menstrual cycle - cervical abnorm Flashcards
Function of Follicles and Oocytes
- The follicle is the basic functional unit of ovary
- Oocytes lie inside follicles in various stages of development
- Follicular maturation (folliculogenesis) accompanies the oocyte maturation process
- 120 day cycle from primordial to dominant (also called a Graafian follicle)
How does thyroid impact the HPO Axis
- Can impact the HPO axis!
- elevated thyrotropin releasing hormone (TRH) stimulates the pituitary gland to produce prolactin
- prolactin inhibits GnRH
- Can cause pregnancy loss and complications in fetal development
Steps in normal Menstrual cycle
Describe steps in the ovarian phase of the menstrual cycle
describes changes that occur in the follicles of the ovary
Follicular phase (corresponds to the proliferative phase of the uterine cycle)
- Luteal phase (corresponds to the secretory phase of the ovarian cycle)
- Oocytes are surrounded by granulosa cells and theca cells
- Granulosa cells contain FSH receptors and produce estrogen as well as convert androgens to estrogens
- Theca cells contain LH receptors and produce androgens
- Progesterone is produced by the corpus luteum
Oocytes are surrounded by ______ cells and _____ cells
functions of these cells?
- Granulosa cells contain FSH receptors and produce estrogen as well as convert androgens to estrogens
- Theca cells contain LH receptors and produce androgens
The Uterine (endometrial) Cycle consiste of
describes changes in the endometrial lining of the uterus.
Proliferative phase (corresponds to the follicular phase of the ovarian cycle)
- Secretory phase (corresponds to the luteal phase of the ovarian cycle)
- Menstruation (or pregnancy)
list steps in the HPO axis
- DEC estradiol levels cause hypothalamus to release GnRH to ant. pituitary
- anterior pituitary releases FSH and LH that stimulate granulosa cells of follicle to produce estradiol & LH stimulated theca cells to produce androgens
- due to INC estradiol of growing follicle FSH is suppressed
- INC in estrogen, progesterone and testosterone inhibit GnRH
- inhibin suppresses FSH
- INC in estrogen causes ant. pituitary to release surge of LH
- surge of LH = final maturation of egg and release from the follicle (ovulation)
FSH is suppressed by ____
INC estradiol of growing follicle
INC in estrogen, progesterone and testosterone inhibit ____
GnRH release from hypothalamus
DEC estradiol levels cause release of _____
GnRH from hypothalamus
Functions of FSH and LH
stimulate granulosa cells of ovarian follicle to produce estradiol
LH stimulates theca cells to produce andorgens
INC estrogen causes ??
ant. pituitary to release surge of LH
the final surge of LH causes?
final maturation of egg and release from follicle (ovulation)
define Amenorrhea
absence of menstruation
- may be transient, intermittent, or permanent ‒
- may result from dysfunction of the hypothalamus, pituitary, ovaries, uterus, or vagina
- primary versus secondary
causes of Amenorrhea
primary vs secondary
PRIMARY -
Gonadal dysgenesis – 43%
Mullerian agenesis – 15%
Constitutional delay of puberty – 14%
Polycystic ovarian syndrome (PCOS) – 7%
GnRH deficiency – 5%
Transverse vaginal septum – 3%
Weight loss/anorexia nervosa – 2% § Hypopituitarism – 2%
SECONDARY
PREGNANCY!
Hypothalamic – 35%
Pituitary – 17%
Ovarian – 40%
Uterine – 7%
Other – 1%
questions specific to PRIMARY Amenorrhea
- Completed other stages of puberty?
- Family history of delayed or absent puberty?
- Height in relation to family members?
- Normal neonatal and childhood health?
uestions specific to SECONDARY Amenorrhea
- Are there any symptoms of estrogen deficiency, including hot flashes, vaginal dryness, poor sleep, or decreased libido?
- Is there a history of obstetrical catastrophe, severe bleeding, dilatation and curettage, or endometritis or other infection that might have caused scarring of the endometrial lining (Asherman syndrome)?
Workup of amenorrhea
imaging and labs
Primary workup
- Evaluated most efficiently by focusing on the presence or absence of breast development, uterus, and FSH level
- Ultrasound ‒ If needed to determine whether uterus is present
LABS
- Human Chorionic Gonadotropin (hCG)
- Follicle Stimulating Hormone (FSH)
- Thyroid Stimulating Hormone (TSH)
- Prolactin (PRL)
- Testosterone if indicated
hypothalamic dysfunction is a common cause of (primary/secondary) amenorrhea?
and what may hypothalamic dysfunctuion present as?
SCONDARY
Constitutional delay of puberty
- Isolated GnRH deficiency
- Functional hypothalamic amenorrhea
- Other ‒ infiltrative diseases and tumors of the hypothalamus ‒ systemic illnesses
define dysmenorrhea
what causes it?
recurrent crampy lower abdominal pain that occurs during menstruation in the absence of pelvic pathology
primary versus secondary
Caused by excess production of endometrial prostaglandin F2 alpha
si/sx of Dysmenorrhea
Crampy lower abdominal or pelvic pain
Back pain
Nausea / Vomiting
Diarrhea
Headache
Fatigue
Dizziness
tx od dysmenorrhea
first and second line
First line – NSAID
•Most effective when begun early in onset of symptoms
•Ibuprofen or Naproxen
- Mefenamic acid if above not effective
- Always take with food!
- Acetaminophen is alternative if C/I to NSAIDs
Second Line – Hormonal
•Can also be appropriate 1st line treatment for patients who are sexually active
•OCPs prevent dysmenorrhea by suppressing ovulation, can take continuously
•Can also use transdermal patch or vaginal ring, injectable or implantable contraceptives, or levonorgestrel-releasing intrauterine devices
contrast PMS from PMDD
severe form of PMS in which symptoms of anger, irritability, and internal tension are prominent
tx of PMS / PMDD
Mild symptoms
Exercise
Stress reduction techniques such as relaxation techniques
Moderate to severe symptoms
- 1st line (SSRIs)
- 2nd line (OCPs) ‒ Can also consider augmentation with low-dose alprazolam
- 3rd line (GnRH) agonist therapy with low-dose estrogen-progestin replacement)
- 4th line surgery
Define Dysfunctional Uterine Bleeding (DMB)
usually caused by problem with?
