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Year 4 - O&G > O&G - Cervical Screening and STI > Flashcards

O&G - Cervical Screening and STI Flashcards

1
Q

What does an asymptomatic sexual health screen involve?

i.e. screen on a pt who has no symptoms and just wants to check for STIs

A

Self taken vulval-vaginal swap is done (can be done at home)

swab plaed into tube filled with medium –> NAAT (nucleic acid amplification test) i.e. a PCR test done for:

  1. Gonorrhoea
  2. Chlamydia
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2
Q

If a pt presents with vaginal discharge what swabs / tests might you do?

A
  1. High vaginal swab (from posterior fornix) - swab can then be placed on:
    • pH strip - swab can be placed on a pH strip, if it turns darker –> pH is ↑ –> could indicate bacterial vaginosis or STI e.g. Trichomonas vaginalis (grows in alkaline pH)
    • Dry microscopy slide - microscopy + gram stain - looking for:
      • Candida (thrush)
      • Bacterial vaginosis e.g. gram -ve diplococci –> suggestive of Gonorrhoea
    • Wet microscopy slide - microscopy done testing for
      • Trichomoniasis (caused by Trichomonas vaginalis)
    • Culture & Sensitivity - tests for:
      • Candida
      • Trichomonas vaginalis
  2. Endocervical swab (from cervix, inside OS) tests include:
    • NAAT (nucleic acid amplification test) - PCR test for Gonorrhoea + Chlamydia
    • Culture & sensitivity –> Gonorrhoea
  3. Urethral swab - put on agar plate (looking for Gonorrhoea)
  4. Urine sample - can be NAAT tested for Chlamydia but is less sensitive than endocervical or vulvo-vaginal swab
  5. Blood test for:
    • HIV
    • Syphilis
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3
Q

What is Colposcopy?

A

Speculum is inserted then a colposcope (instrument for illumination + magnification) is used to examine the cervix, vagina and vulva (often looking for pre-cancerous / cancerous signs)

  • May involve acetic acid and/or iodine to identify area of abnormality
    • Acetic acid - turns areas white if ↑ nuclear density –> may consider for biopsy
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4
Q

A woman presents with vaginal discharge - what questions about the discharge might you want to ask?

A
  • Onset
  • Duration
  • Timing (cyclical vs constant)
  • Colour
  • Consistency
  • Blood
  • Odour
  • Other symptoms e.g. itchyness / pain / burning / dysuria / dyspareunia
  • Sexual Hx - partners, contraception
  • Menstrual Hx - frequency, last period, amount of blood
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5
Q

Name some causes of vaginal discharge using the following categories.

  1. Infective (non-sexually transmitted)
  2. Infective (sexually transmitted)
  3. Non-infective
A

Bold = common

  1. Infective (non-sexually transmitted)
    • Bacterial vaginosis
    • Candida
  2. Infective (sexually transmitted)
    • Chlamydia trachomatis
    • Neisseria gonorrhoeae
    • Trichomonas vaginalis
    • Herpes simplex virus
  3. Non-infective
    • Foreign bodies (e.g. retained tampons, condoms)
    • Cervical polyps
    • Malignancy e.g. Genital tract Ca
    • Cervical ectropion
    • Fistulae
    • Physiological e.g. sexual arousal, menstrual cycle-related, puberty, COCP
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6
Q

What is cervical ectropion?

A

Cervical ectropion (cervical ectopy or cervical erosion) = when glandular cells (columnar epithelium) that line the inside of the cervical canal spread to the outer surface

Outer cervix appears red as glandular cells are red

Is indistinguishable on appearance from early cervical cancer –> investigate

  • Cervical canal = columnar epithelium
  • Vaginal cervix = squamous epithelium

Causes of ectropion:

  • Hormonal changes (thus more common in young women)
  • Oral contraceptives
  • Pregnancy
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7
Q

For the following conditions describe the associated vaginal discharge features + main management option:

  • Physiological
  • Candida
  • TV (Trichomonas Vaginalis)
  • Gonorrhoea
  • Bacterial vaginosis
  • Malignancy
  • Foreign body
  • Atrophic vaginitis
  • Cervical ectropion
A
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8
Q

What does this image show?

A

Cervical ectropion

(also called cervical erosion or ectopy)

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9
Q

What does this image show?

A

Normal cervix

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10
Q

What does Dyskaryosis mean?

A

Dyskaryosis:

  • Abnormal changes of squamous epithelial cells - which may be found in a cervical smear sample
    • ​specifically hyperchromatic nuclei and/or irregular nuclear chromatin
  • Dyskaryosis is NOT a histological diagnosis - it is simply a description of how abnormal cells on the surface of the cervix appear
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11
Q

A pt is identified as having moderate dyskaryosis with high-risk HPV on a smear test. When the pt goes for colposcopy what might the doctor decide to do to treat there and then?

