patho II exam #6

female differentiation

- needs estrogen

- occurs in the absence of SRY gene expression

- requires the presence of estrogen and absence of testosterone to cause regression of the wolffian system

two female gonads develop into ovaries during what week of gestation

between 6-8 weeks

what occurs during the 10th week of female gestation

loss of wolffian ducts allows the mullerian ducts to join and become the uterus, fallopian tubes, cervix, and upper 2 thirds of vagina

female puberty

- begins at approx 8-9 yo with breast development

- obese girls mature earlier (higher estrogen due to leptin)

- ovaries begin to release mature ova

hormones involved in female puberty

- hypothalamic pituitary gonadal axis, CNS, and endo system

- estradiol: breast development; vagina, uterus, ovarian maturation; fat deposits in hips

- estrogen and increased growth factor production: rapid skeletal growth

when is female puberty complete

first ovulatory menstrual period (capable of reproduction)

mons pubis

fatty layer of tissue over the pubic symphysis

labia majora

two folds of skin that arise at the mons pubis, forming a cleft

labia minora

two smaller, thinner folds of skin that lie within labia majora

clitoris

erectile organ that lies anterior between the labia minora; produces smegma

vestibule components

- introitus: external vaginal opening

- hymen: thin, perforated membrane covering the introitus

- urinary meatus: opening of the urethra

- lesser glands (skene): both sides of meatus

- greater glands (bartholin): both sides of introitus

perineum

subcutaneous tissue lying between the vaginal orifice and anus

vagina

- elastic fibromuscular canal

- 4 layers

- self cleaning: acid base balance, thickness

- contains lactobacillus acidophilus

lactobacillus acidophilus

- harmless resident bacterium that maintains acidic pH of vagina

- condition that causes vaginal pH to rise lowers vaginal defenses against infection

uterus

- hollow, pear shaped organ

- fundus: top of corpus

- corpus: body

- isthmus: narrow portion

- cervix

layers of the uterus

- perimetrium: out serous membrane that covers uterus

- myometrium: thick muscular middle layer; helps childbirth

- endometrium: inner uterine lining

fallopian tubes

- oviducts, uterine tubes

- conduct ova from spaces around ovaries to uterus

- ampulla, or distal third of fallopian tube: usual site of fertilization

ovaries

- female gonads

- primary female reproductive organs

- secrete female sex hormones: estrogen and progesterone

- develop and release female gametes (ova)

- component: medulla (inside), cortex (outside) contains follicles, theca cells, granulosa

ovulation

release of an ovum

ovarian cycle

process of follicular maturation, ovulation, corpus luteum development and corpus luteum degeneration

estrogen types

- estradiol: most potent and plentiful

- estrone: converted from androgens in the ovaries

- estriol: the peripheral metabolite of estradiol and estrone

progesterone

- needs LH

- is the hormone of pregnancy

androgens

- mainly male sex hormones

- are produced in small amounts in women

phases of menstruation

- normally 28 days long

- follicular or proliferative phase (postmenstrual)

- ovulation is the beginning of the luteal or secretory phase (premenstrual)

- if no implantation occurs, then menses begin

female fertility tests determine whether

- the reproductive tract is patent to allow for the passage of ovum and sperm

- ovulation is normal

- the endometrium is responding normally to hormones

- tumors or infections are present in reproductive tissue

menopause

- normal developmental event, marking the end of reproduction

- ceasing of menses

perimenopause

transitional period between reproductive and nonreproductive years

ovarian age changes

- begin to decrease in size at 30 yo, accelerates after 60 yo

- 500000 follicles at onset of puberty, 1000 with menopause

uterine age changes

- thickness of the endometrium is greater

- periods are heavier; menorrhagia (heavy) or metrorrhagia (midcycle) occur

female GU age changes

- ovaries shrink, uterus atrophies, vagina shortens and narrow, loses some elasticity

- lubrication of vagina diminishes and vaginal pH increases (vaginitis)

female aging and cardiovascular changes

- coronary heart disease significantly increases after menopause

- increased risk for metabolic syndrome

- vasomotor flushes

other age changes in females

- emotional stress symptoms due to changing estrogen levels

- skin dryness and wrinkling increases

- alopecia and unwanted facial hair

androgen insensitivity

- female phenotype, despite a male genotype

- testes palpable in the labia majora, inguinal ring, or abdominal cavity

- absence of cervix, uterus, and ovaries

delayed puberty

- secondary sex characteristics have not appeared in girls by 13 yo

- no menarche by 15-16 yo

- physiologic factors cause delayed puberty (axis normal, maturation delay)

