INFECTION AND DISORDER

OF
FEMALE GENITAL TRACT

Dr. Bambang K,SpOG

anatomy
 OVERVIEW

Diseases of FGT are common:

- Inflammation and infection
- Tumors (benign and malignant)
- Hormone-related conditions
- Pregnancy-related conditions
 INFECTIONS OF THE LOWER
FEMALE GENITAL TRACT
Herpes
Candida
Trichomonas
Pelvic Inflammatory Disease (PID)
Human Papilloma Virus (HPV)
 HERPES VIRUS
Vulva, vagina, cervix
Sexually transmitted
(HSV-2, less commonly
HSV-1)
Fever, malaise, tender
inguinal lymph nodes
Severe discharge
Latency in regional
nerve ganglia
Transmission during
active phase
Lethal to neonates
(herpetic viral
meningitis)
 CANDIDA ALBICANS
NOT sexually transmitted
Common fungal organism
10% of women are carriers
Predisposing factors:
pregnancy, DM, recent A/B,
OCP, immunosuppression
C/F: itching, moist red lesions
with thick white cheesy
discharge
Pap smears, skin scrapings
Biopsy (rarely done):
spongiosis, intraepithelial and
dermal neutrophils (PAS
stains, cultures)
 TRICHOMONAS VAGINALIS
Common sexually
transmitted disease
(protozoan)
10% of women are
asymptomatic carriers
C/F: Frothy, watery, gray-
green vaginal
discharge,fishy odor,
pruritis, dyspareunia
Erythematous and punctate
hemorrhages (strawberry
cervix)
Pap smear: pear-shaped 8-
30 um cyanophilic organism
with cytoplasmic eosinophilic
granules
Bx: Acute and chronic
inflammation
 PELVIC INFLAMMATORY
DISEASE (PID)
Infectious disorder of
upper and lower FGT
- Gonococcus, chlamydiae,
enteric bacteria
- Postpartum or post-abortion
infection (staph. spp., strep.
spp., coliforms)
Pelvic pain, adnexal
tenderness, fever, vaginal
discharge
Ascending infection (from
vagina to tubes)
 PELVIC INFLAMMATORY
DISEASE (PID)
May extend to involve
ovaries and tubes
(salpingo-oophoritis)

Complications
- Infertility
- Bacteremia (endocarditis,
meningitis, arthritis)
- Intestinal obstruction
(adhesions)
- Peritonitis

Acute suppurative salpingitis

 HUMAN PAPILLOMA VIRUS
(HPV)
Sexually transmitted disease implicated in
epidemiology of cervical cancer
- Early age at first intercourse
- Multiple sexual partners
- Male partner with many previous sexual partners
- HPV DNA is detected in 85% of cervical cancers, and
in 90% of cervical condylomata and precancerous
lesions
Responsible for squamous proliferations
(benign, premalignant, and malignant)
High risk (16, 18) and low risk (6, 11) types
 HUMAN PAPILLOMA VIRUS
(HPV)
Responsible for dysplastic changes within the
mucosal epithelium, most commonly in the
cervix
Low risk HPV types 6 & 11: low grade
intraepithelial neoplasia (anogenital warts or
condyloma accuminatum); potentially
premalignant
High risk HPV types 16 &18: high grade
intraepithelial neoplasia; premalignant
anogenital warts or condyloma
accuminatum
 INTRAEPITHELIAL NEOPLASIA
Premalignant dysplastic changes
occurring within an epithelium (not
invasive, not yet cancer)
Precursor to squamous cell carcinoma
papsmears
 KOILOCYTE
Hallmark of HPV
infection in an
epithelium
Raisinoid nucleus
(enlarged,
hyperchromatic,
irregular), perinuclear
halo and cytoplasmic
thickening
Upper epithelial layer
 PAP SMEAR SCREEN
PAP screening has reduced incidence of
cervical cancer (SCC) from leading cancer
killer of women (50 years ago) to eighth
leading cause today
PAP screen successful because
Koilocytes and dysplasia are detectable
Most cervical cancer is preceded by these
precancerous changes
 PAP SMEAR SCREEN
NORMAL LSIL

HSIL
HSIL
 CERVICAL INTRAEPITHELIAL
NEOPLASIA (CIN)
Three grades of severity:
CIN I: mild dysplasia
CIN II: moderate dysplasia
CIN III: severe dysplasia (highest risk for
progression to invasive squamous cell
carcinoma)
Progression to invasion may take from a
few months to twenty years; unpredictable
 CERVICAL INTRAEPITHELIAL
NEOPLASIA

Spectrum of cervical intraepithelial neoplasia (CIN): normal

squamous epithelium for comparison
CERVICAL TRANSFORMATION
ZONE

NORMAL PREINVASIVE
SQUAMOUS CELL CARCINOMA
(CERVIX, VAGINA, VULVA)

Peak incidence 40 - 45 years

Spreads by direct extension into any
neighboring structures (bladder, rectum,
vagina, peritoneum, ureters)
Regional and distant metastasis: regional
lymph nodes, lungs liver, and bone.
 SQUAMOUS CELL CARCINOMA
OF CERVIX

