Cervical and Uterine Abnormalities Flashcards
1
Q
What is a Nabothian cyst?
A
Cystic structure that forms when columnar epithelium is covered by squamous epithelium
2
Q
Presentation of Nabothian cyst
A
Appear as translucent or yellow, millimeters to 3 cm
Benign and asymptomatic seen during speculum exam
3
Q
Tx for Nabothian cyst
A
Excision is not required
4
Q
Presentation of cervical polyps
A
Usually <3 cm
Benign
May cause post-coital bleeding or abnormal uterine bleeding
5
Q
Tx for cervical polyps
A
Polypectomy for symptomatic pts
6
Q
What is in the exocervix?
A
Stratified squamous epithelium
7
Q
What is in the transformation zone?
A
Squamo-columnar junction
Metaplastic squamous epithelium
*most important part
Most sample it b/c this is where HPV goes
8
Q
What is in the endocervical canal?
A
Single layer mucin-producing columnar cells
must get this to get adequate sampling
9
Q
Which HPV is related to which cervical cancers?
A
16- squamous cell carcinoma
18-adenocarcinoma
10
Q
What do pts with adenocarcinoma have concurrently?
A
HSIL cytology
11
Q
High and low risk HPV
A
High: 16 and 18
Low: 6 and 11
12
Q
Risk factors for HPV infection
A
Multiple sex partners
Early onset of sexual activity, history of STDs, smoking (carcinogens in cervical mucus), immunosuppression, long term oral contraceptive use, multiparity (maintenance of transformation zone)
13
Q
HPV vaccines
A
Gardasil 9 (6, 11, 16, 18, 31, 33, 45, 52, 58)
Cervarix (16 and 18)
-if get vaccination then get ongoing Paps based on age guidelines
-potential to prevent 45% of HPV associated cancers
*** look at slide for what it decreases!!
14
Q
Types of pap smears
A
ThinPrep and SurePath
Very specific
15
Q
Type of HPV DNA testing
A
Cervista and Hybrid capture high risk HPV test
Very sensitive and specific
16
Q
2 components of pap smear
A
Cytology (cellular makeup of cervix)
HPV testing (in conjunction with pap smear to assess for HPV DNA)
*only screening for cervical cancer
17
Q
Best screening test for cervical cancer
A
Pap smear/ HPV DNA testing (Cobas does just HPV but best to do both)
18
Q
When is screening for cervical cancer initiated?
A
Start at 21 despite age of sexual debut!
- only .1% occur before 20–screening before 21 doesn’t reduce rate of cervical cancer
- doesn’t apply to high risk (immunocompromised)
19
Q
Most cases of HPV infection
A
Cleared within 1-2 yrs without producing neoplastic change
20
Q
What should all adolescent encounters contain?
A
Contraceptive counseling STI screens (no speculum when asymptomatic) Gardasil education and administration Safe sex practices No pap unless high risk
21
Q
Screening for HPV in women 21-29
A
Cytology performed alone q 3 years
DO NOT perform HPV DNA testing
22
Q
Screening for HPV in women 30-64
A
Cytology (+) HPV DNA testing q 5 yrs OR
Cytology alone q 3 years OR
HPV alone q 5 years
23
Q
Who is at high risk for developing cervical cancer and need yearly screening?
A
HIV positive women Immunocompromised Personal history of cervical cancer History of CIN II/III Exposure to diethylstilbestrol (DES) in utero
24
Q
What is diethylstilbestrol?
A
Given to pregnant women to reduce risk of pregnancy complications and losses
Causes vaginal/cervical malignancies, breast cancer, malformations of reproductive tract and infertility
25
Cervical cancer screening for HIV positive women
q 6 mos the year of diagnosis then q year and begin screening at age of diagnosis
26
When to stop screening for cervical cancer
Stop at age of 65 if in past 10 years:
- Pt has evidence of 3 prior consecutive negative results with cytology alone
- 2 consecutive negative Co-testing results
- Most recent test has to have occurred within 5 yrs
- Cannot have history of CIN 2+ within last 20 yrs
* not when high risk, do not resume screening even if woman reports a new sexual partner
27
When to stop screening for cervical cancer in women with hysterectomy?
