-Numerous follicle cysts -Superficial

cortical fibrosis

1. CERVICITIS Muco-purulent cervicitis (endocervix)

- STD! - Chlamydia trachomatis, Neisseria Gonorrhea - spread upwards PIDinfertility

Chronic persistent/recurrent infection of squamous epithelium of exocervix - HPV / HSV 2

Mild non-specific inflammation of endocervix - vaginal bacteria

2. CERVICAL POLYP - non-neoplastic lesion dt overgrowth of endocervical mucosa that protrudes as a polyp in the endocervical canal cause intermittent uterine bleeding - X associated with malignancy

3. CERVICAL INTRAEPITHELIAL NEOPLASIA - dysplastic changes of squamous epithelium of cervix at transformation zone - recognized as the precursor of squamous cell carcinoma

CIN 1 CIN 2 CIN 3 incidence 25 years 30-40 years 30-40 years

atypical cells involve

lower 1/3 of epithelium

lower 2/3 of epithelium

all layers of epithelium

type of HPV low risk hi risk hi risk

fate

85% regress 10% - CIN 3 2-3% - risk to cerv.carcinoma

> risk to cervical carcinoma than CIN 1

>25% of untreated case cervical carcinoma

treatment follow up conization conization

-risk factors 4. INVASINE CERVICAL CARCINOMA - arise from CIN ( dt infection of HPV! ) - 50 years old - gross : fungating, ulcerating, infiltrating mass! - micro type : 1. squamous cell carcinoma(85%) 2. adenocarcinoma (10%) - pic : Asymptomatic, abnormal uterine bleeding, malodorous vaginal discharge

clinical pic: -Asymptomatic!

-palpable abd mass -sudden abd pain

OVARY CERVIX UTERUS

1. OVARIAN CYSTS

FUNCTIONAL CYST Follicular cyst : non ruptured follicles *lined by granulosa cells Corpus luteum cyst : CL that fails to collapse & resolve POLYCYSTIC OVARY (Stein Leventhal )SYNDROME

- pathogenesis : overproduction of androgens! impaired maturation of developing follicles & failure of ovulation - pic : menst.irregularities, obesity, hirsutism, anovulation

ENDOMETROITIC (chocolate) CYST

2. TUMORS OF OVARY - PRIMARY

SURFACE EPITHELIAL TUMORS Serous tumors Mucinous tumors Endometrioid tumors

*Pseudomyxo peritonei

Brenner’s tumors

GERM CELL TUMORS Teratoma (dermoid cyst) ↑ in women <25 yrs old!

Mature (benign) cystic teratoma - cystic !

- with hair & greasy yellowish sebaceous material Immature (malignant) solid teratoma

- with immature tissue, behaves like malignant tumor

Teratoma with malignant transformation Monodermal (highly specialized) teratoma

- Struma ovarii! + Ovarian carcinoid! ↑ thyroid tissue!

Dysgerminoma = seminoma Yolk sac tumor : young age! ↑α fetoprotein Choriocarcinoma ↑ HCG

at any age! Steroid hormone-secreting!

SEX CORD-STROMAL TUMORS (10% of all ovarian tumor)

Granulosa cell tumor : E2 secreting! Granulosa-theca cell tumor : E2 secreting! Fibrothecoma tumor Fibroma : Meigs syndrome! *non-functioning Thecoma E2 secreting Sertoli-Leydig cell tumor : androgen secreting!

