Sexual organs

Sexual organs
* Genitalia
* Reproductive tracts
* Glandular systems
* Nervous system

Women
* Genitalia
o Vulva
o Clitoris
o Vagina
* Reproductive tracts
o Ovaries
o Fallopian tubes
o Uterus
The vulva
* Mons pubis or mons veneris
* Labia majora
* Labia minora
* Prepuce or clitoral hood
* Bartholin’s glands
* Vaginal opening
* Skene’s glands
* Introitus or vestibule; vestibular bulbs
* Pubococcygeal muscles and Kegel exercises: close to 1 cm diameter
o Vaginismus and dyspareunia
* Perineum and episiotomy

The clitoris
* Glans
* Shaft
* Smegma
* Circumcision, clitoridectomy (excision), Pharaonic circumcision, and infibulation
* Urethra, between clitoris and vagina

The vagina
* Hymen or maidenhead
* Mucosal lining: Lubrication
* Nerve endings: Outer 1/3 of vagina
* Grafenberg spot

Vaginal health
* Self-examination with mirror, flashlight
* Do not douche or use vaginal deodorants
* Wash vulva daily, but do not scrub
o Insist that a sexual partner is also freshly clean
* Wear all-cotton panties
o Especially if taking antibiotics or perspiring
* Normal signs:
o A creamy discharge, clear to white in color
o Odor from sweet to musky, varies with hormones, medication, perspiration
* Limit tampon use: TSS, ulceration
o Avoid superabsorbent types
o Four-hour limit; no overnight use
* Change panty liners frequently
* Warning signs of vaginitis:
o Yellow or green discharge, clumps in discharge
o Foul odor
o Irritation, itching, or burning
o Urgent need to urinate

Reproductive tract
* Uterus
o Fundus and body: Perimetrium, myometrium, and endometrium: Endometriosis
o Cervix and Os
* Ovaries: Hormones and ova
o Ovarian ligaments
o Follicles and oocytes
* Fallopian tubes
* Hysterectomy

Fallopian tubes
* Fimbriae collect ova
* Infundibulum and ciliary movement
* Fertilization
* Ectopic pregnancy

Menstruation
* Menarche
* Dysmenorrhea
* Oligomenorrhea, amenorrhea, and menorrhagia
* Attitudes toward menstruation
* Sexual activity during menses: Safer sex
* PMS/PMDD: Does it exist?

The menstrual cycle
* 1. Menstrual phase, 5 days (variable)
* 2. Proliferative phase, 9- 11 days
o FSH --> Estrogen --> Endometrial growth
* 3. Ovulation, 14 days before menses
* 4. Secretory or luteal phase, 14 days
o LH --> Progesterone --> Preparation for implantation
Menopause
* Clemacteric, perimenopause, and menopause
* Decreased responsiveness of ovaries to pituitary hormones
* Perimenopausal symptoms
o Flashes, flushes, and sleep problems
o Dizziness, pains, and paresthesias
o Vaginal dryness, impaired cognition
* HRT/ERT
HRT/ERT: Increased risk of health problems counter obvious benefits
* Breast cancer:
o Estrogen alone: 15% increased risk; Estrogen + progestin: 58%; Estrogen + testosterone: 77% (all compared to no HRT) (Tamimi et al, 2006)
o The Women’s health Initiative study (2002) reported 26% increase in estrogen + progestin group—from 30/10,000 to 38/10,000

Other health risks of HRT
* Contrary to predictions, a 29% increased risk of heart attack (37/10,000 vs 30/10,000)
* 41% increased risk of stroke (29/10,000 vs. 21/10,000)
* Blood clot risk more than doubles (34/10,000 vs 16/10,000)
* Risk of ovarian cancer triples in women using estrogen for 20 or more years (NCI, 2002)
* Estrogen + progestin HRT impairs hearing (Frisina et al, 2006)

The gynecological examination
* Medical and sexual history
* External examination
* Speculum examination
* Pap smear
* Palpation
* Recto-vaginal examination
* Breast examination
o Breast self-examination
Breasts

