Cervical Disorders Flashcards
Causes of cervicitis
- Gonorrhea, chlamydia
- Trichomonas, BV, yeast
- Viruses - HSV, HPV, CMV
complications of cervicitis
- PID
- passing infection to newborn during delivery
___ ____ ____ increases risk of diagnosis
High-risk sexual behavior
acute s/s of cervicitis
- Often asx
- MC sx - discharge; Varies depending on pathogen; Cervical and vaginal exudate present on exam
- Vaginal bleeding - Postcoital, intermenstrual, and/or during exam
- Cervical Tenderness
- Urethritis - frequency, urgency, dysuria
- Salpingitis - pelvic pain, fever, chills, abnormal menses, nausea
- Discharge - thick, creamy, purulent, may be malodorous
- Cervix - acutely inflamed, edematous
Gonorrhea/Chlamydia
- Discharge - thick, white, “curd like,” itchy, non-malodorous
- Cervix - may see inflammation and edema; adherent white discharge
Candidiasis
- Discharge - foamy, greenish or whitish, may be malodorous
- Cervix - inflamed and edematous with “strawberry” petechiae
Trichomonas
- Discharge - thin, gray, “fishy” odor
- Cervix - noninflamed if bacterial vaginosis; varying degrees of inflammation and edema if true bacterial cervicitis
Bacterial
- Discharge - from clear or serous and watery to white and purulent
- Cervix - vesicular lesions on erythematous base that evolve to shallow ulcerations
Herpes Simplex Virus
chornic s/s of cervicitis
- Often asx
- discharge usually less than acute
- Purulent or mucoid discharge from cervix
- Proximal vagina may be normal
- Vaginal bleeding
- Cervical Tenderness
- urethritis
- pain - lower abdominal/pelvic pain, lumbosacral backache, dysmenorrhea, dyspareunia
w/u for cervicitis
-
Microscopic Analysis
- Gram’s Stain - inflamed cervical cells, purulent material and 10+ PMN per HPF
- Wet mounts - clue cells, mobile trichomonads
- KOH prep - hyphae or fishy odor
- ID of specific pathogens - cx, PCR/nucleic acid probe, plasma VDRL or RPR -
Pap Smear/Colposcopy
- Nonspecific atypia - can be difficult to distinguish from neoplasia
- Large number of PMNs or leukocytes = acute cervicitis
- Trichomonads and yeast can be identified directly on microscopy
“double hairpin capillaries” on colposcopy
dx?
Trichomonas
pap smear/colposcopy shows cell enlargement, multinucleation, perinuclear halos, hyperchromasia
dx?
HPV
pap smear/colposcopy shows enlarged, multinucleated cells, ground-glass cytoplasm, inclusion bodies
dx?
HSV
tx for Gonorrhea/Chlamydia
- Ceftriaxone
- Doxy (preferred) OR azithromycin
tx for Candidiasis
- Azoles - fluconazole
- ibrexafungerp
tx for Trichomonas
- Metronidazole, tinidazole, or secnidazole - 2 g PO x 1 dose
- Metronidazole 500 mg orally BID x 7 d
tx for Bacterial cervitis/BV
- Metronidazole
- Tinidazole
- Secnidazole
- Clindamycin oral
- Clindamycin PV
tx for HSV
- Initial - acyclovir 400 mg PO TID x 7-10 d, valacyclovir 1 g PO BID x 7-10 d
- Recurrent - acyclovir 800 mg PO TID x 2 d, valacyclovir 1 g PO QD x 5 d
tx for Salpingitis
- Outpt - Ceftriaxone + doxy +/- metronidazole
- Inpt - Ceftriaxone + doxy+ metronidazole
tx for HPV
- Tissue ablation/excision - cryotherapy, electroablation, CO2 laser, conization, LEEP
- Topical - if vulvar lesions present - bichloracetic acid, trichloracetic acid, podophyllin
prevention of cervicitis
- STI Avoidance - abstinence, barrier methods
- Removal of cervix at time of hysterectomy, if possible
- Many people with STIs are asymptomatic
Routine screening in groups at high risk of STIs
- Young adults 19-25
- Patients with a previous history of STIs
- Patients who inconsistently use condoms
- High risk-behaviors such as substance abuse
- Patients with multiple sexual partners or a high-risk sexual partner
- tx of partners in patients with STIs
Painless cervical shortening or dilation in the second or early third trimesters
Up to 28 weeks
Results in preterm birth
Cervical Insufficiency
RF for Cervical Insufficiency
- Hx of cervical insufficiency
- Hx of cervical injury, surgery, or conization
- DES exposure
- Anatomic abnormalities
s/s of cervical insufficiency
- significant cervical dilation (2+ cm) with minimal contractions
- Classically in the 2nd trimester
- At 4 cm + of dilation, active contractions or ROM may occur
w/u for cervical insufficiency
-
US at 14-16 wks or later: Funnelling and shortening abnormalities
- Prior to pregnancy and in 1st trimester - no way to determine if cervix will eventually be incompetent
tx for cervical insufficiency
- Cervical Cerclage: Purse-like ring of stitch around the cervix
- progesterone at 16 wks and continue to 36+ wks
CI for cervical cerclage
- ROM
- infection
- fetal demise
what to do before a cervical clerage?
