Gynecology Flashcards
Ontario Cervical Screening Guidelines
21-70 years
Interval 3 years if normal
Cessation at 70 if adequate negative screening history last 10 years (3 negative tests q 3y)
Exceptions
Previously treated for dysphasia - annual screening or HPV test and screening both negative q2y
Immunocompromised - annual screening
Total hysterectomy (patient does not have cervix) for benign disease - no screening
REMEMBER any visual cervical abnormality or abnormal sx should be investigated regardless of etiology findings
Abnormal cytology results
ASCUS - atypical squamous cells of undetermined significance
ASC-H - atypical squamous cells, cannot exclude HSIL
AGC - atypical glandular cells
LSIL - low grade squamous intraepithelial lesion
HSIL - high grade squamous intraepithelial lesion
Neoplasia - squamous carcinoma, adenocarcinoma, others
Follow up of ASCUS under age 30
- Repeat cytology in 6 months
- Abnormal result: colposcopy
- Negative result: repeat colpo - Repeat colpo in 6 months
- Abnormal: colpo
- Negative result: routine screening in 3 years
Follow-up ASCUS 30 years +
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Follow up of LSIL
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What’s the deal with Trichomoniasis
Only STI that you need vaginal culture for
Need to get to lab <12h
Regular swab, mid vagina, rub well on sides
Cervical cultures
For chlamydia and gonorrhea
Into cervical os 1-2 cm, wipe away heavy discharge if needed
180o rotating into os (chlamydia intracellular)
Labelling needs to say “cervical culture”
Bloodwork
For HIV, Hepatitis C, Hepatitis B, Syphilis
Needs specific consent for HIV and document on chart
Remember latency periods - if concerned about recent contact repeat at 3 and 6 months
Urine Test (PCR)
Now available for chlamydia and gonorrhea
Culture still gold standard
Need dirty urine (urethral) first stream 20 mL (as opposed to UTI need midstream) - no voiding for 2h before taking sample
Diagnosing Herpes
No accepted screening test
Very common - 75% HSV1, 20% HSV 2 (no longer great distinction between oral and genital)
If lesion present - need to open intact vehicle (carefully! With a needle) and culture the liquid with a special swab with liquid virus transport medium - send to lab ASAP within hours
Pharynx swab tests for
Gonorrhea
Hepatitis C screening
Because there is treatment now, 45 years+ everyone gets Hep C testing
Rectum swab tests for
Gonorrhea and Chlamydia
Syphilis
- Starts at soft chancre that is painless at the site of entry (usually genitals) — thus less likely to diagnose as primary syphilis
- First lesion resolves
- Rash and swollen nodes
- Tertiary syphilis with brain, liver manifestations
Pelvic inlet
Sacrum
Ileopetineal line
What nerve is at risk of denervation during childbirth
Pudendal nerve
Internal pudenedal nerve and vessels pass behind the ischial spine through Alcock’s canal.
Components of the lavatory ani muscles
Iliococcygeus
Pubococcygeus
Puborectalis
Role of elevator ani muscles
Pulls rectum
Uterosacral ligament origins
Originate from S2-4
Pelvic diaphragm
Legatos ani plus _ coccygeus muscles posteirorly and fasciae coverings of these muscles
Urogenital diaphragm
External to pelvic diaphragm
Comprised of deep
Parasympathetic innervation of the bladder
ACh
Muscarinic (M2 + M3)
S2-S4
Sympathetic innervation of the bladder
NA
Alpha1 and beta 3 adrenoreceptors
T10-12
Somatic innervation of the bladder
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Risk factors for urinary incontinence
Immobility Medcition use Smoking - nicotine and cough (valsalva) Chronic valsalva maneuvers (constipation) Pelvic floor relaxation Pregnancy and childbirth Obesity Neurological problems Hypoestrogenic state - tissues weakened and dry and can fracture with hypoestrogen
Stress incontinnece definition and etiology
Involuntary loss of urine during increased intra-abdominal pressure
Etiology
Displacement of UVJ from normal anatomic location (lets urine go before tube hits the back wall, which provides the back pressure to close the tube. This is because the back wall is more floppy and the tube takes more time to get there)
Intrinsic sphincter deficiency (tube is very rigid such as past surgery or radiation and becomes more like a tube. ISD is like a plastic straw vs paper straw)
Urge incontinence definition and etiology
Known as overactive bladder now
The involuntary loss of urine preceded by strong urge to void whether or not the bladder is full
Etiology:
Detrusor instability — overactive wet
Bladder irritants — overactive dry (this one is just giving in to sensation to pee at a certain volume, usually no nocturia)
Overflow incontinence
Urine loss associated with over distension of the bladder
Etiology
Obstructive
Neurogenic
Functional incontinence
Mental or physical issues may prevent individual from reaching the toilet in time
Such as dementia, or mobility, environmental factors
If you have women with new overflow incontinence and no previous surgical history, what condition do you have to rule out
MS
Most common type of fistula in women
Bladder and vagina (vesicuvaginal fistula)
Most common cause of vesicovaginal fistulas in developed world
Hysterectomy
Abdominal hysterectomy more commonly because bladder is empty and cleared and easier to miss, vs vaginal
Most common cause of vesicuvaginal fistula in developing country
Prolonged labour (constant pressure on bladder from baby’s head causes ischemia)
Pelvic organ prolapse
Hernia like protrusions
Types of prolapse
Cystocele (anterior vaginal prolapse)
Rectocele (lower posterior vaginal prolapse)
Enterocele (upper posterior vaginal prolapse)
Apical vaginal/uterine prolapse
Etiology uterine prolapse
Poor cardinal or uterosacral ligament support
Potential complications of cytocele
High PVR and risk of recurrent UTIs due to kinking of the urethra and difficulty voiding. This can result in renal implications
Rectocele etiology
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Enterocele etiology
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Rectocele complication
Chronic constipation, diarrhea
Flatal, fecal incontinence
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Baden Walker Classification system
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Urogynocological exam
Stroke labia and then clitoris with q tip
Looking for symmetric rise of the legatos ani muscles
If not symmetric rise need to investigate MS
Prolapse examination
Empty bladder before examination
Q tip test
Q tip in urethra
30o+ of hyper mobility is positive test
Stress incontinence management
Kegels
Topical estrogen, alpha adrenergics (no longer used due to hypertension), duloxetine (no longer available)
Prolapse devices
Surgery
Urge incontinence management
Decrease caffeine and nicotine Bladder drill Vaginal estrogen Medications - anticholinergics, beta 3 agonist Pessary Surgery
What are the most common HPV types that cause cervical cancer?