* Secondary sex characteristics and self-esteem: Breasts vs. menstruation
* Mammary glands and ducts
* Adipose tissue
* Nipples and areolas
o Respond to stimulation: Temperature, arousal
o May be involuted
* Sensitivity varies with menstrual cycle

Sexual organs.ppt

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Cervical/Vulvar/Vaginal Cancer

Cervical/Vulvar/Vaginal Cancer
By:Steve Remmenga, M.D.
The McClure L Smith Professor of Gynecologic Oncology
Division of Gynecologic Oncology, Department of OB/GYN
University of Nebraska Medical Center

Cervical Cancer

Cervical CA
* International estimates
Pap Smear
* With the advent of the Pap smear, the incidence of cervical cancer has dramatically declined

Cervical CA Etiology
* Cervical cancer is a sexually transmitted disease.
* HPV DNA is present in virtually all cases of cervical cancer and precursors.
* Some strains of HPV have a predilection to the genital tract and transmission is usually through sexual contact (16, 18 High Risk).
* Little understanding of why small subset of women are affected by HPV.
* HPV may be latent for many years before inducing cervical neoplasia.

Cervical CA Risk Factors
* Early age of intercourse
* Number of sexual partners
* Smoking
* Lower socioeconomic status
* High-risk male partner
* Other sexually transmitted diseases
* Up to 70% of the U.S. population is infected with HPV

Prevention
* Educate all providers, men and women regarding HPV and the link to cervical cancer.
* Adolescents are an especially high-risk group due to behavior and cervical biology.
* Delay onset of sexual intercourse.
* Condoms may help prevent sexually transmitted disease.

Screening Guidelines for the Early Detection of Cervical Cancer, American Cancer Society 2003
* Screening should begin approximately three years after a women begins having vaginal intercourse, but no later than 21 years of age.
* Screening should be done every year with regular Pap tests or every two years using liquid-based tests.
* At or after age 30, women who have had three normal test results in a row may get screened every 2-3 years. However, doctors may suggest a woman get screened more if she has certain risk factors, such as HIV infection or a weakened immune system.
* Women 70 and older who have had three or more consecutive Pap tests in the last ten years may choose to stop cervical cancer screening.
* Screening after a total hysterectomy (with removal of the cervix) is not necessary unless the surgery was done as a treatment for cervical cancer.

Pap Smear
* Single Pap false negative rate is 20%.
* The latency period from dysplasia to cancer of the cervix is variable.
* 50% of women with cervical cancer have never had a Pap smear.
* 25% of cases and 41% of deaths occur in women 65 years of age or older.

Symptoms of Invasion
* May be silent until advanced disease develops
* Post-coital bleeding
* Foul vaginal discharge
* Abnormal bleeding
* Pelvic pain
* Unilateral leg swelling or pain
* Pelvic mass
* Gross cervical lesion

Cell Type
* Squamous Cell Carcinoma 80-85%
* AdenoCarcinoma 15%
* Adenosquamous
* Others

Staging
* Clinical Staged Disease
o Physical Exam
o Blood Work
o Cystoscopy
o Proctoscopy
o IVP

Staging Cervical Cancer
* Stage I Confined to Cervix
Microscopic Disease
* Squamous carcinoma of the cervix that has <3mm invasion from the basement membrane
* The diagnosis must be based on a cone or hysterectomy specimen.
* No lymph-vascular invasion
* May be successfully treated with fertility preservation in selected patients
* These patients should all be referred for consultation.





Staging

* Stage III Lower 1/3 Vagina, Sidewall or ureteral involvement
* IIIA Lower 1/3 of Vagina
* IIIB Sidewall or Ureteral Involvement
* Stage IV Bladder, Rectal or Distal Spread
* IVA Bladder or Rectal Involvement
* IVB Distal Spread

Treatment of Early Disease
* Conization or simple hysterectomy (removal of the uterus) - microinvasive cancer
* Radical hysterectomy - removal of the uterus with its associated connective tissues, the upper vagina, and pelvic lymph nodes. Ovarian preservation is possible.
* Chemoradiation therapy

Advanced Disease
* Chemoradiation is the mainstay of treatment

What is Standard Therapy for
Stage IB2 - IVA Cervical Carcinoma?
* External beam pelvic radiation (4,000 to 6,000 cGy)
* Brachytherapy (8,000 to 8,500 cGy to Point A)
* I.V. Cisplatin chemotherapy