abnormal uterine bleeding unrelated to anatomical lesions of the uterus, pelvic pathology, pregnancy, or systemic disease; usually caused by a problem with the HPO axis
Anovulation
dx of exclusion!!! - r/o EVERYTHING else
Key component to evaluation of dysfunctional uterine bleeding is to determine whether _______ is occurring
ovulation
define menopause vs premature ovarian insufficiency (POI)/premature ovarian failure (POF):
menopause
- permanent cessation of menstruation; defined retrospectively
- Average age of menopause is 51.4 years old in the USA
premature ovarian insufficiency (POI)/premature ovarian failure (POF): premature menopause before age 40
ages to evaluate for menopause:
If patient presents with irregular menstrual cycles +/- menopausal symptoms…
- If patient presents with irregular menstrual cycles +/- menopausal symptoms…
- <40 y/o -> complete evaluation
- 45-50 y/o -> evaluation similar to workup of oligo/amenorrhea, other causes of menstrual dysfunction must be ruled out
- >45 y/o -> diagnostic testing not recommended
pathophys of menopause
•Decline in the quality and quantity of follicles and oocytes
_1 . Granulosa cell_s in follicles stop making estrogen and inhibin
- Loss of inhibin = loss of the negative feedback loop to hypothalamus and pituitary
- Therefore FSH and LH increase in production by pituitary
- Ovary cannot respond to FSH
- Permanent amenorrhea once all follicles are depleted
tx for menopause
(MHT)
oral 17-beta estradiol: If baseline VTE and stroke risk low
- AVOIDED in:
- Hypertriglyceridemia
- gallbladder disease
- known thrombophilias
- migraine headaches with aura
transdermal 17-beta estradiol: Lower risk of VTE, stroke, & hypertriglyceridemia
vaginal estrogen:Will only treat vaginal atrophy, not hot flashes,
Progestin probably not needed , but maybe with vaginal creams due to higher systemic absorption
May be used indefinitely, low risk of adverse effects
- vaginal ring (estring)
- vaginal tablet (vagifem)
- vaginal cream (premarin or estrace)
- unopposed estrogen therapy (ET) for women s/p hysterectomy
- combined estrogen- progestin therapy (EPT) for women with an intact uterus
Unopposed estrogen therapy is a risk for developing endometrial hyperplasia!
•Give estrogen and progesterone bc progesterone is protective to the Uterus
Unopposed estrogen therapy is a risk for developing _______ ________.
Unopposed estrogen therapy is a risk for developing endometrial hyperplasia!
- Give estrogen and progesterone bc progesterone is protective to the Uterus
- combined estrogen- progestin therapy (EPT) for women with an intact uterus
non hormonal tx of menopause
Used for women who are not candidates for MHT due to breast cancer or cardiovascular risk
- SSRIs
- SNRIs
- anti-epileptics, and centrally acting drugs
low-dose paroxetine (7.5 mg/day) 1st choice because only drug that has received approval by the FDA for the treatment of hot flashes
Gabapentin (Neurontin) – especially if hot flashes occur primarily at night
CI of menopause hormonal therapy
- Breast cancer
- Coronary heart disease (CHD)
- Venous thromboembolism (VTE)
- Cerebrovascular accident (CVA)
- Transient ischemic attack (TIA)
- Liver disease
- Unexplained vaginal bleeding
- Endometrial cancer
•Infertility is defined as the inability to conceive after:
in women < 35 y/o = >12 months of regular intercourse / donor insemination without use of contraception
in women < 35 y/o = >6 months of regular intercourse or donor insemination without use of contraception
infertility work up female
Labs
TSH
Prolactin
CBC
ABO, Rh, & antibody screening
ovarian evaluation
Antral Follicle Count (AFC)
Anti-Mullerian Hormone (AMH)
Day 3 labs (FSH & estradiol) -> FSH is HIGH w/ LOW egg reserve, Measure at SAME time
Clomiphene Citrate Challenge Test (CCCT)
uterine evaluation
Hysteroscopy – look inside uterus w/ camera – no evaluation of tubes
Hysterosalpingogram (HSG) – first evaluation, looks at uterus and fallopian tubes (detect tubal lesions)
•Uncomfortable and not well tolerated
S_onohysterogram/Sonohystogram_ - saline infused into uterus w/ US guidance, can view ovaries as well
•More comfortable and well tolerated
tx for infertility
•Based on the underlying pathology
Based on the manipulation of the HPO axis via
Ovulation Induction vs. Controlled Ovarian Stimulation in combination with timed intercourse (TI), intrauterine insemination (IUI), or assisted reproductive technologies (ART)
•Lifestyle modifications and psychological/emotional support are important
Intrauterine Insemination (IUI) - Semen is spun down in the lab, washed, and injected into the uterine cavity via catheter threaded through the cervix
In Vitro Fertilization (IVF)
Cryopreservation
Si/Sx of PCOS
Irregular menstrual cycles (oligo- or anovulation)
Hyperandrogenism
Acne
Hirsutism
Male pattern (scalp) hair loss or thinning
Deeping of voice and clitoromegaly rare
Elevated serum testosterone
Obesity
Acanthosis nigricans
Mood changes
dx of PCOS
Rotterdam criteria (must have 2/3 of the following)
- Ovulatory dysfunction (oligo and/or anovulation)
- Chemical and/or biochemical signs of hyperandrogenism
- Polycystic “string of pearls” appearance of ovaries on transvaginal ultrasound
Tx of PCOS (FIRST LINE)
•Weight loss via diet and exercise is 1st line intervention
tx of PCOS in women pursing pregnancy and not pursing pregnancy
•In women not pursuing pregnancy
FIRST LINE - (OCPs)
SECOND LINE - Metformin
- Antiandrogens added after 6 months of OCP use if response suboptimal… 1st line is Spironolactone 50- 100 mg twice/daily
- GnRH agonists
•In women pursuing pregnancy
FIRST LINE - Letrozole
SECOND LINE - Clomid
•although Letrozole is not approved by the FDA for this indication
define vaginitis
and most likely causes
*General term for vag infxn, inflam, or chg in norm vag flora
Sx: Discharge change, pruritus, odor, discomfort/dyspareunia, dysuria
Majority is caused by infectious agents*:
**90%; = Gonorrhea, Chlamydia, Mycoplasma
(bacterial = MC)
describe vaginal ecosystem
normal pH??
vLactobacilli (95%)!!
Ø Other 5% includes…
- Streptocococci sp, Staphylococcus epidermis
- Diptheroid sp.
- *Gardnerella vaginalis
- Peptostreptococci sp, Bacterioides sp. , Anaerobic Lactobacillus
- Ureaplasma urealyticum , Mycoplasma hominis
•Non keratinized, squamous epithelium, Estrogenized
•Rich in Glycogen -> substrate for Lacto, breaks down -> Lactic acid, fostering acidic envt -> pH 4.0-4.5, maintaining norm flora
•Norm pH is 4.0-4.5 = important for DX vaginal issues*
define BV and what causes it
Shift in vaginal flora from lactobacilli to diverse bacteria
•Increase production of amines by new bacteria
•pH rises- loss of lactobacilli
• Leads to overgrowth of anaerobes
•Anaerobes produce and enzyme that breakdowns vaginal peptides into amines producing the malodorous smell of BV
Most common cause of abnormal vaginal discharge in women of childbearing age (40-50%)
•50% AA
microbiology of BV
how is pH affected?
Gardnerella vaginalis
Prevotella species
Bacteroides species
Porphyromonas species
Peptostreptococcus Mycoplasma/
Ureaplasma
Resultant rise in pH to >4.5
si/sx of BV
Asymptomatic- 50-75%
Discharge (thin, off-white)
Odor (fishy)- 50%
More noticeable after intercourse
During menses
pt w/ BV complaining of dysuria, dyspareunia, pruritis, or vaginal inflammation:
what are you thinking?
