Menopause and Pap Smear

Question 1

Pap Smear

Answer 1

Normal = negative for intraepithelial neoplasia
Atypical Squamous Cells of Undetermined Significance
ASC - H
Low-grade squamous intraepithelial lesion
High-grade squamous intraepithelial lesion
Squamous Cell Carcinoma
Atypical Glandular Cells
AGC - favor neoplasia
Endocervical adenocarcinoma in situ

Question 2

Screening Recommendations

Answer 2

Annual at age 21, before 21 if pregnancy or other
>30 yrs with normal annual paps, every 3 years
- periodic screening if neoplasia high risk

Question 3

High Risk Factors

Answer 3

Multiple Partners, early age intercourse, partner had multiple partners, HPV, HSV, HIV, STDs, smoker, drugs

Question 4

Dysplasia

Answer 4

CIN 1 - mild dysplasia
CIN 2 - moderate dysplasia
CIN 3 - severe dysplasia
CIS - carcinoma in situ

Question 5

HPV

Answer 5

> 100 types, lots of oncogenes

• All grades of CIN and invasive cervical cancer contain HPV DNA
• Peak age 14-24

Question 6

Koilocytosis

Answer 6

cellular change from HPV –> perinuclear cavitation and nuclear atypia

Question 7

Squamous Cell Carcinoma

Answer 7

most common, often HPV 16

Question 8

Adenocarcinoma

Answer 8

2nd most common, HPV 18 and 45

Question 9

HPV infection is atypical

Answer 9

NOT bloodborne, no viremic phase

- immunoevasive nature limits host immune response

Question 10

Colposcopy

Answer 10

examination of cervix, vagina, vulva with magnifying instrument at 10-16x

• Acetowhite epithelium results from piling up of cells with increased nuclear-cytoplasmic ratio
• Mosaic pattern from neovascularization
• Punctation from perpendicular capillaries

Question 11

Colposcopy criteria

Answer 11

1. Sharpness of peripheral margin
2. Color of acetowhite staining
3. Type of vascular pattern
4. Iodine staining reaction (mustard yellow)
5. Adequate visualization of squamocolumnar junction

Question 12

Dysplasia Treatment

Answer 12

Superficial techniques can be used if:
- entire SCJ visualized, biopsy consistent with pap, endocervical curettage negative, no suspicion of occult invasion
Other techniques
- cone biopsy -> can't see SCJ, CIN 2-3
- hysterectomy

Question 13

Atypical Glandular Cells

Answer 13

atypical enometrial cells -> EMBX

>35 years or abnormal bleeding -> EMBX

Question 14

LSIL

Answer 14

No CIN/cancer -> cytology and coloposcopy

Question 15

HSIL

Answer 15

No CIN/CIN 1 Bx ->

• no change = diagnostic excision
• change = manage per guidelines

Question 16

HPV Vaccinations

Answer 16

HPV 6, 11, 16, 18

- recommended for girls age 11-12

Question 17

Perimenopause

Answer 17

time before, during, after menopause (transition)

• uneventful or major symptoms
• irregular menses for about 4 years

Question 18

Menopause

Answer 18

permanent cessation of menses after cessation of ovarian function
- amenorrhea in presence of signs of hypoestrogenemia and FHS >40

Question 19

Postmenopausal

Answer 19

more than 1/3 of woman’s life!
CONCERNS:
- osteoporosis, skin, mood, hot flashes, CVD, sex, vaginal atrophy, incontinence, HRT

Question 20

Hormonal changes

Answer 20

• follicles decrease, inhibin falls, FSH rises -> estradiol level decline -> endometrial development fails -> abscence of menses
• progesterone production ceases -> unopposed estrogen –> increased endometrial cancer early in menopause
• Androgens production decreases from both ovaries and adrenals -> libido?

Question 21

Physiologic Changes

Answer 21

1. Body mass -> weight and fat increase, CVD risk?
2. Decreased Collagen -> thinning skin, tooth loss, atrophic vagina, poor uterovaginal support
3. Hot Flashes -> pathognomonic for menopause, directly related to estrogen levels, GnRH pulses from hypothalamus
   - Other symptoms - depression, libido, loss of youth, headaches, amenorrhea

Question 22

Abnormal uterine bleeding

Answer 22

> 50% of women (perimenopausal)

- RULE OUT PREGNANCY!!!!!

Question 23

Osteoporosis

Answer 23

post-menopause bone density decreases 1-2% per year
- age 60 -> 25% spinal compression
- age 80 -> 20% hip fracture, 15% die in 6 months
Tx = HRT, bisphosphanates, calcitonin, SERMs, calcium, Vit D

Question 24

Hormone Replacement Therapy

Answer 24

Indications -> hot flashes, vaginal atrophy, osteoporosis, high risk
Contraindications -> pregnant, undiagnosed vaginal bleeding, active VTE, GB disease, liver disease

Question 25

Osteoporosis Risk Factors

Answer 25

White/Asian, low weight/height, early menopause, fam hx, low Ca, low Vit D, high caffeine, high alcohol, high protein, cigs, diabetes, hyperthyroidism, Cushings