- Confirm viable intrauterine pregnancy
- Cx gonorrhea, chlamydia and group B strep beforehand and tx
- Caution if advanced cervical dilation or membranes prolapsed into vagina
Cystic structures on the surface of the cervix
Often asx - may feel a lump when placing a cervical cap or diaphragm
Usually an incidental finding on exam
Nabothian Cysts
Smooth, rounded area on cervix
White or yellow, single or multiple
No associated inflammation
dx?
tx?
- Nabothian Cysts
- Benign - no tx; spontaneously resolve
- If very large - may do drainage
- mild cervical dysplasia
- disordered growth of lower ⅓ of epithelial lining
CIN I
- moderate cervical dysplasia
- disordered growth of lower ⅔ of epithelial lining
CIN II
- severe cervical dysplasia
- disordered growth of over ⅔ of epithelial lining
- considered full thickness (CIS)
CIN III
Always treat CIN II and III except:
- Pregnant women (wait until postpartum period)
- CIN II in adolescents (high spontaneous regression chance, lower cancer risk)
CIS peak incidence at what age?
25-35 years
Cervical cancer peak incidence at what age?
40+ years
- s/s of cervical dysplasia
- w/u?
- Usually no signs and visibly normal cervix on examination
- Dx: abnormal routine cytology smear
- If cervical lesion visible on pelvic exam - consider bx
Cervical Dysplasia - Risk Factors
- Multiple sexual partners
- Early onset of sexual activity
- High-risk sexual partner
- HPV infection
- History of sexually transmitted infection
- Immunosuppression (including HIV/AIDS)
- Multiparity
- Long term oral contraceptive pill use
- Most others statistically insignificant compared to HPV infection
HPV present in ?% of all CIN lesions and in ?% of all invasive cervical cancers
- > 80
- > 99.7
high-risk HPV types?
16, 18, 31, 33, 45, 52, 58
- HPV-16 - found in 50-70% of cervical cancers
- HPV-18 - found in 7-20% of cervical cancers
what substances has a synergistic effect with HPV
cigs
prevention of cervical dysplasia
1st dose 9-12 yrs old
- Gardasil - 6, 11, 16, 18; Cervarix - 16, 18; Gardasil-9 - 6, 11, 16, 18, 31, 33, 45, 52, 58
- for preventing CIN II or worse
- Prophylactic, not therapeutic
Cervical cancer screening
start age 21
- Ages 21-29 - Pap every 3 yrs
- Ages 30-65 - Pap every 3 yrs OR Pap+HPV every 5 yrs
- Age > 65
when to stop cervical cancer screening for ages >65 if:
- no h/o moderate/severe dysplasia or cancer AND…
- 3 negative Paps OR 2 negative Pap+HPV in a row in past 10 yrs (last result in the last 5 yrs)
when do cervical cancer screenings not apply?
If hx of cervical cancer, HIV+, immunodeficient or DES exposure
May still need yearly Paps even after hysterectomy
what is the Bethesda System
Abnormal Pap Smears
- Atypical Squamous Cells (ASC)
- Undetermined significance - ASC-US
- Cannot exclude high-grade lesion - ASC-H - Low-grade Squamous Intraepithelial Lesion - LGSIL or LSIL - Corresponds to CIN-I
- High-grade Squamous Intraepithelial Lesion - HGSIL or HSIL - Corresponds to CIN II and CIN III
- Atypical glandular cells - AGC
mgmt for Minimally abnormal cervical cytology smears (ASC-US)
-
Repeat serial cytology - q 6 mo till 2 consecutive normal
- Second abnormal smear - colposcopy - Test for high-risk HPV - Refer for colposcopy if positive
- Immediate referral to colposcopy
- Before repeat smear - treat underlying conditions
- Hormones if atrophic vaginitis
- Antimicrobials for infections
what abnormal pap smears would need a colposcopy?
