WOMEN'S DISEASES
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

I am active in HealthTap, which provides free medical guidance from your cell phone. There is also a fee site at www.afraidtoask.com.


If you have a Second Life account, please visit my teammates and me at the Medical Examiner's office.

Freely have you received, give freely With one of four large boxes of "Pathguy" replies.

I'm still doing my best to answer everybody. Sometimes I get backlogged, sometimes my E-mail crashes, and sometimes my literature search software crashes. If you've not heard from me in a week, post me again. I send my most challenging questions to the medical student pathology interest group, minus the name, but with your E-mail where you can receive a reply.

Numbers in {curly braces} are from the magnificent Slice of Life videodisk. No medical student should be without access to this wonderful resource.

I am presently adding clickable links to images in these notes. Let me know about good online sources in addition to these:

Freely have you received, freely give. -- Matthew 10:8. My site receives an enormous amount of traffic, and I'm still handling dozens of requests for information weekly, all as a public service.

Pathology's modern founder, Rudolf Virchow M.D., left a legacy of realism and social conscience for the discipline. I am a mainstream Christian, a man of science, and a proponent of common sense and common kindness. I am an outspoken enemy of all the make-believe and bunk that interfere with peoples' health, reasonable freedom, and happiness. I talk and write straight, and without apology.

Throughout these notes, I am speaking only for myself, and not for any employer, organization, or associate.

Special thanks to my friend and colleague, Charles Wheeler M.D., pathologist and former Kansas City mayor. Thanks also to the real Patch Adams M.D., who wrote me encouragement when we were both beginning our unusual medical careers.

If you're a private individual who's enjoyed this site, and want to say, "Thank you, Ed!", then what I'd like best is a contribution to the Episcopalian home for abandoned, neglected, and abused kids in Nevada:

I've spent time there and they are good. Write "Thanks Ed" on your check.

Help me help others

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

This site is my hobby, and I do not accept donations, though I appreciate those who have offered to help.

During the eighteen years my site has been online, it's proved to be one of the most popular of all internet sites for undergraduate physician and allied-health education. It is so well-known that I'm not worried about borrowers. I never refuse requests from colleagues for permission to adapt or duplicate it for their own courses... and many do. So, fellow-teachers, help yourselves. Don't sell it for a profit, don't use it for a bad purpose, and at some time in your course, mention me as author and KCUMB as my institution. Drop me a note about your successes. And special thanks to everyone who's helped and encouraged me, and especially the people at KCUMB for making it possible, and my teaching assistants over the years.

Whatever you're looking for on the web, I hope you find it, here or elsewhere. Health and friendship!

PicoSearch
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More of Ed's Notes: Ed's Medical Terminology Page

Perspectives on Disease
Cell Injury and Death
Accumulations and Deposits
Inflammation
Fluids
Genes
What is Cancer?
Cancer: Causes and Effects
Immune Injury
Autoimmunity
Other Immune
HIV infections
The Anti-Immunization Activists
Infancy and Childhood
Aging
Infections
Nutrition
Environmental Lung Disease
Violence, Accidents, Poisoning
Heart
Vessels
Respiratory
Red Cells
White Cells
Coagulation
Oral Cavity
GI Tract
Liver Pancreas (including Diabetes)
Kidney
Bladder
Men
Women
Breast
Pituitary
Thyroid
Adrenal and Thymus
Bones
Joints
Muscles
Skin
Nervous System
Eye
Ear
Autopsy
Lab Profiling
Blood Component Therapy
Serum Proteins
Renal Function Tests
Adrenal Testing
Arthritis Labs
Glucose Testing
Liver Testing
Porphyria
Urinalysis
Spinal Fluid
Lab Problem
Quackery
Alternative Medicine (current)
Preventing "F"'s: For Teachers!
Medical Dictionary

Courtesy of CancerWEB

LEARNING OBJECTIVES:

KCUMB Students
"Big Robbins" -- Female
Lectures follow Textbook

QUIZBANK
    Vulva and vagina: Women's problems 13-17, 26-35, 61-62, 67-68, 72
    Cervix: Women's problems 80-93
    Endometrium / Myometrium: Women's problems 1-12, 18, 37-59, 64-66, 69-71, 73-75, 77-79, 94-101
    Oviduct: Women's problems 24-25,
    Ovary: Women's problems 76, 102-128
    Mother and Child: Fetus and pregnancy (all)


Picasso, "Mother and Child"

If I were asked to what the singular prosperity and growing strength of [the Americans] ought mainly to be attributed, I should reply, "To the superiority of their women".

Never try to impress a woman because if you do, you'll have to keep up that standard for the rest of your life.

Not from Adam's brain, to have the same mind as him, nor from Adam's foot, to be subordinate to him, but from the rib next to Adam's heart, to love and be loved by him.

Let men tremble to win the hand of a woman, unless they win also with it the utmost passion of her heart.

If that this thing we call the world
By chance on atoms was begot
Which though in ceaseless motion twirled
Yet weary not
How doth it prove
Thou art so fair and I in love.

Global views on women's health: Sci. Am. 271(2): Aug., 1994. Still good reading, especially for anyone offering easy, wrong answers to the world's problems.

In sub-Saharan Africa, one woman in 16 dies in childbirth, compared with one woman in about 5000 in the developed world (Br. Med. J. 326: 567, 2003). British aid workers among the poor were able to cut mortality in pregnancy and delivery by about 40% with very little effort or expense (BMJ 336: 145, 2008).

The best hope for women in the resource-poor environment today seems to be other women mobilized to make their lives -- including health-care outcomes -- better. See Lancet 381: 1721 & 1731, 2013.

Special thanks to Dr. Tony Racela for the wonderful kodachromes. You may find them here.

Cytopathology
Photo Library of Pathology
U. of Tokushima

Female
Photo Library of Pathology
U. of Tokushima

Female
Taiwanese pathology site
Good place to go to practice

Reproductive
Surgical Pathology Atlas
Nice photos, hard-core

Archive of Histologic Images
of Gynecologic & Breast Path
Greek, minimal commentary

Female Reproductive Tract Images
University of Washington
Pictures and comments

Gynecologic and Breast Pathology
Photomicrograph collection
In Portuguese

Reproductive
Utah cases for path students
Juliana Szakacs MD

Reproductive
Photos, explanations, and quiz
Indiana U.

GYN Pathology
Photos by Tony Racela MD (Thanks!)
Notes by Ed

Female
Iowa Virtual Microscopy
Have fun

Female
First Section
Chaing Mi, Thailand

Female
Second Section
Chaing Mi, Thailand

Female
Third Section
Chaing Mi, Thailand

Webpath
Female

Female Histology
Ed's Histology Notes

Female Reproductive
Brown Digital Pathology
Some nice cases

Dgital Atlas of Gynecologic Pathology
Meenakshi Singh, MD
Outstanding resource


{47710} human female
{15787} normal internal female genitalia

Normal

Normal female internal organs
WebPath
Sorry, no caption just now

Normal female internal organs

WebPath

Normal female internal organs

WebPath

The pathology of the human female presents a few special problems.

You remember the embryology.

