Cervical disorder

Question 1

What is the transformation zone of the cervix?

Answer 1

The area where the cells of the vagina (squamous cells) and the cells of the uterus (columnar or glandular cells) meet. Also called the squamocolumnar junction

Question 2

Cervical changes premenarchal

Answer 2

Columnar cells (blue) are within the
endocervix, while the ectocervix and vagina are completely lined with
squamous epithelium (yellow). The SCJ lies close to the external os.

Question 3

Cervical changes post menarche

Answer 3

The SCJ is generally found on the ectocervix post menarche, with
increased eversion during pregnancy

Question 4

Cervical changes post menopause

Answer 4

The SCJ is often found within
the endocervical canal post
menopause

Question 5

Etiology of cervicitis

Answer 5

Most common causes are Herpes
simplex virus, Chlamydia,
Gonorrhea, HPV, Trichomonas (70%
asymptomatic), Cytomegalovirus,
and Bacterial vaginosis
Should also evaluate for syphilis,
hep B, HIV, and HPV as needed

Question 6

Risk factors for Cervicitis

Answer 6

Women age 19 – 25y
Multiple sexual partners
Unprotected intercourse (no
condom use)
High risk sexual partner
Infected sexual partner
Hx of STIs
Current/prior drug use

Question 7

Cervicitis clinical features

Answer 7

Often asymptomatic
Change in vaginal discharge: Thick, runny, colored, malodorous
Post-coital bleeding**
Vulvar burning/itching
Dysuria, urgency, ↑ Urination
Cervical friability
Lower abdominal pain
Dysmenorrhea
Cervical motion tenderness (chandelier sign)

Question 8

Diagnosis of cervicitis

Answer 8

Take detailed social sexual history
Physical
Wet mount
pH
Pap smear
Nucleic acid amplification testing (CT, GC,
Trich)

Question 9

complications of cervicitis

Answer 9

Cervical hemorrhage, Leukorrhea, Cervical
Stenosis, Salpingitis (inflammation of the
fallopian tubes), PID, infertility, ectopic
pregnancy, and chronic pelvic pain

Question 10

Etiology of PID

Answer 10

PID encompasses a spectrum of
inflammatory disorders of the upper
female genital tract

Question 11

Risk factors of Cervicitis

Answer 11

Undiagnosed infection
Multiple sexual partners
Inconsistent condom use
High risk partner
Partner with hx of infection
Can be from IUD as well, from
introducing bacteria into the area.

Question 12

DDx for PID

Answer 12

Ectopic Pregnancy***
Endometritis
Salpingitis
Tubo-ovarian abscess
Pelvis peritonitis
STIs

Question 13

Clinical Features of PID

Answer 13

Pelvic pain
Cervical motion tenderness
Cervical discharge of unknown cause
Cervical friability
Oral temperature >101*F
Abundant WBCs on wet mount
Elevated C-reactive protein
Elevated erythrocyte sedimentation
rate

Question 14

Diagnosis of PID

Answer 14

Standard is Laparoscopy
Supported by ESR, CRP, CT/NG, Bx of endometrium,
US, CT, MRI, etc.
Difficult to diagnose due to wide variety of
symptoms and presentations

Question 15

Treatment of PID

Answer 15

Typical Management (outpatient):
Ceftriaxone 150mg IM
PLUS Doxycycline 100mg PO BID x 14d
With or without Metronidazole 500mg PO BID x 14d
Abstain from intercourse during treatment to prevent transmission

Presumptive treatment should be initiated in sexually active women if they are experiencing pelvic/lower abdominal pain with no other identifiable etiology

Question 16

Complications of PID

Answer 16

Yeast infection (Tx)
GI upset (Tx)
Adherence to medication
Fertility issues**
Ectopic pregnancies (scarring)**
Chronic pelvic pain**
Male partners within 60 days of PID diagnosis need presumptive treatment for CT and GC regardless of etiology of PID

Question 17

Atypical squamous cells of
undetermined significance

Answer 17

ASC-US

Question 18

Atypical squamous cells in which high-
grade lesions cannot be excluded

Answer 18

ASC-H

Question 19

Low-grade squamous intraepithelial
lesion
Cellular changes consistent with CIN I

Answer 19

LSIL:

Question 20

High-grade squamous intraepithelial
lesion
Includes cellular changes consistent with
CIN II and CIN III

Answer 20

HSIL

Question 21

Disordered grown of the lower third of
the epithelial lining

Answer 21

CIN I

Question 22

Abnormal maturation of the lower 2/3
of the lining.