1. ENDOMETRIAL POLYP - solitary polypoidal lesion in uterine cavity covered by endometrial surface epithelium - formed of cystic endometrial glands +cellular fibrocytic stroma - pic : intermenstrual/postmenopausal bleeding (ulcerated polyp)

2. ENDOMETRIAL HYPERPLASIA - ↑ number of glands relative to endometrial stroma - dt : prolonged unopposed estrogen stimulation of endometrium - pic : menorrhagia, irregular uterine bleeding -types:

1. Simple endometrial hyperplasia 2. Complex endometrial hyperplasia 3.Complex endometrial hyperplasia with atypia

↑risk of endometrial carcinoma -risk factors: Anovulatory cycles, exo.E2, polycystic ovary, nulliparity, obesity, E2 producing tumors

3. ENDOMETRIAL CARCINOMA - risk : endometrial hyperplasia (precursor) + its risk factors - gross : fungating, infiltrating mass - micro type : 1. Endometrioid adenocarcinoma : post menopausal women, related to hyperestrenism, better prognosis 2. Papillary serous carcinoma : older women, X relatn with hyperestrenism, endometrial atrophy, worse prognosis

4. ENDOMETRIOSIS -red brown nodules ! - presence of functional endometrial tissue outside the uterus - pathogenesis : implantation/metaplastic/metastatic theories - pic : dysmenorrhea, infertility, constipation, rectal pain

5. ADENOMYOSIS - presence of non-functional endometrial tissue within the uterus - menorrhagia, dysmenorrhea 6. TUMORS OF UTERUS

Uterine leimyoma/fibroids - benign smooth muscle tumors of myometrium - X malignant association - gross: multiple, well-defined, non-capsulated, diff.sizes, greyish-white, whorly appearance - subserosal/intramural/submucosal - pic : infertility, abn.uterine bleeding, obstruct of delivery, abortion, twisted & necrotic, some are Asymptomatic!

Leiomyosarcoma (malignant) Malignant mixed mullerian tumor

(carcinosarcoma)

- infection of hi risk HPV (16,18) CIN - multiparity - sexual activity at early age - immunosupression - multiple hi risk sexual partners - cigarette smoking

from ovarian follicles that becomes abnormally cystic during their development

mucinous deposits in peritoneum with implantation of tumor cells in peritoneum & production of large amount of

mucin dt rupture of tumor

TUMORS OF THE UTERUS

GRAVID UTERUS NON-GRAVID UTERUS BENIGN INVASIVE MOLE MALIGNANT CERVIX BODY OF UTEURS VESICULAR MOLE CHORIOCARCINOMA CERVICAL CARCINOMA ENDOMETRIUM MYOMETRIUM ENDOMETRIAL CARCINOMA BENIGN MALIGNANT LEIOMYOMA LEIOMYOSARCOMA

DISEASES OF PREGNANCY

ECTOPIC PREGNANCY GESTATIONAL TROPHOBLASTIC DISEASE PRE-ECLAMPSIA & ECLAMPSIA

BENIGN VESICULAR MOLE LOCALLY INVASIVE MOLE MALIGNANT CHORIOCARCINOMA

SURFACE EPITHELIAL TUMORS

- arise from small mesothelial lined cysts which become incorporated into the substance of ovary following rupture & repair of ovulation site. - peritoneal mesothelium + epithelial lining all female genital tract = derived from ceolomic epithelium of the embryo - mesothelial cell lining the inclusion cysts of the ovary may become neoplastic & differentiate into epithelial cells which resembles the lining of endocervix, endometrium & FT

Benign (cystadenoma) Malignant (cystadenocarcinoma) SEROUS tumors

-resemble FT epithelium -most commonly bilateral

- 60% -usually cystic -30-40 yrs - 20% are bilateral

-25% -partly cystic -34-60 yrs - 66% are bilateral

- unilocular smooth-lined cyst filled with clear serous fluid

-complex multilocular cyst with focal solid areas & nodular irregularities

- cyst wall lined by single layer of columnar ciliated cells

- stratified tumor cells, showing atypical nuclear features - tufting & papillary structures - psammoma bodies - stromal invasion detected!

-spread by seeding of peritoneal cavity -lymphatic spread to regional LN -secretes tumor marker : CA125!

