DO of the Cervix and Uterus Flashcards
______ are fingerlike growths that start on the surface of the cervix or endocervical canal.
These small, fragile growths hang from a stalk and push through the cervical
opening.
Cervical polyps
Causes of cervical polyps
They may be associated with chronic inflammation, an abnormal response to increased levels of estrogen, or
thrombosed cervical blood vessels.
What is the hx of cervical polyp
The history is usually positive for vaginal bleeding, often after intercourse. This bleeding occurs between normal menstrual periods
PE of pts with cervical polyp
Speculum examination reveals smooth, red or purple, fingerlike projections from the
cervical canal
Mx of cervical polyp
Polyps can be removed by gentle twisting or by tying a surgical string around the base
and cutting it off.
Removal of the polyp’s base is done by electrocautery or with a laser.
A ______is a mucus-filled cyst on the surface of the uterine cervix.
The cervical canal is lined by glandular cells that normally secrete mucus
nabothian cyst
PE of Nabothian Cyst
Pelvic examination reveals a small, smooth, rounded lump (or collection of lumps)
on the surface of the cervix.
Mx of Nabothian cysts
They can be easily cured through electrocautery or cryotherapy. Both procedures can be done in the doctor’s office
The most common finding is mucopurulent cervical discharge and a friable
cervix. This diagnostic finding is confirmed by endocervical bleeding easily induced by passage of a cotton swab through the cervical os
Cervicitis
Findings of cervicitis
Routine cervical cultures are positive for chlamydia or gonorrhea. WBC and ESR are normal
Mx of Cervicitis
Oral azithromycin in a single dose or oral doxycycline BID for 7 days.
The progression from premalignant to invasive cancer has been reported to be approximately ______
8–10 years
HPV_________ are the most common
HPV types associated with premalignant and cancerous lesions of the cervix
16, 18, 31, 33, and 35
HPV 6 and 11 are the most common HPV types associated with ______
benign condyloma acuminata.
RF for Cervical Neoplasia
These include early age of intercourse, multiple sexual partners, cigarette smoking,
and immunosuppression. The mediating factor for all these conditions is probably HPV
What cytologic screening methods can be used for cervical neoplasia
conventional method
thin-layer, liquid-based cytology
Pap smear should be started at the following ages:
• Age <21: ________
• Age 21: _____
no Pap test or screening for HPV, regardless of sexual activity
Start Pap test with cytology alone without HPV testing; the recommendation is the same whether HPV vaccinated or not
The frequency of recommended Pap smear is as follows:
• Age 21–29: _____
repeat Pap every 3 years with cytology alone; do not perform HPV testing in this age group
The frequency of recommended Pap smear is as follows:
• Age 30–65:
repeat Pap every 3 years with cytology but no HPV testing OR repeat Pap
every 5 years if both cytology and HPV testing (the recommended option in this age
group)
Pap smears should be discontinued:
- After age 65 if_________
- Any age if________
negative cytology and/or HPV tests for past 10 years AND no history of CIN 2, CIN 3 or cervical carcinoma
total hysterectomy AND no history of cervical neoplasia
Pap Smear Classification
________is the current classification used in the United States.
The Bethesda system
Negative for intraepithelial lesion or malignancy; comments may report 1 2 3 4 5
trichomoniasis, candida, BV, HSV, or atrophy
Pap Smear
________: changes suggestive
of but not adequate to label LSIL
ASC-US (atypical squamous cells of undetermined significance)
Pap Smear
_______: biopsy is expected to show histologic findings of HPV, mild dysplasia, or CIN 1
LSIL (low-grade squamous intraepithelial lesion)
________: changes suggestive of but not
adequate to label HSIL
ASC-H (atypical squamous cells can’t rule out HSIL)
________: biopsy is expected to show histologic findings of moderate–severe dysplasia, CIN 2, CIN 3, or CIS
HSIL (high-grade squamous intraepithelial lesion)
Examples of Abnormal endocervical cells (1% of abnormal Pap smears)
1
2
3
4
– AGC-NOS (atypical glandular cells, not otherwise specified)
– AGC-neoplastic (atypical glandular cells, can’t rule out neoplasia): changes suggestive
of but not adequate to call AIS or cancer
– AIS (adenocarcinoma in situ)
– Adenocarcinoma
Diagnostic Approach to Abnormal Pap Smears
This is an option for findings of ASC-US in patients of any age, and the preferred option with either ASC-US or LSIL in patients ages 21-24.Repeat the Pap in 12 months.
Accelerated repeat Pap.
Mx of repeated pap
– If repeat cytology is negative,____
– If repeat cytology is anything other than negative, _______
repeat Pap in another 12 months.
proceed to colposcopy and biopsies
Diagnostic Approach to Abnormal Pap Smears
_______This is the preferred option for findings of ASC-US in patients age
≥25.It is acceptable but not preferred in patients ages 21-24
HPV DNA testing.
