2- Cervical and Uterine Disease Flashcards
When does a nabothian cyst form?
Columnar epithelium is covered by squamous epithelium
On cervical exam you note a translucent or yellow cyst. Pt states it is asx. What are you concerned for and what is the management?
Nabothian cyst
Benign- excision is not required
Pt presents with post-coital bleeding or AUB and you suspect cervical polyps. What is the management?
Polypectomy (if sx)
What portion of the cervix includes metaplastic squamous elithelium and serves as the squamo-columnar junction?
Transformation zone
Adequate sampling of the cervix requires what?
Presence of endocervical sampling
What tissue of the cervix is very susceptible to HPV compared to squamous tissue?
TZ/ metaplastic tissue
(can remain latent here)
Which HPV strain is responsible for the greatest % of cervical SCC, although prevalence is falling?
HPV 16
Which HPV strain is responsible for the greatest % of adenocarcinomas, with prevalence rising?
HPV 18
What strains of HPV are high risk and will be reported on pap smear?
Types 16, 18
(low risk types 6 and 11 = warts, not reported on pap smear)
What is the biggest RF for HPV infection?
Multiple sexual partners
What are the types of HPV DNA testing?
Cervista, Capture
What is the best screening test for cervical cancer?
Pap smear/ HPV DNA testing
When do you start screening for cervical cancer?
Age of 21 despite age of sexual debut
When does screening prior to the age of 21 reduce the rate of cervical cancer?
Only high risk populations
What is included in cervical CA screening for a woman 21-29 yo?
Cytology q 3 years, NO HPV DNA testing
What is included in cervical CA screening for a woman 30-64 yo?
Cytology + HPV DNA testing q 5 years OR
Cytology q 3 years
Pts at high-risk for developing cervical CA need yearly screening. Who are these high-risk populations?
HIV (+)
IMC
Hx of cervical CA or CIN II/ III
Exposure to DES in utero
With the exception of high risk populations, cervical CA screening is stopped at the age of 65 if if what conditions are true w/i the past 10 years? (4)
- 3 consecutive (-) results w/ cytology
- 2 consecutive (-) results with co-testing
- Most recent test w/i 5 yrs
- No hx of CIN 2+ w/i 20 yrs
Cervical CA screening stops at the time of surgery if what 2 conditions are true?
Hysterectomy performed for benign disease
No hx of CIN 2+ w/i 20 yrs
When performing a speculum exam, you note an abn cervical lesion. What is your next step?
Biopsy- diagnostic
NOT pap smear (just screening tool)
Pap smear results show ASCUS. What are possible causes (in the absence of HPV)?
STIs, vulvovaginal atrophy
Pap smear shows enlarged, hyperchromatic nuclei, and abundant cytoplasm. You suspect LSIL (low grade). What are these lesions usually consistent with?
CIN I
Pap smear shows enlarged, hyperchromatic nuclei, and little/ no cytoplasm. You suspect HSIL/ ASC-H (high grade). What are these lesions usually consistent with?
CIN II- III, AIS (androgen insensitivity syndrome)
Pap smear shows ASCUS or LSIL and pt is 21-24 yo. What is the management?
Repeat pap smear in 1 year (regardless of HPV result)
(if 24-64 yo, refer to guidelines)
Pap smear shows HSIL/ ASC-H. What is the management?
Refer for colposcopy for ALL ages (despite HPV result)
Pt has persistently (+) HPV DNA test x 2. What are you concerned for?
Development of CIN II/III w/i 36 month
What portion of the epithelial lining is affected by CIN I, II, and III (shown on bx from colposcopy?
CIN I- lower 1/3
CIN II- lower 2/3
CIN III- more than 2/3
What is considered a satisfactory colposcopy?
Complete visualization of TZ
What is considered an unsatisfactory colposcopy and what should you perform?
Incomplete visualization of TZ
Perform endocervical curettage (ECC)/ bx acetowhite epithelium (HPV cells)
What is included in the management/ tx of abn bx results showing CIN?
Loop electrosurgical excision procedure (LEEP)
When is LEEP contraindicated? (management for CIN)
Invasion suspected
Glandular abn on pap
Pregnancy (risk pf pre-term delivery/ membrane rupture)
What is included in pt edu for LEEP f/u?
- Avoid: heavy lifting, intercourse, intravaginal FB/ products x 4 wks
- Malodorous discharge x 2-3 wks
- First menses post procedure is heavier
What are the possible adverse effects of LEEP (aside from pre-term delivery)?
Bleeding, infection, cervical obliteration/ incompetence, stenosis
What is the 3rd most common GYN CA in the US?
Cervical CA
(and 2nd most common CA in women worldwide)
How do you determine between microinvasion vs invasive cervical SCC?
Microinvasion ≤ 3mm
Invasive > 3mm or visible
Pt presents with abn vaginal bleeding, postcoital bleeding, pelvic pain w/ radiation to hip/ thigh, and vaginal discharge (although frequently asx). What are you concerned for?
Cervical CA
How is cervical CA staged?
Clinical exam of bladder, uterus, rectum (FIGO)
What imaging is used for cervical CA is evaluating local extension?
MRI > CT
What imaging is used for cervical CA to evaluate thoracic involvement?
CXR or CT
then PET if no metastases
Where do uterine fibroids arise from?
Smooth muscle cells w/i uterine wall
Although etiology is unknown, what is implicated in the growth of uterine fibroids?
Estrogen
How are uterine fibroids classified?
According to anatomic location w/i myometrium
Submucosal- beneath endometrium
Subserosal- at serosal surface of uterus
Intramural- w/i uterine wall
Pt presents with AUB, pain, pelvic pressure, infertility, and hx of spontaneous abortion. What are you concerned for?
