Cervical Disorders

Question 1

Describe the presentation of nabothian cysts

Answer 1

*Glandular material becomes trapped

• Benign
• Asymptomatic (seen on speculum exam)

Question 2

Nabothian cysts: tx

Answer 2

excision is not required

Question 3

Cervical polyps: clinical presentation

Answer 3

• post-coital bleeding (maybe)
• abnormal uterine bleeding (maybe)
• Benign

Question 4

Cervical polyps: tx

Answer 4

polypectomy if symptomatic

Question 5

Describe the difference in cells from the endo and ectocervix

Answer 5

Ectocervix - stratified squamous epithelial

Endocervical - single layer mucin-producin columnar cells

Question 6

Adequate sampling requires adequate sampling from where?

Answer 6

endocervical sampling

Question 7

Between HPV 16 and 18, the more common types to cause cancer, which causes squamous or adenocarcinoma more often?

Answer 7

HPV 16 –> Squamous cell carcinoma

HPV 18 –> Adenocarcinoma

Question 8

Low risk HPV types

Answer 8

6 and 11

Question 9

What are the biggest risk factors for HPV infection

Answer 9

Multiple sex partners**
Smoking*
Sexually active at early age
History of STDs
History of VIN and VAIN

Question 10

What does Gardasil 9 protect against

Answer 10

HPV 6, 11, 16, 18, (31, 33, 45, 52, 58)

Question 11

For a patient 21-29yrs, what type of screening test and frequency is recommended?

Answer 11

Pap test every 3 years

Question 12

For patients over 30, what is the recommended screening test and frequency?

Answer 12

Pap test and HPV screen every 5 years

or

Pap test every 3 years

Question 13

When do pap smears need to start?

Answer 13

age 21 (doesn’t matter if sexually active)

Question 14

Do you need to screen for HPV in patients 21-24?

Answer 14

NO!!!!! (can consider it at age 25)

Question 15

What should be included in adolescent patient encounters?

Answer 15

1. Contraceptive counseling
2. STI screening (urine sample)
3. HPV vaccination education/administation
4. Safe sex practices

Question 16

Describe the high risk patients who need to be screened every year for cervical cancer

Answer 16

1. HIV (every 6 months the year of diagnosis, then every year)
2. Immunocompromised
3. Hx of cervical cancer
4. History of CIN II/III
5. Exposure to diethylstilbestrol in utero

Question 17

When does screening for cervical cancer stop?

Answer 17

65

(Evidence of 3 prior consecutive negative results with cytology. but can’t have history of CIN II/III within last 20 years, Doesn’t apply to high risk pts.

Question 18

When does screening stop for patients with hysterectomy?

Answer 18

at time of surgery

if they have no history of cervical cancer and no history of CIN II/III within 20 years

Question 19

What is the next best step if doing a speculum exam and you see an abnormal cervical lesion?

Answer 19

biopsy! (pap smear is for screening, if you don’t see anything suspicious)

Question 20

If your patient is between 21-24, what is the next best step for finding atypical cells of undertermined significance?

Answer 20

repeat Pap smear/cytology in 1 year

Question 21

If your patient is 25+ and you find atypical cells, what is the next clinical step?

Answer 21

If abnormal pathology, need a reflex HPV DNA**

If HPV DNA is negative–> repeat co-testing in 3 years

If HPV DNA is positive–>colposcopy

Question 22

What is the next clinical step for a 21-24 year old patient with a low grade squamous intraepithelial lesion?

Answer 22

repeat Pap smear/cytology in 1 year (same as ASCUS)

Question 23

What is the next clinical step for a low grade squamous intraepithelial lesion in a patient 25+?

Answer 23

Colposcopy

or

Repeat Pap + HPV in 1 year if HPV DNA test is negative

Question 24

What is the next clinical step for a patient with high grade lesion (CIN II-AIS (adenoscarinoma insitu))?

Answer 24

Colposcopy

Question 25

If Negative cytology, no endocervical cells in 21-29?

Answer 25

repeat pap in 3 years :)

Question 26

If negative cytology, no endocervical cells and age 30+?

Answer 26

perform HPV DNA test.
-If + for HPV 16 or 18 –> colposcopy

or

Repeat cytology + HPV in 1 year
If -, repeat pap in 5 years

Question 27

IF an unsatisfactory cytology returns, when do you need to repeat pap?

Answer 27

2-4 months

Question 28

IF unsatisfactory cytology and HPV testing was positive in 30+ year old patient?

Answer 28

colposcopy

Question 29

IF unsatisfactory cytology and HPV negative in 30+ year old patient?

Answer 29

repeat pap in 2-4 months

Question 30

In patients under 24 with ASCUS or LSIL what is the management?

Answer 30

repeat PAP in 1 year

Question 31

In patients 25 and older, what is the management strategy if LSIL/CIN I and negative HPV?

Answer 31

Pap + HPV in 1 year

If that is negative–>Pap + HPV in 3 years

If that is abnormal–> colposcopy

Question 32

What is the management for CIN 1 persistent for 24 months?

Answer 32

LEEP (or contnue to monitor)

Question 33

LEEP indications for <24

Answer 33

1. persistent HSIL (high grade lesion) for 24 months
2. CIN II+
3. Unsatisfactory colposcopy

Question 34

When is LEEP indicated for 25+ patients

Answer 34

If colposcopy and HSIL at 12 or 24 months

If colposcopy done and HSIL/CIN II+

Question 35

When is LEEP contraindicated?

Answer 35

• pregnancy

- if invasion suspected

Question 36

Follow up after LEEP

Answer 36

Pap+HPV screen at 12 and 24 months
if negative–> retest in 3 years
if abnormal–>repeat colposcopy

Question 37

Prevalence of cervical squamous cell cancer versus cervical adenocarcinoma

Answer 37

cervical squamous cell cancer is falling

cervical adenocarcinoma is rising

Question 38

Cervical cancer clinical presentation

Answer 38

• Asymptomatic**

- Abnormal vaginal bleeding (post coital)*