2. Diseases of the female genital system and breast

3. Anatomy of female genital system

4. Diseases of female genital system
Diseases of the cervix
Diseases of body of uterus
Diseases of pregnancy
Tumors of the ovary
Diseases of the breast

5. Normal cervix

6. Normal cervix
Squamocoluminar junction is the seat of most of the epithelial diseases that occur in the cervix

7. Diseases of the cervix
Chronic cervicitis
Neoplasia of the cervix

8. Chronic cervicitis
Erosion of cervix

9. Chronic cervicitis
Nabothian cyst

10. Cervical polyps

11. Chronic cervicitis

12. Diseases of the cervix
Chronic cervicitis
Neoplasia of the cervix

13. Neoplasia of the cervix
Cervical intraepithelial neoplasia(CIN)
Invasive carcinoma of the cervix

14. CIN
CIN I
CIN II
CIN III

15. Normal cervical squamous epithelium
CIN I

16. CIN II

17. CIN III

18. Risk factors for CIN and invasive carcinoma
Sexual intercourse
Early age at first intercourse(≤ 17 years old)
Smoking
Human papillomavirus (HPV 16, 18, 33)
HIV infection
Male factors

19. Neoplasia of the cervix
Cervical intraepithelial neoplasia(CIN)
Invasive carcinoma of the cervix

20. Invasive carcinoma of the cervix
Arise from transformation zone
Vast majority are squamous cell carcinomas
Preceded by CIN
Average is 50 years

21. Cervical carcinoma (early microinvasion)

22. Cervical carcinoma (early stage)
Abnormal hardness of the cervix

23. Fungating ulcerated areas destroy the cervix
Cervical carcinoma ( late stage)
Fungating ulcerated areas destroy the cervix

24. Pap smear ( diagnostic cervical cytology)

25. Invasive carcinoma of the cervix

26. Clinical feature Unscheduled vaginal bleeding Leukorrhea
Painful coitus (dyspareunia)
Dysuria (advanced stage)

27. Prognosis The size and depth of invasion of the primary tumor
The prescence and the extent of lymph node metastasis

28. Outline of female genital system
Diseases of the cervix
Diseases of body of uterus
Diseases of pregnancy
Tumors of the ovary
Diseases of the breast

29. Diseases of body of uterus
Adenomyosis
Endometriosis
Endometrial hyperplasia
Tumors of the endometrium and myometrium

30. Adenomyosis and endometriosis
Adenomyosis: growth of endometrium down into the myometrium
Endometriosis: growth of endometrium outside the uterus
ovaries
fallopian tubes
round ligaments
pelvic peritoneum

31. Adenomyosis and endometriosis

32. Adenomyosis

33. Endometriosis (uterine serosa)

34. “Chocolate” cyst of the ovary

35. Clinical feature Adenomyosis Endometriosis Cyclic pelvic pain
Dysmenorrhea
Dyspareunia (painful intercourse)
Infertility(30% of cases)
Menstrual abnormalities
dysmenorrhea

36. Diseases of body of uterus
Adenomyosis
Endometriosis
Endometrial hyperplasia
Tumors of the endometrium and myometrium

37. Endometrial hyperplasia
Occurs in the third and fourth decades
In response to estrogen stimulation
Functional uterine bleeding

38. Endometrial hyperplasia

39. Diseases of body of uterus
Adenomyosis
Endometriosis
Endometrial hyperplasia
Tumors of the endometrium and myometrium

40. Tumors of the endometrium
Tumors of the myometrium
Leiomyoma and leiomyosarcoma
Endometrial carcinoma

41. Endometrial carcinoma
The most common cancer of the female genital tract
Mean age : 56 years (80% of women are postmenopausal)

42. Risk factors Obesity Hyperestrogenic state Diabetes Late menopause
Prolonged use of estrogen
Estrogen-secreting tumors
Hyperestrogenic state
Previous pelvic irradiation
Lower parity

43. Endometrial carcinoma (early stage)

44. Endometrial carcinoma

45. Endometrial adenocarcinoma

46. Clinical feature Irregular bleeding Postmenopausal bleeding
Blood-stained discharge

47. Diagnosis of endometrial disease
Transvaginal ultrasonography
Hysteroscopy
Endometrial biopsy

48. Tumors of myometrium
Leiomyoma and leiomyosarcoma

49. Leiomyoma
Commonest tumor of all pelvic tumors (affect over half of all women over the age of 30)
Benign tumor
Arise from the smooth muscle cells in the myometrium

