disorders of the cervix Flashcards
what is a nabothian cyst?
Cystic structure that forms when columnar epithelium is covered by squamous epithelium
translucent/yellow
benign, asx., no excision required
characteristics of cervical polyps
may be d/t chronic inflammation of cervical canal
benign, usu. < 3cm
Polypectomy for symptomatic patients
what cells make up the 3 parts of the cervix?
Ectocervix = Stratified squamous epithelium
*Transformation zone =
Squamo-columnar junction and metaplastic squamous epithelium
Endocervical canal =
Single layer mucin-producing columnar cells (sample needs endocervical cells)
HPV pathophys
enters through microlacerations during intercourse
Transition zone/metaplastic tissue very susceptible to virus vs. squamous tissue
infects basal layer 1st
can be latent mo’s to yr’s
migrates away from BM toward the surface
Squamous cell carcinoma and adenocarcinoma assoc. w/ which type of HPV?
SCC = HPV 16
adeno = HPV 18
what are low risk types of HPV
6 and 11
Who typically has highest rates of HPV
women, adolescents/young adults 15-24y/o
75-80% sex active will acquire before age 50
RF’s for HPV infx
- Multiple sexual partners
Smoking, immunosuppression, early onset sex activity, h/o STI’s, long-term OCP use, Hx VIN and VAIN
Performing a pap smear
go into T. zone including endocervical canal and rotate 180 degrees.
Pap smears and HPV DNA testing
Patients who have received HPV vaccination require…
ongoing Pap smears based on age appropriate guidelines
primary screening tool for cervical CA?
PAP alone vs. co-testing vs. HPV
25-29 PAP q 3 yrs
never HPV testing until 25…ever!!
start at age 21y/o til 65
when is screening for cervical cancer initiated?
the age of 21 despite the age of sexual debut
screening does NOT reduce rate of cerv. CA prior to 21
nearly all cases of HPV are cleared w/in…
1-2 yrs w/out producing neoplastic change
Adolescent patient encounters should include:
Contraceptive Counseling STI screening HPV vaccination education/administration safe sex practices No Pap smear unless in high-risk population
screening for cervical CA women aged 21-29
Cytology performance alone q 3 years
Do not perform HPV DNA testing
screening for cervical CA women aged 30-64
Cytology (+) HPV DNA testing q 5 years or
Cytology alone q 3 years
screening for cervical CA in pt’s at high risk who need yrly screening
HIV positive women (6mo, 12mo, then yrly) Immunocompromised Personal h/o cervical cancer h/o CIN II/III exposure to DES in utero
when does screening for Cerv. CA stop?
65y/o…
so long as they are up to date (3 neg cytology in past 10yrs OR 2 neg co-tests w/most recent w/in 5 yrs) AND not high risk
hysterectomy (cervix removed)
When Performing speculum exam & an abn. cervical lesion is noted, perform…
BIOPSY NOT PAP SMEAR.
ASC-US (atypical cells of undetermined significance) result, plan?
Age 21 – 24: preferred to repeat cytology in 1 year
Age 25+:
Must reflex to HPV DNA
- Neg HPV DNA = norm (repeat x3yrs)
- Pos HPV DNA = colposcopy
in absence of HPV: chlamydia trachomatis, Herpes simplex, vulvovaginal atrophy
LSIL: low grade squamous intraepithelial lesion result, plan?
Age 21 – 24: preferred to repeat cytology in 1 year
Age 25+:
- Refer for colposcopy despite HPV result OR
- Repeat co-testing in 1 yr if HPV DNA testing is neg
- Lesions usu. consistent w/CIN I
HSIL/ASC-H: High grade result, plan?
Assume HPV DNA is present (no testing)
Refer for colposcopy
lesions usu. consistent w/ CIN II-III, AIS (adenocarcinoma insitu)
neg. cytology, no endocervical cells result, plan?