Stops at time of surgery
Hysterectomy performed for benign disease
No history of CIN 2+ within 20 yrs
28
What must be done during speculum exam when note abnormal cervical lesion?
Biopsy not pap smear (b/c biopsy is diagnostic)
29
How to further define an abnormal pap smear
ASCUS
LSIL
HSIL
30
What is ASC-US?
Atypical cells of undetermined significance
- Causes of ASCUS cytology in absence of HPV are chlamydia, herpes simplex, vulvovaginal atrophy
- If no HPV, then treated as normal pap
31
What is LSIL?
Low grade
- Lesions usually consistent with CIN I
- Cellular features include enlarged, hyperchromatic nuclei, abundant cytoplasm
32
What is HSIL?
High grade (assume HPV DNA is present)
- Lesions usually consistent with CIN II-III, AIS
- Cellular features include enlarged, hyperchromatic nuceli, little/no cytoplasm
33
No endocervical cells or unsatisfactory pap smear report
Negative cytology, no endocervical cells (so didn't get transformation zone)
Unsatisfactory cytology due to insufficient squamous component (HPV test may be falsely negative due to insufficient sampling)
34
Association with persistently positive HPV DNA test (x2)
CIN II/III will be present in 36 mos in some ppl
35
Cervical intraepithelial neoplasia I (based on colposcopy biopsy)
Lesions typically regress in 12 mos (involves lower third of epithelial lining)
36
Cervical intraepithelial neoplasia II
43% of lesions regress and 35% persist and 22% progress (involves lower 2/3 of epithelial lining)
37
Cervical intraepithelial neoplasia III
32% of lesions regress, 56% persist and 14% progress
| more than 2/3 of epithelial lining
38
How to classify colposcopy results
Satisfactory: complete visualization of transformation zone
Unsatisfactory: incomplete visualization of transformation zone, have to do endocervical curettage (ECC)
May need magnified view of cervix with 5% acetic acid-vinegar turns them white
Acetowhite epithelium
39
What is the loop electrosurgical excision procedure?
High electrical current density results in rapid heating of nearby tissue and steam envelop surrounding wire is created to vaporize adjacent tissue (sent to pathology)
*goal is to take off transformation zone
Replaced laser surgery for tx of CIN
40
When is loop electrosurgical excision procedure C/I?
If invasion is suspected, have glandular abnormality on pap or pregnant
41
Education for loop electrosurgical excision procedure
No heavy lifting for 4 wks to avoid bleeding
May have malodorous vaginal discharge for 2-3 wks
Avoid intercourse for 4 wks
Avoid douches, creams and tampons for 4 wks
First menses after is heavier due to partial removal or endocervical canal
42
Complications of loop electrosurgical excision procedure
Bleeding, infection, cervical obliteration/incompetence/ stenosis, pre-term delivery (after PPROM)
43
3rd most common GYN cancer in US
Cervical cancer
44
Characteristics of cervical squamous cell cancer
Mostly HPV 16 and 18
Prevalence is falling
Microinvasion (<3 mm)
Invasive (>3 mm or visible lesion)
45
Characteristics of cervical adenocarcinoma
HPV 16 and 18 associated with more cases then squamous
Prevalence is rising
Typers (endocervical, endometrioid, clear cell, adenoid cystic)
46
Cytology of cervical cancer
Columnar cells with elongated nuclei
Nuclear enlargement
Hyperchromatic nuclei
Mitosis and apoptotic bodies
47
Presentation of cervical cancer
Frequently asymptomatic but most common sxs if abnormal vaginal bleeding!!
Postcoital bleeding
Pelvic pain, unilateral with radiation into hip or thigh (advanced)
Vaginal discharge (watery, mucoid, purulent, malodorous)
48
How to stage cervical cancer
***(only one that is clinically staged-rest are when go in for surgery)
Clinical exam of bladder, uterus and rectum
(CXR or CT for thoracic involvement)
49
Where do uterine fibroids come from?