50. Risk factors Age: rare under 30 years.
Parity: more common in nulliparous and women with low fertility.
Genetic: often with a family history

51. Features of leiomyoma Estrogen sensitive Fast growing in pregnancy
Shrink at menopause

52. Submucosal leiomyoma

53. Submucosal, intramural, subserosal leiomyomas
Smooth muscle tumors of the uterus are often multiple. Seen here are submucosal, intramural, and subserosal leiomyomata of the uterus.
               
           

54. Leiomyoma

55. Clinical features Abnormal menstrual bleeding Dysmenorrhea Infertility
Compression

56. Leiomyosarcoma

57. Leiomyosarcoma

58. Outline of female genital system
Diseases of the cervix
Diseases of body of uterus
Diseases of pregnancy
Tumors of the ovary
Diseases of the breast

59. Diseases of pregnancy Gestational trophoblastic tumors
Hydatidiform mole
Invasive mole
Choriocarcinoma

60. Hydatidiform mole
Chracterised by swollen chorionic villi and trophoblastic hyperplasia
Associated with high HCG levels
Complete mole: no fetus
Partial mole: fetus or placenta may be present
May be complicated by chriocarcinoma

61. Complete mole

62. Hydatidiform mole

63. Doppler scan

64. Partial mole

65. Clinical feature
Amenorrhea followed by continuous or intermittent vaginal bleeding
Other symptoms of pregnancy: vomoting
Human chorionic gonadotropian (HCG)
Enlarged soft uterus (often larger than dates would suggest)

66. Invasive mole
Hemorrhage

67. Choriocarcinoma Malignant tumor of trophoblastic tissue
With a propensity for invading vessel walls
Blood-borne metastasis occur early to many sites (lung, brain…)

68. Etiology 50% develop from a hydatidiform mole
20% arise after a normal pregnancy

69. Choriocarcinoma
Hemorrhagic necrotic masses

70. Choriocarcinoma Villi are not present
Proliferation of bizarre trophoblastic cells
Highly aggressive

71. Choriocarcinoma
Dissemination to lung

72. Prognosis
Excellent as the tumors respond well to cytotoxic chemotherapy

73. Outline of female genital system
Diseases of the cervix
Diseases of body of uterus
Diseases of pregnancy
Tumors of the ovary
Diseases of the breast

74. Classification of ovarian tumor

75. Tumors of the ovary
Responsible for more deaths than any other gynaecological malignancy

76. Serous cystadenoma

77. Serous papillary cystadenoma

78. Serous adenocarcinoma

79. Mucinous cystadenoma

80. Mucinous adenocarcinoma

81. Krukenberg tumor (metastatic carcinoma from gastrointestinal tract)

82. Krukenberg tumor (metastatic carcinoma from gastrointestinal tract)

83. Outline of female genital system
Diseases of the cervix
Diseases of body of uterus
Diseases of pregnancy
Tumors of the ovary
Diseases of the breast

84. Normal breast

85. Key facts for proliferative conditions of the breast
Present as diffuse granularity, ill-defined lump or discrete swelling
Increased in frequency towards menopause, then rapid decrease
Variety of histological changes

86. Fibrocystic changes

87. Fibrocystic changes

88. Key facts Fibrocystic disease
Increased risk of subsequent development of carcinoma is related to the presence of epithelial hyperplasia, particularly atypical hyperplasia
Sclerosing adenosis can be clinically and radiologically confused with carcinoma

89. Predisposing factors for breast carcinoma
Atypical epithelial proliferation
Mutations of BRCA 1 and 2 genes
Long interval between menarche and menopause
Older age at first pregnancy
Obesity
High-fat diet
Lonizing radiation

90. Breast carcinoma

92. Carcinoma
Fibroadenoma

93. Paget’s disease

94. Prognosis Tumor grade and type Size of the tumor Lymph node status
Estrogen receptor status

95. Estrogen receptror staining

96. Progesterone receptor staining

97. Cerb-B2 staining

98. Diagnostic methods Fine-needle aspiration cytology Tru-cut biopsy
Examination of frozen section
Mammography and ultrasound

99. Fine Needle Aspiration

100. Fine needle aspiration under control of mammography

102. Diagnostic methods Fine-needle aspiration cytology Tru-cut biopsy
Examination of frozen section
Mammography and ultrasound

103. Case study
A 35-year-old sales assistant at a discount frozen-food warehouse, attends her doctor for a routine cervical smear. She is asymptomatic and well, but has not visited her doctor for the previous five years and has not had a smear in that time.
The cervical cytological report shows severe dyskarosis.