Alone typically does not cause dysuria, dyspareunia, pruritis, or vaginal inflammation
•May be associated with acute cervicitis
• Presence may suggest mixed vaginitis
•Think co-infection – BV & yest commonly co-infected
dx of BV
Amsel criteria
- Thin, grayish-white discharge
- pH >4.5
- Positive whiff test (amine)- drop of KOH on sample of discharge with resultant fishy odor
- Clue cells on saline wet mount epithelial cell covered in bacteria
“crushed glass” appearance = epithelial cells surrounded in bacterial
tx of BV
along w/ alternatives and suppressive therapy
Metronidazole – do not drink alc = N/V
Metrogel
Clindamycin (avoid if pregnant / breast feeding)
Alternative:
Tinidazole
Clindamycin
Clindmycin ovules
Suppressive: recurrent BV
- Metrogel 0.75% twice weekly for 4-6 months
- Oral Metronidazole course, followed by boric acid 600 mg intravaginally for 21 days and suppressive metronidazole gel for 4-6 months
define Candidiasis
Characterized by inflammation in presence of Candida species (Candida albicans 80-92%)
•Present in normal flora of 25% of women
Second most common cause of vaginitis
- As many as 50% of clinically dx women have another condition
- Highest among women during reproductive years
- Uncommon in postmenopausal women unless they are taking estrogen therapy and prepubertal girls
si/sx of yeast infection
Vulvar pruritis (dominant feature)
Burning, Soreness, Irritation
Dysuria
Dyspareunia
Erythema of external genitalia, vagina and cervix
Vulvar excoriation and fissures
Scant discharge
Discharge is white, thick, adherent to vaginal walls, clumpy (cottage cheese)
No or minimal odor
Cervix is usually normal
dx of yeast infection
Microscopy of vaginal dc
pH is typically normal 4-4.5 ******
• Distinguishes from BV, Trich
KOH on discharge - > Hyphae and budding
tx of yeast infection
simple
complicated
pregnant
Simple uncomplicated infection
• Fluconazole (Diflucan) 150 mg 1 dose
Complicated Infections
- Fluconazole 2-3 sequential doses 72 hours apart
- 7-14 days of topical if preferred
- Clotrimazole, miconazole, terconazole
Pregnancy
• Clotrimazole, miconazole intravaginally x 7 days
define trich
what causes it?
Genitourinary infection with the protozoan Trichomonas vaginalis
The most common non-viral STD worldwide
Can be asymptomatic
si/sx of trich
Mostly asymptomatic
- Erythema of vulva and vaginal mucosa
- Classic green-yellow, frothy, malodorous discharge (10-30%)
- Punctate hemorrhages on cervix (strawberry cervix) (2%)
tx of trich
5-nitroimidazole drugs are the only class that provide curative therapy
- Metronidazole 500 mg BID x 7 days
- Tinidazole 2 g qd x 2 days or 1 g qd x 5 days
Tinidazole better tolerated with less GI side effects but $$$
Topical therapy is ineffective
if a male is infected w/ trich and has si/sx…?
MOSTLY asymptomatic:
- Mucopurulent or clear urethral discharge
- Burning sensation
- Associated with prostatitis, epididymitis, infertility, balanitis, prostate cancer
pH levels of:
normal vagina
BV
candidasis
Trich
normal pH 4.0-4.5
BV - Elevated pH to >4.7
Candidasis - pH is typically normal 4-4.5
Trich - pH is elevated >4.5
dx of trich
Nucleic acid amplification tst (NAAT)
Point of care (POCT) - AFFIRM VP III, OSOM Trich Rapid Test
Gonorrhea causes ____ in women and ___ in men.
Causes cervicitis in women and urethritis in men
Extragenital infections- pharynx and rectum
si/sx of gonhorrhea in women
Women: mostly asymptomatic
Cervicitis- most common friable cervical mucosa
If sx do develop - w_ithin 10 days post exposure_
- Pruritis
- Mucopurulent discharge
Pain is atypical unless PID- abdominal or dyspareunia
•10-20% of women with gonorrhea develop PID
si/sx of gonhorrhea in men
Men: Majority of men are asymptomatic
Urethritis
Incubation period 2-5 days:
Mucopurulent discharge
Dysuria
- Epididymitis can develop if not treated
- Rare complications include penile lymphangitis, periurtehtral abscess
- Urethral strictures
dx of gonnorrhea
HX & PE
Genital swab-female
Urine-male (first catch)
NAAT (quicker than cx- looks for RNA test of choice for diagnosis
•But does not test for susceptibility- culture
tx of gonnorrhea
Ceftriaxone 250 mg IM x 1 plus
However also recommended is to add on Azithromycin 1 g x 1 (Even if you are only treating gonorrhea)
Alternate: for cephalosporin allergy
- Azithromycin 2 g PO x 1 plus
- Gentamycin 240 mg IM x 1
Pregnant women-same preferred regimen
•Coinfection with chlamydia should use azithromycin instead of doxy
screening for Chlamydia & gonorrhea should occur??
Screening: Sexually active women 25 and under- annual
pathogen responsible for Chlamydia
Gram-negative Chlamydia trachomatis – gram negative
- Efficient disease transmission
- Incubation period of symptomatic disease from 5-14 days
- Long growth cycle-why treatment with antibiotics with a long half-life or a prolonged course is necessary
si/sx of Chlamydia in women
Women: majority asymptomatic, rationale for screening
•Cervix is the most common affected site
- Nonspecific sx
- Change in vaginal discharge
- Mucopurulent endocervical dc
- Cervical bleeding
- Sexually active, young female with UA pos but cx negative, may or may not present with sx
- Misdiagnosed as having cystitis unless specific chlamydia test is sent
si/sx of Chlamydia in men
Men: asymptomatic from 40-90%
- Urethritis chlamydia is most common cause of nongonoccal urethritis
- Mucoid or watery discharge which is scant
- Dysuria
- Incubation period is 5-10 days
- Chlamydia frequent cause of epididymitis in men under 35
dx test for gonorrhea and chlamydia of throat and rectum
Aptima Combo 2 Assay
Xpert CT/NG- 90 minutes
•First cleared for extragenital diagnostic testing of gonorrhea and chlamydia of throat and rectum
tx of Chlamydia
including alternate and pregnant
Azithromycin
Doxycycline
Alternate
Ofloxacin
Levofloxacin
Pregnant-
Azith, no doxy
woman w/ Gonorrhea presenting w/ pain… what are we thinking ??
Pain is atypical unless PID- abdominal or dyspareunia
•10-20% of women with gonorrhea develop PID
pregnant women w/ gonnorrhea & Co-infection w/ Chlamydia should be treated w/ ______ instead of ______.
Azithromycin instead of Doxy
most common reported bacterial infection in US
Chlamydia
Gonorrhea
- 2nd MC reported communicable DZ,
- 2nd most prevalent STI
Comparing GRHEA + CHLA
- Extragenital infxns; pharynx + rectum > can cause invasive infxns including Endocarditis + Meningitis
- Long life cycle = need prolonged ABX; efficient transM of DZ, incubation PD 5-14 D
- Strain typing: can be done in outbreaks
- TX: Azithromycin 1g, Doxy 100 mg
GON - 1. 3.
