Uterine and vulvovaginal Disorders

1.1 - Abnormal Uterine Bleeding (AUB) & Endometriosis

1) Fertile uterine soil:

endometrium (epithelium)

2) Smooth muscle tile path:

myometrium (smooth muscle)

3) PALM COEIN fountain:

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abnormal uterine bleeding can be due to structural problems (Polyps, Adenomyosis, Leiomyomas,

Malignancy/Hyperplasia) and non-structural problems (Coagulopathy, Ovulatory, Endometrial,

Iatrogenic, Not otherwise specified)

4) Polypy beets:

endometrial polyps (hyperplastic growth of endometrial glands and stroma) can cause abnormal

uterine bleeding

5) Spots of beet juice:

endometrial polyps can cause light intermenstrual bleeding (spotting)

6) Small crab roots:

endometrial polyps have a small risk of underlying endometrial cancer

7) ADDING dirt to the myometrial path:

in adenomyosis, the stratum basalis layer of the endometrium grows into the myometrium

8) Enlarged globular pumpkins:

adenomyosis causes myometrial hypertrophy → uniformly enlarged globular uterus

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9) Leaking pumpkin:

adenomyosis causes heavy prolonged menstrual bleeding

10) Pain in abdomen:

adenomyosis presents with dysmenorrhea (painful menses)

11) Bulging myometrial tiles:

leiomyomas (fibroids) are benign smooth muscle tumors of the uterus

12) Black female on tiles:

fibroids are most common in black women

13) Female symbol:

fibroids are estrogen-sensitive

14) Pregnant lady laying down tiles:

fibroids increase in size during pregnancy (estrogen sensitive) and decrease in size after

menopause

15) Inner bulging myometrial tiles:

fibroids may be located near the inner endometrial surface (submucosal)

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16) Outer bulging myometrial tiles:

fibroids may be located underneath the outermost serosal surface of the uterus (subserosal)

17) Middle bulging myometrial tiles:

fibroids may be located in the middle of the uterine wall (intramural)

18) Pooling red sap:

submucosal fibroids can cause heavy menstrual bleeding

19) Barren tree:

submucosal fibroids can cause infertility

20) Obstruction of colonic plant cover:

large posterior fibroids can compress the colon or rectum → obstructive symptoms (e.g.

constipation)

21) Knocking over bladder can:

large anterior fibroids (or posterior fibroids causing the uterus to displace upward) can cause

obstructive urinary symptoms (urgency or incomplete emptying)

22) Irregular proliferating grass:

endometrial hyperplasia (abnormal proliferation of endometrial cells)

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23) ESTRO-GROW fertilizer:

endometrial hyperplasia can be caused by exposure to unopposed estrogen (relative to

progesterone) (e.g. estrogen replacement therapy, tamoxifen use, estrogen secreting tumor,

anovulatory cycles)

24) "™":

tamoxifen (SERM used in treatment of breast cancer) is a risk factor for endometrial hyperplasia

(due to agonist effect at estrogen receptors in the uterus)

25) Obese gardner:

obesity is a risk factor for endometrial hyperplasia (due to increased aromatization of androgens

to estrogen in adipose tissue)

26) Unruptured polycystic buds:

polycystic ovarian syndrome (PCOS) is a risk factor for endometrial hyperplasia (due to

anovulatory cycles)

27) Early bloomers:

early menarche is a risk factor for endometrial hyperplasia (due to anovulatory cycles

28) Evergreens/Late deciduous:

late menopause is a risk factor for endometrial hyperplasia (due to anovulatory cycles)

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29) Seedless:

nulliparity is a risk factor for endometrial hyperplasia (due to anovulatory cycles)

30) L-inch worm:

Lynch syndrome (hereditary nonpolyposis colorectal cancer - HNPCC) is a risk factor for

endometrial hyperplasia

31) OCP lawnmower:

oral contraceptive pills decrease the risk of endometrial hyperplasia (due to presence of both

progestins and estrogen)

32) Leaking puddle:

in premenopausal women, endometrial hyperplasia can present with heavy menstrual bleeding

33) Trailing spots:

in premenopausal women, endometrial hyperplasia can present with light intermenstrual bleeding

