Cervix And Uterus Problems (Lauren 🌭) Flashcards
1
Q
When you contract HPV, do you start having abnormal Pap smears right away?
A
No, the virus remains latent for awhile and for some reason it becomes active and thats when it starts causing problems
2
Q
If you got a hysterectomy for endometriosis or fibroids or something, when should you stop doing Paps?
A
Right then and there
3
Q
When should you start screening women for cervical cancer?
A
AGE 21
**
4
Q
What are the surgical options for Adenomyosis?
A
Hysterectomy (definitive treatment)
Uterine Artery Embolization
Endometrial ablation (WORST option. They’re gonna have more pain afterward and youre just gonna have to do a hysterectomy anyways)
5
Q
What is the ONLY modifiable risk factor for HPV, CIN, and VAIN?
A
Smoking
6
Q
What is the tumor marker in endometrial cacner?
A
CA-125
She barely talked about this
7
Q
Why does Depot Lupron help for endometriosis?
A
It shuts off the ovaries and kills off any microscopic cells by cutting off their estrogen and progesterone supply
8
Q
What is a “Satisfactory” vs “Unsatisfactory” colposcopy?
A
Satisfactory: they could see the entire transformation zone
Unsatisfactory: couldn’t see the whole TZ, so they need to do an endocervical curettage (ECC)
9
Q
What is a LEEP?
A
Loop Electrosurgical Excision Procedure
They slice out any lesions and send it to pathology
10
Q
What is the risk of hysteroscopy?
A
Fluid overload and hyponatremia
All that fluid you blow into the uterus can flow out the Fallopian tubes
11
Q
What are the 4 classifications of endometrial hyperplasia?
A
Simple hyperplasia without atypia
Complex hyperplasia without atypia
Simple atypical hyperplasia
complex atypical hyperplasia
12
Q
What is the clinical presentation of Adenomyosis?
A
Menorrhagia
Dysmenorrhea
Pelvic pain
Hx of prior uterine surgery
13
Q
How do you treat hyperplasia with atypia?
A
Hysterectomy if they’re done having kids
Progesterone if they still want kids. (Mirena IUD or Megace)
14
Q
Whyyyy do they put vinegar on your cervix when they do a colposcopy?
A
Causes HPV-infected cells to turn white and they can see the exact spots they need to biopsy
“Acetowhite epithelium”
15
Q
At what age should you stop doing Paps?
A
Age 65
16
Q
Are prophylactic HPV vaccines having a good effect on women’s health
A
They sure are!
Reductions in CIN III, Colposcopy, Treatments, and cervical cancer!
17
Q
Unopposed ________ leads to endometrial hyperplasia and atypia
A
Estrogen
18
Q
Endometrial ablation is used to treat __________
A
Menorrhagia
19
Q
What is a D+C Hysteroscopy and why would you do one instead of endometrial biopsy for the workup of endometrial hyperplasia?
A
It is a full thickness sample of the the entire uterus that is done while the patient is under anesthesia.
Done if lining is too thick to rely on EMB results, cervical stenosis, or EMB gave you insufficient sample
20
Q
What effect does progesterone have on the endometrium?
A
It has antiproliferative effects causing shedding of the endometrial lining.
21
Q
What will you find on physical exam of a woman with endometriosis?
A
Tenderness at posterior cul-de-sac
Fixed or Retroverted uterus (secondary to adhesions. Endometriosis is an adhesive process)
Adnexal masses or tenderness
22
Q
What do you need to do if you suspect endometrial hyperplasia?
A
Pelvic exam
Pelvic ultrasound to assess thickness
Endometrial Biopsy or D+C Hysteroscopy
23
Q
Why don’t we do Pap smears in women under 21?
A
Because at that age almost ALL of them will clear the virus before it causes any problems.
24
Q
What is the BEST test we have to screen for cervical cancer?
A
Pap smear with HPV testing
25
What kinds of labs could be done to diagnose endometrial cancer?