You remember the anatomy and physiology. Here are a few common points of confusion.

We have already covered infectious diseases.

On rotations youlll need to know the acronym TORCH for multifocal, chronic inflammation of the plancenta. (T is for toxoplasmosis O is for the others, notably varicella, Epstein-Barr, Chagas disease, and syphilis. R is for rubella. C is for cytomegalovirus. H is herpes simplex. In the United States, you will probably only run into CMV and syphilis.) Here is a review of the major infections of the female genital system, adapted from "Big Robbins".

HERPES SIMPLEX II


{14134} herpes simplex of vulva, patient
{06017} herpes simplex infection, pap smear
{25909} herpes simplex infection, pap smear

Herpes simlex of the vulva

Yutaka Tsutsumi MD

MOLLUSCUM CONTAGIOSUM


{27023} molluscum contagiosum, histology

HUMAN PAPILLOMA VIRUS (HPV)

CHLAMYDIA TRACHOMATIS


{11562} chlamydia, pap smear
{25911} chlamydia infection, pap smear

Chlamydia in vacuoles
Pap smear
Wikimedia Commons

Chlamydia of the cervix

Yutaka Tsutsumi MD

GONORRHEA

HEMOPHILUS DUCREYI

TREPONEMA PALLIDUM (syphilis)


{25539} chancre of vulva, gross (syphilis)
{25545} condylomata lata, vulva (syphilis)
{25546} condylomata lata, vulva (syphilis)

MYCOBACTERIUM TUBERCULOSIS


{26585} tuberculosis of oviduct, low power
{26591} tuberculosis of oviduct, high power
{26627} tuberculosis of oviduct, high power

CALYMMATOBACTERIUM

GARDNERELLA


{08370} Gardnerella vaginalis on Pap smear (these aren't outstanding examples of "clue cells")
{25908} Gardnerella vaginalis infection, good "clue cell"

Clue cell

Tom Demark's Site

CANDIDA:

TRICHOMONAS: Vulva, vagina, cervix: Trichomonas vulvovaginitis

Trichomonas

Yutaka Tsutsumi MD

Vulva

Female -- inflammation
From Chile
In Spanish

Vulva
Nice case photos
Charam M. Ramnani MD

Vulva
"Pathology Outlines"
Nat Pernick MD

NON-NEOPLASTIC DISORDERS


{49364} acute vulvitis


{27119} Bartholin gland cyst, vulva
{27110} lichen sclerosis of vulva, histology

BENIGN TUMORS


{49365} condyloma acuminatum of vulva, gross (HPV)
{27113} condyloma acuminatum of vulva, histology (HPV)
{06026} HPV effect ("koilocytes") in pap smear from cervix
{11470} HPV effect ("koilocytes") in pap smear from cervix

Severe dysplasia of the cervix
HPV-16
Yutaka Tsutsumi MD

Condyloma acuminatum
HPV-6
Yutaka Tsutsumi MD

HPV koilocytes
Cervix biopsy
KU Collection

HPV koilocytes
Cervix biopsy
KU Collection

HPV-16
Bowenoid papulosis
Yutaka Tsutsumi MD

CIN3
Cervix premalignancy
Wikimedia Commons

CARCINOMA OF THE VULVA


{25666} melanoma of vulva, gross


{24592} squamous cell carcinoma of vulva, gross
{25664} squamous cell carcinoma of vulva, gross
{25665} squamous cell carcinoma of vulva, gross
{27005} squamous cell carcinoma of vulva, histology
{27008} squamous cell carcinoma of vulva, histology
{25662} carcinoma in situ of vulva, gross
{25663} carcinoma in situ of vulva, gross
{11499} Paget's disease of the vulva, gross
{08903} Paget's disease of the vulva, histology
{08906} Paget's disease of the vulva, histology

* CHILD SEXUAL ABUSE

Vagina

Normal vagina with cervix

WebPath

Vagina
"Pathology Outlines"
Nat Pernick MD

NON-NEOPLASTIC LESIONS


{27050} vaginal adenosis (DES exposure in utero), histology

Enterobius vermicularis in vagina

Yutaka Tsutsumi MD

Bacteria on vaginal smears
Rogues' gallery
Yutaka Tsutsumi MD

CANCER OF THE VAGINA

Cervix


{08914} normal histology of uterine cervix (endocervix is left, ectocervix is right)
{10271} normal ectocervix histology
{10274} normal endocervix histology
{36059} normal endocervical cells, pap smear

Cervix I
From Chile
In Spanish

Cervix II
From Chile
In Spanish

Normal cervix

WebPath

Normal cervical squamous epithelium

WebPath

Cervix
"Pathology Outlines"
Nat Pernick MD

INFLAMMATION

Chronic cervicitis

WebPath

NON-TUMORS


{39991} endocervical polyp, gross


{27137} cervix, micro-glandular hyperplasia, histology CANCER OF THE CERVIX (Lancet 361: 2217, 2003; Ob. Gyn. 107: 1152, 2006)

General Cytopathology
Johns Hopkins
A work in progress

Pap Smears
Chinese Pathologists
Includes a quiz

Cytopathology gallery
International Agency for Research on Cancer
Huge site

{09755} normal cervical pap smear (do you know the cell types?)


{11789} dysplasia of uterine cervix, histology
{11789} cervix, dysplasia, histology
{41963} cervix, dysplasia, histology
{25939} cervix, dysplasia, pap smear
{27101} cervix, dysplasia, pap smear
{27104} cervix, dysplasia, pap smear
{11790} severe dysplasia of uterine cervix, histology

Dysplasia.
HPV -- trust me.
WebPath Photo

Cervix with dysplasia

WebPath

Dysplasia on a pap smear

WebPath

Squamous cell carcinoma of the cervix

WebPath

Cervix with dysplasia

WebPath

Squamous cell carcinoma of the cervix

WebPath

Squamous cell carcinoma of the cervix

WebPath

Squamous cell carcinoma of the cervix

WebPath

Squamous cell carcinoma of the cervix
Large
WebPath

Squamous cell carcinoma of the cervix
Radical surgery
WebPath

Squamous cell carcinoma of the cervix
Radical surgery
WebPath

Glassy cell carcinoma
of the cervix
Pittsburgh Pathology Cases

Mild dysplasia
HPV effect
Wikimedia Commons


{08911} uterine cervix, carcinoma in situ, histology
{08912} uterine cervix, carcinoma in situ, histology
{46209} cervical conization specimen. One may cure CIS by removing the entire ring of abnormal cells.

Carcinoma in situ
Cervix
KU Collection


{25962} cervix, carcinoma in situ, pap smear
{34775} carcinoma in situ of cervix, pap smear
{10292} carcinoma of the cervix, gross
{10583} carcinoma of the cervix, gross; bladder is above, rectum below
{10913} carcinoma of the cervix; bladder is right, rectum is left
{46321} carcinoma of cervix, gross
{46322} carcinoma of cervix, gross

    * THE DEATH OF EVA PERON

      Eva Peron ("Evita"), wife of Argentina's left-wing dictator Juan Peron, died in January 1952 of cervical cancer.

