Detailed Study Notes on Female Genital Diseases

Female Genital Diseases

Diseases of the Vulva

Infectious Vulvitis

• Definition: Inflammation of the vulva due to infectious agents.
• Key Infectious Agents:
  1. Human Papillomavirus (HPV): Produces condylomata acuminata (warts) and vulvar intraepithelial neoplasia.
  2. Herpes Simplex Genitalis (HSV 1 or 2): Causes vesicular eruptions, characterized by painful blisters on the genital area.
  3. Gonococci: Induces suppurative infection of the vulvovaginal glands, leading to painful inflammation and discharge.
  4. Syphilis: Results in a primary chancre at the site of inoculation, typically presenting as a painless ulcer.
  5. Candida: Causes an itchy rash on the vulva, compounded by vaginal discharge that may be thick and white.

Complications

• Abscess Formation: Often resulting from infectious vulvitis, especially involving Bartholin's glands.
• Bartholin Gland Cyst: Formed by occlusion of the main ducts, potentially becoming infected and progressing to an abscess.

Inflammatory Dermatoses of Vulva

Contact Dermatitis of Vulva

• Definition: Reactive inflammatory response to exogenous stimuli such as irritants (e.g., urine, chemicals) or allergens (contact allergic dermatitis).

Non-Contact Vulval Dermatitis

1. Lichen Sclerosus:

   • Description: Chronic inflammatory dermatosis, often occurs in postmenopausal women. Characterized by smooth white to gray plaques on genitalia.
   • Pathophysiology: Considered an autoimmune issue; shows hyperkeratosis, thin epidermis, and disappearance of rete ridges microscopically.
   • Dermal Changes: Amorphous homogeneous degenerative changes with infiltration of chronic inflammatory cells at mid-dermis.

2. Lichen Simplex Chronicus (Neurodermatitis):

   • Description: Chronic itchy condition due to repetitive scratching/rubbing. Thickening of skin occurs where inflammation started.
   • Microscopic Findings: Acanthosis, hyperkeratosis, and inflammatory cell infiltration in the dermis.

Neoplasms of the Vulva

Benign Tumors

1. Papillary Hidradenoma:

   • Description: Arises from apocrine sweat glands, presenting as circumscribed nodules primarily located in the labia.
   • Microscopic Characteristics: Irregularly shaped tubular structures with intraluminal papillary projections lined by two cell layers: inner (columnar) and outer (cuboidal).

2. Condyloma Acuminatum:

   • Description: Wart-like lesions caused by low-risk HPV types (e.g., type 6, 11), typically on vulva, perineum, or vagina.
   • Microscopy: Features sessile or pedunculated epithelial proliferation with perinuclear cytoplasmic clearing.

Malignant Vulval Tumors

1. Vulval Intraepithelial Neoplasia (VIN):

   • Causes: Primarily linked to HPV type 16.
   • Age of Onset: Typically manifests during the 4th or 5th decades of life, with progression to invasive carcinoma possible by the 6th decade.

2. Invasive Squamous Cell Carcinoma (SCC):

   • Histology: Generally well-differentiated SCC with keratin pearls and intracellular bridges.
   • Prognosis Factors: Depends on lesion size, depth of invasion, and lymph node involvement.

3. Paget’s Disease of the Vulva:

   • Description: Epidermal carcinoma primarily on labia majora, presenting as a red, crusted, sharply demarcated area.
   • Histological Features: Composed of large anaplastic cells found singly or in small clusters within the epidermis without underlying intra-duct carcinoma.

4. Other Malignant Carcinomas:

   • Basal Cell Carcinoma
   • Adenocarcinoma of Bartholin or sweat glands
   • Malignant Melanoma

Vaginal Diseases

Vaginal Infectious Inflammation

• Common Symptoms: Vaginal discharge, often sexually transmitted.
• Key Organisms:
  • Gardnerella vaginalis
  • Neisseria gonorrhoeae
  • Candida albicans
  • Trichomonas vaginalis

Vaginal Neoplasia

1. Vaginal Intraepithelial Neoplasia (VaIN):

   • Definition: Presence of squamous cell atypia without invasion, classified by depth of epithelial involvement (VaIN 1, 2, 3).
   • Relation to HPV: Associated with HPV infection.

