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Gynecologic, Reproductive, and Sexual Disorders > Cervical Cancer Screening, Infertility, Breast Disorders > Flashcards

Cervical Cancer Screening, Infertility, Breast Disorders Flashcards

1
Q
  1. atypical squamous cells
A

cannot exclude high grade intraepithelial lesion (ASC-H)

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1
Q

epithelial cell abnormalities
1. atypical squamous cells of undetermined significance

A

squamous cells do not appear completely normal but not able to determine cause of abnormal cells

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2
Q
  1. low grade squamous intraepithelial lesions (LSIL)
A

encompasses transient HPV infection/mild dysplasia/cervical intraepithelial neoplasia 1 (CIN 1)

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3
Q
  1. high grade squamous intraepithelial lesions (HSIL)
A

encompasses persistent HPV infection/moderate dysplasia (CIN2)/severe dysplasia or carcinoma in situ (CIN 3)

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4
Q
  1. squamous cell carcinoma
A

cancer

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5
Q

the 2014 Bethesda System for interpreting results of cervical cytology incluedes the following:

A
  1. specimen type
  2. specimen adequacy
  3. general categorization (squamous or glandular)
  4. interpretation/results:
    a. non-neoplastic cellular changes
    b. organisms: trich, candida
  5. epithelial cell abnormalities
  6. glandular cell abnormalities
  7. other- endometrial cells in women 45 years of age and older
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6
Q

endocervical transformation zone

A

region of the cervix where glandular columnar cells of the endocervix (inner) are converting into squamous cells on the ectocervix; aka the squamocolumnar junction

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7
Q

what should you do if pap comes back unsatisfactory for evaluation? what about if there are two unsatisfactory results on pap?

A
  1. if HPV unknown or HPV negative (age >30): repeat pap in 2-4 months
  2. if HPV positive (>30), colposcopy or repeat pap test in 2-4 months
  3. two consecutive unsatisfactory results: colposcopy
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8
Q

what if pap test comes back + for actinomyces?

A

you should evaluate for s/sx of pelvic infection if IUC present
-if patient has pelvic infection: remove IUC and treat with antibiotics
-if no infection then no treatment or IUC removal needed

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9
Q

what is the follow up for women whose pap is + for endometrial cells?
1. premenopausal with normal menses
2. premenopausal with irregular menses
3. postmenopausal

A

premenopausal and regular: nothing
premenopausal and irregular: EMB
postmenopausal: EMB

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10
Q

women ages 21-24 pap test
1. if unsatisfactory
2. ASC-US
3. LGSIL
4. ASC-H
5. HSIL

A
  1. if unsatisfactory: repeat pap in 2-4 month
  2. ASC-US: repeat pap in 12 months, if negative repeat again in 12 months
  3. LGSIL: repeat pap in 12 months; if negative, ASC-US, or LGSIL: repeat again in 12 months; otherwise colposcopy
  4. ASC-H: colposcopy
  5. HSIL: colposcopy
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11
Q

when pap test is negative how many times can you resume pap tests every 3 years for women aged 21-24 with single ASC-US pap

A

2 consecutive!!

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12
Q

women ages 25 to 29 pap test
1. if unsatisfactory
2. ASC-US
3. LGSIL
4. ASC-H
5. HSIL

A
  1. if unsatisfactory: repeat in 2-4 months
  2. ASC-US: reflex HPV test, if negative: repeat pap in 3 years, if positive: colposcopy
  3. LGSIL: colp
  4. ASC-H: colp
  5. HSIL: immediate excisional treatment
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13
Q

pap alone every 3 years from women ages…

A

21-29

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14
Q

women 30 and older recommended cervical cancer screening

A

co-testing every 5 years (pap + HPV preferred) OR pap alone every 3 acceptable too

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15
Q

women 30 and older pap and HPV
1. pap test unsatisfactory
2. Normal pap, HPV +
3. ASC-US HPV negative
4. ASC-US HPV positive
5. LSIL with no HPV test
6. LSIL HPV negative
7. LSIL HPV positive
8. ASC-H
9. HSIL

A
  1. pap test unsatisfactory: if HPV unknown or negative: repeat in 2-4 months; if HPV positive: colposcopy OR repeat pap in 2-4 months
  2. Normal pap, HPV +: co testing in 12 months –> if pap and HPV negative: repeat co-testing in 3 years; HPV typing also acceptable
  3. ASC-US HPV negative: repeat co-testing in 3 years
  4. ASC-US HPV positive: colpo
  5. LSIL with no HPV test: colpo
  6. LSIL HPV negative: repeat co-testing in 12 months
  7. LSIL HPV positive: colposcopy
  8. ASC-H: colposcopy
  9. HSIL: immediate excisional treatment or colposcopy
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16
Q

the latest update regarding cervical cancer screening is based on….