      Juan Peron's previous wife had also died of cancer of the cervix. Pap smears were in use in the developed world in the late 1940's, but had not caught on in Argentina.

      In January 1950, Ms. Peron fainted in public and was found to be anemic, evidently as the result of iron deficiency from blood loss due to her cancer. It's not clear whether her cancer was found at the time, but she continued to have heavy vaginal bleeding. She was taken to surgery and operated by an American "ghost surgeon"; she was never informed of what had been done, who operated her, or the nature of her illnesss.

      How much of this was the "fifties" mentality ("beneficience" / "paternalism" / "the duty NOT to tell a cancer patient the diagnosis" / the general concealing of unpleasant truths)? How much was the "VIP syndrome", in which prominent people get their health problems concealed from the public? You'll have to decide this for yourself.

      Ms. Peron was enormously popular with her people, especially for her advocacy for the poor. She was one of the most beautiful and charismatic women of her era -- perhaps any era. My reading tells me that most of today's historians consider her a genuine humanitarian. You can read about her final illness in Lancet 355: 1988, 2000.

Eva Peron
Evita

* "The Toxic Lady!"

* In the monster movie Godzilla 2000, a photomicrograph of the monster's skin is examined by a group of scientists. Fascinatingly, it appears identical to normal human ectocervix.

Endometrium / Myometrium

Uterus Exhibit
Virtual Pathology Museum
University of Connecticut

www.endometrium.org
Photomicrograph collection
Lots and lots of photos

Uterine Corpus I
From Chile
In Spanish

Uterine Corpus II
From Chile
In Spanish

Uterine Corpus III
From Chile
In Spanish

Uterine Corpus IV
From Chile
In Spanish

Uterus
"Pathology Outlines"
Nat Pernick MD


{24701} normal proliferative endometrium
{08915} normal proliferative endometrium
{27149} normal proliferative endometrium
{27152} normal secretory endometrium, note subnuclear glycogen
{24702} normal secretory endometrium, histology
{14318} normal secretory endometrium, histology
{14321} normal secretory endometrium, histology
{14987} normal secretory endometrium; glycogen stain
{20681} normal secretory endometrium, histology

Normal proliferative endometrium

WebPath

Normal secretory endometrium
Later
WebPath

Normal secretory endometrium
Post-ovulatory
WebPath

INTRODUCTION


{40183} bicornuate uterus, gross
{40184} bicornuate uterus, gross
{49373} double uterus
{00093} prolapsed uterus protruding from vagina

Female -- birth defects
From Chile
In Spanish

Bifid uterus

WebPath

Prolapsed uterus
Ed Uthman

THE NORMAL CYCLE

ENDOMETRITIS


{49374} pyometra, gross


{27170} chronic endometritis; notice the plasma cells

Entamoeba gingivalis endometritis
Advanced students
Yutaka Tsutsumi MD

ADENOMYOSIS ("endometriosis interna")


{14330} adenomyosis, histology

Adenomyosis

WebPath

Adenomyosis

WebPath

Adenomyosis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

ENDOMETRIOSIS ("endometriosis externa", BMJ 334: 249, 2007)


{25284} endometriosis, histology
{46270} endometriosis, histology
{39843} endometriosis of appendix, gross
{10283} ovarian endometriosis, gross ("chocolate cyst")

Endometriosis

KU Collection

Endometriosis
GIF animation
WebPath

Endometriosis

WebPath

Endometriosis

WebPath

Endometriosis

WebPath

Endometriosis

WebPath

Endometriosis of ovary

WebPath

Endometriosis of Ovary
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

ENDOMETRIAL POLYPS


{24593} endometrial polyp, gross
{49375} endometrial polyp, gross
{24447} endometrial polyp, histology

Endometrial polyp

WebPath

ENDOMETRIAL HYPERPLASIA / "ENDOMETRIAL INTRAEPITHELIAL NEOPLASIA"


{00096} endometrial hyperplasia, gross
{00099} endometrial hyperplasia, gross
{10907} endometrial hyperplasia, gross
{38986} endometrial hyperplasia, gross
{08918} "cystic hyperplasia" of endometrium, histology
{08919} "cystic hyperplasia" of endometrium, histology

Simple hyperplasia of endometrium
Great labels
Romanian Pathology Atlas

Endometrial hyperplasia

WebPath

Cystic hyperplasia

WebPath


{27164} "adenomatous hyperplasia" of endometrium

ENDOMETRIAL ADENOCARCINOMA


{05319} uterine carcinoma, radiograph
{08437} endometrial adenocarcinoma, gross
{39635} carcinoma of the endometrium, gross
{18782} adenocarcinoma of the endometrium, gross
{18783} adenocarcinoma of the endometrium, gross
{21075} endometrial adenocarcinoma, gross
{10586} carcinoma of the endometrium; dissection with bladder at bottom, uterus and vagina in middle, rectum at top
{10589} carcinoma of the endometrium, cross-section of uterus
{27161} adenocarcinoma of endometrium; notice glands-within-glands
{08916} adenocarcinoma of endometrium, low magnification
{08917} adenocarcinoma of endometrium, high magnification
{10694} adenocarcinoma of the endometrium, cytology

Endometrial adenocarcinoma

WebPath

Endometrial adenocarcinoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Endometrial adenocarcinoma

WebPath

Endometrioid carcinoma of endometrium
Great labels
Romanian Pathology Atlas

Endometrial adenocarcinoma

WebPath

Endometrial adenocarcinoma

WebPath

Endometrial adenocarcinoma

WebPath

Endometrial Adenocarcinoma
Dino Laporte's PathosWeb

MIXED MULLERIAN / MESENCHYMAL TUMORS

Endometrial Stromal Sarcoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

LEIOMYOMAS (Lancet 357: 293, 2001; Ob. Gyn. 104: 393, 2004)


{08438} leiomyoma of uterus, gross
{09774} leiomyoma of uterus, gross
{10910} leiomyoma of uterus, gross
{24703} leiomyoma of uterus, gross
{39636} leiomyoma of uterus, gross
{49380} leiomyoma of uterus, gross
{08728} leiomyoma, histology
{08729} leiomyoma, histology
{49383} lipoleiomyoma
{20184} calcified uterine leiomyomas, radiograph

Leiomyoma of uterus

WebPath

Large uterine leiomyoma
Whorls on cross-section
KU Collection

Leiomyomas of uterus

WebPath

Uterine Fibroids

Dino Laporte's PathosWeb

Leiomyomas
Red degeneration
WebPath

Leiomyoma

WebPath

Uterine Leiomyoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Leiomyoma of uterus
Great labels
Romanian Pathology Atlas


{09016} leiomyosarcoma of uterus, mitotic figure
{39637} leiomyosarcoma, showing mitotic figure

Leiomyosarcoma

WebPath

Leiomyosarcoma

WebPath

Leiomyosarcoma

WebPath

Leiomyosarcoma

WebPath

Oviduct

Fallopian Tubes
"Pathology Outlines"
Nat Pernick MD

Fallopian Tube Exhibit
Virtual Pathology Museum
University of Connecticut

PELVIC INFLAMMATORY DISEASE ("salpingitis")


{39001} intrauterine device (coil type)
{10280} intrauterine device in place
{10904} actinomycosis of the endometrium, histology (note "sulfur granules")


{10901} gonorrheal salpingitis
{27176} acute salpingitis, histology
{27173} chronic salpingitis, histology

Tubo-ovarian abscess

WebPath

Acute salpingitis

WebPath

OTHER LESIONS OF THE OVIDUCT

Ovary

A HERMAPHRODITE is defined to possess at least some ovarian and some testicular tumor. This is very uncommon, and you'll learn how it can happen in your embryology course.