CBC
Endometrial Biopsy or D+C
Transvaginal ultrasound
Pap smear (not specifically for screening for endometrial cancer, but it might get picked up)
CA-125
(This is probably not on the test)
26
Which two types of surgeries for uterine fibroids will preserve fertility/ability to safely get pregnant?
Myomectomy
Hysteroscopy
27
How will the lab report abnormal **biopsy** results?
CIN I, II, III
28
What are the 2 broad Types (not classifications) of endometrial cancer, and what are the main points of each one?
Type I: caused by estrogen. Good prognosis due to well-differentiated tumors.
Type II: has nothing to do with estrogen. Poor prognosis due to poorly-differentiated tumors
29
What does it mean if your Pap comes back “HSIL” or “ASC-H”
“High Grade”
You can assume you have HPV
Lesions would probably be CIN II/III or AIS if you did a biopsy
30
How will women with endometrial cancer present?
Abnormal bleeding, ESPECIALLY post-menopausal bleeding
Cramping, back pain
Weight loss
Dyspareunia
31
What are the possible complications of LEEP?
Bleeding
Infection
Cervical incompetence or stenosis
Pre-term delivery (baby falls out of your now-thinner cervix)
32
What kind of imaging can be done for uterine fibroids?
Transvaginal ultrasound*****
Saline-infused Sonohystogram- filling uterus with water and then doing an ultrasound. For submucosal fibroids only
Hysteroscopy- camera into uterus. Submucosal fibroids only. Done in OR
33
What are the risk factors for endometrial hyperplasia?
OBESITY OBESITY 🐖 OBESITY
Early menarche
Late menopause
Never having kids
Tamoxifen (increased estrogen receptors in uterus)
Unopposed estrogen replacement therapy
Diabetes
PCOS
Hx of breast or ovarian cancer
Pelvic radiation
Lynch Syndrome (HNPCC)
*****OBESITY WAS IN RED***
34
Adenomyosis is associated with ________
Prior surgery on the uterus (C-section or myomectomy)
35
What are fibroids made of?
Collagen, smooth muscle and elastin wrapped up in a nice pseudocapsule
36
Why does it matter if you have a transient vs a persistent HPV infection?
Persistently positive HPV test is associate with a pretty good chance that you’ll have CIN II/III within 3 years
(Probably not on test)
37
Cervical cancer is the ONLY cancer that is staged (clinically/surgically)
Clinically
38
Uterine Artery Embolization preserves ________ not _______
Uterus
Fertility
39
What are your options for screening women age 30-64 for cervical cancer?
Cytology plus HPV testing q 5 years
OR
Cytology alone q 3 years
OR
HPV alone q 5 years
40
For women age 21-29, what do you need to do to screen them for Cervical cancer?
Cytology every 3 years
Do NOT do HPV testing
41
After a myomectomy, a patient MUST avoid:
1.
2.
Pregnancy for 3-6 months
Vaginal deliveries forever
(Uterus will rip open and you’ll die)
42
What are the 2 types of cervical cancer?
Squamous Cell (most common but prevalence is declining)
Adenocarcinoma (prevalence is rising)
BOTH are associated with HPV 16 and 18 in most cases
43
When does endometriosis cause pain?
Premenstrual****
44
If we start screening women before age 21, will it reduce their rate of cervical cancer?
NO
45
What are the surgical procedures available for uterine fibroids?
Myomectomy
Hysteroscopy
Endometrial ablation
Uterine Artery Embolization
46
Hysteroscopy is a nice little outpatient procedure that is only performed on __________ fibroids
Submucosal
47
Who is considered at HIGH RISK for developing cervical cancer and needs a Pap every year even before age 21?
HIV+
Immunocompromised
History of cervical cancer
History of CIN II/III
Exposure to DES in utero (removed from market in 1970)
48
How would you detect uterine fibroids when you do a pelvic exam?
