Contraception/STI/TOP/Cervical screening Flashcards
CIN III
If we do not treat CIN3: there is a 30% chance that these changes will progress to a cervical cancer within 10 years.
Follow up: GP for a repeat smear and test for HrHPV in 6 months and 18 months after LLETZ. If HrHPV positive or cytology abnormal on either you will need another colposcopy.
Description of Colposcopy
- Colposcopy literally means ‘looking at the cervix’
- Patient in lithotomy
- Microscope is used to magnify the image of the cervix
- Smear will be re-taken and swabs for microbiology
2 solutions are applied:
5% acetoacid is used to enhance the transformation zone. After 30 to 60 seconds, the acidic solution dehydrates cells so that squamous cells with relatively large or dense nuclei (eg, metaplastic cells, dysplastic cells, cells infected with human papilloma virus) reflect light and thus appear white. Blood vessels and columnar cells are not affected, but become easier to visualize against the white background.
Uniform uptake of Lugol’s iodine stain would confirm the colposcopist’s impression that no lesion is present. Glycogen containing cells will take up iodine and become dark brown. Nonglycogenated cells, such as normal columnar or glandular cells, high-grade lesions, and many low-grade lesions, will not take up iodine and remain light yellow. Thus, they can be easily differentiated from normal tissue for sampling or treatment purposes. Iodine staining should not reveal any lesions the examiner has not previously identified with saline or acetic acid.
- Punch biopsy may be taken of areas of concern. Bleeding is stopped with silver nitrate stick or monsel’s solution.
- Whole experience may be uncomfortable but does not hurt.
- Nil PV 2-4 week
CIN
Abnormal squamous cell changes or growth in the surface layers of the cervix. These
changes are not cancer but some could develop into cancer if not treated. CIN is
graded as low-grade CIN1, or high-grade CIN2 or 3; CIN3 means the most severe
changes and is the same as carcinoma in situ.
Cervical screening
3 yearly from ages 25-69
Recall in 12 months if the first smear, or more than 5 years have elapsed since the previous smear
What to do with an unsatisfactory smear result
Repeat the cervical smear within 3 months.
Refer for colposcopy after 3 consecutive unsatisfactory
smear reports.
Low-grade Squamous Abnormalities: ASC-US and LSIL
Cervical cancer is a very rare outcome of a low-grade abnormality. Low-grade cytology is a manifestation of a viral infection that will resolve spontaneously in the
majority of women under 30. Median clearance is 6-18 months. HrHPV infection are at increased risk of
developing a high-grade lesion so should be reflex tested.
If under 30 repeat smear in 12 months.
Women aged 30 years and over who have not had an
abnormal smear report within the last 5 years should
be offered an HPV test:
1. If the reflex HrHPV test is negative, repeat
cytology in 12 months. If the repeat cytology is
negative, return to normal screening.
2. If the HrHPV test is positive, refer for colposcopy.
If the 12-month repeat smear is reported as:
• HSIL or ASC-H, refer for colposcopy
• ASC-US/LSIL, refer for colposcopy
• negative, repeat the smear in 12 months
History taking in sexual assualt
Should be performed in privacy and taken in sensitive, non-judgemental & supportive manner Details of sexual assault: ● Date / time / place ● Number assailants ● Orifices penetrated ● Objects used ● Condoms? Details of associated physical assault ● Blows inflicted ● Restraint type & site ● Use of weapons ● Use of intoxicants – drugs / EtOH Sites of possible assailant DNA ● Areas with possible semen or saliva contact Risk of pregnancy & STIs ● Menstrual hx ● Contraception ● Hep B & tetanus vaccination ● Assailant risk factors if known
Therapeutic aspects of sexual assault work up
● Baseline pregnancy testing, HIV, Hep B VDRL status emergency contraception ● levonorgestrel 1.5mg stat STI screening ● Swabs ● +/- bloods STD prophylaxis: ● Azithromycin 1g stat ● Ceftriaxone 250mg IM ● +/- metronidazole ● Hep B vaccination & immunoglobulin ● HIV post-exposure prophylaxis – if high risk assailant Support – rape crisis, counselling, social work ● Ensure safety ● ? police involvement Follow up: ● 2 weeks – swabs, HCG, psychosocial counselling ● HIV & VDRL testing 3 & 6 months
