancer in women
• Danger: no definitive signs until advanced
• Peak age: 50
• Most are cystadenocarcinomas
128
128
131. Ovarian Cancer
Symptoms
• feeling of fullness or bloating
• pelvic pain
• back pain
• abnormal menses
Risk factors
• nulliparity
• family history (BRCA gene mutation)
• NOT using oral contraceptives!
131
131
132. Ovarian Cancer
• Treatment: surgery, radiation, chemotherapy
• Prognosis depends on stage
• cancer confined to the ovary: 5y survival 70%
• cancer through ovarian capsule: 5y survival 13%
132
132
134. OVARIAN TUMORS
• Solid vs. Cystic
• Functional vs. NON-functional
• Benign vs. Malignant
• First clinical presentation may be ascites
• Malignant ascites in a woman is ovarian
cancer until proven otherwise
• CA-125 is THE important tumor marker in
ovarian cancer, especially as a follow up.
134
134
143. “GERM CELL” Tumors
• Teratomas (usually benign in ovary), i.e.,
“mature” cystic teratoma or dermoid cyst
• “Immature” teratomas are regarded as
malignant
• Dysgerminoma (look exactly like the
testicular seminoma), malignant
• Endodermal Sinus (Yolk Sac),
malignant, Just like testicular
• Choriocarcinoma, malignant, just like
testicular 143
143
158. Ectopic Pregnancy
• Chiefly TUBAL, but ovarian or
abdominal rare
•1% OF NORMAL WOMEN
•35%-50% OF WOMEN with
previous SALPINGITIS/PID
• + HCG, Abdominal pain, 1st
trimester, ultrasound 158
158
171. Placental Infections
• Villitis vs. chorionamnionitis vs. funisitis
• ASCENDING vs. hematogenous
• ASCENDING are usually bacterial, and
chorionamnionitis
• Hematogenous are often TORCH, and
villitis
171
171
172. Placental Neoplasms,
i.e. gestational trophoblastic disease
• Benign: MOLES (Hydatidiform moles)
• Malignant: CHORIOCARCINOMA
• BOTH are associated with increased or
persistent levels of the placental
hormone HCG
172
172
174. Hydatidiform Mole
• 1/1000 in USA
• 1% in Indonesia
• Also called NON-invasive mole in
its most common benign variant,
but can also be “invasive”
• Complete (2% chorioCA incidence)
or partial (0% incidence)
• Grapelike clusters, i.e., swollen villi
174
174
179. Breast
• Many breast diseases present as lumps
• Most lumps represent benign things…
• …but a lump always needs to be evaluated
• Ultrasound, mammography, fine needle
aspiration, and biopsy are the usual methods
179
179
181. Fibrocystic Change
• Two kinds: nonproliferative and proliferative change
• Cause: exaggeration of normal breast cycles
• Rarely associated with increased cancer risk
• Very common (present in most women at autopsy)
• Called fibrocystic change, not fibrocystic disease
181
181
182. Fibrocystic Change
• Nonproliferative fibrocystic change
• increased stroma
• dilation of ducts, formation of cysts
• Proliferative fibrocystic change
• hyperplasia of breast epithelium
• If epithelium shows atypia, 5x ↑ risk of cancer
182
182
187. Fibroadenoma
• Most common benign breast tumor
• Stimulated by estrogen
• Peak incidence 20s
• Solitary, discrete, moveable mass
• Fibrous tissue with compressed ducts and lobules
187
187
190. Breast Carcinoma
• 180,00 new cases / 40,000 deaths in 2007
• Most common, 2nd deadliest cancer in women
• Lifetime risk: 1 in 8
• 75% of patients are >50
• Rate was increasing but now stable
190
190
191. Breast Carcinoma Risk Factors
• Age
• Family history
• Increased estrogen exposure
• Obesity
• Alcohol consumption
• High-fat diet
191
191
192. Breast Carcinoma Family History
• 5-10% of all cases are hereditary
• Worry if first degree relative with breast cancer
• Most have BRCA-1 or BRCA-2 mutations
• Tumor suppressor genes; help repair DNA
• Genetic testing difficult
• Most carriers get cancer by age 70
192
192
193. Breast Carcinoma Clinical Findings
If discovered by palpation
• Solitary, painless, moveable mass
• 2-3 cm in diameter
• Axillary nodes positive in 50% of patients
If discovered by mammography
• 1 cm in size
• Axillary nodes positive in only 15% of patients
As disease progresses
• Fixation to chest wall
• Adherence to overlying skin
• Peau d’orange
193
193
208. Overall stage
Stage 0
Stage I
Stage II
Stage III
Stage IV
TNM staging system for breast cancer
T
DCIS
<2 cm
<5 cm
>5 cm
<5 cm
>5 cm
Any T
Any T
Any T
N
0
0
<3
0
4+
1+
10+
Any N
Any N
M
M0
M0
M0
M0
M0
M0
M0
skin or
chest wall
M1
5y survival
92%
87%
75%
46%
13%
208
208