104. She is recalled and has colposcopy performed which demonstrates the abnormal area of the cervical squamous epithelium which is biopsied. The changes seen colposcopically extend up the endocervical canal, and the upper margin of the abnormality can not be seen.
Histology shows that this is indeed an area of CIN (cervical intraepithelial neoplasia) grade 3, at the transformation zone, with atypical cells extending through the full thickness of the epithelium and showing no maturation towards the surface.

105. Mitotic figures, including abnormal forms, are present through all layers. There is no evidence of invasion in the biopsy.
She then has a cone biopsy performed. This confirms that CIN 3 is present at the transformation zone. There is no evidence of invasive squamous-cell carcinoma, no glandular atypia and the sever atypia is completely excised at both ecto- and endocervical margins.

106. Questions
If she had not had the disease identified by screening what would have been her risk of developing invasive cervical carcinoma?

107. Questions
What are the risk factors for developing cervical carcinoma?

109. Diseases of reproductive system
Diseases of male reproductive system
Sexually transmitted disease (STD)
Diseases of female reproductive system

110. Male reproductive system

111. Normal prostate

112. Normal prostate

113. Normal adult prostate

114. Diseases of prostate gland
Prostatitis
Nodular hyperplasia of the prostate
Carcinoma of the prostate

115. Chronic prostatis

116. Nodular hyperplasia of the prostate
The most common disorder of the prostate
A common non-neoplastic lesion
Often involves peri-urethral zone

117. Nodular hyperplasia of the prostate
Nodular hyperplasia affects most males over the age of 70 years
Nodular hyperplasia is termed glandular and stromal hyperplasia

118. Etiology Androgen-estrogen imblance Other factors
Dehydrotesterone (DHT) is the main stimulator
DHT binds to nuclear receptors on both stromal and epithelial cells
Other factors

119. Affected lobes
Arises most commonly in the inner, periurethral glands of the prostate
Arises particularly from those that lie above the seminal vesicles

120. Gross feature
Nodular pattern of hyperplastic glandular acini separated by fibrous stroma
Some nodules are cystically dilated and contain a milky fluid
Other nodules contain numerous calcific concretions(corpora amylacea)

121. Nodular prostatic hyperplasia
Normal prostate gland

122. Nodular prostatic hyperplasia

123. Histological feature
Reveals two components: hyperplasia of both glands and of stroma
The acini are larger than normal

124. Prostatic hyperplasia

125. Prostatic hyperplasia

127. Clinical presentation
Compression of the urethra difficulties with micturition
Complications- prolonged prostatic obstruction can lead to outflow diseases

128. Acute cystitis

129. Trabeculation of the bladder
Stone formation
Enlarged prostate gland

130. Treatment
Anti-androgens
Surgical treatment

131. Prostate gland Prostatitis Nodular hyperplasia of the prostate
Carcinoma of the prostate

132. PIN (prostatic intraepithelial neoplasia) low grade

133. PIN (high grade)

134. Prostatic carcinoma
Adenocarcinoma occurring in males usually > 50 years (peak incidence: years)
Metastasis mainly to bone (osteosclerotic metastasis)
Obstructs bladder outflow
Many are hormone(androgen)-dependent
Genetic and environmental factors may play a role in pathogenesis

135. Types of prostatic carcinoma
Latent- small foci of well-differentiated carcinoma, remain confined to prostate for a long period
Invasive- invade locally and metastasize
Occult- not clinically apparent in primary site but present as metastatic disease

136. Prostatic carcinoma

137. Adenocarcinoma of the prostate
Well differentiated
Poorly differentiated

138. Prostatic adenocarcinoma with prominent nucleoli

139. Carcinoma of the prostate

140. PSA staining of prostate carcinoma

141. Clinical feature Often clinically silent
Urinary symptoms (delay in starting to pass urine, poor stream, terminal dribbling)
Hard, craggy prostate on rectal examination

