Week 4 pt 2 Flashcards
Define:
1) Internal os
2) External os
3) Ectocervix
4) Endocervical canal
1) Upper part of the cervix that opens into the endometrial cavity
2) Lower part of the cervix that opens into the vagina
3) Exterior portion of the cervical canal (what we can see)
4) Interior cervical canal leading to the uterus (what we cannot see)
Squamocolumnar junction (SCJ):
1) What is it?
2) What represent the newest and least mature cells in the cervix?
3) What is highest during adolescence and early pregnancy?
4) Where does >90% of metaplasia and cervical neoplasia arise?
1) Area between the original SCJ and active SCJ (transformation zone)
2) Metaplastic cells within the TZ
3) Rate of metaplasia
4) The active (new) SCJ
Give the basics of HPV
1) Most HPV-infected women asymptomatic
2) Most women, especially younger women, can clear the infection in 8-24 months
3) HPV type and persistence of HPV infection appear to be the most important factors in the progression into squamous intraepithelial lesions (SIL)
4) HPV is easily spread via sexual intercourse
6) HPV 16, 18 most commonly cause cervical cancer
13 other HPV types cause remainder of cervical cancer (15 types are high-risk)
5) HPV 6, 11 are associated with genital warts (condylomata acuminata)
List the Cervical CA screening essentials
1) Decrease cervical cancer rates and mortality rates
2) Current and previous cervical cancer screening results
3) Hx of treatment and findings on pathology
4) Abnormal vaginal bleeding? (possible cervical ca present?)
5) Compromised immune system? (increased risk for cervical cancer)
6) Hx of hrHPV vaccination
7) Pregnancy?
Describe how common HPV and cervical CA are
1) HPV infection is very common in young women which is why the new cervical cancer guidelines are based on HPV status and age.
2) BUT invasive cervical cancer is very rare.
Women at increased risk for cervical cancer may be screened more frequently, including what groups?
HIV, patients on immunosuppression therapies, women exposed to DES in utero, and women previously treated for CIN 2, CIN 3, or cancer
ACOG:
1) Women aged ___________ represent around 20% of new cervical cancer cases
2) Reasonable to discontinue screening at either ____ or ___ years of age if they have had three or more negative tests in a row within the past 10 years.
1) 65 and older
2) 65 or 70
*If screening is stopped, risk factors should still be assessed annually, and screenings resumed if indicated.
If a total hysterectomy was for benign causes (i.e., fibroids) and they have NO history of high-grade neoplasia (CIN2, CIN 3, or AIS), can paps be discontinued?
Yes
Give some Pap Techniques
1) Speculum should be large enough to adequately displace the vaginal side walls and allow visualization
-Cervix should be completely visualized
2) Minimal water-based lubricant should be placed on the speculum
3) Pap should be deferred if there is heavy cervical bleeding or active cervicitis
Ideally, a Pap should be completed in the middle of a patient’s cycle (days 9-20)
Give some reasons for a pap test result being unsatisfactory and what you should do next
1) -Specimen rejected/not processed
-Specimen processed and examined, but unsatisfactory for evaluation of epithelial abnormality because of a specified reason
2) Retest in 2-4mos recommended
-If retest also unsatisfactory, recommend colposcopy.
-If retest abnormal or negative, follow 2019 ASCCP Guidelines (more on this later)
1) What would a normal pap smear be negative for?
2) What organisms can it detect?
1) Negative for Intraepithelial Lesion or Malignancy (NILM)
2) Trichomonas vaginalis
Candida
Bacterial vaginosis
Actinomyces
Herpes simplex virus (HSV)
What are some other non-neoplastic findings that can be seen on a Pap result?