CHLA - 2 , 4
define PID and what causes it
Acute infxn of upper genital tract in W
•Including uterus, ovaries, fallopian tubes, endometrium
- Initiated by STI, *MC GRHEA or CHLA;
- 15% of W with GRHEA and 30% (10-15%) of W with CHLA -> will go on to dvp PID
- GRHEA PID tends to be more severe
- Prev has DEC in U.S, 90,000 outpt visits
PID affects what anatomical structures?
Uterus
Ovaries
Fallopian tubes
Endometrium
microbiology of PID
Neisseria gonorrhoeae
Chlamydia trachomatis
Mycoplasma genitalium
E.coli (postmenopausal)
si/sx of PID
Typically acute but can be indolent and develop over weeks to months
Varying clinical syndromes
Mild vague pelvic symptoms to tubo-ovarian abscess
Rarely fatal intra-abdominal sepsis
Liver inflammation-perihepatitis (Fitz-Hugh Curtis Syndrome) 10% of women with PID
Si/Sx of acute PID
-Lower ABD or pelvic pain (bilat); MC
- Character of pain variable, can be subtle; worsens with sex
- Onset of pain during or shortly after menses; abnorm bleeding
- Rebound tenderness, pelvic organ tenderness, fever, decreased bowel sounds, inflamm of genital tract (CMT)
- Uterine + adnexal tenderness on bimanual
- Purulent cervical or vaginal discharge
describe importance of subclinical PID?
_*Does not prompt W to seek car_e; SX not severe enough ->
*Sequelae can be devastating:
-Tubal factor infertility
-Many W presenting with infertility due to tubal adhesions or distal tubal occlusion, which appear PID related, gave no HX of PID!!*
Dx of PID
HX: risk factors (sexual hx)
PE:
- Pelvic – pelvic organ tenderness (CMT)
- Purulent discharge
Imaging: CT (uncertain dx or complications), US
Additional Criteria]:
- Temp >101F (38.3 C)
- Abnormal discharge
- WBC on micro
- Documentation of GC/Ch infxn
- ELEV CRP
*Sensitivity of clinical DX is 60-90%
*Presumptive DX is sufficient to warrant empiric TX of PID due to…??
reproductive sequelae
PID Indications for Hospitalization:
Severe clinical illness – (high fever, N/V, severe ABD pain)
Complicated PID with pelvic abscess
Possible need for invasive diagnostic testing - (ex-lap)
Inability to take PO meds; Lack of response to PO meds
Concern for nonadherence
Pregnant
tx of PID
mild-mod
inpatient
~ Mild to Moderate DZ:
*Ceftriaxone IM + Doxy
Cefoxtin IM + Doxy + Probenecid
~ Inpatient:
*Cefoxtin IV or Cefotetan IV + Doxy
*Clinda + Gentamycin
cause of syphillis & transmission
Treponema pallidum
- Spirochete (delicate corkscrew shaped organism), discovered 1905
- Too small for ID on direct micro, complicates DX
*Transmission occurs from direct contact with infectious lesion during intercourse
- Can initiate infxn wherever inoculation occurs!!!
- Can spread via kissing, touching person’s active lesions on lips, oral cav, breasts, or genitals
- Crosses placenta; cause fetal infxn
si/sx of early syphillis
*Occurs within wks – mths after initial infxn
1°: Chancre = painless lesions @ site of inoculation
2°: Untreated = Dvp constitutional sx, rash, adenopathy, alopecia, hepatitis
Early-Latent: ASX infxn acq within prev 12 mths = considered infxnious
si/sx of late syphillis
Untreated pts that go on to dvp complications from infxn
Late-Latent: untreated asyx after 12 mths = have DZ but not considered infective + are ASX
Tertiary: major complications = **Aortitis, Aortic Valve regurg, Gummatous DZ (granulomatous lesions everywhere)
dx tests for syphillis
Non-Treponemal
Reagin antibodies – NON SPECIFIC
Initial screening in ASX: cheap, easy
Quantifiable: reported as titers (1:32) AB in serum diluted
Can be used to monitor TX; titers DECLINE after TX!
Treponemal:
SPECIFIC for Abs against SPECIFIC treponemal antigens
- INCly used as initial screen, not just confirmatory (but can be used to confirm when nonT tests are reactive)
tx of syphillis
early
late
neuro
Early SYP]
*Penicillin G benzathine
*Doxy
[Late SYP]
*Penicillin G benzathine
*Doxy
*Prednisone –w/ CV SYP
[NeuroSYP]
*Penicillin G cont.infusion
*Procaine penicillin IM + Probenecid
*Ceftriaxone D
*Doxy
HPV Mucosal Types __, __, __, __ : assoc with genital warts, precancerous + cancerous lesions of the cervix, vag, vulva, anus, penis, + oropharynx
6, 11, 16, 18:
transmission of HPV
•When SX are absent = ‘Subclinical Viral Shedding’
- May occur quickly in new sex parts (3.5 mths)
- Infreq condom use
- 1° infxn incub after exposure: 4 D (2-12 range)
si/sx of HPV
*Most are ASX
- Abnormal PAP or (+) HPV test may be 1st indication
- Vulvar/vag warts
- Itchy + painful
- Most HPV strain that cause cervical cancer do NOT cause warts !!!!
vaccine reccommendations for HPV
Routine vacc is recommended for ALL adolescents + young adults:
Young M&W – 26
11-12: (2) shots given 6-12 mths apart
>14: (3) shots given over 6 mths
vaccines available for HPV
Three vaccines available ->
- 9-valent (Gardasil-9): types 6,11,16,18,31,33,45,52,&58
- Quadvalent (Gardasil): 6,11,16,18
- Bivalent (Cervarix): 16,18
ACOG reccommendations for screening for HPV
<21): no screening
(21-29): PAP q 3 yrs, no HPV tst
(30-65): PAP q 3 yrs & HPV tst q 5 yrs
(>65): no screening
(hyster removal of cervix): no screening
tx of HPV
Self-admin
Podofilox gel
Aldara + Zyclara (Imiquimod) cream
Sinecatechins (Veregen) ointment
Office Based
Trichloroacetic acid (TCA): = remove vag warts
Cryoablation: liquid nitrogen
Laser ablation
Herpes define :
1
non 1
reccurrent
1°: infxn in a pt w/o previous Ab’s
Non 1° 1st episode:
acq of gen HSV-1 in a pt with Ab’s to HSV-2
acq of gen HSV-2 in a pt with Ab’s to HSV-1
Recurrent: reactive of gen HSV in which HSV type recover from lesion = same type as Ab’s in serum
Si/sx of herpes in
1
non 1
reccurrent
1° - *Painful gen ulcers = Systemic SX:
- Dysuria, fever, HA
- Tender inguinal LAD
- Infxn can be mild to ASX
- SX tend to be more severe in W
Non 1 *Fewer lesions, Less systemic SX
-AB’s from one HSV offer some protection against the other
Recurrent - *Less severe than either 1° or Non1°
- Mean duration of lesions = shorter than 1°
- Systemic SX infrequent
-Approx 25% of recurrent episodes are ASX
dx of herpes
Choice of test may vary with clin presentation
- Active lesions can be ‘unroofed’ for fluid (sent for viral cx & PCR)
- Serologic testing
reccommendtions for screening for herpes virus
Even though it is one of the MC STI’s, it is NOT recommended in ASX adolescents & adults
tx of herpes
1
non 1
reccurrent
1° HSV Infxn: *b/c DZ tends to be more severe;
all pts should be _started on antivirals w/I 72 hrs of onset of clinical SX (_Usu duration = 7-10 D)
Famciclovir 250 mg TID
Acyclovir 400 mg TID, or 200 mg 5x daily
Valacyclovir 1000 mg BID
Recurrent DZ: Chronic Suppressive Therapy -
Acyclovir 400 mg BID
Famciclovir 250 mg BID
Valacyclovir 500 mg QD, or 1000 mg QD
Episodic Therapy ->
Acyclovir
Famciclovir
Valacyclovir
Most common cause of the benign breast disorders
Fibrocystic Breast Changes
compare/ contrast
Fibrocystic Breast Changes vs fibroadenoma
fibrocystic
Hormone induced breast changes -cyclic in nature
Painful bilateral breasts,
Freely moving in regard to adjacent structures
“Lumpiness” fluctuates with the menstrual cycle
fibroadenoma
noncyclic, Painless, Increase size with pregnancy
•Round, oval, Hard or rubbery
imaging modalities for looking at breast cycts
- Ultrasound = Distinguishes cystic from solid mass
- Fine Needle Aspirate = US is done before a fine needle aspirate with cyst.
