Female Genital Diseases Overview

Female Genital Diseases-1

• Vulva Diseases: Infectious vulvitis is caused by various agents, namely HPV, causing condylomata acuminata (warts) and vulvar intraepithelial neoplasia (VIN). Also, HSV (herpes simplex virus) 1 or 2 causes vesicular eruptions. Gonococci produce suppurative infections in vulvovaginal glands. Syphilis manifests as a primary chancre at inoculation sites. Candida causes itchy rashes on the vulva and surrounding areas.

• Vulva Complications: Complications include Bartholin gland cysts, resulting from duct occlusion. These cysts can become infected and form abscesses.

• Inflammatory Dermatoses of Vulva: Contact dermatitis is a common cause, stemming from reactions to irritants (like urine, chemicals) or allergens.

• Non-contact Vulval Dermatoses: Lichen sclerosus (formerly known as lichen sclerosus et atrophicus) is a chronic inflammatory dermatosis affecting genital areas of both sexes, typically characterized by itchy, smooth, white-to-gray plaques. It predominantly affects postmenopausal women. Microscopically, it exhibits hyperkeratosis and a thin epidermis without rete ridges. Another form, Lichen simplex chronicus (neurodermatitis), is a chronic skin condition causing thickened skin due to repeated scratching or rubbing. Microscopically, this shows acanthosis, hyperkeratosis, and dermal inflammation.

• Benign Vulval Tumors: Papillary hidradenoma arises from apocrine glands, often localized to the labia. Microscopically, it's characterized by irregularly shaped tubular structures, duct-like structures, and intraluminal papillary projections, all lined by two cell layers (columnar and cuboidal).

• Condyloma Acuminatum: A wart-like, verrucous lesion caused by HPV types 6 or 11. It typically affects the vulva, perineum, and vagina and is characterized by sessile or pedunculated epithelial proliferations of stratified squamous cells. Perinuclear cytoplasmic clearing can also occur in some cells.

• Malignant Vulval Tumors: Vulvar intraepithelial neoplasia (VIN), caused by HPV 16, is a precancerous condition occurring most frequently in the 4th or 5th decade of life; it often progresses to invasive carcinoma in the sixth decade.

• Invasive Squamous Cell Carcinoma (SCC): Histologically, this usually presents as well-differentiated squamous cell carcinoma with keratin pearls and nests, and distinct intracellular bridges. Prognosis hinges on the size, invasion depth, and lymph node status.

• Paget's Disease of the Vulva: This is a carcinoma in situ (CIS) mainly observed on the labia majora, appearing as a red, crusted, sharply demarcated area. It's characterized by large, anaplastic cells arranged singly or in clusters and lacks underlying intraductal carcinoma.

• Other Vulvar Carcinomas: Other malignant entities include basal cell carcinoma, adenocarcinoma of Bartholin or sweat glands, and malignant melanoma.

Vaginal Diseases

• Vaginal Infectious Inflammation: Common causes include discharge, and are usually sexually transmitted. The main vaginal organisms include Gardenella vaginalis, Neisseria gonorrhoeae, Candida albicans, and Trichomonas vaginalis.

• Vaginal Intraepithelial Neoplasia (VaIN): Defined by squamous cell atypia without invasion. VaIN grades (1, 2, 3) are based on epithelial involvement layers. VaIN 3 involves the full epithelial thickness. It is often related to HPV infection.

• Invasive Vaginal Squamous Cell Carcinoma: Primary vaginal squamous cell carcinoma is uncommon. The vast majority are HPV-associated and preceded by VaIN 3.

• Clear Cell Adenocarcinoma: This very rare tumor predominantly affects young women whose mothers were exposed to diethylstilbestrol during pregnancy. It's composed of glands lined by vacuolated clear cells. Embryonal rhabdomyosarcoma also exists; it is a rare, polypoid tumor in young girls.

• Cervical Diseases: Infectious cervicitis, is extremely common, often caused by Chlamydia trachomatis, N. gonorrhoeae, and Trichomonas vaginalis. It may be chronic or acute, often resulting in purulent discharge. Cervicitis can also occur due to chemical or mechanical irritation. In chronic forms, there is infiltration by chronic inflammatory cells, and possible metaplasia of endocervical columnar epithelium to squamous epithelium and Nabothian cysts.

Endocervical Polyps:

• Endocervical Polyps: These are commonly found at any age, and range in size. They consist of a connective tissue stroma containing blood vessels, often lined by endocervical or metaplastic squamous epithelium. Chronic inflammation may play a role. These polyps commonly pose no malignant risk.

Cervical Intraepithelial Neoplasia (CIN):

• Cervical Intraepithelial Neoplasia (CIN): CIN lesions are typically caused by HPV infection, starting at the squamo-columnar junction and commonly occurring in adolescents. The tissue exhibits squamous metaplasia, maturation changes, and cytologic atypia. Nuclear atypia includes features such as hyperchromasia, pleomorphism, increased mitotic activity, and an increased nuclear-to-cytoplasmic (N/C) ratio.

Cervical Squamous Cell Carcinoma (SCC):

• Invasive Cervical Squamous Cell Carcinoma (SCC): Peak incidence is around 45, typically affected individuals are multiparous, having had several pregnancies; typically precedes by CIN3 severity. Clinical symptoms include pain, bleeding and/or painful intercourse. Predisposing factors include early sexual activity, high parity, infection with herpes simplex type II and HPV, and prolonged exposure to estrogen. Grossly, it is usually polypoid (most common), ulcerative, or infiltrative. Microscopically, keratinizing SCC displays keratin pearls, abundant keratohyaline granules, intercellular bridges, and hyperchromatic nuclei. Nonkeratinizing SCC is distinguished by polygonal cells forming sheets or nests, intercellular bridges and lacking keratin pearls. Papillary SCC displays papillae with fibrovascular cores lined by multilayered epithelium. Basaloid SCC shows defined nested groups of immature basaloid cells. The stages of SCC are determined based on the extent and depth of invasion, and regional or distant metastasis; a classification system exists, and these are included in the notes.

Other Malignant Cervical Tumors:

• Other Malignant Tumors of the Cervix: The cervix can be affected by other malignant neoplasms including adenocarcinoma, adenosquamous carcinoma, clear cell adenocarcinoma, and small cell carcinoma, sarcomas and melanoma.

Effects of Cervical Cancer:

• Spread and Complications: Cancer of the cervix can spread locally to surrounding tissues, through lymph nodes (e.g., iliac, sacral, hypogastric), and through the bloodstream to other organs like liver, lungs, and bones. It may lead to vesico-vaginal or recto-vaginal fistulas, and pyometria.

This quiz explores various diseases and complications of the vulva, including infectious vulvitis from agents like HPV and HSV, as well as inflammatory dermatoses such as contact dermatitis. It also covers non-contact conditions like lichen sclerosus and complications like Bartholin gland cysts. Test your understanding of these critical women's health issues.