Prevention and Screening and Gynecologic Cancers Flashcards
1
Q
top causes of female morbidity and mortality for all ages
A
- Heart Disease
- Cancer
- Cerebrovascular events
- COPD
- Pneumonia, Influenza
2
Q
female mobidity and mortality by age
A
- Ages 15-34 years
- Accidents
- Cancer
- Homicide/Suicide
- Ages 35-54 years
- Cancer
- Heart Disease
- Accidents
- Ages 55-74 years
- Cancer
- Heart Disease
- COPD
- Age 75 years and over
- Heart Disease
- Cancer
- Cerebrovascular events
3
Q
disease prevention
A
- Cervical Cancer → Pap smear, HPV vaccine
- Breast Cancer → Mammogram
- Skin Cancer → Physical exam, SPF use
- Colorectal Cancer → Hemoccult testing, Colonoscopy
- Anemia → Hemoglobin, Hemoglobin electrophoresis
- Counseling to reduce risk factors – safe sex practices, using SPF/sun exposure, diet and exercise, healthy BMI, smoking cessation, etc.
- Coronary Artery Disease → lipid profile, BP screening, smoking cessation, ASA
- Thyroid Disease → TSH
- Sexually Transmitted Infections → HPV vaccine, screening
- Diabetes → FBS, Hgb A1c, diet/exercise
- Osteoporosis → bone density (DXA) scan, wt bearing exercise, Ca/vit D supplements
4
Q
well women exam
A
- History
- Menstrual history: menarche, LMP, menopause, abnormal bleeding, symptoms
- Obstetric history: GaPbcde, OB complications
- Gynecologic history: gynecologic diseases, surgeries, STI history, breast disease, urinary complaints
- Sexual and contraceptive history: number of partners, history of sexual abuse, contraception used
- Immunizations
- G=pregnancies; P=outcomes of pregnancies (b=term deliveries, c=premature deliveries, d=abortions, e=living children)
- Immunization recommendations: cdc.gov
- No evidence exists of risk to the fetus from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. In spite of the lack of evidence of risk, HPV vaccine, an inactivated vaccine, is not recommended during pregnancy. Live vaccines administered to a pregnant woman pose a theoretical risk to the fetus; therefore, live, attenuated virus and live bacterial vaccines generally are contraindicated during pregnancy. Women should avoid conception for 4 weeks after vaccination with live vaccines. However, benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm.
5
Q
immunizations
A
- Tetanus-diphtheria (Td or TDaP)
- Every 10 years from age 11 years
- Pregnancy in 3rd trimester (27-36 wks) of each pregnancy – INCLUDING PERTUSSIS!! GET TDAP
- Anyone who has questionable vaccine history and current high-risk injury
- TDaP (including pertussis) once in adulthood
- HPV
- HPV types vary depending on brand/formulation
- Ages 9-26 years; start at 11-12 yr visit
- 2 dose series given 6-12 months apart
- Not recommended for use in pregnancy at this time
- Cervarix = HPV vaccine types 16 & 18 only
- Gardasil = HPV vaccine types 6, 11, 16, 18
- Gardasil 9 = HPV vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58
- Influenza
- Yearly for everyone
- Inactivated vaccine for any women who is or will be pregnant during flu season
- Pneumococcal
- All adults age 65 and older should get vaccinated with PCV13 and PPSV23, 1 year apart
- Adults at high risk should be vaccinated once with each vaccine
- MMR
- Everyone should have 2 doses by the age of 6 years
- Required for school entrance
- All women of childbearing age unable to show proof of Rubella immunity with titers
- Live virus not indicated during pregnancy
- Hepatits B
- IVDA, health care workers, current recipients of blood products, Hepatitis C, prostitutes
- 3 dose series, given at 0, 4 weeks and 8 weeks
- Now required for school entrance in most areas
- At postpartum visit if not immune
- Hepatitis A
- Two-dose series, given 6 months apart
- Recommended in endemic areas, not yet required for school entrance except in some border areas
- Varicella/Zoster
- Recommended for anyone not previously exposed to chicken pox
- 2 doses given 4-8 weeks apart
- Live virus not indicated during pregnancy
- Zostavax available for adults >50 years of age, given routinely at age 60
- PPD (TB skin testing)
- Every 2 years for high-risk individuals
- Should be considered in any patient with a cough lasting >4 weeks
- Should be placed at the first prenatal visit
6
Q
Vaccines for Pregnant women
A