You are already familiar with the "streak ovaries" of Turner's 45 XO.

* Are there perhaps normally more than one ovulation per month? Br. Med. J. 327: 124, 2003.

Ovary I
From Chile
In Spanish

Ovary II
From Chile
In Spanish

Ovary III
From Chile
In Spanish

Ovary Exhibit
Virtual Pathology Museum
University of Connecticut

Ovary
"Pathology Outlines"
Nat Pernick MD


{24817} normal ovary in pregnancy
{24695} normal graafian follicle
{24696} normal graafian follicle, higher power


{24698} radiation injury to ovary; note loss of germ cells and radiation change in vessels

CYSTIC FOLLICLES ("follicular and luteal cysts")


{00105} cystic follicles in ovary

Ovary with corpus luteum

WebPath

Ovary with hemorrhagic corpus luteum

WebPath

Ovary with hemorrhagic corpus luteum

WebPath

Benign Ovarian Cysts

Dino Laporte's PathosWeb

Ovary with follicular cyst

WebPath

Ovary with theca-lutein cyst

WebPath

STEIN-LEVENTHAL SYNDROME ("polycystic ovarian disease / syndrome"; Lancet 370: 685, 2007)


{40757} polycystic ovary in Stein-Leventhal syndrome, gross
{46500} polycystic ovary in Stein-Leventhal syndrome, histology

INTRODUCING THE OVARIAN TUMORS (research pathologists see Am. J. Path. 177: 1053, 2010)


{05318} ovarian carcinoma, radiograph

    Ovarian cancers are common and deadly. In 2000, around 23,000 US women were discovered to have the disesase, and there were 14,000 deaths. Prognosis varies tremendously with the histology and the stage.
In memory, Gilda Radner


{11503} Krukenberg tumor of ovary, gross
{11500} Krukenberg tumor of ovary, histology; mucin stain (cancer cells are pink)

Krukenberg tumor

WebPath

SURFACE EPITHELIAL TUMORS


{09779} papillary cystadenoma of ovary, gross

Ovarian serous cystadenoma

WebPath

Ovarian serous cystadenoma

WebPath

Ovarian serous cystadenoma

WebPath


{11515} serous cystadenocarcinoma of ovary, gross
{39560} serous cystadenocarcinoma of ovary, histology
{10382} serous cystadenocarcinoma of ovary, cytology
{10727} serous cystadenocarcinoma of the ovary, psammoma bodies in pap smear

Ovarian papillary serous cystadenocarcinoma

WebPath

Ovarian papillary serous cystadenocarcinoma

WebPath

Ovarian borderline serous tumor

WebPath

Ovarian serous cystadenocarcinoma

WebPath

Ovarian cancer
Bryan Lee

Ovarian serous cystadenocarcinoma

WebPath

Ovarian serious cystadenocarcinomas
Biilateral. CDC photo
Wikimedia Commons

Serous cystadenocarcinoma

Tom Demark's Site


{14165} ovarian mucinous cystadenoma, gross
{14177} ovarian mucinous cystadenoma, gross
{49396} mucinous cystadenoma of ovary, gross; unfortunately there's no ruler, but this might have weighed 30 lb.
{08938} mucinous cystadenoma of ovary, histology
{08940} mucinous cystadenoma of ovary, histology
{14171} ovarian mucinous cystadenoma, histology
{14180} ovarian mucinous cystadenoma, histology
{21090} endometrioid carcinoma of ovary, gross
{27200} endometrioid carcinoma of the ovary, histology
{25260} endometrioid carcinoma of the ovary


{27083} Brenner tumor, histology
{39859} Brenner tumor, gross
{40518} Brenner tumor, histology

Brenner tumor

Tom Demark's Site

GERM CELL TUMORS (Am. J. Clin. Path. 109(S1): S82, 1998)


{28667} cystic teratoma of ovary, benign, gross ("dermoid cyst")
{28670} cystic teratoma of ovary, benign, gross ("dermoid cyst")
{00111} dermoid cyst of ovary, gross
{11527} dermoid cyst of ovary, gross
{24595} dermoid cyst, gross
{17543} dermoid cyst, gross
{17547} dermoid cyst, brain tissue (white matter)
{17548} dermoid cyst, skin tissue

Ovarian teratoma
Great labels
Romanian Pathology Atlas

Mature teratoma
Classic ovarian dermoid
KU Collection

Ovarian dermoids

WebPath

Dermoid
Pilosebaceous apparatus
Tom Demark's Site

Ovarian dermoids

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Dermoid, fibroid, fibroma

WebPath


{15392} immature ovarian teratoma, histology
{15394} immature ovarian teratoma, histology
{15395} immature ovarian teratoma, histology; the bad section

Struma ovarii

WebPath


{24705} dysgerminoma of ovary, gross
{27038} dysgerminoma of ovary, histology

Ovarian dysgerminoma

WebPath


{27107} endodermal sinus tumor of ovary (Schiller-Duvall bodies)

Yolk sac tumor
Pittsburgh Pathology Cases

SEX CORD TUMORS


{14192} granulosa cell tumor of ovary, gross
{14195} granulosa cell tumor of ovary, gross
{14198} granulosa cell tumor of ovary, histology; notice Call-Exner bodies

Ovarian granulosa cell tumor

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Ovarian granulosa cell tumor

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Ovarian granulosa cell tumor

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{21084} ovarian fibroma, gross
{24599} ovarian fibroma, gross
{40105} thecoma, gross (good yellow color)
{40127} thecoma, H&E
{40126} thecoma, oil-red O stain for fat

Ovarian fibrothecomas

WebPath

Ovarian fibroma

WebPath


{21086} Sertoli-Leydig cell tumor of ovary (good yellow color)
{20235} Sertoli-Leydig cell tumor of ovary, histology

Pregnancy

Early placenta and decidua
Probably a very early elective
abortion. Romanian Pathology Atlas

Placenta I
From Chile
In Spanish

Placenta II
From Chile
In Spanish

Placenta Exhibit
Virtual Pathology Museum
University of Connecticut

Placenta
"Pathology Outlines"
Nat Pernick MD

Measles of the placenta

Yutaka Tsutsumi MD

Conception
GIF animation
WebPath

Third trimester pregnancy

WebPath

Postpartum uterus

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Uterus, second trimester

WebPath

{47859} pregnant
{08434} normal pregnant uterus, gross
{09780} normal pregnant uterus; baby below match-stick
{24666} normal placenta
{21104} normal pregnancy
{38995} normal pregnancy
{08928} normal placental villi in ectopic pregnancy
{08930} normal placental villi in ectopic pregnancy
{11024} placental infarct, gross; these are common and usually harmless


