Cervical Diseases Flashcards
os
opening in middle of cervix
Most common site of dysplasia
“transformation zone” = squamocolumnar-junction
cervical ectropion
large squamocolumnar-junciton; may be normal but get consult
Chadwick’s sign
engorgement and bluish tint of cervix, vagina, and labia due to increased blood flow; early sign of pregnancy
How does cervix change during pregnancy?
softer on palpation, bigger and elongated, more white secretions
How does cervix change during postmenopause?
May have petechiae on surface caused by friction on thin, dry, atrophic epithelium
shallow, thin, friable
Normal postpartum cervix
healed lacerations from delivery
“fish mouth” os
Diagnosis of cervicitis in lab and on PE
Mucopurulent discharge from cervix
Wet Mount with > 10 WBC’s/HPF
Cervix often friable
Causes of cervicitis
Chlamydia GC Herpes Mycoplasma Ureaplasma Other organisms
strawberry cervix =
Trichomonas
Treatment of cervicitis
Treat STD
If organism unknown, treat empirically with Doxy 100 mg PO BID x 7 days
Treat partner?
Benign fleshy lesions with stalk on cervix
polyps
Common symptom of cervical polyps?
post-coital and intermenstrual bleeding
Signs that cervical polyps are not benign
- different color than rest of cervix
- angiogenesis (increased blood vessels within)
Common benign cervical lesions and treatment
polyps (none) Nabothian cysts (none) Laceration (suturing) Myomas (excise if large) Cervical stenosis (dilation)
Asymptomatic retention cyst covering a gland on cervical. Appear white on exam.
Nabothian cysts
Lesions caused by delivery that create a “fish mouth” appearance
Laceration
Smooth, firm mass on cervix without stalk. Usually asymptomatic and solitary.
Myomas
Presentation of cervical stenosis
Frequently in post-menopausal women
Occurs at internal os
+/- dysmenorrhea and infertility
Treatment of cervical stenosis
dilation
Specific strains of HPV that are associated with invasive cervical cancer?
16 and 18
Risk factors for cervical cancer
SMOKING First coitus < 20 yro Multiple sex partners Immunosuppression African American
_____ is a cofactor necessary, but not sufficient, to develop cervical cancer.
HPV
many HPV+ women with never develop cervical cancer; clear infection within 8-24 mon
Why is it so rare for young women to get cervical cancer?
younger have stronger immune systems that are likely to clear HPV infection
What does HPV vaccine prevent?
cervical, vulvar, and vaginal cancers
throat, anal, and penile cancer
precancerous or dysplastic lesions
genital warts
What HPV types are included in Gardasil?
Types 6, 11, 16, 18
What does optimal Pap smear sample include?
squamous and columnar epithelium, particularly of transformation zone (TZ)
What is “thin prep?”
Pap smear sample rinsed in liquid-based cytology vial and sent to lab for staining and fixing on slide
used for dx assessments of HPV, gonorrhea, chlamydia
How can Pap smear be used for dx?
Pap smear does not diagnose!
use cervical tissue sampling from TZ from Pap smear to dx
Who should have a Pap smear? (according to ASCCP guidelines)
Begin at 21 yo regardless of onset of sexual activity
How often should pap smear be done for average risk women 21 years or older?
Annual screening until 3 consecutive pap smears are negative
Then screen every 3 years OR every 5 years with HPV co-testing
When can pap smear screening be discontinued?
At age 65 if adequate prior screening and not otherwise high risk (3 consecutive neg cytology or 2 consecutive neg HPV w/i 10 years)
Total hysterectomy for benign conditions
How often should pap smear be done for high risk women?
20 years of annual screening after treatment even if goes past age 65
Who are the high risk women for pap smear screening?
cervical intraepithelial neoplasia
cervical cancer
HIV+ or immunocomp’d
What is next step if abnormal pap smear results?
co-test with HPV DNA testing = “Reflex HPV testing”
What is the Bethesda Classification System?
Classification of pap smear results
Evals likelihood of cells to progress to cancer
Describe reported specimen adequacy of Bethesda System.
satisfactory # of squamous cells?
endocervical/TZ cells present?
any inflammation or blood?
Possible positive findings on pap smear reported by Bethesda System
Squamous intraepithelial lesion (SIL): low grade (LSIL) or high grade (HSIL) cervical cancer precursors
Atypical squamous cells: ASC-US or ASC-H
Atypical glandular cells (AGC)
Adenocarcinoma in situ (AIS)
What should you do if positive results on pap smear?
refer to gynecology for colposcopy
What is colposcopy?
Primary technique for eval of abnormal pap smears
Acetic acid solution applied to cervix epithelium and then viewed with binocular microscope to magnify abnormalities
Cervical biopsies taken of abnormal tissue
How is cervical tissue sample collected for biopsy?
directed biopsy and endocervical curettage (D&C)
When does colposcopy indicate need for excision?
CIN II or III (moderate to severe dysplasia)
Procedures to treat cervical dysplasia and cancer
Ablation: cryotherapy or laser
Excision: LEEP (electrosurgical loop), laser conization, or cold-knife conization
When is hysterectomy not appropriate for cervical cancer treatment?
NEVER use as 1st line treatment for CIN-1
Not used as 1st line for CIN-2 or 3 except in special circumstances
Management of atypical squamous cells ASCUS (undetermined significance)
Usually a self-limited disease
Women age 21-24:
Consider HPV testing (if negative continue routine screening)
If positive or unknown, repeat Pap smear every 12 months for 2 years
Any increase refer!
Women 25 and older:
If HPV positive, refer for colposcopy
Postmenopausal and immunosuppressed:
refer for colposcopy
Pregnant women:
managed as if non-pregnant
Management of atypical squamous cells ASC-H
Refer for colposcopy
If ASC-H results on pap smear, ______ cannot be excluded.
HSIL
Management of atypical glandular cells (AGC)
Refer for colposcopy
What is the only difference in management of LSIL and ASC-US?
Pregnant women with LSIL always needs colposcopy
ASC-US only if over 25 yo and positive HPV
Management of high-grade squamous intraepithelial (HSIL)
Refer for colposcopy
No endocervical curettage in pregnant woman
What is method of inserting speculum on pelvic exam?
insert with blades oblique, then dive down and turn
Why would you not see cervix os on pelvic exam?
speculum on top of it or not inserted far enough
How is the bimanual exam of pelvis performed?
insert 2nd and 3rd digits of one hand and use opposite hand to palpate abdomen on suprapubic region
Examine uterus - note cervical position
Examine adnexa - assess ovaries, fallopian tubes, and support structures
What is uterine prolapse?
uterus drops into vaginal canal due to weakened supporting structures (elderly, women with multiple children)
What is cystocele?
bladder prolapse; bladder falls into vaginal canal due to weakened structure
What is rectocele?
rectal prolapse; vaginal bulge from front wall of rectum pushing into back wall of vagina
How to chart normal pelvic exam?
external genitalia without erythema/edema/lesion
no discharge noted from vagina/urethra
Cervix smooth without erythema/lesion
NTTP without CMT
Uterus/adnexa without mass/nodule and NTTP
What is rectrovaginal exam? When is it indicated?
insert one finger in vagina and one in rectum
suspicion of post pelvic mass or eval of chronic pelvic pain