This is indicated for evaluation of LSIL in patients age ≥25, and all patients with ASC-H and HSIL.
Colposcopy
Satisfactory or adequate colposcopy is diagnosed if
the entire T-zone is visualized and no lesions disappear into the endocervical canal
All nonpregnant patients undergoing colposcopy which shows metaplastic epithelium entering the endocervical canal will undergo an
ECC to rule out endocervical lesions.
If the Pap smear is worse than the histology (suggesting the site ofabnormal Pap smear cells was not biopsied), then a________ is performed
cone biopsy
SSx of Invasive Cervical Cancer
Patients with invasive cervical cancer can present with postcoital vaginal bleeding.
Other symptoms of cervical cancer include irregular vaginal bleeding and, in advanced
stage, lower extremity pain and edema.
_________ is the third most common gynecologic malignancy with a
mean age at diagnosis of 45 years
Cervical carcinoma
Work-up for cervical CA
Cervical biopsy.
Metastatic workup
Imaging studies
Patients with these findings are offered adjuvant therapy (radiation therapy and chemotherapy).
These include metastatic disease to the lymph nodes, tumor size >4 cm,
poorly differentiated lesions, or positive margins
Mx
Stage Ia1: ______
Stage Ia2:_______
Total simple hysterectomy, either vaginal or abdominal
Modified radical hysterectomy
Mx
Stage IIB, III, or IV: ________
Radiation therapy and chemotherapy for all ages.
All patients with invasive cervical cancer should be followed up with Pap smear
________ after treatment, and then ___________
every 3 months for 2 years
every 6 months for the subsequent
3 years
Patients who have a local recurrence can be treated with ________; if they had
received radiation previously, they might be considered candidates for a _______
radiation therapy
pelvic exenteration.
Patients with distant metastases should be considered for chemotherapy treatment.
The most active chemotherapeutic agent for cervical cancer is _______
cisplatinum
Uterine anomalies may result from 3 mechanisms:
Stage 1: ________
Stage 2: ________
Stage 3: ________
failure of one or both of the 2 müllerian ducts to form
failure of the 2 ducts to fuse completely
failure of the 2 fused mullerian ducts to dissolve the septum that results from fusion
MU¨ LLERIAN ANOMALIES
Failure to Form
Hypoplasia/Agenesis
Unicornuate Uterus
When one of the müllerian ducts fails to form, a single-horn (banana-shaped) uterus
develops from the healthy müllerian duct. This single-horn uterus may stand alone.
Unicornuate Uterus
Problem with Unicornuate Uterus
a girl may have monthly pain during adolescence because there is no
outlet for the menses from this rudimentary horn
There is a risk that a pregnancy will implant in this rudimentary horn, but because of
space limitations, _______
90% of such pregnancies rupture
A double uterus results from the complete failure of the 2 Müllerian ducts to fuse
together (stage 1 of development).
So each duct develops into a separate uterus, each of which is narrower than a normal uterus and has only a single horn
Didelphys Uterus
In 67% of cases, a didelphys uterus is associated
with 2 vaginas separated by a thin wall
Didelphys Uterus Cx
Preterm delivery is common if pregnancy occurs in these patients.
A ______results from a problem in stage 2 or 3 of uterine development. The
two müllerian ducts fused normally; however, there was a failure in degeneration of
the median septum.
septate uterus
If this failure was “complete,” a median septum persists in the entire uterus, separating the uterine cavity into______
two single-horned uteri that share one cervix
If this failure was “partial,” resorption of the lower part of the median septum
occurred in stage 2 but the top of the septum failed to dissolve in stage 3. Thus, there
is a __________
single cervix and uterine cavity at the bottom, but at the top that cavity divides
into two distinct horns.
This type of uterus is essentially normal in shape with a small midline indentation in the
uterine fundus, which results from failure to dissolve the median septum completely.
Arcuate Uterus
The daughters of mothers exposed to diethylstilbestrol (DES) during pregnancy are predisposed to ______ and _______
uterine abnormalities and clear cell carcinoma of the vagina
It is a benign smooth muscle growth of the myometrium. It is the most common
benign uterine tumor. It is 5 times more common in black women than white women.
Leiomyoma Uteri
The most common location of a leiomyoma is within the wall of the uterus.
Intramural.
These myomas are located beneath the endometrium and can distort the
uterine cavity. The distorted overlying endometrium may not respond appropriately
to the normal hormonal fluctuations, resulting in unpredictable, often intermenstrual,
bleeding
Submucosal.
______ is the most common symptom of a submucosal
myoma and can result in anemia
Abnormal vaginal bleeding
These are located beneath the uterine serosa. As they grow they distort
the external contour of the uterus causing the firm, nontender asymmetry
Subserosal.
