cervical disorders Flashcards
What is a Nabothian cyst
Benign cyst that forms when columnar (glandular) epithelium is covered by squamous epithelium (retain glandular material)
Yellow or transluscent filling
Hoe do you diagnose and treat a nabothian cyst
Usually found incidentally on speculum exam
excision not required
What are cervical polyps
benign polyps, <3cm, likely 2/2 chronic inflammation of cervical canal
Cervical polyps can cause
post-coital bleeding or abnormal uterine bleeding
How do you treat cervical polyps
If symptomatic, polypectomy
What is normal cervical histology
Ectocervix: stratified squamous
Transformation zone: squamo-columnar junction (metaplasia)
Endocervical canal: mucin producing columnar
What does an adequate cervical sample include
endocervical tissue
What is cervical ectropion
normal variation, endocervical canal becomes everted
What is the pathophys of HPV
- virus enters cervical epithelium through microlacerations (2/2 intercourse)- TZ is very susceptible to HPV
- HPV infects basal layer and only local cells
- Virus stays latent for mo-yrs (until host cant fight anymore, or, a trigger)
- Mature basal epithelial cells travel away from BM, to surface
Which strains of HPV cause CIN
HPV 16: SCC
HPV 18: adenocarcinoma (many have HSIL as well)
What strains of HPV can block the protective apoptic process
HPV E6 and E7
Low risk HPV strains are
6 and 11
Nearly half of all HPV patients are (age)
15-24
RF for HPV infection are
Multiple sexual partners!!! Smoking immunosupresison early onset sex Hx STD long term OCP use (estrogen receptors on HPV gene) Hx VIN/VaIN
What is the HPV vaccine
Gardasil 9- protects against 6, 11, 16, 18, 31, 33, 45, 52, 58
ONLY US option
*still need pap smear based on age guidelines
How do you dose Gardasil 9
<15: 2 doses, 0 and 6-12 months
15+: 3 doses, 0, 1-2, and 6 months
How do you perform a pap smear
Thin prep or Surepath
insert into cervix, rotate 180
What is the HPV DNA test
Cervista, or Hybrid Capture high risk HPV
At what ages do you perform PAP smear testing
21 y/o (no matter onset of sex) - 65 y/o, every 3 years
NO HPV testing 21-24
(these guidelines do not apply to high risk pops, ex. immunocompromised)
When do you begin co-testing for HPV
30+ y/o, every 5 years
NOT indicated if s/p hysterectomy
Why not screen for cervical cancer with PAP before 21?
It does NOT reduce the rate of cervical cancer
- 1% of cervical cancer occurs prior to 20 y/o
- No pap unless high risk!!
Who don’t we screen for HPV in young women
You acquire HPV shortly after intercourse, but almost all cases clear w/in 1-2 yrs WITHOUT neoplastic change
-early screening can lead to anxiety, higher expenses, and overuse of follow up procedures
What SHOULD adolescent encounters include
contraceptive counseling
STI screening (urine sample, no speculum if ASx)
HPV vaccine education/admin
Safe sex practices
For women 21-29, screening includes
Cytology alone q3 years
NO HPV testing
For women 30-64, screening includes
Cytology + HPV DNA testing q5 years
or
Cytology alone q3 years
What pts are high risk for developing cervical cancer (yearly PAP)
HIV + immunocompromised Hx cervical cancer Hx CIN 2/3 Exposure to DES from mom
How do you screen HIV + women
screen q6 months year of diagnosis
screen q1 year after first year
*start screening at whatever age the diagnosis is
When do you stop screening for cervical cancer (not high risk obvs)
at 65 if in the past 10 years: 3 consecutive negative cytology alone 2 consecutive negative Co-testing results Most recent test w/in 5 years NO Hx of CIN w/in 20 years
What screening should you do if a woman >65 y/o reports a new sexual partner
TRICK question; None!
don’t resume screening even if she has a new partner
When does screening stop in a woman w/ a hysterectomy (w/ cervix removed)
at time of surgery, if for a benign disease
and NO Hx of CIN 2 w/in 20 years
-If you had a hysterectomy for a sketch reason, still need to swabvaginal cuff and wall
**What do you do if on speculum exam you note an ABNORMAL cervical lesion
BIOPSY!!!!!!
any abnormal lesion needs to be biopsied, NOT pap smeared
a PAP is screening tool. Biopsy is diagnostic!
What is ASC-US
Atypical Cells of Underetmined Significance
They dont look that bad, they are the least worrisome pathologic finding
What causes ASC-US, if not HPV
Chlamydia trachomatis
Herpes simplex
Vulvovaginal atrophy
What is LSIL
Low grade Squamous Intraepithelial Lesion
What is HSIL
High grade Squamous Intraepithelial Neoplasm
Assume HPV is present!!
Does HSIL with negative HPV mean you are in the clear
NO- it carried a 29% 5 year risk for CIN 3+
That is why you need Colposcopy immediately for HSIL
What does a negative cytology with no endocervical cells indicate
You did not get an adequate sample, you only got EXOcervical cells
What does Unsatisfactory cytology indicate
insufficient squamous component; HPV test can be falsely negative
Persistently (+) HPV test (2x) is associated with
21% chance that CIN 2-3 will persist in 36 months
What is CIN I
Lesion involving lower 1/3 of epithelial lining
typically regresses in 12 months
What is CIN II
Lesion involving lower 2/3
43% regress, 35% persist
What is CIN III
Lesion involving >2/3 epithelial lining
32% regress, 56% persist
Explain satisfactory vs unsatisfactory colposcopy results
Satis: completely visualize transformation zone
Unsatis: incomplete visualization of transformation zone. Have to perform endocervical curettage
What is a colposcopy
apply 5% acetic acid
magnified view of the cervix
Biopsy epithelium that turns white (leukoplakia, ulceration, punctation, mosaicism, atypical vessels)
What is a LEEP
Loop Electrosurgical Excision Procedure (aka cauterizing);
High electrical current rapid heating of tissue (steam envelope surrounds wire vaporizing adjacent tissue)- send tissue to patho
When is a LEEP contraindicated
if invasion is suspected
glandular abnormality on PAP
Patient is pregnant
LEEP has replaced
Laser surgery in the treatment if CIN
Follow up for LEEP includes
avoid heavy lifting, sex, douching, tampon or cream use for 4 weeks
May have malodorous discharge for 2-3 wewks
First menses after LEEP may be heavier 2/2 partially removing endocervical canal
Side effects of LEEP include
Bleeding
Infection
Cervical obliteration, incompetence, stenosis
Pre-term delivery
What follow up testing is required after LEEP
Co-testing at 12 and 24 months
If you have (+) margins after LEEP, repeat cytology and EEC at 4-6 months
If you have persistent CIN2 after LEEP, repeat LEEP, or hysterectomy
Mean age of cervical cancer diagnosis is
48 years old
What are the types of cervical cancer
Squamous (MC HPV 16): prevalence falling. 3mm or less is microinvasive. >3 is invasive
Adenocarcinoma (MC HPV 18): prevalence rising. endocervical, endometrioid, clear cell, adenoid cystic
How does cervical cancer present
Asymptomatic!
**Abnormal vaginal bleeding (cervix is friable)
post-coital bleeding
unilateral pelvic pain with radiation to hip/thigh (mets)
Vaginal discharge (watery, mucoid, purulent, malodorous)
