MedicoPlexus
Contributing Authors:
Linus Kutup, Eric Hoffmeister, Benjamin Kersch, Niclas Samirae, Tobias Verdegem, Alexander Wolff, Lara Afaneh, Joana Strzlkowski, Nadine Fernandez, Katharina Weitzel
86. Inflammatory diseases of the uterus, the fallopian tubes and the ovaries – morphology, complications.
Introduction to female genitalia:
1) Gross anatomy:
a) Vulva = external genitalia: Labia majora, Labia minora, clitoris
b) Vagina = ‘tube’ that connects vulva with cervix
c) Cervix uteri: distal part of uterus, a part of cervix extends into vagina
d) Uterus
e) Uterine tubes/ Fallopian tubes/ Salpinx: connect uterus with ovaries
f) Ovaries
2) ‘Healthy’ histology:
a) Vagina: Squamous epithelium, no mucus glands (only serous!) -> In case there are vaginal mucus secretions, the mucus actually comes from the cervix (cervicitis,)
b) Cervix:
The epithelium of the cervix is of 2 types:
1) Ectocervix:
– Stratified squamous non-keratinizing epithelium
– covers the outer surface of cervix (see picture below), can be seen during vaginal examination due to its location on the outside of that part of cervix, that extends into vagina
– is simply a continuation of the vaginal epithelium
– has pale color
– lines the ‘external os/ external orifice’ (=Muttermund) of cervix, from there continuous inwards into the cervical canal and there the transformation into the endocervix takes place
2) Endocervix:
– Simple columnar epithelium with mucus secreting glands
– lines the cervical canal (inside of cervix) -> see picture
– has red color
– In young adult females we might find some endocervix in the area of the ectocervix, which can be seen during vaginal inspection as red areas in the white ectocervix. It is often mistaken as inflammation. Always make brush biopsy to make sure that it is only endocervix and not any disease tho! The abnormal areas of endocervix within the ectocervix are called ‘ectropion’.
- The location where the 2 types of epithelium meet is called ‘Squamocolumnar junction’
- Here we will also find the transformation zone -> the glandular columnar epithelium from endocervix is replaced by non- glandular squamous epithelium from ectocervix -> Squamous metaplasia. The immature squamous metaplastic cells here at the junction are most susceptible to HPV infections -> most HPV related cancer develop in the transformation zone.
- These 2 zones move upwards the cervical canal over time!
b) Uterus:
– the epithelium that lines the uterus is called endometrium
– endometrium is a columnar epithelium and it undergoes monthly changes during the menstrual cycle
– The endometrium is said to consist of 2 layers of epithelium:
– Functionalis: is the surface layer that grows during menstrual cycle and which is then repelled during menstruation
– Basalis: is the deeper layer of epithelial cells, which is constant and always present
– The menstrual cycle can be divided into 4 phases:
1) Proliferative phase: small glands in mucosa (small lumina), nuclei are at BASAL cell membrane (away from lumen) of the columnar cells that form the gland (see picture)
2) Early secretory phase: Nuclei are now at APICAL cell membrane (close to lumen) -> look like piano keys -> There are subnuclear vacuoles (filled with the substance to be secreted) that push the nuclei upwards
3) Late secretory phase: Secretions in lumen -> irregular shape of lumen
4) Bleeding phase: Hemorrhages, neutrophilic infiltration (misses in the picture below)
Now, syllabus point:
Inflammatory diseases of the uterus, the fallopian tubes and the ovaries – morphology, complications.
1) Inflammation that affects all(!!!) of the above- mentioned structures: Pelvic inflammatory disease (PID):
– PID is an infection that begins in the vulva or vagina and then spreads upwards and ultimately involves all/most structures of the female genital system
– PID results in pelvic pain, adnexal tenderness (adnexa= all structures that are functionally and anatomically closely related to uterus), fever, vaginal discharge.
– Most common causative agents: Neisseria gonorrhea, Chlamydia, infections after abortion (puerpal infections) due to streptococci, staphylococci, clostridium perfingens
– Complications of acute PID: peritonitis and bacteremia which then may result in endocarditis, meningitidis, suppurative arthritis.
– Complications of chronic PID: infertility, tubal obstruction, ectopic pregnancy, intestinal obstructions due to adhesions between the bowel organs and the pelvic organs
– Morphology of inflammation of the individual structures is discussed below
2) Inflammatory diseases of the cervix:
The squamous epithelial cells of vagina and ectocervix produce much glycogen, which allows especially lactobacilli to survive in this region. The lactobacilli produce lactic acid -> lactic acid keeps the vaginal and cervical pH below 4.5. This inhibits the growth of many bacteria and serves as a good protection. Also, the low pH resulting from lactic acid secretion stimulates the lactobacilli themselves again to produce H2O2, which also suppresses growth of other bacteria. BUUUUT: Sexual intercourse, bleeding, etc. can change the pH of the vagina and cervix and can decrease H2O2 synthesis by lactobacilli -> more alkaline pH and decreased H2O2 synthesis means less protection for vagina and cervix after sex, bleeding etc -> allows overgrowth of other microorganisms -> Cervicitis and vaginitis -> This is why women are at an increased risk of genital tract infections after sex!
