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Women's Health Unit 2 > 2 Cervical and Uterine Abnormalities > Flashcards

2 Cervical and Uterine Abnormalities Flashcards

1
Q

Cystic structure that forms when columnar epithelium is covered by squamous epithelium —> glandular material becomes retained

A

Nabothian cysts

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2
Q

What do nabothian cysts look like?

A

Translucent or yellow

Range in size form millimeters to 3 cm

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3
Q

Are nabothian cysts bad?

A

Nope - they’re benign and asymptomatic

You usually just see them incidentally on speculum exam

Excision is not required

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4
Q

Where do cervical polyps come from?

A

Etiology unknown but may be due to chronic inflammation of cervical canal

Usually <3 cm and benign

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5
Q

Sx of cervical polyps

A

May cause post-coital bleeding or abnormal uterine bleeding

Polypectomy is indicated for symptomatic patients

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6
Q

What are the different histological layers of the cervix?

A

Exocervix

Transformation zone

Endocervical canal

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7
Q

What types of cells make up the exocervix?

A

Stratified squamous epithelium

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8
Q

What type of cells make up the endocervical canal?

A

Single layer mucin-producing columnar cells

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9
Q

What types of cells make up the transformation zone?

A

Squamo-columnar junction

Metaplastic squamous epithelium

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10
Q

When performing a Pap smear, adequate sampling requires…

A

Presence of endocervical sampling

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11
Q

How does the HPV virus infect the cervix?

A

Enters the cervical epithelium through microlacerations that occur during intercourse

TZ/metaplastic tissue is very susceptible to virus vs squamous tissue

HPV infects the basal layer first and only locally infects neighboring cells

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12
Q

Once the HPV virus infects the cervix, what happens?

A

Can remain latent for months to years until the host immune system no longer can successfully suppress the virus or poorly understood co-factors are present

Mature basal epithelial cells containing viral HPV migrate away from teh basement membrane towards the surface

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13
Q

______ causes 50-60% of squamous cell carcinoma of the cervix

A

HPV 16

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14
Q

_____ causes 40-60% of adenocarcinoma of the cervix

A

HPV 18

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15
Q

HPV 16 —> what type of cervical cancer?

A

Squamous cell carcinoma (from the squamous layer)

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16
Q

HPV 18 —> what type of cervical cancer?

A

Adenocarcinoma (from the columnar cells)

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17
Q

What do E6 and E7 do for HPV?

A

Blocks the protective apoptotic process (why your body doesn’t clear them)

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18
Q

HPV 16 and 18 cause cervical cancer, and HPV ___ and ____ cause genital warts

A

6, 11

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19
Q

_____ of sexually active adults will acquire a genital tract HPV infection before the age of 50

A

75-80%

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20
Q

Risk factors for HPV

A 
Multiple sex partners****
Early onset of sexual activity
Hx of STIs
Smoking
Immunosuppression
Long-term oral contraceptive use 
Multiparity (maintenance of transformation zone —> adenocarcinoma)
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21
Q

What are the two HPV vaccines

A

Gardasil 9 (covers Types 6, 11, 16, 18, 31, 33, 45, 52, 58)

Cervarix (just covers 16 and 18)

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22
Q

Do you still need Pap smears if you got the HPV vaccine?

A

YES

Requirements vary by age but you still need regular screening

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23
Q

What are the two components of a Pap smear?

A

Cytology - evaluating the cellular makeup of the cervix (any abnormal cells?)

HPV testing - performed in conjunction with the Pap smear to assess for HPV-DNA

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24
Q

Are Pap smears considered STD screening?

A

No - it’s only a screening for cervical cancer

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25
Q

What is combined (co-testing) cervical cancer screening?

A

Pap smear and HPV DNA testing together

Pap + HPV is 86.4% sensitive, vs 49% for Pap alone and 75% for HPV alone

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26
Q

When should you start cervical cancer screening?

A

Starting at the age of 21 despite age of sexual debut

Only 0.1% of cases of cervical cancer occur before age 20, and screening prior to age 21 does NOT reduce their rate of cervical cancer

Exception: high-risk pops (ie immunocompromised)

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27
Q

Why don’t we screen adolescents for HPV?

