stuff-3 Flashcards
what is the abnormal growth of squamous cells detectable on a smear called?
squamous intraepithelial lesion (SIL). Abnormal cells in the cervix detected by biopsy and histological examination are classified as cervical intraepithelial neoplasia (CIN). Graded 1 to 3 according to the proportion of cervix affected.
outline the UK HPV immunisation programme
2 dose regime of 16/11/18/6 Quadrivalent vaccine
what age is it started at?
25
Taking Screening Sample
5 yearly smears , Liquid Based Cytology (LBC), Test for high risk HPV, If positive; triage with cytology
what is a HPV test?
Molecular test on cells sampled from cervix, Identifies high risk type HPV viral DNA or RNA, Any high risk type →→type specific genotyping, Works on LBC samples, Technology: Hybridisation, PCR
what is a cervical cytology sample?
Microscopic assessment of cells scraped from the transformation zone, Look for abnormal cells (dyskaryosis), indicate that woman has underlying cervical intraepithelial neoplasia - CIN
what are the 2 components of the cervical canal?
endocervix - columnar epithelium, ectocervix - squamous epithelium
The majority of cells present are
mature squamous cells,
what method is the slide stained by
The slide is then stained by the Papanicolaou method for viewing under the microscope.
where are women reffered after a abnormal smear is detected?
for a colposcopy
Dyskaryosis has what features?
abnormal cells, Nuclear features: increased size and nuclear:cytoplasmic ratio, variation in size, shape and outline, coarse irregular chromatin, nucleoli
what do Koilocytes reflect?
HPV infecition
how do HPV tests and cytology differ?
HPV - cervical cells, machine, indentifies infection which could be transient or CIN associated, sensitive.
Cytology - cervicl cells, human interpretation, indentifies cellular chhanges (low grade - persisting infection/CIN1, high grade - CIN 2/3), specific.
what happens if +ve hrHPV?
if cytology is normal repeat the test in 1 year BUT if the cytology shows dyskaryosis then refer to colposcopy
what is a Colposcopy?
Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix as well as the vagina and vulva. Many pre-malignant lesions and malignant lesions in these areas have discernible characteristics that can be detected through the examination.
what is it used for and how is it done?
excluding obvious malignancy, magnificaiton and light to see the cervix, use of acetic acid/ iodene to identify areas to treat, identify limits of the lesion, select the biopsy site. PUNCH BIOPSY DONE TO MAKE A DIAGNOSIS. Return for tx if CIN2/3
what is the action of HPV in the transformation zone?
infects the basal layer, utilises the host for replication, as the host cell matures different viral genes are expressed.
describe the histology of HPV infection of koliocytosis
cells wit wrinkled nuclei and periuclear halo. Multinucleation
which are low risk HPV types?
6, 11, 42, 44 - geital warts ad low grade CIN, ofte trasient ad resolve.
which are low risk HPV types?
16, 18, 31, 45, persistent infection increases the risk of developing high grade CIN and more cancer.
how does HPV cause high grade CIN?
persistent infection, viral DNA integrates into the host cell genome, overexpressio of viral e6 ad e7 protein, deregulation of the host cell cycle.
histology of CIN3
Neoplastic cells or undifferentiated cells fill full thickness of epith here , no normal differentiated cells seen
summarise what CIN is…
Disorganised proliferation of abnormal cells in squamous epithelium (dysplasia), Lack of maturation, variation in cellular size and shape, nuclear enlargement, irregularity, hyperchromasia, cellular disarray, CIN 1: low grade dysplasia–will regress, CIN 2: moderate dysplasia – may regress, CIN 3: severe dysplasia – unlikely to regress, Precursor of invasive cancer, it is invisible to the naked eye.
how is CIN treated?
LLETZ, Thermal Coagulation, Laser ablation
what is the peak age of cervical cancer?
44-45
what are the RF of cervical cancer?
HPV related (16 & 18), Multiple partners, Early age at first intercourse, Older age of partner, Cigarette smoking
what is the main vaccination for primary prevenetion of hpv?
HPV 16 and 18 vaccine
40f para 3 attends gp with heavy irregular periods, smoker, hasn’t had a cervical screen since 2005, what should the gp do?
refer as an irgent cancer referral as a suspected cancer patient
what are the symptoms of cervical cancer?
abnormal vaginal bleeding, postcoital bleeding, intermenstrual bleeding, discharge, sometimes pain if it is advanced
how is cervical cancer diagnosed?
clinically, screening, biopsy
what is the purpose of screening?
to detect precancerous disease NOT cancer
what does histopathology look to pickup?
