Gynaecology clinic Flashcards
How are HPV results reported?
HPV 16/18 detected
Oncogenic HPV (not 16/18) detected
Oncogenic HPV not detected.
HPV strains 16 and 18 cause what % of cx cancer?
70%
Ranzcog guideline.
How many oncogenic types of HPV can the CST detect?
14
If a women has a negative CST test, when should she return for CST screening?
5 years
Which is the most common type of cx ca? squamous vs adenocarcinoma?
squamous 80%
adenocarcinoma 20%
What ages do we screen for Cx ca?
25-74, who has ever been sexually active, including same-sex relationships, even if they have received HPV vaccination.
What are the three outcomes of HPV screening?
There are three risk categories:
• Women who are classified as Low risk will be re-invited to re-screen in five years.
• Women who are classified as Intermediate risk will be invited to have another HPV test in 12 months. This is to check that the infection has cleared.
• Women classified at Higher risk will be referred directly to colposcopy for further investigation
What happens if a women’s HPV screening turns up an unsatisfactory result?
Invited to retest for HPV in 6 months.
A HPV test demonstrates a non-16/18 HPV strain. What happens next?
LBC -> if neg - > 5 yearly screening
LBC ->pLSIL/LSIL -> repeat screen in 12 months
LBC -> pHSIL/HSIL - > colposcopy
A serial HPV screening in 12 months from a previous screen that detected HPV non-18/16 demonsrated persisting HPV infection. What happens next?
LBC + colposcopy.
Define PID?
Pelvic inflammatory disease (PID) is an infection of the female upper genital tract and may involve the uterus, fallopian tubes, ovaries and, occasionally, adjacent pelvic structures. Pelvic inflammatory disease includes endometritis, salpingitis, tubo-ovarian abscess, pelvic cellulitis and pelvic peritonitis.
Describe the microbiological origins of PID?
usually polymicrobial
Chlamydia trachomatis is the most commonly identified sexually transmitted pathogen, followed by Neisseria gonorrhoeae and Mycoplasma genitalium
How does PID differ from post-procedural pelvic infection in terms of micro?
PPPI is usally caused by vaginal flora (c.f. STIs with PID)
You suspect a women has PID and decide to undertake endocervical swab. What tests do you request?
nucleic acid amplification testing (NAAT) (eg polymerase chain reaction [PCR]) for C. trachomatis, N. gonorrhoeae, and M. genitalium
Gram stain and culture of N. gonorrhoeae for susceptibility testing.
When would you consider IV ABX for a women with PID? (7)
pregnancy
inability to tolerate oral therapy
severe pain
fever (38°C or higher)
systemic features (eg tachycardia, vomiting)
sepsis or septic shock
suspicion of tubo-ovarian abscess.Prompt treatment of pelvic inflammatory disease (PID) reduces the risk of …?
tubal damage and, consequently, infertility, ectopic pregnancy and chronic pelvic pain.
Empirical therapy for non-severe PID?
ceftriaxone 500 mg in 2 mL of 1% lidocaine intramuscularly, or 500 mg intravenously, as a single dose [Note 1]
PLUS
metronidazole 400 mg orally, 12-hourly for 14 days
PLUS EITHER
1. doxycycline 100 mg orally, 12-hourly for 14 days
OR for patients who are pregnant, breastfeeding [Note 2] or likely to be nonadherent to doxycycline
2 azithromycin 1 g orally, as a single dose, repeated 1 week later.
Describe empirical therapy for severe PID?
1) ceftriaxone 2 g intravenously, daily; for adults with septic shock or requiring intensive care support, use 1 g intravenously, 12-hourly. See Modification and duration of therapy for severe PID
OR
1) cefotaxime 2 g intravenously, 8-hourly; for adults with septic shock or requiring intensive care support, use 2 g intravenously, 6-hourly. See Modification and duration of therapy for severe PID
PLUS (with either of the above drugs)
azithromycin 500 mg intravenously, daily; see Modification and duration of therapy for severe PID
PLUS
metronidazole 500 mg intravenously, 12-hourly; see Modification and duration of therapy for severe PID.
How is endometrial hyperplasia classified?
Hyperplasia without atypia
Atypical hyperplasia.
What diagnostic and surveillance methods are available for endometrial hyperplasia?
Endometrial sampling by outpatient endometrial bx
Diagnostic hysteroscopy (considered to facilitate or obtain an endometrial sample, especially where outpatient sampling fails or is non-diagnostic)
What is the risk of endometrial hyperplasia without atypia progressing to endometrial ca?
How should endometrial hyperplasia without atypia be managed?
Risk of EHWA progressing to EC = < 5% over 20 years.
- > the majority of the cases of EHWA will regress spontaneously.
Correct reversible causes:
e.g. obesity, HRT
F/U with serial bx
OR
treatment with progestogens has a higher disease regression rate compared with observation alone.
Progestogen treatment is indicated in women who fail to regress following observation alone AND in symptomatic women with abnormal uterine bleeding.
What should be first line medical treatment of EHWA?
Both continuous and local intrauterine progestogens are effective in achieving regression.
LNG-IUG = 1st line (b/c compared with PO progestogens it has a higher disease regression rate with a more favourable bleeding profile and it is a/w fewer adverse effects.
For women with EHWA who opt for PO progestogens, what medication + doses can you offer?
Medroxyprogesterone 10-20mg/day or norethisterone 10-15mg/day
What should the duration of treatment and f/u of EHWA be?
Tx with progestogens for a minimum of 6 months in order to induce histological regresion of EHWA.
If adverse effects are tolerable and fertility is not desired, women should be encouraged to retain teh LNG-IUS for up to 5 years as this reduces relapse.
Offer OPD endometrial surveillance at 6 monthly intervals. At least two consecuitive 6 monthly neg bx should be obtained prior to d/c.
Advise women to seek further referral if abnormal vaginal bleeding recurs after completion of tx as may indicate disease relapse.
Nb: women at higher risk, i.e. high BMI, PO progestogens should be followed up with annual endometrial biopsies following two neg bx results.
