Cervical Cancer Screening, Infertility, Breast Disorders Flashcards
1
Q
- atypical squamous cells
A
cannot exclude high grade intraepithelial lesion (ASC-H)
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
2
Q
- low grade squamous intraepithelial lesions (LSIL)
A
encompasses transient HPV infection/mild dysplasia/cervical intraepithelial neoplasia 1 (CIN 1)
3
Q
- high grade squamous intraepithelial lesions (HSIL)
A
encompasses persistent HPV infection/moderate dysplasia (CIN2)/severe dysplasia or carcinoma in situ (CIN 3)
4
Q
- squamous cell carcinoma
A
cancer
5
Q
the 2014 Bethesda System for interpreting results of cervical cytology incluedes the following:
A
- specimen type
- specimen adequacy
- general categorization (squamous or glandular)
- interpretation/results:
a. non-neoplastic cellular changes
b. organisms: trich, candida - epithelial cell abnormalities
- glandular cell abnormalities
- other- endometrial cells in women 45 years of age and older
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
7
Q
what should you do if pap comes back unsatisfactory for evaluation? what about if there are two unsatisfactory results on pap?
A
- if HPV unknown or HPV negative (age >30): repeat pap in 2-4 months
- if HPV positive (>30), colposcopy or repeat pap test in 2-4 months
- two consecutive unsatisfactory results: colposcopy
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
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
10
Q
women ages 21-24 pap test
1. if unsatisfactory
2. ASC-US
3. LGSIL
4. ASC-H
5. HSIL
A
- if unsatisfactory: repeat pap in 2-4 month
- ASC-US: repeat pap in 12 months, if negative repeat again in 12 months
- LGSIL: repeat pap in 12 months; if negative, ASC-US, or LGSIL: repeat again in 12 months; otherwise colposcopy
- ASC-H: colposcopy
- HSIL: colposcopy
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!!
12
Q
women ages 25 to 29 pap test
1. if unsatisfactory
2. ASC-US
3. LGSIL
4. ASC-H
5. HSIL
A
- if unsatisfactory: repeat in 2-4 months
- ASC-US: reflex HPV test, if negative: repeat pap in 3 years, if positive: colposcopy
- LGSIL: colp
- ASC-H: colp
- HSIL: immediate excisional treatment
13
Q
pap alone every 3 years from women ages…
A
21-29
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
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
- pap test unsatisfactory: if HPV unknown or negative: repeat in 2-4 months; if HPV positive: colposcopy OR repeat pap in 2-4 months
- Normal pap, HPV +: co testing in 12 months –> if pap and HPV negative: repeat co-testing in 3 years; HPV typing also acceptable
- ASC-US HPV negative: repeat co-testing in 3 years
- ASC-US HPV positive: colpo
- LSIL with no HPV test: colpo
- LSIL HPV negative: repeat co-testing in 12 months
- LSIL HPV positive: colposcopy
- ASC-H: colposcopy
- HSIL: immediate excisional treatment or colposcopy
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
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
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
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)
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
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
22
Q
most common physical finding of DES in utero is…
A
- 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
23
Q
diagnostic tests/findings for DES in utero
A
- pap test of cervix and all four vaginal walls to rule out cancer
- colposcopy and biopsy of suspicious areas
24
chronic pelvic pain is defined as...
-etiology...
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
25
gynecologic causes of chronic pelvic pain include
-endometriosis
-adhesions
-post-PID chronic pain
-pelvic varicosity pain syndrome/pelvic congestion syndrome
-ovarian mass
-uterine fibroids
-adenomyosis
-vulvodynia
-malignancies (especially late stages)
26
non gyn causes of chronic pelvic pain
a. painful bladder syndrome/interstitial cystitis
b. myofascial pain syndrome
c. IBS
d. GI or urologic malignancies
27
symptoms of chronic pelvic pain (big range here)
-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)
28
lab work up for patient with chronic pelvic pain
-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
29
pelvic relaxation disorders include
-recommended management?
cystocele, urethrocele, rectocele enterocele, uterine prolapse
-kegel exercises, PT with pelvic floor, local estrogen therapy for postmenopausal women, pessary
30
symptoms of TSS
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
30
Toxic shock syndrome (TSS)
-etiology
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
31
Differential diagnoses for TSS
1. septic shock
2. rocky mountain spotted fever
3. scarlett fever
32
how to avoid TSS? education for patients
-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
DSM-5 criteria for sexual dysfunction
experiencing disorder at least 75% of the time for at least 6 months and causing significant distress
34
female sexual dysfunction falls into three categories
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
causes of sexual dysfunctions include
-relationship factors
-medical conditions
-medications: some antidepressants, antihypertensives, lipid-lowering agents, digoxin, combined hormonal contraceptives, opioids, amphetamines, anticonvulsants
36
lap workup for sexual dysfunction includes...
