1
Q
Papanicolaou test – “Pap Smear”
* Routine screening for what?
* May also screen for what?
* When should you should you start screenign?
* What should be biopsied?
A
- Routine screening for cervical cancer, or cell changes known to lead to cancer
- May also screen for HPV
- Should start screening at age 21, even if sexually active earlier.
- ALL visible abnormal cervical lesions should be biopsied
2
Q
Under notes
What is the timeline for paps?
A
Anyone with a cervix between the ages of 21 and 30 should get a Pap smear at least once every three years.Between the ages of 30 and 65, you should have one every five years.
3
Q
How do you do the brush at the cervix?
A
Brush is the best at he squamocolumnar junction.
4
Q
Where does 90% of squamous cervical intraepithelial neoplasia (CIN) occurs?
A
within the transformation
* This is why it is so important to get cells from the squamous epithelium (exocervix) and the columnar epithelium (endocervix).
5
Q
She said FYI
A
6
Q
Cervical Intraepithelial Neoplasia (CIN)
* Hormonal influence of puberty + changes in vaginal pH causes what?
A
causes squamous margin to encroach on the single-layer, mucous secreting epithelium, creating an area of metaplasia - “transformation zone”
7
Q
Cervical Intraepithelial Neoplasia (CIN): HPV types
* What are the high risk HPV cancer related types
* HPV types associated with genital warts?
A
Human papillomavirus (HPV) types.
* High Risk HPV-cancer related types: 16 and 18 (70%), 31, 33 and 45
* HPV types associated with genital warts: 6 & 11 (90%) (condyloma acuminata)
8
Q
Cervical Intraepithelial Neoplasia (CIN)
* What are the classification?
A
Describes degree of abnormality
* CIN 1 = LSIL
* CIN 2, 3 = HSIL
9
Q
U. S. Preventive Services Task Force Recommendation: PAP
* When do you do screenings? (average risk group)
A
- Women aged 21-29 - screening with cytology (pap smear or liquid based) every 3 years
- Women aged 30-65 - screening with cytology every 3 years + HPV testing every 5 years or with co-testing (both) q 5 years
10
Q
U. S. Preventive Services Task Force Recommendation: PAP
* What is the screening timeline for high risk group?
A
ANY previous abnormal cytology screening or HIV or DES exposure in utero -> yearly screening
11
Q
A
12
Q
American Cancer Society Guidelines: pap+HPV
* Screening should begin when?
* What is the timeline?
* Who should stop cervical cancer screening?
A
- Screening should begin at age 25
- Women aged 25-65 should have HPV test q 5 years combined with PAP test or a PAP test alone q 3 years
- Women over 65 who have had regular screenings for past 10 years with no history of CIN2 or more serious diagnosis should stop cervical cancer screening
13
Q
Cerival cancer
* What is the most primary initating event? What is it?
* What are other risk factors?(4)
A
HPV infection is the primary initiating event
* HPV a double stranded DNA virus infects epithelium near transformation zone.
* HPV 16 & 18 most frequently associated
Other risk factors: Multiple sex partners, first intercourse <18yo, smoking, STD and DES exposure
- Most women are infected with HPV, but most clear it.
- Some women keep a chronic infection, and it is thought there is a genetic predisposition associated
14
Q
Screening for cervical cancer
* What test
* make take how long to progress?
* Primary prevention is what?
A
- Pap test
- May take years to progress from dysplasia to cancer
- Primary prevention is via HPV vaccines
15
Q
Clinical Presentation: Cervical cancer
* What are the early stages and later stages?
A
Early stages are asymptomatic
Later stages:
* Post-intercourse bleeding
* Intermenstrual cycle bleeding
* Persistent yellow discharge
* Foul smelling discharge
* Heavy menstrual bleeding
* Pelvic/sacral pain
* Most common presentation of later stage cancer is a visible lesion on the cervix
16
Q
A
17
Q
cervix cancer
* how do you dx it?
A
- Most found during Pap test screening of asymptomatic women
- Colposcopy with biopsy
- MRI or PET-CT used for staging
18
Q
cervix cancer
* What are all the different treatments? (5)
A
19
Q
How do you do cryotherapy?
A
20
Q
Cervix cancer
* How do you conization/cone biopsy?
A
21
Q
Cervix cancer
* How do you do a loop Excisional Biopsy?
A
22
Q
A
23
Q
LSIL Management
A
24
Q
HSIL Management
A
25
AGC Management
* What do you for Atypical endocervical cells, favor neoplastic ; or Atypical glandular cells, favor neoplastic ?
* Colposcopy
* Endocervical Bx
* Diagnositic excisional cervical procedure
26
AGC Management
* What do you do for adenocarcinoma in-situ?
