The Female Genital Tract

Dr. Senani Williams

Dept. of Pathology
Faculty of Medicine
University of Kelaniya

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Female Genital Tract

 Vulva, Vagina and Cervix

 Endometrium, Myometrium and
Fallopian tubes
 Ovarian tumours
 Placental and trophoblastic
diseases

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Vulva, Vagina and Cervix
 Vulva
 Normal hair bearing skin
 psoriasis
 eczema

 allergic dermatitis

 epidermal inclusion cysts

 non specific vulvitis

 uraemia, blood dyscrasias,

diabetes mellitus, malnutrition,
avitaminosis

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Vulva contd.
 Vulval skin is exposed to
moisture.
 Therefore it’s more prone to
infections.
 Eg. Bartholin’s cysts

 Bartholin’s abscesses
 Vestibular adenitis

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Vulvar dystrophy
 Presents as
“leukoplakia”
 May be benign

premalignant

malignant

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Causes of vulvar leukoplakia
 Vitiligo
 Inflammatory dermatoses -
psoriasis, chronic dermatitis
 Carcinoma in situ - Paget’s
disease, invasive carcinoma
 Other non specific changes

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Non specific vulvar dystrophy
 2 types
 lichen sclerosus

 squamous hyperplasia

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Vulval tumours
 Benign
 Malignant

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Benign vulval tumours
 Fibromas  Hidradenoma
 Neurofibromas  Condyloma
 Angiomas acuminatum

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3 Benign Wart like Conditions
 Condyloma
acuminatum
 Venereal

wart
 HPV-STD

 Histo.
Cytopathic
effect

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Benign wart like conditions
 Mucosal polyp

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Benign wart like condition
 Syphilitic
condyloma
latum

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Malignant Tumours of the Vulva
 Uncommon
 2/3 occur >60 yrs.
 85% squamous carcinoma
 15% - Basal cell carcinoma
 Malignant Melanoma

 Adenocarcinoma

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Vulval Carcinoma
 2 specific groups - cause

pathogenesis
 presentation

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Associated with Papilloma virus
 HPV 16 & 18
 Precancerous change (VIN)

Carcinoma in situ
 Bowen’s
disease
 Poorly differentiated

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Associated with dystrophy
 Squamous carcinoma
 Begins as “leukoplakia

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Extramammary Paget’s disease
 Large anaplastic
cells
 May not invade
for yrs.

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Vulval Intraepithelial Neoplasia
 Nuclear atypia
 Increased
mitoses
 Lack of surface
differentiation

 Graded
according to
severity of
atypia

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Malignant Melanoma
 2% of all
melanomas
 Survival < 32%
 >60% mortality
for invasion
>1mm

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Vagina
 Rarely involved in disease
processes
 Congenital abnormalities
 Absent/double vagina rare

 Vestigial structures -

Gartner’s cysts

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Vaginal tumours
 Benign
 rhabdomyoma

 leiomyoma

 haemangioma

 Malignant

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Vaginal tumours
 VIN & Squamous carcinoma -
very uncommon
 95% squamous carcinoma
 Incidence 60 - 70 yrs.
 Presentation - leukorrhoea /
irregular spotting

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Vaginal tumours
 Risk Factors
 Carcinoma of cervix or vulvar

 Multicentric squamous

neoplasia
 HPV infection

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Spread of Vaginal tumours
 Direct
 Cervix

 urethra

 bladder

 rectum

 Lymphatic
 Lower 2/3 - inguinal lymph nodes
 Upper 1/3 - iliac

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Adenocarcinoma of Vagina
 Occurs in children
 In mothers treated with
Stilboestrol for threatened
abortion.
 Presents at 15 to 20 yrs.

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Embryonal Rhabdomyosarcoma
 Sarcoma Botryoides
 Very uncommon
 Occurs in infants and children
<5 yrs
 Causes death by invasion of
GUT.

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CERVIX
 Target for infections
 Target for carcinogens
 Carcinoma causes 5% of
deaths in women.

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Infections
 Acute
 Chronic
 Organisms - gonorrhoea,
chlamydia, mycoplasma, herpes
II

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Cervical infections
 Menarche  Squamous
 Increased metaplasia
oestrogens  Reduced pH
 Increased  Increased
vaginal bacterial growth
glycogen

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CIN & Invasive Neoplasia
 Risk factors
 Early age at first intercourse

 Multiple sexual partners

 Male partner with multiple previous

partners

 Potential Risk factors

 smoking, parity, family history, genital
infections, circumcision of male partners

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HPV - STD & Carcinogenesis
 HPVDNA detected in 85% of CA
cervix.
 HPV type 16,18,31,32 high risk.
 HPVtransforms culture cells by
E6,E7 oncogenes.
 E6, E7 oncoproteins accelerate
p53 gene degradation.

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CERVICAL INTRAEPITHELIAL
NEOPLASIA

 CIN ALMOST ALWAYS begins

at the squamo-columnar junction
 3 grades.
 CIN I - epithelium exhibits viral
cytopathic effect.

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CIN
 CIN II
 Atypical cells in lower epithelial cells.
 Abnormal differentiation.
 Increased mitotic figures
 Variation in nuclear:cytoplasmic ratio
 Loss of polarity
 Hyperchromasia

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CIN III
 Total
replacement of
epithelium by
immature cells.
 No surface
differentiation

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SQUAMOUS CELL CARCINOMA

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Squamous cell carcinoma
 Peak 40 - 45 yrs
 30 yrs precancerous
 Presentation - leukorrhoea,
postcoital bleeding, pain, dysuria
 3 patterns
 fungating - most common

 ulcerative

 infiltrative

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Spread of CA Cervix
 Direct - peritoneum
 bladder
 rectum
 vagina
 Metastases - lungs
 bone marrow

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Squamous CA of Cervix
3 types
 Large cell
keratinizing

 Well
differentiated

 95%

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Squamous CA of Cervix
 Large cell non
keratinizing

 Moderately
differentiated

 5%

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Squamous Carcinoma of Cervix
 Small cell
 neuroendocri

ne
 oat cell - poor

prognosis

 Poorly
differentiated
 5%

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Screening for CA Cx
 Papanicolaou smear - exfoliative
cytology
 CIN - white patches with acetic
acid at colposcopy

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Staging of CA Cx
 I - confined to Cervix
 II - beyond cervix but not the pelvic
wall
 CA involves vagina but not lower
1/3
 III - invades pelvic wall
 involves lower 1/3 of vagina
 IV - CA beyond pelvis / mucosa of
bladder/rectum

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PROGNOSIS WITH TREATMENT
 Stage I - 80 - 95% 5 yr survival
 II - 75%
 III - 35%
 IV - 10 - 15%
 Cause of death - GUT
involvement
 pyelonephritis

 uraemia

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