Cervical Disorders - Exam 3 Flashcards
What are the 2 MC causes of cervicitis?
gonorrhea and chlamydia- 2 MC
trich, mycoplasma, BV, and yeast
What are the 2 MC viruses that cause cervicitis? What are chronic causes of cervicitis?
HSV and HPV
pessary, contraceptive devices, tampons, spermicides
What are 2 complications of cervicitis?
PID
passing infection to newborn during delivery
What is the main presenting symptom in cervicitis? What are 4 additional s/s?
DISCHARGE but may be asymptomatic!! - discharge is main presenting symptom
vaginal bleeding: postcoital or intermenstrual
cervical tenderness
salpingitis: pelvic pain, fever, chills, abnormal menses
**Draw the chart that differentiates gonorrhea/chlamydia, candidiasis, trich, bacterial and HSV from each other
What am I?
chlamydial cervicitis
What am I? What dx?
strawberry cervix commonly found in trich
cervical candidiasis
What are the difference between acute and chronic cervicitis in terms of presentation?
have all the same s/s and can still be asymptomatic!
discharge is still MAIN presenting symptoms but chronic is LESS than acute
What is the pap smear/colposcopy finding in trich?
“double hairpin capillaries”
What does a large number of PMNs or leukocytes indicate on pap smear/colposcopy?
acute cervicitis
How can trich and yeast be identified?
directly on microscopy
What am I?
HPV infected cervical cell
What am I?
normal cervical epithelial cell
What is the treatment for gonrrhea/chlamydia, candidiasis, trich, bacterial, HSV, salpingitis, HPV?
What is the prevention for cervicitis?
avoid getting an STI with abstinence or barrier method
remove cervix if having a hysterectomy
What is cervical insufficiency? Up to ____ weeks. What is the end result?
Painless cervical shortening or dilation in the second or early third trimesters
up to 28 weeks
results in preterm birth
What are risk factors for cervical insufficiency?
Hx of cervical insufficiency
Hx of cervical injury, surgery, or conization
DES exposure
Anatomic abnormalities
What are the s/s of cervical insufficiency? When does it classically occur?
significant cervical dilation (2+ cm) with minimal contractions
Classically in the second trimester
In cervical insufficiency at ____ cm dilated, what can occur?
4cm +
active contractions or ROM may occur
How is cervical insufficiency diagnosed?
US at 14-16 wks or later to evaluate internal anatomy of lower uterus and cervix
What is the early prediction of cervical insuffiency?
there is NOT one
Prior to pregnancy and in 1st trimester - no way to determine if cervix will eventually be incompetent
**What are the 4 stages of cervical insufficiency?
T, Y, V, U
What is the tx of choice for cervical insufficiency? Describe it. What 2 things do you need to confirm first?
Cervical Cerclage - typical treatment of choice
Purse-like ring of stitch around the cervix
- Confirm viable intrauterine pregnancy prior to placement!!!
- culture for gonorrhea, chlamydia, group B strep and tx if needed
What are the CI to cervical insufficiency?
ROM (rupture of membranes)
infection
fetal demise
____ is used for supplemental therapy in cervical insufficiency. When should you start? Continue until _____
vaginal progesterone or IM/SC hydroxyprogesterone caproate
start around 16 weeks and continue until 36+ weeks
can due before or after surgical cerclage to promote cervix staying closed
_____ are often asymptomatic cystic structures on the surface of the cervix. What will the pt complain of?
Nabothian Cysts
patient may feel a lump when placing a cervical cap or diaphragm
What am I?
What is the tx?
nabothian cysts
BENIGN!! no tx necessary and usually will resolve spontaneously
What am I?
nabothian cysts
What are the different classifications of cervical dysplasia? What classifications need to be treated? What are the 2 exceptions?
Always treat CIN II and III except:
- Pregnant women (wait until postpartum period)
- CIN II in adolescents (high spontaneous regression chance, lower cancer risk)
How common is cervical dysplasia? When does CIS incidence peak? What age range has cervical cancer peak incidence?