A

the patients history!!!

you should use the pap app and make decisions based off previous results

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17
Q

when does cervical cancer screening end?

A

at age 65 with three consecutive normal paps of cytology alone or 2 consecutive normal co-tests

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18
Q

cervical cancer screening for patients with hysterectomy that included removal of cervix?

A

no screening for individuals with no history of high grade lesions or cervical cancer

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19
Q

HPV vaccine series

A

a 3 does series offered starting at 9 years old in females (rec 9-11 y.o)
second dose recommended 1-2 months after 1st dose, third dose is recommended 6 months after first dose (dosing schedule: 0 months, 1-2 months, 6 months)

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20
Q

Diethylstillbestrol (DES) in utero
-why do we care about it?
-when was it used?

A

this was a drug used from 1940-1971 to prevent miscarriage and premature labor
prenatal DES exposure increased risk for reproductive abnormalities, infertility, clear cell adenocarcinoma of the cervix and vagina
-most women exposed in utero are > 35 years old now

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21
Q

how does DES effect vaginal columnar epithelium?

A

so the vagina is originally lined with columnar epithelium, which is eventually replaced by squamous epithelium BUT DES exposure prevents that transition from happening, and one-third of exposed females have columnar epithelium in their vagina

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22
Q

most common physical finding of DES in utero is…

A
  1. columnar cells in the vagina- glandular tissue extends from endocervix into vagina with a red, granular appearance

others: nodularity of cervix or vagina, transverse or longitudinal vaginal septum, uterine abnormalities, visible cervical abnormalities

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23
Q

diagnostic tests/findings for DES in utero

A
  1. pap test of cervix and all four vaginal walls to rule out cancer
  2. colposcopy and biopsy of suspicious areas
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24
Q

chronic pelvic pain is defined as…
-etiology…

A

noncyclic pain that lasts longer than 6 months, localized to pelvic/lower abdominal/lumbosacral region and of sufficient severity to cause functional disability

-can be gynecologic, musculoskeletal, GI, urologic, neurologic, and psychosomatic origin

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25
Q

gynecologic causes of chronic pelvic pain include

A

-endometriosis
-adhesions
-post-PID chronic pain
-pelvic varicosity pain syndrome/pelvic congestion syndrome
-ovarian mass
-uterine fibroids
-adenomyosis
-vulvodynia
-malignancies (especially late stages)

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26
Q

non gyn causes of chronic pelvic pain

A

a. painful bladder syndrome/interstitial cystitis
b. myofascial pain syndrome
c. IBS
d. GI or urologic malignancies

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27
Q

symptoms of chronic pelvic pain (big range here)

A

-paroxysms of sharp, stabbing, sometimes crampy, or dull continuous pain that is severe
-dysmenorrhea, dyspareunia, dysuria, vulvar pain
-pain may or may not be reproducible on bimanual exam
-feeling of pelvic pressure or heaviness
-PAIN HISTORY IS IMPORTANT: onset, location, duration, character, alleviating/aggravating factors and associated symptoms, radiation, temporal, severity (OLDCARTS)

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28
Q

lab work up for patient with chronic pelvic pain

A

-labs are often of little value
-pregnancy test, CBC, ESR, urinalysis, tests for vaginal infections, STIs, stool for occult test
-pelvic u/s
-diagnostic lap: ultimate method of diagnosis

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29
Q

pelvic relaxation disorders include

-recommended management?

A

cystocele, urethrocele, rectocele enterocele, uterine prolapse

-kegel exercises, PT with pelvic floor, local estrogen therapy for postmenopausal women, pessary

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30
Q

symptoms of TSS

A
  1. sudden onset of fever, 102 or greater
  2. diffuse macular sunburnlike rash over face, trunk, and extremities that desquamates 1 to 2 weeks after onset
  3. hyperemia of conjunctiva, oropharynx, tongue, vagina
  4. GI symptoms- N/V
  5. GU symptoms- vaginal discharge, adnexal tenderness
  6. Cardiorespiratory symptoms: pulmonary edema, DIC, endocarditis
  7. flu-like symptoms: headahce, sore throat, myalgia
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30
Q

