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Women's Health > Cervical Screening and STI > Flashcards

Cervical Screening and STI Flashcards

1
Q

What questions do you want to ask about discharge?

A
  • Colour
  • Consistency
  • Blood
  • Duration
  • Timing - cyclical/constant (cyclical more likely period related)
  • Odour - infective cause
  • Previous hx
  • Sexual and menstrual hx
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2
Q

What are the infective causes of discharge?

A 
Non-sexually transmitted:
- Bacterial vaginosis
- Candida
Sexually transmitted:
- Chlamydia trachomatis
- Neisseria gonorrhoeae
- Trichomonas vaginalis
- HSV
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3
Q

What are non-infective causes of discharge?

A
  • Foreign bodies e.g. retained tampons, condoms
  • Cervical polyps and ectopy
  • Genital tract malignancy
  • Fistulae
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4
Q

What are post-coital bleeding questions?

A
  • Timing? Duration? Previous hx?
  • Dyspareunia
  • IMB
  • Menstrual hx
  • Smear hx
  • Any other symptoms
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5
Q

What is ectropion?

A

Cells that line the inside of the cervix grow on the outside - these are redder and more sensitive. Exam would show a reddened area around the external os.

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6
Q

What is bacterial vaginosis (BV)?

A

Refers to an overgrowth of anaerobic bacteria in the vagina. It is caused by a loss of the lactobacilli (produce lactic acid to keep pH <4.5) “friendly bacteria” in the vagina. It can increase the risk of women developing STIs.

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7
Q

What are examples of anaerobic bacteria that can cause BV?

A
  • Gardnerella vaginalis (most common)
  • Mycoplasma hominis
  • Prevotella species
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8
Q

What are risk factors for BV?

A
  • Multiple sexual partners
  • Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
  • Recent abx
  • Smoking
  • Copper coil
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9
Q

What is a classic presentation of BV?

A

Fishy-smelling watery grey or white vaginal discharge, half are asymptomatic

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10
Q

What investigations can be done for BV?

A
  • Speculum can be performed to confirm discharge, high vaginal swab and exclude other causes of symptoms
  • Vaginal pH with swab and pH paper (normal 3.5-4.5)
  • Charcoal vaginal swab - clue cells on microscopy, gardnerella vaginalis (epithelial cells from cervix with bacteria stuck inside
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11
Q

What is the managemet for BV?

A
  • Metronidazole - PO or vaginal gel
  • Clindamycin is an alternative but less optimal
  • Always assess risk of additional pelvic infections with swabs for chlamydia and gonorrhoea
  • Asymptomatic BV does not require treatment
  • Provide advice about measures to reduce the risk of further episodes e.g. avoid vaginal irrigation or cleaning with soaps
  • When prescribing metronidazole, advise patient to avoid alcohol for duration of treatment - n+v, flushing, sometimes shock and angioedema
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12
Q

What are complications of BV in pregnant women?

A
  • Miscarriage
  • Preterm delivery
  • Premature rupture of membranes
  • Chorioamnionitics
  • LBW
  • Postpartum endometritis
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13
Q

What is candidiasis?

A

Otherwise known as ‘thrush’, candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs e.g. during pregnancy or after treatment with broad-spectrum abx that alter flora.

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14
Q

What are risk factors for candidiasis?

A
  • Increased oestrogen (increased in pregnancy, decreased in pre-puberty and post-menopause)
  • Poorly controlled diabetes
  • Immunosuppression e.g. coricosteroids
  • Broad spectrum abx
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15
Q

What are the symptoms for candidiasis?

A
  • Thick, white discharge that does not typically smell
  • Vulval and vaginal itching, irritation or discomfort
  • More severe infection - erythema, fissures, oedema, dyspareunia, dysuria, excoriation
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16
Q

What is the management for candidiasis?

A
  • Candidiasis pH <4.5
  • Oral anti-fungal tablets i.e. fluconazole 150mg
  • Anti-fungal cream i.e. clotrimazole - into vagina with applicator (5g of 10% cream at night)
  • Anti-fungal pessary i.e. clotrimazole (500mg at night or 3 doses with 200mg total)
17
Q

What is dyskariosis?

A

This is not a histological diagnosis, it is a description of how abnormal the cells on the surface of the cervix appear from a smear test. It often corresponds with CIN i.e. mild dyskaryosis CIN1, moderate CIN2 etc., but smear cannot diagnose CIN. A biopsy must be taken to assess the depth of invasion and therefore the grade of CIN.
It is not cancer, abnormal cells often return to normal cells on their own, but if left untreated, these changes may develop into cancer in future.

18
Q

Describe low grade dyskariosis

A

Indicated by the presence of dyskariotic cells with a nuclear : cytoplasmic diameter ratio of <50%. Such cells may also show koilocytosis, indicated by the presence of a large sharply defined, clear perinuclear halo, surrounded by a condensed rim of cyanophilic or eosinophilic cytoplasm.

19
Q

Describe high-grade dyskariosis (moderate)

A

Dyskariotic cells are present with a nuclear : cytoplasmic diameter ratio of >50% but <75%. Distinguishing precisely between high-grade dyskariosis (moderate) and high-grade dyskariosis (severe) is difficult.

20
Q

Describe high-grade dyskariosis (severe)

A

Dyskariotic cells with nuclear : cytoplasmic diameter ratio >50% and probably >75%.
Basically the nucleus is outgrowing the cytoplasm, which shouldn’t happen and the bigger the nucleus is compared to the cytoplasm, the more concerning it is.

21
Q

What investigations should be done based on the smear result?

