Diagnostic Imaging and Procedures: Women's Health Flashcards
Mammography
what is it
what is it used for
limitations
indications
Mammography
what is it: xray machine which take images of the breast tissue from above and different angles in order to visualize the breast tissue through low dose radiation
used for
- gold standard for breast cancer screening
- not great nor used for inflammatory BC
Limitiations
- can miss cancers! up to 95% of the time it is fond
- denser breast tissue: more difficult to find small masses
- dense breast tissue falst negatives up to 50% of the time
- overall sensitivity is 80%
Indications (other than breast cancer screening) for Mammo.
- tenderness/pain
- swelling
- nipple discharge
- calcifications (seen on US)
- mass
- lymph node enlargement (supraclavicaulr or axillary)
Mammogram
how is it done
Mammography machine
- two plates = squish breast to get best image
- xary machine above
- need at least 2 views of the breast: above and from sides
- markers are placed where there are palpable lesions
Calcifications can be seen; but cysts may be missed
as a woman ages: breasts get less dense & mammograms become easier to read
dont let size deter: larger v smaller breasts done indicate easier/harder reading
Breast Ultrasound
when is it used
Breast US : automatic breast US or diagnostic US can be done
When is it used
- to help increase sensitivity of a mammogram
- WILL NOT AND SHOULD NOT REPLACE A MAMMOGRAM alone just used to help differentiate results
Helpful to…
- define Mammo & MRI Findings: determining cysts v. solid masses
- help to screen: very dense breasts (in addition to mammo.)
- screen in young pt. (under 30)
-screen in those with implants
ABUS: is good for screening, NOT diagnostic
US: can be diagnostic (assuming handheld)
which specific issues would you us a breast US to work up
reading US
specific issue
- palpable lump/mass
- follow up to a biopsy
- pain
- evaluation of skin
- abcess
*dont want to see christimas tree**
US: can be diagnostic
Reading
- bottom left corner: the “clock position” of the image finding
- next to that: distance from the nipple
MRI
when is it used
Recommended for who to get MRI
Downsides
MRI: sensitive but not specific
will find things, but those “things” may not be cancer, etc.
Recommended for…
- those with > 20% ligetime risk of breast CA due to known personal or family history
- knownc BRCA 1 or BRCA 2 mutations
- first degree relative has known mutations
- those with extremely dense breasts
- those with a known malignancy
Positives
- can detect the very small cancerous massess
Downsides
- $$$ expensive
- cannot have any metal
- Requires IV contrast!!
Wet Mount
who needs it & when is it done
method
Wet Mount
- patient presents with discharge, ithcing and odor or a change in dicharge, itching or order
- concern for the following: BV, trichomonas, candidiasis
Method
- sample discharge from the posterior fornix (space located posterior to the cervix during speculum exam
- sample taken; observed under the microscope (usually in office)
- under scope; observed, then KOH added to appreciate smell and evaulate discharge further
Wet Mount Results by diagnosis
BV: bacterial vag.