-Reactive cellular changes associated with
-Inflammation
-Radiation
-Intrauterine contraceptive device
-Glandular cell status post-hysterectomy
-Atrophy
What is another finding that can be seen in a woman ≥45 years of age
Endometrial cells
Abnormal Pap Results: List the 3 categories of Squamous Cell Abnormalities
1) ASC: ASC-US or ASC-H
2) LSIL: Commonly correlates with CIN1
3) HSIL: Commonly correlates with CIN2 or CIN3
Give some examples of abnormal pap results from least to most concerning
1) ASC-US
2) ASC-H
3) LSIL: Low-grade Squamous Intraepithelial Lesions
Includes findings of CIN1 (low-grade dysplasia) and findings consistent with HPV infection
4) HSIL: High-grade Squamous Intraepithelial Lesions
CIN2 and CIN3 lesions (moderate dysplasia, high-grade dysplasia)
5) Carcinoma in situ
6) Squamous Cell Carcinoma
7) Glandular Cell
CIN (cervical intraepithelial neoplasia):
1) Small percentage progress to cervical cancer, usually ______________________
2) The major cause of CIN is infection with what?
1) squamous cell carcinoma (SCC)
2) HPV (16 and 18)
1) CIN 1 (low-grade dysplasia) much less likely to progress to cervical cancer unless ________________ present
2) CIN 2 and CIN 3 (high-grade dysplasia) progression to invasive cancer usually gradual over __________ years
1) high-risk HPV (16 or 18)
2) several
So, our pap smear comes back ABNORMAL… What do we do now?
Follow 2019 ASCCP guidelines
2019 ASCCP Guidelines: Treatment guidelines are dichotomized by younger than _____ years and ______ years or older because of high spontaneous regression rates of HPV infection and CIN 2 and low incidence of cancer in those younger than _______ years
25; 25; 25
2019 ASCCP Guidelines: Providers must know (at minimum) patient’s age and current test results SO recommendations are based on risks of immediate and future CIN 3+ diagnoses; what are the caveats to this?
1) Previous screening history not always known
2) HPV testing guides management options and if positive, should perform reflex testing to determine which type of HPV is positive
Persistent HPV infection necessary for developing precancer and cancer; how is this defined?
Defined as CIN 3+ (CIN 3, AIS, and cancer)
List the first 2 new (2019) principles of cervical CA testing
1) HPV-based testing = basis for risk estimation
-HPV type and duration of infection determine patient’s risk of CIN 3+
2) Current results + past history provides personalized risk-based management for having or developing CIN 3+
-Management recommendations use thresholds of risk which correspond to a risk stratum (a range of risk for CIN 3+). These recommendations include:
a) Routine screening
b) 1yr or 3yr surveillance
c) Colposcopy
d) Treatment
-The level at which the management recommendation changes is at the lower threshold of each risk stratum (Clinical Action Threshold)
List the second 2 new (2019) principles of cervical CA testing
1) Guidelines continue to evolve as more patients of screening age received HPV vaccination
2) Colposcopy practice must follow guidance from ASCCP Colposcopy Standards
-Colposcopy + targeted biopsy = primary method detecting precancers requiring treatment (must detect CIN 2+ if present because managed more aggressively than less concerning results)
Give the continued principles from 2012
1) Screening and management goal is cancer prevention
2) Guidelines apply to all individuals with a cervix.
3) Equal management for equal risk
For example, HPV-positive ASC-US and LSIL cytology have very similar risks of CIN 3+ and are therefore managed similarly
More on risk on the next several slides…
4) Balance benefits and harms
5) Guidelines apply to asymptomatic patients who require management of abnormal cervical screening test results
6) Guidelines differ country to country. These are for the US.
One year return: Recommended for patients with risks above the 3-year threshold but below the Clinical Action Threshold for ____________ (0.55-3.99% CIN 3+ risk)
colposcopy
Describe the Colposcopy Clinical Action Threshold
1) Approximates the risk for a patient after an HPV-positive ASC-US or LSIL screening result in the general population (for whom colposcopy was recommended in the 2012 guidelines)
2) Patients with risks at or above this threshold but below the expedited treatment threshold (>4%-24% CIN 3+ risk) are recommended to receive colposcopy
a) Pregnant women may also have colposcopy (but no further invasive tests such as endocervical sampling)
Expedited treatment or colposcopy Clinical Action Threshold:
1) What does it do?
2) What is included in this?
1) Approximates the risk for a patient after an HPV-positive atypical squamous cells cannot exclude HSIL (ASC-H) cytology screening result in the general population.
2) ASC-H included in this regardless of HPV result
Expedited treatment or colposcopy Clinical Action Threshold:
1) What did it recommend?
2) What is expedited Tx?