Symptoms of Recurrence
* Weight loss, fatigue and anorexia
* Abnormal vaginal bleeding
* Pelvic pain
* Unilateral leg swelling or pain
* Foul discharge
* Signs of distant metastases
* NOTE: must distinguish radiation side effects from recurrent cancer

Management of Recurrence
* Chemoradiation may be curative or palliative, especially in women who have not received prior radiation therapy.
* Isolated soft tissue recurrence may occasionally be treated by resection with long-term survival.
Topotecan in Recurrent Cervical Cancer – Overview of Phase II Studies
Reference Regimen Evaluable Prior CT ORR Median OS
Survival
By Treatment Group
Proportion Surviving
Vulvar Cancer
Vulvar Cancer Etiology
* Chronic inflammatory conditions and vulvar dystrophies are implicated in older patients
* Syphilis and lymphogranuloma venereum and granuloma inguinal
* HPV in younger patients
* Tobacco
* Paget’s Disease of Vulva
Symptoms
* Most patients are treated for “other” conditions
* 12 month or greater time from symptoms to diagnosis
* Pruritus
* Mass
* Pain
* Bleeding
* Ulceration
* Dysuria
* Discharge
* Groin Mass
* May look like:
o Raised
o Erythematous
o Ulcerated
o Condylomatous
o Nodular
* IF IT LOOKS ABNORMAL ON THE VULVA
* BIOPSY!
Tumor Spread
* Very Specific nodal spread pattern
* Direct Spread
* Hematogenous

Treatment
* Primarily Surgical
o Wide Local Excision
o Radical Excision
o Radical Vulvectomy with Inguinal Node Dissection
+ Unilateral
+ Bilateral
+ Possible Node Mapping, still investigational

* Local advanced may be treated with Radiation plus Chemosensitizer
* Positive Nodal Status
* Special Tumor
o Verrucous Carcinoma

Vulva 5 year survival
* Stage I 90
* Stage II 77
* Stage III 51
* Stage IV 18

Recurrence
* Local Recurrence in Vulva
o Reexcision or radiation and good prognosis if not in original site of tumor
o Poor prognosis if in original site
Melanoma
Melanoma Treatment
Clear Cell Carcinoma
Treatment

Cervical/Vulvar/Vaginal Cancer.ppt

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Vulvar Lesions

Vulvar Lesions
Presentation by:Anna Mae Smith, MPAS, PA-C
Lock Haven University

Anatomy
* Mons pubis
* labia majora and minora
* clitoris
* vestibule
* urethral meatus
* It covers and protects the entrance to the vagina, vestibule, and urethra.

Vulvar Hygiene
* use mild, nondrying soap
* washing underwear with mild soap and rinsing well
* 100% cotton underwear
* avoid extra layers and tight slacks (unneeded medicines, tinted toilet tissue, all "feminine hygiene" products), excessive sweating without aeration, and public pools and hot tubs
* It is important to be keenly conscious of what "aggravates" the skin.
* A dermatologic cliche is to "dry wet lesions" (soaks and compresses) and "moisturize dry lesions" (creams and ointments).

Vulvar Cancer
* 4th most common site of gynecologic neoplasia
* Squamous neoplasia most common type of neplasia
* HPV (16,18) infections are most commonly associated with squamous cell changes of the vulva, vagina & cervix. However the vulva tends to be more resistant to oncogenesis

Histopathology of Vulvar Neoplasia
* Squamous
* Malignant melanoma
* Sarcoma
* Basal Cell
* Adenocarcinoma
* Paget’s Disease
* Undifferentiated


Classification of VIN
* VIN I - mild dysplasia with hyperplastic vulvar dystrophy with mild atypia
* VIN II - Moderate dysplasia, hyperplastic vulvar dystrophy with moderate atypia
* VIN III - Severe dysplasia, carcinoma in situ, Bowen’s Dz; hyperplastic vulvar dystrophy with severe stypia