Answer 22

CIN II

Question 23

Involves more than 2/3 of the
epithelial thickness

Answer 23

CIN III

Question 24

Involves the full thickness
of the epithelium - covered in a later unit

Answer 24

Cancer in Situ (CIS):

Question 25

Cervical Dysplasia etiology

Answer 25

Cigarette smoking Human Papilloma Virus (HPV) infection HPV is found in more than 80% of CIN lesions

Question 26

Risk factors of cervical dysplasia

Answer 26

Multiple sexual partners HPV infection Genital neoplasia HIV or AIDS Hx of Immunosuppression Multiparous Long term oral contraceptive pill user High-risk sexual partners HPV infection (more to come) Hx of a partner with HPV infection Lower genital neoplasia Hx of exposure to cervical neoplasia

Question 27

There are ____ types of HPV, of which ____ strains infect ano-genital tissue

Answer 27

130; 30-40

Question 28

HPV prevention

Answer 28

➢ Condom usage is 60% effective but does not protect from labial-scrotal transmission ➢ Gardasil, Gardasil-9, and Cervarix ■ NEW 2 doses 9-14 yo ■ 3 doses 15-26yo

Question 29

HPV transmission

Answer 29

Contagious spread through sexual contact

Question 30

HPV wart appearance

Answer 30

Usually flat, papular or pedunculated growths on genital mucosa - Resemble a cauliflower texture - Often located in multiple locations - Diagnosed by visual inspection

Question 31

Will HPV warts resolve on their own?

Answer 31

No

Question 32

How to treat HPV warts

Answer 32

85% Tri-chloric acid or freezing Imiquimod 5% (aldara) placed on the wart for 8-10 hrs, 3x weekly for several weeks/months

Question 33

Cervical dysplasia Ddx

Answer 33

Cervicitis Pelvic Inflammatory Disease Vaginitis Trichomoniasis Herpes Lesion Abnormal cells on pap from surrounding tissue, not from cervix

Question 34

Clinical Features of cervical dysplasia

Answer 34

Often asymptomatic Visible cervical lesion Friable cervix Bleeds easily Post-coital bleeding

Question 35

Evaluation/screening of cervical dysplasia

Answer 35

PAP initial Obtain cervical cytology or biopsy Check for vaginal infections

Question 36

USPSTF recommendation grading for pap smears in women ages 21-65

Answer 36

A

Question 37

Cervical Dysplasia diagnosis

Answer 37

Cervical cytology (pap smear) Cervical biopsy

Question 38

Management of Cervical dysplasia

Answer 38

- CIN I spontaneously regresses in a large number of patients, therefore multiple paps over time is typical first line management - More severe dysplasia can also regress (not as frequently) - All patients with CIN II and CIN III need treatment - Excisional Tx preferred for this group (histologic HSIL) - Treatment for pregnant women should be done postpartum

Question 39

Cervical Dysplasia complications

Answer 39

If HPV infection is not cleared it takes approx. 3-5 years for development of CIN II or CIN III It takes an additional 10-20 years to progress to cervical cancer 30-40% of CIN III progresses to cancer

Question 40

_____% of CIN III progresses to cancer

Answer 40

30-40

Question 41

Colposcopy

Answer 41

A Colposcopy allows for evaluation of an abnormal pap smear The colposcope uses magnification(5-15x) and light, in combination with aqueous acetic acid, and sometimes iodine to allow abnormal cells to be seen more easily punch biopsies are obtained as needed for further pathologic analysis

Question 42

Advantages and disadvantages of a colposcopy

Answer 42

Advantages Inexpensive Relatively quick (approx. 10-20 min) Can be done in the office Low risk of infection Disadvantages: Discomfort Possible infection

Question 43

Cryosurgery

Answer 43

compressed nitrogen gas flows through a cryo probe making the metal cold enough to freeze and destroy the abnormal cervical tissue

Question 44

Advantages and disadvantages to cryosurgery

Answer 44

Advantages: Inexpensive Easy to do Widespread availability Minimally invasive Can be done in the office Does not require anesthesia Low complication rate Disadvantages: Can be difficult to cover the entire lesion Mild uterine cramping Copious watery vaginal discharge for several weeks Possible infection and cervical stenosis (Rare) not good for more extensive forms of CIN

Question 45

Loop Electrosurgical Excision Procedure (LEEP)

Answer 45

LEEP uses a small, fine, wire loop that excises tissue with the assistance of an electrosurgical generator Varying loop sizes are available Usually take a second thin layer off for histologic evaluation (called a “top hat”)

Question 46

Advantages and disadvantages of LEEP procedure

Answer 46

Advantages: Easy Low cost Fewer complications than Cold Knife Conization Allows for additional tissue samples for histology Disadvantages: Requires local anesthesia Requires an insulated speculum to prevent electrical conduction Requires a grounding pad Requires a vacuum to remove smoke PRN Bleeding Possible Infection Cervical Stenosis

Question 47

Which types of HPV cause genital warts?

Answer 47

Types 6, 11, 42, 43, and 44 cause warts and low grade lesions

Question 48

Cold Knife Conization

Answer 48

Excision of a cone-shaped section of the cervix with a scalpel Done under local or general anesthesia

Question 49

Advantages and disadvantages of cold knife conization

Answer 49

Advantages: - Can be individualized to accommodate cervical anatomy, as well as the lesion size and shape - Histologic specimens are devoid of thermal damage (Found with Cryo and LEEP) Disadvantages: Done in the operating room ($$$) Bleeding Infection Cervical stenosis Cervical insufficiency Higher complication rate

Question 50

Cervical cancer is most prevalent in women over _____

Answer 50

40