1) Recommended to receive counseling from their providers to choose between evaluation with colposcopy and biopsy or expedited treatment.
2) Expedited treatment = an excisional procedure (i.e.. LEEP, cold-knife conization) without confirmatory colposcopic biopsy.
-Reasons for choosing expedited treatment vary and may include personal preference, limited healthcare access, financial concerns, and cancer-related anxiety.
Explain the expedited treatment preferred Clinical Action Threshold
1) HPV 16–positive (or any) HSIL cytology screening result
2) HSIL cytology that is HPV 16–positive has an immediate CIN 3+ of 60%
3) Risks at or above the threshold, in this case a 60-100% CIN 3+ risk, should receive expedited excisional treatment
4) Unless they are pregnant, <25yo, or have concerns about the potential effects of treatment on future pregnancy outcomes that outweigh concerns about cancer
ASC: Atypical Squamous Cells:
List the 2 categories
1) ASC-US-Atypical squamous cells of undetermined significance
2) ASC-H-cytologic changes suggestive of HSIL but lacking definitive interpretation.
-Has a significantly higher predictive value for diagnosing CIN2 or CIN3 than ASC-US Paps
AGC: Is it common or rare?
Rare; <1% of cervical cytology samples (usually >40yo)
Atypical Glandular Cells (AGC) subdivided into what?
Atypical endocervical
Atypical endometrial
Not otherwise specified (NOS)
Atypical glandular cells, favors neoplastic
Endocervical adenocarcinoma in situ (AIS)
Adenocarcinoma
List the types of cervical CA & the average age of Dx with cervical CA
Squamous cell carcinoma (~80%)
Adenocarcinoma
Adenosquamous carcinoma (combined 15%)
Small cell carcinoma
Neuroendocrine carcinoma
Avg age of diagnosis= 50yo
List some risk factors for cervical neoplasia
More than one sexual partner or a male sexual partner who has had sex with more than one person
Smoking
HIV infection
HPV infection (90%)
Organ (especially kidney) transplant due to immunosuppression
Diethylstilbestrol (DES) exposure
History of cervical cancer or high-grade squamous intraepithelial lesions
Infrequent or absent cervical cytology screening tests
What are the Sx of cervical CA?
1) Asymptomatic
2) Abnormal bleeding such as postcoital bleeding or intermittent spotting
3) Vaginal discomfort
4) Watery or foul-smelling vaginal discharge
5) Mets symptoms depending on location
What is the 5 yr survival rate for localized cervical CA?
92%
List some prevention methods for cervical CA
1) HPV vaccination
2) Sexual abstinence
3) Barrier protection use (+/- spermicides)
4) Regular gyn exam with cervical screening (and tx if required)
Complaints worrisome for recurrence of cervical cancer include what?
1) Vaginal bleeding or discharge
2) Bleeding after intercourse
3) Abdominal or pelvic pain
4) Urinary symptoms
5) And/or change in bowel habits
Physical examination findings suspicious for recurrence include what?
1) Enlarged lymph nodes
2) Vaginal lesions that are friable, raised, or nodular
3) Nodularity in the rectovaginal septum
4) Palpable mass at any location, particularly the pelvis.
Chronic pelvic pain:
1) What % of women have it?
2) What can cause it?
3) What have studies found correlations between?
4) What sign can help Dx this?
1) 15-20% of women aged 18-50 have some level of chronic pelvic pain that lasts longer than a year
2) Can be caused by other diseases of reproductive, GU and GI tracts
3) Studies have found a significant correlation between a history of abuse and chronic pain
4) Carnett sign
Differentiate primary and secondary dysmenorrhea
1) Primary Dysmenorrhea: Excessive prostaglandin
Younger women > Older women
>50% of menstruating women
2) Secondary Dysmenorrhea: Uterine/Pelvic pathology
Older women>Younger Women
>25% of women with dysmenorrhea
Primary dysmenorrhea: What are some risk factors?
Menarche before 12yo
Nulliparity
Smoking
Family hx
Obesity
Primary dysmenorrhea: What are some Sx?