1.05-13.7%
CIS peak incidence - 25-35 years
Cervical cancer peak incidence - 40+ years
What will cervical dysplasia look like on PE?
often NO signs and cervix will look completely normal on PE
Diagnosis usually made by abnormal routine cytology smear
What are risk factors for cervical dysplasia? **What is the super highlighted one?
Multiple sexual partners
Early onset of sexual activity
High-risk sexual partner
HPV infection THIS IS THE MAJOR ONE
History of sexually transmitted infection
Immunosuppression (including HIV/AIDS)
Multiparity
Long term oral contraceptive pill use
HPV present in ____ of all CIN lesions and in _____ of all invasive cervical cancers
> 80%
99.7%
What are the high risk types of HPV? Do most HPV+ women develop CIN or cervical cancer?
High-risk types - 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68
NO, they do NOT develop
_____ have a negative synergistic effect with HPV. What is the cervical dysplasia prevention?
cigarettes
HPV vaccination!!!!
How effective is the HPV vaccination against preventing CIN II or worse?
93-100% and is good for prophylactic tx NOT therapeutic
What age should you start screening for cervical cancer? What is the recommendation throughout a pt’s lifetime?
starting at 21 years old
Ages 21-29 - Pap every 3 yrs
Ages 30-65 - Pap every 3 yrs OR Pap+HPV every 5 yrs
Age > 65 - Stop screening if…
no history of 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)
What 4 factors automatically disqualifies a pt from following the recommended cervical cancer screening guidelines? What are the recommendations for this subset of pts?
hx of cervical cancer
HIV+
immunodeficient
DES exposure
May still need yearly Paps even after hysterectomy
What is the grading system called for abnormal pap smears? What are the 5 different options? What do they each stand for?
Bethesda system
- ASC-US: Atypical Squamous Cells undetermined significance
- ASC-H: Atypical Squamous Cells cannot exclude high-grade lesion
- LGSIL: Low-grade Squamous Intraepithelial Lesion
- HGSIL: High-grade Squamous Intraepithelial Lesion
- AGC: Atypical glandular cells
What Bethesda system grade corresponds to CIN I? CIN II and CIN III?
LGSIL - > CIN I
HGSIL -> CIN II and CIN III
What are 2 different types of atypical glandular cells? What do each mean? What are they associated with?
Glandular cells - normal components of the endocervix; secrete mucus
Atypical - do not match normal glandular cells but are not definitely cancer
Associated with adenocarcinoma of endocervix or of endometrium
What are the 3 different options for the tx of an ASC-US pap result?
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
If choosing to repeat serial cytology in ASC-US, what needs to be treated before repeat testing?
Before repeat smear - treat underlying conditions
Hormones if atrophic vaginitis
Antimicrobials for infections
Which Bethesda system grade treatment is straight to colposcopy?
LSIL, HSIL, ASC-H, AGC
What are the procedure steps for a colposcopy? Can you take bx if pregnant?
3-5% aqueous acetic acid solution applied
+/- Lugol’s solution (iodine/iodide)
Illuminated low-power magnification to inspect cervix, vagina, vulva, anal epithelium
bx of abnormal areas and curette or brush of endocervical canal
+No endocervical sampling done if pregnant+
What is Lugol’s solution? When is it used? Does HPV lesion take up the solution well?
iodine/iodide solution sprayed during colposcopy to help visualize suspicions areas
NO!! HPV does not uptake the iodine solution well
What are 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
What does coarse punctation combined with acetowhite lesion indicate?
more than likely a high grade cancer
aka NOT a good finding
What is the best way to perform a colposcopy direct bx?
do a slow smooth bx motion for LESS pain
What is the management for a CIN I lesion after colposcopy?
expectant management due to high chance of spontaneous regression
What is the management for CIN II/III after colposcopy?
surgical therapy!!
either ectocervix-only lesion -> use cryotherapy, laser ablation or superficial LEEP
OR
deeper LEEP or cone bx
When would you want to use a deeper LEEP/cone bx?
lesion extends to endocervical canal
endocervical curettage shows dysplasia or other abnormality
major discrepancy between cytology and colposcopy
Draw the summary chart of pap smear results and follow-up tests and tx
Which cervical dysplasia treatment can be done in the office without anesthesia? What substance? What are the margins?