A

HPV infection is acquired shortly after initiation of intercourse

Nearly all cases are cleared within 1-2 years w/o producing neoplasticism change

Early onset screening increases anxiety, morbidity, accrual of higher expenses and causes overuse of follow-up procedures

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28
Q

What should adolescent patient encounters include?

A

Contraceptive counseling

STI screening (urine sample, speculum exam not required for asymptomatic women)

Gardasil education/administration

Safe sex practices

No pap unless high-risk (immunocompromised)

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29
Q

Cervical cancer screening guidelines for women aged 21-29

A

Cytology performance ALONE q3 years

Do NOT perform HPV DNA testing

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30
Q

Cervical cancer screening guidelines for women aged 30-64

A

Cytology + HPV DNA testing q5 years

OR

Cytology alone q3 years

OR

HPV alone q5 years

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31
Q

Patients at high-risk for developing cervical cancer who need yearly screening

A

HIV (+) (q6 months the year of dx, then q1 year)

Immunocompromised

Personal Hx of cervical cancer

Hx of CIN II/III

Exposure to diethylstilbestrol (DES) in utero (removed from market in 1970)

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32
Q

When do you stop screening for cervical cancer?

A

At age 65 if in the past 10 years:
• Evidence of 3 prior consecutive negative results w/ cytology alone
• Two consecutive negative co-testing results
• The most recent test to have occurred within 5 years
• Can not have a hx of CIN 2+ within last 20 years

Does not apply to women considered high risk

Do not resume screening even if a woman reports a new sexual partner(s)

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33
Q

When does screening stop in women after hysterectomy?

A

Assuming cervix is removed, stop at time of the surgery

Hysterectomy must have been performed for benign disease, and no Hx of CIN 2+ within last 20 years

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34
Q

When performing speculum exam and an abnormal cervical lesion is noted, what should you do?

A

Perform biopsy, not Pap smear

A pap is a SCREENING tool, whereas a biopsy is DIAGNOSTIC

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35
Q

What are the steps in the grading system for abnormal Pap smears?

A

ASCUS
LSIL
HSIL

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36
Q

What does ASCUS mean?

A

Atypical cells of undetermined significance

Causes in the absence of HPV:
Chlamydia trachomatis, herpes simplex
Vulvovaginal atrophy

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37
Q

What is LSIL?

A

Low grade lesion, usually consistent with CIN I

Features: enlarged, hyperchromatic nuclei, abundant cytoplasm

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38
Q

What is HSIL?

A

High grade lesions (sometimes called ASC-H)

Assume HPV DNA present

Lesions usually consistent with CIN II-III, AIS

Features: enlarged, hyperchromatic nuclei, little/no cytoplasm

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39
Q

What does it mean when the Pap smear results are returned as Unsatisfactory?

A

Negative cytology means no endocervical cells - you didn’t sample the transformation zone

Unsatisfactory cytology is due to insufficient squamous component

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40
Q

What is important to know about combined screening?

A

Important to differentiate between transient and persistent HPV infection

If cytology negative and HPV DNA positive (for 16/18) —> COLPOSCOPY

If cytology negative and HPV DNA positive (other subtypes) —> repeat pap and HPV in 1 year, if positive agin —> colposcopy

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41
Q

Persistently positive HPV DNA test (x2) is associated with…

A

21% chance CIN II/III will be present within 36 months

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42
Q

CIN I lesions involve _________ of the epithelial lining

A

Lower 1/3

Typically regress in 12 months

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43
Q

CIN II lesions involve ______ of the epithelial lining

A

Lower 2/3

43% regress, 35% persist and 22% progress

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44
Q

CIN III lesions involve _______ of the epithelial lining

A

More than 2/3

32% of lesions regress, 56% persist, and 14% progress

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45
Q

What is considered a satisfactory colposcopy?

A

Complete visualization of the transformation zone

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46
Q

When is a colposcopy considered unsatisfactory?

