Female Genital Pathology
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Direct answer
Female genital pathology concentrates on the cervix — human papillomavirus-driven CIN progressing to squamous carcinoma, with postcoital bleeding the early alarm — and the uterine corpus, where unopposed oestrogen links endometrial hyperplasia to carcinoma presenting as postmenopausal bleeding. Benign disease includes endometriosis with chocolate cysts, adenomyosis and leiomyoma, the commonest tumour of the female genital tract. India's national HPV vaccination programme for adolescent girls frames the prevention angle.
What you must remember
- Cervical carcinogenesis: high-risk HPV 16 and 18 whose E6 degrades p53 and E7 disables Rb; koilocytosis marks productive infection; CIN I involves the basal third, CIN II up to two-thirds, CIN III the full thickness as carcinoma in situ.
- Screening and prevention: cervical cytology, visual inspection with acetic acid in programme settings and HPV DNA testing; India has launched nationwide free quadrivalent HPV vaccination for girls around age fourteen on a single-dose schedule.
- Cervical carcinoma: squamous commonest, spreading into parametrium and vagina then pelvic nodes; postcoital or intermenstrual bleeding early, foul discharge; advanced disease causes hydronephrosis and uraemia.
- Endometriosis: endometrial glands and stroma outside the uterus — ovarian chocolate cysts and pouch of Douglas implants — with dysmenorrhoea, dyspareunia and subfertility; adenomyosis is basal endometrium invading myometrium in a boggy, symmetrically enlarged painful uterus.
- Endometrial hyperplasia: unopposed oestrogen from anovulation, polycystic ovaries, obesity or tamoxifen; atypical hyperplasia carries marked progression risk and needs progestins or hysterectomy.
- Endometrial carcinoma: postmenopausal bleeding is the red flag; type I oestrogen-driven endometrioid disease with PTEN alterations against type II serous carcinoma with p53 in older atrophic uteri, which behaves worse.
- Leiomyoma: commonest female genital tract tumour — oestrogen-dependent whorled smooth muscle in a pseudoencapsule, causing menorrhagia and mass effects; submucosal fibroids bleed most, red degeneration complicates pregnancy, and shrinkage follows menopause. Leiomyosarcoma is a solitary soft necrotic mass with atypia and brisk mitoses, arising de novo.
- Vulva and vagina: lichen sclerosus with atrophic parchment skin predisposing to squamous cancer; sarcoma botryoides, a grape-like embryonal rhabdomyosarcoma of young children.
Common confusion
CIN grading is by epithelial thickness occupied, while invasion means basement-membrane breach. Adenomyosis is a symmetric boggy painful uterus against discrete firm fibroid nodules; endometriosis sits outside the uterus altogether. Cervical cancer is HPV-driven while type I endometrial cancer is oestrogen-driven — students frequently swap these mechanisms.
Exam-focused takeaway
FMGE gives a young woman with postcoital bleeding and asks for the virus and its oncogenes, or a postmenopausal woman with bleeding and asks for the first investigation. Koilocytes, CIN III, unopposed oestrogen, whorled fibroid architecture and red degeneration are recurring marks, with the single-dose HPV schedule a new public-health favourite.
Frequently asked questions
Which HPV types cause cervical cancer?
Types 16 and 18 cause the great majority, with 31, 33 and 45 next; types 6 and 11 cause warts. Quadrivalent vaccines cover 6, 11, 16 and 18.
What are koilocytes?
Cells with perinuclear halos and wrinkled raisin-like nuclei indicating productive HPV infection, the cytological hallmark of low-grade lesions.
Why does unopposed oestrogen cause endometrial cancer?
Proliferation without progestin-driven shedding allows progression through hyperplasia and atypia to carcinoma in anovulatory states, obesity and oestrogen-secreting tumours.
How does endometriosis present?
Cyclical pelvic pain, severe dysmenorrhoea, dyspareunia and subfertility, with powder-burn implants and chocolate cysts at laparoscopy; histology needs glands plus stroma outside the uterus.
What separates leiomyosarcoma from fibroid?
A solitary soft, necrotic, haemorrhagic mass with atypia, brisk mitoses and invasive borders, generally arising de novo; rapid postmenopausal enlargement of a fibroid is suspicious.
What is sarcoma botryoides?
An embryonal rhabdomyosarcoma of the vagina or bladder in children under five, protruding as a grape-like cluster; multimodal chemotherapy with conservative surgery is current practice.