Diseases of the female genital organs are many and varied, so in this section, their main types are reviewed.
Pathology of the vulva
Pathological processes occurring in the vulva can be divided into the following types: inflammatory processes, dystrophic processes, cysts, tumors.
Inflammation of the vulva - vulvitis often continues with inflammation of the vagina in the form of loose, vulvovaginitis and can be caused by staphylococci, streptococci, Escherichia coli, trichomonas. Sometimes gonococci, spirochetes, viruses, fungi also cause vulvovaginitis. Damage to the skin of the vulva and mucous membrane (rupture, laceration, injury) leads to vulvovaginitis. Pathological secretions from the cervix (for example, where the cancer is eroding) or infection of the urine also play a certain role in the onset of vulvovaginitis. Vulvovaginitis is characterized by swelling and burning of the mucous membrane of the vulva, as well as purulent or purulent-serous mucus. When the disease is severe, erosions may appear on the vulva. Microscopic examination reveals neutrophilic infiltration and swelling.
Dystrophy of the vulva is considered to be a non-tumor change of the vulva epithelium, which includes two main processes: 1) atrophy of the mucous membrane and the beginning of subepithelial fibrosis (lichen sclerosis); 2) the infiltration of the epithelium begins and the appearance of hyperkeratosis (granular hyperplasia). These two processes can continue together and damage different parts of the mucous membrane of the vulva.
Lichen sclerosis is often observed in women during menopause. Not only the mucous membrane of the vulva is affected, but also the skin in any place. The pathogenesis is unknown. Tightening of the epidermis continues with fibrosis of the dermis, perivascular inflammatory infiltration of mononuclear cells can also be found in the dermis. Affected areas are visible in the form of yellowish papules or papules, which sometimes merge with each other. Their surface is similar to silyl or parchment. When the entire mucous membrane of the vulva is damaged, the labia become atrophied, thin, dense, which leads to a narrowing of the entrance to the vagina.
Vulvar epithelial hyperplasia is often accompanied by hyperkeratosis. The epithelium softens, and the mitotic activity of cells in the basal and spinous layers increases. Leukocyte infiltration is observed in the dermis. Cell atypia is not characteristic for this type of vulva epithelial hyperplasia. When atypical epithelial cells appear, it should be called dysplasia.
Tumors of the vulva
Among vulva tumors, condyloma, Paget's disease, carcinoma (invasive and non-invasive carcinoma) are common.
Condyloma of the vulva is divided into two main biological forms: condyloma in the form of a cerbaric papule and condyloma with a sharp tip. The first of these is characteristic of the second period of the lesion and is visible as a flat structure that is slightly raised. Condyloma acuminate, which is somewhat more common, can have a papillary structure or can be found in the form of papillary growths. Vulvar condyloma can be single or multiple. Its diameter ranges from several millimeters to several centimeters, and its color ranges from pale pink to pinkish-brown.
Microscopic examination reveals a villi-like connective tissue covered with hyperplastic epithelium. The most important histological sign distinguishing acute condyloma is polymorphism of nuclei (koilocytosis) with perinuclear vacuolation of the cytoplasm of epithelial cells. The appearance of such cells is considered a pathognomonic sign indicating that they are infected with the human papilloma virus. The appearance of acute condylomas is considered to be related to two (6 and 11) virus genotypes. This virus is sexually transmitted, so condylomas with sharp points are common around the glans penis and anus.
Condyloma is not a precancerous process, but it can be found together with intraepithelial carcinoma of the vulva and cervix. The genotype of the virus isolated from the condyloma is different from the genotype of the virus isolated from the cancer tumor.
Paget's disease of the vulva is much less common than mammary Paget's disease. It is usually visible in the form of a dense or nodular structure, located on the labia majora of the vulva. The surface is sometimes ulcerated (eroded). The pathognomonic histological sign of Paget's disease is the widespread anaplastic tumor cells within the epidermis. They can be alone or in small groups. There is a light-colored flange around the core. These cells remain within the epidermis for a long time. If Paget's cells migrate into the subepithelial layer (invasion), the cause of the disease is much worse.
Noninvasive carcinoma of the vulva or carcinoma in situ. This tumor is also referred to as Bowen's disease and macroscopically resembles a cutaneous leukoplakia or scaly-colored papule, which may appear on the labia majora or minora, near the clitoris, or in the perianal region. The microscopic structure is different. In some cases, it can be seen that the cells inside the epithelium have undergone some degree of atypia and the number of normal mitoses has increased in the basal layer of the epithelium. In primary cases, cell atypia and anaplasia are sharply expressed. Pathological mitoses also occur. However, epithelial tumor cells do not migrate to the dermis.