A

Incomplete visualization of transformation zone

Have to perform endocervical curettage

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47
Q

What is a LEEP?

A

Loop Electrosurgical Excision Procedure

High electrical current density results in rapid heating of the nearby tissue

Steam envelope surrounding the wire is created which vaporizes adjacent tissue, which is then sent for pathology

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48
Q

When is LEEP contraindicated?

A

In patients if invasion is suspected, they have glandular abnormality on pap, or patient is pregnant

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49
Q

Can you do a LEEP on a pregnant woman?

A

Not unless you want her to go into labor RIGHT NOW

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50
Q

LEEP has _____ cure rate for CIN

A

90-95%

Has replaced laser surgery for treatment of CIN

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51
Q

What follow up instructions do you give for LEEP?

A

Avoid heavy lifting for 4 weeks to avoid bleeding

Malodorous vaginal discharge for 2-3 weeks is normal

Avoid intercourse for 4 weeks

Avoid douches, creams, and tampons within the vagina for 4 weeks

First menses after LEEP is heavier due to partial removal of endocervical canal

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52
Q

Complications of LEEP

A

Bleeding
Infection
Cervical obliteration, incompetence, stenosis (can cause sampling issues in the future)
Associated with preterm delivery (measure cervical length at 2nd trimester U/S)
Associated with preterm delivery after PPROM

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53
Q

3rd most common GYN cancer

A

Cervical cancer

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54
Q

What are the two types of cervical cancer?

A

Cervical Squamous cell (most common - 65-85%)
• Microinvasion (≤3mm)
•Invasive (>3mm or visible lesion)

Cervical adenocarcinoma
• Subtypes: Endocervical, endometrioid, clear cell, adenoid cystic

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55
Q

Cytology features in cervical cancer

A

Columnar cells with elongated nuclei
Nuclear Enlargement
Hyperchromatic nuclei
Mitosis and apoptotic bodies

56
Q

Clinical presentation of cervical cancer

A

Frequently asymptomatic

ABNORMAL VAGINAL BLEEDING most common sx

Post-coital bleeding

Pelvic pain, unilateral with radiation into the hip/thigh (sign of advanced disease)

Vaginal discharge (watery, mucous, purulent, malodorous)

57
Q

Most widely used system for staging cervical cancer

A

International Federation of Gynecology and Obstetrics (FIGO)

Staged by clinical examination of the bladder, uterus and rectum via colposcopy, cystoscopy, and proctoscopy

58
Q

What imaging modality is best for evaluating local extension of cervical cancer?

A

MRI superior to CT

59
Q

What imaging modality is used for evaluating for hydronephrosis/retroperitoneal spread of cervical cancer?

A

MRI or CT

60
Q

What imaging modality is used for evaluating thoracic involvement in cervical cancer?

A

CXR or CT

PET scan if CT/CXR show no metastasis

61
Q

Uterine fibroids arise from…

A

Smooth muscle cells within the uterine wall

62
Q

Fibroids are made up of…

A

Collagen, smooth muscle, and elastin surrounded by a pseudocapsule

Present in 20-25% of women of childbearing age

63
Q

Fibroids are 2-3x more common in ______ women

A

African American

64
Q

Etiology of uterine fibroids is unknown but _______ is implicated in their growth

A

Estrogen

Myomas contain higher concentration of estrogen receptors than what is observed in the surrounding myometrium

+/- growth in presence of hormonal therapy and pregnancy

65
Q

_______ increases mitotic activity and possibly suppresses apoptosis within the fibroids

A

Progesterone

66
Q

How are uterine fibroids classified?

A

By anatomic location within the myometrium

67
Q

Name that uterine fibroid:

Lie just beneath the endometrium

A

Submucosal (Type 0, I, II)

68
Q

Name that uterine fibroid:

Lie just at the serosal surface of the uterus

A

Subserosal

69
Q

Name that uterine fibroid:

Lie within the uterine wall

A

Intramural

70
Q

Name that uterine fibroid:

Fibroids that are attached by a stalk to endometrium

A

Pedunculated submucosal fibroid

71
Q

Name that uterine fibroid:

Fibroids that are attached by a stalk to the outer layer of the uterus

A

Pedunculated subserosal fibroid

72
Q

Symptoms of uterine fibroids vary based on…

A

Location and size

73
Q

Abnormal uterine bleeding occurs with fibroids when…

A

Submucosal fibroids increase the surface area of the endometrium, leading to menorrhagia (+/- Fe anemia)

74
Q

Why do you get pain with uterine fibroids?