MUCINOUS tumors

-resemble endocervical epithelium

- 80% - 5% are bilateral

- 10% - 20% are bilateral - better prognosis than serous carcinoma

*rupture of tumors may result in pseudomyxoma

- large multilocularcystic masses filled with mucinous material - tumor cell is mucin secreting

ENDOMETRIOID tumors

-resemble endometrial epithelium

TERATOMA (dermoid cyst) cystic ! - formed of elements from all 3 germ layers Ectoderm : skin hair, neural tissue Mesoderm : bone, cartilage, fat Endoderm : bronchial & gastrointestinal mucosal lining -complication : torsion of the ovary! SEX CORD STROMAL TUMOR

FIBROMA THECOMA GRANULOSA CELL TUMOR SERTOLI-LEYDIG

CELL TUMOR

- benign non-functioning tumor formed of fibroblasts!

- benign

- may occur at any age -most are benign *25% may recur / metastasize during 10 years following diagnosis considered potentially malignant!

biphasic tumor that contains cells resembling -testicular sertoli cells -leydig cells

C.S: solid, grey-white in colour firm consistency

solid, firm, with yellow cut surface dt high steroid content of tumor cells

solid, yellowish with cystic element

Microscopic: formed of spindle cells that contain fat

formed of granulosa cells that may form Call-Exner bodies, like the normal granulosa cells in the ovarian follicles

- may be associated with right pleural effusion & ascites (Meig’s syndrome)

- secrete estrogen endometrial hyperplasia + uterine bleeding

- often produce excess estrogen clinical presentation : * depends on age! -prepubertal precocious puberty -reproductive age irregular menses -postmenopausal post menopausal uterine bleeding

-secrete androgens cause virilization

KRUKENBERG TUMORS (secondary!) : bilateral ovarian metastasis of mucin-secreting gastrointestinal adenocarcinoma, most of gastric origin

*MALIGNANT TERATOMA = teratocarcinoma (1%) - Usually squamous cell carcinoma

INVASIVE CERVICAL CARCINOMA ENDOMETRIAL CARCINOMA incidence 50 years 50 – 60 years

precursor lesion

Cervical Intraepithelial lesion (CIN) Endometrial hyperplasia

cause Infection of HPV Hyperestrenemia

risk factor - infection of hi risk HPV (16,18) CIN - multiparity - sexual activity at early age - immunosupression - multiple hi risk sexual partners - cigarette smoking

- obesity - DM & hypertension - infertility & nulliparity - anovulatory cycle - polycystic ovary - early menarche & late menopause - estrogen-producing tumor - estrogen replacement therapy - endometrial hyperplasia

gross - ulcerative - exophytic fungating mass - endophytic invasive (infiltrating)lesion causing induration/deformities of the cervix (barrel-shaped cervix)

- exophytic polypoidal (fungating) mass projecting into uterine cavity - invasive infiltrating lesion extending into myometrium - diffuse thickening on endometrium

microscopic types

1. Squamous cell carcinoma(85%) 2. Adenocarcinoma originating from endocervical glands(10%) 3. Small cell carcinoma/Undiff. Carcinoma (5%)

Endometrioid adenocarcinoma

Papillary serous carcinoma

- post menopausal - related to hyperestrenism -better prognosis

- older women - X related to hyperestrenism *develops against the background of endometrial atrophy -worse prognosis

clinical picture - Asymptomatic - abnormal uterine bleeding (intermittent/post-coidal) - malodorous vaginal discharge

spread - local vagina, parametria, rectum, UB (obstructing ureters leading to renal failure – the most common cause of death) - meastatis LN & lungs

- local myometrium, cervix & surrounding organs - lymphatics regional LN - hematogenous distant sites commonly the lung!

ENDOMETRIAL HYPERPLASIA Types: (according to extends of increase of the number of glands & presence of atypia)

Simple endometrial hyperplasia - increase number of endometrial glands, some are cystically dilated with intervening cellular stroma

Complex endometrial hyperplasia - glands are crowded & branching - stroma is relatively scanty

Complex endometrial hyperplasia with atypia

- endometrial glands appear crowded & irregular - lining epithelial cells show nuclear atypia

ENDOMETRIOSIS Common site : OVARY, OVARIAN & UTERINE ligaments, DOUGLAS pouch, serosa of bowel & urinary bladder, peritoneal cavity Pathogenesis:

IMPLANTATION theory endometrial deposits arise when endometrial glands are regurgitated into peritoneal cavity thru FT during menstruation, then implant in peritoneal surface.