Subserosal myoma
If they are pedunculated, attached to the uterus by a stalk, they can become ____
parasitic fibroids
Estrogen receptors are increased in leiomyomas resulting in rapid
enlargement during times of high estrogen levels, such as ______
pregnancy
During times of rapid growth, myomas may outgrow their blood supply,
resulting in ______
ischemic degeneration of a fibroid
Common myoma degenerations that are
seen include ______, ______ and ______
hyaline, calcific, and red degeneration
______can cause such extreme, acute pain that the patient requires hospitalization
and narcotics. This is most common during pregnancy.
carneous
degeneration,
_______is helpful for identifying submucosal
myomas by instilling 5–10 mL of saline into the uterine cavity before visualizing
the uterine cavity with an endovaginal sonogram probe.
Saline infusion sonography
Submucosal myomas may be identified by visualizing them directly
with ______
hysteroscopy
Most leiomyomas can be managed
conservatively and followed expectantly
with regular pelvic examinations
After 3–6 months of_______ with resultant hypoestrogenic state, a 60–70% reduction in size of the fibroids can be expected.
GnRH analog therapy,
Thus, GnRH analogs cannot be used for definitive cure, but they can be used in
the_______
adjuvant setting with surgical therapy
This is a surgical procedure performed if the patient desires to maintain fertility. The uterus is incised and the myoma removed through either a laparoscopic
or laparotomy approach
Myomectomy
If the myomectomy incision entered the endometrial cavity, delivery of any subsequent pregnancy should be by cesarean section because of
i________
increased risk of scar rupture in labor
This is an invasive radiology procedure in which a catheter is placed into the vessels supplying the myoma.
Microspheres are injected, causing ischemia and necrosis of the myoma.
Embolization.
If the patient has completed her childbearing, definitive therapy is an
abdominal or vaginal hysterectomy.
Ectopic endometrial glands and stroma are located within the myometrium of the
uterine wall. The most common presentation is diffuse involvement of the myometrium
Adenomyosis
The lesion is known as an _______if the involvement is focal, surrounded by a pseudocapsule.
adenomyoma
Dx of adenomyosis
In most cases the diagnosis is made clinically by identifying an enlarged, symmetric,
tender uterus in the absence of pregnancy. The only definitive diagnosis is by histologic
confirmation of the surgically excised tissue
PE of adenomyosis
The uterus is globular and diffusely up to 2–3 times the normal size.
Tenderness is most common immediately before and during menses
Imaging of adenomyosis
Ultrasound study or MRI imaging shows a diffusely enlarged uterus with cystic
areas found within the myometrial wall.
Mx of adenomyosis
Medical treatment includes the levonorgestrel (LNG) intrauterine system
(IUS), which may decrease heavy menstrual bleeding.
Surgery, in the form of hysterectomy, is
the definitive treatment
________ is the most common gynecologic malignancy, occurring in 1% of women. The mean age at diagnosis is 61 years
Endometrial carcinoma
A patient is considered to be in menopause after
1
2
3 continuous months of cessation
of menses and elevated gonadotropins.
Although the most common cause of postmenopausal bleeding is ______ or _____, the most important diagnosis to rule out is endometrial carcinoma
vaginal or
endometrial atrophy
The mediating factor for most endometrial carcinomas appears to be ______
unopposed estrogen. This results from excessive hyperstimulation of the endometrium without the
stabilizing effect of progesterone
RF for endometrial CA
These include obesity, hypertension, and diabetes mellitus.
Other risk factors include nulliparity, late menopause, and chronic anovulation conditions, such as PCO disease
MC Stage at Dx
Spread limited to the uterus (most common stage at diagnosis)
Stages of Endometrial CA
Stage I: Spread limited to the uterus (most common stage at diagnosis)
Stage II: Extension to the cervix but not outside the uterus
Stage III: Spread adjacent to the uterus
Stage IV: Spread further from the uterus
If the endometrial histology sampling reveals atrophy and no evidence of cancer,
it can be assumed the patient is bleeding from atrophy and can be treated with _______
hormone replacement therapy
With hormone replacement therapy, estrogen and progesterone should be
given to the patient. If estrogen is given alone, the risk of ______
endometrial cancer increases
The mainstay of treatment of endometrial carcinoma is a
total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO), pelvic
and para-aortic lymphadenectomy, and peritoneal washing
An evaluation of the postoperative pathology report will classify patients into poor or good prognosis. Patients with poor prognosis should be considered for______
radiation therapy
Poor prognostic factors include 1 2 3 4
metastasis to lymph nodes, >50%
myometrial invasion, positive surgical margins, or poorly differentiated histology
Postmenopausal patients taking estrogen replacement therapy must be also treated with ______ to prevent unopposed estrogen stimulation, which may lead to endometrial cancer.
progestins
Reproductive age women who have chronic anovulation, such as_______ should also
be treated with progestins to avoid endometrial hyperplasia from unopposed estrogen
PCO syndrome,