* Colposcopy
* Endocervical Bx
* Diagnositic excisional cervical procedure
27
Atypical Glandular Cells Management
28
Cervical Dysplasia Summary:
* What do you do if pap result show ASCUS or LSIL/CIN I
| ⭐️TEST
Test for HPV
Repeat pap in 2-12 months
If the pap shows ASCUS/LSIL CIN I is present again then perform a colposcopy: use of a colposcope to visualize vulva, vagina and cervix with magnification to evaluate benign, premalignant and potentially malignant disease
**The lesions will turn white when acetic acid is applied**
* **Higher grade will cause greater/more rapid absorption** (Higher grade= more white and faster)
29
Cervical Dysplasia Summary:
* What do you do if pap result shows HSIL/CIN II or III
LEEP or colposcopy and biopsy
30
Cervical Dysplasia Summary:
* What do you do if pap result shows AGC?
AGC can indicate adenocarcinoma in situ
* Repeat pap with endocervical brush, and if confirmed:
* Endometrial bx and cone bx of cervix
31
Cervical cancer: Prognosis
* Dependent on what?
* What is the treatment?
* How is it preventable?
* **Gardasil vaccination targets what HPV Strands?**
| ⭐️TEST
32
33
What is this?
Vestibulitis
34
Vulvar Intraepithelial Neoplasia: VIN, usualy type
* Occurs in who? What are the risk factors?(3)
* Occurs in younger, premenopausal women
* Risk factors: HPV infection, cigarette smoking, immunodeficiency or immunosuppression
35
Vulvar Intraepithelial Neoplasia: VIN, usualy type
* What does basaloid subtype have?
* What is warty subtype?
* Basaloid subtype has a thickened epithelium with a relatively flat, smooth surface
* Warty (condylomatous) subtype is characterized by a surface that is undulating or spiking, giving it a condylomatous appearance
36
Vulvar Intraepithelial Neoplasia: VIN, differentiated type
* Comprises of how much?
* Typically occurs in who?
* Not often assoicated with what?
* Comprises less than 5 percent of VIN
* Typically occurs in postmenopausal women
* Not often associated with HPV infection
37
Vulvar Intraepithelial Neoplasia
* What are the clinical manifestations?
* Pruritis
* Visible lesions
* Palpable abnormality
* Perineal pain or burning
* Dysuria
* 50% asymptomatic
38
Vulvar Intraepithelial Neoplasia
* What is for definitive dx?
* Tissue biopsy for definitive diagnosis; biopsy sites are identified by physical examination and colposcopy
39
40
What is this?
VIN usual
41
Vulvar Intraepithelial Neoplasia
* What are the goals of treatment?
Goals of treatment are to prevent development of invasive vulvar cancer and relieve symptoms, while preserving normal vulvar anatomy and function.
42
Vulvar Intraepithelial Neoplasia
* What are the management options?
Surgical
Topical treatment
* Imiquimod cream (Aldara®)
* 5-fluorouracil cream
43
Vulvar Intraepithelial Neoplasia
* Despite treatment, what happens?
* When is f/u?
* Despite treatment, VIN recurs in one-third of women
* Follow-up every six months for five years after the last treatment and then annually
44
Vulvar Intraepithelial Neoplasia
* 4-8% of patients develop what?
* What could prevent 2/3 of neoplasia?
* 4 - 8% of patients develop locally invasive cancer
* Prophylactic HPV vaccination could prevent 2/3 of vulvar, vaginal, and perianal intraepithelial neoplasia in younger women
45
Ovarian cyst:
* most ovarian masses are what?
* Divided into what?
* Difficult to do what?
* Majority is what?
46
Ovarian cyst: Signs & Symptoms
* Most are what?
* What is the MC sxs?
* When should you think torsion?
* Most are asymptomatic
* Pain is most common symptom
* Acute, severe pain with vomiting--think torsion
47
Ovarian cyst-Sxs
* How is the pain?
* May be accompanied by what?
* What is on pelvic exam?
48
What are the functional ovarian cysts?(3)
* Follicular cyst
* Corpus luteum cyst
* Theca luteum cyst
49
What are the benign ovarian neoplasms?(3)
* Epithelial cell tumors
* Germ cell tumors
* Stromal cell tumors
50
Functional Ovarian Cyst
* What is a follicle?
* Development and release of what?
* What is corpus luteum?
* Follicle: Contains a single oocyte (egg); once a month, hormonal influences stimulate growth
* development and release of a single, competent oocyte (ovulation)
* Corpus Luteum: develops from an ovarian follicle following the release of an oocyte from the follicle during ovulation.