- Mammogram = Further evaluation of clinically suspicious masses & Further evaluation of solid masses
- Core Needle Biopsy (CNB) = for solid mass, definitive dx for fibroadenoma
qhat is the BI-RADS score and how is it used in regards to fibrocystic breast changes
It’s a scoring system radiologists use to describe mammogram results.
Simple – reassurance
Complicated: risk of cancer directly related to findings on bx
- BI-RADS 2 – benign
- BI-RADS 3 – repeat imaging in 6 mo, FNE can be performed instead of 6mo imaging to Confirm lesion is benign.
Complex: BI-RADS 4/5
- Require ultrasound guided CNB to Dx benign vs malignant.
- FNE is NOT sufficient
•Core Needle Biopsy (CNB) - Definitive Dx for??
fibroadenomas
cause of mastitis and how we tx
Blockage of duct and reduced drainage
Offending organism: S. aureus, MRSA -> grows in stagnant milk
Antibiotics:
dicloxacillin or cephalexin
Get rid of milk
how to tx Breast Abscess:
in pregnant women?
abx?
Breastfeeding or pumping is important for resolution of infection and relief of discomfort.
Reduces duration & Improves outcomes
I&D
Empiric therapy against S. aureus
- Dicloxacillin
- Cephalexin
- trimethoprim-sulfamethoxazole
Benign proliferation of the glandular tissue of the male breast is called??
caused by???
Gynecomastia
Caused by an increase in the ratio of estrogen to androgen activity
si/sx of Gynecomastia
concentric, rubbery-to-firm disk of tissue
often mobile
located directly beneath the areolar area
when assessing Gynecomastia make sure you differentiate it from what 2 conditions???
& what can you NOT miss??
Be careful to differentiate from:
pseudogynecomastia = (fat)
from breast carcinoma = (commonly unilateral, non-tender, fixed masses)
Don’t miss a testicular cancer! *
age affected by & give short description of lesions:
fibroadenoma
fibrocystic changes
cancer
cancer until proven otherwise
fibroadeonma - 10-30
s_mooth, rubbery_, round, NONTENDER, PAINLESS
fibrocystic & cancer - 30 - 50
“lumpy” rope-like, tender, size fluctuation w/ menses / premenstraul pain is worse, cysts are round and mobile
cancer until proven otherwise - >50
firm, hard, non-tender, irregular borders, fixed to usrrounding tissue
Breast cancer:
Most common non-invasive:
Most common invasive:
Most common non-invasive: Ductal carcinoma in situ
Most common invasive: infiltrating ductal
Leading cause of cancer death in women worldwide
breast cancer
2nd most Dx malignancy behind lung cancer
si/sx of breast cancer
early and late
Early
- Immobile, fixed, ill-defined margins
- Linear calcifications on mammography
•Painless mass
Late
- Mass fixed to skin/chest wall
- Skin/nipple retractions
- Asymmetrical breast enlargement
- Breast edema, erythema, and pain
- Bloody nipple discharge
- Jaundice
•Bone pain
•Weight loss
•Peau D’ orange - Resemblance to the skin of an orange due to lymphedema
define inflammatory breast cancer vs lymphadenopathy
Inflammatory: Rapidly progressing, tender, firm, and enlarged breast with thickening of the underlying skin
- Require full-thickness skin biopsies
- Presence of dermal lymphatic invasion = Inflammatory Breast Cancer
- It is important to rule out inflammatory breast cancer if a suspected breast infection does not respond to antibiotics
Lymphadenopathy:
- Normal lymph nodes are movable, non-tender <5 mm
- Nodes affected by malignancy, Matted, hard, firm, immovable
- Fixed to skin or deeper tissues
- >1cm denote metastases
•Axillary LN involvement and/or Supra/infraclavicular nodes (think metastatic disease)
•Sentinel nodes are first lymph nodes targeted by tumor invasion
•Sampled 1st in surgery to check for spread
tx of breast cancer w:
Her 2+
ER/PR+, HER -
Her 2+ = herceptin
ER/PR+, HER - = tamoxifen, aromatase inhibitors
what is tamoxifen used to tx?
side effects?
•ER/PR+, HER2-) = premenopausal women
side effects: DVT, uterine cancer, vasomotor sx
•Given for 5-10 yrs then switch to AI
dec reccurrence by 40-50%, dec mortality by 25%
caution w/ strong CYP2D6 inhibitors
what is aromatase inhibitors used to tx?
side effects?
ER/PR+, HER2-) - CI in premenopausal women
side effects: Less DVT / uterine ca B_UT more bone loss, myalgia and arthralgia_
superior to SERM
anatrozole
exemestane
letrozole
what is Herceptin used to tx?
side effects?
•HER2+ w/ chemo regimen
- Against HER-2 oncogene (+) ‘over-expression’
- Dramatically improved survival
breast cancer is MOST likely to spread to:
Bone
- Liver
- Lung
- Brain
first LN affected by breast cancer
sentinel LN
imaging modalities to screen for breast cancer and when they should be used
mammo - For women at average risk, screening mammograms should be performed annually beginning at age 40
US- diagnostic follow-up of an abnormal screening mammogram
- can differentiate a solid mass from a cyst
- to provide guidance for biopsies and other interventions
•Ultrasound is the first line of imaging in a woman who is pregnant or less than 30 years old with focal breast symptoms or findings
US is first line imaging modality to screen for breast cancer IF ????
