Infection and Inflammation
Infections
Infections of the female reproductive tract are often classified as exogenous or endogenous. Exogenous infections result from pathogenic organisms transmitted from another person, such as sexually transmitted diseases (STDs).
Endogenous infections result from pathogens that normally inhabit the intestines, vulva, or vagina. You may recall from Chapter 6 that many areas of the body are normally inhabited by pathogenic microbes but that they cause infection only when there is a change in conditions, or they are moved to a new area.
Pelvic inflammatory disease
Pelvic inflammatory disease (PID) occurs as either an acute or chronic inflammatory condition that can be caused by several different pathogens, which usually spread upward from the vagina. PID is a major cause of infertility and sterility and affects more than 800,000 women each year in the United States. It is a common complication following infection by gonococcal (Neisseria gonorrhoeae) and chlamydial microorganisms (see Table 23-4).
In PID any inflammation involving the uterus, uterine tubes, ovaries, and other pelvic organs often results in development of scar tissue and adhesions. As a result, serious complications, including infertility resulting from tubal obstruction or other damage to the reproductive tract, may occur. Uterine tube inflammation is termed salpingitis and inflammation of the ovaries is called oophoritis.
Laparoscopic examination is often used to make a definitive diagnosis or to determine the severity of the infection and the reproductive organs involved. Although some chlamydial infections may not cause symptoms, most cases of PID are accompanied by fever, pelvic tenderness, and pain. Unfortunately, because of scarring and adhesions, pain may continue even after antibiotic therapy has eliminated the active infection.
If left untreated, PID infections may spread to other tissues, including the blood, resulting in septic shock and death.
Vaginitis
Vaginitis is inflammation or infection of the vaginal lining.
Vaginitis most often results from STDs or from a yeast infection. Yeast infections are usually opportunistic infections of the fungus Candida albicans, producing vaginal candidiasis. Candidiasis infections are characterized by a whitish discharge—a symptom known as leukorrhea.
Tumors and related conditions
Benign uterine tumors
The terms fibroid, myoma, and fibromyoma are all words used to describe benign (noncancerous) tumors of uterine fibrous or smooth muscle tissue.
Individual fibroids may occur but multiple growths are not unusual. Fibroids are common in women during their reproductive years and develop most often in the myometrium of the uterine body and rarely in the cervix. The fact that they are seldom seen before puberty, increase in size during pregnancy, and tend to shrink in postmenopausal women suggests that age and estrogen levels may play a role in their development.
Fibroids range in size from small asymptomatic nodules to massive tumors that may be painful and exert pressure on other pelvic organs. Growth during pregnancy may result in placental hemorrhage or malpresentation of the fetus, complicating labor and delivery.
In addition to pain, symptoms of benign uterine tumors will vary depending on the size and location of the tumor. For example, if a large fibroid compresses the bladder and rectum, symptoms of urinary frequency and constipation may result. Even small tumors developing beneath the endometrium can cause severe hemorrhage (DUB).
Tumor size, location, and severity of symptoms determine treatment options. A relatively new technique, similar to a heart catheterization, called uterine artery embolization involves snaking a small catheter through an artery in the groin into the arterial vessel supplying blood to a fibroid. Tiny inert pellets are then injected into the artery, blocking the flow of blood. The procedure results in dramatic shrinkage of the treated fibroid and a reduction in symptoms, including hemorrhage.
Surgical removal of individual fibroids or, in more severe cases, hysterectomy may be indicated.
Ovarian cysts
Ovarian cysts are very common fluid-filled cysts that develop either from follicles that fail to rupture completely (follicular cysts) or from corpora lutea that fail to degenerate (luteal cysts).
Most women develop a number of these cysts during their reproductive years and their presence does not represent a diagnosis of polycystic ovary syndrome. Although ovarian cysts are often multiple, they rarely become dangerous. However, on occasion they may become quite large and painful and be diagnosed by palpation or ultrasonography.
Luteal cysts are less common than follicular cysts but tend to cause more symptoms, such as pelvic pain and menstrual irregularities. Rarely, rupture of a large luteal cyst will result in internal bleeding that requires surgical intervention. The vast majority of all ovarian cysts will disappear within a few months of their appearance, most within 60 days.
Polycystic ovary syndrome (PCOS) is a condition that affects 10% of reproductive-age women but also can affect girls as young as 11 years old. It is characterized by enlarged ovaries that usually are studded with fluid-filled cysts about 0.5 to 1.5 cm in diameter (Figure 23-17). The cysts are found on both ovaries and develop from mature follicles that fail to rupture completely. Corpora lutea are generally absent.