(spotting)

34) Old woman with spotted pants:

endometrial hyperplasia can present with postmenopausal bleeding

35) Simple hyperplasia grass:

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endometrial hyperplasia may be simple (increased number of glands), with or without atypia

36) Complex hyperplasia grass:

endometrial hyperplasia may be complex (crowded glands), with or without atypia

37) ATYPICAL:

the presence of atypia (dysplastic epithelial cells) confers a higher rate of progression to

endometrial carcinoma

38) Invasive endometrial crabgrass:

endometrial carcinoma is usually caused by exposure to unopposed estrogen (relative to

progesterone), and has the same risk factors as endometrial hyperplasia

39) CRAB in the uterus:

endometrial carcinoma (most common gynecologic cancer, median age onset 60 years, most

commonly presents with postmenopausal bleeding)

40) Extra-uterine endometrial soil:

in endometriosis, endometrial glands and stroma are located outside the uterus

41) Throwing endometrial dirt:

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reverse menses through the fallopian tube is a hypothesis for formation of extrauterine

endometrial tissue (endometriosis)

42) Coelomic compost pile:

coelomic metaplasia (inappropriate differentiation of pluripotent stem cells) is a hypothesis for

formation of extrauterine endometrial tissue (endometriosis)

43) Red sprinkler lines:

vascular and lymphatic spread is a hypothesis for formation of extrauterine endometrial tissue

(endometriosis)

44) Pile of dirt on ovarian patio:

endometriosis forms endometriomas (“chocolate cysts”) in the ovaries (most common site)

45) Dirt on intestinal tunnel:

the serosal surface of the intestines is a site of implantation for endometriosis

46) Dirt on Fallopian path:

the fallopian tubes are a site of implantation for endometriosis

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47) Dirt in Douglas’s pouch:

the rectal pouch of Douglas (space between rectum and uterus) is a site of implantation for

endometriosis

48) Abdomen hit with dirt:

endometriosis presents with pain (dysmenorrhea, dyspareunia), not abnormal bleeding

49) Painful poop pile:

endometriosis can present with dyschezia

50) Barren tree:

endometriosis can cause infertility

51) Dirt powder spots, pink nodules, and creepers:

endometriosis appears as “powder burn” lesions, flesh colored nodules, and filmy adhesions on

serosal surfaces

52) OCP leaf blower:

endometriosis can be treated with oral contraceptive pills (OCPs)

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1.2 - Cervical Neoplasia

1) Stairs to uterine platform:

INTERNAL OS of the cervix (opening of cervical canal into uterus)

2) Stairs to vaginal walkway:

EXTERNAL OS of the cervix (opening of cervical canal into vagina)

3) ENDOcervical wall:
ENDOcervix (area of cervix lining CERVICAL CANAL)

4) EXOcervical wall:
EXOcervix (area of cervix exposed to VAGINA)

5) COLUMNAR caterpillars:
ENDOCERVIX is lined by mucus-secreting COLUMNAR cells

6) SQUAMOUS butterflies:
EXOCERVIX is lined by stratified SQUAMOUS cells

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7) Polpy fruit:
ENDOCERVICAL POLYPS (benign polyps arising from ENDOcervix)

8) COLUMNAR caterpillar:
ENDOCERVICAL POLYPS are lined by mucus-secreting COLUMNAR cells (similar to
endocervix)

9) Middle-aged woman with kids:

ENDOCERVICAL POLYPS are most common in middle-aged women with history of multiple
pregnancies

10) Leaking red fruit:

ENDOCERVICAL POLYPS cause VAGINAL BLEEDING

11) Caterpillar to butterfly juction:

SQUAMO-COLUMNAR JUNCTION ("TRANSFORMATION ZONE") (columnar epithelium
meets squamous epithelium)

12) Purple stamens on milky white flowers:

LACTOBACILLI (gram positive rods) in the vagina produce LACTIC ACID → acidic pH (3.8-
4.5)

13) Caterpillar to butterfly METAmorphosis:

at the TRANSFORMATION zone, endocervical columnar cells undergo benign SQUAMOUS
METAPLASIA (due to acidic pH in the vagina)