-what is NOT recommended?
really only indicated by history and physical exam findings (such as TSH) but androgen levels and estrogen levels are not recommended
37
management/treatment of sexual dysfunction
PLISSIT model
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
what is recommended treatment for postmenopausal women with vulvovaginal atrophy?
low dose localized estrogen (for those who can have it)
39
Flibanserin (Addyi) was approved in 2015 for....
treatment of hypoactive sexual desire disorder in premenopausal women; oral tablet taken once at bedtime
40
Bremelanotide (Vylessi) was FDA approved in 2019 for...
treatment of acquired, generalized HSDD in premenopausal women; self administered subq into abdomen or thigh at least 45 minutes before anticipated sexual activity
41
Infertility
-women < 35
-women > 35
in women less than 35: 1 year
in women >35: 6 months
unprotected coitis or inability to carry a pregnancy to live birth
42
etiology/incidence of infertility
-female factors
-male factors
-combined male and female factors (incidence)
-unexplained cause
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
assessment/workup for infertility includes
-history
-physical exam
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
diagnostic tests and lab workup for infertility
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
management/treatment of infertility depends on the cause...
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
congenital and chromosomal abnormalities
-Mullerian abnormalities result from the absence of...
AMH
results in anomalies involving the uterus, fallopian tubes, and upper vagina
47
physical findings of patient with Mullerian abnormality may include...
-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
symptoms of Mullerian abnormalities/what as a clinician would make you suspect a patient possibly had this?
-history of pregnancy loss or infertility
-amenorrhea, dysmenorrhea
-dyspareunia
47
diagnostic tests for Mullerian Abnormalities includes
structural abnormalities detected by u/s, MRI, etc.
chromosomal abnormalities ruled out with karyotyping
48
where do we refer patients with suspected mullerian abnormalities?
reproductive endocrinologist
49
androgen insensitivity/resistance syndrome is a genetically transmitted androgen receptor defect where the individual is genotypic...
-when is this often detected?
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
Turner's Syndrome definition
gonadal dysgenesis; an abnormality in or an absence of one of the X chromosomes; phenotypically female (45X)
51
presentation of Turner's syndrome
-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
Breast disorders
-fibrocystic breast changes
"non-disease" that includes non proliferative microcysts, macrocysts, and fibrosis, as well as proliferative changes such as hyperplasia and adenosis
53
cystic changes vs fibrous changes vs hyperplasia vs adenosis
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
symptoms of fibrocystic breast changes include
-breast pain and nodulatiry; usually bilateral
-frequently occurs 1-2 weeks before menses
-may have clear, white nipple d/c
55
physical exam findings of fibrocystic breast changes
-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
when is a mammogram recommended in women with fibrocystic changes?
age 40 and older otherwise no interventions really needed- maybe u/s to determine if mass is really cystic
57
biopsy of excision if dominant mass or following findings are present
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
treatment/management of fibrocystic breast changes
-pts with symptomatic nodularity or with mastalgia may be treated wtih...
-reassurance; supportive bra
-NSAIDs
-reduction in caffeine intake has shown limited effectiveness
*aspiration of palpable cysts may be curative
59
fibroadenoma definition
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
how do fibroadenomas present? symptoms?
painless, single, round, rubbery mass
no nipple discharge
does NOT change with menstrual cycle
61
physical findings on breast exam of fibroadenoma
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
whats the next step if you palpate a fibroadenoma in a patient?
-Best for younger women: ultrasound
FNA to determine whether cystic or solid and excisional biopsy ok too
63
follow up and management of fibroadeoma
-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
T/F each breast mass should be carefully evaluated to rule out carcinoma
TRUE
65
breast discomfort is usually associated with...
fibrocystic changes
66
intraductal papilloma definition
benign lesion of lactiferous duct; most common in perimenopausal age group 35-50
67
intraductal papilloma is the most common cause of...
pathologic nipple discharge!!!
68
symptoms of intraductal papilloma
bloody, serous, or turbid discharge (not milk), which may occur spontaneously
mass not usually palpable**
feeling of fullness or pain beneath areola (possible)
69
physical findings of intraductal papilloma include...
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
what is a definitive evaluation for intraductal papilloma?
excisional biopsy!
mammogram and or u/s depending on age
71
nonpuerperal/periductal mastitis
-aka painful, tender nipple
periareolar inflammation with mass or abscess in woman who is NOT lactating; most common in reproductive age group
breast u/s recommended
72
management of nonpuerperal/periductal mastitis
-pharm
-non pharm
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
mammary duct ectasia aka...
-most commonly seen in women who are ______ old and ____
dilation of ducts with surrounding inflammation and fibrosis
50 year old women who smoke
74
symptoms of mammary duct ectasia
-green, brown, or black discharge; spontaneous and often bilateral
-may have burning, itching, sensation of pulling in nipple area
75
management of mammary duct ectasia...
mammogram!
biopsy if mass is present
76
breast carcinoma
-malignant neoplasm of the breast
77
risk factors for breast carcinoma
-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
who is eligible for genetic counseling regarding breast cancer risk?
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
genetic breast cancer counseling considerations in women who..
-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
symptoms and physical findings of breast carcinoma
-breast mass that is fixed, poorly defined, and nontender
-may have nipple discharge, skin retraction
-dimpling, edema, color changes
-enlarged lymph nodes