{49415} hydrops fetalis
{49416} fetal death, cord around neck

Parvo B-19 hydrops fetalis

Yutaka Tsutsumi MD

EXAMINING THE PLACENTA (still good: Am. Fam. Phys. 57(5), March 1998)

SPONTANEOUS ABORTION

PREMATURE DELIVERY

FETAL DEATH

ECTOPIC PREGNANCY (Am. Fam. Phys. 72: 1707, 2005; JAMA 309: 1722, 2013)


{00102} tubal pregnancy, gross
{40140} ectopic pregnancy, gross
{40365} ectopic pregnancy, gross

Ectopic pregnancy

WebPath

Ectopic pregnancy

KU Collection

Ectopic pregnancy
GIF animation
WebPath

Ectopic pregnancy, ruptured

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Ectopic pregnancy, ruptured

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Ectopic pregnancy

WebPath

Ruptured Ectopic Pregnancy
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Ectopic pregnancy
CDC
Wikimedia Commons

9 week fetus
Ectopic pregnancy
Wikimedia Commons

PROBLEMS IN LATE PREGNANCY

{15876} abruption of the placenta, sectioned in situ

Rubella of the placenta
Advanced students
Yutaka Tsutsumi MD

CMV of the placenta

Yutaka Tsutsumi MD

TWINS


{15651} twin placenta
{39022} twin placenta, gross
{39989} monochorionic monoamniotic twin
{15709} in utero death of a twin

Stillborn twin


TOXEMIA OF PREGNANCY (Am. Fam. Phys. 70: 2317, 2004; Lancet 376: 631, 2010)

ACUTE FATTY LIVER OF PREGNANCY (Lancet 375: 594, 2010' Am. J. Ob. Gyn. 209: 456, 2013; South. Med. J. 106: 588, 2013)

HYDATIDIFORM MOLE (Am. J. Ob. Gyn. 203: 531, 2010)


{27062} hydatidiform mole, histology
{08921} hydatidiform mole, histology
{08922} hydatidiform mole, histology
{18785} hydatidiform mole

Partial mole

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Parital mole

WebPath

Big uterus with mole

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Mole

WebPath

Mole

WebPath

Mole

WebPath

Mole

WebPath

Partial mole

WebPath

Partial mole

WebPath

INVASIVE MOLE ("chorioadenoma destruens")

CHORIOCARCINOMA


{25185} choriocarcinoma, gross (looks like ketchup)
{49378} choriocarcinoma with right ovary, gross
{49379} choriocarcinoma, gross
{25186} choriocarcinoma, histology
{25187} choriocarcinoma, histology
{27056} choriocarcinoma, uterus, histology
{27059} choriocarcinoma, uterus, histology
{40660} choriocarcinoma, histology

Choriocarcinoma
Classic drawing
Adami & McCrae, 1914

Choriocarcinoma

WebPath

Choriocarcinoma

Tom Demark's Site

{47859} pregnant

* Acupuncture and other "alternative" medicines (with the exception of black cohosh and phytoestrogens) completely fail for relief of menopausal syndromes (Ann. Int. Med. 137: 805, 2002). "Vitex" (Chasteberry, named for its known-for-centuries effects on sex hormones that are obvious but still not understood) passed a small Louisiana study glowingly as a treatment for PMS; women also say it works for cyclic mastalgia.

* Politics

When politicians get involved, the real losers are usually ordinary, decent folk. As physicians, you are called to bring reason and science into public discussions. Again, the following "women's health issues" unit is non-testable.

ESTROGEN REPLACEMENT: In summer 2002, the first big prospective randomized study of the health effects of estrogen-progesterone replacement was stopped early because the treatment group was having more cardiovascular problems and breast cancer than the controls. Especially the cardiovascular effects were opposite to the "conventional wisdom" that replacement is beneficial. If the conventional wisdom is indeed incorrect, perhaps it reflects that women who go to the doctor more often are both healthier and more likely to receive hormone replacement. Gee whiz. Watch this business. Another study found that replacement increases the risk for venous thrombosis and gallstones (JAMA 288: 99, 2002), without much beneficial effect on fracture risk. The fact that there wasn't an impressive impact on fractures obviously results from the study covering only a few years, which was stupid, and the slightly higher mortality rate in the treated group doesn't look statistically significant. The media parlayed this into estrogens causing tremendous cardiovascular risk, and there will be trouble for the next several years over this.

THE BENDECTIN FIASCO: The United States pays the price for its tort system and ignorance of science.

In 1983, the best drug for severe nausea and vomiting of pregnancy (doxylamine, marketed with pyridoxine as "Bendectin" by Merrell-Dow) was withdrawn because of lawsuits alleging the medicine had caused babies to be born deformed.

The hoopla followed an exposé in The National Enquirer (1979). The principal researcher alleging that Bendectin was a teratogen was denounced by his own co-workers as a blatant fraud (JAMA 263: 1468, 1990). Other animal studies supposedly demonstrating teratogenicity found similar effects for sugar and tap water, but could not show a teratogenic effect for thalidomide (JAMA 264: 569, 1990). The NIH epidemiology found no link whatever (Teratology 40: 151, 1989). I found a single recent abstract (89300349) alleging a link, and it is an sorry effort from the former Soviet Block, where there has been no real biology since nature-mystic Thaddeus Lysenko oversaw Stalin's extermination of his country's honest biologists. However, as late as mid-1994, a jury awarded $19 million to a kid whose mother (Ms. Daubert) took Bendectin; the kid's only problem was common clubfoot. Last case thrown out: Science 267: 167, 1995.

Almost all the other lawsuits were unsuccessful, but had placed a tremendous burden on the corporation. The whole business went to the Supreme Count, which in 1993, in a solid, landmark decision ("Daubert vs. Merrell Dow"), required judges to bar junk science from their courtrooms (JAMA 270: 423 & 2964, 1993; Science 261: 22, 1993, thanks Mr. Justice Scalia). Good luck. Nowadays, nobody is going to market a drug for use by pregnant women, or a vaccine, or anything else that invites silly lawsuits. As usual, it is the people who are really sick who suffer. Review of the whole business: NEJM 370: 1081, 2014.

Of course, today doxylamine and pyridoxine are offered as a combination to treat morning sickness.

THE PAP SMEAR FIASCO: The United States pays the price for its tort system and ignorance of the limits of screening.

The pap smear for cervical cancer was designed as an inexpensive screening test. The key was "inexpensive". The consensus among pathologists is that a 10% false-negative rate is quite acceptable, and if it's that low, probably even good practice. (College of American Pathologists, cited in Path Yearbook 1994 p. 42). The idea was that the test should be repeated frequently, in case the technician misses a few cancer cells on one slide.