Uterus would feel all big and lumpy on bimanual exam
49
What are the symptoms of endometrial hyperplasia?
Post menopausal bleeding
Menorrhagia
Intermesntrual bleeding
Prolonged menses >7 days
Decreased menses interval less than 21 days
Oligomenorrhea/Amenorrhea
(WOW pretty much ANYTHING! These seem pretty vague and nonspecific to me, but she said any of these would make her do an endometrial biopsy so thats why i made this card)
50
Can you get an endometrial ablation on your lunch break?
Yes this procedure only takes 2 minutes and you can go home in 1-2 hours
Local anesthesia only
51
True or false:
A Pap smear can be used to test for other STDs
False.
Cytology and HPV only
52
What percentage of sexually active adults will acquire an HPV infection of their genital tract before they are age 50
75-80%
53
How do you treat Hyperplasia without atypia?
With progesterone
(Mirena IUD or Provera)
(If there’s no atypia, there’s no problem)
54
Who should get a Pap every single year forever for the rest of their life?
High risk women
| History of cervical CA, immunocompromised, CIN II/III, DES exposure
55
What is the most common diagnosis responsible for hospitalization of women 15-44 yo?
Endometriosis
56
You have an 84 year old patient come in and she reports that she has finally decided to put herself out there and make a tinder profile. She says she has 2 new boyfriends and she is sexually active with them.
Should you do a Pap just in case?
No. Do not resume Paps after age 65
57
Soooo what should you do for a 19 year old patient that comes in for her well woman exam if you’re not supposed to do a Pap?
Contraceptive talk
STI screening (with urine sample)
Gardasil shot
Safe sex talk
58
What are the 3 “zones” of the cervix?
Exocervix- squamous epithelium
Transformation zone-metaplastic squamous epithelium
Endocervical canal- columnar cells
59
Should you ever resume Pap smears after age 65?
No
60
Why would obesity cause endometrial hyperplasia?
Adipose releases estrogen
61
How do you contract HPV
The virus enters the cervical epithelium through microlacerations that occur during intercourse
62
If your patient requests Gardasil vaccine but she is already positive for HPV 16, should you still do it?
YES
63
What does it mean if your Pap smear comes back “No endocervical cells or unsatisfactory”
Your sample was missing endocervical cells or sufficient squamous cells
64
What is the 3rd most common GYN cancer in the US?
Cervical cancer
65
What does it mean if your Pap comes back with “ASC-US?’
“Atypical cells of undetermined significance”
```
Can be caused by:
HPV
Chlamydia
Herpes
Vulvovaginal atrophy
```
66
****DEFINITIVE diagnosis of Adenomyosis requires________________*********
Histological exam after hysterectomy
| ⭐️⭐️⭐️⭐️⭐️⭐️⭐️
67
If you got the Gardasil vaccine, do you still need to get Pap smears?
Yes
68
When you’re doing a Pap smear:
Adequate sampling requires presence of ___________ sampling
ENDOCERVICAL ***
69
What do you need to do when you discover a Nabothian cyst on exam
Nothing
70
What will you feel on bimanual exam of Adenomyosis?
Diffuse uterine enlargement=
| “GLOBULAR” uterus 🌎
71
How is hysteroscopy done?
1. Blow up uterus like water balloon
| 2. Stick a camera up vagina and into uterus and cut out the fibroid with a heated loop
72
When is LEEP contraindicated?
Invasion is suspected
Glandular abnormality on Pap
Pregnant
73
Why is it SO important to send the tissue you cut out during a LEEP to pathology?
To make sure you got clear margins
74
What does it mean if your Pap report comes back “LSIL”
“Low Grade”
| Usually consistent with CIN I if you were to do a biopsy
75
WHY are HPV 16 and 18 such a problem?
