Week 4 pt 2 highlights Flashcards
Review:
1) The outside of the cervix and the vagina are covered by ________________ cells.
2) The canal of the cervix is lined by tall column-like cells called ______________ cells.
3) Size and shape of the cervix change depending on what 3 things?
1) squamous
2) columnar
3) on age, hormonal status, and number of children (parity)
Review:
1) Metaplasia during __________ moves the squamocolumnar junction (SCJ)
2) During __________________, the new SCJ recedes upward into the endocervical canal
1) puberty
2) perimenopause
The interior cervical canal leading to the uterus (what we cannot see) is called what?
Endocervical canal
Area between the original SCJ and active SCJ is called what?
Transformation zone
The active (new) SCJ is where >_____% of metaplasia and cervical neoplasia arise
> 90%
1) Most HPV-infected women are _____________.
2) HPV _______ and ____________ of HPV infection appear to be the most important factors in the progression into squamous intraepithelial lesions (SIL)
1) asymptomatic
2) type and persistence
True or false: HPV is easily spread via sexual intercourse
True
HPV ________ and _____ most commonly cause cervical cancer
16, 18
HPV _____ and ________ are associated with genital warts (condylomata acuminata)
6 and 11
Cervical Cancer Screening:
1) Evaluates _________ patients
2) What is a key part of cervical screening?
3) What does screening vary based on?
1) asymptomatic
2) Pregnancy
3) Age, screening hx, presence of a cervix, immune status
Cervical CA screening:
Speculum exam should appear __________ ; if gross abnormality visualized, it must be biopsied.
normal
Pap smears; USPSTF Guidelines (for normal risk) ppl say:
1) For women younger than 21 years, ______ screening for cervical cancer.
2) For women aged 21 to 29 years, screening for cervical cancer every ___ years with ______________ alone
(memorize this)
1) NO screening
2) 3 years; cervical cytology
Pap smears; USPSTF Guidelines (for normal risk) ppl say what abt women aged 30 to 65 years?
(memorize this)
1) Screening every 3 years with cervical cytology alone
2) Every 5 years with high-risk human papillomavirus (hrHPV) testing alone,
3) OR every 5 years with hrHPV testing in combination with cytology (cotesting).
True or false: ACOG endorses the USPSTF guidlines
True
Pap smears; USPSTF Guidelines (for normal risk) ppl:
What do they say for women >65 y/o?
NO screening for cervical cancer in those who have had adequate prior screening and are not otherwise at high risk for cervical cancer
Pap smears; USPSTF Guidelines (for normal risk) ppl:
What do they say abt women who have had a hysterectomy with removal of the cervix?
NO screening for cervical cancer in women who do not have a history of a high-grade precancerous lesion (i.e., CIN 2 or CIN 3) or cervical cancer.
The ACOG guidelines add that:
1) Women under 21 years of age should STILL be screened for _______ if they are sexually active
2) ACOG recommends annual pelvic exam and risk assessment in women _______ yrs & older
1) STIs
2) 21
True or false: HPV infection is very common in young women which is why the new cervical cancer guidelines are based on HPV status and age, but invasive cervical CA is very rate
True
Women with a history of ____________ lesions prior to their hysterectomy (CIN 2, CIN3, or AIS) can develop recurrence years postoperatively, therefore they should continue to be screened every _________yrs + hrHPV testing
high-grade; 3
If hysterectomy was to treat CIN2, CIN3, or AIS (adenocarcinoma in situ), patient should have ______ consecutive annual hrHPV tests followed by every _____yrs surveillance + hrHPV testing
3; 3
Ideally, a Pap should be completed in the ________of a patient’s cycle (days ____-____)*
middle; 9-20
A pap result will be marked as “_____________” or “_______________” for interpretation
Satisfactory; Unsatisfactory
If a pap result is “Unsatisfactory”, what should you do?
1) Retest in 2-4mos recommended
2) If retest abnormal or negative, follow 2019 ASCCP Guidelines (more on this later)
Pap results:
If Endocervical Cells are Absent, when is routine screening recommended? When is an HPV test preferred?