CIN (1, 2 or3 ) - cervical interepithelial neoplasia - abnormal proliferation of squamous epithelial cells.
what abnormalities are seen?
cytological atypia, in CIN 1 there is atypia effecting the lower part of the epithelium, 2 and 3 progress onto atypia effecting further up the epithelium
what type of cancer is picked up in histopathology?
squamous cell carcinoma (80%), adenocarcioma (20%)
what is FIGO staging?
Cervical cancer staging is the assessment of cervical cancer to decide how far the disease has progressed. Cancer staging generally runs from stage 0, which is pre-cancerous or non-invasive, to stage IV, in which the cancer has spread throughout a significant part of the body
what are the criteria of FIGO staging?
1a1, 1a2, 1b. 2 is vagina, 3 lower vagina, 4 distant mets
what other modalities are used to stage cervical cancer?
PET-CT, MRI
what is the Tx of cervical cancer?
hysterectomy, combination of chemotherapy and radiotherapy. External beam radiotherapy, chemo (5 cycles of cisplatin), caesium insertion.
what is lletz?
Large loop excision of the transformation zone (LLETZ)LLETZis the most common treatment for removing abnormal cells from the cervix
what is removed in a radical hyterectomy?
uterus, cervix, upper vagina, parametria, pelvic lymph nodes. BUT conserve the Ovaries
brachy therapy?
Brachytherapy is a form of radiotherapy where a sealed radiation source is placed inside or next to the area requiring treatment.
how does vulval cancer present?
pain, itch, bleeding, lump/ulcer
RF of vulval cancer?
neoplasia or cancer at another lower genital tract site, lichen sclerosus, smoking, immunosupression
how is vulval cancer staged?
surgical-pathological, size of lesion, lymphnode involvement (inguinal AND upperfemoral, also pelvic). Stage 1a is micro-invasion
what lymph nodes are involved in vulval cancer?
inguinal AND upper femoral nodes, also pelvic lymph nodes
what type of biopsy is done
punch or excisional biopsy
what to look for in histopathology?
if there is invasion thenm it is squamous cell csarcinoma, abnormal nuclei
what is usual type VIN (Vulvar Intraepithelial Neoplasia)
HPV related, Younger women, Multifocal, Multizonal, Immunosuppression, Past history of intra-epithelial neoplasia
what is differentiated type VIN
Non-HPV related, Older women, Lichen Sclerous, Often presents as cancer at first diagnosisthickened epithelium, extra surface keratin
what staging is used for vulval cancer?
FIGO, on biopsy depth of invasion is looked at
what sis the Tx of vulval cancer?
local excision, node disection (bilateral needed if there is central involvement), chemo and radio therapy
what are the side effects of groin node dissection?
wound infecion, lymphocysts, nerve damage
how much blood is lost in average menstruation?
30-40ml, over 2-7 days.
what age is menarche and menopause at?
menarche: 10-16yo, menopause: 50-55yo
when does LH, FSH and osestrogen peak?
just before ovulation
when does progesterone peak?
after ovulation till the stage of a regressing corupus luteum
what are the mentrual parameters?
frequency, regularity, duration, volume
Define Menorrhagia, Dysmenorrhoea, Intermenstrual bleeding, Postcoital bleeding, Oligomenorrhoea
Menorrhagia = heavy periods
Dysmenorrhoea = painful periods
Intermenstrual bleeding = bleeding between periods
Postcoital bleeding = bleeding after intercourse
Oligomenorrhoea = infrequent periods e.g. 45-90
how is heavy menstrual bleeding (Menorrhagia) defined?
bleeding over 80ml over 7 days AND/OR the need to change menstrual products every one to two hours AND/OR passage of clots greater than 2.5 cm, Bleeding through the clothes, AND/OR ‘very heavy’ periods as reported by the woman/affecting quality of life, it can also occur with dysmenorrhea. health implications (anaemia), 20%women in UK have hysterectomy aged <60 due to HMB.
what are the common causes of HMB?
ovarian dysfunction, uterine fibroids, endometrial polyps, endometriosis,
pelvic inflammatory disease, endometrial cancer, cervical cancer, adenomyosis,
coagulation disorders, hypothyroidism, liver/renal disease, anticoag treatments, IUD causes it too, herbal supplements.
what are the common causes of HMB? USING PALMCOEIN…
polyp, adenomyosis, leiomyoma/fibroid, malignancy, coagulopathy, ovulation dysfunction, endometrium/hyperplasia, iatrogenic, not yet classified
What are Fibroids?