Adenocarcinoma in situ of the cervix
HPV associated precancerous lesion of glandular cells of the endocervix and the precursor to endocervical adenocarcinoma. Difficulty with detection, screening and colp and bx due to endocervical nature and skip lesions. o Prognosis ▪ AIS cone- pos margins ● Recurrence- 52% ● Cancer 6% ▪ AIS cone neg margins ● Recurrence 20% ● Ca 1.5% ▪ AIS TAH ● <1.5% cancer risk o FU ▪ with histology ▪ 6m colp and cytology ▪ Repeat cytology and hpv at 12m ▪ Then annual cytology until TH+ BS and routine screening until 70yo
IUCuD as emergency contraceptive
▪ Prevents implantation
● Can be used within 5 days of UPSI with same efficacy (can actually be used up to 5 days post ovulation if this can be calculated, and cover for all UPSI that cycle) – usually day 12 of cycle is the limit
▪ Toxic to sperm
▪ Provides ongoing contraception 10 years
▪ Risk of PID in first 21 days, risk of heavy periods, risk of perforation
▪ Need equipment/ procedure to insert
▪ Efficacy 99%
ECP
▪ LNG 1.5mg single dose
▪ Works by blocking LH surge, only works pre-ovulation
▪ Most effective within 24 hours, still effective but only 58% 49-72 hours
▪ If vomit - needs repeat
▪ Next period may be early late heavy light
▪ Increased risk of ectopic
▪ SE: nausea, vomiting, abdo pain, fatigue, dizzy
Precocious Puberty
Constitutional / Idiopathic
• Gonadotrophin dependent
• No organic abnormality (accounts for 90% of cases)
• Caused by premature release of gonadotrophins from anterior pituitary with no organic lesions
• Signs of puberty appear in correct order (growth spurt, thelarche, adrenarche, menarche)
• Bone age and height advanced for chronological age
Treatment:
1. GnRH agonist is the treatment of choice, causing reversible inhibition of HPO axis
Pubertal changes stabilise or regress
Growth velocity and skeletal maturation slow
Continued until normal puberty is desired
Management of syphillis
o Confirm diagnosis of primary syphilis:
Confirmatory tests – EIA, TPPA (will always be positive)
o Treat with Benzathine Penicillin 2.4 MU IM x 1
o Notify Ministry of Health
o Counsel regarding syphilis diagnosis:
Sexually transmitted infection
Responds well to treatment
If not treated, risk of developing to secondary/latent/tertiary syphilis
Sexual contact screening for last 3 months
Partner needs testing and treatment
Avoid sexual intercourse til both self and partner treated and reviewed by sexual health specialist
o Monitor response to treatment:
Serology at 0, 3, 6 and 12 months
If serology negative or Titre falls by > 4 – successful treatment
If titre stagnant – inadequate treatment – repeat
If titre increases by > 4 – reinfection
Primary HSV at in pregnancy at term
Risk of neonatal HSV is 30-50% if vaginal delivery within 6 weeks of primary infection as protective antibodies have not yet had time to form and cross the placenta to protect the baby
95% due to exposure to maternal secretions
5% due to transplacental infection
• Plan:
o Treat current HSV infection
Commence valciclovir 500mg PO BD for 7 days then daily ongoing
Consider admission with IDC if urinary retention
Analgesia + topical lidnocaine gel
o Counsel regarding mode of delivery
Recommend elective caesarean section at 39 weeks to reduce risk of neonatal HSV
If declines elective caesarean and wants vaginal birth or presents in labour with membranes ruptured > 4 hours - offer IV acyclovir in labour, avoid FBS/FSE/instrumental
o Neonatal monitoring:
Swabs and bloods for HSV PCR at 24 hours (if caesasaren delivery) or immediately (if vaginal birth)
Advise parents to monitor for signs of neonatal HSV – vesicular skin lesions, difficulty breathing, sepsis, jaundice, corneal ulcer
If signs present, paediatric referral for testing (CSF, repeat swabs, serology, FBC, LFT’s) if present
Treatment of neonatal HSV is with IV acyclovir
Depo Provera and fertility
- Depo may delay return to baseline fertility by 18-24 months, but may also be immediately reversible
- Discuss impact to bone mineral density (consider DEXA, increase dietary vit D and calcium, increase resistance exercise and increase sun exposure)
