Reproductive system pathology

Ectopic pregnancy , abortion, DUB ,

carcinoma cervix, benign prostatic
hyperplasia, different causes of breast lump.
 Ectopic pregnancy
• Implantation and development of fertilized ovum
outside the normal endometrial cavity .
• Most common site is ampulla of fallopian tube.
Other sites of implantation are ovaries, cervix,
abdomen.
Implantation sites of ectopic pregnancy
• Etiology :
• 1. infections – salphingitis, PID(pelvic
inflammatory disease)
• 2. Iatrogenic cause- contraception failure(IUD,
Postcoital pills), tubal surgery, intrapelvic
adhesions
• 3. others – history of ectopic pregnancy, prior
induced abortions, history of infertility
 Signs and symptoms
• Amenorrhea (75%)- usually short period of 6-8
weeks, may be absent
• Abdominal pain (100%)- acute agonizing or colicky
pain in the lower abdomen is almost always present.
• Vaginal bleeding (70%) may be slight and
continuous.
• Occasionally in cases of ruptured ectopic pregnancy
patient presents with features of shock like
hypotension, tachycardia, anemia
 Abortion
• Expulsion or extraction of embryo or fetus
before the period of viability i.e. 28 weeks .
• Expulsion or extraction of embryo or fetus,
from its mother weighing <500gm which is not
capable of independent survival - WHO
• 2 types :
• 1. spontaneous abortion (miscarriage)
• 2. induced abortion :
 Spontaneous abortion
• Abortion itself without using any external medicine and
surgical process.
• Etiology
• Genetic factors- chromosomal abnormalities in the embryo is
the most common cause of spontaneous abortion
• Hormonal and metabolic disturbances affect implantation and
placentation.
• Anatomic abnormalities -hinders implantation and growth of
fetus
• Infections
• Autoimmune disease
 Induced abortion
• Deliberate termination of pregnancy either by medical
or by surgical methods before the viability of the fetus
is known as induced abortion.
• Indications:
• Therapeutic indication- to save the life of the mother
• Social indication- to prevent grave injury to the physical
and mental health of the mother
• Eugenic indication- when there is substancial risk of
child being born with serous physical and mental
abnormalities.
 Methods
I. Medical methods of termination of pregnancy
• Mifepristone and misoprostol- in first trimester
• Methotrexate and misoprostol- less commonly used
• Prostaglandins and oxytocins are used beyond first trimester for
medical termination.
II. Surgical methods
• Vacuum aspiration, suction evacuation and curettage, dilatation
and curettage are commonly used surgical techniques for surgical
termination of pregnancy in the first trimester
• Intrauterine instillation of hypertonic saline is the preferred
method beyond first trimester
 DUB
• DUB(Dysfunctional uterine bleeding) is
defined as a state of abnormal uterine
bleeding without any clinically detectable
organic, systemic, and iatrogenic cause.
• Menorrhagia- cyclic heavy +-/prolonged
menstrual bleeding
• Polymenorrhea- menstrual cycle of <21 days
lenghth
• Polymenorrhagia- polymenorrhea + heavy and
or prolonged bleeding
• Oligomenorrhea- menstrual cycle of >35 days
lenghth
 Types
I. Ovular bleeding
• Polymenorrhea –usually occurs following childbirth
and abortions, during adolescence and
premenopausal period. It occurs due to
hyperstimulation of follicles by FSH, so that the
follicular phase is shortened.
• Oligomenorrhea- usually rare and occurs during
adolescence and preceding menopause. It occurs
due to decreased sensitivity of FSH on follicles, so
that the follicular phase is lenghthened.
 Anovular
Anovular bleeding is usually excessive. In the of
growth limiting progesterone due to
anovulation, the endometrial growth is under
the influence of estrogen throughout the
cycle. Thus, with the withdrawal of estrogen
due to negative feedback action of FSH, the
endometrial shedding continues for a longer
period
 Causes of abnormal uterine bleeding

• Uterine fibroid
• Endometriosis
• Adenomyosis
• IUCD
• Genital malignancy
• Throbocytopenia
• Leukemia
• Thyroid disorders
 Carcinoma cervix
• It is the 3rd most common cancer of female
malignancy and is the leading cause of cancer
related death among female. The commonest
variety is squamous cell carcinoma.
Adenocarcinoma may be present in some
cases.
 Pathogenesis
• The ectocervix is lined with squamous
epithelium while columnar epithelium lines
the endocervix. Initially there is squamous
metaplasia of the squamocolumnar junction
and endocervix. These metaplastic cells have
potential to tranform into malignant cells
following prolonged infection or trauma.
 Risk factors

• HPV(human papilloma virus)

• Early age at intercourse
• Early age of first pregnancy
• Multiple sexual partners
• Too many and too frequent births
• Sexually transmitted disease
• Low socio-economic status
• OCP users
• C/F:
• Irregular or continued vaginal bleeding
• Offensive vaginal discharge
• Pelvic pain, leg oedema
• Inreased frequency of micturitation, dysuria,
hematuria, fistula formation
• Diarrhoea, rectal pain, bleeding per rectum, recto
vaginal fistula
• Recurrent pyelonephritis, cachexia, anemia, uremia.
BPH (benign prostatic hyperplasia)
• Benign prostatic hyperplasia (BPH) — also
called prostate gland enlargement — is a
common condition as men get older. An
enlarged prostate gland can cause
uncomfortable urinary symptoms, such as
blocking the flow of urine out of the bladder. It
can also cause bladder, urinary tract or kidney
problems
• Etiology – excess of testosterone
• Pathology – increase testosterone changes
into dihydroxy testosterone cause hyperplasia
of prostatic cells and growth in the size of
prostate. Increased size of prostate squeeze
the urethra and cause urine retention.
 Clinical features

