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O&G > Cervical screening + STI > Flashcards

Cervical screening + STI Flashcards

1
Q

Hx taking: DISCHARGE - Questions to ask?

A
  • Colour
  • Consistency
  • Blood
  • Duration
  • Timing? cyclical/constant
  • Odour
  • Previous hx
  • Sexual hx
  • Menstrual hx
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2
Q

Hx taking: POST-COITAL BLEEDING - Questions to ask?

A
  • Timing?
  • Duration?
  • Previous hx?
  • IMB?
  • Menstrual hx?
  • Smear hx?
  • Any other symptoms?
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3
Q

ABNORMAL discharge: Differential Diagnosis

  • Physiological (3)
  • Infective (non-sexually transmitted) (2)
  • Infective (sexually transmitted) (4)
  • Non-infective (6)
A

Physiological:

  • Oestrogen related (puberty, pregnancy, COCP)
  • Cycle related (max. mid cycle + premenstrual)
  • Sexual excitement/intercourse

Infective (non-sexually transmitted):

  • Bacterial vaginosis
  • Candida

Infective (sexually transmitted):

  • Chlamydia trachomatis
  • Neisseria gonorrhoea
  • Trichomonas vaginalis
  • Herpes simplex virus

Non-infective:

  • Foreign bodies (e.g. retained tampons, condoms)
  • Cervical polyps and ectopy
  • Genital tract malignancy
  • Fistulae (urinary of faecal)
  • Allergic reactions
  • Atrophic vaginitis (often blood stained)
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4
Q

Large Loop Excision of the Transformation Zone (LLETZ): Definition

A

Removal of the transformation zone with a loop diathermy device, usually under local anaesthetic.

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5
Q

DYSKARYOSIS: Definition

A
  • Abnormal epithelial cell which may be found in a cervical sample.
  • Dyskaryosis is NOT a histological diagnosis.
  • It often corresponds with CIN - however a smear cannot diagnose CIN.
  • A biopsy must be taken to assess the depth of invasion and therefore grade of CIN.
  • Around 1:20 women will have some form of abnormal smear.
  • 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 the future.
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6
Q

CIN

A

Cervical intraepithelial neoplasia (CIN), also known as cervical dysplasia, is the abnormal growth of cells on the surface of the cervix that could potentially lead to cervical cancer.

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7
Q

STIs: Confidentiality

A

Confidentiality paramount:

  • GUM notes are kept separate from hospital notes.
  • Patient’s GP is not routinely informed of patients attendance
  • This is a requirement defined by statute in the Veneral Disease Act of 1917.
  • Assessment of competency should be undertaken if under 16 years old (Fraser competence)
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8
Q

Risk factors for STIs

A
  • Multiple partners (>2 in last year)
  • Concurrent partners
  • Recent partner change (in last 3 months)
  • Non-use of barrier protection
  • STI in partner
  • Other STI
  • Younger age (<25 yrs)
  • Involvement in the commercial sex industry
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9
Q

INCUBATION period - Testing for sexually transmitted infections

A

Test should be done at the time of presentation. Incubation period before tests for STIs become positive can give false negative after a single episode of sex:

  • Bacterial STIs 10-14 days
  • HIV/syphilis may be up to 3 months
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10
Q

CHLAMYDIA: Definition

A
  • Most prevalent sexually transmitted infection in the UK.
  • It is caused by Chlamydia trachomatis, an obligate intracellular pathogen.
  • Approximately 1 in 10 young women in the UK have Chlamydia.
  • The incubation period is around 7-21 days, although it should be remembered a large percentage of cases are asymptomatic.
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11
Q

CHLAMYDIA: Features

A
  • Asymptomatic in around 70% of women and 50% of men
  • Women: cervicitis (discharge, bleeding), dysuria
  • Men: urethral discharge, dysuria
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12
Q

CHLAMYDIA: Potential complications

A
  • Epididymitis
  • Pelvic inflammatory disease
  • Endometritis
  • Increased incidence of ectopic pregnancies
  • Infertility
  • Reactive arthritis
  • Perihepatitis (Fitz-Hugh-Curtis syndrome)
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13
Q

CHLAMYDIA: Investigations

A
  • Traditional cell culture is no longer widely used
  • Nuclear acid amplification tests (NAATs) are now the investigation of choice
  • Urine (first void urine sample), vulvovaginal swab or cervical swab may be tested using the NAAT technique
  • For women: the vulvovaginal swab is first-line
  • For men: the urine test is first-line
  • Chlamydia testing should be carried out two weeks after a possible exposure
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14
Q