1) Spasmodic, colicky, labor like pain
2) Aching or heaviness in lower mid abdomen
3) Begins 1-2 days before the onset of menstruation
4) 90% with N/V
5) Dyspareunia (painful sexual intercourse) not common (suggests secondary cause)
Secondary dysmenorrhea: List some risk factors
Hormonal imbalance
Multiparity
Family history
Increased age
Obesity
Secondary dysmenorrhea: List some Sx
Dyspareunia
Heavy Menstrual flow
Rectal pain
Fever (if PID)
Early satiety or loss of appetite (due to mass)
Infertility
What is the etiology and location of secondary dysmenorrhea?
1) Structural abnormalities
2) Can be within the uterus or just outside
List causes of secondary dysmenorrhea
Endometriosis (40%)
Pelvic Inflammatory Disease
Leiomyoma (fibroids)
Adenomyosis
Endometrial polyps
Ovarian cysts
Retroverted uterus
Cervical Stenosis
Pelvic adhesions
Congenital uterine anomalies
Intrauterine Device
…and many more
Give the OLDCARTS for dysmenorrhea
1) Onset: When and how did the pain start? Does it change over time
2) Location: Localize specifically-can the woman put a finger on it
3) Duration: How long does it last?
4) Characteristics: Cramping, aching, stabbing, itching?
5) Alleviating/Aggravating factors: What makes it better? (change or position, medication, stress reduction) What makes it worse? (menstrual cycle, stress, specific activity)
6) Associated symptoms:
Gynecologic: (dyspareunia, dysmenorrhea, abnormal bleeding, discharge)
Gastrointestinal: (constipation, diarrhea, bloating, gas, rectal bleeding)
Genitourinary: (urinary frequency, dysuria, urgency, incontinence)
7) Radiation: Does the pain move to other areas of the body?
8) Temporal: Time of day and relationship to daily activities
9) Severity: On a scale of 0-10, 10 being the worse
List some Tx for the Sx of dysmenorrhea
1) Heating pads/hot showers
2) Exercise
3) Vitamins B&E
-Works to decrease arachidonic acid
Describe how to rule out other causes of dysmenorrhea
1) Treat PID
2) Surgery/hysterectomy might be needed if pain does not resolve
Leiomyomas:
1) What are they?
2) Can they become malignant?
3) When may they stop growing or will atrophy?
1) Benign smooth muscle tumors
2) Very small malignant potential
< 1:1000
3) Menopause
Concerning leiomyoma symptoms, particularly in post menopausal women incl. what?
1) Rapidly enlarging uterine masses
2) Postmenopausal bleeding
3) Unusual vaginal discharge
4) Pelvic pain
Leiomyomas are classified by location; define the following locations:
1) Intracavitary
2) Submucosal
1) Intracavitary: inside the body of the uterus
2) Submucosal: below the endometrial lining
higher rate of infertility
Leiomyomas are classified by location; define the following locations:
1) Intramural
2) Subserosal
3) Pedunculated
1) Within the muscular wall of the uterus; most common
2) Below the outer serous covering of uterus
3) Connected to the uterus by a stalk
Risk Factors for leiomyoma include what?
1) Ethnicity: African Americans have 2-3 x risk compared to Caucasians
2) Family history
3) BMI > 30
4) Early menarche (<10yo)
5) Red meat consumption
6) Alcohol consumption
Most leiomyoma pts are asymptomatic, but list some Sx
1) Menorrhagia (Heavy flow) – most common fibroid symptom
-Blood loss >80mL
2) Metrorrhagia (Bleeding between periods)
3) Pelvic pain/pressure
4) Stress Urinary Incontinence
5) Ureteral Obstruction
6) Reproductive dysfunction (infertility, miscarriage)
7) Low back pain
Commonly, uterine fibroid size described being similar to __________ uterus.
pregnant
Leiomyoma Dx: If further imaging necessary to plan intervention or when malignancy is suspected, what is the most accurate way to diagnose uterine fibroids if diagnosis is uncertain?
MRI
Leiomyoma Tx:
1) What should you do for asymptomatic ppl?
2) What should you do for the pts you don’t treat?
3) Rapidly enlarging fibroids may be sarcomas called what?
4) What is the most accurate way to watch a leiomyoma?