Unfortunately, the lawyers and militants got into the act in the mid-1980's. ("Murderers" missed a few cancer cells on pap smears; this is likely to be fatal only if the women aren't screened as often as they should be.) The price of a "pap smear" rose from $5 to over $50 because of all the regulations; I haven't seen anything to suggest that quality is better, and "to save money", lots of gynecologists switched to a one-slide specimen, which means less sensitivity but much better cover-your-butt. The result, of course, was that the test became unavailable to the underclass women who are at greatest risk, and the rate of invasive cancer of the cervix has increased. See Med. Care. 30: 1067, 1992; Acta Cytol. 36: 461, 1992.

FEMALE GENITAL MUTILATION: ("female circumcision"); Women in the world's poorest nations suffer, while the rich nations ignored a horrible problem for ideological reasons.

The custom is most common in Africa, where some people believe it ensures a woman's chastity and, after she is married, her fidelity by reducing sexual pleasure.

Until 1992-4, the abominable practice of female circumcision was a taboo subject, thanks to the politics of the era. ("You cannot criticize these people's culture.") In 1994, the medical literature (until then, strangely silent) suddenly was filled with physicians saying the obvious: FEMALE CIRCUMCISION IS A CRIME AGAINST HUMANKIND.

What is female circumcision? It's a "cultural practice" to which around 100,000,000 living human females have been subjected, mostly in Africa north of the equator. For example, almost every human female in Somalia is circumcised. It involves the surgical amputation of the clitoris, sometimes with the surrounding tissue, part or all of the labia majora, and/or the labia minora. Sometimes the introitus is sewn shut with needle and string, and the new husband cuts the string when he buys the wife. It's usually performed on children, often with no anesthetic. What's the basis for this "cherished traditional cultural practice"? The intent, of course, is to make the girl less interested in sex, and less able to do it, so that she will be a virgin when she is ready to marry and will therefore get more money for her parents.

Complications include huge dermoid cysts arising in the scar, loss of sexual pleasure, inability to menstruate, inability to have intercourse, pelvic and back pain, chronic pelvic infections leading to stones and hydroureters, stitch abscesses, traumatic neuromas, reopening of the incisions, pain on intercourse, vesicovaginal fistulas (dribble continuously), and catastrophic problems with delivery of children. Every one of these is common. Unlike male circumcision, there are no health benefits whatsoever. Opposition to female circumcision comes from mainstream Islam (Saudi Medical Journal 21: 921, 2000, thanks) and Christianity, and even the WHO, which in 1992 (after knowing about the problem since its founding, of course) finally condemned it officially (Eur. J. Ob. Gyn. 45: 153, 1992). Here's a reading list on female circumcision, including a few pieces by Leftists who ask, with a straight face, whether concern for health can ever override "multicultural sensitivity":

ATTENTION TO WOMEN'S PROBLEMS: Right or wrong, it's human for each individual to interact differently with males and females, even when pursuing gender-neutral activities, and in this regard, every human being's behavior is different. Where things go wrong is when fairness is compromised, as in the old days, when medical schools wouldn't take women "because they'll just get pregnant and then never practice." That really happened, and happened frequently. Things are better since the 1950's ended, at least in this regard. Thankfully it's now possible to punish those who really commit sexual harassment, which has historically been the bane of a professional woman's existence, in the health-care setting and otherwise. But there's still a tendency by physicians to thoughtlessly ignore health problems specific to women. In one chart review (at an M.D. institution, mind-you), housestaff (male and female) doing history-and-physicals almost never asked about pap smears, mammograms, or breast self-exam, and were only half as likely to do breast exams (35%) as to do a rectal (70%). When I was a med student, I was, to my knowledge, the only one who discussed breast self-exam with every adult female patient. See Academic Medicine 68: 698, 1994. There's plenty of evidence now that women get under-treated, or at least get less treatment for the same things, as do men. See, for example, Am. J. Psych. 150: 1309, 1994 (on being human, as well as disparities in care), JAMA 268: 1872, 1994 (women alcoholics get less care than men), Arch. Int. Med. 152: 972, 1994 (women with myocardial infarcts get treated less aggressively; the latter effect might be due to women being better protoplasm and less sick than men: NEJM 330: 1101, 1994). Hip arthroplasty: NEJM 342: 1016, 2000. Reperfusion in heart attack: NEJM 342: 1094, 2000. Docs: Unless you want Uncle Sam to get involved, you need to do something about this yourselves. And this should come as no surprise: In India, where most families supposedly want sons rather than daughters, three girls die of diarrhea for every boy (Br. Med. J. 327: 126, 2003). South India has by far the highest known suicide rate of anyplace in the world; most often, it is a young woman who commits suicide rather than be forced to marry a man she hates (Lancet 363: 1117, 2004). Women in many traditional societies commit suicide to avoid forced marriage or escape domestic violence (NEJM 358: 2201, 2008). Well over half of all wives in Yemen are beaten or worse (Am. J. For. Med. Path. 33: 163, 2012) -- your lecturer's personal conversations have led us to believe that men from this kind of culture "hate America" because we treat women decently and want others to do so as well. Call me something bad if you want. Click here for the Archbishop of Canterbury's remarks after England passed an act protecting its women from forced marriage. This was quoted out of context by outraged militants of various kinds, resulting in a world news story.

IN-VITRO FERTILIZATION: Some people say it's your inalienable right to have Uncle Sam pay for it, while for others, it's anathema on religious-ideological grounds. Averages: To get one born baby when all the factors are favorable, somebody will pay $50,000 if it works the first try; when there's male-factor infertility and five previous failures, the cost is $800,000 per baby (NEJM 331: 239, 1994). I bet third parties (Uncle Sam, managed care) won't pay for this.

FETAL MONITORING is fancy-tech, and since it's available, the savvy physician has to use it to cover his butt. However, the benefits to the human race are by no means apparent, and people are finally getting up the courage to say so (Can Med. Assoc. J. 148: 1737, 1994; J. Fla. Med. Assoc. 78: 303, 1994). Even the American College of Obstetricians and Gynecologists has come out with a statement that listening occasionally with the stethoscope is every bit as good as hooking up a monitor (Ob. Gyn. 76: 1130, 1994; this has held up). There are more muddy-the-waters technologies on the horizon; there's no reason yet to think they'll do much to help patients, though they'll surely increase health-care expenditures and incomes (Curr. Op. Ob. Gyn. 5: 647, 1994; Br. J. Ob. Gyn. 100: 733, 1994). One fancy intervention ("home fetal monitoring") didn't seem to do much that simply explaining things to the patient didn't (Am. J. Ob. Gyn. 164: 756, 1994). This trend has continued to the present; in the "managed care" era, the decisions of obstetrician-gynecologists about which technologies to use are a curious subject (Am. J. Ob. Gyn. 188: 162, 2003); a Canadian group points out the obvious fact that "defensive medicine" can itself generate income for physicians (Soc. Sci. Med. 51: 523, 2000), etc., etc. Especially welcome is the loss of the fetal scalp blood monitor as a standard of care.

Androgens for female sexual dysfunction / low libido: Mayo Clin. Proc. 79(4S): S-19, 2004. No joke -- when one partner loses interest in sex, the effect on a marriage is often devastating.