They have E6 and E7 which block the protective apoptosis process
76
Is there any test out there you can use to ONLY test for HPV
Yes it is called Cobas, and it didn’t seem like she was a big fan of doing “HPV only” testing
77
What do you need to tell your patient after you do a LEEP?
No heavy lifting for 4 weeks
You’ll have some smelly discharge for 2-3 weeks
Nothing goes in the vagina for 4 weeks (penises, fingers, tampons, douches, etc)
First period after LEEP will be heavy since you just removed part of the cervical canal
78
A 19yr old female comes into your office for her well woman exam and says that she lost her virginity at age 12 and estimates that she has had 75 sexual partners since then. She has also been smoking a pack a day since she was 5 years old.
Do you need to do a Pap smear and screen her for HPV today?
NO!!!!
You screen them starting at age 21 unless they’re High Risk
79
What is the ONLY WAY to diagnose endometriosis?
LAPARASCOPY
⭐️⭐️⭐️⭐️⭐️⭐️⭐️⭐️⭐️💫
THIS IS A TEST QUETION!
80
What causes the symptoms from uterine fibroids?
Location and size
81
Can you remove cervical polyps if they are bothering the patient?
Yep just twist em off
82
Why is contraception MANDATORY after an endometrial ablation?
If you get pregnant after this, the zygote would implant right into your myometrium=placenta accreta= you die
83
Youre doing a pelvic exam on your SP during women’s health lab and when you get to the bimanual part, you feel a GLOBULAR uterus. You ask the SP how many C-sections she’s had and she confirms that she’s had 2. You know exactly what’s going on here. Ms. Black hands you the transvaginal ultrasound probe and there it is, Adenomyosis.
Can you diagnose this standardized patient with Adenomyosis?
NO!!
The ONLY way to diagnose Adenomyosis is to do a hysterectomy and then look at the histology
*****SHE HINTED that this would be a test question****
84
What is this:
Benign, yellow, asymptomatic cyst on the cervix. Forms when columnar epithelium is covered by squamous epithelium and the glandular material becomes retained
Nabothian Cyst
85
If doing a LEEP has a 90-95% cure rate, why don’t we just do it every time someone has cervical dysplasia?
Because it would be better if she beat HPV on her own and developed the antibodies against that strain of HPV
86
HOw does a Uterine Artery Embolization work?
Interventional Radiologist threads a catheter into the uterine artery and injects some shit that cuts off the blood supply to the fibroid
87
What are the risk factors for endometrial cancer?
Exact same risk factors as for endometrial hyperplasia (obesity, lots of estrogen exposure, etc)
88
What part of the cervix does HPV LOVEEEEE
Transformation zone ********
89
What is the MOST common GYN cancer?
Endometrial Cancer
| 💫💫💫💫
90
Other than a Mirena IUD, what kind of progesterone would you give for hyperplasia without atypia vs with atypia?
Without: Provera
With: Megace
(Idk she made a point to say you wouldn’t give Provera for hyperplasia with atypia)
91
Is infertility common among women with endometriosis?
Yes 30-40% of women are infertile
92
Are Serous carcinoma and Clear Cell Carcinoma associated with a hyperestrogenic state?
NO!!!
| Only Adenocarcinoma and Adenocarcinoma with Squamous differentiation are
93
Uterine fibroids arise from ___________ ________ cells within the uterine wall
Smooth muscle
94
What will you see when you stick a laparascope in someone’s belly and she has endometriosis?
Erythematous, petechiae lesions on peritoneal surface
Surrounding peritoneum thickened and scarred
Ovaries will have lesions or endometriomas (“chocolate cysts”)
Adhesions
95
What is the most common site of disease in endometriosis?
OVARIES
96
True or false:
Most CIN I lesions will regress in 12 months
True
97
Can endometrial hyperplasia progress to endometrial cancer?
Yes
98
In endometrial hyperplasia, what is the main reason that the endometrium grows out of control?
ESTROGEN
| *********
99
What are the 2 pieces of information you can get from a Pap smear?
