Cervical Disorders

Question 1

Cervicitis

Answer 1

• Definition:
  
  • inflammation or infection of the cervix
• Etiology:
  
  • STI (chlamydia or gonorrhea, herpes, HPV, trichomonas), chemical irritation (lubricants, spermicide), bacterial vaginosis
• S/sxs:
  
  • most are asymptomatic
  • vaginal discharge, postcoital bleeding, dyspareunia, or pelvic pain
• Tx:
  
  • appropriate abx
  • d/c irritants

Question 2

Cervical Cancer: Types, Histology, Risks, Epidemiology, HPV vaccine

Answer 2

• Types:
  
  • Squamous cell carcinoma (90%)
  • Adenocarcinoma (10%)
• Histology:
  
  • >90% of cervical neoplasms arise at the squamo-columnar junction (esp carcinogenic) -→ right at the os of the cervix
• Risks:
  
  • HPV (HPV-16&HPV 18cause majority of cervical cancers), hx of cervical cancer, STIs, poor access to screening, smoking (3.5x), immunosuppressed (HIV, transplant), early sex, Diethylstilbestrol (DES) exposure in utero
• Epidemiology:
  
  • 4th most common cancer among women, most common cause of GYN malignancy (esp in underdeveloped nations), increased survivability in HIV + women due to ART meds/HPV vaccine/paps
• HPV vaccine:
  
  • Gardasil 9 covers 9 strains
  • Cervarix only covers HPV types 16 & 18

Question 3

Cervical Cancer: S/sxs, PE, Diagnostics

Answer 3

• S/sxs:
  
  • usually asymptomatic until late stages
    
    • but can have:
      
      • postcoital bleeding or spotting
      • irregular or heavy vaginal discharge or watery vaginal discharge
      • pelvic or back pain (advanced disease)
• PE:
  
  • cervical discharge or ulceration if invasive
• Diagnostics:
  
  • HPV testing: highly sensitive, identifies DNA from high-risk HPV types, used in routine testing of women > 30yo, if HPV + = manage as LSIL
  • Colposcopy:
    
    • must visualize the entire squamo-columnar junction and the margin of any visible lesion
  • *Developing countries: perform a visual inspection with acetic acid

Question 4

PAP smear Bethesda System

Answer 4

• *Bethesda system: reports specimen as satisfactory (negative for intraepithelial lesions or malignancy) or unsatisfactory:
  
  • -Atypical squamous cells of undetermined significance (ASCUS): cannot exclude high-grade squamous lesion
  • -Low-grade squamous intraepithelial lesions (LSIL): HPV, mild dysplasia, CIN1
  • -High-grade squamous intraepithelial lesions (HSIL): moderate or severe dysplasia, CIN 2 & 3
  • -Squamous cell carcinoma
  • -Unsatisfactory: <1% of samples, less often with liquid based collection
  • -Atypical Glandular cells

Question 5

Screening with PAP & for HPV

Answer 5

• 21-29 yo: screen with PAP q 3 years
• 30-65 yo: screen with co-testing (PAP & HPV) q 5 years or PAP q 3 years
• If hx of cervical cancer:
  
  • screen for 20 years after management (even if past 65)
• if hx of total hysterectomy:
  
  • no screening required
• **Stop screening at age 65 in women with adequate prior screening & not otherwise high risk

Question 6

Management of Cervical Cancer/Dysplasia

Answer 6

• ASCUS (Atypical squamous cells of undetermined significance):
  
  • HPV testing -→ if + then colposcopy, if - then repeat testing in 3 years; OR repeat cytology at 1 year -→ if ASC or more then do colposcopy
• ASCUS or LSIL (low-grade squamous intraepithelial lesion) in 21-24yo:
  
  • repeat cytology in 1 year, if neg x 2 return to routine screening
• HSIL:
  
  • immediate loop electrosurgical excision or colposcopy with endocervical assessment
• Unsatisfactory:
  
  • if HPV - then repeat PAP in 2-4 months
• Atypical glandular cells:
  
  • colposcopy with endocervical & endometrial sampling