- Women who are pregnant should receive a dose of Tdap for the prevention of infant pertussis whether or not they have previously received Tdap. Vaccination of the mother generates antibodies that pass transplacentally to the fetus. Vaccination in the third trimester optimizes the duration of this antibody protection until after birth. Additionally, preventing pertussis in the mother reduces the risk that the infant is exposed to pertussis after birth. Health care personnel should administer Tdap during pregnancy, preferably during the third trimester. If Tdap is not administered during pregnancy to women who have never received it, it should be administered immediately postpartum. Pregnant women who are not vaccinated or are only partially vaccinated against tetanus should complete the primary series. Women for whom Td is indicated but who did not complete the recommended 3-dose series during pregnancy should receive follow-up after delivery to ensure the series is completed. One dose of the tetanus vaccine series should be Tdap, if Tdap has not already been received.
- Pregnant and postpartum women are at higher risk for severe illness and complications from influenza than women who are not pregnant. Pregnant women have protective levels of anti-influenza antibodies after vaccination. Passive transfer of anti-influenza antibodies that might provide protection from vaccinated women to neonates has been reported. Routine vaccination with inactivated influenza vaccine is recommended for all women who are or will be pregnant (in any trimester) during influenza season.
- PCV13 = Pneumococcal Conjugate Vaccine (Prevnar); PPSV23 = Pneumococcal Polysaccharide Vaccine (Pneumovax)
- Pregnant women should be evaluated for evidence of immunity to rubella and varicella and be tested for the presence of HBsAg during every pregnancy. Women without evidence of immunity to rubella and varicella should be vaccinated immediately after delivery.
- A woman found to be HBsAg positive should be followed-up carefully to ensure that the infant receives HBIG and begins the hepatitis B vaccine series no later than 12 hours after birth and that the infant completes the recommended hepatitis B vaccine series on schedule (20). No known risk exists for the fetus from passive immunization of pregnant women with immune globulin preparations.
7
Q
physical exam for well woman exam
A
- Height, Weight, BMI; BP, pulse; LMP
- Think of LMP as a vital sign for pregnant women
- Urinalysis, UPT if indicated
- You get urinalysis on pregnant women, but women who are not pregnant only get it if indicated
- Infections in pregnant women can cause preterm labor
- FBS or Hgb if indicated
- Laboratory tests: TSH, lipid profile, CBC, Chemistry panel as indicated
- Breast exam and lymph nodes
- Chest (CV and Respiratory)
- Pelvic exam, including exam of abdomen and lymph nodes
- Bimanual exam
- Collection of samples for STI testing, Pap smear
- Rectovaginal exam, including guaiac testing if indicated (women who are over 50, retroflexed uterus, etc.)
8
Q
Well woman exam: counseling and education
A
- Diet and exercise
- STI prevention
- Contraception use, hormone therapy
- (Self breast exam)
- Skin self exam and SPF use
- Smoking cessation, EtOH use
9
Q
vulvar neoplasia
A
- 4th most common gynecologic cancer
- 5% of malignancies of female genital tract
- Most frequently in postmenopausal women
- Risk factors include smoking, vulvar dystrophy (eg, lichen sclerosus), vulvar or cervical intraepithelial neoplasia, HPV infection, immunodeficiency syndromes, a prior history of cervical cancer, and northern European ancestry
- The most useful means of generating a differential diagnosis of vulvar lesions is by morphologic findings rather than by symptomatology, which is often nonspecific. In all patients, one or more vulvar biopsies should be performed if the lesion is clinically suspicious for malignancy (asymmetry, border irregularity, color variation, rapid change, bleeding, non-healing). Additional indications for biopsy are if a diagnosis cannot be made confidently by visual inspection and noninvasive methods, if the lesion does not resolve after standard therapy, or to address patient concern. Any lesion on the vulva that is not known to be benign warrants biopsy. An ulcerative lesion that does not heal may need additional and more extensive biopsy despite an initial negative office biopsy result.