LSIL, HSIL, ASC-H, AGC
Indications for colposcopy
- Abnormal cervical cytology or HPV testing
- Clinically abnormal cervix
- Unexplained intermenstrual or postcoital bleeding
- Vulvar or vaginal neoplasia
- History of in utero DES exposure
after colposcopy mgmt for CIN I
expectant management
- High chance of spontaneous regression
- 2 Pap q 6 mo OR Pap + HPV test at 6 months
- Repeat colposcopy if cytology is abnormal or if HPV +
- If 2 smears are WNL and/or HPV negative, routine screening resumes
after colposcopy mgmt for CIN II/III, Invasive cancer, otherwise abnormal or unsatisfactory colposcopy
surgical therapy
- Ectocervix-only lesion - cryotherapy, laser ablation, superficial LEEP
- Deeper LEEP or cone bx done if:
- lesion extends to endocervical canal
- endocervical curettage shows dysplasia or other abnormality
- major discrepancy between cytology and colposcopy
- Office procedure - no anesthesia required
- Nitrous oxide or carbon dioxide - supercooled probe
- Cryoprobe must cover entire lesion
- Activated until blanching extends 7 mm beyond probe in all directions
Cryotherapy
pros, cons, SE of Cryotherapy
- Pros - easy to use, low cost, widely available, low risk of complications
- Cons - f/u colposcopy can be unsatisfactory, only appropriate for superficial lesions
- SE - mild uterine cramping, copious watery discharge for several weeks; Rare - infection, cervical stenosis
- Destroys tissue with narrow zone of injury
- Vaporizes tissue to depth of at least 7 mm
- Used for ablation of transformation zone or as a tool for cone biopsies
Carbon Dioxide Laser
pros, cons, and SE of Carbon Dioxide Laser
- Pros - precise, versatile, can be done in office or as outpatient hospital procedure
- Cons - requires local or general anesthesia, expensive, requires significant training
- SE - Post-procedural pain, vaginal discharge for 1-2 wks; Bleeding; Rare - infection, cervical stenosis
- Small fine wire loop attached to electrosurgical generator
- Used to excise portion of the cervix
- An additional narrow endocervical specimen may also be removed after primary LEEP excision
- Frequently used for CIN II and CIN III
Loop Electrosurgical Excision Procedure (LEEP)
pros, cons, and SE of Loop Electrosurgical Excision Procedure (LEEP)
- Pros - easy to use, provides tissue for histology, office procedure under local anesthesthesia, can be used for superficial or deep lesions, less expensive than cold knife conization or CO2 laser
- Cons - inc risk of premature delivery
- SE - cramping, bleeding (1 wk), vaginal discharge (3 wks)
- Rare - cervical stenosis, infection
- Less frequent than cold knife conization
- Excision of cone-shaped portion of cervix using a scalpel
- Individualized to accommodate lesion
- Can be wide and shallow or narrow and deep
Cold Knife Conization
Pros, cons, and SE of Cold Knife Conization
- Pros - Histologic specimen has no thermal artifact
- Cons - Expensive, needs to be done in OR (regional or general anesthesia), increased risk for premature delivery (cervical insufficiency)
- SE - cramping, bleeding, vaginal discharge (2-3 wks); Rare - infection, cervical stenosis
Higher risk for recurrence of cervical dysplasia if:
- larger lesions
- endocervical gland involvement
- positive margins
- positive endocervical curettage
Treatment reduces risk of cervical cancer by ?%
Still have higher risk of cervical cancer than the general population for at least ? years
95
20-25
avg age at cervical cancer dx?
51
- Can occur as young as 20s or during pregnancy
- Nearly 20% diagnosed in women 65 and up
- Over 95% with early cancer can be cured!
RF for Cervical Cancer
similar to CIN
- HPV DNA - HPV-16 most common; HPV-18 and HPV-45
- Other: tobacco, immunosuppression, HIV, other STIs, high parity, oral contraceptive use
MC type of carcinoma in cervical cancer?
- 70-75% - SCC
- 20-25% - adenocarcinomas
- 3-5% - adenosquamous carcinomas
- May see undifferentiated carcinomas
prevention of cervical cancer?
recognition and tx of preinvasive and early invasive disease
- > 60% of cervical cancer pts in developing countries either have never been screened or have not been screened in the last 5 yrs
- HPV vaccination
- Safe sex practices
- Avoidance of risks (e.g. HIV, tobacco)
s/s of cervical cancer
- Early - may be asymptomatic
- MC sx - abnormal vaginal bleeding - Bloody leukorrhea, scant spotting, frank bleeding, postcoital
- Leukorrhea
- Involuntary loss of urine or feces through vagina - Sign of fistula formation
- Late - weakness, weight loss, anemia, pelvic pain - Pain is usually unilateral, may radiate to hip or thigh
- Early - Cervix normal; Ulceration to cervix may be primary manifestation
- Later - enlargement, irregularity and firmness of cervix and eventually also surrounding tissues
cervix is seen to be a barrel-shaped and enlarged, what is this term?
endophytic - cervical cancer
cervix is friable, bleeding, and has cauliflower-like lesion, what is this term?
exophytic - cervical cancer
in cervical cancer, eventually parametrial involvement may lead to ?
nodular thickening of the uterosacral ligaments with fixation of cervix
dx and tx for cervical cancer
Cancer may be present despite negative cytology
- Any suspicious lesion - bx
- If bx reveals CIS or if colposcopy is negative but Pap is significantly abnml - conization - If grossly suggestive of invasive cancer - conization not indicated; simple bx only
- radical hysterectomy and lymphadenectomy
- +/- radiation and chemotherapy
- Advanced - chemotherapy is usually palliative, not curative
Prognostic Factors of cervical cancer
stage, lymph node status, tumor volume, depth of invasion, lymphovascular invasion
prognosis for cervical cancer?
- Pts with less advanced disease - 88-96% 5-year survival rates
- Local confinement and negative LN - Later disease (+ LN) - 64-73% 5-year survival rates