51
# ⭐️⭐️⭐️⭐️
52
Follicular Cyst
* Forms when?
* Presents as what?
* Clinically significant when?
* Rupture may cause what?
* How do you evaluate?
* Forms when an ovarian follicle fails to rupture
* Presents as a unilateral (ovulate from one side only), +/- palpable, mobile adnexal mass
* Clinically significant if large enough to cause pain
* Rupture may cause acute pain
* U/S to evaluate
53
Follicular Cyst
* Most do what?
* What may prevent the development of new cyst?
* What is no longer used?
* When is cystectomy considered?
* Most resolve spontaneously within 60 days
* OCPs may prevent development of new cyst
* “Therapeutic” aspiration is no longer used due to high rate of recurrence
* Consider cystectomy if symptomatic or large (≥ 5cm)->High risk of torsion
54
Corpus Luteum Cyst
* Develops after what?
* Size?
* Develops after the oocyte is released from the follicle (end of the menstrual cycle)
* May reach 5-12cm in size
55
Corpus Luteum Cyst
* May do what?
* Increase risk for what?
* What is first line?
* What is for persistent cysts?
* May expand, fill with blood and rupture (if rupture - corpus hemorrhagicum)
* Increase risk for ovarian torsion
* Observation (up to three months) is first-line therapy even with hemorrhage or severe pain
* Cystectomy for persistent cysts
56
Theca Lutein Cyst
* Common or rare?
* Associated with what?
* Least common functional cyst
* Associated with pregnancy (Particularly molar pregnancy)-form as a result of overstimulation or hypersensitivity to hCG
57
Theca Lutein Cyst
* Usually what?
* Regresses how?
* Usually bilateral
* Regress spontaneously in weeks to months after source of hCG is eliminated (normal pregnancy is delivered or molar pregnancy is eliminated).
58
# ⭐️⭐️⭐️
What is a must in the eval of ovatian cysts with acute pain?
* Rule out Ectopic Pregnancy!
* Any adnexal finding evaluation must include a serum beta hCG test to rule out pregnancy.
59
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Benign vs. Malignant in Premenopausal Women
* What are the different sizes+ what you need to do?
60
# ⭐️⭐️⭐️⭐️
In Postmenopausal Women……
* What are the different sizes+what you need to do?
61
What is a tumor marker?
CA 125
62
Ovarian Cyst Pearls
* Vast majority are what
* What are the red flags?
* What is typically required?
63
Polycystic Ovarian Syndrome
* What are some sxs?
* Often presents as what?
* Ranging from what?
* What are on ovaries?
* Chronic anovulation, polycystic ovaries and hyperandrogenism.
* Often presents as a menstrual disorder.
* Ranging from amenorrhea to menorrhagia and infertility
* Numerous cystic lesions on ovaries.
64
Clinical sxs of PCOS
* What is the classic clinical presentation?
* Oftern presents as what type of disorder?
* What happens to the face?
* Higher risk of what?
65
# ⭐️
Dx of PCOS
* What are the labs?
66
# ⭐️⭐️
Dx of PCOS
* What is the imaging?
Pelvic US may reveal polycystic ovaries "sting of pearls"
67
Treatment of PCOS
* What do you give to a patient that desires to become pregnant
* What do you give to a paitent that does not desire pregnant?
* For patients who desire to become pregnant-Clomiphene
* For patient who do not desire to become pregnant medrozyprogesterone actate for the first 10 days of every 1 to 3 months-may combine with contraceptive
68
Treatment of PCOS
* What do you do for hirsutism?
* What is teratogenic?
* What other supportive measures?
69
Metformin in PCOS
* Can produce what?
* Alters what?
* Positive effect on what?
* Can produce ovulatory cycles
* Alters insulin's effect on ovarian androgen synthesis to allow reutn of ovulation
* Positive effect on blood glucose and hyperinsulinemia
70
Metformin in PCOS
* What happens to the weight?
* Inhibits what?
* Less waht?
* Weight loss (10lbs)
* Inhibits ovarian gluconeogenesis and androgen synthesis
* Less androgens to conver into estrone that persistently promotes LH release
71
Benign Ovarian Neoplasms
* What is an adnexal tumor?
Adnexal Tumor – growths that form on the organs and connective tissues around the pelvic organs
72
Benign Ovarian Neoplasms
* Categorized by the cell type of origin: (3)
* Germ cell tumors (Ovarian teratoma) – most common
* Epithelial cell tumors
* Stromal cell tumors
73
Ovarian Teratoma
* What is it?
* Also called what?
* Arise from what?
74
Ovarian Teratoma
* How does it grow?
* May contain what?
* What is struma ovarri?
75
Solid Ovarian Mass
* Typically what?
