Weatherly's Woes

VAGINA

The vagina is a fibromuscular canal lined by non-keratinized stratified squamous epithelium. The upper two-thirds come from the Mullerian ducts, have columnar epithelium in utero, and drain into the iliac lymph nodes. The lower one-third comes from the urogenital sinus, has stratified squamous epithelium and drains into the inguinal nodes. Before birth, the squamous cells replace the columnar cells, so that the whole vagina is filled with stratified squamous epithelium. That embryological process is blocked by a banned estrogenic medication called diethylstilbestrol (DES). So if your mom took DES while she was pregnant with you, the columnar cells will remain in your upper vagina. This is called adenosis. It’s completely asymptomatic, because the columnar cells are often buried, turning into little epithelial glands. Adenosis is bad because it can lead to vaginal clear cell adenocarcinoma in adulthood. As the name suggests, the cells have big, empty cytoplasms.

Note - DES doesn’t cause cancer in the moms who took it, but it does in their unborn daughters. 1 in 1,000 women exposed in utero go on to get clear cell adenocarcinoma.

Note - the most common cause of cancer in the vagina is local invasion from cervical cancer. The most common primary vaginal cancer is due to HPV infection.

Yikes. An old Diethylstilbestrol advertisement that hasn’t aged well

VULVA

Outer vagina

The vulva refers to the skin and mucosa around the vagina that is external to the hymen, which is lined by stratified squamous epithelium. It’s composed of the inner labia majora and the outer labia majora.

The bartholin glands produce lubricating fluid for the vagina, and they are located at the 5 o’clock and 7 o’clock position. If either duct is blocked (sex, STD, vaginal atrophy, vaginitis), a painless cyst will appear. Bartholin cysts tend to get infected, becoming painful Bartholin abscesses. These abscesses are treated with an incision and drainage (I&D). They are especially foul smelling.

Leukoplakia refers to a white plaque on any mucosal tissue that can’t be scraped off (in contrast, candida can be scraped off). It’s itchy and annoying. Leukoplakia is a common finding on the vulva. There are four causes, one of which is cancerous. Therefore, leukoplakia warrants a biopsy.

Extramammary Paget disease is a brand new intraepithelial cancer (carcinoma in situ) in the vulva. It causes red, itchy and ulcerated skin. Compare it to Paget disease of the nipple, which was caused by local invasion of a full blown cancer.