Age 21 – 29: repeat Pap in 3 years
DO NOT perform HPV DNA testing
Age ≥ 30:
Perform HPV DNA testing
- if pos. –> colposcopy or repeat cytology and HPV in 12 mo’s
- if neg –> repeat pap 5yrs
unsatisfactory cytology results, plan?
d/t insufficient squamous component
HPV may be falsely neg.
NO HPV testing: repeat pap in 2-4 mo’s (do not add HPV if not initially ordered)
HPV testing performed age > 30
- neg –> Repeat Pap in 2-4 mo’s
- pos –> refer for colposcopy
combined screening
Women 30+ years with neg cytology but pos. high risk HPV DNA:
- Colposcopy if genotype is (+) for HPV 16/18
- Repeat co-testing in 12 months for non- HPV 16/18
if neg in 12mo’s repeat co-testing in 3 yrs
if pos in 12mo’s refer for colposcopy
differentiate btwn transient and persistent HPV infection
Persistently positive HPV DNA test (x2) assoc. w/CIN II/III
if colposcopy is unsatisfactory?
incomplete visualization of transformation zone then have to perform ECC (endocervical curettage)
Colposcopy: bx acetowhite epithelium?
Leukoplakia, ulcerations, punctation, mosaicism, atypical vessels
management of ASCUS/LSIL age 21-24
Cytology ALONE in 12 months
Persistent ASCUS/LSIL at 24 months –> colposcopy
ASC-H/HSIL –> Colposcopy
management of ASCUS/LSIL Age > 24
ASCUS or LSIL/CIN 1, negative HPV:
Co-testing at 12 months
- Neg–> Co-test in 3 yrs
- abn. –> Colposcopy
management of ASCUS/LSIL w/persistent CIN 1 for 24 months
LEEP Vs Continued follow-up
management of HSIL/ASC-H age 21-24
Immediate triage to LEEP is unacceptable
Colposcopy
HSIL/CIN I or less –> cytology and colposcopy q 6 months up to 24 mo’s
LEEP is indicated for the following:
- Persistent HSIL (24 mos)
- CIN 2+
- Unsatisfactory colposcopy
management of HSIL/ASC-H age 25+
Colposcopy or LEEP
If colposcopy done and HSIL/CIN 1 or less:
LEEP OR co-test at 12 and 24mo’s
- neg. retest at approp. age level
- HPV pos & cytology < HSIL –> colopscopy
- HSIL at 12-24 mo’s = LEEP
If colposcopy done and HSIL/CIN 2+
LEEP is indicated
LEEP procedure
High electrical current heats up and vaporizes nearby tissue that is sent for path
CI w/ susp. invasion, glandular abn on PAP or pregnant
90-95% cure rate
LEEP f/u pt education
Avoid heavy lifting, intercourse, douches, creams, tampons for 4 weeks
First menses after LEEP is heavier due to partial removal of endocervical canal
Malodorous vaginal discharge for 2-3 weeks
LEEP morbidity
Bleeding
Infection
Cervical obliteration, incompetence, stenosis
assoc. w/pre-term delivery, after PPROM
LEEP f/u
Repeat co- testing at 12 and 24 months:
- both neg > retest 3 yrs
- abn. > repeat colposcopy w/ECC
- continue age approp. screening at least 20yrs
(+) margins after LEEP: repeat cytology and ECC at 4-6mo’s
persistent CIN 2+ following LEEP: repeat LEEP, hysterectomy
cervical CA etiology
Cervical squamous cell cancer: HPV 16 & 18, prevalence 65-85%, microinvasion (< 3mm), invasive (>3mm)
Cervical adenocarcinoma: HPV 16 & 18, prevalence 1-25%, type endocervical, endometrioid, clear cell, adenoid cystic
clinical presentation for cerv. CA
Frequently ASYMPTOMATIC
MC = Abnormal vaginal bleeding
Postcoital bleeding
vaginal dc
Unilateral pelvic pain with radiation into the hip or thigh