Assume negative screening cytology + absent endocervical cells (TZ component)
1) If 21-29yo
2) If >/= 30 y/o and NO (or UNK) HPV test result
*LSIL, ASC-US (HPV positive or w/o HPV testing) = high probability for _____________ and decreased risk for rapid progression
regression
Cervical Intraepithelial Neoplasia (CIN) = the abnormal growth of potentially ___________________ cells on the cervix.
precancerous
Differentiate SIL and CIN
2019 ASCCP Guidelines: Providers must know (at minimum) patient’s age and current test results SO recommendations are based on risks of _____________ and ___________ __________ diagnoses
immediate; future CIN 3+
List the 4 2019 ASCCP guidelines/ principles
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
3) Guidelines continue to evolve
4) Colposcopy practice must follow guidelines
Pap smear continued principles from 2012: Screening and management goal is ________ prevention + guidelines apply to all individuals with a ________.
cancer; cervix
Give the overview for the ASCCP guidelines (i.e. next steps after abnormal pap)
Evaluating pt risk post pap smear: For each combination of current test results and screening history (including unknown history), recommendation determined by first estimating ___________ and ____-year risk of CIN 3+
immediate; 5-year
Pap smear: Treatment recommendations for nonpregnant patients only are what?
Excisional procedure during pregnancy only if invasive cancer suspected
5-year return Clinical Action Threshold approximates risk for a patient after a ____________ screening test using HPV testing or co-testing in the general population
(Remember this)
negative
Patients with risks at or below this threshold (<0.15% CIN 3+ risk) are recommended to receive ___________ screening at _____-year intervals with hrHPV-based testing or co-testing
(Remember this)
routine; 5-year
3-year return Clinical Action Threshold:
Approximates the risk for a patient after a ____________ cervical cytology screen in the general population, for whom retesting in 3 years is recommended by national screening guidelines.
negative
Patients with risks at or below this threshold but above the 5-year threshold (0.15-0.54% CIN 3+ risk) are recommended to receive hrHPV-based testing in ____ years
3
One-year return (1 year surveillance and hrHPV testing) results include what 2 scenarios?
1) HPV-positive but negative cytology
2) HPV-neg LSIL, s/p colposcopy w results of <CIN 1
Colposcopy Clinical Action Threshold:
Approximates the risk for a patient after an _____________ ASC-US or _________ screening
HPV-positive; LSIL
Colposcopy Clinical Action Threshold:
Patients with risks at or above this threshold but below the expedited treatment threshold (>4%-24% CIN 3+ risk) are recommended to receive _______________
colposcopy
Expedited treatment or colposcopy Clinical Action Threshold:
Approximates the risk for a patient after an HPV-positive atypical squamous cells that cannot exclude ______________cytology screening
HSIL (ASC-H)
Expedited treatment or colposcopy Clinical Action Threshold:
Recommended to receive counseling from their providers to choose between evaluation with colposcopy and biopsy or _____________ treatment.
expedited.
Expedited treatment preferred Clinical Action Threshold includes which individuals?
HPV 16–positive (or any) HSIL cytology screening result
(HSIL cytology that is HPV 16–positive has an immediate CIN 3+ of 60%)
Risks at or above a 60-100% CIN 3+ risk, should receive ___________________________
expedited excisional treatment
ASC: Atypical Squamous Cells: Nuclear atypia present but not sufficient to warrant the diagnosis of _______________________
squamous intraepithelial lesion
Define ASC-US and ASC-H
1) ASC-US-Atypical squamous cells of undetermined significance
2) ASC-H-cytologic changes suggestive of HSIL but lacking definitive interpretation.
AGC:
1) Atypia that is of ___________ rather than squamous origin
2) *More likely to be serious with ___________ abnormalities than an ASC-US pap, so the work-up more aggressive than ASC-US
1) glandular
2) glandular
If + for AGC (nonpregnant females of all ages), what should you do?