Ultrasound is the first line of imaging in:
a woman who is pregnant
_<30 years ol_d with focal breast symptoms or findings
Most common pelvic tumor in women:
define this tumor
Leiomyoma (Fibroids)
Benign tumor arising from smooth muscle cells of the myometrium
- Resemble normal tissue
- Feel firm and smooth
locations of Leiomyoma (fibroids)
Locations:
•Intramural Myoma
- Subserosal Myoma
- Submucosal Myoma
- Cervical Myoma
- Pedunculated (Stemmed)
dx of Leiomyoma (Fibroids)
Enlarged Uterus
Irregular Uterus
+/- Tender uterus
Transvaginal Ultrasound
Saline Infused Sonography (sonohysterography)
Hysteroscopy
MRI
Hysterosalpingography (HSG)
tx of Leiomyoma (Fibroids)
Goal: Symptomatic relief
Studies have found menopause causes fibroids to shrink → relief of symptoms
Treatment options: Watchful waiting
Medical Management
- NSAIDS – only for dysmenorrhea
- OCPS
- Levonorgestrel IUD (Mirena/Skyla)
- Gonadotropin releasing hormone (GnRH)
- Danazol
Surgery: Mainstay of treatment
•Indications for treatment: AUB, bulk related symptoms, infertility, recurrent miscarriages
define Adenomyosis
Ectopic endometrial tissue within the myometrium
- Ectopic tissue induces hypertrophy and hyperplasia in the myometrium
- Diffusely enlarged uterus → “Boggy Uterus”
Resemble fibroids
dx of Adenomyosis
Definitive diagnosis only via histology s/p hysterectomy
Transvaginal ultrasound and MRI very helpful
MRI better but more expensive –
KEY WORDS:
- “Asymmetric thickening of the myometrium”
- “Linear striations”
- “Loss of clear endomyometrial border”
- “Increased myometrial heterogeneity”
Tx of Adenomyosis
Hysterectomy – only guaranteed treatment
Uterine artery embolization – some success (not well studied)
OCPs/IUD – Can attempt to help decrease bleeding and pain. –> Not FDA approved for Adenomyosis
_Gonadotropin releasing hormone analogs (Lupron) and Aromatase Inhibitors (Anastrozole, Letrozol_e
•May decrease dysmenorrhea and menorrhagia symptoms, Temporary
contrast pathophys of
Leiomyoma (Fibroids) vs Adenomyosis
Leiomyoma (Fibroids) - Benign tumor arising from smooth muscle cells of the myometrium
•Resemble normal tissue, Feel firm and smooth
Adenomyosis: Ectopic endometrial tissue within the myometrium
- Ectopic tissue induces hypertrophy and hyperplasia in the myometrium
- Diffusely enlarged uterus → “Boggy Uterus”
contrast si/sx of
Leiomyoma (Fibroids) vs Adenomyosis
Leiomyoma (Fibroids) : Most are small and asymptomatic,
Heavy or prolonged menstrual bleeding
Adenomyosis: Diffusely enlarged uterus → “Boggy Uterus
- Heavy Menstrual Bleeding – 65%
- Dysmenorrhea- 25%
- Chronic pelvic pain
define endometreosis and what causes it
Presence of normal endometrial mucosa abnormally implanted in locations other than the uterine cavity
Ectopic areas respond to cyclical hormonal fluctuations similar to intrauterine endometrium
Including release of prostaglandins leading to inflammatory process and scarring of ectopic areas
Estrogen dependent disease – Menopause leads to resolution of symptoms
most common locations for endometriosis
•Ovaries (MOST COMMON)
- Uterus (Perimetrium)
- Posterior cul-de-sac
- Broad ligament/Uterosacral ligament
- Rectosigmoid colon
- Bladder
si/sx of endometriosis
Severity of symptoms do not always correlate to extent of disease
Asymptomatic
Dysmenorrhea
Heavy or irregular bleeding
Lateral displacement of the cervix
Localized tenderness in the posterior culde-sac (Pouch of Douglas)
Palpable tender nodule in the posterior cul-de-sac (Endometrioma)
dx endometriosis
Laparoscopy with biopsy – Primary diagnostic modality
•Classic blue black or powder burned appearance
Transvaginal or Endorectal ultrasonagraphy
Pelvic Ultrasound
• first line study to help rule out other pathology and identify findings suggestive of endometriosis
MRI
complication of endometriosis
Endometrioma – “Chocolate Cyst”
•Most common on ovaries
tx endometriosis
95% response to medical management – 50% will have return of symptoms after 5 years of medical management
Hormonal Contraceptive:
Combined (Estrogen/Progestin)
•Progestin only
(GnRH) analogues (Lupron)
• Restricted to 6 months –> Risk osteoporosis and lots of menopause type side effects
Danazol (Androgenic Steroid)
Surgical Options:
Hysterectomy with or without bilateral oophorectomy – Hysterectomy with BSO considered definitive therapy
Laparoscopic uterine nerve ablation – Resection of nerve bundles
Drainage and laparoscopic cystectomy
L_aparoscopy and surgical endometrial implant ablation_ – Reoperation rate high 50%
define ovarian cysts and name the types of them
Cyst: sac filled with liquid or semiliquid material
Occur in women of all ages including neonatal/infancy phases
• Most prevalent during infancy, adolescence, and childbearing years
Functional ovarian cysts → Most common cystic ovarian lesion – Occur most commonly in women of reproductive age
- Follicular
- Corpus luteal cyst
- Theca lutein cyst
- Endometrioma
Simple cyst: Simple fluid, thin wall. E.g: Follicular, Luteal, serous cystadenoma
Complex cyst: debris, blood, varied wall thickness, septations, hemorrhagic
name the functional ovarian cysts
- Follicular
- Corpus luteal cyst
- Theca lutein cyst
- Endometrioma
contrast follicular cyst vs corpus luetal cyst
Follicular Cysts
- Balloon does not pop / NO RUPTURE – cyst is formed
- Resolve spontaneously 2-3m -> 70-80% resolve on their own
On ultrasound, present as simple unilocular, anechoic cysts with a thin, smooth wall
Corpus Luteal Cyst
•Occurs after ovulation– it pops but corpus luteum
does not dissolve and becomes cyst
•Thicker walls
“Ring of Fire” Doppler appearance = ring of blood flow
Theca Lutein Cysts cause?
appearance?
•Hormonal Overstimulation by βhCG – hyperstimulation ovaries and cysts created
bilateral
Gestational Trophoblastic Disease;
Hormonal therapy (E.g. infertility treatment); - seldom in singleton pregnancy
Septations do not show enhancement on ultrasound
define endometrioma
si/sx?
- Cyst formed with endometrial tissue → “Chocolate Cyst”
- Most common during reproductive years
Chronic pelvic pain
Hormonally responsive
PCOS AKA Stein-Leventhal Syndrome appearance on US?
- 10 or more peripheral simple cysts
- Characteristic “string-of-pearls” appearance
name the 3 Benign Ovarian Tumors
Mature Cystic Teratoma
Cystadenoma
Cystadenofibroma
benign ovarian tumor that appears in 70% in women of reproductive age
&
Appears cystic → calcifications, fat, sebaceous tissue, hair, and/or teeth
complications???