- some type of disruption of the HPG axis causes delayed puberty

female precocious puberty

- sexual maturation before 8 yo

- partial, complete, mixed (virilization)

- central (GnRH dependent): normal but premature axis, failure of GnRH inhibition

- peripheral (GnRH independent): sex hormones produced by mechanism other than stimulation by the gonadotropins

primary dysmenorrhea

painful menstruation assoc with prostaglandin release in ovulatory cycles

secondary dysmenorrhea

painful menstruation related to pelvic pathologic conditions at any time in the menstrual cycle; occurring later in life

primary amenorrhea

failure of menarche and the absence of menstruation by 14 yo without the development of secondary sex characteristics or by 16 years of age, regardless of the presence or absence of secondary sex characteristics

disorders that cause primary amenorrhea

- of the outflow tract or uterine target organ

- of an ovary

- of the anterior pituitary gland

- of CNS or hypothalamic factors

secondary amenorrhea

absence of menstruation in women who have previously menstruated

secondary amenorrhea causes

- pregnancy (most common)

- anovulation

- dramatic weight loss

- malnutrition or excessive exercise

- thyroid disorders

- hyperprolactinemia

- polycystic ovary syndrome

- common during early adolescence, perimenopause, and lactation

secondary amenorrhea symptoms

- infertility

- vasomotor flushes

- vaginal atrophy

- acne

- osteopenia

- hirsutism

abnormal uterine bleeding

- abnormal bleeding in duration, volume, frequency, present for majority of previous 6 mos

- menstrual irregularity due to lack of ovulation

- irregular bleeding, excessive, or both

structural causes of abnormal uterine bleeding (PALM)

- polyp

- adenomyosis

- leiomyoma

- malignancy and hyperplasia

nonstructural causes of abnormal uterine bleeding (COEIN)

- coagulopathy

- ovulatory dysfunction

- endometrial

- iatrogenic

- not yet classified

PCOS has at least two of these signs

- irregular ovulation

- elevated levels of androgens

- appearance of polycystic ovaries on ultrasound

PCOS

- leading cause of infertility in the U.S.

- assoc with metabolic disorder: excessive androgen, estrogen. insulin resistance

- 3x greater chance of uterine cancer

- dysfunction in ovarian follicle development

- sx: dysfunctional bleeding or amenorrhea, hirsutism, infertility

premenstrual syndrome/premenstrual dysphoric disorder

- cyclic physical, psychologic, or behavioral changes that impair interpersonal relationships or activities

- both occur in luteal (postovulatory) phase

- sx: depression, anger, irritability, fatigue

pelvic inflammatory disease

- acute inflammation caused by infection

- may involve any or all organs of upper reproductive tract (salpingitis, oophoritis)

- STIs migrate from vagina to upper genital tract and cause edema, then obstruction or necrosis

- sx: sudden, severe abdominal pain with fever or no symptoms at all

- can cause infertility or ectopic pregnancies

PID evaluation

- sexually active women who have abdominal or pelvic tenderness and one of the other signs

- cervical motion tenderness

- uterine tenderness

- adnexal tenderness

vaginitis

- infection of the vagina

- irritation: vaginosis

- STIs and candida albicans

- related to alteration in vaginal enviro: skin integrity, immune rxn, pH

- acidic nature of vagina provides some protection

- sx: copious, malodorous, or irritating discharge

cervicitis

- inflammation or infection of the cervix

- mucopurulent cervicitis: caused by more than 1 STI

vulvodynia

- vulvitis, vestibulitis, or vulvovestibulitis

- chronic pain and inflammation of the external genitalia

- causes: soaps, detergents, shaving, tight fitting clothing, vaginal infxns

batholin cyst

- inflammation of one or both ducts that lead from the vaginal opening to the glands

- caused by microorganisms that infect the lower female reproductive tract

- inflammation narrows the distal portion of the ducts, leading to obstruction and stasis of secretion

- sx: cyst may be reddened and painful with pus at opening

pelvic organ prolapse

- endopelvic fascia and perineal muscles support bladder, urethra, rectum

- muscular and fascia tissue loses tone and strength with aging

- one or more descend: vaginal wall, uterus, apex of vagina

- direct trauma (childbirth, surgery, nerve damage) can be cause

enterocele

rectouterine pouch herniates into the rectovaginal septum

benign ovarian cysts

- common

- unilateral

- produced when follicles are stimulated but no dominant follicle develops and reaches maturity

follicular cysts

- dominant follicle fails to rupture, or one or more nondominant fail to regress

- tx: oral contraceptives

corpus luteum cysts

- formed by the granulosa cells left behind after ovulation

- can cause hemorrhage

- tx: oral contraceptives

dermoid cysts

- growths may contain mature tissue (skin, hair, muscle, bone)