CHLAMYDIA: Screening

A
  • In England the National Chlamydia Screening Programme is open to all men and women aged 15-24 years
  • The 2009 SIGN guidelines support this approach, suggesting screening all sexually active patients aged 15-24 years
  • Relies heavily on opportunistic testing
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15
Q

HERPES simplex virus: Definition

A
  • There are two strains of the herpes simplex virus (HSV) in humans: HSV-1 and HSV-2.
  • Whilst it was previously thought HSV-1 accounted for oral lesions (cold sores) and HSV-2 for genital herpes it is now known there is considerable overlap
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16
Q

HERPES simplex virus: Features

A
  • Primary infection: may present with a severe gingivostomatitis
  • Cold sores
  • Painful genital ulceration
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17
Q

HERPES simplex virus: Management

A
  • Gingivostomatitis: oral aciclovir, chlorhexidine mouthwash
    cold sores: topical aciclovir although the evidence base for this is modest
  • Genital herpes: oral aciclovir.
  • Some patients with frequent exacerbations may benefit from longer term aciclovir.
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18
Q

HERPES simplex virus: Pregnancy

A
  • Elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
  • Women with recurrent herpes who are pregnant should be treated with suppressive therapy and be advised that the risk of transmission to their baby is low
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19
Q

GONORRHOEA: Definition

A
  • Gonorrhoea is caused by the Gram-negative diplococcus Neisseria gonorrhoeae.
  • Acute infection can occur on any mucous membrane surface, typically genitourinary but also rectum and pharynx.
  • The incubation period of gonorrhoea is 2-5 days.
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20
Q

GONORRHOEA: Features

A
  • Males: urethral discharge, dysuria
  • Females: cervicitis e.g. leading to vaginal discharge
    rectal and pharyngeal infection is usually asymptomatic.

Local complications that may develop include urethral strictures, epididymitis and salpingitis (hence may lead to infertility). Disseminated infection may occur.

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21
Q

GONORRHOEA: Microbiology

A

Immunisation is not possible and reinfection is common due to antigen variation of type IV pili (proteins which adhere to surfaces) and Opa proteins (surface proteins which bind to receptors on immune cells)

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22
Q

GONORRHOEA: Management

A
  • Ciprofloxacin used to be the treatment of choice.
  • However, there is increased resistance to ciprofloxacin (around 36% in the UK) and therefore cephalosporins are now more widely used
  • There was a change in the 2019 British Society for Sexual Health and HIV (BASHH) guidelines.
  • Previously the first-line treatment was IM ceftriaxone + oral azithromycin.
  • The new first-line treatment is a single dose of IM ceftriaxone 1g (i.e. no longer add azithromycin).
  • If sensitivities are known (and the organism is sensitive to ciprofloxacin) then a single dose of oral ciprofloxacin 500mg should be given if ceftriaxone is refused (e.g. needle-phobic) then oral cefixime 400mg (single dose) + oral azithromycin 2g (single dose) should be used.
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23
Q

SYPHILIS: Definition

A
  • Syphilis is a sexually transmitted infection caused by the spirochaete Treponema pallidum.
  • Infection is characterised by primary, secondary and tertiary stages.
  • The incubation period is between 9-90 days.
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24
Q

SYPHILIS: Primary features

A
  • Chancre - painless ulcer at the site of sexual contact
  • Local non-tender lymphadenopathy
  • Often not seen in women (the lesion may be on the cervix)
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25
Q

SYPHILIS: Secondary features

A

Occurs 6-10 weeks after primary infection:

  • Systemic symptoms: fevers, lymphadenopathy
  • Rash on trunk, palms and soles
  • Buccal ‘snail track’ ulcers (30%)
  • Condylomata lata (painless, warty lesions on the genitalia)
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26
Q

SYPHILIS: Tertiary features

A
  • Gummas (granulomatous lesions of the skin and bones)
  • Ascending aortic aneurysms
  • General paralysis of the insane
  • Tabes dorsalis
  • Argyll-Robertson pupil
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27
Q

SYPHILIS: Congenital syphilis

A
  • Blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
  • Rhagades (linear scars at the angle of the mouth)
  • Keratitis
  • Saber shins
  • Saddle nose
  • Deafness
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28
Q

SYPHILIS: Investigations

A
  • Treponema pallidum is a very sensitive organism and cannot be grown on artificial media.
  • The diagnosis is therefore usually based on clinical features, serology and microscopic examination of infected tissue
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29
Q

SYPHILIS: Management

A
  • Intramuscular benzathine penicillin is the first-line management
  • Alternatives: doxycycline

