Menopause/Cervical Screening Flashcards
What is Perimenopause?
time b4, during & after menopause aka menopausal transition
- uneventful or can have major Sx’s
- 90% have irregular menses for about 4 yrs
- 10% abrupt cessation of menses
What is menopause?
what is premature menopause?
permanent cessation of menses after cessation of ovarian fxn
- amenorrhea in the presence of signs of hypoestrogenemia & FSH >40
- climacteric
- median age 51
- premature menopause= before age 40 [1%]
What is postmenopausal period?!
What are some of the concerns associated with it?
more than 1/3 of a woman’s life!!!
CONCERNS: HRT, osteoporosis, CVD, sexual fxn, uterovag prolapse, skin, mood, hot flashes, vag atophy, incontinence
What hormonal changes are associated with menopause?
E?
FSH?
P?
androgens?
- follicles decrease [exhausted]–>inhibin decreases–>FSH rises–>eventual estradiol decline–>endometrial development fails–>absence of menses
-
E from aromatization of androgens [in muscle & adipose]
- obesity–>^^endometrial cancer
- thin–> osteoporosis, hot flashes
- **P ** prodxn ceases due to unopposed E [initially higher] & ^^endometrial cancer in early menoP
- androgens prdxn decreases [both from ovaries & adrenals]–> effect libido?
What happens to body mass in menopausal yrs?
- weight & total body fat ^^
- ^^ in waist:hip
- above 2 contribute to CVD risk
- HRT [E replacement] DOES NOT contribute to weight gain
What happens to collagen in menopausal women?
Collagen Decreases:
- thinning skin
- tooth loss
- atrophic vaginitis
- poor uterovag support–>cystocele, rectocele, enterocele, uterine prolapse
- urinary –> OAB, SUI, dysuria, ^^frequency
What is the cause of hot flashes?
pathognomonic Sx of menopause!!!! aka hot flush
- recurrent transient periods of flushing, sweating, heat sensation, often w/ palpitations, anxiety & chills [usually 2-3 yrs]
- up to 30/day for 1-5 min [avg = 5-10/day]
- >50% of women in natural menopause, even more w/ surgical menopause
- directly correlated to E levels–> correspond to GnRH pulses from hypothalamus [probably not the cause, but a marker for disturbance of thermoreg]
Wht are other common Sx’s of menopause?
- depression, anxiety, irritability, fatigue, insomnia
- loss of libido
- sense of loss of youth
- HAs [most women with migraines premenopause, have improved migraines after menopause]
- amenorrhea
What is abnormal uterine bleeding? AUB
What do we need to rule out?
Other possible causes?
menstrual irregularity
- >50% of women
- irregular, heavy, prolonged
- usually anovulatory
- RULE OUT PREGNANCY
- endometrial cancer [postmenopausal & AUB risk is 10%]
- EM hyperplasia, polyps, cervical cancer, fibroids, adenomyosis also possible
What are the Tx’s for AUB?
- meds: cyclic HRT, CCHRT, OCPs
- hysteroscopy/EM ablation/D & C
- hysterectomy
- none
How does menopause cause/contribute to osteoporosis?
What do we use to screen for osteoporosis?
how do we tx?
- post-menoP; BMD decreases by 1-2% per yr [whites & asians]
- 60yo= 25% have spinal compression fracture
- 80yo= 20% hip fracture, 15% die 6 mo later
- Screening: DEXA
- Tx: HRT, bisphosphates, calcitonin, SERMs, Ca++, VitD
What are risk factors for osteoporosis?
- white/asian
- low w8/height
- early menopausefamily Hx
- low Ca+ & vitD intake
- high caffeine, protein, & alcohol intake
- cigarette smoking
- DM
- hyperT
- Cushings
What is HRT?
who should/shoudl not use HRT?
SE’s?
Hormone Replacement Therapy [E+/-P, P with many types of admin]
- indicated if: hot flashes, vaginal atrophy, osteoporosis/high risk, osteopenia
-
contraindicated: pregnancy, unDx’d vag bleeding, active VTE, current GB dz, liver dz, unopposed ERT w/ uterus, CVD
- relative contraindications: hx of breast cancer, hx of VTE
- SE’s: vag bleeding, breast tenderness, mood changes
What is the WIH?
What should we conclude from this data?
Women’s Health Initiative–> study of HRT effects
-
women with uterus:
- increased: breast cancer, new CVD, embolic stroke, VTE
- decreased: colon cancer, & hip fracture
- NO increased mortality from all causes
-
women WITHOUT uterus:
- increased: embolic stroke, VTE
- no change: new CVD, colon cancer, hip fracture, breast cancer
- NO increased mortality from all causes
HRT has less side effects/comorbidities in women w/o uterus
What % of annual cervical cancer screening failures [i.e. new cervical cancer] is a false negative Pap responsible for?
30%!!!! or 3,651 women
What does ASC-US stand for?
LSIL
HSIL
ASC-H
AGS-NOS
AGS
AIS
- *ASC-US** - Atypical Squamous Cells of Undetermined Significance
- *LSIL** - Low grade Squamous intra-epithelial neoplasia
- *HSIL** - High grade Squamous intra-epithelial neoplasia
- *ASC-H** - Atypical Squamous Cells of Undetermined Significance can’t exclude high grade
- *AGS-NOS** - Atypical Glandular cells-NOS [not of significance?]
