vagina - cervix Flashcards
premestrual syndrome (PMS) and premestrual dysmophic disorder (PMDD) - when
begin when women are in their 20-30
premestrual syndrome (PMS) and premestrual dysmophic disorder (PMDD) - symptoms
- headache
- breast tenderness
- Pelvic pain and bloating
- irritability and luck of energy
premestrual syndrome (PMS) vs premestrual dysmophic disorder (PMDD)
PMDD is a more severe vesrion that will disrupt the patient’s daily activities
premestrual syndrome (PMS) and premestrual dysmophic disorder (PMDD) - diagnostic tests
- no tests
- PMDD has DSM-V diagnostic criteria
- tha patient chart her symptoms
premestrual dysmophic disorder (PMDD) - diagnostic criteria
- symptoms should be present for 2 consecutive cycles
- symptoms-free period of 1 week in the first part of the cycle (follicular phase)
- symptoms must present in the second half of the cycle
- Dysfunction in life.
premestrual syndrome (PMS) and premestrual dysmophic disorder (PMDD) - treatment
patient should decrease consumption of caffeine, alcohol, cigarettes and chocolate and should exercise.
IF SEVERE SYMPTOMS –> SSRI
Menopause starts with …. (presentation)
it starts with irregular menstrual bleeding. Women are symptomatic for an average of 12 months, but some women can experience symptoms for years
Menopause starts with …. (mechanism)
the occytes produce less estronege and progesterone, and both LH and FSH start rise
symptoms of menopause - next step
check TSH and FSH
OCPs for vasomotor symptoms
in women younger tha n60 who have undergone menopause within the past 10 years
Pap test - how often
begenning at age 21, repeat evry 3 years. at 30, pap test with HPV co-testing may be done and repeated every 5 years
when to stop Pap testing
age 65 or hysterectomy
PLUS no history of cervical intraepithelial neoplsia 2 or higher
AND 3 conscecutive negative Pap tests
OR 2 consecutive negative co-testing terults
(if intraepithelial neoplasia 2 –> 20 more years)
Cerivical cancer - management of advanced Cerivical cancer
CLEAR: perform a hysterectomy
prevention of cervical ca
- HPV vaccine to all women between 11-26
- pap smear starting at 21. Repeat the test every 3 years until 65.
(of women with fatal Cerivical cancer, 85% have never a pap smear) - pap and hpv testing increase the interval to 5 years
detection of cervical ca
- low grade and high grade dysplasia on Pap tsmear is followed up with a colposcopy for biopsy
- atypical squamous cells of undetermined significance (ASCUS) can be a sign of early, preinvasive cancer or an infection, or may simply be a false positive
- IF ASCUS –> perform HPV testing –> hpv (+) –> colposcopy. IF (-) –> pap at 6 months
Pap smear vs mammography vs colonoscopy - mortality
pap smear does not lower mortality as the others
Cervical dysplasia and carcinoma - Classification
CIN 1, CIN 2, CIN 3 (severe dysplasia or carcinoma in situ), depending on extend of dysplasia
cervical dysplasia and carcinoma - pathogenesis
HPV 16, 18 –> both produce E6 (inh p53) and E7 (inh RB)
cervical dysplasia and carcinoma - presentation
- typically asymptomatic (detected with Pap smear - koilocytes)
- presents as abnormal vaginal bleeding (often postcoital - after sexual intercourse)
cervical invasive carcinoma - type / Diagnosis / complication
often SCC
colposcopy and biopsy
lateranl invasion –> block ureters –> renal failure
cervical dysplasia and carcinoma - Risk factors (MC?)
- HPV
- STD history
- immunosuppresion
- tovacco
- OCPs
- early onsert of sexual activity
- multiple or high risk sexual partners
postcoital bleeding - etiology
- cervical cancer
- cervical polyps
- atrophic vaginitis
postcoital bleeding - diangosis
cervical cancer until proven otherwise
cervical conization - indications
cervical intraepithelial neoplasia grades 2 + 3
observation is preferred for grade 2 in young women
cervical conization - SE
- cervical stenosis
- preterm birth
- preterm premature rupture of membranes
- 2nd trimester pregnancy loss
cervical insuf ?