- tx: careful eval for removal, have malignant potential

endometrial polyp

- benign mass of endometrial tissue (glands, stoma, blood vessels)

- common cause of intermenstrual or excessive menstrual bleeding

- malignancy is rare

leiomyomas

- myomas or uterine fibroids

- benign tumors of smooth muscle cells in myometrium

- very common

- risk: nulliparity, obese, PCOS, DM, AA, asian, HTN

- sx: abnormal uterine bleeding, pain

adenomyosis

- presence of endometrial tissue within the uterine myometrium

- tissue does not respond to cyclic hormone changes

endometriosis

- functioning endometrial tissue implants outside uterus

- responds to hormone fluctuations of the menstrual cycle

- causes: retrograde men., autoimmune, depressed immune cells tolerate tissue

- sx: infertility, pain, dysmenorrhea, dyschezia (defecation pain), dyspareunia (sex pain)

cervical cancer

- cervical dysplasia

- cervical carcinoma in situ: precursor of invasive carcinoma of cervix

- invasive carcinoma of cervix

- almost exclusively caused by cervical HPV infection

- common in transformation zone of cervix

vaginal cancer

- rarest form

- starts as intraepithelial lesions

- occurs in sexually active women, assoc with HPV

- asymptomatic until fairly late into disease process

- risk: in utero exposure to nonsteroidal estrogens, prior or current cervical cancer

vulvar cancer

- risk: HPV, vagina or cervix squamous dysplasia, smoking, HIV

- sx: chronic vulvar irritation, pruritus, bloody discharge, hard ulcerated area of vulva, large cauliflower lesion

- peak: postmenopausal women

endometrial cancer risk factors

unopposed estrogen exposure, obesity, infertility, failure to ovulate, early menarche or late menopause, tamoxifen

uterine sarcoma

- risk: chronic excess estrogen exposure, tamoxifen, AA

- sx: abnormal uterine bleeding, awareness of mass, pelvis pressure or pain

ovarian cancer

- frequently diagnosed after metastases occurs

- epithelial ovarian neoplasm: loss of tumor suppressor gene and activation of oncogene

- germ cell tumor: derived from primitive germ cells

- sx: vague, persistent abdominal distension, loss of appetite

types of sexual dysfunction

- disorders of desire most common

- vaginismus: involuntary muscle spasm in response to penetration attempt

- anorgasmia: inability to orgasm

- dyspareunia: painful sex

infertility

- the inability to conceive after 1 yr of unprotected sex with same partner

- most common causes include ovulatory factors and tubal blockage

galactorrhea

- inappropriate lactation

- persistent and/or excessive secretion of milky fluid from breasts of woman who is not pregnant or nursing

- primary causes: hormone imbalance, pituitary tumors, neurologic damage

- menstrual abnormalities

nonproliferative breast lesions

- fibrocystic changes

- cysts

proliferative breast lesions without atypia (deviation from normal)

- usual ductal hyperplasia

- sclerosing adenosis

- radial scar: radial sclerosing lesions

- intraductal papillomas

- simple fibroadenoma

proliferative breast lesions with atypica

- abnormal structures are present

- atypical hyperplasia: increase in # of cells with some variation in structure, lacks carcinoma features

except for skin cancer, what is the most common cancer in american women

breast cancer

breast cancer reproductive factors

- younger age when first child born decreases risk

- risk is reduced in parous women compared with nulliparous

breast cancer lobar involution

- with aging, parenchymal elements progressively atrophy and disappear

- is assoc with reduced risk of breast cancer

- delayed involution increases risk

hormonal factors of breast cancer

- ovarian hyperandrogenism/luteal inadequacy hypothesis: Increases risk

- androgen excess: main stimulator of estrogen-receptive positive (ER+) tumors

- hormone replacement therapy (HRT) with estrogen and progesterone in combination: increases risk

- insulinlike growth factor: increases risk

- growth hormone and prolactin: increases risk.