- *AGS** – favor neoplasia
- *AIS** - Adenocarcinoma in-situ
What do these cells show?
ASC-US: atypical squamous cells of undetermined signifcance
What do these cells show?
LSIL- low grade squamous intra-epithelial neoplasia
What do these cells show?
HSIL- high grade squamous cell intraepithelial neoplasia
What does CIN 1, 2, & 3 stand for?
CIS?
AIS?
- *CIN 1, 2, 3** - Cervical intra-epithelial neoplasia (mild, moderate, severe dysplasia)
- *CIS**- Carcinoma in situ
- *AIS** – Adenocarcinoma in situ
How do CIN 1-3 compare to/are part of LSIL & HSIL?
What type of cervical neoplasia is this?
how would it look on gross exam?
CIN-2
what type of cervical neoplasia is this?
CIN-3
What is one of the biggest contributors/risk factors to Cervical cancer?
HPV!!!
- identified in 99.7% of cervical cancers
- serotypes 16 & 18 are oncogenic and cause 70% of cervical cancers
- others do too but not as significant
- serotypes 16 & 18 are oncogenic and cause 70% of cervical cancers
- STD/I
- most HPV infections regress
What are other cervical cancer risk factors?
- HIV +
- Immunosuppressed
- Hx of abn tests in past 10 yrs
- Hx of cervical cancer
- Hx of CIN 2/3/CIS
- Hx of in utero DES exposure
What does a gynecologist think is a reasonable pattern of cervical cancer screening?
yearly Pap & pelvic
When [age] should we begin cervical screening tests?
Why do we wait until then to screen?
AFTER/AT 21 yo!!!
Wait til age 21 due to:
- HPV prevalence is high [25-505]
- 90% of cases of HPV infxn resolve w/in 24 mos
- dysplasia [CIN] is common [also regress spontaneously]
- Anxiety, Expense, maybe preterm labor
- cancer is rare
- .01% < 21 yo
What kind of screening should ages 21-29 yo’s get?
Screen w/ cervical cytology every 3 years
- DO NOT do HPV testing unless ASC-US present
- HPV test will help triage these pts
- OR if immunosuppressed, HIV+, DES exposed
What type of screening should females aged 30-65yo get?
who do we screen annually in this age grp?
USPSTF: screen w/ cytology alone every 3 yrs or w/ combo cytology & HPV testing every five
ALL other ORGANIZATIONS: screen w/ combo of cytology & HPV testing every 5 yrs [preferred]
- or cytology alone every 3 yrs
Annual screen: HIV+, immunosuppressed, Hx of DES exposure, maybe for Hx of CIN 1-3
What type of screening should we do on women greater than 65 yo?
USPSTF: DO NOT screen women who have had adequate prior screening & otherwise not @ high risk for cervical cancer
Everyone ELSE: DO NOT screen women who have adequate prior screening & no Hx of CIN2+ w/in past 20yrs
- DO NOT resume screening for any reason, even if woman has new sexual partner
WHat is adequate prior screening?
3 ocnsecutive (-) cytology screenings [at 3 yr intervals] w/in past 10 yrs
OR
2 consecutive (-) cotests [cytology & HPV] w/in past 10 yrs
How long/often do we screen HIV pts?
screen every 6mos until 2 pap tests are negative
THEN annual screening
How do we screen women who have had a total hysterectomy [uterus + cervix removed]?
USPSTF: DO NOT screen women who have undergone removal of cervix & have no Hx of CIN2+ or cervical cancer
Everyone ELSE: DO NOT screen for vaginal cancer in women who have hysterectomy and w/o Hx of CIN2+
- DO NOT resume screening for any reason
- CONTINUE SCREENING if Hx of CIN2/3/CIS/AIS/or cancer
When is HPV testing appropriate?
- triage >/= 21yo w/ ASC-US
- postmenoP omen w/ LSIL
- 1’ screen > 30 as an adjunct to cytology
- follow up after Tx of CIN2 or 3
- follow up after CIN-1 or (-) findings on colposcopy w/ prior Pap ASCUS, ASCH, LSIL, or AGS
NOT IN WOMEN <21 YO
How do we screen women who have been vaccinated for HPV?
What does Gardasil vaccinate against?
Screen the same as those unvaccinated
GARDASIL: HPV 16, 18, 6, & 11
- ages 9-26: 3 injxns given @ 0, 2, and 6 months [post initial vaccination]
What happens if Co-test results are discordant?
cytology (-) & HPV (+), 2 options:
- repeat cotesting in 1 year
- if HPV(-) & cyto is norm or ASCUS–> repeat cotesting in 5 yrs
- anything else–> do colposcopy
- immediate genotype specific testing for HPV 16 or 16/18
- HPV (+) = colposcopy
- HPV (-) = repeat cotest in 1 yr
- if after 1 yr is (-) & norm/ASCUS: repeat in 5 yrs
- anything else= do colposcopy
If a woman has previously had CIN 2 or higher, how long/often do we screen?
after regression: continue routine screening for @ least 20 yrs–> even if that means past age 65