Women with PCOS frequently have numerous endocrine abnormalities, including high levels of testosterone, infrequent menstrual cycles, and persistent anovulation. PCOS is the most common cause of female infertility.
Endometriosis
Endometriosis is the presence of functioning endometrial tissue outside the uterus. The displaced endometrial tissue can occur in many different places throughout the body but is most often found in or on pelvic and abdominal organs. The tissue reacts to ovarian hormones in the same way as the normal endometrium—exhibiting a cycle of growth and sloughing off.
Symptoms of endometriosis may include unusual bleeding, dysmenorrhea, and pain during intercourse. If symptoms are mild, pain medications are sometimes effective. Oral contraceptives, which alter the hormone levels that produce endometrial changes during the menstrual cycle, are effective in reducing the activity of endometriosis.
Cancer
Malignancies of reproductive and related organs, especially the breasts, account for the majority of cancer cases among women.
Breast cancer
About 1 in 8 women eventually get breast cancer, often a form of adenocarcinoma. Treatment of breast cancer is often successful if the cancerous tumor is detected early. Because such tumors are often painless, most physicians recommend regular, frequent self-examination of breast tissue, as well as annual mammograms for women (see Chapter 6). Treatments often involve surgery, chemotherapy, and radiation therapy.
Breast surgeries can be very conservative, as in a simple lump removal or lumpectomy. If metastasis to surrounding tissue is suspected, a modified radical mastectomy may be performed. In this procedure the entire breast, with nearby lymph nodes, is removed.
Just as lumpectomy results in less trauma than modified radical mastectomy, so called limited-field radiation can provide effective treatment for clearly defined early-stage cancers that have not spread. It does so with shorter treatment cycles and fewer side effects than whole-breast radiation.
In the past, after women had completed their initial treatment for breast cancer they had few options available to lessen the possibility of recurrence. For a number of years the drug tamoxifen has been used extensively to prevent the recurrence of breast cancer fueled by estrogen. It does so by blocking the estrogen receptor sites on the cancer cell membrane. Unfortunately, tamoxifen effectiveness is limited to about 5 years.
Newer drugs classified as aromatase inhibitors actually block estrogen production, instead of blocking estrogen receptors. This type of drug may replace tamoxifen or be prescribed for use after 5 years of tamoxifen therapy. Other “rational” drugs and other treatments are being developed to alter or block crucial metabolic pathways in treating breast and other forms of cancer.
Ovarian cancer
Ovarian cancer is another malignancy that affects 1 in 70 women in America. Usually a type of adenocarcinoma, ovarian cancer is difficult to detect early and is often not easily apparent until it has grown into a large mass. Regular pelvic examinations that include palpation of the ovaries may result in earlier detection.
Risk factors for ovarian cancer include age (over 40), infertility, childlessness or few children, a history of miscarriages, and endometriosis.
Ovarian cancer is often treated by surgical removal of the ovaries combined with radiation therapy and chemotherapy.
Uterine cancer
Cancer of the uterus can affect the body of the uterus or the cervix.
Cancers of the uterine body most often involve the endometrium (endometrial cancer) and mostly affect women beyond childbearing years; a common symptom is postmenopausal uterine bleeding. Risk factors for this type of cancer include obesity, prolonged estrogen therapy, and infertility.
Cervical cancer occurs most often in women between the ages of 30 and 50.
Cervical cancer is often diagnosed early, through screening tests such as the Papanicolaou test, or Pap smear (Figure 23-18). In this test, cells swabbed from the cervix are smeared on a glass slide, stained, and examined microscopically to determine whether any abnormalities exist. Current recommendations suggest two Pap smears 1 year apart beginning at age 21. If these two Pap smears are negative (that is, revealing no abnormalities), subsequent Pap smears should occur every 1 to 3 years thereafter.
Because early or frequent intercourse is a risk factor for cervical cancer, sexually active young women should have their first Pap smear much earlier—and have follow-ups done more often.
Because screening tests and other early detection methods have been so successful, the death rates for uterine cancers have dropped dramatically over the last few decades. Because human papillomavirus (HPV) infections dramatically increase the risk of developing cervical cancer, widespread use of HPV vaccines in both men and women have already begun to reduce the spread of HPV—thus reducing death rates from this type of cancer.