METAPLASTIC theory arise due to metaplasia of peritoneal surface epithelium into endometrial type epithelium, * both arise from the same embryonic cell ( ceolomic epithelium)

METASTATIC theory hematogenous spread if endometrial tissue which enter the circulation at menstruation *explains cases if endometriosis affecting organs such as lungs

ADENOMYOSIS : presence of non-functional endometrial tissue within the uterus - surrounding myometrial smooth muscle cells undergo HYPERTROPHY and result in enlargement of uterus

Pathogenesis/Etiology 1. Follicular cyst : unruptured follicles 2. Luteal cyst : CL that fails to collapse & resolve 3. Polycystic ovary : overproduction of androgen by ovaries (defect in hypothalamic control of pituitary secretion) 4. Chocolate (endometriotic) cyst : endometriosis of the ovary 5. Surface epithelial tumor : - arise from small mesothelial lined cysts which become incorporated into the substance of ovary following rupture & repair of ovulation site. *peritoneal mesothelium + epithelial lining all female genital tract = derived from ceolomic epithelium of the embryo - mesothelial cell lining the inclusion cysts of the ovary may become neoplastic & differentiate into epithelial cells which resembles the lining of endocervix, endometrium & FT 6. Mucopurulent cervicitis : Chlamydia Trachomatis, Neisseria gonorrhoea 7. Chronic persistent/recurrent infection of squamous epith of exocervic : HPV, HSV 8. Cervical polyp : non-neoplastic lesion dt overgrowth of endocervical mucosa that protrudes as a polyp in the endocervical canal 9. CIN : dysplastic changes of squamous epithelium of cervix at transformation zone 10. Invasive cervical carcinoma : - arise from CIN ( dt infection of HPV!) 11.Endometrial polyp : solitary polypoidal lesion in uterine cavity covered by endometrial surface epithelium 12. Endometrial Hyperplasia & Endometrial carcinoma : prolonged unopposed estrogen stimulation of endometrium 13. Endometriosis : - presence of functional endometrial tissue outside the uterus 14. Adenomyosis : presence of non-functional endometrial tissue within the uterus Ages! 1. Functional cysts : most common in women in the reproductive age 2. Follicular cyst : most common ovarian mass 3. Corpus luteal cyst : most common ovarian mass in pregnancy * Ovarian tumor : 80% are benign, occurs mostly in young women aged 20-45 years : 2nd most common group of tumors in female genital tract : malignant ovarian tumors are seen inolder women aged 45-65 years! 1. Surface epithelial tumors : most common tumors of the ovary 2. Serous tumors : most frequent ovarian tumors & most commonly bilateral! - Benign serous tumor : most common benign ovarian tumor - Serous cystadenocarcinoma : most common malignant ovarian tumor 3. Teratoma : most common germ cell tumor in women younger than 25 years old , most common benign germ cell tumor of ovary 4. Fibroma : most common sex cordal stromal tumor! 1. Invasive cervical carcinoma : least common gynaecologic cancer 2. Leiyomyoma/fibroids : most common benign tumor of female genital system 3. Leiomyosarcoma : most common sarcoma of uterus Hormone-secreting diseases

Follicular cyst ↑ estrogen endometrial hyperplasia Polycystic ovary ↑ androgen impaired maturation of developing follicles & fsilure of ovulation

oligomenorrhea, hirsutism, infertility

Struma Ovarii hyperthyroidism

Thecoma & Granulosa-theca cell tumor

↑ estrogen endometrial hyperplasia & uterine bleeding

Sertoli-leydig tumor ↑ androgens virilization

Yolk sac carcinoma ↑ α feto protein

Choriocarcinoma ↑ HCG

Surface epithelial tumor glycoprotein CA-125