Most common causative agents of cervitis:
Cervitis is almost always caused by sexual transmission (Sexually transmitted diseases = STD), it is different from urinary tract infections which are mostly caused by your own gut bacteria. Possible microorganisms that are transmitted via the sexual route:
a) Herpes simplex infection
– HSV type 2 (HSV type 1 is responsible for facial herpes)
– Clinical symptoms
– in about 1/3 of infected individuals painful red papules 3-7 days after sexual relations; progress to vesicles, then to coalescent ulcers; cervical or vaginal involvement causes severe leukorrhea (genital discharge)
– the initial infection often produces systemic symptoms such as fever, malaise, and tender inguinal lymph nodes
– Heals spontaneously in 1-3 weeks, but latent infection of regional nerve ganglia persists → recurrences occur due to stress, etc! Herpes implex infection stays for life!
– Transmission during sex may occur during active or also during latent phases
– Transmission to the neonate during birth is possible
– HSV usually involves the vulva, vagina, and cervix concomitantly
b) Chlamydia trachomatis
– as many as 1 in 10 adolescent females test positive for chlamydia
c) N. gonorrhea:
– approximately 2-7 days after inoculation of the organism occurs acute suppuration, which is confined to the superficial mucosa and underlying submucosa,
– Smears – intracellular Gram (-) diplococcus, but confirmation requires culture
– as the infection spreads upwards, the endometrium is usually spared, but acute suppurative salpingitis occurs
– after days or weeks: salpingo-oophoritis; tubo-ovarian abscesses, pyosalpinx
– Adhesions of the tubal plica may produce glandlike spaces (follicular salpingitis)
d) Trichomonas vaginalis
– a large, flagellated ovoid protozoan (parasite!)
– Infections may occur at any age
– a purulent vaginal discharge and discomfort; vaginal and cervical mucosa typically has a characteristic fiery red appearance (strawberry cervix)
– Histo – the inflammation is usually limited to the mucosa and immediately subjacent lamina propria
- Remember: among other functions, cervix serves as the protective shield for uterus, fallopian tubes and ovaries -> gets more often infected!
3) Inflammatory diseases of the uterus:
– are rare, because usually the endocervix forms a barrier to ascending infections
– inflammation of cervix are thus very common, but inflammation of uterus is abnormal and should be of concern (excluding the menstrual phase! -> in menstrual phase we have endometritis due to all the necrosis that triggers an inflammation as the endometrium is repelled -> many neutrophils in endometrium!)
a) Acute endometritis:
– rare
– is limited to bacterial infections occurring after delivery or miscarriage
– usually is due to the retained ‘products’ of conception which often contain group A streptococci, staphylococci, etc
– Removal of the retained gestational fragments together with antibiotic therapy clears the infection
– Many neutrophils in endometrium (there are always some neutrophils in endometrium due to the menstruation- linked inflammation every month!)
b) Chronic endometritis:
– is associated with the following disorders:
– chronic PID
– Retained gestational tissue (postpartum or postabortion)
– Intrauterine contraceptive devices
– Tuberculosis (from miliary spread or from drainage of tuberculous salpingitis)
– plasma cells (produce antibodies) and other lymphocytes in endometrium
4) Inflammatory diseases of the fallopian tubes (=salpinx)
– also rare, because of the endocervix that acts as a barrier
a) Suppurative salpingitis = pyosalpinx
– may be caused by any pyogenic bacteria, most often Gonococcus = N. gonorrhea, followed by chlamydia
– occurs usually as ‘component’ of PID
– Neutrophils!!! -> pus
b) Tuberculous salpingitis:
– rare in developed world
– in developing world, where TB is still quite widespread, tuberculous salpingitis in an important cause of infertility
– granuloma with caseous necrosis!!!
Cysts: usually not of inflammatory origin!
– are thought to arise in remnants of the Müllerian duct and are of little significance
5) Inflammatory disorders of ovaries (Oophoritis):
The most common lesions found in the ovaries are benign cysts and tumors. Oophoritis is rare and uncommon. If they occur, they are usually related to salpingitis and the inflammatory effects in the ovaries may lead to infertility.
According to syllabus point, we do not need to talk about it, but he has many slides about it in the lecture, so enjoy the disorders of the vulva 😊
Disorders of the vulva (external female genitalia):
– can be inflammatory, can be cysts, can be tumors,…
1) Bartholin cysts:
– They arise from the Bartholin glands (greater vestibular glands) which are the female analog of the Cowper’s (bulbourethral) glands in men
– Bartholin cysts are due to acute infections of the
Bartholin glands (-> adenitis) or due to obstruction of
the Bartholin glands
– relatively common, occur at any age,
– can be up to 5cm large
– often recurrent, but never become malignant!
– pain and local discomfort
2) Leukoplaquia:
– opaque, white, scaly, plaque-like mucosal thickenings -> pruritus (itching)
– may reveal one of several conditions:
– vitiligo
– dermatoses – psoriasis, chronic dermatitis
– vulvar intraepithelial neoplasia, Paget disease, or even invasive carcinoma
– alterations of unknown etiology
3) Nonspecific inflammatory alterations of the vulva:
– classified using accepted dermatologic diagnoses:
a) lichen sclerosis – subepithelial fibrosis:
– any age, most common after menopause
– unclear pathogenesis, but may be autoimmune
– slow in developing, insidious, or progressive
– not a precancerous condition, but greater risk of
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