Goya The Disasters of War
Goya's sketch of women resisting

For more on the vile crime of RAPE, check the current literature. There are around 20,000 convictions per year in the USA for adult rape, and 23,000 for child sexual abuse. Examining and treating the woman who has been raped: NEJM 332: 234, 1995; Ped. Clin. N.A. 46: 809, 1999. Dudes: Forcing yourself on an unwilling woman is the most un-masculine thing you can do. Most rape is committed by an acquaintance, and (despite what's below) I suspect most rapes go unreported, which is bad. "Roofies" is flunitrazepam ("Rohypnol"), which when added to her drink makes rape easy (review South. Med. J. 93: 558, 2000). One bizarre article even cites industry-specific rates for being raped by a co-worker (Am. J. Pub. Health 84: 640, 1994). Under the common law, a husband may lawfully penetrate his wife without her consent; this is changing. The serial rapist generally starts shortly after puberty, as a stupid-hurtful way of expressing anger. The first victim is usually an acquaintance. In most jurisdictions, rape means putting any part of his penis into any part of her body without her consent. In others, it may include putting something else into her vagina or anus without her consent. (Contrary to what you may have read in the magazine article, unwanted touch through clothing is not rape.) He doesn't have to have an erection, he doesn't have to ejaculate, it doesn't have to be her vagina, it doesn't matter if she's known to be easy, or if she consented last night, or if she happily took off her clothes and got in bed with him, or was petting for a long time, or if she just teased him, or said she would and then changed her mind, etc., etc. A man can get raped, too. A mentally-retarded or very crazy person cannot lawfully consent, no matter what her age. Dudes: if she changes her mind later, and says you raped her, it's her word against yours. Nowadays, the law and public opinion are stacked against you in this (and many other situations, too) simply because you are a man. For example, a judge isn't even allowed to remind a jury that it's easy to bring a false accusation or rape, and hard to defend against it, and the defense may not even be allowed to present evidence that a particular woman had already made a previous false allegation "because it might inflame the jury" (Arkansas Supreme Court, Ralph Taylor). "Rape shield laws" forbidding any discussion of the accuser's previous sexual history have been interpreted to include the accuser's currently facing criminal charges for having consensual sex with minors (Charles Steadman, 1993). In some juristictions, the law specifically allows that a man can be convicted of rape solely on the uncorroborated testimony of an accuser, without any physical evidence whatsoever. This results from litigation from the 1970's prompted by militants, including the author of "Against our Will: Men, Women, and Rape", whose mentality is illustrated by her statement that rape is "nothing more or less than a conscious process of intimidation by which all men keep all women in a state of fear." Be careful, dudes, especially around people you don't know aren't "fantasy-prone", mentally-ill, or malicious or worse. However, until 1994, the subject of "factitious rape", i.e., a woman making a false accusation, was a forbidden subject in the medical literature for political reasons, and patently false ideology ("No woman would lie about something so personal"; "The FBI has proof that only a few percent of claims are false", etc., etc.) dominated discussion. That false claims get made, and that they are very difficult to defend against, has been documented for over 3500 years -- remember Potiphar's wife, Phaedra and other tales from the classics. A major article by the US Air Force Office of Special Investigations that got no attention at the time appeared in Forensic Science Digest 11(4): 64, December 1985; of accusations of rape brought in the Air Force, a panel of three reviewers unanimously agreed 60% were false, with many of the women recanting before or after failing a polygraph. The landmark article appeared in Arch. Sex. Behav. 23: 81, 1994. Now that we have DNA testing, it's become clear, in retrospect, that plenty of men serving prison time for a particular rape didn't do it (KC Star March 13, 1993 was the first in what has now become a frequent feature of new stores.) The now-classic 1996 article from the US Department of Justice "Convicted by Juries, Exonerated by Science" cited a statistic of 25% for cases in which DNA specifically excludes the accused; this does not include those for which results are indeterminate, and of course it does not exclude the possibility that the sex was consensusal (remember the defense in the Kobe Bryant case). By 2008, there have been over 200 convictions overturned -- all men were serving long prison terms. This is in keeping with my own experience doing exams, which range from godawful cases of genuine rape to women trying to get out of a non-rape abusive situation to malicious women simply trying to get a particular man in trouble. The latter works. My reading of law articles indicates there are perhaps 33,000 false accusations of rape per year in the US, primarily against African-American men. "Rape counsellors": Before you tell her absolutely to... please be sure that.... Your lecturer doesn't take anybody's word on anything any more, in the absence of physical evidence. He also considers himself a macho-man, and is glad that the same science that now protects a man against a false claim of rape also brings real perpetrators to swift justice. For "Factitious rape", see South. Med. J. 87: 736, 1994; Arch. Sex. Behav. 23: 81, 1994 (the latter found 41% of police rape accusations to be false; my informal series in 1982-3 was at least this high). Self-inflicted wounds by a women claiming to be raped: Am. J. Forens. Med. Path. 20: 374, 1999; Med. Sci. Law. 38: 202, 1998. Wood's lamp is notoriously nonsensitive and nonspecific in looking for semen: Pediatrics 104: 1342, 1999. Examining the clothing can support a claim (saving the woman a terrible ordeal) or refute a claim (saving the man a terrible ordeal) -- the authors of this paper talk about the "sensitive" politics: J. Forens. Sci. 45: 568, 2000. The false memories syndrome has produced women who accuse both family and physicians of terrible crimes -- for a case of a woman with uterine agenesis who "remembered" incest, a resulting pregnancy, and a resulting criminal abortion by a particular physician: J. Ped. Adol. Gyn. 11: 181, 1998. (A few years before, it would have been extremely difficult to defend against this accusation.) As I mentioned, you will find nothing whatsoever on this very important subject in the English-language medical literature before 1994. Today, before love happenes, he should text her, "I want you" and she should text back "I want you." How romantic -- and the perfect defense should there be a misunderstanding.

Current dogma in "child sexual abuse" circles is that a normal physical exam is consistent with any manner of horrid abuse, including recent full penetration of a baby girl by an adult male's erect penis. This strange idea is based on misrepresenting the actual data from an article in Pediatrics 94: 310, 1994, rebutted Pediatrics 97: 148, 1996. The best study so far on healing of the hymen (Pediatrics 119: e1094, 2007) does document that it heals well, like the buccal mucosa, often without marks. Even an 8-month-old girl healed with only neovascularity at the site of previous transection. Of course, this makes it much more difficult to defend against a coached accusation. A problem that I have with this paper, which will be of great importance in sex-abuse trials in the years to come, is a strange selectivity in discussion of the data. Despite all the talk about how well the hymen heals, and how even the worst trauma can heal without a trace, a look at the data shows that of prepubertal girls sustaining transection/laceration (i.e., what you might expect after full penetration -- and 16 of 39 children sustained these severe injuries), the vast majority did NOT heal either smoothly, continuously, or "delicately". The medical profession needs to do something about this, now, despite the political climate.