Mature Cystic Teratoma
•Do not resolve spontaneously
•Associated with ovarian torsion if >5cm
•10% of all ovarian neoplasms – can turn into cancer
describe the 2 types of Cystadenoma
Serous – older women (40-50 yo)
- Benign ovarian tumors
- 15-25% bilateral
Mucinous - less frequent than serous, younger women (20-40 yo)
- Can be very large
- Filled with mucinous material
- 5-10% bilateral
Surface epithelial tumor of ovary that resembles malignant tumor
age group?
Tx?
Cystadenofibroma: Rare & Benign
•Surface epithelial tumor of ovary
Common in 15-65 yo
- Complex cystic to solid appearing mass
- Tx: Oophorectomy (ovary removal)
Benign Ovarian Tumors that appear in women of:
reproductive age
40-50
20-40
15-65
reproductive age - Mature Cystic Teratoma
40-50 - Cystadenoma (serous)
20-40 - Cystadenoma (Mucinous)
15-65 -Cystadenofibroma
si/sx of a ruptured cyts
Sudden onset sharp pain
Ovarian Cysts & Benign Tumors imaging modalities
Ultrasound – First line method of choice
•Helps distinguish complex, simple or solid lesions
CT Pelvis - Only for malignancy staging
MRI - Done after u/s if needed
- Can evaluate for complex masses
- Use with caution as may delay care if neoplasm is of concern
Ovarian Cysts & Benign Tumors US Management of reproductive age
simple vs hemhorragic
Reproductive Age
Simple:
- <5 cm observe
- 5-7cm f/u annually
- >7 cm either MRI or surgery
Hemorrhagic:
• >5cm f/u ultrasound 6-12 weeks
Ovarian Cysts & Benign Tumors US Management of post-menopausal
•>1cm-7cm ultrasound annually +/- CA-125
Ovarian Cysts & Benign Tumors US Management of dermoid & endometriomas
Dermoid
- U/S q6-12 months
- Cystectomy
Endometrioma
- Initial f/u ultrasound 6-12 weeks
- U/S annually
- Cystectomy
Tx of Ovarian Cysts & Benign Tumors
Analgesia management
_Hormonal Contraceptio_n - Recurrent Functional Cysts
Indications for ovarian cystectomy or oophorectomy
- Symptomatic cysts – Persistent 5-10cm cysts (esp. symptomatic)
- Ovarian Torsion or Suspected malignancy
Surgery not indicated required for
- Follicular or Corpus Luteal Cyst
- unless very large or hemorrhagic with rupture
define pelvic organ prolapse and anatomy involved
Herniation of pelvic organs to or beyond the vaginal walls
Anatomic support of pelvic organs via pelvic floor and connective tissues.
- Levator ani muscle complex – primary support
- Pubococcygeus
- Puborectalis
- Iliococcygeus
define these locations of POP
Cystocele
rectocele
enterocele
•Anterior Compartment Prolapse (Cystocele) –Hernia of anterior vaginal wall with descent of bladder
_•Posterior Compartment Prolapse (Rectocele) -_Hernia of posterior vaginal segment with descent of the rectum.
•Enterocele –Hernia of the intestines to or through the vaginal wall.
si/sx of POP
Sitting on egg or balloon
Prolapse does NOT cause pain ***
Defecatory Symptoms: Constipation – most common*
- Fecal urgency
- Fecal incontinence, e.g. during intercourse
- Incomplete emptying
Urinary symptoms
- Slow urine stream
- Sensation of incomplete emptying
- Overactive bladder (urgency, frequency, incontinence)
- 2-5x increase risk
Sexual
- Avoidance, shame
- +/- dyspareunia
define stages of POP and what is the staging system called
I-IV
Simplified Pelvic Organ Quantitation System (POP-Q)
Stage 0- No prolapse
Stage I –Prolapse 1cm above hymenal plane
Stage II – Prolapse descends to introitus
Stage III – Prolapse greater than 1cm past hymenal remnant, but does not cause complete vaginal vault eversion or complete uterine procidentia.
Stage IV – Complete vaginal vault eversion or complete uterine procidentia,
- i.e. vagina and/or uterus are maximally prolapsed with entire extent of vaginal mucosa everted
tx for POP
Indicated only for symptomatic (urinary, bowel, or sexual dysfunction)
•Do NOT have to treat if patient is asymptomatic or if they are not bothered by their symptoms
Conservative:
Pessary - Silicone devices vary size and shape
- 50% discontinue use after 1-2 years
- Must be removed and cleaned regular basis
P_elvic Floor Muscle Exercise (PFME)_ - Physical Therapy
Surgical:
Anterior vaginal wall prolapse repair - Anterior colporrhaphy (highly recurrent)
Posterior vaginal wall prolapse repair - Posterior colporrhaphy
Apical defect
- Sacral colpopexy
- Hysterectomy with Uterosacral or Sacrospinous Ligament Suspension
complications of Ovarian Cysts & Benign Tumors
Ovarian torsion – 70% women 20-39yo age, Mature Cystic Teratoma
- Adnexa and ovary typically involved
- Most cases involve ovarian masses measuring 6-10cm
•Typical symptoms –sharp sudden, then waxing/waning pain, n/v
•Goal of emergent surgery: laparoscopic detorsion for adnexa and ovary salvage → TIME IS OVARY
Hemorrhagic cyst - Rupture and internal bleeding
• Common – Corpus luteal cyst day 20-26 of cycle
Persistent pain or pressure
POP does NOT cause _____.
main concerns w/ POP are: ____ & _______
Prolapse does NOT cause pelvic pain *****
•Main concerns are:
- inability to empty bladder (incr. risk for infections)
- and defecatory dysfunction
Cervical Squamous Intraepithelial Lesions -> CSIL are divided into???
- Low-grade squamous intraepithelial lesion (LSIL)
- High-grade squamous intraepithelial lesion (HSIL)
Cervical Intraepithelial Neoplasia -> CIN are categorized by?
CIN 1 -> LSIL (condyloma/cervical intraepithelial lesion)
•CIN 2
- p16-negative are referred to as LSIL
- p16-positive are referred to as HSIL
CIN 3 -> HSIL
Pathogenesis of Cervical Intraepithelial Neoplasia
Role of human papillomavirus - HPV infection is necessary for development of cervical neoplasia
- HPV alone is not sufficient to cause these disorders
HPV types/persistence
Cervical “transformation zone” (T-zone)- of the cervix is the site of carcinogenesis by infection with oncogenic subtypes of HPV
Sexual transmission
name low risk and high risk HPV subtypes ?
Squamous cell carcinoma & Adenocarcinoma are HPV types ???