- clue cells on scope
- KOH: fishy smell on wiff test
- pH in vagina has changed: the increase in lactobacili allows the cells to look spotted under the microscope
Trichamonas
- flagellated tichomoads see swimming on the slide
- these will look different than sperm cells swimming: which you can sometimes see
Candiasis
- miniaml appreaciation
- when KOH added: apprecaite the hyphae and budding yeast
Cervical Cancer Screening
what is a pap smear
types of pap options
Pap smear: papanicolaou smear: visualization of cerivcal cells underneath a microscope
- essentailly: looking at precancerous changes
Types of Pap Options that can be preformed
- cytology alone: looking at the cells to see if theres dysplasia
- cytology + reflex HPV: cytology, if abnormal, reflex to HPV test
- cytology + HPV test: done concurrently
- HPV only: only testing for HPV, not looking at cells for cellular changes
- HPV testing for 16/18 genotype: only looking for 16/18: the strains of HPV most assocaited with cancer
HPV: human papilloma virus: MC cause of cervical cancer, anal and throat cancers
- 200 strains: 16 and 18 : cancerous; 6 and 11 = warts
- most come and go without our knowledge: body clears the infection
Cervical Cancer Screening
who needs a pap/hpv testing
Cervical Cancer Screening Recommendations
under 21: no screening recommended : still need annual exam! but dont need the pap to be done
age 21-29
- Pap Smear every 3 years (cytology alone)
- high risk for HPV: can do a pap cytology with reflex HPV
- dont need to specific test for HPV strains
age 30-65
- pap + hpv testing ever 5 years
OR
- pap alone (cytology) every 3 years
- HPV genotyping: can be done “reflex” in those whose pap is “negative” but the HPV testing is positive
Over 65 y/o
- discontinue pap if adequate negative screenings in previous tests
- UNLESS: hisotry of CIN2+: then continue
How is a Pap Smear/HPV test conducted
During the Speculum Exam
- cells are removed from the cervix via a “brush”, spatula or broom
- these tools take cells from endo and ecto cervical cells at the tranformation zone : aka outside and slightly inside the os
Abnormal Pap Smear
Bethesda Grading System
Bethesda Grading System : atypical results
unsatisfactory: didnt get enought cells
Atypical Squamous cells of undetermined significance: ASC-US
Atypicl Glandual cells & subcategoreis: AGC
Atypical squamous cells - high grade cannot be excluded: ASC-H
Low-grade squamoud intraepithelial lesions (LGSIL)
High-grade squamous intraepithelial lesions (HGSIL)
squamous cell carcinoma MC cancer
endocervical adenocarcinoma in situ or adenocarcinoma
Unsatisfactory Cytology result
- why might this occur
- what to do
Unsat. Cytology
recommendation: Repeat pap in 2-4 months
Results due to
- insufficient cellulairty obtained
- excessive lubrication used
- cells couldnt be visualized due to inflammation, blood or mucus (could be due to obtaining during ovulation)
- tests, slides nt prepared properly
Negative Pap Smear; postive HPV test
- what to do
- who this result may come back in
Negative pap (cytology) but postive HPV
- this result would only be coming back to you in a sample you obtained from someone over the age of 30, because you should not be getting HPV testing done on those under 30
Recommendation:
co-test (HPV and cytology) in 1 year
or
HPV DNA testing
if this resut returns:
- same or worse abnormality at the repeat: refer for a Colposcopy
- returns iwth 16/18 strains positive: refer for colposcopy
ASC-US result on pap
- what to do for age 21-24, age 25-65
ASC-US
- abnormal squamous cells of undetermined significance when you obtatiend the pap
What to do: age 21-24
- repeat the cytology in 1 year (preferred)
OR
- reflex HPV test : if HPV + = repeat cytology in 1 year, if HPV - = return to normal screening
this is because when you are younger you are more likely to clear the infection without an issue
what to do: ages 25-64 (assuming you got HPV?)
- HPV + : refer for colposcopy
- HPV - : repeat the cotesting: cytology and HPV in 3 years
sometimes pt. dont want to wait 3 years: so it is perfectly acceptable to repeat the test before then; often times these results are secondary to inflammation
AGC result
- what do you do
- what categories are there
AGC: atypical glandular cells
glandular cells: are cervical cells; of which should not be on the cervix….. so were sus….