A

Degeneration, myometrial contractions, dyspareunia

75
Q

Why do you get pelvic pressure with fibroids?

A

Mass effect —> compression of surrounding organs

76
Q

Why do you get infertility with uterine fibroids?

A

Submucosal fibroids —> impingement of intrauterine cavity

Can also lead to spontaneous abortion

77
Q

PE findings for uterine fibroids

A

Uterine Enlargement
Irregular shape
Masses

78
Q

You think your patient has uterine fibroids. What Labs/imaging you wanna get?

A

Transvaginal U/S

Saline-infused sonohystogram (done in office)

Hysteroscopy (done in OR)

MRI

H/H

79
Q

What is saline-infused sonohystogram?

A

Performed in office under US guidance

Pediatric catheter is advanced within intrauterine cavity and H2) is instilled to define fibroid size/location

80
Q

What is a hysteroscopy?

A

Performed in OR

Utilizes a camera that is advanced into the intrauterine cavity to define fibroid size and location

Downside: only sees the ones INSIDE the uterus

81
Q

What is the standard of care for fibroid treatment in the US?

A

There is none.

Symptoms should drive the treatment, SO DO A GOOD HISTORY AND PHYSICAL 🙄

82
Q

Medical options for the treatment of uterine fibroids

A

GnRH analogs

Steroid therapies

Transexamic acid

83
Q

Surgical options for the treatment of uterine fibroids

A

Hysteroscopy can resection

Endometrial ablation

Labroscopic myomectomy

Abdominal myomectomy

Laparoscopic radiofrequency ablation

Uterine artery embolization

MRI-guided focused ultrasonography

84
Q

What is Depot Lupron?

A

GnRH agonist that will decrease fibroid size

Basically shuts off estrogen/progesterone

85
Q

Benefits of Depot Lupron

A

Improves anemia prior to surgery
Decreases blood loss during surgery
Allows minimally invasive approach

May play primary role in treatment near menopause

86
Q

Downside of Depot Lupron

A

Not approved for use over 6 months

87
Q

When we say “steroidal therapies” for the treatment of uterine fibroids, what do we mean?

A

Any form of BC - OCPs, Mirena, Ortho Evra, NuvaRing

Indicated for patients with prolonged, heavy menses with no SUBmucosal fibroids

88
Q

When is Lysteda (transexamic acid) indicated for treating fibroids?

A

For patients with prolonged, heavy menses with no SUBMUCOSAL fibroids

It’s an oral antifibrinolytic used for menorrhagia - can demonstrate 50% decrease

Used only during menstrual cycle (two 650mg tab TID)

89
Q

Does a myomectomy preserve fertility?

A

Yep

90
Q

What types of fibroids can be treated with a myomectomy?

A

Intramural, subserosal, and pedunculated fibroids

Indicated for patients with pressure symptoms

Can be done laparoscopically too

91
Q

What is the patient ed regarding pregnancy for patients who have a myomectomy?

A

Delay pregnancy for 3-6 months

Must have a c-section 2˚ to risk of uterine rupture

92
Q

Which surgical treatment for uterine fibroids is only performed on submucosal fibroids?

A

Hysteroscopy

Non-ionic solution used as distention media and a heated loop is used to respect fibroid

93
Q

Risks of hysteroscopy

A

Fluid overload and hyponatremia

Must monitor their I&Os

94
Q

Upsides of hysteroscopy

A

Outpatient procedure

Return to normal activities 1-2 days later

Return to sexual activity one month post-op

95
Q

Possible complication of hysteroscopic resection

A

Asherman’s Syndrome

Can —> infertility

96
Q

What surgical treatment for fibroids precludes any future childbearing?