Spread of vulvar Ca
* Local growth with extension to the perineum, anus, urethra, vagina & pelvic bone
* Lymphatics - inguinal & femoral nodes to the external iliac, common iliac, & para-aortic chains

Paget’s Disease
* presents with extreme pruritus and soreness, usually of long duration
* red or bright pink, desquamated, exzematoid areas among scattered, raised, white patches of hyperkeratosis
* borders are well demarcated and raised

Basal Cell Carcinoma
* very rare
* associated with a long history of pruritus
* occurs over the anterior two-thirds of the labia majora, with slightly elevated margins
* appears as condyloma
* does not respond to treatment for HPV

Invasive Squamous Cell Carcinoma
* occurs when a woman is in her 60s and 70s
* presents with ulceration, friability, or induration of surrounding tissues

Sarcoma
* occurs in women of all ages
* rapidly expanding, painful mass

Diethylstilbestrol (DES) Exposure
* used extensively in US during the 1940s and early 1950s to prevent miscarriage and premature births
* studies during the late 1950s proved its ineffectiveness
* DES use continued through 1971
* estimated 2 million women were exposed in utero

DES Exposure Sequelae
* structural changes
* vaginal adenosis shows columnar epithelium on or beneath the vaginal mucosa; it is self-limiting and gradually disappears
* clear-cell adenocarcinoma of the cervix or vagina may develop (incidence rises at age 15, and median age at diagnosis is 19 years
* increased incidences of:

Lesions
* Often present with prurutis
* Elevated above the skin
* Gray, white , red or pigmented
* May also look verrucous
* INVASIVE- all the above plus ulcerated & bleeding

Treatments
* Local - laser
* Invasive - total vulvectomy & nodes

Vulvar Lesions
* RED - neoplasm, inflammation, or atrophy
* Inflammation-
o Fungi - most common cause of red, nonulcerative, infectious lesion of the vulva
o Folliculitis - secondary to Staph. Aureus may cause painful, itchy vulva
Vulvar Lesions/ RED
* Noninfectious
* Vestibular adenitis
* Psoriasis
* Seborrheic Dermatitis

White Lesions/ Leukoplakia
* Hyperkeratosis
* Depigmentation
* Absolute or relative avascularity

Vulvar Dystrophy
* Benign epithelial disorders
* Lichen Sclerosis 70%, vulvar hyperplasia accounts for the rest
* Biopsy is mandatory of any white lesion!!!
* VIN - neoplastic, premalignant lesion

Depigmented disorders
* Vitiligo - inherited, autosomal dominant
* Often progressive & often associated with increased incidence of
o Addison’s disease
o Thyroiditis
o DM
o Lymphoma
o Pernicious anemia

Intertrigo
* Nonspecific hyperkeratotic epithelial reaction to inflammation in the skin folds

DARK Lesions
* Usually secondary to increase in melanocytes or melanin production
* Must biopsy any dark lesion of the vulva!
* Lentigo - most common - freckle - no malignant potential
* Nevi - moles. Localized collections of neural crest cells which are usually present from birth
* Asymptomatic and rarely become malignant
* 30% of all malignant melanomas develop from nevi
* Neoplasms
* Reactive Hyperpigmentation
* Seborrheic keratosis

Ulcerative Lesions
* VIRAL - HSV - 48 hrs to 7 days after initial contact
* Bacterial - Syphillis, Granuloma inguinal, pyoderma, cutaneous TB
* Inflammatory/noninfectious

Tumors < 1cm
* Inflammation - condyloma acuminata(HPV) Molluscum contagiosum
* Cysts- epidermal inclusion, vestibular gland, mesonephric duct
* Neoplasia - VIN, hemangioma, hidradenoma, neurofibroma, syringoma
* Other - Accessory breast tissue, acrocordon, endometriosis, Fox-Fordyce Dz., Pilonidal sinus
Tumors > 1 cm

* Inflammatory - Bartholin’s cyst/abscess, lymphogranuloma venereum
* Neoplasm - fibroma, lipoma, verrucous carcinoma, sq. cell carcinoma
* Hernia, Edema
* Hematoma
* Other - skin tag, epidermal cysts, neurofibromatosis, accessory breast tissue

Vulvar Dysplasia.ppt

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