- Two independent pathways of vulvar carcinogenesis are felt to currently exist:
- mucosal HPV infection
- chronic inflammatory (vulvar dystrophy) or autoimmune processes
- HPV has been shown to be responsible for 60% of vulvar cancers
- HPV 16 and 33 are the predominant subtypes accounting for 55.5% of all HPV-related vulvar cancers
- 90% squamous cell carcinomas; other histologies include melanoma, Bartholin gland adenocarcinoma, sarcoma, Paget disease, or basal cell carcinoma
- Squamous is slow growing and destroys locally
- Classification:
- VIN-I, mild dysplasia
- VIN-II, moderate dysplasia
- VIN-III, severe dysplasia or carcinoma in situ
- VIN-I and VIN-II are likely to progress to CIS or carcinoma
- Lesions are normally localized and isolated
- Melanoma is the second most common type of vulvar cancer. Lesions typically arise de novo on the clitoris or labia minora, but can also develop within preexisting junctional or compound nevi
- Extramammary Paget disease (an intraepithelial adenocarcinoma) and basal cell carcinomas are associated with a high incidence of antecedent or concomitant malignancy elsewhere in the body.
10
Q
Dds: vulvar cancer
A
- epidermal inclusion cysts
- lentigos
- disorders of Bartholin gland
- acrochordons
- hidradenomas
- seborrheic keratoses
- lichen sclerosus
- other dermatoses
- condyloma acuminate
- If one of these disorders is initially suspected but does not respond to appropriate treatment, biopsy should be performed
- **UpToDate: Vulvar lesions: Differential diagnosis based on morphology
11
Q
Ddx: vulvar lesions
A
- Flesh colored lesions: sebaceous glands, vestibular papillae, skin tags, cysts, and infections (warts, molluscum contagiosum)
- White lesions: lichen sclerosus, lichen simplex chronicus, and vitiligo
- Brown, black, or red vulvar lesions can be due to a wide variety of benign, infectious, inflammatory, and malignant conditions
- Pustules, vesicles, and erosions are usually related to infection or inflammation
- Ulcers and fissures can be caused by infection, malignancy or systemic disease with vulvar involvement
- We recommend that any atypical-appearing dark lesion be biopsied to exclude premalignant or malignant lesions
12
Q
diagnosis of vulvar neoplasia
A
- Pt c/o vulvar pruritis, chronic irritation, development of raised mass lesions
- Diagnosis is made by biopsy
- Any suspicious lesion, chronic pruritis, lesion that does not resolve with standard treatment should be biopsied
- may use colposcopy for better visualization
- Vulvar pruritus is the most common symptom of vulvar cancer and a unifocal vulvar nodule, plaque, ulcer, or mass (fleshy, nodular, or warty) on the labia majora is the most common physical finding
13
Q
vulvar cancer
A
- Staging using TNM & FIGO criteria (FIGO: International Federation of Gynecology and Obstetrics)
- Treatment is primarily surgical
- Wide local excision
- Inguinal/femoral lymphadenectomy
- Chemoradiation as adjunct or for advanced disease
- 5-year survival 70% - 90% for localized disease, 20% if deep pelvic nodes are involved
14
Q
vulvar paget disease
A
- Extensive intraepithelial disease
- Not common (<1%)
- May be associated with carcinoma of the skin
- Higher incidence of internal carcinoma, particularly of the colon and breast
- Treatment is wide local excision or simple vulvectomy and wide margins to prevent recurrence
15
Q
vulvar melanoma
A
- Raised, irritated, pruritic, pigmented lesion
- 5% of all vulvar malignancies
- Wide local excision is required for diagnosis and staging
