Gynecological Pathology

Condition	Cause	Pathology/Histology	Clinical Features	Other Features
Proliferative Enodmetrium		· Straight glands · Narrow lumens · Pallisading nuclei · Ovoid nuclei · Mitoses
Early Secretory Endometrium	First manifestation of effect of ovulation on endometrium	· Glands remain straight · Lumens remain narrow · Subnuclear vacuoles appear		24-36 hours after ovulation
Mid Secretory Endometrium		· Glands become coiled · Vacuoles no longer present in glands · Secretory product appears in lumen		Postovulatory days 5-9
Late Secretory Endometrium		· Intralumenal secretions are spent · Stromal predecidua appears · First predecidua around spiral arteries · Later predecidua beneath surface		Postovulatory days 10-14
Menstrual Endometrium		· Stromal collapse · Fribrin thrombi and blood · Glands are broken apart · Glands have no secretions
Hyper-secretory Endometrium of Pregnancy		· Arias-Stella reaction · large, hyperchromatic nuclei · prominent cytoplasmic vacuolization
Atrophic endometrium		· short glands · glandular cells – flat, without significant mitotic activity
Dysfunctional Uterine Bleeding		· anovulatory bleeding · luteal phase defect
Unopposed Estrogen		· proliferative glands · stromal breakdown · fibrin thrombi · wreathing of stroma by glandular cells
Contraceptives	Combined oral agents	· mix of proliferative and secretory changes · long use à · atrophic glands · stromal predecidual pattern dominates
	Depoprovera	· unopposed progesterone
Tamoxifen		· inc risk of carcinoma · inc incidence of polyps · large, mucinous metaplasia, fibrotic
Endometrial Hyperplasia	· unopposed estrogen stimulation – exogenous, endogenous · no progestational stimulation	· simple or complex architecture · typical or atypical nuclei	Vaginal bleeding, 60s Risk factors – obesity, diabetes, nulliparity, early menarche, late menopause	Complex atypical hyperplasia progresses to carcinoma – 1/3 T – hysterectomy, hormonal manipulation
Endometrial Carcinoma Type 1 Endometrioid	· PTEN gene mutation à cell growth and apoptosis	· squamous or mucinous		Grade determines prognosis T – hysterectomy, good survival Low grade – hormonal
Endometrial Carcinoma Type 2 Unfavorable Histology	· serous-p53 mutations	· clear cell		Early spread outside uterus à long term survival uncertain
Uterine Mesenchymal Tumors
Leiomyoma	·	· smooth muscle · multiple nodules · no coagulative necrosis · mitotic rate is low		Extremely uncommon
Leiomyosarcoma	·	· increased mitotic rate (>10/10 hpf) · necrosis · cytologic atypia
Stromal Sarcoma	·	· vascular invasion · receptors for progesterone	Appearance of endometrial stroma	T- hormonal therapy
Uterine Mixed Tumors
Adenomyoma	·	· benign glands and stroma
Adenosarcoma	·	· benign glands and malignant stroma
Carcinosarcoma	·	· malignant epithelial and stromal elements
Fallopian Tube
Infection	· STD · Polymicrobial infection			Important cause of infertility
Ecotpic Pregnancy	· Possible result of salpingitis		Ruptured fallopian tube is life threatening	Most common site of ectopic pregnancy
Ovary and Placenta
Polycystic Ovary Syndrome (Stein-Levanthal)		- Increased ovarian androgen production - Arrested follicle development due to androgens	- Androgen excess, ovarian cysts - Common cause of infertility
Endometriosis	- Mestrual implantation - Surgical - Vascular spread - Coelomic metaplasia	- Benign endometrial glands and stroma present outside the uterus	- cyclic pain with menses - may cause infertility
Ovarian Tumors	-	-	-
Ovarian Epithelial Carcinomas	- c-erbB-2 42% - K-ras mucinous lesions - P53 mutation 50-60% - BRCA1 and BRCA2 -15X risk, 10% - Lynch Syndrome II, subtype of HNPCC	-	-	Highest mortality rate of female genital cancers Difficult to detect early, spread beyond ovaries Adults, first-degree relatives, industrialized Inc with age, dec with parity and oral contraceptive
Benign Ovarian Germ Cell Tumors	-	- mature adult type tissue - all three germ layers - “dermoid cysts” - adult type carcinoma arises from tissue elements	-	Wide age range
Malignant Ovarian Germ Cell Tumors	-	- Dysgerminoma – undifferentiated germ cells – best prognosis - Immature (malignant) teratoma – fetal type tissue - Choriocarcinoma – mimics placental trophoblast - Endodermal sinus tumor – embryonic yolk sack type tissue	-	Highly malignant course but responsive to chemotherapy or radiation Exclusively children, young adults
Sex Cord Stromal Tumors	- ovarian stroma or primitive sex cords	-	-	- Variable from benign ot low grade malignancy - most hormonally active ovarian tumors
fibroma	-	-	- hormonally inert	- most common,
Thecoma	-	- lipid laden theca cells	- produces estrogen	-
Granulosa cell tumor	-	-	- produces estrogen	- low grade malignancy
Sertoli-Leydig cell tumor	-	-	- produces androgens	- rare
Metastatic Tumors to the Ovary (Krukenberg)	-	-	- can stimulate stroma to cause hormone production	- 3% of ovarian carcinoma - colon and upper GI
Placenta	-	-	-	-
Chorioamnionitis	- ascending infection through the birth canal - coliforms, vaginal bacteria	-	-	- preterm labor - neonatal infections
Villitis	- blood borne source of infection - viral, parasitic, spirochetes	-	-	-
Sponataneous Abortion	- infections - mechanical - endocrine - fetal abnormality - immunologic	-	-	- 15% of recognized pregnancy - 30% of unrecognized pregnancy
Septic Abortion	- uterine infection following induced abortion	- acute inflammatory cells and necrosis	-	- uncommon in hospital performed procedures
Toxemia of Pregnancy	- failure of spiral arterioles to fully dilate - placenta shows acute atherosis in maternal vessels - kidney: vacuolization of endothelial and mesangial cells, fibrin deposition	-	- hypertension - proteinuria - edema - convulsions - eclampsia	- more common in first pregnancy
Placental Abnormalities	-	-	-	-
Retroplacental Hematoma/ Abruption	- Hematoma separates placenta from uterine blood supply - Abruption: premature separation of placenta	-	-	-
Placenta Accreta	-	- abnormal adherence of placenta to myometrium - +/- invasion of myometrium	-	-
Gestational Trophoblastic Disease	-	-	-	-
Complete Hydatidiform Mole	- Fertilization of empty ovum - 23x paternal chromosome - divides to 46xx (diploid)	-	-	- Hydropic, avascular villi
Partial Hydatidiform Mole	- Fertilization of normal ovum by 2 sperm - Triploid karyotype	-	-	- some villi normal and others avascular
Choriocarcinoma	- malignant tumor derived from trophoblast	-	- vaginal bleeding - excessively high HCG levels	- good response to chemotherapy