The clinical course of this tumor is different, as well as its macro- and microscopic structure. In 5-10 percent of cases, especially in elderly women or in immunocompromised patients, the tumor becomes malignant. In the first cases, it is also possible to lose it. It is believed that herpes simplex virus plays a certain role in the genesis of vulvar tumor as well as in the genesis of cervical tumor.
Invasive cancer of the vulva is rare and occurs mainly in women over 50 years of age. In many cases, it continues to disappear along with condylomas and atrophic processes of the vulva. Most invasive cancers are squamous cell carcinomas. Melanocarcinoma, adenocarcinoma, basal cell cancer are observed. Squamous cell carcinoma is seen as a small, slightly raised nodule in the nascent area. Later, the shy area becomes sore. Microscopic examination reveals well-scaly cells with keratohyaline spines. This type of tumor metastasizes very early. In the etiology of invasive vulvar cancer, simple herpes virus and papilloma virus are considered to be of great importance.
Lin pathology
A solitary infection of the vagina is rare. Most of the pathological processes that begin in the vagina develop in a secondary manner and are associated with the pathology of the vulva, cervix, rectum, and vulva. Among the primary diseases of the vagina can be included: uterine anomalies, vaginitis, primary tumors.
There are not many congenital anomalies of the spleen, among them complete absence of the spleen (aplasia of the spleen), bifurcation of the spleen, two divisions of the spleen, and cysts of Gartner's tract.
Vaginitis - that is, inflammation of the vaginal membrane - occurs mostly in adolescents or in young people with vulvitis (vulvovaginitis). The causative agents of vaginitis are herpes simplex virus, gonococci, trichomonads, candida, chlamydia. In vaginitis, depending on its cause, erythema, superficial erosion of the mucous membrane is observed. In vaginitis caused by the common herpes virus, there are fragments filled with thin fluid in the mucous membrane, when they rupture, erosions occur in the mucous membrane. Vaginitis caused by fungi is characterized by a discharge similar to rotten milk, in trichomoniasis, the exudate is frothy in nature and has a yellow-green color. In specific vaginitis, a characteristic granulomatous inflammation begins in the vaginal mucosa. Atrophy of the mucous membrane is observed in chronic nonspecific vaginitis.
Tumors of the liver, especially benign tumors (fibromyoma, adenosis, papilloma, hemangioma) are rare. Among dangerous tumors, there is squamous cell cancer, adenocarcinoma (squamous cell adenocarcinoma). Leprosy tumors are primary in nature in only 2-3 percent of cases and are usually observed in the loins and in women whose mothers took the hormone diethylstilbestrol during pregnancy. This tumor sometimes appears after 30-40 years. Secondary tumors include chorionepithelioma, sarcoma in the vagina.
Cervical pathology
Various pathological processes can occur in the cervix, among which congenital anomalies, inflammatory processes and tumors are common. It should be mentioned that malignant tumors of the cervix cause the death of women in 5 percent of cases. Congenital anomalies of the cervix include its hypoplasia, bifurcation (most of the time this anomaly occurs together with the bifurcation of the uterus), the presence of cysts on the cervix. In addition, atresia and stenosis of the cervix are also observed, which causes the cervix to narrow or completely disappear. Cervical effacement can cause infertility or hematoma.
Cervicitis
Cervicitis - inflammation of the mucous membrane of the cervix - is divided into specific and non-specific types. Specific types include servicitis with wounds, warts, and tuberculosis. Nonspecific cervicitis is often caused by Escherichia coli, streptococci, and staphylococci. For example, cervical rupture, hypoestrogenemia, and hyperestrogenemia in the pathology of the cervix have a certain significance in the examination shaft with instruments.
Nonspecific cervicitis can be acute or chronic. The causative agent of acute cervicitis is streptococcus or staphylococcus. In this case, the inflammatory process occurs in the surface layers of the mucous membrane of the endocervix and its glands (endocervicitis). The pharynx becomes inflamed and swollen.
In chronic cervicitis, the process also extends to the exocervix. It begins with the mucous membrane slightly sliding and swelling. At the point of transition from the cylindrical epithelium to the multi-layered flat epithelium (near the exit hole of the cervical canal), the mucous membrane has a granular color. When the inflammatory process is significant, erosions and ulcers may appear. In such cases, areas of full crimson color can be seen on the light pink mucous membrane that has not changed. Microscopic examination of the endocervical epithelium shows monocytic infiltration mixed with polymorphous nuclear leukocytes. Here, the inflammatory infiltrate can pass to the mucous membrane of the cervix (endocervix) and spread to the mucous glands. When chronic inflammation continues for a long time, the epithelium can meet with complete metaplasia and even dysplasia.