14) ABNORMAL dead butterflies:

squamous metaplasia (a normal process) can progress to DYSPLASIA (cervical intraepithelial
neoplasia [CIN])

15) PILL bugs:
cervical dysplasia (CIN) and cancer are caused by human papilloma virus (HPV)

16) Car keys:
HPV 16 is a HIGH RISK HPV strain (causes dysplasia and cancer)

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17) "I voted":
HPV 18 is a HIGH RISK HPV strain (causes dysplasia and cancer)

18) Broken CHECKPOINT:
p53 tumor suppressor gene (CHECKPOINT of cell cycle) is INHIBITED by high risk HPV →
uncontrolled cellular replication → dysplasia → cancer

19) ROOT BEER:
Rb tumor suppressor gene is INHIBITED by high risk HPV → uncontrolled cellular replication
→ dysplasia → cancer

20) buG room 1 → Solarium:

p53 and Rb tumor suppressor genes function at G1 to S phase TRANSITION

21) "6" on checkpoint:
high risk HPV strains integrate into host DNA → overexpression of oncogene E6 → inhibition of
p53

22) 7 straw in root beer:

high risk HPV strains integrate into host DNA → overexpression of oncogene E7 → inhibition of
Rb

23) Kissing couple:
multiple HIGH RISK PARTNERS and unprotected intercourse are risk factors for CIN and
cancer (due to increased HPV risk)

24) Crutches:
IMMUNODEFICIENCY is a risk factor for CIN and cancer

25) Smoker:
SMOKING is a risk factor for CIN and cancer

26) Pill bugs at the transformation zone:

HPV has an affinity for the IMMATURE METAPLASTIC SQUAMOUS cells at the
transformation zone

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27) KOI fish eating pill bugs:
on histology, HPV causes KOILOCYTOSIS within squamous epithelial cells

28) Big-eyed KOI fish:

koilocytosis presents as PERINUCLEAR CLEARING (“perinuclear vacuolization”) within
squamous cells

29) ABNORMAL dead butterflies:

HPV can cause DYSPLASIA (cervical intraepithelial neoplasia [CIN])

30) "C-Inside" for ABNORMAL dead butterflies:

cervical dysplasia (CIN) arises from the BASAL epithelial cells and has 3 classes (CIN 1, 2, or 3)

31) ONE-THIRD abnormal butterflies:

CIN 1 (MILD dysplasia involving lower ONE-THIRD of epithelium)

32) TWO-THIRD dysplastic butterflies:

CIN 2 (MODERATE dysplasia involving lower 2/3 of epithelium)

33) More than 2/3 dysplastic butterflies:

CIN 3 (SEVERE dysplasia involving MORE THAN TWO-THIRDS or full thickness of
epithelium)

34) Breaking through bottom of glass:

CIN can progress to invasive cervical carcinoma (invasion of BASEMENT MEMBRANE)

35) Low SIL:
LSIL (LOW-GRADE squamous intraepithelial lesion) (alternate term for CIN 1

36) Pool filter clearing butterflies:

CIN1 (aka LSIL) usually RESOLVES spontaneously in young healthy women

37) High SIL:
HSIL (HIGH-GRADE squamous intraepithelial lesion) (alternate term for CIN 2 and 3)

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38) Filter clogged with butterflies:
CIN2/3 (aka HSIL) are at higher risk of progressing to cervical CANCER

39) Brushing butterflies:
PAP SMEAR (screening test for cervical DYSPLASIA and CANCER (collected by taking a swab
of the cervix) (important to sample transformation zone)

40) ABNORMAL butterflies detected:

if abnormal cells are detected by Pap smear, colposcopy and biopsies are performed

41) Scope:
COLPOSCOPY is performed by visualizing the cervix with a scope

42) Pool tester turning water WHITE:

during colposcopy, ACETIC ACID is applied to the cervix to turn abnormal areas WHITE

43) Grabber tool:
during colposcopy, abnormal tissue is BIOPSIED

44) Cancer crabs:
cervical cancer is most commonly SQUAMOUS CELL carcinoma (less commonly
adenocarcinoma)