Cytology- are the cells normal?
HPV testing- is HPV present?
100
What are the risk factors for HPV infection (and therefore CIN and VAIN)?
⭐️⭐️⭐️⭐️⭐️⭐️
MULTIPLE SEXUAL PARTNERS🌟
Early onset of sexual activity
History of STDs
Smoking!
Immunosuppresion
Long term oral contraceptive use
Multiparity
101
When it comes to uterine fibroids what is the role of estrogen and progesterone?
Estrogen: makes them grow
Progesterone: increases mitosis and suppresses apoptosis
102
What are the different classifications of uterine fibroids?
Submucosal: lie just beneath the endometrium
Subserosal: lie just at the subserosal surface of the uterus
Intramural: lie within the uterine wall (in the muscle)
103
What is this:
“The presence of endometrial glands and stroma outside the endometrial cavity and uterine musculature”
Endometriosis
104
What is the treatment for endometrial cacner?
Hysterectomy with bilateral salpingoophorectomy (MUST take ovaries to get rid of estrogen)
Chemo/radiation
105
Why do you have to take the ovaries when you do a hysterectomy to treat endometriosis?
Because if you remove the estrogen and progertsoen supply, it will kill off any microscopic endometriosis cells that might be hiding
106
What causes the pelvic pain of endometriosis?
The lesions grow when they’re exposed to hormones, but their expansion is inhibited by the surrounding organs/fibrosis, which causes pressure and inflammation PAIN
107
What is the most common location of endometriosis?
| **************
Ovaries
| *****************
108
What needs to be done before an endometrial ablation?
You gotta get all those lumpy fibroids out of the uterus because the walls have to be smooth and non distorted
109
What are the two REALLY bad strains of HPV?
16
18
110
We don’t totally understand what causes uterine fibroids, but we have a pretty good idea that WHAT is involved in making them grow
Estrogen
111
HPV 16 is most associated with (Squamous Cell Carcinoma/Adenocarcinoma)
Squamous
112
Endometrial ablation preserves the ________ but not _______
Uterus
Fertility
113
When the lab gives you the cytology report back for a PAP SMEAR, how are abnormal results going to be reported?
ASC-US
LSIL
HSIL
(Not CIN I,II, III etc. which comes from a Biopsy report)
114
What are the pharmacological options for treating uterine fibroids?
Depot Lupron
Hormones
Lysteda (Tranexamic acid)
115
You are doing a totally routine pelvic exam on your patient and when you open up the speculum, you see a SUPER suspicious lesion on her cervix and you’re almost positive it is cancerous.
What is your next step?
A.) Pap smear
B.) Biopsy
BIOPSY********
Pap smears are for screening
Biopsies are for DIAGNOSING
🌟🌟🌟🌟🌟🌟🌟
WAS IN BIG RED CAPITAL LETTERS
116
How is cervical cancer staged?
CLinical examination of the bladder, uterus, and rectum.
117
What’s the difference between CIN I, II and III?
CIN I: 1/3 of epithelial lining
CIN II: 2/3 of epithelial lining
CIN III: more than 2/3 of epithelial lining
118
When does endometrial pain go away?
PAIN SUBSIDES WHEN YOUR PERIOD STARTS
| 🌈🌈🌈🌈🌈🌈🌈🌈🌈🌟🌟🌟🌟🌟⭐️⭐️⭐️⭐️
119
How do your treat endometriosis when it is mild?
NSAIDS
120
What is the most common type of endometrial cacner?
Adenocarcinoma (Type I)
| *****************
121
What are “Chocolate Cysts”
Endometrial tissue on the ovaries
| When you cut them open it looks like chocolate inside 💩
122
Why does endometriosis pain go away for a week when you start your period?
Hormones are at their lowest level.
Estrogen and progesterone make the lesions grow, and the expansion leads to pressure and inflammation = pain.