A

LLETZ

Large Loop Excision of the Transformation Zone

  • LLETZ - involves removal of transformation zone of cervix with loop diathermy, usually under local anaethetic (cervical block)
  • LLETZ has a 90-95% cure rate
  • Transformation zone is an area between the columnar epithelium of the cervix canal and the squamous epithelium of the vaginal cervix (columnar cells are constantly transforming into squamous cells)
  • Transformation zone = most common area of cervix for abnormal cells e.g. > 90% cervical squamous cell carcinomas
  • A LLETZ is often followed by a ‘test-of-cure’ smear test after 6-months
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12
Q

What is Acetic acid used for in Colposcopy?

A

Acetic acid in Colposcopy:

  1. Washes away mucus for better visualisation
  2. Stains‘abnormal’ areas white (see image)
    • Areas stained white are called ‘acertowhite lesions’
    • Acetowhite lesions - can be genital warts, pre-cancerous dysplasia and cancer
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13
Q

What is Iodine used for in Colposcopy?

A

Dilute Iodine solution (also called Lugol’s or Schiller’s solution):

  • Normal cells –> take up iodine (turn brown) in uniform manner
  • Pre-cancerous / cancers –> don’t take up iodine (not brown)
    • Note: cells on inner part of cervix do not stain brown
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14
Q

What is Cervical intraepithelial neoplasia (CIN)?

A

Cervical intraepithelial neoplasia (CIN) or cervical dysplasia:

  • Abnormal pre-cancerous growth of cells on surface of cervix
  • Can lead to cervical cancer
  • Most common at squamocolumnar junction (i.e. transformation zone - difference is histologically debated)
    • CIN can also occur in vaginal walls & vulvar epithelium
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15
Q

What causes Cervical intraepithelial neoplasia (CIN)?

A

Human Papilloma virus (HPV)

especially with types 16, 18 & 33

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16
Q

If CIN progresses to form cervical cancer, what type of cancer is most commonly formed?

A

Cervical squamous cell carcinoma (SCC)

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17
Q

How is CIN diagnosed?

A

Biopsy via colposcopy + histological analysis

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18
Q

What test is commonly used to screen for HPV / pre-maligant cervical changes?

A

Cervical smear test

19
Q

To whom is a smear test offered and how often?

A

Smear test is offered to all women aged 25-64-yrs

In England / Wales:

  • 25-49 yrs –> 3-yearly screening
  • 50-64 yrs –> 5-yearly screening
  • Cervical screening can NOT be offered to women > 64-yrs
  • Women who have never been sexually active have VERY low risk of cervical cancer –> so can opt out
20
Q

Smear tests can show the following results - for each what is the appropriate management?

  • Negative
  • Inadequate
  • Borderline changes in squamous or endocervical cells
  • Low-grade dyskaryosis
  • High-grade dyskaryosis (moderate)
  • High-grade dyskaryosis (severe)
  • Suspected invasive cancer
A
  • Negative –> no action
  • Inadequate:
    • Repeat smear - if 3 consecutive inadequate results –> colposcopy
  • Borderline changes in squamous or endocervical cells OR Low-grade dyskaryosis
    • Original sample tested for high-risk subtypes of HPV e.g. 16, 18 & 33
      • If -ve –> pt goes back to routine recall
      • If +ve –> colposcopy
  • High-grade dyskaryosis (moderate):
    • Indicative of CIN 2 –> urgent colposcopy < 2-weeks
  • High-grade dyskaryosis (severe):
    • Indicative of CIN 3 –> urgent colposcopy < 2-weeks
  • Suspected invasive cancer:
    • urgent colposcopy < 2-weeks
21
Q

What does the image show?

A

CIN (not able to tell grade from image alone)

  • Abnormal pre-cancerous growth of cells on surface of cervix has been stained white with acetic acid (acetowhite lesions)
22
Q

After a LLETZ procedure to excise abnormal cervical cells, if the cells are found to be CIN then when should the pt be followed-up and how?

A

6-month smear test follow-up

23
Q

Can a smear test with the results Dyskaryosis be used to diagnose CIN?

A

NO!

Dyskaryosis is a description of how abnormal the cells on the surface of the cervix appear. CIN is a histological diagnosis requiring biopsy!

24
Q

What % of smear test results are abnormal?

A

~ 5% of all smears = abnormal

25
Q

What courses can CIN take?

A
  1. Develop into cervical cancer e.g. cervical squamous cell carcinoma (SCC) - less likely
  2. Abnormal cells often return to normal on their own
26
Q

How is CIN managed?