Uterine fibroids
(specifically submucosal if AUB/ infertility)
What imaging is used for eval of uterine fibroids?
Transvaginal US = 1st line
Saline-infused sonohystogram/ hysteroscopy if concern for submucosal
What medical tx for uterine fibroids decreases fibroid size, improves anemia prior to surgery, decreases blood loss during surgery and should not be used over 6 months?
Depot Lupron
What medical tx for uterine fibroids is indicated for pts with prolonged, heavy menses with no submucosal fibroids?
Steroidal therapy (BC)
What medical tx for uterine fibroids is indicated for pts with prolonged, heavy menses with no submucosal fibroids or as an antifibrinolytic for menorrhagia, and is only used during menstrual cycle?
Lysteda (tranexamic acid)
What surgical tx for uterine fibroids preserves fertility/ uterus, removes intramural, subserosal and pedunculated fibroids, and requires pts to delay pregnancy for 3-6 months/ have subsequent c-sections?
Myomectomy
What outpatient surgical tx for uterine fibroids preserves fertility/ uterus, can only be performed on submucosal fibroids and can be a/w fluid overload/ hyponatremia?
Hysteroscopy
What pt edu should be provided for hysteroscopic resection for tx of uterine fibroids?
Return to normal daily activities 1-2 days later
Return to sexual activity 1 month post-op
What surgical tx for uterine fibroids preserves the uterus but does NOT preserve fertility, is used in the tx of menorrhagia, and requires continued use of a contraceptive?
Endometrial ablation
What are the main pros of endometrial ablation for uterine fibroids?
No fluid overload
Can be performed at anytime during menstrual cycle
What are the main cons of endometrial ablation for uterine fibroids?
Must first remove polyps/ submucosal fibroids
Does not address sxs
Childbearing rare after procedure
What tx for uterine fibroids stops BF to fibroid and preserves uterus but NOT fertility?
Uterine artery embolization
What tx for uterine fibroids is a/w potential adverse effect that may require overnight hospitalization to manage pain and is contraindicated for numerous/ large fibroids?
Uterine artery embolization
What is defined as growth of endometrial glands and stroma into uterine myometrium?
Adenomyosis
Pt presents with menorrhagia, dysmenorrhea, pelvic pain, and hx of previous uterine surgery (c-section/ myomectomy). Bimanual exam reveals diffuse uterine enlargement. What are you concerned for?
Adenomyosis
What is required for definitive dx/tx of adenomyosis?
Hysterectomy w/ histologic examination
What is the goal of medical options (birth control) in the tx of adenomyosis?
Improve dysmenorrhea and menorrhagia
What is considered last line for tx of adenomyosis?
Endometrial ablation
What is defined as the presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature, is usually located in the pelvis, and is a/w increased risk of ovarian CA?
Endometriosis
Pt presents with premenstural pelvic pain that subsides after menses +/- infertility, dysmenorrhea, dyspareunia (although most asx). What are you concerned for and what might be elevated?
Endometriosis
Elevated CA-125
Pt presents with GYN complaint. On PE you note tenderness at posterior cul-de-sac, fixed/ retroverted uterus, and masses/ tenderness. What are you concerned for?
Endometriosis
How is endometriosis dx?
Labaroscopy
On laparoscopy you note erythematous and petechial lesions on peritoneal surfaces with surrounding thickening/ scarring. Ovaries demonstrate “chocolate cysts”. What are you concerned for?
Endometriosis
What is the tx for mild endometriosis?
Expectant management + NSAIDS
What is the tx for mod to severe endometriosis to interrupt stimulation of endometrial tissue?
OCPs, Progestins, Depot Lupron, laparoscopy w/ excision, hysterectomy + bilateral salpingo-oophrectomy
What is the greatest RF for endometrial hyperplasia and endometrial CA?
Obesity
How is endometrial hyperplasia classified?
Simple or complex +/- atypia
Unopposed estrogen will have what effects on the endometrium?
Endometrial hyperplasia and atypia
What is the most common clinical presentation of endometrial hyperplasia if not asymptomatic?
Post-menopausal bleeding
What tests are included in the workup for suspected endometrial hyperplasia?
Pelvic exam/ US, endometrial bx (EMB), +/- D+C hysteroscopy
What is the tx for endometrial hyperplasia without atypia?
Mirena/ Provera + reassess w/ EMB to ensure resolution
What is the tx for endometrial hyperplasia with atypia (a/w increased risk of endometrial CA)?
Hysterectomy (if completed childbearing)
(otherwise progesterone therapy)
What is the most common GYN cancer and occurs at a mean age of 50-69 yo?
Endometrial CA
What type of endometrial CA arises due to unopposed estrogen and has a more favorable prognosis due to well-differentiated tumors?
Type I (adenocarcinoma > adenocarcinoma w/ squamous diff)
(adenocarcinoma = most common type)
What type of endometrial CA arises independently of estrogen and has a poor prognosis due to poorly differentiated tumors?
Type II (serous, clear cell)
Clear cell = high grade, aggressive, deep invasion
Pt presents w/ abn vaginal bleeding (menorrhagia, intermenstrual spotting, post-penopausal), abn cramping, back pain, weight loss, and dyspareunia. What are you concerned for?
Endometrial CA
Pts with what condition should be screened (Colaris testing) for endometrial CA?
Lynch syndrome
How is endometrial CA diagnosed?
EMB, TVUS, CA-125
What is the tx for endometrial CA?
Hysterectomy w/ bilateral salpingoophorectomy w/ pelvic and periaortic lymphadenectomy +/- chemo
Radiation if surgery c/i