N.B. The Jarisch-Herxheimer reaction is sometimes seen following treatment - fever, rash, tachycardia after the first dose of antibiotic. No treatment is needed other than antipyretics if required

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30
Q

TRICHOMONAS: Definition

A
  • Trichomonas vaginalis is a highly motile, flagellated protozoan parasite.
  • Trichomoniasis is a sexually transmitted infection (STI).
31
Q

TRICHOMONAS: Features

A
  • Vaginal discharge: offensive, yellow/green, frothy
  • Vulvovaginitis
  • Strawberry cervix
  • pH > 4.5
  • In men is usually asymptomatic but may cause urethritis
32
Q

TRICHOMONSA: Investigation

A

Microscopy of a wet mount shows motile trophozoites

33
Q

TRICHOMONAS: Management

A

Oral metronidazole for 5-7 days, although the BNF also supports the use of a one-off dose of 2g metronidazole.

34
Q

Human Papillomavirus (HPV): Definition

A

It has been known for a longtime that the human papilloma virus (HPV) which infects the keratinocytes of the skin and mucous membranes is carcinogenic.

There are dozens of strains of HPV. The most important to remember are:

  • 6 & 11: causes genital warts
  • 16 & 18: linked to a variety of cancers, most notably cervical cancer

HPV infection is linked to:

  • over 99.7% of cervical cancers
  • around 85% of anal cancers
  • around 50% of vulval and vaginal cancers
  • around 20-30% of mouth and throat cancers
35
Q

Human Papillomavirus (HPV): Features

A
  • Majority asymptomatic.
  • Painless lumps anywhere in the genitoanal area.
  • Perianal warts are common in the absence of anal intercourse.
36
Q

Human Papillomavirus (HPV): Testing

A

Testing for HPV has now been integrated into the cervical cancer screening programme. If a smear is reported as borderline or mild dyskaryosis the original sample is tested for HPV

  • if HPV negative the patient goes back to routine recall
  • if HPV positive the patient is referred for colposcopy
37
Q

Bacterial VAGINOSIS (BV): Definition

A

Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH.

Whilst BV is not a sexually transmitted infection it is seen almost exclusively in sexually active women.

38
Q

Bacterial VAGINOSIS (BV): Features

A
  • Vaginal discharge: ‘fishy’, offensive

- Asymptomatic in 50%

39
Q

Bacterial VAGINOSIS (BV): Diagnosis

A

Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present:
- Thin, white homogenous discharge
- Clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
- Positive whiff test (addition of potassium hydroxide results in fishy odour)

40
Q

Bacterial VAGINOSIS (BV): Management

A
  • Oral metronidazole for 5-7 days
  • 70-80% initial cure rate
  • Relapse rate > 50% within 3 months
  • The BNF suggests topical metronidazole or topical clindamycin as alternatives
41
Q

Vaginal CANDIDIASIS (Thrush):

  • Definition
  • Predisposing factors
A

Vaginal candidiasis is an extremely common condition which many diagnose and treat themselves. It is caused by a yeast-like fungus (90% Candida albicans, remainder other species)

Predisposing factors

  • Diabetes mellitus
  • Drugs: antibiotics, steroids
  • Pregnancy
  • Immunosuppression: HIV, iatrogenic
42
Q

Vaginal CANDIDIASIS (Thrush): Features

A
  • ‘cottage cheese’, non-offensive discharge
  • Vulvitis: dyspareunia, dysuria
  • Itch
  • Vulval erythema, fissuring, satellite lesions may be seen
43
Q

Vaginal CANDIDIASIS (Thrush): Investigations

A
  • A high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis
44
Q

Vaginal CANDIDIASIS (Thrush): Management

A
  • Options include local or oral treatment
  • Local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
  • Oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
  • If pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated
45
Q

Vaginal CANDIDIASIS (Thrush): Recurrent

A
  • BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
  • Compliance with previous treatment should be checked
    confirm initial diagnosis i.e. high vaginal swab, exclude differential diagnoses such as lichen sclerosus
    exclude predisposing factors (see above)
  • Consider the use of an induction-maintenance regime, with daily treatment for a week followed by maintenance treatment weekly for 6 months
46
Q

Pelvic Inflammatory Disease (PID): Definition

A

PID is infection of the upper genital tract.