A

Usually LLETZ (loop excision)

+ 6-month cervical smear & HPV test

  • HPV -ve –> return to routine call
  • HPV +ve –> colposcopy follow-up
27
Q

For each of CIN 1, 2 & 3:

  • What % regress (abnormal cells become normal)?
  • What % persist?
  • What % progress to CIS (carcinoma in situ)?
  • What % progress to invasive cancer?
A
28
Q

What is Bacterial Vaginosis?

A

Bacterial Vaginosis (BV) - describes an overgrowth of mixed anaerobic organisms e.g. Gardnerella vaginalis & Mycoplasma hominis

  • Commonest cause of vaginal discharge
  • Commoner in black African women
  • NOT an STI
29
Q

What are the features of Bacterial Vaginosis?

A

BV features:

  • Asymptomatic in ~ 50%
  • Vaginal discharge - whiteish / grey, ‘fishy’ offensive odour
30
Q

What criteria are used for diagnosis of BV?

What are the criteria?

A

Amsel’s Criteria - 3 of the following 4 present:

  1. Homogenous grey-white discharge
  2. ↑ vaginal pH > 4.5
  3. +ve ‘fishy’ odour
  4. ‘Clue cells’ on microscopy - squamous epithelial cells with bacteria adherent on their walls
31
Q

What does this image show?

What condition does the pt have?

A

Clue Cells

Bacterial Vaginosis

32
Q

How is Bacterial Vaginosis managed?

A

May resolve spontaneously - but most choose for treatment:

  • 1st line = Oral Metronidazole - 400mg BD 5-7 days OR 2g single dose
    • 70-80% initial cure rate
    • relapse rate > 50% within 3-months
  • 2nd line = Topical metronidazole or topical clindamycin at night 5-7 days
33
Q

How does BV affect pregnancy?

A

BV increases the risk of the following in pregnancy:

  1. Preterm labour
  2. Low birth-weight
  3. Chorioamnionitis
  4. Late miscarriage
34
Q

What is vaginal candidiasis?

A

Vaginal Candidiasis (Thrush) - common fungal infection that many woman diagnose themselves

  • > 90% cases are Candida Albicans
35
Q

What are risk-factors for developing ‘Thrush’?

A

Thrush more likely if:

  • Diabetic
  • Pregnancy
  • Immunosuppression e.g. HIV
  • Antibiotics
  • Steroids
  • Anaemic
36
Q

What are the features of Vaginal Candidiasis?

A

Vaginal Candidiasis:

  • Vaginal discharge:
    • ​white, ‘cottagecheese’,non odourous
  • Vulvitis results in:
    • dyspareunia
    • dysuria
  • Itch
  • Vulval erythema, fissuring, satellite lesions (may be seen)
37
Q

How is Vaginal Candidiasis diagnosed?

A

Often pts are familiar with it and self-diagnose

  • Appearance:
    • Vulval erythema
    • Vulval fissuring - linear erosions
    • Typical white, ‘cottage-cheese’ plaques adherent to vaginal wall
  • Cultures from HVS or LVS (higher and lower vaginal swabs)
38
Q

How is Vaginal Candidiasis managed?

A

Only treat if symptomatic (as many women are carriers and asymptomatic)

  • Clotrimazole 500mg pessary (soluable block into vagina)
    • OR
  • Oral Itraconazole 200mg BD 1-day Oral Fluconazole 150mg single dose

If pregnant then Clotrimazole pessary ONLY!!

39
Q

What is Trichomonas vaginalis (TV)?

A

Trichomonas vaginalis (TV) - is a very motile, flagellated protozoaen parasite that cause Trichomonas

  • TV = an STI
  • TV is found in vaginal, urethral and para-urethral glands
40
Q

What are the features of Trichomonas?

A

Trichomonas features:

  1. Vaginal discharge:
    • ​yellow / green, frothy, offensive odour
  2. Vulvovaginitis causing:
    • Itch
    • Dysuria
  3. Strawberry cervix - due to punctate haemorrhages
  4. pH > 4.5

Can occur in men - is usually asymptomatic but may cause urethritis

41
Q

How is TV Trichomonas diagnosed?

A

High Vaginal Swab

send for culture & wet microscopy

42
Q

How is TV Trichomonas managed?

A

Trichomonas management:

  • Oral Metronidazole 400-500 mg BD for 5-7 days
    • ​OR
  • Oral Metronidazole 2g single-dose
43
Q

How can Trichomonas complicate pregnancy?

A
  • Preterm delivery
  • Low birth-weight

Year 4 - O&G (12 decks)

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