Smooth muscle cells within uterine wall (made of collagen, smooth muscle and elastin surrounded by pseudocapsule)
-More common in AA women
50
Pathophys of uterine fibroids
Estrogen is implicated in growth (myomas have higher conc of estrogen that in surrounding myometrium)
Progesterone may increase mitotic activity and suppress apoptosis
51
How to classify uterine fibroids
By anatomic locations within myometrium:
Submucosal: just beneath endometrium (0, I, II)
Subserosal: just at serosal surface of uterus
Intramural: lie within uterine wall
52
Presentation of uterine fibroids
```
About 1/2 have sxs (often due to location and size)
Abnormal uterine bleeding
Pain
Pelvic pressure
Infertility
Spontaneous abortion
```
53
Abnormal uterine bleeding of uterine fibroids
Submucosal fibroids increase SA of endometrium leading to menorrhagia
54
Pain with uterine fibroids
Due to degeneration, myometrial contractions, dyspareunia
55
Pelvic pressure with uterine fibroids
Mass effect, compression of surrounding organs
56
Infertility with uterine fibroids
Submucosal fibroids (impingement of intrauterine cavity)
57
What might be seen on bimanual for uterine fibroids?
Enlargement
Irregular shape
Masses
58
Imaging used for uterine fibroids
```
Transvaginal u/s
Saline-infused sonohystogram
Hysteroscopy
MRI
H and H
```
59
What is saline-infused sonohystogram?
Under US guidance a ped catheter is advanced within intrauterine cavity and H2O is instilled to define size and location of fibroid
60
Hysteroscopy
Utilize camera advanced into intrauterine cavity to define size and location
61
How to think about tx for uterine fibroids
Sxs drive the tx (no standard of care)
62
Medical options for uterine fibroids
GnRH analogs
Steroids
Tranexamic acid
63
Surgical options for uterine fibroids
```
Hysteroscopic resection
Endometrial ablation
Laproscopic myomectomy
Abd myomectomy
Laproscopic radiofrequency ablation
```
64
Other tx options for uterine fibroids
Uterine artery embolization
| Magnetic resonance guided focused ultrasonography
65
Depot Lupron for uterine fibroids
GnRH agonist that will decrease fibroid sixe
Improves anemia prior to surgery
Decrease blood loss during surgery
66
How to use Depot Lupron
May be primary role in tx near menopause
| Not for over 6 mos use
67
When to use steroidal therapies for uterine fibroids
Pts with prolonged heavy menses with NO submucosal fibroids
68
Types of steroidal therapies for uterine fibroids
OCPs
| Mirena, Ortho Evra, NuvaRing
69
When is Lysteda (tranexamic acid) used in uterine fibroids?
Pts with prolonged, heavy menses with no submucosal fibroids
| -oral antifibrinolytic for menorrhagia
70
When to use Lysteda
During menstrual cycle (two 650 mg tablets TID)
71
Myomectomy for uterine fibroids
Preserves fertility and uterus!!
| Delay pregnancy for 3-6 mos b/c c-section secondary to uterine rupture
72
When to do myomectomy
Intramural, subserosal and pedunculated fibroids
| Pressure sxs
73
Laparoscopic myomectomy for uterine fibroids
With robotic assistance
| Depends on number and size of fibroids so may need to convert to laparotomy
74
Complications of laparoscopic myomectomy
Hemorrhage, re-operation, adhesions, vascular and visceral injuries
75
Hysteroscopy for uterine fibroids
Preserves fertility/uterus
Only on submucosal fibroids
Non-ionic solution used as distention media
Heated loop to resect fibroid
76
Risks of hysteroscopy
Fluid overload and hyponatremia
77
Education for hysteroscopic resection
Outpatient-anesthesia by paracervical block or general
Return to normal daily activities in 1-2 days
Can have sex 1 mo post-op
78
Endometrial ablation for uterine fibroids
Minimally invasive and preserves uterus
Tx of menorrhagis
No major distortions of uterine cavity
Cavity should be <9 cm to prevent reoccurrence of menses
79
Very important to tell pt with endometrial ablation
No future childbearing so must continue contraceptives! (they cannot have kids!!!-placenta apreva)
80
Pros of endometrial ablation
```
Outpatient or in office
General lor paracervical block
Medium is small amount of CO2 so no fluid overload
2 min procedure and can go home in 2 hrs
Any time during menstrual cycle
```
81
Cons of endometrial ablation
B/c not distort cavity, polyps and submucosal fibroids must first be removed
Doesn't address fibroid symptomatology in general
May have amenorrhea
Poor childbearing and reproductive outcomes b/c destory endometiral lining
82
Uterine artery embolization for uterine fibroids
Preserves uterus NOT fertility
Arteriogram IDs blood supply to fibroid
Puth cath in uterine artery and embolizing agent infused until blood flow stops
83
Who is a candidate for uterine artery embolization?
