Female genital tract

• Chapter 22: The Female Genital Tract
• Chapter Contents

  • Infections
  • Infections of the Lower Genital Tract
  • Herpes Simplex Virus
  • Other Lower Female Genital Tract Infections
  • Infections Involving the Lower and Upper Genital Tract
  • Pelvic Inflammatory Disease (PID)
  • Vulva
  • Bartholin Cyst
  • Non-Neoplastic Epithelial Disorders
  • Lichen Sclerosus
  • Squamous Cell Hyperplasia
  • Benign Exophytic Lesions
  • Condyloma Acuminatum
  • Squamous Neoplastic Lesions
  • Vulvar Intraepithelial Neoplasia and Vulvar Carcinoma
  • Glandular Neoplastic Lesions
  • Papillary Hidradenoma
  • Extramammary Paget Disease
  • Vagina
  • Developmental Anomalies
  • Premalignant and Malignant Neoplasms of the Vagina
  • Vaginal Intraepithelial Neoplasia and Squamous Cell Carcinoma
  • Embryonal Rhabdomyosarcoma
  • Cervix
  • Inflammations
  • Acute and Chronic Cervicitis
  • Endocervical Polyps
  • Premalignant and Malignant Neoplasms of the Cervix
  • Cervical Intraepithelial Neoplasia (Squamous Intraepithelial Lesions)
  • Cervical Carcinoma
  • Cervical Cancer Screening and Prevention
  • Body of Uterus and Endometrium
  • Endometrial Histology in the Menstrual Cycle
  • Functional Endometrial Disorders (Dysfunctional Uterine Bleeding)
  • Anovulatory Cycle
  • Inflammatory Disorders
  • Acute Endometritis
  • Chronic Endometritis
  • Endometriosis and Adenomyosis
  • Endometrial Polyps
  • Endometrial Hyperplasia
  • Malignant Tumors of the Endometrium
  • Carcinoma of the Endometrium
  • Endometrioid Endometrial Carcinoma
  • Serous Endometrial Carcinoma
  • Carcinosarcoma (Malignant Mixed Müllerian Tumors)
  • Tumors of Endometrial Stroma
  • Adenosarcoma
  • Stromal Tumors
  • Tumors of the Myometrium
  • Leiomyoma
  • Leiomyosarcoma
  • Fallopian Tubes
  • Inflammations
  • Tumors and Cysts
  • Ovaries
  • Non-Neoplastic and Functional Cysts
  • Follicle and Luteal Cysts
  • Polycystic Ovaries and Stromal Hyperthecosis
  • Ovarian Tumors
  • Epithelial Tumors
  • Serous Tumors
  • Mucinous Tumors
  • Endometrioid Ovarian Tumors
  • Clear Cell Carcinoma
  • Cystadenofibroma
  • Transitional Cell Tumors
  • Clinical Course, Detection, and Prevention of Ovarian Epithelial Tumors
  • Germ Cell Tumors
  • Teratoma
  • Dysgerminoma
  • Yolk Sac Tumors
  • Choriocarcinoma
  • Other Germ Cell Tumors
  • Sex Cord–Stromal Tumors
  • Granulosa Cell Tumors
  • Fibromas, Thecomas, and Fibrothecomas
  • Sertoli-Leydig Cell Tumors
  • Other Sex Cord–Stromal Tumors
  • Metastatic Tumors
  • Gestational and Placental Disorders
  • Disorders of Early Pregnancy
  • Spontaneous Abortion
  • Ectopic Pregnancy
  • Disorders of Late Pregnancy
  • Twin Placentas
  • Abnormalities of Placental Implantation
  • Placental Infections
  • Preeclampsia and Eclampsia
  • Gestational Trophoblastic Disease
  • Hydatidiform Mole
  • Complete Mole
  • Partial Mole
  • Invasive Mole
  • Choriocarcinoma
  • Placental Site Trophoblastic Tumors
• Diseases of the female genital tract are extremely common and include complications of pregnancy, infections, tumors, and hormonally induced abnormalities
• The following discussion presents the pathology of the major diseases that result in clinical problems
• Additional details can be found in current textbooks of gynecologic pathology and clinical obstetrics and gynecology
• We will discuss the pathologic conditions peculiar to each segment of the female genital tract separately
• Before doing so we will briefly review infections and pelvic inflammatory disease because they can affect many of the various anatomic structures concomitantly
• A large variety of organisms can infect the female genital tract
• Some infections with microorganisms such as Candida, Trichomonas, and Gardnerella are very common and may cause significant discomfort, but are without serious sequelae
• Common infections of the female genital tract