1) Observation
2) Make measurements when fibroids are diagnosed so that fibroid size can be observed in follow-up visits yearly
Fibroids size should regress at menopause
3) Leiomyosarcoma
4) MRI
Desc. the first tier of leiomyoma Tx
1) Myomectomy (submucosal only; everyone who wants to preserve fertility)
2) Be aware of risk of uterine rupture in subsequent pregnancies!
3) Hormonal Treatment (for menorrhagia):
Oral contraceptives (COCs), progestin-releasing IUD
Desc. the second tier of leiomyoma Tx
1) Leuprolide: Gonadotropin-releasing hormone agonists and antagonists (GnRH)
Short courses only due to side effects
2) Uterine artery embolization
Desc. the third tier of leiomyoma Tx
1) Endometrial ablation
2) Hysterectomy: Most common reason for hysterectomy
Endometriosis:
1) What is it?
2) How common is it?
3) What is the pathophys?
1) Growth of endometrium outside of the uterus.
2) Prevalence in the US: 6-10%
3) Pathophysiology is unknown but there are theories.
What are the 3 main Sx of endometriosis?
Dysmenorrhea
Dyschezia
Dyspareunia
What are the S/Sx of endometriosis?
Variable symptoms (3Ds)
Dysmenorrhea
Dyschezia
Dyspareunia
Cyclical premenstrual pelvic or low back pain
Metrorrhagia
25% of women will have infertility
Endometriosis Sx based on location are?
1) Thoracic cavity = chest pain, hemoptysis
2) GI tract = Diarrhea, cramping, abdominal pain, bloatin
True or false: many w endometriosis are asymptomatic
True
What are 3 endometriosis labs?
1) CBC: to differential pelvic infection from endometriosis, assess degree of blood loss
2) U/A/ urine culture: if UTI on differential
3) Gram stain and cultures: if STD on differential (pelvic pain and infertility)
Describe endometriosis imaging
1) Used to rule out other reasons for pain
-Neoplasms, masses or lesions
2) TVUS can identify ovarian cysts
3) HSG may be completed due to infertility
4) May see tubal occlusion or peri-adnexal adhesions
5) Gold standard/Definitive Diagnosis: Laparoscopy
6) Histology of lesions removed at surgery
Choice depends on the patient’s individual circumstance, including what factors?
1) The presenting symptoms and their severity
2) The location and severity of endometriosis
3) The desire for future childbearing
List some other options for endometriosis Tx
Progesterone (orally, injectable or IUD)
GnRH analog
Leuprolide or Gosarelin
Ovarian Suppressant
Danazol
Surgery
Ablation or hysterectomy with bilateral salpingo-oophorectomy
Women older than _____ are the typical adenomyosis patient
35
Adenomyosis:
1) How common is it?
2) What is it?
3) Describe the typical patient
4) Etiology?
5) Duration?
1) 20-35% of women
2) Endometrial stroma within the myometrium
Endometrium grows into the muscular myometrium
3) Typical Patient: Women older than 35 (symptoms usually start between 40-50yo)
4) Unknown
5) Typically resolves after menopause
List the Sx of Adenomyosis
Menorrhagia
Metrorrhagia
Dysmenorrhea
Dyspareunia not as common as with endometriosis
Abdominal bloating
Chronic pelvic pain
What will you see on a bimanual exam when a pt has Adenomyosis?
Uterus is mobile, diffusely enlarged (“globular”), and soft (“boggy”), +/- tender
Describe how to Dx adenomyosis
1) H&P & about 85% confirmed by post-op pathology
2) hCG testing to r/o pregnancy
3) H&H to check for anemia if heavy bleeding
4) TVUS first line for evaluation of an enlarged uterus, pelvic pain, and/or abnormal bleeding
5) MRI to determine management if leiomyoma vs adenomyosis
Describe Adenomyosis Tx for patients who have not completed childbearing
-NSAIDs and hormones, particularly a levonorgestrel releasing IUD that may stop menses with direct action on the uterus
-May consider partial resection. Fertility has been variable
Endometrial Hyperplasia:
1) What is it a precursor to?
2) What is the pathophys?