A

Endometrial ablation

Preserves uterus and treats menorrhagia without distortions to uterine cavity BUT a pregnancy afterwards is DISASTEROUS - embryo would implant in myometrium 😬)

97
Q

Pro’s of endometrial ablation

A

Can be in or out patient

Distention medium is small amount of CO2 so no risk of fluid overload

Takes less than 2 min and patient goes home in 1-2 hours

Can be performed at anytime during menstrual cycle

98
Q

Con’s to endometrial ablation

A

Since no distortion of the uterine cavity is allowed, polyps and submucosal fibroids have to be removed first

Does not address fibroid symptomatology in general

Childbearing is rare afterwards and outcomes poor if they do conceive b/c of risk of placenta accreta

99
Q

What is placenta accreta?

A

Embryo implants into the myometrium

What happens when you get preggers after an endometrial ablation

100
Q

Tell me more about uterine artery embolization

A

Preserves uterus but NOT fertility

Arteriogram identifies blood supply to fibroid. Catheter is placed into uterine artery and embolizing agent infused until blood flow ceases

Done by interventional radiology

101
Q

Candidates for uterine artery embolization

A

Patient does not desire future childbearing

102
Q

What are contraindications for uterine artery embolization?

A

Numerous and large fibroids

103
Q

Side effects and complications of uterine artery embolization

A

Post embolization Syndrome requires overnight hospitalization to manage pain

Non-purulent vaginal discharge

Endometritis and uterine infection

Recurrence rate is 10-15%

Embolization agent found in non-target tissues
• Ovaries —> premature ovarian failure

Uterine necrosis, sepsis, bacteremia, and death

104
Q

Growth of endometrial glands and stroma into uterine myometrium

A

Adenomyosis

105
Q

What is the etiology of adenomyosis?

A

Unknown

Ovarian hormones implicated in process

Invagination of endometrium (myometrium weakens with degeneration)

Associated with parity, esp c-sections

106
Q

Clinical presentation of adenomyosis

A

Menorrhagia
Dysmenorrhea
Pelvic pain
History of previous uterine surgery (c-section or myomectomy)

107
Q

PE findings for adenomyosis

A

Bimanuel exam reveals diffuse uterine enlargement (globular, size not exceeding 12w gestation)

108
Q

Definitive diagnosis of adenomyosis requires…

A

Histologic examination after hysterectomy

Imaging can AID in Dx but there is no standard criteria
• U/S 72% sensitive, 81% specific
• MRI 77% sensitive, 89% specific

109
Q

Treatment for adenomyosis

A

Meds to improve dysmenorrhea and menorrhagia
• OCPs
• Mirena
• NuvaRing

Surgery
• HYSTERECTOMY = definitive treatment
• Uterine artery embolization
• Endometrial ablation (high failure rate - just don’t do it)

110
Q

The presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature

A

Endometriosis

Usually located in the pelvis (OVARIES, posterior curl-de-sac, uterine surface) but can be elsewhere

111
Q

Most common diagnosis responsible for hospitalization in women aged 15-44

A

Endometriosis

112
Q

What is the etiology of endometriosis

A

Really unknown

Retrograde menstruation - retrograde flow of endometrial tissue through Fallopian tubes and peritoneum

Deficient cellular immunity (increased risk of AI disorders)

Hereditary

113
Q

Clinical presentation of endometriosis

A

Premenstrual pelvic pain that subsides after menses

Associated with infertility in 30-40% of women

Dysmenorrhea

Dyspareunia

Most are asymptomatic

Elevated CA-125

114
Q

PE findings for endometriosis

A

Tenderness at posterior cul-de-sac

Fixed or retroverted uterus 2˚ to adhesions

Endometriomas that cause adnexal masses or tenderness

115
Q

How is endometriosis diagnosed?

A

LAPAROSCOPY

Shows erythematous, petechiae lesions on peritoneal surfaces, with thickened and scarred surrounding peritoneum

Ovaries can demonstrate lesions or endometriomas (“chocolate cysts”)

Adhesions

116
Q

Most common site of endometriosis?