Non cancerous growths made of muscle and fibrous tissue. also called myoma or lieomyoma, Common and usually asymptomatic – 60% of 40 year olds have fibroids, Higher incidence in Afro-Caribbean women
who has a higher incidence of Fibroids?
Afro-carribean women!
Sy/sx
HMB, pelvic pain, urinary symptoms, pressure symptoms, backache , Infertility, miscarriage, Enlargement of the uterine cavity surface area may cause menorrhagia, Submucous or polyp may cause intermenstrual bleeding
types and diagnosis…
Diagnosis: Clinical exam, Ultrasound, Hysteroscopy
Types: Sub mucous = protrude into uterine cavity, Intramural = within uterine wall, Sub serous = project out of uterus into peritoneal cavity
Tx
Usually no treatment needed, Standard menorrhagia Rx (NSAID’S AND NAPROXEN) if uterine cavity is not too distorted, Transcervical resection of submucous fibroids, Uterine artery embolisation, Hysterectomy.
What is Endometriosis?
Endometrial type tissue outside the uterine cavity, Common sites = ovary, pouch of Douglas (rectouterine pouch), pelvic peritoneum, May be asymptomatic and resolve without Rx. During menstruation this ectopic tissue behaves the same as endometrium and bleeds.
Sy/sx
Symptoms: Premenstrual pain, Dysmenorrhoea, Deep dyspareunia (difficult/painful sex), Subfertility, pelvic pain, cramps worse over time, intermenstrual bleeding and spotting, diarrhea, nausea, painful bowel movements and urinaiton, lower back pain.
(PELVIC PAIN BEFORE AND DURING MENSTURATION, IRREGULAR UTERINE BLEEDING, POST-COITAL BLEEDING, DYMENORRHOEA.)
REDUCED FERTILITY, DYSPARENURIA, SHORTER CYCLE LENGTH, MENORRHAGIA, USE OF OCP INCREASES RISK OF ECTROPION, FHX OF CERVICAL CANCER, AGE OF FIRST SEXUAL INTERCOURSE, SMEAR HX
Signs: Tender nodules in rectovaginal septum, Limited uterine mobility, Adnexal mass.
SX: FIXED RETROVERTED UTERUS, ADNEXAL MASS, THICKENING OF UTEROSACRAL LIGAMNENTS, POSSIBLE CYSTIC SWELLINGS
ddx od endometriosis?
cervical cancer, fibroids.
stages 1-4 of endometriosis
1 - patches, surface lesions or inflammation on or around organs on the pelvic cavity,
2 - widespread, infiltrating pelvic organs,
3 - peritoneum, scarring and adhesions,
4 - infiltrative and affecting many pelvic organs and ovaries,often anatomical distortion and adhesions.
Diagnosis/ Ix
Laparoscopy, MRI, pelvic exam. Bloods (FBC - anaemia, TFT’s - hypothyroidism, CLOTTING- abnormality may lead to increased blood loss)
Complication of an exploratory laproscopy?
Bowel perforation, major vessel perforation
Mx
Medical: Progesterone = oral/injection/Mirena, Combined pill, GnRH analogues
Surgical: Excision of deposits from peritoneum/ovary, Diathermy/laser ablation of deposits, Hysterectomy/oophorectomy
SURGICAL EXCISION, COCP, POP, GnRH ANALOGUES
What is Adenomyosis?
Endometrial tissue found deep in myometrium, Thickened wall of uterus can be mistaken for fibroids
sy/sx
menorrhagia, bulky tender uterus, dysmeorrhea
Ix
Usually normal Us, Laparoscopy, Hysteroscopy, Histology of uterine muscle = not endometrial biopsy
tx
Hysterectomy (may partially respond to hormones)
Endometrial Polyps
Overgrowth of endometrial lining can lead to formation of pediculated structures called polyps which extend into endometrium
dx and tx
US, hysteroscopy, mostly benign, Polpectomy
Mx of heavy menstrual bleeding…
hx, pelvic examinaiton, clotting profile, thyroid function, uss, laparoscopy then tx depending on QOL impact, pathology, fertility, prefrences.