•Low-risk types (HPV 6 and 11)
• High-risk types (HPV 16 and 18)
- Squamous cell carcinoma – HPV 16 (59%), 18 (13%)
- Adenocarcinoma – HPV 16 (36%), 18 (37%)
HPV persistence is caused by
The reason HPV infection persists in some women and not in others is unknown
•Older age - 50% high-risk HPV infections persist in women older than 55 years of age
20% rate of persistence in women under age 25
•Duration of infection - The longer an HPV infection has been recognized, the longer it will take to clear
•High-risk HPV subtype - More likely to persist than low oncogenic types
define the transformation zone and its clinical significance
•The area when glandular epithelium replaces squamous epithelium is called transformation zone (T-zone)
Cervical neoplasia originates within the T-zone
primary vs secondary Prevention of Cervical Lesions
Primary prevention - vaccination
•condoms are only partially protective
Secondary prevention - aimed at cervical cancer rather than CIN itself
•CIN -> appropriate monitoring and treatment
types of HPV vaccines
•Quadrivalent vaccine (Gardasil) targets HPV types 6, 11, 16, and 18. - targets all 4 subtypes
•9-valent vaccine (Gardasil 9) targets HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58. - Targets high risk HPV
Bivalent vaccine (Cervarix) targets HPV types 16 and 18.
19 Advisory Committee on Immunization Practices (ACIP) Recommendation for Vaccination (HPV)
Children and adults aged 9‐26 yo
Adults aged >26 yo
Special populations
Children and adults aged 9‐26 yo
- routinely recommended at age 11 or 12 y;
- vaccination can be given starting at age 9 yo.
Adults aged >26 yo
- Catch‐up HPV vaccination is not recommended for all adults
Special populations
pregnant - delayed until after pregnancy.
breastfeeding or lactating - can receive HPV vaccine.
HPV testing after atypical squamous cells: (2)
Cervical cancer screening co-testing
Testing with both cervical cytology (Pap test) and high-risk HPV infection
Reflex HPV testing aka HPV triage
The collection of a specimen for HPV testing when the cytology sample is collected, but performing the HPV test only if the cytology results are ASC-US
define ASC-US vs ASC-H
ASC-US - Atypical squamous cells of undetermined significance
More marked than simple reactive changes but do not show LSIL abnormalities
Reflex HPV testing aka HPV triage
ASC-H - Atypical squamous cells: cannot exclude high-grade squamous intraepithelial lesion
Cells that likely consist of a mixture of true high-grade SIL and other findings that mimic such lesions
require further HPV testing - Cervical cancer screening co-testing
Tx of Cervical cancer
- The mainstays of treatment of HSIL are excision and ablation of the transformation zone of the cervix
- Hysterectomy is an option for women who are
- incompletely treated with excision or ablation
- who have recurrent CIN
define excisional vs ablative tx for cervical cancer
Excisional treatments are referred to as cone biopsies or cervical conization
•LEEP, Loop electrosurgical excision procedure, also called large loop excision of the transformation zone (LLETZ)
•Laser conization is another technique
Ablative treatments use an energy source (eg, cryotherapy, laser) to destroy the transformation zone
According to US Professional Organizations Pap Test Starts at Age ____
21
define expeditied tx of cervical cancer.
when is Expedited treatment neccessary for tx cervical cancer
Expedited treatment - treatment with excision (usually in the form of loop electrosurgical excisional procedure [LEEP]) without having first doing a colposcopy
•SKIP CULPOSCOPY!!!*** if immediate CIN3+ risk _>_4%
•Clinical Manifestations of cervical cancer
- Irregular or heavy vaginal bleeding
- Post-coital bleeding - most specific presentation of cervical cancer, may also result from cervicitis
progression of cervical cancer
- Oncogenic HPV infection at the cervical transformation zone
- Persistence of the HPV infection
- Progression from persistent viral infection to pre-cancer
- Development of carcinoma and invasion
tx of cervical cancer
microinvasive disease (stage IA1) with no evidence of intermediate- or high-risk features
stage IA2 and IB1 cervical cancer
IB2 stage
early-stage cervical cancer with intermediate-risk features
early-stage cervical cancer with high-risk features
microinvasive disease (stage IA1) with no evidence of intermediate- or high-risk features - conization or extrafascial hysterectomy – preferred
stage IA2 and IB1 - modified radical hysterectomy
IB2 stage - radical hysterectomy
early-stage cervical cancer with intermediate-risk features - adjuvant chemoradiation rather than RT alone
early-stage cervical cancer with high-risk features - adjuvant chemoradiation rather than RT alone
Origins of Ovarian Cancer: The majority of ovarian malignancies (95%) are derived from ______ cells
epithelial
•Ovarian cancer is the second most common gynecologic malignancy and the most common cause of gynecologic cancer death
risk factors for ovarian cancer
Genetic predisposition
- The Lynch syndrome
- BRCA gene mutations
Age - The incidence of ovarian cancer increases with age
The risk of ovarian cancer appears to be decreased in women with a history of
Previous pregnancy
Use of OCPs
Breastfeeding
ALL result in less ovulation = less chance to damage ovary
e risk of ovarian cancer may be increased in patients with a history of
Infertility
Endometriosis
PCOS
Cigarette smoking
ALL result in INCREASED ovulation = more likely to damage ovaries
acute vs subacute presentations of ovarian cancer
Acute presentations
Pleural effusion
Bowl obstruction
Subacute presentations
Adnexal mass – palpate mass in abdominal region
Pelvic or abdominal pain
Bloating
GI symptoms
early symptoms of ovarian cancer
& the Role of early detection
Presence of early symptoms
Advanced epithelial ovarian cancer typically presents with
abdominal distention
Nausea
Anorexia
or early satiety due to the presence of ascites and bowel metastases
Most women with epithelial ovarian cancer have pelvic or abdominal symptoms prior to their diagnosis
Role of early detection: The goal of early detection is to reduce epithelial ovarian cancer mortality
evaluation for ovarian cancer consists of:
decribe the 2 phase process
Tumor markers - CA 125 ( most common biomarker used to detect ovarian cancer)
Pelvic ultrasonography
Pelvic exam
1. initial evaluation
- If there is no indication for diagnostic surgery -> an evaluation for other etiologies
- If an adnexal mass is found and based upon the initial evaluation, there is a suspicion of EOC -> surgical evaluation
2. Surgical evaluation
dx of ovarian cancer
•Histopathologic examination of excised tissue – GOLD STANDARD
•Evaluate pelvic mass
•Serum CA 125 is for the evaluation of adnexal masses
- OVA1 and Overa (aka OVA2) are serum biomarkers for evaluation of malignancy
- includes CA 125, HE4, and three additional markers
when to refer pelvic masses to gyn oncologist
premonopausal
postmenopausal
Refer if ANY are present:
premonopausal
elevated CA 125 level
ascites
evidence of abdominal or distant metastases
postmenopausal
all above +
nodular or fixed pelvic mass
tx for ovarian camcer
The novel immunotherapeutic vaccine DSP-7888 (ombipepimut-S or adegramotide/nelatimotide), in combination with pembrolizumab (Keytruda)
- The anti-cancer vaccine t_argets the Wilms Tumor 1 (WT1) protein_
- DSP-7888 induces WT1-specific cytotoxic T lymphocytes and helper T cells to attack WT1-expressive cancer cells
reccomendations on screening for ovarian cancer
No North-American expert groups recommend routine screening for ovarian cancer.
The US Preventive Services Task Force (USPSTF) recommends against screening for ovarian cancer, except for the known carriers of genetic mutations that increase ovarian cancer risk.