Types
- endocervical cells
- endometrial cells
- “undertermines significance” : most commonly the result you will get
What to do: recommendation
- endometrial biopsy if they were endometrial cells
- colposcopy and endometrial biopsy for all other
- if bleeding, consider getting US first
ASC-H result
- what do to
ASC-H
- atypical squamous cells - cannot rule out high grade sqamous interepithelial lesions
What to do: recommendation
- Colposcopy, regardless of age or HPV
LSIL Result
- what to do for age 21-24; age 35-64
LSIL Result: low-grade squamous interepitheial lesions
What to do: age 21-24
- Repeat cytology at 12 months regardless of teh reflex HPV results
What to do: age 25-64
- if HPV negative: repeat co-testing in 1 year or colposcopy
- if HPV postive: colposcopy
when in doubt: refer to gynecologist for counceling
HSIL Result
what to do: age 21-24; age 25-64
HSIL
- high-grade squamous interepitheial lesions
what to do: age 21-24
- colposcopy regardless of HPV status
what to do: age 25-64
- coloposocopy or immediate LEEP procedure
Colposcopy Procedure
what is it
what does it do
soluitions used
Colpsocopy
- a specialized microscope used to visualize the cervix and vaginal walls in detaail if needed
- solutaions applied to see color changes on different cell types
- +/- a biopsy to be taken if needed
Solutions used
- saline: to rise between applications of the solutions
- Acetic Acid: applied; things which turn white = HPV lesions, all else will be brown
- Lugol’s soluation (the Shiller’s Test) = application of the lugol solutaion to see vascualr changes; helathy tissue = brown, all else (unheatlhy) will not stain brown
Colposcopy
indications
procedure: how its done
Indications
- abnormal cytology results
- abnormal HPV results
- clinically abnormal or suspicious looking cervic on exam
- unexplained intermenstrual or post-cotial bleeding
- vulvar or vaginal neoplasia
- history of in-utero DES expsoure (older women this may still be a concern)
Procedure: how its done
- speculum exam: placed in vagina
- inspect cervix
- obtain swabs
- apply lugol’s soluation to scervix
- swab os with ECC brush: endocervical curretage (scraping inner cervix)
- biopst nay concerning areas with scrubbing end/tischler
- add monsel’s solution to stop bleeding
pt. may have brown discharge, cramping after procedure
Bartholian Gland Abcess
what are they & where
infected via which organisims
treatment
Bartholain gland Abcesses
- bartholian glans located at the 4 and 8 clock positions of the introtius and vaginal opening
- cyts form when the duct becomes blocked
if the cyst gets infect - abcess formation
Organisims
- e. coli
- n. gonrrorhae
- c. trachomatis
Treatment
- antibiotics
- surgery: two appraoches (or removal)
one approach = Surgical Drainge via word catheter
-out pt. procdueres
but can recurr with this method
ohter appraoch = marsupialization : creating a perminent pocket opening for continuous drainge
- pt needs to be sedated for this procedure & needs recovery time
- very low risk of recurrance
or removal of the gland
Endometrial Biopsy
indications
Indications for an Endometrial Biopsy
- determining cause of AUB
- postmenopausal bleeding
- assessment of response of the endometirum to hormone treatment
- status of the endometrum during infertility workup
- evacuation of POC (spontaneous or non)
other indications
- ACG or EM cells in pap smear: need to biopsy EM
- thickened EM in a post-menopasual women on US
Endometiral biopsy
procedure
Procedure
- concel + consent
- insert speculum
- clean cervix
- paracervical anesthestic wait 3-5 mins
- apply tenaculum to stabilize cervix
- insert sound (long metal rod) to measure uterine size from the fudus (approx. 6-10 cm)
- cervical diation if needed
- insert pipelle curette which created vacuum to sample in 260 degree motion
IUD Insertion and Removal
Insertion
- tenaculum: used to straighten cervix to allow instrument to enter os
- use sound to measure the cervix (6-9cm)
- then insert IUD straw; not to entire full depth, and fan out; release the sides and then push up to full depth
- cut the strings long
Removal
- obtain strings and pull
Transvaginal US & transabdominal US
Trasnvaginal
- obtain better image of the uterus and ovaries
- internal image
Indications for pelvic US
- infertility
- dysparenuina
- dysuria
- pelvic or abd. pain
- abnormal abd. swelling
- irregular menses
- post-menopausal bleeding
- urinary incont.
- fetal viability and developemnt under 8 weeks
- IUD presence and placement
- assist in IVF procedures
Hysteroscopy
what is it
indications
procedure
Hysteroscopy
- a procedure to directly fisualize the uterus/cervix
- scope inserted; air/gas or liquid fills up the uterus and a light is used to visualzie walls
Indications
- abnormal bleeding MC
- adhesolysis
- recurrent miscarraiges
- placement of IUD
- sterilization (to put implants into fallopian tubes)
Procedure
- general/local anesthesia
- place speculum
- clean vagina and cervix
- hysterscope inserted into uterus through cervix
- CO2 or saline used to exand
- visualization, biopsy, etc. done