Toxic shock syndrome (TSS)
-etiology

A
  1. often asx with caucasian women younger than 30 using absorbent tampons
  2. non-menstruation associated causes: puerperal sepsis, post c/s endometritis, mastitis, PID, wound infection, insects
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31
Q

Differential diagnoses for TSS

A
  1. septic shock
  2. rocky mountain spotted fever
  3. scarlett fever
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32
Q

how to avoid TSS? education for patients

A

-avoidance of tampons/do not leave in longer than 4 hours
-educate regarding s/sx
-pt with hx of TSS: avoid tampons, cervical caps, diaphragms, sponges

33
Q

DSM-5 criteria for sexual dysfunction

A

experiencing disorder at least 75% of the time for at least 6 months and causing significant distress

34
Q

female sexual dysfunction falls into three categories

A
  1. sexual interest/arousal disorder
  2. orgasmic disorder
  3. genito-pelvic pain/penetration disorder (dyspareunia, vaginismus, noncoital pain, marked fear or anxiety about vulvovaginal pain)
35
Q

causes of sexual dysfunctions include

A

-relationship factors
-medical conditions
-medications: some antidepressants, antihypertensives, lipid-lowering agents, digoxin, combined hormonal contraceptives, opioids, amphetamines, anticonvulsants

36
Q

lap workup for sexual dysfunction includes…
-what is NOT recommended?

A

really only indicated by history and physical exam findings (such as TSH) but androgen levels and estrogen levels are not recommended

37
Q

management/treatment of sexual dysfunction
PLISSIT model

A

a. permission- validate concerns
b. limited information- provide basic education about sexual response cycle, components of desire
c. specific suggestions- lubricants, erotica
d. intensive therapy- refer to sex specialist

38
Q

what is recommended treatment for postmenopausal women with vulvovaginal atrophy?

A

low dose localized estrogen (for those who can have it)

39
Q

Flibanserin (Addyi) was approved in 2015 for….

A

treatment of hypoactive sexual desire disorder in premenopausal women; oral tablet taken once at bedtime

40
Q

Bremelanotide (Vylessi) was FDA approved in 2019 for…

A

treatment of acquired, generalized HSDD in premenopausal women; self administered subq into abdomen or thigh at least 45 minutes before anticipated sexual activity

41
Q

Infertility
-women < 35
-women > 35

A

in women less than 35: 1 year

in women >35: 6 months

unprotected coitis or inability to carry a pregnancy to live birth

42
Q

etiology/incidence of infertility
-female factors
-male factors
-combined male and female factors (incidence)
-unexplained cause

A

FEMALE (25-50%)
a. ovulatory dysfunction- annovulation, luteal-phase insufficiency, poor ovarian reserve
b. pelvic pathology- uterine anomaly, adhesions from surgery or peritonitis, tubal occlusion, endometriosis

MALE (25-50%)
a. low sperm production- low testosterone, varicocele, toxin exposure
b. adhesion in vas deferens
c. anatomic abnormalities- varicocele, hypospadias, phimosis
d. erectile dysfunction

-combined (30%)
-unexplained (10-25%)

43
Q

assessment/workup for infertility includes
-history
-physical exam

A
  1. focused history- BOTH PARTNERS
    a. prior pregnancies, duration of infertility, any previous evaluated and treatment, frequency of intercourse, sexual dysfunction
    b. history of STIs, other GU infections
    c. endocrine disorders?
    d. prior chem or tx for cancer
    e. current medications
    f. smoking, marijuana use, alcohol use, illicit drugs
    g. exposure to toxic environmental or chemical substances
    h. family hx of birth defects or infertility
  2. additional femal info: menstrual history, dyspareunia, abnormal paps
  3. male- hx of varicocele, mumps, testicular torsion, regular exposure to high levels of heat

PHYSICAL-female
-BMI, vital signs, signs of potential genetic or hormonal abnormalities (short stature, acne, alopecia, hirsutism, galactorrhea, thyroid enlargement)
-pelvic exam (sxs of anatomic abnormalities, masses, infections, hormonal status)

PHYSICAL- male
-breast exam, thyroid exam, signs of androgen deficiency, genital exam

