Postcoital bleeding & cervical ca Flashcards
Postcoital bleeding
Vaginal bleeding after sex
- pathological until proven otherwise
- light/heavy
- fresh/altered blood
Causes of postcoital bleeding
PREGNANCY!!
Cervical
- Red Flags TRO: Cervical CA
- Cervical Ectropion (Common)
- Cervical Polyps / Fibroids
- Cervicitis (Chlamydia/ BV)
*Screen STI
- Previous cervical instrumentation
Vagina (rare)
- Atrophic Vaginitis (>60)
*If unable to find other reasons for >60y/o, Ix TRO endometrial CA first
*Dryness and itch
- Torn vagina/ Trauma 2° rough sex
- Genital prolapse 2° to ulcerations
- Vaginal CA (Very rare)
- Benign vascular neoplasm
Cervical ectropion (physiological)
- Columnar epithelium exposed to vaginal milieu by eversion of endocervix
- Everted epithelium has a reddish appearance similar to granulation tissue
- Common and normal, can lead to contact bleeding during intercourse/ speculum/ bimanual examination
Risk factors of cervical ectropion
Pregnancy
Use of OCPs
Main causative agent of cervical cancer
HPV types 16 & 18
- only cancer preventable by screening
Risk factors of cervical cancer
Increase exposure to HPV infection
- HPV infection (16/18) ++
- Multiple sexual partners
- Early age of 1st coitus < 20y/o
Reduce ability for body to eradicate HPV infection
- STI
- Smoking
- Immunosuppression
Protective factors for cervical cancer
- Cervical screening (Pap smear for pre-cancer/ HPV DNA)
- HPV vaccination: Cervarix (Bivalent 16/18) and Gardasil Tetravalent, also includes 16 and 18
Symptoms of cervical cancer
- Asymptomatic, discovered on PAP smear
- Abnormal vaginal bleeding
- PCB, IMB or PMB**
- Blood stained discharge - Symptoms due to local invasion
- Fistula: Dysuria, hematuria, per-vaginal leaking of urine
- Obstructive uropathy (hydronephrosis): Flank pain, LUTS
- Constipation
- Vaginal passage of urine/ feces
- Rectal bleeding
- Pelvic pain
- DVT: swelling of one leg, pain - Metastatic symptoms
- LOW, LOA
- Dyspnea, hemoptysis
- Abdominal discomfort, RUQ mass
- Bone pain, pathological #
- Headache, nausea, focal neurological deficit
Physical examination
- General
- Pallor, lymph nodes, cachexia - Abdominal examination
- Abdominal masses
- Hepatomegaly, ascites - Pelvic examination (speculum, VE)
a. Evaluate entire lower genital tract
- Vulva
- Perianal region
- Vagina
- Cervix
b. NO lesion seen on cervix -> Do pap smear/HPV test
- Pap/HPV test negative -> Observe
- Abnormal Pap/HPV -> Colposcopy
c. Lesion SEEN on cervix
- Perform punch BIOPSY (not pap smear!) to confirm diagnosis
- Exophytic or endophytic
- Size (cm) of tumour
- Any vaginal involvement
DRE
- Any parametrial/pelvic side wall involvement
- Any rectal mucosal involvement
d. Ectropian
e. Mucopurulent discharge -> Screen for STIs
Most common subtype of cervical cancer
Squamous cell carcinoma
Investigations for cervical cancer
No lesion -> Colposcopy with punch biopsy
Pre-op bloods (FBC, RP, LFT, PT, PTT, GXM, Serum Ca2+ for bone mets)
Staging scans
- CT/ MRI to evaluate local extent of disease + detect para-aortic lymph node involvement
- PET scan scan for nodes but more expensive
- Cystoscopy/ sigmoidoscopy to look for bladder/ rectal involvement
- CTAP: asess liver mets, lung mets, hydronephrosis
What staging criteria is used for cervical ca?
FIGO staging
Figo staging of cervical ca
I: Confined to uterus
II: Invades beyond uterus
- IIa: upper 2/3 of vagina &/or
- IIb: parametrial involvement
III: Involves either
- lower third of vagina
- pelvic wall
- hydronephrosis or non-functioning kidney
- pelvic lymph nodes
- para-aortic lymph nodes
IV: extends beyond pelvis to mucosa of the bladder/rectum, distant organs
Principles of treatment for cervical cancer
2 main modalities: surgery and radiation
- Radiation can be given for ALL stages (KIV concurrent chemo to increase sensitivity to radiation)
- Surgery for early disease
*Avoid dual therapy (surgery + RT) -> increases morbidity
Treatment options for cervical cancer according to Figo stage
Stages I, IIa: Surgery OR pelvic radiation (no need for concurrent chemo because no parametrial involvement)
Stages IIb, III, IV: Pelvic radiation WITH concurrent chemotherapy (aka chemoradiation)