Pt doens't desire future childbearing
C/I: numerous and large fibroids
A lot will get the pre-op MRI and then decide to do something else
84
Side effects and complications of uterine artery embolization
Postembolization syndrome (overnight admit to manage pain)
Non-purulent vaginal discharge
Endometritis and uterine infection
Recurrence
Embolization agent in non-target tissues and cause premature ovarian failure
Uterine necrosis, sepsis, bacteremia and death
85
What is adenomyosis?
Growth of endometrial glands and stroma into uterine myometrium
86
Why does adenomyosis occur?
Think ovarian hormones implicated
Invagination of endometrium (myometrium weakens with degeneration)
Parity
87
Presentation of adenomyosis
Menorrhagia
Dysmenorrhea
Pelvic pain
History of previous uterine surgery (C-section, myomectomy)
88
What is seen on bimanual exam for adenomyosis
Diffuse uterine enlargements (globular) but size does not exceed >12 wk gestation
89
How to diagnose adenomyosis
Histologic examination AFTER hysterectomy
| imaging can aid in it but suggestive and must look at uterus after take it out-u/s or MRI
90
Medical options to treat adenomyosis
Improve dysmenorrhea and menorrhagia
| OCPs, Mirena, NuvaRing
91
Surgical options for adenomyosis
```
Hysterectomy (definitive)
Uterine artery embolization (not much recurrence of sxs)
Endometrial ablation (high failure rate and increased pain after)
```
92
What is endometriosis?
Presence of endometrial glands and stroma outside endometrial cavity and uterine musculature
Increased risk of ovarian cancer
93
Where do you usually see glands in endometriosis?
Pelvis (ovaries, posterior cul-de-sac or uterine surface) but can be other places
94
Most common diagnosis for hospitalization of women 15-44 YP
Endometriosis
95
Pathophys of endometriosis
Retrograde menstruation (endometrial tissue goes into fallopian tubes and peritoneum)
Deficient cellular immunity (Increase risk of AI disorders)
Hereditary
96
Presenation of endometriosis
```
Premenstrual pelvic pain!!
Infertility
Dysmenorrhea
Dyspareunia
Elevated CA-125
```
97
Premenstrual pain in endometriosis
Lesion growth is stimulated by estrogen and progesterone
Lesions grow and are secretory but expansion is inhibited by surrounding fibrosis (pressure and inflammation leads to pain)
Pain subsides after menses-b/c hormones have subsided do they're not affecting it!!!!
98
PE for endometriosis
Tenderness at posterior cul-de-sac
Fixed or retroverted uterus (secondary to adhesions)
Endometrioma cause adnexal masses or tenderness
99
How to diagnose endometriosis
Laparoscopy (only way to diagnose):
Erythematous, petechial lesions on peritoneal surface
Surrounding peritoneum thickened and scarred
Ovaries can have lesions or endometriomas (chocolate cysts)
Adhesions
100
Most common site of endometriosis
Ovaries
101
Tx for mild endometriosis
Expectant management
| NSAIDs
102
Tx of moderate to severe endometriosis
*want to interrupt stimulation of endometrial tissue
OCPS, progestins (mirena is best for this!!!), Depot Lupron, laparscopy with excision or hysterectomy with bilateral salpingo-oophorectomy
103
OCPS for endometriosis
Causes atrophy of endometrial tissue
Decrease risk of ovarian cancer
(continuous with no placebo week)
104
Depot Lupron for endometriosis
Suppression of estrogen and progesterone by down-regulation of pituitary gland
12 mo therapy: norethindrone acetate to prevent bone loss
105
Risk factors of endometrial hyperplasia and cancer
OBESITY!!!