  • Candida
  • Trichomonas
  • Gardnerella
• Major causes of infertility

  • Neisseria gonorrhoeae
  • Chlamydia
• Implicated in preterm deliveries, stillbirths, and neonatal infections

  • Group B Streptococcus infections
• Viruses causing considerable morbidity

  • Herpes simplex viruses (HSVs)
  • Human papillomaviruses (HPVs)
• HSV infections

  Cause painful genital ulcerations
• HPV infections


  Involved in the pathogenesis of cervical, vaginal, and vulvar cancers
• Sexually transmitted infections

  • Trichomoniasis
  • Gonorrhea
  • Mycoplasma
  • Chlamydia
  • HSV
  • HPV
  • Syphilis
  • Chancroid
  • Granuloma inguinale
  • Lymphogranuloma venereum
• Cesarean delivery is warranted in cases of certain infections to prevent transmission to the neonate
• A brief review of the development and anatomy of the female genital tract is fundamental to understanding the diseases that affect this complex organ system
• Normal development of the female genital tract

  Proceeds through a series of tightly choreographed events involving the primordial germ cells, the müllerian (paramesonephric) ducts, the wolffian (mesonephric) ducts, and the urogenital sinus
• Germ cells

  Arise in the wall of the yolk sac by the fourth week of gestation. By the fifth or sixth week, they migrate into the urogenital ridge and induce proliferation of the mesodermal epithelium, which gives rise to the epithelium and stroma of the ovary
• Lateral müllerian ducts formation


  Occurs at about the sixth week of development through invagination and fusion of the coelomic lining epithelium. The ducts progressively grow caudally into the pelvis, where they swing medially to fuse with the urogenital sinus at the müllerian tubercle. Further caudal growth brings these fused ducts into contact with the urogenital sinus. The unfused upper portions of the müllerian ducts mature into the fallopian tubes, while the fused lower portion develops into the uterus, cervix, and upper vagina
• Urogenital sinus development

  Occurs when the cloaca is subdivided by the urorectal septum; it eventually forms the lower part of the vagina and the vestibule of the external genitalia
• Mesonephric ducts regression

  Normally regress in the female, but remnants may persist into adult life as epithelial inclusions adjacent to the ovaries, tubes, and uterus. In the cervix and vagina, these rests may be cystic and are termed Gartner duct cysts
• Causes of Infertility

  • Gardnerella
  • N. gonorrheae
  • Chlamydia
  • GUPB-strep
  • U. vrelyticum & hominic
  • HSV
  • HPV
• Preterm, still births, neonatal infxls


  • Various consequences of infections during pregnancy
• Active genital HSV infection

  Increases the risk of HIV-1 acquisition and transmission
• Diagnosis of HSV infection

  1. Based on typical clinical findings and HSV detection

  2. Purulent exudate is aspirated from the lesions and inoculated into a tissue culture

  3. Viral cytopathic effect can be seen after 48 to 72 hours

  4. Virus can then be serotyped

  5. Some laboratories offer more sensitive tests like polymerase chain reaction, enzyme-linked immunosorbent assays, and direct immunofluorescent antibody tests for detection of HSV in the lesional secretions
• Individuals with primary, acute HSV infection do not have serum anti-HSV antibodies
• Detection of anti-HSV antibodies in the serum is indicative of recurrent/latent infection
• There is no effective treatment for latent HSV; however, antiviral agents like acyclovir or famciclovir shorten the length of the initial and recurrent symptomatic phases
• The ultimate solution for HSV is an effective vaccine, a goal yet to be realized
• Other Lower Female Genital Tract Infections

  • Molluscum contagiosum
  • Various viruses, fungi, and bacteria causing symptomatic infections of the lower genital tract
• Molluscum contagiosum is caused by poxvirus and has four types, with MCV-1 being the most prevalent and MCV-2 being most often sexually transmitted
• Molluscum contagiosum infections are common in young children transmitted through direct contact or shared articles, and in adults, they are typically sexually transmitted affecting the genitals, lower abdomen, buttocks, and inner thighs
• Genital herpes simplex virus (HSV) infection is common and may involve the vulva, vagina, or cervix
• HSV-1 typically results in perioral infection, whereas HSV-2 usually involves genital mucosa and skin
• Approximately 30% of women are seropositive for antibodies against HSV-2 by 40 years of age
• About one-third of newly infected individuals are symptomatic with lesions developing 3 to 7 days after transmission
• Lesions progress from red papules to vesicles and then to painful coalescent ulcers
• HSV infections persist indefinitely due to viral latency, and any decrease in immune function can trigger reactivation and recurrence of the virus