- human chorionic gonadotropin: decreases risk.

extensive breast density

one of the strongest risk factors for developing breast cancer, second to age and carrying BRCA1 or BRCA2 gene

breast cancer environmental factors and lifestyle

- radiation: increases

- diet: fiber, iodine, and soy decrease. fat, red meat increase

- weight and alc: increases risk for postmenopausal

- chemicals: xenoestrogens, synthetic chemicals that mimic actions of estrogens

- physical activity decreases

breast cancer familial factors and tumor related genes

- in first degree relatives, increases risk 2-3x

- most important of dominant genes are BRCA1 and 2

- BRCA1: on chromosome 17

- BRCA2: on chromosome 13

breast cancer patho factors

- tissue based disease with possible abnormal wound healing and inflammatory stroma

- early alterations in stoma occur with wound healing and inflammation

- inflammation causes activation of mesenchymal fibroblasts, endothelial cells, immune cells

- multiple genetic and epigenetic pathways

- components of microenvironment play role in normal duct morphogenesis, major regulators of carcinogenesis

types of breast cancer

- ductal carcinoma in situ: complex, heterogenous group of proliferations limited to breast ducts and lobules w/o invading basement membrane

- lobular carcinoma in citu: originates from the terminal duct-lobular unit

- lobular neoplasia: an atypical lobular hyperplasia (ALH) and LCIS

breast cancer symptoms

- painless lump

- palpable lymph nodes in axilla

- dimpling of skin, nipple

- skin retraction

- nipple discharge

- ulcerations

- reddened skin

gonorrhea

- caused by neisseria gonorrhoeae

- transmission requires contact of epithelial surfaces

- pregnant woman can pass gonorrhea to fetus

- humans are only natural hosts

- presence of pili help it attach to epithelial cells of mucous membranes

gonorrhea common sites

- endocervical canal (inner portion) most common site for women

- urethra

- skene and/or bartholin glands

- urethra or rectum MC for men

gonorrhea female symptoms

- asymptomatic

- dysuria

- increased vaginal discharge

- increased flow or dysmenorrhea

- dyspareunia

- lower abdominal and or pelvic pain

- fever

- mucopurulent discharge from the cervical os

disseminated gonococcal infection

- rare systemic complication brought about by the spread of infection through the bloodstream

- life threatening condition causing a generalized rash and severe joint pain

ophthalmia neonatorum

gonococcal eye infection in an infant from an infected mother

treponema pallidum (syphilis)

- corkscrew shaped, anaerobic bacterium that can not be cultured in vitro

- infects any body tissue

- becomes a systemic disease shortly after infection

- maternal fetal transmission can occur as early as 9 wks

primary syphilis

- from 12 days to 12 weeks after exposure

- avg duration: 3 wks

- granulomatous tissue rxn: hard chancre (eroded, painless, firm, and indurated ulcer)

- microorganisms drain with the lymphatic fluid

- firm, enlarged, and nontender regional lymph nodes

secondary syphilis

- systemic manifestations

- develops 6 wks after 1st appearance of chancre

- low grade fever, malaise, sore throat, hoarseness

- anorexia, generalized adenopathy, headache, joint pain, and skin or mucous membrane lesions/rashes

- condylomata lata: cauliflower like lesions

latent syphilis

- duration: as short as 1 yr or as long as lifetime

- divided into early and late stages

- medical evidence of the infection

- asymptomatic individual

tertiary syphilis

- appearing after the latent stage

- most severe

- formation of gummas: destructive skin, bone, and soft tissue lesions

- destructive systemic manifestations

- neurosyphilis

congenital syphilis

- vasculitis, necrosis, fibrosis, and distribution of T pallidum throughout the tissues

- early and late stages: growth abnormalities, changes in fetal bones, teeth, and neuro system

syphilis tests

venereal disease research laboratory (VDRL) antigen and the rapid plasma reagin (RPR) tests

chancroid

- painful, tender, soft chancre

- acute infectious disease caused by haemophilus ducreyi (gram neg bacillus)

- sx in women: asymptomatic but can have dysuria, dyspareunia, vaginal discharge, pain on defecation, or rectal bleeding

granuloma inguinale (donovanosis)

- chronic, progressive, and destructive bacterial infxn

- cause: klebsiella granulomatis, gram neg non spore forming encapsulated bacteria

- mildly contagious, repeated exposure required

- concurrent infection w/ syphilis is common

- more prevalent in india, new guinea, africa, central australia, carribean, brazil

- donovan bodies: bacteria filled vacuoles within white cells

- sx: painless nodule w itching, ulcers on penis or labia