1) Endometrial carcinoma
2) High Unopposed Estrogen
List the Sx of endometrial hyperplasia
1) Menorrhagia
2) Metrorrhagia
3) Post-menopausal bleeding
Describe how to Dx Endometrial Hyperplasia
1) Screening: Transvaginal Ultrasound > Endometrial stripe >4mm
2) Definitive = Endometrial biopsy
Describe the main Txs of endometrial hyperplasia
1) Biopsy shows endometrial hyperplasia without atypia:
-Synthetic progesterone and repeat biopsy in 3-6 months
2) Biopsy shows endometrial hyperplasia with atypia:
-Hysterectomy (if patient still desires children, can trial progesterone…discuss risks)
-+ or – chemotherapy/radiation
Describe Type 1 Endometrial CA (prognosis and when it’s usually diagnosed)
1) Generally good prognosis
2) 70% diagnosed in stage 1 (90% cure Stage I)
Describe Endometrial CA type II
Unrelated to estrogen exposure
Spontaneous in thin, older postmenopausal women
Poorer prognosis
List some risk factors for Endometrial Carcinoma Type I
Long-term hormone replacement (estrogen w/o progesterone)
Obesity
PCOS
Lynch Syndrome
Long term Tamoxifen use
Alcohol intake: 2 or more drinks per day
Describe how obesity is linked to endometrial CA
BMI > 30 = 2.6- fold increase of endometrial cancer risk
BMI >35 = 4.7- fold increased risk
Endometrial cancer rates have risen steadily with _________ rates
obesity
List the types of endometrial carcinoma
Adenocarcinoma– 75%
Adenosquamous
Clear cell carcinoma
Serous carcinoma
List the Sx of endometrial CA
1) 5-20% asymptomatic
2) Abnormal Uterine Bleeding
5% of endometrial cancers diagnosed < age 40
Postmenopausal Bleeding
3) Suprapubic pain or fullness
4) Fatigue
5) Dysuria
6) Dyspareunia
You should do further evaluation to r/o underlying [endometrial] carcinoma for who?
1) Any patient with AUB over 45yo
2) A woman with AUB <45yo in the presence of additional risk factors
Describe Screening & prevention of endometrial cancer in women w Lynch syndrome
1) Annual endometrial sampling and TVUS beginning at age 30 to 35
2) Risk-reducing hysterectomy
3) Oral contraceptives for possible chemoprevention.
Cowden syndrome:
1) What is it?
2) What is a main characteristic?
3) What is present in 40% of pts?
4) What CAs do they have an increased risk of?
1) Autosomal dominant condition with a mutation in the PTEN tumor suppressor gene, prevalence 1/200,000
2) Characteristic benign mucocutaneous hamartomas
3) Uterine fibroids
4) Increased endometrial, breast, thyroid, colorectal, and renal cancers.
Carriers of the BRCA gene mutations: Data suggest BRCA1 > BRCA2 mutations associated with ________________ carcinoma.
endometrial
Describe the surgical Tx for endometrial CA
1) Hysterectomy
-Surgical staging: Bilateral salpingo-oophorectomy, lymph node dissection, and peritoneal washing
2) +Lymph nodes (stage IIIc) = radiation therapy
Radiation and chemotherapy commonly added for more advanced stage and high-risk features of endometrial CA; give some examples of these features
Pathologic grade 3, serous, or clear-cell tumors, invasion of more than 1/2 the myometrium, or extension to the cervix or adnexa.
The 5-year survival rate for endometrial cancer is what?
75% to 95% for stage 1
50% for stage 2
30% for stage 3
less than 5% for stage 4
Endometrial CA is 40% more common in what race?
White ppl
Uterine Sarcoma:
1) How common is it?
2) Sarcomas about 5% of uterine cancers generally poor prognosis if what?
1) 2.8/100,000 females 30-79yo in the US (avg 60yo)
2) > 10 mitoses per 10 HPF (mitotic count)
Hematogenous spread to lungs, liver, and bone
Uterine Sarcoma:
1) When is it often diagnosed?
2) What would TVUS show with this CA?
1) Post-myomectomy/hysterectomy after routine pathology
2) Focal mass in uterus w features suggesting sarcoma
Uterine Sarcoma: Clinical suspicion is appropriate if what S/sx?
1) Rapidly enlarging “fibroids” and uterine enlargement
2) Postmenopausal bleeding, unusual pelvic pain + uterine enlargement, increase in unusual vaginal discharge