A

Ovaries

Will see “chocolate cysts” - endometriomas on the surface of the ovary

117
Q

Treatment for endometriosis in patients with mild disease

A

Expectant management and NSAIDs

118
Q

Treatment for moderate-severe endometriosis

A

Goal: interrupt stimulation of endometrial tissue

OCPs - those with continuous cycle preferred (cause atrophy of endometrial tissue and reduces risk of ovarian cancer)

Progestins (Depo-provera, Provera, Mirena****)

Depot Lupron for severe disease x 12 month

119
Q

What do you need to know if you are giving Depot Lupron for endometriosis?

A

It’s a 12 month therapy (vs 6 month for fibroids)

Co administer with Norethindrone acetate to prevent bone loss

120
Q

Risk factors for endometrial hyperplasia

A 
Early menarche
Late menopause
Infertility, nulliparous
OBESITY******
Treatment with Tamoxifen for BC
Unopposed estrogen replacement therapy 
Diabetes
PCOS
Hx of BC or ovarian cancer
Prior radiation for pelvic cancer
Family Hx of lynch syndrome
121
Q

Classification of endometrial hyperplasia

A

Simple hyperplasia without atypia

Complex hyperplasia without atypia

Simple atypical hyperplasia

Complex atypical hyperplasia

122
Q

Pathophysiology of endometrial hyperplasia

A

Estrogen stimulates proliferation of endometrium

Progesterone has antiproliferative effects —> shedding of endometrial lining

Unopposed estrogen leads to endometrial hyperplasia and atypia

Adipose tissue releases estrogen which is why obesity is a risk factor

123
Q

Clinical presentation of endometrial hyperplasia

A 
Asymptomatic
Post-menopausal bleeding
Menorrhagia
Intermenstrual bleeding
Prolonged menses (>7 days)
Decreased menstrual interval (<21 days)
Oligomenorrhea/amenorrhea
124
Q

Workup for suspected endometrial hyperplasia

A

Pelvic exam
Pelvic U/S (asses endometrial thickness - <4mm means malignancy unlikely)
Endometrial biopsy**
D&C hysteroscopy if complications preclude biopsy

125
Q

Treatment for endometrial hyperplasia without atypia

A

Mirena
Provera 10mg qd x 3-6 months
Reassess with EMB to ensure resolution

126
Q

Treatment for endometrial hyperplasia with atypia

A

Increased risk of endometrial cancer so be more aggressive

Hysterectomy is treatment of choice*****

Progesterone therapy
• Megace 40-80mg BID
• Mirena
• Reasses q3 months until resolution

127
Q

Most common GYN cancer

A

Endometrial cancer

128
Q

Mean age of incidence for endometrial cancer

A

50-69 years

129
Q

______ is implicated as the causative factor for endometrial cancer

A

Estrogen

Exogenous estrogens vs alterations in estrogen metabolism

130
Q

Type 1 endometrial cancer arises from…

A

Unopposed endogenous or exogenous estrogen

Favorable prognosis due to well-differentiated tumors

Typically adenocarcinoma (80% of all endometrial cancers)

131
Q

Type 2 endometrial cancer arises…

A

Independently of estrogen and seen with endometrial atrophy

Poorly differentiated with poor prognosis

Typically Serous carcinoma or Clear cell carcinoma

132
Q

Clinical presentation of endometrial cancer

A

Abnormal vaginal bleeding - ESP POST-MENOPAUSAL BLEEDING

Abdominal cramping
Back pain
Weight loss
Dyspareunia

133
Q

Screening for endometrial cancer is recommended for women with…

A

Lynch Syndrome (aka HNPCC)

Perform Claris testing

134
Q

How is endometrial cancer diagnosed?

A 
CBC
Endometrial biopsy (EMB)
D&amp;C
Transvaginal U/S
Pap smear
CA-125
MRI/CT
135
Q

Treatment for endometrial cancer

A

HYSTERECTOMY with bilateral salpingoophorectomy with pelvic and periaortic lymphadenectomy

+/- Radiation and chemo

Women's Health Unit 2 (4 decks)

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