Define (DUB) Dysfunctional uterine bleeding
Abnormal bleeding but no structural/endocrine/neoplastic/infectious cause found for complaint, Subjective – 50% women who complain of heavy periods actually only lose <80ml per cycle, 50% hysterectomies for menorrhagia are because of DUB
Medical tx to control DUB
Mefenamic acid (prostoglandin inhibitor) - reduces blood loss, suitable for those trying to conceieve.
Tranexemic acid (antifibrinolytic) - reduces blood loss
GnRh Analogues
Combined contraceptive pill (COCP)makes periods lighter, regular and less painful
Oral Progesterone - regulates cycle more
Surgical tx
Endometrial abalaiton - permenant destruction of the endometrium to below basal layer, Can use diathermy/thermal balloon, Treatment done through cervix, No effect on ovarian hormones/bladder, 60% will have no periods.
Hysterectomy - surgical removal of the uterus, abdominal or vaginal, laproscopic, (total = cervix and uterus removed) (wertheims = total + salpingo-oophorectomy)
hysterectomy complications
infection/DVT/bladder/bowel/vessel injury/ altered bladder function / adhesions
what is FIGO?
Classification of Abnormal Uterine Bleeding
age predictors of the cause of menstrual disorders
• Early teens: Anovulatory cycle = menstrual cycle without release of oocyte, Congenital anomaly
• Teens – 40: Chlamydia, Contraception related, Endometriosis/adenomyosis, Fibroids, Endometrial or cervical polyps, Dysfunctional bleeding
• 40-menopause: Perimenopausal anovulation, Endometrial cancer, Warfarin, Thyroid dysfunction
ALWAYS CONSIDER PREGNANCY
ALWAYS LOOK AT THE CERVIX
Ix to do for these disorders in general
Full blood count if menorrhagia, Endometrial biopsy, Chlamydia, Thyroid/coagulation if other symptoms, Pregnancy test, TV (trans-vaginal) ultrasound, Hysterectomy, Laparoscopy.
FBC, BIOPSY OF ENDOMETRIUM, PREGNANCY TEST, TVUSS, HYSTEROSCOPY, LAPAROSCOPY.
what is Amennorhea and what are its causes?
infrequent or very light periods, causes: Life changes:stress, eating disorders/malnourishment, obesity, Intense exercise, Hormones:POP, Mirena, depot injection, Primary ovarian insufficiency, Polycystic ovarian syndrome, Hyperprolactinemia (elevated levels of prolactin in the blood), Prolactinomas (adenomas on the anterior pituitary gland), Thyroid disorders (Graves’s disease), Obstructions of the uterus, cervix, and/or vagina, Investigate and treat the cause.
What is Polycystic Ovary Syndrome?
Polycystic ovary syndrome (PCOS) is a complex condition of ovarian dysfunction thought to affect between 5-20% of women of reproductive age.
sy/sx
subfertility and infertility, menstrual disturbances: oligomenorrhea and amenorrhoea, hirsutism, acne (due to hyperandrogenism), obesity, acanthosis nigricans (due to insulin resistance).
(OLLIGOMENORRHAGIA, MENORRHAGIA, ERRATIC PERIODS)
DDX for PCOS?
Hypothryroidism, endometriosis, coagulopathy, uterine polyps, dysfunctional uterine bleeding.
questions to ask pt with PCOS to differentiate betweenm the ddx?
bleeding regularlity, bleeding from other places, fhx of coagulopathy, any sy of hypothyroidism (weight gain, lethargy, constipation). Hirsutism, acne, DM? dysmenorrhea? dysparenuria?
Ix
PELVIC USS: multiple cysts on the ovaries
BLOODS - LH:FSH RATIO, INCREASED SERUM ANDROGEN INDEX, DECREASED SEX HORMONE BINDING GLOBULIN, INCREASED PROLACTIN, DECREASED HB DUE TO MENORRHAGIA, (FSH, LH) prolactin, TSH, and testosterone are useful investigations: raised LH:FSH ratio is a ‘classical’ feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes. check for impaired glucose tolerance.
Tx
Lose weight, COCP, POP, metformin, clomiphene (induces ovulation), Mirena IUS
What are 2 long term sequalae of PCOS?
infertility, T2DM, increased risk of endometrial hyperplasia and endometrial carcinoma, increased risk of CHD.