47
Q

Pelvic Inflammatory Disease (PID): Causes

A
  • Ascending infection from endocervix (common)
  • Descending infection from organs e.g. appendix (rare)

Multiple causative organism:

  • Chlamydia trachomatis - the most common cause
  • Neisseria gonorrhoeae
  • Mycoplasma genitalium
  • Mycoplasma hominis
48
Q

Pelvic Inflammatory Disease (PID): Risk factors (6)

A
  • Age <25
  • Previous STIs
  • New sexual partner
  • Multiple sexual partners
  • Uterine instrumentation (e.g. surgical TOP, IUCD)
  • Post-partum endometritis
49
Q

Pelvic Inflammatory Disease (PID): Protective factors (3)

A
  • Use of barrier contraception
  • Levonorgestrel (LNG)
  • COCP
50
Q

Pelvic Inflammatory Disease (PID): Features

A
  • Lower abdominal pain
  • Fever
  • Deep dyspareunia
  • Dysuria and menstrual irregularities may occur
  • Vaginal or cervical discharge
  • Cervical excitation
  • Perihepatitis (Fitz-Hugh Curtis Syndrome) occurs in around 10% of cases. It is characterised by right upper quadrant pain and may be confused with cholecystitis
51
Q

Pelvic Inflammatory Disease (PID): Investigations

A
  • Screen for chlamydia and gonorrhoea
  • WCC
  • CRP
  • USS (if tubo-ovarian abcess suspected)
  • Laparoscopy (Gold standard) - however invasive and only used if diagnosis is uncertain.
52
Q

Pelvic Inflammatory Disease (PID): Management

A
  • Due to the difficulty in making an accurate diagnosis, and the potential complications of untreated PID, consensus guidelines recommend having a low threshold for treatment
  • Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
  • RCOG guidelines suggest that in mild cases of PID intrauterine contraceptive devices may be left in. The more recent BASHH guidelines suggest that the evidence is limited but that ‘ Removal of the IUD should be considered and may be associated with better short term clinical outcomes’
53
Q

Pelvic Inflammatory Disease (PID): Complications

A
  • Infertility - the risk may be as high as 10-20% after a single episode
  • Chronic pelvic pain
  • Ectopic pregnancy
  • Recurrent PID
  • Fitz-Hugh Curtis Syndrome
  • Tubo-ovarian abscess
54
Q

ACUTE pelvic pain: Hx

A
  • Pain (SOCRATES)
  • LMP
  • Contraception
  • Recent unprotected sexual intercourse (UPSI)
  • RF for ectopic pregnancy
  • Vaginal discharge/bleeding
  • Bowel symptoms
  • Urinary symptoms
  • Precipitating factors

N.B. Acute pelvic pain in a woman of reproductive age with a +ve pregnancy test is an ectopic pregnancy until proven otherwise.

55
Q

ACUTE pelvic pain: CAUSES overview

  • GYNAE causes (4)
  • Non-GYNAE causes
    • GI (6)
    • Urological (2)
A

GYNAE causes:

  • Early pregnancy
  • PID
  • Ovarian cyst accident
  • Adnexal pathology
  • Mittelschmerz
  • Pregnancy complications
  • Primary dysmenorrhoea
  • Acute excerbation of chronic pelvic pain
Non-GYNAE causes:
GI:
- Appendicitis
- IBS
- IBD
- Mesenteric adenitis
- Diverticulitis
- Strangulation of a hernia

Urological:

  • UTI
  • Renal/bladder calculi
56
Q

CHRONIC abdo pain: Definition

A

Intermittent or constant pelvic pain in the lower abdomen or pelvis of at least 6 months duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.

57
Q

CHRONIC abdo pain: GYNAE causes

A
  • Endometriosis
  • Adenomyosis
  • Adhesions
  • Pelvic venous congestion
58
Q

CHRONIC abdo pain: Non-GYNAE causes

  • GI causes (3)
  • Urological causes (3)
  • MSK causes (1)
  • Neurological causes (2)
A

GI causes:

  • IBS
  • Constipation
  • Hernia

UROLOGICAL causes:

  • Interstitial cystitis
  • Urethral syndrome
  • Calculi

MSK causes:
- Fibromyalgia

NEUROlogical causes:

  • Nerve entrapments
  • Neuropathic pain
59
Q

CHRONIC abdo pain: Treatments (4)

A
  • Analgesia
  • Hormonal treatments
  • Complementary therapy
  • Surgery
60
Q

Ovarian vs. Endometrial cancer

A

Ovarian cancer: tends to present late

Endometrial cancer: tends to present early

61
Q

CERVICAL cancer: Definition

A

Around 50% of cases of cervical cancer occur in women under the age of 45 years, with incidence rates for cervical cancer in the UK are highest in people aged 25-29 years, according to Cancer Research UK. It may be divided into:

  • Squamous cell cancer (80%)
  • Adenocarcinoma (20%)
62
Q

CERVICAL cancer: Features

A
  • May be detected during routine cervical cancer screening
  • Abnormal vaginal bleeding: postcoital, intermenstrual or postmenopausal bleeding
  • Vaginal discharge
63
Q

CERVICAL cancer: Risk factors

A

Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Risk factors for HPV include:

  • Early first sexual experience
  • Multiple partners
  • Non-barrier contraception

Other risk factors include:

  • Smoking
  • Human immunodeficiency virus
  • Early first intercourse, many sexual partners
  • High parity
  • Lower socioeconomic status
  • Combined oral contraceptive pill*
64
Q

CERVICAL cancer: Mechanisms of HPV causing cervical cancer

A
  • HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively
  • E6 inhibits the p53 tumour suppressor gene
  • E7 inhibits RB suppressor gene
65
Q

Cervical cancer SCREENING: Definition

A

The UK has a well established cervical cancer screening program which is estimated to prevent 1,000-4,000 deaths per year. The main aim of cervical screening is to detect pre-malignant changes rather than to detect cancer.

It should be noted that cervical adenocarcinomas, which account for around 15% of cases, are frequently undetected by screening.

66
Q

Cervical cancer SCREENING: Who is screened and how often?

A

A smear test is offered to all women between the ages of 25-64 years:

  • 25-49 years: 3-yearly screening
  • 50-64 years: 5-yearly screening

Cervical screening cannot be offered to women over 64 (unlike breast screening, where patients can self refer once past screening age)

Special situations:

  • Cervical screening in pregnancy is usually delayed until 3 months post-partum unless missed screening or previous abnormal smears.
  • Women who have never been sexually active have very low risk of developing cervical cancer therefore they may wish to opt-out of screening
67
Q

Cervical cancer SCREENING: How is it performed?

A

There is currently a move away from traditional Papanicolaou (Pap) smears to liquid-based cytology (LBC). Rather than smearing the sample onto a slide the sample is either rinsed into the preservative fluid or the brush head is simply removed into the sample bottle containing the preservative fluid.

Advantages of LBC includes

  • Reduced rate of inadequate smears
  • Increased sensitivity and specificity

It is said that the best time to take a cervical smear is around mid-cycle. Whilst there is limited evidence to support this it is still the current advice given out by the NHS.

68
Q

CERVICAL cancer: Definition

  • Cytology
  • Colposcopy
  • Histology
A
  • Cytology: study of individual cells of the body.
  • Colposcopy: medical diagnostic procedure.
  • Histology: study of whole human tissue.
69
Q

CERVICAL cancer: Cytology

A
  • Primary screening tool for cervical malignancy.
  • NICE recommends liquid based cytology (LBC).
  • Dyskaryosis = cytological term.
  • Abnormal cytology is further assessed by colposcopy.

Cytological markers seen with abnormal smears:

  • Increased nuclear/cytoplasmic ratio.
  • Shape of the nucleus (poikilocytosis - abnormal shape)
  • Density of the nucleus (koilocytosis - abnormal density)
  • Inflammation, infection and mitoses.
70
Q

CERVICAL cancer: Colposcopy

A

Involves the magnified (6-40x) visualization of the transformation zone after application of 5% acetic acid or Lugol’s iodine.

Upon identification of colposcopic abnormalities either:

  • Direct punch biopsy to gain histological confirmation
  • Definitive treatment ‘see and treat’

Adequate colposcopic assessment:

  • Visualization of the entire transformation zone
  • Any lesion identified must be completely seen.
71
Q

CERVICAL cancer: Histology

A

CIN is a histological diagnosis and is characterised by loss of differentiation and maturation from the basal layer of the squamous epithelium upwards.

  • Bottom 1/3 = CIN I
  • Bottom 2/3 = CIN II
  • Full thickness = CIN III
72
Q

CIN: Management

A

CIN can be managed conservatively, by excision, by destruction, or rarely by hysterectomy.

Management depends on the grade of CIN and patient preference, but excision is the preferred treatment modality. This is usually by LLETZ.

73
Q

LLETZ:

  • Definition
  • Benefits
A

LLETZ: (Large Loop Excision of the Transformation Zone) - procedure used to treat high grade cervical dysplasia discovered on colposcopic examination.

Benefits:

  • Easy and safe
  • Usually possible with local anaesthetic
  • Tissue available for histology + assessment of excision margin.
74
Q

LLETZ: Complications

  • Short term (4)
  • Long term (2)
A

Short term:

  • Haemorrhage
  • Infection
  • Vaso-vagal reaction
  • Anxiety

Long term:

  • Cervical stenosis
  • Cervical incompetence + premature delivery

O&G (13 decks)

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