Early menarche <12, late menopause >52, infertility or nulliparous, tamoxifen, unopposed estrogen therapy, DM, PCOS, history of breast or ovarian cancer, radiation for pelvic cancer, HNPCC (lynch syndrome)
106
Classification of endometrial hyperplasia
Simple hyperplasia without atypia
Complex hyperplasia without atypia
Simple atypical hyperplasia
Complex atypical hyperplasia
107
Pathophys of endometrial hyperplasia
Estrogen stimulates proliferation of endometrium
Progesterone has antiproliferative effects to endometrial lining sheds
Unopposed estrogen leads to it (adipose tissue releases estrogen)
108
Presentation of endometrial hyperplasia
```
Asymptomatic
Post-menopausal bleeding
Menorrhagia
Intermenstrual bleeding
Prolonged menses (>7 days)
Decreased menstrual interval (<21 days)
Oligo or amenorrhea
```
109
What to do when suspect endometrial hyperplasia
Pelvic exam and pelvic u/s (endometrial thickness-< 4 mm malignancy is unlikely)
Endometrial biopsy!!!
D&C hysteroscopy
110
D&C hysteroscopy for endometrial hyperplasia
Performed if lining too think to rely on EMB results or insufficient sample
Cervical stenosis
Persistent irregular or PMB despite - EMB
111
Tx for endometrial hyperplasia without atypia
Mirena IUD
Provera 10 mg QD 3-6 mos
Reassess with EMB to ensure resolution
112
Tx for endometrial hyperplasia with atypia
Increased risk of endometrial cancer
TOC: hysterectomy (half have underlying endometrial cancer)
High dose progesterone therapy (megace 40-80 mg BID, mirena IUD, reassess q 3 mos until resolved)
113
Most common gynecologic cancer
Endometrial cancer (seen at 50-69)
114
Pathophys of endometrial cancer
Estrogen!
| Progression from endometrial hyperplasia
115
Type 1 endometrial cancer
Arise due to unopposed endogenous or exogenous estrogen
| Favorable prognosis b/c well-differentiated tumors
116
Type 2 endometrial cancer
Arise independently of estrogen and seen with endometrial atrophy
Poorly differentiated with poor prognosis
117
Most common type of endometrial cancer
Adenocarcinoma!!! (type 1)-80%
118
Adenocarcinoma with squamous differentiation
Type 1 endometrial cancer (20%)
119
Serous carcinoma
Type 2 endometrial cancer
Not associated with hyperestrogenic state!!
Seen when relapse from stage 1-poor prognosis
Looks histologically like serous carcinoma of ovary so tx is same
120
Clear cell carcinoma
Type 2 endometrial cancer
Not associated with hyperestrogenic state!
High grade, aggressive with deep invasion
121
Presentation of endometrial cancer
Abnormal vaginal bleeding (menorrhagis, intermenstrual spotting, post-menopausal bleeding!!)
Abd cramping, back pain, weight loss, dyspareunia
122
What to do with women with Lynch syndrome (HNPCC)?
Screening for endometrial cancer- Colaris testing
123
Labs for endometrial cancer
```
CBC
Endometiral biopsy
D&C (dilatation and curettage)
Transvag u/s!!!1
Paps (not really part of the work-up tho, indicator for cancer if seen on pap)
CA-125 (seen elevated in stage 1)
MRI/CT
```
124
Tx for endometrial cancer
Hysterectomy with bilateral salpingoophorectomy
Radiation
Chemo (infrequent, usually just advanced)
125
When to use radiation for endometrial cancer
Pts with contraindications to surgery
| Advanced pelvic disease prior to TAH (total abd hysterectomy)