Cryotherapy
Nitrous oxide or carbon dioxide - supercooled probe
Activated until blanching extends 7 mm beyond probe in all directions
What are the pros and cons of cryotherapy?
pros: easy to use, low costs, available, low risk of complications
cons: f/u colposcopy can be unsatisfactory, only appropriate for superficial lesions
What are the SEs of cryotherapy?
mild uterine cramping, copious watery discharge for several weeks
How does the carbon dioxide laser work? When is it used?
Destroys tissue with narrow zone of injury by vaporizing tissue to a depth of at least 7mm
Used for ablation of transformation zone or as a tool for cone biopsies
What are the pros and cons of a 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
When are LEEP procedures used? What is the general principle?
Frequently used for CIN II and CIN III
Small fine wire loop attached to electrosurgical generator and used to excise part of the cervix
Do you need anesthesia for LEEP procedure?
yes, done in the office under local anesthesthesia
What are the cons of the LEEP?
increased risk of premature delivery in pregnancy and do NOT have clean edges
What is the general principle of the cold knife conization?
Excision of cone-shaped portion of cervix using a scalpel and can be individualized to accommodate lesion
What are the pros and cons 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)
aka LOTS of cervical tissue is cut away with this procedure and usually considered 2nd line!
How successful are the treatment rates for cervical dysplasia? Treatment reduces risk of cervical cancer by ____. But still have higher risk of cervical cancer than the general population for at least ____
80-90% successful treatment rates
95%
20-25 years
What is the average age of cervical cancer diagnosis? Over ___ with early cancer can be cured
51 but can occur as young as 20s or during pregnancy
95%
HPV DNA found in ___ of all cervical carcinomas.
____ most common; HPV- __ and HPV- __
99.7%
HPV-16 then 18 then 45
70-75% of cervical cancer is ______ carcinoma
20-25% are _____
3-5% are ____
70-75% squamous cell (think ectocervix)
20-25% - adenocarcinomas (think endocervix)
3-5% - adenosquamous carcinomas
What is the MC symptom for cervical cancer? Name some additional ones? _____ is frequently present
MC symptom - abnormal vaginal bleeding
Bloody leukorrhea, scant spotting, frank bleeding, postcoital
Leukorrhea
What would indicate a fistula formation that is associated with cervical cancer? What are some late stage findings?
Involuntary loss of urine or feces through vagina
weakness, weight loss, anemia, pelvic pain
Pain is usually unilateral, may radiate to hip or thigh
What is the difference between endophytic and exophytic cervical signs? When are they seen?
Endophytic - barrel-shaped enlargement of cervix
Exophytic - friable, bleeding, cauliflower-like lesions (think outer into tissue)
typically associated with later stage cervical cancer
What is this picture demonstrating?
in cervical cancer eventually - parametrial involvement may lead to nodular thickening of the uterosacral ligaments with fixation of cervix
Can cancer still be present despire negative cytology?
YES!! so need to bx any suspicious lesion
What should you do if biopsy reveals CIS or if colposcopy is negative but Pap is significantly abnormal? What should you do if you find gross evidence of invasive cancer?
conization
conization not indicated; simple biopsy only
What is the tx for cervical cancer?
radical hysterectomy and lymphadenectomy
+/- radiation and chemotherapy
Advanced - chemotherapy is usually palliative, not curative
What are the prognostic factors in cervical cancer?
stage
lymph node status
tumor volume
depth of invasion
lymphovascular invasion
What is the 5 year survival rate of pts with less advanced cervical cancer? later disease (+ lymph nodes)?
less advanced: 88-96% 5-year survival rates
later disease: 64-73% 5-year survival rates