2. Invasive Vaginal Squamous Cell Carcinoma:

   • Characteristics: Rare, primarily HPV-associated; usually progresses from VaIN 3.
   • Age of Onset: Primarily occurs between 60 and 70 years.
   • Morphology: Can appear plaque-like or as a fungating ulcer.

3. Clear Cell Adenocarcinoma:

   • Characteristics: Very rare; associated with diethylstilbestrol exposure during pregnancy.
   • Histology: Comprises glands lined by vacuolated clear malignant cells.

4. Embryonal Rhabdomyosarcoma:

   • Characteristics: Rare polypoid malignant tumor seen in young female children.

Disease of the Cervix

Infectious Cervicitis

• Definition: Common inflammation of the cervix, which can be either acute (purulent discharge) or chronic.
• Most Common Organisms: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis.
• Non-Infectious Causes: Chemical irritation or mechanical trauma can also cause cervicitis.

Chronic Cervicitis

• Histological Features: Infiltrated by chronic inflammatory cells; metaplasia of endocervical epithelium may occur, causing cervical gland obstruction and formation of Nabothian cysts.

Endocervical Polyps

• Characteristics: Common lesions at any age, can vary in size and cause vaginal bleeding. Composed of connective tissue stroma covered by endocervical glandular or metaplastic squamous epithelium.
• Etiology: No known definitive causes but chronic inflammation may play a role; typically possess no malignant potential.

Cervical Intraepithelial Neoplasia (CIN)

• Etiology: Caused mainly by high-risk HPV types, especially HPV 16 and 18.
• Pathology: Begins at the squamocolumnar junction, exhibiting squamous metaplasia and cytologic atypia.
• Nuclear Atypia: Features include hyperchromasia, pleomorphism, increased mitotic activity, and increased nuclear-cytoplasmic (N/C) ratio.

Grading of CIN

1. CIN I: Lower 1/3rd of epithelium shows mild dysplasia.
2. CIN II: Lower 2/3rd exhibits moderate dysplasia.
3. CIN III: Over 2/3rd to full thickness occupied by atypical cells; severe dysplasia present.

• Timeline: Can persist for up to 10 years before potential invasion occurs.

Invasive Squamous Cell Carcinoma of the Cervix

• Statistics: Most common cervical cancer, with a peak incidence around 45 years, typically preceded by CIN 3.
• Manifestations: Advanced cases may lead to pain, bleeding, non-cyclic discharge, and dyspareunia.
• Predisposing Factors:
  • Early sexual activity with high-risk HPV infection (types 16 or 18)
  • Multiparity (≥5 pregnancies of ≥20 weeks)
  • Smoking
  • Prolonged exposure to high estrogen levels.

Gross Appearance of Cervical SCC

• Forms: Typically appears polypoid, ulcerative, or infiltrative within the cervical wall.

Histological Variants of Squamous Cell Carcinoma

• Keratinizing: Presence of keratin pearls and granules, characterized by large hyperchromatic nuclei.
• Nonkeratinizing: Composed of polygonal cells forming sheets or nests, lacking keratin pearls.
• Papillary: Exhibits thin or broad fibrovascular cores lined with multilayered malignant epithelium.
• Basaloid: Defined by nests of immature basaloid cells.

Staging of SCC of the Cervix

1. Stage I: Carcinoma confined to the cervix.
2. Stage II: Carcinoma extending to the upper part of the vagina.
3. Stage III: Carcinoma reaching the pelvic wall or lower third of the vagina.
4. Stage IV: Carcinoma extends to the bladder, rectum, with possible distant metastases.

Other Malignant Tumors of the Cervix

• Adenocarcinoma (classic type)
• Adenosquamous carcinoma (mixed type)
• Clear cell adenocarcinoma
• Small cell carcinoma
• Sarcomas
• Melanoma

Effects and Complications of Cervical Cancer

• Metastasis: Local invasion of adjacent structures, lymphatic spread to regional lymph nodes (iliac, sacral, hypogastric), and hematogenous spread to liver, lungs, and bone.
• Complications:
  • Vesico-vaginal and recto-vaginal fistulas.
  • Pyometra: Infected uterus filled with pus, leading to inflammation and potential systemic effects.