44
Q

diagnostic tests and lab workup for infertility

A
  1. pelvic u/s to r/o uterine anomalies; ovarian volume
  2. hysterosalpingogram- tubal patency
  3. basal body temperatures for ovulation detection
  4. ovulation prediction tests- home urine tests to detect LH surge, predicts ovulation within 24 to 36 hours
  5. Anti-Mullerian hormone (AMH) level and antral follicle count to determine ovarian reserve
  6. FSH, LH, estradiol, progesterone levels
  7. TSH levels
  8. STI screening if indicated
  9. semen analysis- semen volume, sperm number, sperm concentration, motility, vitality, morphology, pH
45
Q

management/treatment of infertility depends on the cause…

A

a. ovulatory dysfucntion- ovulation induction therapy with letrozole, clomiphene citrate
b. luteal-phase defect: IM progesterone or vaginal
c. infections/endometriosis- appropriate therapy
d. tubal occlusion/obstruction- surgery
e. Intrauterine insemination
f. ART: IVF, GIFT, ZIFT

46
Q

congenital and chromosomal abnormalities
-Mullerian abnormalities result from the absence of…

A

AMH

results in anomalies involving the uterus, fallopian tubes, and upper vagina

47
Q

physical findings of patient with Mullerian abnormality may include…

A

-agenesis: lack of development of vagina, uterus, tubes, uterine cavity
-hypoplasia: partial vagina, bicornate uterus
-complete canalization (atresia): imperforate hymen,
-one third have urinary tract abnormalities (ectopic kidney, horseshoe kidney)

47
Q

symptoms of Mullerian abnormalities/what as a clinician would make you suspect a patient possibly had this?

A

-history of pregnancy loss or infertility
-amenorrhea, dysmenorrhea
-dyspareunia

47
Q

diagnostic tests for Mullerian Abnormalities includes

A

structural abnormalities detected by u/s, MRI, etc.
chromosomal abnormalities ruled out with karyotyping

48
Q

where do we refer patients with suspected mullerian abnormalities?

A

reproductive endocrinologist

49
Q

androgen insensitivity/resistance syndrome is a genetically transmitted androgen receptor defect where the individual is genotypic…

-when is this often detected?

A

male (46XY) BUT phenotypic female or has both female and male characteristics

-often not detected until puberty; primary amenorrhea; infertility

-testosterone levels will be > 3 and LH levels normal to slightly elevated

50
Q

Turner’s Syndrome definition

A

gonadal dysgenesis; an abnormality in or an absence of one of the X chromosomes; phenotypically female (45X)

51
Q

presentation of Turner’s syndrome

A

-short stature, webbed neck, shield chest with widely spaced nipples, increased carrying angle of elbow, arched palate, low neck hairline, short fourth metacarpal bones, disproportionately short legs, swollen hands or feet, lack of breast development, scant pubic hair
-amenorrhea
-hearing loss
-normal intelligene
-infertility

52
Q

Breast disorders
-fibrocystic breast changes

A

“non-disease” that includes non proliferative microcysts, macrocysts, and fibrosis, as well as proliferative changes such as hyperplasia and adenosis

53
Q

cystic changes vs fibrous changes vs hyperplasia vs adenosis

A
  1. cystic changes: refers to dilation of ducts; may regress with menses may persist or disappear
  2. fibrous changes: mass develops following an inflammatory response to ductal irritation
  3. hyperplasia: a layering of cells; has malignant potential if atypical
  4. adenosis: related to changes in the acini in the distal mammary lobule; ducts become surrounded by a firm, plaquelike material
54
Q

symptoms of fibrocystic breast changes include

A

-breast pain and nodulatiry; usually bilateral
-frequently occurs 1-2 weeks before menses
-may have clear, white nipple d/c

55
Q

physical exam findings of fibrocystic breast changes

A

-multiple, usually cystic masses that are well-defined, mobile, and often tender
-absence of breast skin changes
-most common sites: axillary tail and upper outer quadrant

56
Q

when is a mammogram recommended in women with fibrocystic changes?

A

age 40 and older otherwise no interventions really needed- maybe u/s to determine if mass is really cystic

57
Q

biopsy of excision if dominant mass or following findings are present

A

a. bloody fluid on aspiration
b. failure of mass to disappear after aspiration
c. solid mass not diagnosed as fibroma
d. recurrence of cyst after two aspiration
e. bloody nipple discharge
f. nipple ulceration

58
Q

treatment/management of fibrocystic breast changes
-pts with symptomatic nodularity or with mastalgia may be treated wtih…

A

-reassurance; supportive bra
-NSAIDs
-reduction in caffeine intake has shown limited effectiveness

*aspiration of palpable cysts may be curative

59
Q

fibroadenoma definition

A

benign breast mass derived from fibrous and glandular tissue
most common, benign mass in younger women (occurs most often in women 15 to 25 years old)

60
Q

how do fibroadenomas present? symptoms?