A
  • Borderline/mild dyskaryosis: test for HPV. If HPV -ve, go back to routine call. If +ve, refer for colposcopy.
  • Moderate/severe dyskaryosis: urgent colposcopy within 2 wks
  • Suspected invasive cancer: urgent colposcopy (within 2 wks)
  • Inadequate: repeat smear within 3 months (if 3 inadequate samples, assess by colposcopy)
22
Q

Why is HPV testing done?

A
  • HPV is the 1st line cervical screening tool
  • If a smear is negative for HPV, it is very unlikely that cervical cancer will develop so further screening at 3 or 5 years depending on the woman’s age
  • If the smear is positive for HPV, cytological exam is carried out on the sample. Follow up pathways are dependent on cytology.
23
Q

What is HPV?

A

HPV is the virus associated with genital warts, there are >100 types but some types are more associated with genital warts and some with cervical cancer. The ones associated with cancer are the ones more termed ‘high risk HPV’. HPV is sexually transmitted but can lay dormant without symptoms for many years. It is estimated that >75% of sexually active women have been infected with one or more type of HPV.

24
Q

How do you triage HPV?

A
  • Borderline or mild dyskaryosis > test for HPV. A positive result will be referred to colposcopy and negative will be returned to routine recall.
  • If HPV positive, but on cytology the cells are normal, then follow-up screen in 12 months time to check if the virus has cleared.
25
Q

How is HPV used to test for cure?

A

All women treated for CIN (usually with LLETZ) will have a smear test for HPV 6 months post-treatment:

  • If negative, no need for follow-up > return to routine recall
  • If positive > need follow-up colposcopy.
26
Q

What is done during colposcopy?

A

During colposcopy, when staining with acetic acid, areas of CIN are seen as white - pale patches around external os.

27
Q

What is Large Loop Excision of the Transformation Zone (LLETZ)?

A

Removal of the transformation zone with a loop diathermy device, usually under LA (cervical block). This method has a 90-95% cure rate.

28
Q

What is the cervical screening programme?

A
  • Smear tests offered every 3 years by NHS for women aged 25-49yrs and every 5yrs for ages 50-64yrs.
  • Abnormal cervical smear - refer for colposcopy. Then, either take biopsy or treatment given called LLETZ. Follow-up depends on what results show but typically involves a ‘test of cure’ smear test after 6 months.
29
Q

What is pelvic inflammatory disease (PID)?

A
  • Results from infection ascending upwards from vagina (cervicitis)
  • Most common causes are Neisseria gonorrhoea, chlamydia
  • If fallopian tubes involved - salpingitis
  • If uterus involved - endometritis
  • If abscesses formed - tubo-ovarian abscess (TOA)
  • Can extend to peritoneum - pelvic peritonitis
  • Rare cases - can spread to liver (Fitz-Hugh-Curtis syndrome) > perihepatitis (most often by chlamydia)
30
Q

What are symptoms of PID?

A
  • Cervicitis alone may not cause any symptoms of maybe increased discharge
  • PID - deep, lower abdo pain, especially during sex
  • TOA - pain localised to TOA area
  • Vaginal discharge (may be yellow/green)
  • Intermenstrual bleeding, post-coital bleeding
  • Systemic symptoms: fever, nausea, malaise
31
Q

What are the examinations and investigations for PID?

A
  • Palpate for abdo pain, vaginal exam to check for adnexal pain and cervical excitation
  • Endocervical swabs for gonorrhoea (culture) and chlamydia (PCR analysis)
  • High vaginal swabs (often negative)
  • FBC
  • LFTs (worried about hepatitis)
  • Pregnancy test (to rule out ectopic)
  • Transvaginal USS - if TOA or physical exam results unclear - will help rule out other ovarian pathology like torsion or ovarian cysts (as they give similar presentation to PID)
32
Q

What is the treatment for PID?

A
  • Often don’t wait for culture results to come back, as risk of extensive damage is high (low threshold for treating)
  • Diagnosis is based on symptoms and physical exam, not necessarily on swab results
  • Mild to moderate cases can be managed in community - outpatient management needs follow-up in 72hrs.
  • Analgesia and ceftriaxone IM 500mg single dose - followed by 14 day course of metronidazole (500mg BD) and either doxycycline (100mg BD) or ofloxacin.
  • If pregnant, then needs to be treated as inpatient
  • If TOA (tubo-ovarian abscess) - needs to be admitted and put on abx - may even need surgery if peritonitis/hepatitis has occurred
  • Patients partner needs to be tested for STD
  • No sexual intercourse until treatment completed
  • Full STI screen (HIV/Hep B/Hep C)
33
Q

What are complications of PID?

A
  • Fallopian tubes can become scarred and narrowed - hard for eggs to pass from ovaries to uterus (increased risk of ectopic pregnancy)
  • 1 in 10 women become infertile
  • Chronic pelvic pain
  • Tubo-ovarian abscess
  • Tubal factor subfertility
34
Q

What is toxic shock syndrome?

A
  • Tampons being left in for too long can get infected with bacteria - can cause toxic shock syndrome.
  • Rare but life-threatening - take tampon out, requires immediate admission > broad spectrum IV abx and fluids
  • Fever, flu-like symptoms, vomiting, diarrhoea, widespread sunburn like rash, dizziness, fainting
35
Q

What do you ask in a sexual history?

A
  • No. of sexual partners last 3 months
  • LMP/contraception
  • Previous STI
  • Date of last sexual contact - partner’s gender, anatomic sites of exposure, condom use
36
Q

What could show up as clear on an USS?

A
  • Pregnancy of an unknown location
  • Early pregnancy (too early to see signs of pregnancy in uterus)
  • Complete miscarriage (pregnancy tissue has passed completely so cannot visualise it on scan)
  • Ectopic pregnancy

Women's Health (19 decks)

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