2 - Disease of Vulva, Vagina, and Cervix

What is this, and what does it indicate?

A slit-like external os, a sign that the cervix has been stretched by a vaginal delivery

Types of cells lining different parts of the cervix/vagina

1. Ectocervix and vagina: Non-keratinized stratified squamous epithelium

2. Endocervix: Simple columnar epithelium

What is the SCJ, and what are it’s cells?

SCJ is the squamocolumnar junction where the squamous epithelium meets the columnar epithelium

• It’s cells are SCJ cells, cuboidal cells believed to be stem cells

What is squamous metaplasia, and is it malignant?

It is a condition where columnar epithelium of the endocervical canal becomes squamous epithelium

• It isn’t malignant, it’s a normal thing

What is a hymen, and what’s the most concerning type, and why?

A hymen is a fold of mucous membrane at the entrance of the vagina, and the most concerning type is an imperforate hymen because this is where the hymen doesn’t open(which it should), and blood gets trapped in it

Typical presentation of an imperforate hymen

A teen girl with primary amenorrhea but normal puberty and normal period cramps

Main normal flora of the vagina

Lactobacillus

Is the vaginal pH basic or acidic, and why?

It’s acidic due to lactobacilli fermenting glycogen

What is this condition?

Bartholin’s cyst

Where are the Bartholin glands located?

4 and 8 o clock of the vaginal opening

Bartholin’s cyst

• How it happens

• Clinical presentation

• When the gland’s duct gets blocked → mucus builds up and forms a cyst

• Asymptomatic soft lump at the lower part of one labium, noticed by chance

  • If painful, it’s likely become infected, forming an abscess

What is this condition?

Lichen sclerosus(LSA)

Lichen sclerosus

• How it happens

• Clinical presentation

• Unknown, thought to be autoimmune

• Itching, worse at night, and shows up as whiter/shiny/film-like skin around the vulva and anus.

  • Can progress to SCC

What is this condition?

Hidradenoma papilliferum

Hidradenoma papilliferum

• What is it?

• Clinical presentation

• An appendage tumor(from structures growing down into dermis) that occurs at the vulva, forming a small, benign lump

• Asymptomatic, a small lump found on accident

What is this condition?

Nabothian cyst

Nabothian cyst

• What is it?

• Clinical presentation

• Associated with ___

• Benign cyst of endocervical glands, often seen on the ectocervix

• Nothing, found by chance

• Squamous metaplasia

What is this condition?

Endocervical polyp

Endocervical polyp

• What is it?

• Clinical presentation

• A benign growth of the lining of the endocervical canal that often pops through the external os

• Often no symptoms, sometimes bleeding

Most common malignant neoplasm of the vulva, vagina, and cervix

Squamous cell carcinoma

What is this condition?

Malignant melanoma

Malignant melanoma

• Cell of origin

• Location

• What is it?

• Cancer of melanocytes

• Mostly vulva, sometimes vagina

• A malignant neoplasm where melanocytes acquire mutations and divide uncontrollably

Malignant melanoma

• Typical symptoms

• Typical demographic

• Relation to UV light

• Bleeding, itching, lump, sometimes pain

• Older women

• No strong relation

What is this condition?

Paget disease of vulva

Paget disease of vulva

• What is it?

• Causes

• Demographic

• Clinical presentation

• An adenocarcinoma involving abnormal glandular cells living in the epidermis called Paget cells

• Primary(unknown cause) or secondary(Adenocarcinomas at the urothelial or anorectal areas)

• Older women, 60-70

• Chronic itching, red, moist plaque with white patches(Strawberries and cream)

What is this condition?

Embryonal rhabdomyosarcoma

Embryonal rhabdomyosarcoma

• What is it?

• Clinical presentation

• Demographic

• A malignant tumor of mesenchymal cells resembling immature skeletal muscle cells

• A tumor looking like “a bunch of grapes” found in girls under 5 with bleeding and a soft, grape-like mass protruding from the vaginal opening

• Girls under 5, mostly in the first 2y

HPV

• Stands for

• What cells does it infect?

• How does it spread?

• Human papillomavirus

• Squamous epithelium

• Skin to skin and sexual contact

HPV main types

• High risk: Can cause cancer, 16, 18

• Low risk: Rarely causes cancers, causes warts instead(หูดหงอนไก่), 6, 11

Which epithelial cells does HPV want, and why?

Basal cells, because these replicate

Which cancer is 95% HPV related, and at which spot?

Cervical, specifically due to the SCJ

What is a gateway to SCC in older women that isn’t HPV?

Lichen sclerosus

SIL, LSIL, HSIL

SIL = squamous intraepithelial lesion, aka when HPV has infected squamous epithelium, but it’s still confined to the epithelium

• LSIL: The virus replicates on it’s own(DNA stable) without inserting itself into the pt.’s chromosomes, most go away on their own, 70% caused by high-risk type HPV

• HSIL: The virus now takes over the epithelium fully, the viral DNA is now inserted/integrated into patient’s chromosomes, 90% caused by high-risk type HPV, can progress to SCC

What grades of vulvar, vaginal, and cervical intraepithelial neoplasia(VIN, VaIN, and CIN) fit with LSIL and HSIL?

• Grade 1 VIN, VaIN, CIN = LSIL

• Grade 2-3 VIN, VaIN, CIN = HSIL

What is this cell, and how do we know, and what is it associated with?

Koilocyte

• Clear halo, two nuclei, wrinkled nuclei

• HPV infection, mostly LSIL

Where would we find adenocarcinoma: Cervix, vagina, or vulva, and why?

Cervix, because the other parts don’t have any glandular tissues(Except bartholin glands etc at the vulva)

Cervical adenocarcinoma

• HPV associated or not?

• Yes, around 85-90% while SCC is basically 100%

What area do screening tests sample for HPV, and why?

Transformation zone, the band where glandular endocervix has been replacd via squamous metaplasia to become squamous ectocervix tissue due to estrogen effect

SCC symptoms

Cervix: Abnormal bleeding, a cauliflower-like mass

Vagina: Bleeding, mass on examination

Vulva: A lump that won’t heal, itching(especially w lichen sclerosus), bleeding

Main screening tests for cervical CA

1. HPV testing: For high-risk HPV, tells us about risk

2. Cervical cytology: Tests cells appearance to see if they’re like LSIL, HSIL, or other abnormalities

3. Visual inspection with acetic acid(VIA): Using vinegar to the cervix to see if any areas turn white(those are abnormal)