A

painless, single, round, rubbery mass
no nipple discharge
does NOT change with menstrual cycle

61
Q

physical findings on breast exam of fibroadenoma

A

firm, well defined, freely movable, smooth, rubbery, round, typically 2-4 cm marble-sized, nontender mass; UNILATERAL, may grow up to 15 cm

NO nipple discharge, NO breast skin changes

62
Q

whats the next step if you palpate a fibroadenoma in a patient?

A

-Best for younger women: ultrasound

FNA to determine whether cystic or solid and excisional biopsy ok too

63
Q

follow up and management of fibroadeoma

A

-observation: if diagnosis is confirmed and patient is younger than 25 years old
-may be removed to alleviate patient anxiety
-follow up with annual breast exam

64
Q

T/F each breast mass should be carefully evaluated to rule out carcinoma

A

TRUE

65
Q

breast discomfort is usually associated with…

A

fibrocystic changes

66
Q

intraductal papilloma definition

A

benign lesion of lactiferous duct; most common in perimenopausal age group 35-50

67
Q

intraductal papilloma is the most common cause of…

A

pathologic nipple discharge!!!

68
Q

symptoms of intraductal papilloma

A

bloody, serous, or turbid discharge (not milk), which may occur spontaneously
mass not usually palpable**
feeling of fullness or pain beneath areola (possible)

69
Q

physical findings of intraductal papilloma include…

A

expression of serosanguinous nipple discharge from single duct when pressure applied
poorly delineated, soft mass may be palpable
usually singular papilloma
no breast skin changes

70
Q

what is a definitive evaluation for intraductal papilloma?

A

excisional biopsy!

mammogram and or u/s depending on age

71
Q

nonpuerperal/periductal mastitis
-aka painful, tender nipple

A

periareolar inflammation with mass or abscess in woman who is NOT lactating; most common in reproductive age group

breast u/s recommended

72
Q

management of nonpuerperal/periductal mastitis
-pharm
-non pharm

A
  1. oral antibiotics for 10 days with agent that covers gram positive organisms (amox-clav, dicloxaxillin, cephalexin)
  2. if poor response to initial antibiotic, culture for methicillin-resistant S. aureus (MRSA), if + treat with doxy or sulfameth.
  3. aspiration or incision and drainage of abscess
  4. removal of foreign objects (nipple ring, nipple bar)
  5. warm packs and NSAIDs for pain relief
  6. smoking cessation
73
Q

mammary duct ectasia aka…
-most commonly seen in women who are ______ old and ____

A

dilation of ducts with surrounding inflammation and fibrosis
50 year old women who smoke

74
Q

symptoms of mammary duct ectasia

A

-green, brown, or black discharge; spontaneous and often bilateral
-may have burning, itching, sensation of pulling in nipple area

75
Q

management of mammary duct ectasia…

A

mammogram!

biopsy if mass is present

76
Q

breast carcinoma

A

-malignant neoplasm of the breast

77
Q

risk factors for breast carcinoma

A

-advancing age
-family history in one or more first-degree relative especially if before 50
-inherited gene mutations (BRCA 1> BRCA 2)
-Ashkenazi Jewish ancestry

78
Q

who is eligible for genetic counseling regarding breast cancer risk?

A

a. personal history of breast cancer at any age <50; triple negative breast cancer at any age <60; breast cancer at any age if Ashkenazi Jewish inheritance; ovarian, fallopian, pancreatic cancer
b. family history of known mutation; breast cancer any age <50; male breast cancer; ovarian, fallopian, primary peritoneal, pancreatic, or metastatic prostate cancer; multiple primary cancers on same side of family

79
Q

genetic breast cancer counseling considerations in women who..

A

-have breast cancer diagnosis
-family members if women with breast cancer is + for BRCA
-women assessed to be high risk for hereditary breast and ovarian cancer syndrome
-personal history of breast, endometrial, or colon cancer
-biopsy confirmed atypical hyperplasia
-high dose radiation to the chest
-high bone density
-menarche before age 12; menopause after 55
-nulliparity, first full-term pregnancy > 30
-homone therapy
-obesity (postmenopausal)
-heavy alcohol use
-dense breasts (MUST inform patients with dense breast of increased risk for breast cancer and reduced sensitivity of mammography)

80
Q

symptoms and physical findings of breast carcinoma

A

-breast mass that is fixed, poorly defined, and nontender
-may have nipple discharge, skin retraction
-dimpling, edema, color changes
-enlarged lymph nodes

Gynecologic, Reproductive, and Sexual Disorders (3 decks)

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