123
What are the medical options for treating Adenomyosis (keeping in mind that the main complaint is dysmenorrhea and menorrhagia)?
birth control pills
Mirena
NuvaRing
124
What is a colposcopy?
Its like a microscope they stick in your vagina to get a real good view of your cervix and then they pour some vinegar on it
(Biopsy usually done at this time too)
125
Most cervical polyps cause no problems and no symptoms. If a woman were to have any symptom though, what would it be?
Bleeding after sex
126
What kind of symptoms can be caused by uterine fibroids?
Abnormal bleeding (submucosal only)
Pain- caused by fibroid dying
Pelvic pressure- compression of organs, urinary frequency
Infertility- submucosal impinges on intrauterine cavity
Spontaneous abortion
127
How does Depot Lupron help with fibroids?
Its a GnRH agonist that shuts off estrogen and progesterone. Usually given before surgery to shrink the uterus so you can do a laparoscopic approach and lose less blood.
128
How often should women age 21-29 get Pap smears?
Every 3 years
| Only have the lab do cytology, dont test for HPV
129
Are fibroids common?
Yes 25% of women of childbearing age have them
Half of all black women get them
130
What are the 2 HPV vaccines available
Gardasil 9
Cervarix
131
If you diagnose cervical cancer, what kind of imaging do you need to do to make sure the chest isn’t involved?
Chest CT or CXR
132
What test do you need to do if you diagnose endometrial cacner?
Colaris®️ Test- to test for HNPCC (Lynch Syndrome)
133
HPV 18 is most associated with (Squamous cell carcinoma/Adenocarcinoma)
Adenocarcinoma
Most patients with adenocarcinoma also have squamous cell
134
What is Adenomyosis?
Growth of endometrial glands and stroma into the uterine myometrium. (Invagination of endometrium into the myometrium)
135
How do Lysteda (Tranexamic acid) and hormonal therapy (oral contraceptive pills, Mirena, Nuvaring, etc) help with fibroids?
Decrease heavy menstrual periods
| Do not help submucosal fibroids
136
How do you treat endometriosis when it is moderate-severe?
Interrupt stimulation of endometrial tissue aka SHUT OFF her period:
OCP’s in a continuous cycle (no placebo week)
Progestin (Depo-provera or Mirena)
Depot Lupron
Laparascopy with excision
Hysterectomy with ovary removal
137
What do we think causes endometriosis?
Retrograde menstruation
| Period blood goes up and out instead of into your tampon
138
What are the 4 Classifications of endometrial cancer?
Adenocarcinoma (Type I)
Adenocarcinoma with squamous differentiation (Type I)
Serous Carcinoma (Type II)
Clear cell carcinoma (Type II)
139
What are the side effects/complications of Uterine Artery Embolization?
Extreme pain afterwards- requires admission for IV pain meds
If the Embolization stuff floats to the ovaries too you can get premature ovarian failure
140
When you do a Pap smear, you need to rotate the endocervical brush (90/180/360) degrees
180
141
Cervical cancer is usually ASYMPTOMATIC, but if a woman is going to have one symptom, what will it be?
Abnormal bleeding/ bleeding after sex
| May also have pain or persistent weird discharge, but the bleeding part was in red
142
Endometriosis increases your risk for____________
Clear cell ovarian cancer
143
Where is the MOST tenderness in a patient with endometriosis
Posterior cul du sac
144
What happens to the position of the uterus in a patient with endometriosis
Retroverted secondary to adhesions
145
In the treatment of uterine fibroids, what is the maximum amount of time a patient can be on GnRH agonists (Depot Lupron)
6 months
146
When can a patient take Tranexamic acid (Lysteda) in the treatment of uterine fibroids
Only during menstural cycle
No submucosal fibroids can be present
147
Which surgery option for uterine fibroids preserves the uterus but NOT fertility
Uterine artery embolization
148
What is the only way we can definitively diagnose adenomyosis
Histologic exam AFTER hysterectomy