• Symptoms: (obstructive)
• Hesitancy (trouble starting or maintaining stream)
• Poor flow
• Dribbling
• Intermittent stream
• Sensation of poor emptying
• Repeated UTI
• (Irritative)
• Frequency
• Urgency(sudden urge to urinate)
• Nocturia
• Urge incontinence
 Molar pregnancy(Hydatidiform mole)

• Most common form of gestational

trophoblastic disease.
• It is a benign form which occurs due to growth
of trophoblastic tissue resulting in swollen
chorionic villi.
 Types
• Complete
• It results from fertilization of an empty egg. All chromosomes
of the fetus has paternal origin. It is more common than
partial mole.
• Karyotype
Fetus has usually 46XX karyotype(46YY type is lethal).
Rarely have 46 XY karyotype
• There is lack of fetal tissue in this type due to lack of maternal
chromosomes.
• Lack of fetal tissues causes chorionic villi to swell and form
cyst.
• Partial
• Less common form
• It occurs due to fertilization of normal egg by 2
sperms.
• There is presence of some form of fetal tissue
due to presence of maternal chromosome.
• Karyotype :
Fetal cells are usually triploid (69XXX,69XXY, 69XYY)
 Clinical features
• Initially may mimic normal pregnancy (amenorrhea,
uterine enlargement)
• Size/date discrepancy (uterus too big for gestational age)
• Vaginal bleeding (commonest symptom)- consists of
blood mixed with gelatinous discharge from ruptured
cyst.
• Varying degree of abdominal pain and discomfort.
• Hyperemesis gravidarum (due to high levels of B hCG)
• Expulsion of grape like vesicles per vaginum usually
occurs in complete mole.
 Different causes of breast lump
• A breast lump is a localized swelling,
protuberance, bulge, or bump in the breast
that feels different from the breast tissue
around it .
 Causes of breast lump

I. Fibrocystic changes
They are a group of benign, non-proliferative breast changes which are
not asociated with the risk of developing cancer. It ocuurs in
premenopausal women.
Types :
a. Simple cyst
• Occurs in terminal duct lobular unit
• Fluid filled round cyst
b. Fibrosis
• When the cyst ruptures, it causes inflammation and subsequent fibrosis
c. Apocrine metaplasia
• Lobular epithelial tissues are replaced by glandular metaplastic tissues.
II. Proliferative breast disorders
In this disorder, there is proliferation of epithelial cells.
Proliferated cells are normal without atypia. It is
associated with small increase in risk for breast cancer.
Types :
a. Epithelial hyperplasia
• There is increase in luminal/myoepithelial cells
• Causes distension of duct/lobule
• Lumen filled with cluster of cells
b. Sclerosing adenosis
• Increased number of compressed acini
surrounded by dense stroma.
• Can cause calcifications
c. Intraductal papilloma
• Growth of ductal epithelial cells
• Cells grow in finger like projections.
• Presents with bloody/serous discharge
 III. Stromal tumors
• Arises from interlobular stroma
Types:
a. Fibroadenoma
• Most common benign breast tumor
• Consist of masses of fibrous and glandular tissues.
• Occurs in premenopausal female(15-35 years common age)
• Hormone sensitive
• Increase in size during menstrual cycle and pregnancy.
• Tumor is well defined, solid tumor and freely mobile.
• Develop in lobules
b. Phyllodes tumor
• Also a stromal tumor
• Low grade form similar to fibroadenoma
• High grade variants can metastasize
• Leaf like growth of stroma covered by
epithelial cells.
 III. Inflammatory breast disorders
a. Mammary duct ecstasia
• Distension of subareolar ducts due to chronic inflammation and
fibrosis
• Presents as painless breast mass with thick whitish discharge
from the nipple.
b. Fat necrosis
• Results from trauma to breast(biopsy, surgery, sports injury etc)
• Often calcified
c. Mastitis
• Results either from infection or inflammation of breast tissues
• Signs of inflammation like redness, warmth and discharge present
Mammary duct ectasia
Discharge from mammary duct ectasia
 IV. Breast carcinoma
• Most common non skin cancer of women
• Mostly a disease of older postmenopausal
women
• Rarely can occur in men
Risk factors
• Female gender
• Increasing Age
• Race – common in non hispanic white women
• First degree relative with breast cancer (mother, sister)
• Increased estrogen exposure ( early menarche/late
menopause, obesity)
• Age at first live birth- early age-protective, older-higher
risk
 Types
I. In-situ carcinoma
These are epithelial tumors with intact, non-invaded basement membrane.
Types:
a. Ductal carcinoma in-situ

• Arises from malignant growth of epithelial cells of terminal duct lobular

unit(TDLU)
• Fills ductal lumen
• Growth limited by intact basement membrane.
• Forms microcalcifications
• Paget’s disease is a special form of DCIS which extnds to nipple causing
erythema and bloody discharge.
b. Lobular carcinoma in-situ
• Malignant proliferation of cells of TDLU, which
resembles lobular cells.
• Limited by intact basement membrane
• Does not lead to microcalcifications
• Often bilateral
• Risk factor for developing invasive carcinoma
 II. Invasive carcinoma
• Invades basement membrane
• Types :
a. Invasive ductal carcinoma
• Cancer cells invade ductal walls and spread to breast tissues.
• Most common type
• Commonly presents as mass on outer quadrants of breast.
Inflammatory carcinoma
• A form of invasive ductal carcinoma
• Due to tumor invasion of skin and lymphatic vessels leading to erythema, swelling of
breast
• Characteristic peau d’orange appearance
b. Invasive lobular carcinoma
• Cancer cells invades lobular walls and spread to breast tissues.
• Less common type
Peau d’orange