NORMAL
SQUAMOUS CELL CARCINOMA
SQUAMOUS CELL CARCINOMA
May take years to evolve with only sign of
its presence the atypical cells shed from
the cervix and found by the PAP screen
Invasive cancers usually trigger
hysterectomy and possibly radiation
 UTERINE DISEASES
BENIGN
- Adenomyosis
- Endometriosis
- Leiomyoma (fibroids)
MALIGNANT
- Endometrial carcinoma
- Leiomyosarcoma
 ADENOMYOSIS
Adenomyosis
Endometrial tissue
(stroma with/without
glands) in the uterine
wall (myometrium)
During menstrual cycle
these glands have no
outlet to shed into
Menorhagia, colicky
dysmenorrhea,
dyspareunia and
pelvic pain
 ENDOMETRIOSIS
Endometrial glands and stroma in abnromal
locations outside the uterus
Ovaries (chocolate cysts), uterine ligaments,
rectovaginal septum, pelvic peritoneum,
laparotomy scars; and rarely umbilicus, vagina,
vulva or appendix
Complications: infertility, dysmenorrhea, pelvic
pain
Disease of reproductive age group, afflicts 10%
of women
 ENDOMETRIOSIS
THEORIES OF
SPREAD
- Regurgitation /
implantation theory
- Metaplasia
- Angiolymphatic spread
 ENDOMETRIOSIS

ENDOMETRIOSIS

FALLOPIAN TUBE

CHOCOLATE CYST OF OVARY

ENDOMETRIAL CARCINOMA
Most common invasive cancer of FGT
Mainly post-menopausal female, causing
abnormal bleeding; permitting early detection
Peak incidence 55- to 65-year-old woman
Higher incidence found in:
Obese
Diabetics
Hypertensive
Infertile
ENDOMETRIAL CARCINOMA

ADENOCARCINOMA
ENDOMETRIAL CARCINOMA
Spread: direct and angiolymphatic
(myometrial invasion, regional lymph
nodes, lung, liver, bone)
 LEIOMYOMA
Benign smooth muscle neoplasm
Affects 25% of women
Estrogen responsive
May produce abnormal bleeding, impaired
fertility, bladder compression,
spontaneous abortion
LEIOMYOMA
 LEIOMYOSARCOMA
Malignant smooth muscle tumor
Uncommon
40 to 60 year peak
Tend to recur and spread via bloodstream
to lung, brain, and bone
LEIOMYOSARCOMA
 OVARIAN DISEASES
BENIGN
- Polycystic ovaries
- Mature teratoma (dermoid cyst)
MALIGNANT
- Carcinomas: serous, mucinous
- Immature teratoma
 POLYCYSTIC OVARIAN
DISEASE (PCOD)
aka Stein-Levanthal
Syndrome
- Oligomenorrhea
- Obesity
- Hirsutism
- Virilism
Etiology unknown
Multiple subcortical cysts
Increased production of
androgen which is
converted to estrone
 OVARIAN TUMORS
Mostly benign (80%)
Affect young women (20 to 45-years-old)
Malignant forms are disproportionately
lethal and affect older women, 40 to 65-
years-old
Risk factors for ovarian cancer
- Nulliparity
- Family history, genetics (BRCA-1, BRCA-2
genes in hereditary forms)
 EPITHELIAL TUMORS
SEROUS TUMORS
Cystic or solid, large masses (30-40 cm)
Subtypes
Benign (60%): serous cyst / cystadenoma
Borderline (10%): serous borderline tumor
(SBLT)
Malignant (30%): serous carcinoma
SEROUS TUMORS
Serous cyst /cystadenoma
- smooth, glistening cyst wall
- clear serous fluid
- tubal lining
- microscopic papillae
- psammoma bodies (concentric
calcification)
 SEROUS TUMORS
Serous borderline Serous
tumor (SBLT) cystadenocarcinoma
- increased papillary - cystic to solid tumor
projections - complex growth pattern
- epithelial stratification - frank stromal invasion
- nuclear atypia present
- NO stromal invasion - peritoneal implants
- poor prognosis
 EPITHELIAL TUMORS
MUCINOUS TUMORS
- Cystic or solid, large multiloculated masses
- Subtypes
Benign (80%): mucinous cyst / cystadenoma
Borderline (10%): mucinous borderline tumor
(MBLT)
Malignant (10%): mucinous carcinoma
- Rupture (mucinous cystadenomas or mucinous
cystadenocarcinomas) leads to pseudomyxoma
peritonei
 GERM CELL TUMORS
15 20% ovarian tumors
Derivatives of all three germ-cell layers
present (teeth, hair, bone, cartilage, etc)
Less than 20 years
Most are mature cystic teratoma (aka
dermoid cyst; benign)
Immature form: more likely malignant
MATURE CYSTIC TERATOMA

TEETH
 ECTOPIC PREGNANCY
1% of pregnancies
Implantation of the fetus
in any site other than a
normal uterine location
Sites: fallopian tubes
(90%), ovary, abdominal
cavity
Predisposing factors:
Previous scarring (PID
with chronic salpingitis)
Rupture is catastrophic