142. Spread of prostatic carcinoma
Direct
Lymphatic
Hematogenic: most commonly to bone

143. Bone metastasis of prostatic carcinoma

144. Treatment Radical prostatectomy Reduce androgen levels Orchidectomy
Treatment with estrogenic drugs

145. Squamous carcinoma of the penis

146. Squamous carcinoma of the penis

147. Germ cell neoplasms Most common types of testicular neoplasm
Most common in the 15 to 34 age range
Types:
Seminoma (malignant)
Embryonal carcinoma (malignant)
Teratoma (benign and malignant)
Yolk sac tumor (malignant)

148. Seminoma of the testis

149. Seminoma

150. Embryonal carcinoma

151. Teratoma

153. Yolk sac tumor

154. Outline Diseases of male reproductive system
Sexually transmitted disease(STD)

155. Classical veneral diseases
Syphilis
Gonorrhea
Chancroid
Lymphogranuloma venereum
Granuloma inguinale

156. Sexually transmitted diseases (STD)
Spectrum has broadened
Transmitted by sexual contact
Transmitted by other means

157. Classification of important STDs

158. Sexually transmitted disease(STD)
Gonorrhea
Syphilis
Condylomata acuminata

159. Gonorrhea Causative organism: Neisseria gonorrheae
Almost always acqiured during sexual intercourse
Morphology: intense suppurative inflammation

160. Neisseria gonorrheae

161. Gonorrhea
Purulent urethral discharge

162. Abscess of epididymitis

163. Purulent infection of eye
Gonorrhea

164. Clinical feature Presence of dysuria Urinary frequency
Mucopurulent urethral or vaginal exudate

165. Complication Disseminated infection Chronic stricture
Chronic scarring of fallopian tubes (salpingitis)
Chronic urethral stricture
Male sterility
Female infertility

166. Transmitted to infants
Neonatal gonorrhea
Transmitted to infants
Ophthalmia neonatorum
Blindness

167. Standard for diagnosis
Detection of gonococci
Bacterial culture

168. Syphilis Causative organism: Treponema pallidum, a kind of spirochete
Almost always acqiured during sexual intercourse

169. Pathological change Infiltration of lymphocytes and plasma cells
Endoarteritis
Gumma ( a kind of granuloma)

170. Histological feature

171. Clinicopathological feature
Acquired syphilis
Congenital syphilis

172. Acquired syphilis
Primary stage
Secondary stage
Tertiary stage

173. Primary stage
Chancre

174. Secondary stage
Lymphode enlargement
Syphilid

175. Systemic involement in tertiary syphilis
Gumma formation

176. Tertiary stage
Gumma

177. Clinicopathological feature
Acquired syphilis
Congenital syphilis

178. Congenital syphilis Osteochondritis Perichondritis
Syphilitic hepatitis
Syphilitic pneumonia
Desquamation of skin
Early death
Osteochondritis
Perichondritis
Bone deformities

179. Malformation of the teeth
Saddle nose

180. Sexually transmitted disease(STD)
Gonorrhea
Syphilis
Condylomata acuminata

181. Condylomata acuminata (veneral warts)
Causative organism: Human papillomavirus(HPV)6,11
Spread of infection
Sexal intercourse
Indirect contact

182. Condylomata acuminata

183. Condylomata acuminata
Koliocytosis

184. Gold criteria for diagnosis
In situ hybridization (ISH)
Electronmicroscopy

185. Suggested reading

187. Case study
A 74-year-old retired fruit-farm labourer says that he has been feeling unusually tired and has lost his appetite. Initial blood tests show that he is anemic, with an Hb of 9.8g/dl and has renal failure with a blood urea of 26mmol/l and a creatinine of 280mmol/l.On further enquiry, you find out that he has had a poor urinary system, with some frequency, nocturia and a post-micturitional dribble.

188. Physical examination
Rectal examination reveals a rubbery, firm, smooth enlargement of the prostate gland. Further investigations include an intravenous urogram (IVU) which showed both kidneys to be functioning but also showed bilateral hydronephrosis with hydroureter.

189. Questions
what is the most likely diagnosis?

190. Questions
what further tests may be helpful?

191. Questions
what abnormality is seen in the bladder?