According to the histological changes, two types of erosions are distinguished: 1) true erosion, the bottom of which consists of granulation filling, and 2) false erosion, in which the cell in the multi-layered epithelium of the exocervix is filled with cylindrical epithelium. At the same time, around the discharge hole of the cervical canal, light gray balls are visible (Fig. 72). In the case of cervicitis, endocervical glands are sometimes enlarged and cysts filled with pus or colloidal fluid are formed (ovulla Nabothi). In initial erosions, papillary tumors lined with cylindrical epithelium appear. In some cases, multi-lobed squamous epithelium appears on the edge of erosions, invades the ducts of the glands and displaces the cylindrical epithelium, which can be mistaken for squamous cell carcinoma. Lymphoid follicles sometimes appear in chronic inflammation of the mucous membrane of the cervix (follicular cervicitis).
Cervicitis in itself is not considered a precancerous process, but if the epithelium undergoes dysplasia and false erosions occur in it, it can be considered a precancerous disease. As a result of bulging of the cervical membrane due to inflammation, or as a result of scarring of the ruptured areas, the cervical membrane can turn into a cavity, this is called ectropion.
Cervical tumors
Cervical tumors are very different. However, polyps and squamous cell carcinomas are common, and we will look at them in this chapter.
Polyps occur in 2-5 percent of women and can sometimes cause mucus to leak out. They usually occur in the endocervical canal. It can be female, in the form of a hemispherical or spherical structure up to 3 cm in diameter. Sometimes it appears in the uterine canal, causing the cervix to swell or become inflamed. Polyps are characterized by being soft. Microscopic examination reveals a fibromyxomatous stroma with enlarged endocervical glands. The epithelium of polyps is cylindrical and produces mucus. At the beginning of chronic inflammation, the cylindrical epithelium can turn into a multi-layered flat epithelium and become an ulcer. Malignancy is rare.
Cervical cancer
Cervical cancer is the 7-8th most dangerous tumor in women in terms of the cause of death. This cancer can be invasive or carcinoma in situ. Most intraepithelial cancers occur in women in their 30s, while invasive cancers occur in women in their 40s and older.
Starting sexual life early, having sexual intercourse with many people are considered to be risk factors for the onset of uterine cancer. This cancer is more common in countries with low socio-economic status and widespread prostitution. Most of them are observed in women with multiple pregnancies, as well as in women whose husbands are not circumcised.
Etiology and pathogenesis. The causes of cervical cancer are still unknown. Many scientists believe that the herpes simplex virus (type II) and the human papilloma virus are related. Condylomas caused by human papilloma virus genotypes 6 and 11 are considered cancer precursors. The main genotypes of this virus are also important in the development of certain cancers and dysplasia: 16, 18, 31. viruses are not always an etiological factor.
There are several key differences in the progression of cancer. Grade I is characterized by mild dysplasia of the cervical epithelium or flat condyloma. Cells with polymorphous nuclei of different sizes appear in stage II. However, mitoses usually appear normally, but are visible in the basal layer. The appearance of moderate dysplasia consists of these changes. Structural changes observed in the first and second layers of the epithelium of the cervix are gradual. In stage III of cancer, dysplasia reaches a significant level and cell atypicality increases. They are polymorphic, their nuclei are hyperchromic, they have lost their epithelial integrity. In all cases, both normal and pathological mitoses are visible, they are even in the cells of the epithelial surface layer. But atypical cells do not migrate to the stroma, but form "cancer in situ" (cancer within the epithelium). The next stage IV of the process is considered invasive cancer, its development takes several years (10-15 years) including stage I.
Pathological anatomy. Dysplasia and cancer often occur at the point where the columnar epithelium transforms into a multi-layered squamous epithelium, that is, around the foramen pit. Epithelial cancer can be detected by eye even in stage III. Early biopsy can detect this type of cancer.
Invasive cancer can be seen in three different ways: 1) lenticular cancer, 2) ulceration (a wound caused by necrosis of the tumor center), 3) infiltrative, which grows endophytically and invades the underlying stroma. cancer Invasive cancer can easily grow into surrounding tissues and organs (cerebral colon, rectum, uvula) and block the urinary tract. Later, lymphogenous and hematogenous metastases appear, and the cancer can also spread to para-aortic lymph nodes, lungs, bones, and liver. In terms of histological structure, squamous cell carcinoma of the cervix is often observed (in 95 percent of cases), and adenocarcinoma is observed in rare cases.
Clinical picture. Stage I intraepithelial cancer is asymptomatic and can be detected during colposcopy. Invasive cancer is sometimes accompanied by vaginal discharge, leucorrhoea, pain in the case of genital warts, and urinary incontinence. Cancer is easy to find by palpation and mirror examination. A biopsy is necessary to confirm the diagnosis.
Local complications of cervical cancer - compression and blockage of both ureters, perforation of the cancer into the pelvis or rectum - are often the cause of death. The cause of the disease depends on the source of the cancer and the treatment in the country. For example, if intraepithelial cancer (stage O) is not the direct cause of death, the survival rate for stage IV is 10%.