45) PEARL necklace:
SQUAMOUS CELL carcinoma of the cervix has keratin PEARLS and intercellular bridges

46) Pinching ureteral hose:

cervical cancer spreads down and out → compression of URETERS → postrenal kidney injury

47) Leaking red post-pollination:

cervical cancer may present with POSTCOITAL BLEEDING

48) Protective syringe fence:

HPV VACCINE protects against common HPV types (including low and high risk strains)

49) ABNORMAL dead butterflies:

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squamous metaplasia (a normal process) can progress to DYSPLASIA (cervical intraepithelial
neoplasia [CIN])

50) Greater than TWO-THIRDS abnormal butterflies:

CIN 3 (SEVERE dysplasia involving MORE THAN TWO-THIRDS or full thickness of epithelium)

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1.3 - Vulvar & Vaginal Lesions

1) Secreting duct at "Garden’s of Bartholin":

Bartholin glands are secretory glands that drain via ducts in the vulva

2) Bulging gunky air duct:

blockage of a Bartholin duct causes the gland to dilate with fluid → Bartholin cyst (forms Bartholin
abscess if infected)

3) "LICHENS":
vulvar lichen sclerosus, lichen planus, and lichen simplex chronicus are benign skin conditions

4) Itchy skin:
the vulvar “lichens” all present with severe pruritus and visual skin changes

5) Sclerotic snake:
lichen SCLEROSUS is a benign vulvar dermatosis

6) Thin snake skin:

lichen SCLEROSUS causes smooth white plaques on thin “parchment-like” tissue

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7) Thinned branch:
on histology, lichen SCLEROSUS appears as thinned epidermis overlying amorphous sclerotic
stroma

8) Crab-patterned snake:
lichen SCLEROSUS has a small risk of progression to vulvar squamous cell carcinoma

9) Purple lichen at hole:

lichen PLANUS can present in the mouth or non-vulvar skin

10) Spider web:
lichen PLANUS can appear as a fine net-like white plaques (Wickham striae) in the oral mucosa

11) Purple polygonal lichen spots:

lichen PLANUS can appear as purple polygonal papules

12) Chronically scratching lichen:

lichen SIMPLEX CHRONICUS presents with severe pruritus → chronic scratching

13) Leathery bark:
lichen SIMPLEX CHRONICUS appears as leathery white plaques with excoriations (due to chronic
scratching)

14) Thick flaking bark:

on histology, lichen simplex chronicus appears as epithelial thickening (due to squamous cell
hyperplasia) with hyperkeratosis

15) "View INside":
vulvar intraepithelial neoplasia (VIN) (a precursor to SCC) is analogous to cervical intraepithelial
neoplasia (CIN)

16) Pill bugs:
Vulvar dysplasia (VIN) is caused by high-risk HPV subtypes (e.g. 16, 18)

17) Varying piles of abnormal leaves:

Vulvar dysplasia is categorized into VIN 1, 2, and 3 (analogous to CIN 1, 2, and 3)
based on depth of abnormal cells and degree of dysplasia)

18) Invading leaves:
VIN can progress to vulvar squamous cell carcinoma
19) Pearl necklace:

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vulvar squamous cell carcinoma has keratin pearls and intercellular bridges (similar to other
squamous carcinomas)

20) Striated leaves:
embryonal rhabdomyosarcoma is a skeletal muscle cancer of the vagina

21) Young girl with cystic raspberries:

embryonal rhabdomyosarcoma occurs in young girls and presents as a jellylike cystic mass
protruding from the vagina

22) Translucent cellular glass:

clear cell adenocarcinoma (appears as clear vacuolated cells on histology)

23) Columnar desk:
vaginal adenosis (exocervix and vagina develop columnar epithelium [rather than squamous])

24) "DESk":
women exposed to diethylstilbestrol (DES) in utero are at increased risk for clear cell
adenocarcinoma and vaginal adenosis (and uterine and cervical anomalies)

25) "INF♀":
DES is a synthetic estrogen

26) Gardener in wolf shirt:

Gartner duct cysts are remnants of the Wolffian duct (mesonephric duct)

27) Cystic planter boxes on lateral wall:

Gartner duct cysts appear on the lateral wall of the vagina

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