Gyncaeological Malignancies + Infections Flashcards
Identify risk factors for CERVICAL CANCER.
✔️ young age of first intercourse ✔️ multiple sexual partners ✔️ regular / infrequent unprotected sexual intercourse ✔️ low SES ✔️ low health literacy ✔️ unvaccinated / partially vaccinated ✔️ immunocompromised ✔️ not up to date with CSTs ✔️ concurrent STIs
Explain the pathogenesis of CERVICAL CANCER.
99% of cases of cervical cancer are caused by the HUMAN PAPILLOMA VIRUS (HPV).
90% of cancers are squamous cell carcinoma (SCC).
10% of cancers are adenocarcinoma.
HPV has two genes that it inserts into the human genome:
✔️ E6
✔️ E7
These genes promote change within the transitional zone of the cervix, where columnar epithelium becomes stratified squamous epithelium.
Cervical cancer takes ~10 years to develop from the time of exposure to time of diagnosis.
What are clinical symptoms of cervical cancer?
✔️ post-coital bleeding ✔️ inter-menstural bleeding ✔️ post-menopausal bleeding ✔️ urinary symptoms (e.g. incontinence, retention) ✔️ pain with intercourse ✔️ abdominal mass / pain ✔️ asymptomatic
What is the CIN classification system for cervical cancer versus the LSIL / HSIL classification system?
CERVICAL INTRAEPITHELIAL NEOPLASM (CIN)
CIN I - one third thickness invasion
CIN II - two thirds thickness invasion
CIN III - full thickness invasion
LSIL / HSIL
LSIL - CIN I
HSIL - CIN II and III
Explain the screening guidelines for CERVICAL CANCER.
CST should be performed every 5 years from 25 years of age or TWO years after first experience of intercourse, whichever is later.
CST can return THREE possible results:
✔️ HPV not detected
✔️ HPV detected (not 16 or 18)
✔️ HP detected (16 or 18)
HPV NOT DETECTED –> repeat CST in 5 years time
HPV DETECTED (NOT 16 OR 18) –> reflex LBC
✔️ LSIL –> repeat CST in 12 months
✔️ HSIL –> colposcopy within 6 months
HPV DETECTED (16 OR 18) –> colposcopy within 6 months
Colposcopy is a procedure in which the cervix is stained with a die (either acetic acid or iodine). This enables lesions to be visualised and biopsied –> sent for histology.
Outline the appropriate management for cervical cancer.
Management of cervical cancer is based on the CIN gradings.
CIN I - repeat CST in 12 months
CIN II - large loop excision for transitional zone (LLETZ) or cone biopsy
CIN III - LLETZ, cone biopsy or cold-knife excision
Depending on involving of lymph nodes / adjacent tissue, chemotherapy, radiotherapy or hysterectomy may be required.
Identify risk factors for ENDOMETRIAL CANCER.
Anything that increases lifetime oestrogen exposure increases an individuals’ risk of endometrial cancer.
✔️ increasing age ✔️ post-menopausal ✔️ previous unopposed oestrogen therapy (e.g. HRT) ✔️ nulliparous (no previous pregnancies) ✔️ obesity / increased BMI ✔️ smoking ✔️ PCOS (chronic anovulation) ✔️ early menarche / late menopause ✔️ confirmed endometrial hyperplasia
What are some clinical symptoms of endometrial cancer?
✔️ post-menopausal bleeding ✔️ post-coital bleeding ✔️ inter-menstural spotting / AUB ✔️ pelvic mass ✔️ urinary symptoms ✔️ B symptoms (e.g. fever, weight loss, night sweats)
Ddx for post-menopausal bleeding?
✔️ vaginal atrophy ✔️ endometrial atrophy ✔️ cervicitis ✔️ polyps (endometrial or cervical) ✔️ endometrial cancer ✔️ cervical cancer
Identify the four stages of ENDOMETRIAL CANCER.
STAGE I - confined to the endometrium (no myometrial invasion)
STAGE II - invasion of myometrium or endocervical glands / stroma
STAGE III - invasion of local organs / tissues
STAGE IV - metastatic involvement
What are some Ddx for PELVIC MASS?