PAINLESS dilation of cervix in the 2nd trimester and loss of pregnancy
Genitourinary syndrome of menopause - symptoms
- vuvlovaginal dryness, irritation, pruritus
- dyspareunia
- vaginal bleeding
- urinary incontinence
- recurrent UTI
- pelvic pressure
Genitourinary syndrome of menopause - physical examination
narrowed introitis
pale mucosa, decreased elasticity
petecheia, fissures
loss of labial volume
High grade squamous intraepithelial lesion in pap –> next step
colposcopy
vaginal tumors - types and characteristics
- SCC: usually 2ry to cervical SCC (rare 1ry)
- clear cell adenocarcinoma: Women who had exposure to DES in utero
- Sarcoma botryoides: girls under 4. Hist: spindle-shaped cells, desmin (+). Gross: clear, grape-like polypoid mass emerging from vagina
menopause - diagonosis
- amenorrhea for 12 months
- is it is unclear –> High FSH levels are diagnostic
labial fusion - definition / mechanism
- labia minora become fused together
- due to excess androgen (exogen, increased production)
- MCC: 21-β-hydroxylase deficiency
labial fusion - treatment
reconstructive surgery
vulva and vagina - epithelial abnormalities types
- lichen sclerosus
- squamous cell hyperplasia
- lichen planus
vulva and vagina - lichen sclerosus - age
any age –> however if Postmenopausal there is an increased risk of cancer
vulva and vagina - lichen sclerosus - appearance and treatment
- thin white, wrinkled skin over the labia majora/minora, atrophic changes that may extend over the perineum + around the anus / can cause painful defacation
- excoriations, erosions, fissures from severe pruritus
- diruria, dyspareunia painful defection
squamous cell hyperplasia - age
any –> patietns who have had chronic vulvar pruritus
squamous cell hyperplasia - treatment
Sitza baths or lubricants (relieve pruritus)
Liches planus - age
prepubertal girls + perimenopausal or postmenopausal women
Liches planus - appearance and treatment
- violet flat papules
- topical steroids
vulvar lichen sclerosus - treatment
superpotent costicosteroid ointment
vulvar lichen sclerosus - workup
punch biopsy of adult onset lesions to exclude malignancy
atrophic vaginitis vs lichen sclerosus regarding treatment
atrophic –> low dose topical estrogen
lichen –> high potency topical steroids
atrophic vaginitis vs lichen sclerosus regarding clinical features
atrophic –> vluvlovaginal dryness, loss of vaginal elasticity/rugae, thinning vulvar skin/loss of minora, decreased vaginal diameter
lichen –> white vulvar plaques/loss of minora/ dryness, pruritus, perianal involvement, spares vagina
vaginal SCC - RF / diagnosis
RF: HPV 16 + 18, smoking, history of cervical dysplasia or cancer
diagnosis by biopsy
vaginal cancer - SCC vs clear cell adeno regarding location
SCC: upper 1/3 of posterior wall
clear: upper 1/3 of anterior
RF for vaginal SCC
HPV
Bartholin gland cyst - location
lateral sides of the vulva
Bartholin gland cyst - presentation
secrete mucus and can become obstructed leading to a cyst or abscess that causes:
1. PAIN 2. TENDERNESS 3. DYSPAREUNIA
Bartholin gland cyst - physical exam
edema and inflammation of the area with a deep fluctuant mass
Bartholin gland cyst - treatment
if asymptomatic –> nothing
IF SYMPTOMATIC –> incision and drainage –> if continue to recur –> marsupialization
culture the fluid (for STDs)
marsupialization?
it is a form of incision and drainage in which the open space is kept open with sutures –> this allows the space to remain open, and decreases the risk of a recurrent Bartholin gland cyst
cervical mucus secreation
close to ovulation –> increases in quantity and can be perceived by patients as vaginal discharge –> mucus is clear, elastic thin and described similar in appearance to an uncooked egg white –> facilitate sperm transport into the uterus
Vaginitis - RF
any factor that will increase the ph of the vagina
- antibiotic use (Lactobacillus normally keeps ph below 4.5
- diabetes
- overgrowth of normal flora
vaginitis - symptoms
- itching
- pain
- abnormal odor
- discharge
types of vaginitis and the pathogen
bacterial –> gardenella
candidiasis –> candida albicans
trichomonas –> trichomonas vaginalis
types of vaginitis and presentation
bacterial –> vaginal discharde with fishy ofor, gray white
candidiasis –> white cheesy vaginal discharge
trichomonas –> profuse, green frothy vagina discharge
types of vaginitis and diagnostic test
bacterial –> saline wet mount shows CLUE CELLS, ph more than 4.5
candidiasis –> KOH shows PSEUDOHYPHAE, ph 4-4.5
trichomonas –>saline wet mount shos MOTILE FLAGELLATES, ph more than 4.5
types of vaginitis and treatment
bacterial –> metronidazole or clindamycin
candidiasis –> miconazole or clotrimazole, econazole, nystatin
trichomonas –> treat patient and partner with metronidazole
vulva - paget disease - definition / epidimiology
intraepithelial neoplasia that MC occurs in POSTMENOPAUSAL CAUCASIAN WOMEN
vulva - paget disease - presentation and appearance
vulvar soreness and prurritus appearing as RED lesion with a superficial white coating
vulva - paget disease - diagnosis
biopsy to confirm
vulva - paget disease - treatment
- radical vulvectomy for bilateral lesion
- modified vulvectomy for unilateral lesion
Squamous cell carcinoma of vulva - presentation
- pruritus
- bloody vaginal discharge
- postmenopausal
Squamous cell carcinoma of vulva - appearance
from small ulcerated lesion to a large cauliflowerlike lesion
Squamous cell carcinoma of vulva - diagnosis / how to stage
diagnosis: biopsy is essential
staging is done whlie the patient is in surgery
Squamous cell carcinoma of vulva - stage
0: in situ
I: limited to vaginal wall less than 2 cm
II: limited to vulva or perineum less than 2 cm
III: tumor spreading to lower urethral or anus, unilateral lymph nodes present
IV: tumor invasion into bladder. rectum, or bilateral lymph nodes
IVa: distant metastasis
Squamous cell carcinoma of vulva - treatment
unilateral lesion without lymph node: modified radical vulvectomy
bilateral lymph node: radical vulvectomy
lymph nodes that are involved must undergo lymphadenectomy
vulvar hematoma
results from a local trauma and presents as a tender ecchymotic indurated firm mass
in contrast to Bartholin cysts, Gartner duct cysts …
do not involve the valvula
Bartholin cysts present as ….. / treatment
soft, mobile, well-circumscribed masses at the base of labia majora and are usually asymptomatic
treatment: observation if asymptomatic, if symptomatic –> incision and drainage
Management of CIN3
if older than 25 and not currently pregnant –> loop electrosurgical excision procedure or cold Knife conization or cryoablation –> Pap test with HPV 1 and 2 years postprocedure
if pregnant –> colposcopy first
Genitourinary syndrome of menopause - treatment
vaginal moisturizer + lubricant
vaginal estrogen