* What do you need to do?
* Most common solid benign tumors are what?
* Typically, benign
* Are surgically removed to confirm
* Most common solid benign tumors are fibromas
76
Ovarian Cancer
* What are most of the tumor?
* Risks? (3)
77
Ovarian Cancer
* Most patients with OC are what?
* May have minor what?
* Advanced signs include what?
78
# ⭐️⭐️
Ovarian Cancer
* What serum marker is high?
* What imaging needs to be done?
* Serum CA125 elevated in 80% of women with epithelial ovarian cancer
* Imaging- US or MRI revels an ovarian mass
79
What is this?
Sister mary joseph node
80
Ovarian Mass Evaluation
* What size is usually benign?
* What requires surgical evaluation?
* What does oophorectomy allows for what?
* Simple cysts up to 5 cm in diameter are universally benign
* Larger masses, or masses that grow larger or unchanged on transvaginal ultrasound require surgical evaluation
* Oophorectomy (removal of ovary) allows for confirmation and staging
81
Ovarian cancer
* What is the treatment?
* Hysterectomy and bilateral oophorectomy and lymphadenectomy.
* In advanced disease, all visible tumor is removed.
* Postoperative chemotherapy
82
Ovarian cancer
* What is the prognosis?
83
Ovarian Torsion
* most often involves what?
* What is IDed in majority of cases?
* Accounts for what?
84
Ovarian Torsion
* Moste common in who?
* when do some of them occur?
* More commonly involves what?
85
Dx of ovarian torsion
* patients typically present with what?
* Typically locatized where?
* Patients typically present with sharp lower abdominal pain with a sudden onset that worsens over several hours.
* Typically localized to one side with radiation to the flank, groin or thigh
86
Dx of ovarian torsion
* What is a red flag?
* What is critical?
* May mimic what?
87
# ⭐️⭐️⭐️⭐️
Specific US Findings Indicative of Torsion
* What does the US show?
* Multiple follicles rimming an enlarged ovary
* “Bulls-eye” target, “whirlpool” or “snail shell” – rounded hyperechoic structure with multiple hypoechoic rings
* Disruption of vascular flow on doppler US
88
Management of ovarian torsion
* Rapid what?
* What is the goal?
* Must monitor for what?
* what is the retorsion rate?
89
Premenstrual Syndrome
* What is it?
“Cluster of physical, mood related and behavioral changes that occur in a regular cyclic relationship to the luteal phase of the menstrual cycle and that interfere with some aspect of the patient’s life.”
90
# ⭐️⭐️
Premenstrual Syndrome: Clinical work up
* R/O what?
* Dx based on what?
* Daily charting of what?
* Actual sxs less important than what?
* Rule out other possible causes for symptoms
* Diagnosis based on relationship of symptoms to the luteal phase of the cycle (one week before menstruation starts)
* Daily charting of symptoms
* Actual sxs less important than their cyclical pattern of occurrence
91
What is the PMS diagnostic criteria?
Patient reports at least one of the following symptoms during the 5 days before menses in each of three cycles:
92
Premenstrual Syndrome: Diagnostic Criteria
* Sxs are relieved when?
* What must exist for dx?
* Patient experiences dysfunction in what?
* Symptoms are relieved within 4 days of the onset of menses
* A monthly symptom free period during the follicular phase must exist for diagnosis
* Patient experiences dysfunction in social or economic performance (depends on intensity)
93
What is the Premenstrual Dysphoric Disorder (PMDD) Diagnostic Criteria?
Patient reports ≥ 5 of the following sxs during most of the last week before menses in most cycles during the past year; at least one sxs must be a “core symptom” (*):
94
Premenstrual Syndrome
* What is the etiology?
Current theory is that of serotoninergic dysregulation
* Progesterone potentiates monoamine oxidase (MAO)
* MAO reduces serotonin
* Therefore, less serotonin is available during the progesterone dominant luteal phase
95
Premenstrual Syndrome Treatment
* What are the lifestyle modifications?
96
Premenstrual Syndrome Treatment
* What do you do for pain?
* What do you take during luteal phase?
* NSAIDS: dysmenorrhea, breast pain and leg edema
* Spironolactone: 100 mg daily during luteal phase
97
# ⭐️⭐️⭐️
Premenstrual Syndrome Treatment
* What do you give for mod- severe PMS or PMDD?
* What do you give for suppressing ovulation?
SSRIs (Therapy of choice in moderate to severe PMS or PMDD)
* Fluoxetine, Sertraline, Paroxetine, Citalopram
Suppressing ovulation (not helpful in PMDD)
* OCPs
* Danazole-modified testosterone
* Gonadotropin-releasing hormone (GnRH)