✔️ pregnancy ✔️ adenomyosis ✔️ leiomyoma ✔️ polycystic kidney disease ✔️ renal cell carcinoma ✔️ ovarian cyst ✔️ ovarian cancer ✔️endometrial cancer
CHLAMYDIA ✔️ pathogen ✔️ risk factors ✔️ clinical symptoms ✔️ investigations and diagnosis ✔️ management
PATHOGEN
Chlamydia trichomonas
RISK FACTORS ✔️ young age (<29 years) ✔️ multiple sexual partners ✔️ regular unprotected sexual intercourse ✔️ Indigenous ✔️ MSM ✔️ sex workers ✔️ previous or concurrent STI
CLINICAL SYMPTOMS Chlamydia in women presents as a cervicitis (inflammation of the cervix). ✔️ dysuria ✔️ deep dyspareunia ✔️ abnormal vaginal discharge ✔️ abdominal pain ✔️ asymptomatic
INVESTIGATIONS AND DIAGNOSIS
✔️ first pass urine sample (MCS)
✔️ endocervical swab (NAAT + MCS)
MANAGEMENT
1. Antibiotic management
✔️ 1g azithromycin PO, stat OR
✔️ 100mg doxycycline BD, PO for 7 days
- Advise NO sexual intercourse until completion of treatment (7 to 10 days)
- Contact tracing up to 6 months
- Treat contacts
- Notify public health
- Advise on safe sex practices in the future
- Follow up in one week
- Test of clearance in 3 months
GONORRHEA ✔️ pathogen ✔️ risk factors ✔️ clinical symptoms ✔️ investigations and diagnosis ✔️ management
PATHOGEN
Neisseria gonorrhoea
RISK FACTORS ✔️ young age (<29 years) ✔️ multiple sexual partners ✔️ regular unprotected sexual intercourse ✔️ Indigenous ✔️ MSM ✔️ sex workers ✔️ previous or concurrent STI
CLINICAL SYMPTOMS Gonorrhoea causes a cervicitis in women. ✔️grey-white discharge ✔️ dysuria ✔️ deep dyspareunia ✔️ abdominal pain ✔️ asymptomatic
INVESTIGATIONS AND DIAGNOSIS
✔️ first pass urine sample (MCS)
✔️ endocervical swab (NAAT + MCS)
MANAGEMENT
1. Antibiotic management
✔️ 1g azithromycin PO, stat plus
✔️500mg ceftriaxone IM, stat
- Advise NO sexual intercourse until completion of treatment (7 to 10 days)
- Contact tracing up to 2 months (minimum)
- Treat contacts
- Notify public health
- Advise on safe sex practices in the future
- Follow up in one week
- Test of clearance in 3 months
TRICHOMONAS ✔️ pathogen ✔️ risk factors ✔️ clinical symptoms ✔️ investigations and diagnosis ✔️ management
PATHOGEN
Trichomonas vaginalis
RISK FACTORS
✔️ Indigenous women!!
CLINICAL SYMPTOMS
✔️ profuse, green / yellow vaginal discharge
✔️ foul fishy odour
✔️ strawberry cervix on speculum exam
INVESTIGTAIONS AND DIAGNOSIS
✔️ high cervical swab (wet swab)
MANAGEMENT
Metronidazole 2g PO, stat
SYPHILIS ✔️ pathogen ✔️ risk facrors ✔️ clinical symptoms ✔️ investigations and diagnosis ✔️ management
PATHOGEN
Treponema pallidum
RISK FACTORS ✔️ Indigenous ✔️ low SES ✔️ area of high prevalence ✔️ MSM ✔️ sex workers ✔️ concurrent or previous STIs
CLINICAL SYMPTOMS
Primary Syphilis (1 to 3 weeks after inoculation)
✔️ single, painless chancre
✔️ red and ulcerative
Secondary Syphilis (1 to 3 months after inoculation) ✔️ flu-like symptoms ✔️ myalgia ✔️ maculopapular rash on hands and feet ✔️ chills
Tertiary Syphilis (variable timeframe)
✔️ neurosyphilis
✔️ cardiosyphilis
INVESTIGATIONS ✔️ PCR swab of chancre ✔️ dark room microscopy ✔️ IgG or IgM antibodies (ELISE) ✔️ TPPA or TPHA ✔️ LP if tertiary neurosyphilis is suspected
MANAGEMENT
1. Antibiotic management
✔️2.4 million units of benzathine penicillin G IM, state
- Advise NO sexual intercourse until completion of treatment (7 to 10 days)
- Contact tracing up to 3 months (primary) OR 6 months (secondary)
- Treat contacts
- Notify public health
- Advise on safe sex practices in the future
- Follow up in one week
- Test of clearance in 3 months, 6 months and 12 months