The term "commercial sex worker", the 1990's politically-correct term for "prostitute", was popularized by the Thai government. Free enterprise brought about "Thailand's economic miracle", which was based largely on sex tourism (Lancet 352: 246, 1998). Girls became CSW's to escape grinding poverty, and the majority paid with their lives when they contracted HIV. This seems to me to be a very great evil, and not something we want to honor and dignify by changing our terminology. Thankfully, with the decline in "political correctness", the term is now changing to "trafficked women", re-emphasizing that these women lose their freedom, their dignity, and their health, especially when they are brought from the poor nations to the rich nations as sex slaves (Lancet 363: 564, 565, & 566, 2004).

In the late 1990's, some countries took my advice and made estrogen-based emergency contraception ("morning-after pill") readily available without a special prescription. It was safe and was not abused. NEJM 339: 1, 1998. The progestin-only "Plan B" pill became legal with a prescripton in the US in 1999; the requirement for a prescription ended for women over 18 in 2006. A pharmacist can Rx it for a 17-year-old; a younger girl needs to see herdoctor. Maybe this is the right approach. For a time, the big flap was over a pharmacist's right not to full a prescription for the morning-after pill for his/her own religious reasons. Some pharmacies also refused to dispense out fear of being targeted by militants. Things seem to have settled down in the US secular health care system. For two decades, whether or not a _____ hospital can/should/must provide emergency contraception for rape victims has been an "issue" (Am. J. Public Health 91: 169, 2001); even Chile made emergency contraception available for rape victims in 2004 (Lancet 363: 1707, 2004) amidst massive hoopla, anti-contraception street demonstrations, refusals of local administrators to cooperate, and the _____ leadership comparing it to genocide under Hitler and Stalin. Mifepristone (formerly RU486) as a safe, effective morning-after pill without side effects: Lancet 353: 697, 1999. For over a decade, right-wing activists made tremendous political capital off keeping this unavailable. It was legalized in the last days of the Clinton administration. Curiously, we hear nothing from the militants about banning methotrexate, which is also a reliable and convenient way of ending an unwanted pregnancy. By contrast, 97% of families in sub-Saharan Africa cannot afford even a condom without a government subsidy (Lancet 369: 715, 2007).

* SLICE OF LIFE REVIEW

{08914} cervix, normal
{09755} cervicovaginal cytology, normal
{10271} cervix, normal
{10274} cervix, normal
{11764} uterus, normal
{11765} cervix, normal
{11766} cervix, normal
{11768} cervix, normal
{11769} breast, normal
{14949} ovary, monkey
{14950} ovary, monkey
{14965} ovary monkey (cortex), normal
{14965} ovary monkey (cortex), normal
{14966} ovary monkey (cortex), normal
{14966} ovary monkey (cortex), normal
{14967} ovary, cortex
{14968} ovary, cortex
{14969} primary follicle, normal
{14969} primary follicle, normal
{14970} primary follicle, normal
{14970} primary follicle, normal
{14971} secondary follicle, normal
{14971} secondary follicle, normal
{14972} secondary follicle, normal
{14972} secondary follicle, normal
{14973} atretic follicle, normal
{14973} atretic follicle, normal
{14974} atretic follicle, normal
{14974} atretic follicle, normal
{14975} corpus hemorrhagicum, normal
{14975} corpus hemorrhagicum, normal
{14976} corpus hemorrhagicum, normal
{14976} corpus hemorrhagicum, normal
{14977} corpus luteum, pig
{14978} corpus luteum, pig
{14979} atretic follicle, with loose pieces of granulosa
{14980} corona radiata, ovary
{14981} oviduct, normal
{14981} oviduct, normal
{14982} oviduct, normal with cilia
{14982} oviduct, normal with cilia
{14983} oviduct (uterine portion)
{14984} oviduct (uterine portion), arrow indicates oviduct
{14985} endometrium secretory, normal
{14985} endometrium secretory, normal
{14986} endometrium secretory, normal
{14986} endometrium secretory, normal
{14987} endometrium secretory (glycogen stain)
{14988} endometrium secretory (glycogen stain) glycogen stain
{14989} vagina, normal
{14989} vagina, normal
{14990} vagina, pap smear
{14991} vagina, pap smear
{15091} vagina, normal
{15091} vagina, normal
{15098} uterus, normal
{15098} uterus, normal
{15099} uterus, normal
{15099} uterus, normal
{15779} female genital organs unfixed, normal
{15780} vagina, normal
{15782} ovary and fallopian tube, normal
{15783} ovary and fallopian tube, normal
{15784} ovary, normal
{15785} ovary, normal
{15786} fallopian tube, normal
{15787} uterus, normal
{15788} uterus, normal
{15789} uterus, normal
{15790} uterus, normal
{15866} placenta, normal
{17495} uterus, normal
{17496} myometrium, normal
{20662} ovary, normal
{20662} ovary, normal
{20663} ovary, normal
{20663} ovary, normal
{20664} ovary, primordial oocyte
{20665} ovary, primordial oocyte
{20666} corpus albicans, ovary
{20667} primary oocyte, ovary
{20668} secondary follicle, ovary
{20669} corpus albicans, ovary
{20670} secondary follicle, ovary
{20671} ovary, blood vessels
{20672} corpus luteum, ovary
{20673} corpus luteum, invading vessels
{20674} granulosa layers, ovary
{20675} oviduct, ampulla
{20676} oviduct, ampulla
{20677} oviduct, ampulla
{20678} oviduct, isthmus
{20679} oviduct, isthmus
{20680} oviduct, isthmus
{20681} uterus, secretory endometrium
{20682} uterus, myometrium
{20683} uterus, glandular epithelium
{20684} uterus, glandular epithelium
{20685} uterus, resting endometrium
{20687} cervix, normal
{20687} cervix, normal
{20689} vagina, stratified squamous epithelium
{20788} endometrium
{20788} endometrium
{20789} endometrium
{20790} uterus, glandular epithelium
{20791} uterus, glandular epithelium
{20952} ovary
{20953} ovary, primary oocyte
{20954} ovary, primary oocyte
{20955} ovary, primordial follicle
{20956} ovary, secondary follicle
{20957} ovary, cumulus oophorus
{20958} ovary, atretic follicle
{20959} ovary, granulosa cells
{20960} ovary, corpus luteum
{20961} oviduct, ampulla
{20962} oviduct, peg cells
{20963} oviduct, isthmus
{20964} uterus, secretory
{20965} uterus, resting
{20966} cervix, squamocolumnar junction
{20967} vagina
{24446} fallopian tube, normal
{24666} placenta, normal
{25778} side-by-side arrangement, normal endocervical cells
{25788} honeycomb arrangement, endocervical cells - normal presentation
{25824} ciliated cells, endocervical cells (normal)
{25873} stratified squamous epithelium, normal cervix
{25875} superficial & intermediate squamous cells; normal pap
{25878} transformation zone, normal cervix
{25879} squamous & endocervical cells, pap smear - normal
{25888} endometrial cells - normal
{25891} endometrial cells - normal, stromal cells
{25893} endometrial cells - normal, stromal cells
{27128} ectocervix, normal glycogenated epithelium
{29291} endometrial cells, normal
{29294} endometrial cells, normal
{39421} trophoblast, normal
{39422} placenta, normal
{39423} trophoblast, normal

BIBLIOGRAPHY / FURTHER READING

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