HPV type 16 and 18 account for 75% of all cervix cancers
Risk factors for cervical cancer
Smoking Immunosuppression HIV Chlamydia High parity OCP use HPV
Acetowhite area on colposcopy meaning
Hallmark of dysplasia
Investigations for gross lesion on cervix
Biopsy needed to rule out cancer and look with colposcope
Pap smear is NOT appropriate
Cervix cancer symptoms
- Abnormal vaginal bleeding
- Pelvic pain
- Involuntary loss of urine or feces through the vagina
- Hydronephrosis due to ureter obstruction
- Weakness, weight loss and anemia
Most common type of cervix cancer
Squamous cell (>60%)
Adenocarcinoma 30%
Unspecified
Consistent decline in SCC, unclear why adeno is on the rise
All due to HPV
Cervical cancer treatment
Early- surgery (stage I)
Locally advanced disease - chemoradiation with external beam radiation and intracavitary brachytherapy with chemo as radiosensitizer
Most common gynaecological malignancy in North America
Endometrial cancer
Endometrial cancer risk factors
Increased estrogen
- Endogenous (obesity, polycystic ovarian syndrome, anovulation/infertility, early menarche, late menopause, nullip)
- Exogenous (Tamoxifen)
HNPCC Syndrome (Lynch Syndrome) - these patients should be screened with endometrial biopsy/TVUS for endometrial thickness
Endometrial cancer signs and symptoms
Signs - obesity, acanthosis nigricans, stigmata of diabetes
Symptoms - Unscheduled vaginal bleeding (postmenopausal, non bloody vaginal discharge)
- pelvic pain, pressure, mass, weight loss in more advanced disease
Most common type of pathology of endometrial cancer
Adenocarcinoma
Histology - endometrioid
Endometrial cancer treatment
Gold standard is surgery - total abdominal hysterectomy, bilateral salpingo-oophorectomy (+/- pelvic nodes)
Surgery is only not recommended if comorbidities that would decrease surgical success
Radiation
- Primary therapy (rare)
- Adjuvant treatment (based on tumour factors)
Precursor to endometrial cancer
Endometrial hyperplasia
Architecture - simplex or complex
Cellularity - atypia or no atypia
Ovarian tumour types and epidemiology
Epithelial tumours - women 50-60s
Germ cell tumours - younger women
Stromal tumours - any age, very uncommon (ex. Granulosa cell tumour, Sertoli-Leydig cell tumour)
Ovarian cancer treatment
Surgery and chemo
Ovarian cancer etiology
Genetic (BRCA 1 and 2) and HNPCC Molecular mechanisms (loss of p53 tumour suppressor gene found in 55% of ovarian cancer)
Ovarian cancer risk factors
Industrialized countries where dietary fat intake is high, have higher incidence
History of nulliparity, infertility, late childbearing and delayed menopause increase risk
OCP reduces risk, prophylactic oophorectomy
Ovarian cancer signs and symptoms
Vague and usually diagnosed late (highest mortality rate of all gynecologic malignancies)
Appetite, N/V
Abdominal girth
Bladder, bowel
Ovarian cancer screening
Ca 125
Ultrasound
Usually in symptomatic or post menopausal women
Vulvar cancer etiology
HPV strongly associated in young, not in older women
Vulvar cancer risk factors
Smoking
Immunosuppression
Vulvar cancer signs and symptoms
Pruritus or mass is presentation for more than 50% of women
Pain
Bleeding
20% of women are asymptomatic
Vulvar cancer diagnosis
Lesion biopsy from edge (compare normal to abnormal tissue)
Vulvar cancer treatment
Staging is surgical, radical local excision and evaluation of regional nodes