Colposcopy recommended regardless of HPV result
+
Endocervical sampling
__________ infection (90%) is the main risk for cervical neoplasia
HPV
Diethylstilbestrol (DES) exposure is a risk for what?
Cervical dysplasia
What are the main Sx of cervical CA?
1) Asymptomatic
2) Abnormal bleeding such as postcoital bleeding or intermittent spotting
Cervical CA staging; describe:
1) Stage 0
2) Stage 1
1) Stage 0: full-thickness involvement of the epithelium without invasion into the stroma (carcinoma in situ)
2) Stage 1: limited to the cervix , no spread
Cervical CA staging; describe:
1) Stage 2
2) Stage 3
1) Stage 2: invades beyond cervix and uterus
2) Stage 3: spread to the lower 1/3 of the vagina and/or the walls of the pelvis; may be blocking the ureters (kidneys affected)
Cervical CA staging; describe stage 4
Stage IV: extension beyond true pelvis or mucosa of bladder or rectum (biopsy proven) (metastatic)
Cervical Cancer Treatment
1) Refer to who?
2) Often treatment involves either _________ or _________ (including brachytherapy) depending on size and location
1) Refer to Gyn/Onc
2) surgery or radiation
Most important prognostic factors for cervical CA are what 2 things?
Disease stage followed by lymph node status
15-61% with cervical cancer have __________ or recurrent disease after treatment, usually within the first 2 years
persistent
Bleeding after intercourse is worrisome for recurrence of what?
Cervical CA
What is Carnett sign for chronic pelvic pain?
Tensing of the abdominal wall while raising legs or chin in the supine position
(Can help identify myofascial pain)
1) Define dysmenorrhea
2) Define chronic pelvic pain
1) Painful Menstruation
2) Noncyclic pelvic pain x 6 months or more
Primary Dysmenorrhea (due to excessive prostaglandin) is more common in older or younger women?
Younger
Secondary Dysmenorrhea (due to uterine/ pelvic pathology) is more common in older or younger women?
Older
Nulliparity is a major risk factor for what?
Primary dysmenorrhea
Multiparity is a major risk factor for what?
Secondary dysmenorrhea
Endometriosis (40%) is the most common cause of what?
Secondary dysmenorrhea
List some common secondary dysmenorrhea causes
Endometriosis (40%)
Pelvic Inflammatory Disease
Leiomyoma (fibroids)
Adenomyosis
List some key points of a Dysmenorrhea workup
1) Pelvic exam
2) To r/o differentials (not all are required, patient by patient basis):
-Pregnancy test (ectopic pregnancy)
-Pelvic u/s
1st line dysmenorrhea Tx is what?
1) NSAIDs at a therapeutic dose
2) Combo OCPs
Leiomyoma means what?
Benign smooth muscle tumor (fibroid)
Leiomyoma:
1) Most prevalent during the _____ decade of a woman’s life
2) Most common indication for _____________ (~30%)
3) Hormonally responsive, which means that _____________ may induce rapid growth
1) 5th
2) hysterectomy
3) estrogen
What leiomyoma location is most common?
Intramural
What leiomyoma location has the highest rate of infertility?
Submucosal
List the 2 most importnt risk factors for leimyoma
1) Ethnicity: African Americans have 2-3 x risk compared to Caucasians
2) Early menarche (<10 y/o)
Most leiomyoma pts are _______________
asymptomatic
Leiomyoma PE findings:
1) With bimanual exam, the uterus feels irregularly _________, ___________,& __________ by large fibroids
2) Is it usually tender?
3) Is the uterus floppy or firm?
4) Is the uterus smooth bumpy?
1) enlarged, firm, & asymmetrical
2) Usually nontender
3) Very firm to palpation
4) Might feel bumpy
What is the imaging of choice for diagnosing leiomyoma?
Pelvic u/s-
Depending on pelvic u/s results, you should eval the uterine cavity by one of what 2 methods?
Saline infusion sonography (similar to HSG but with saline)
OR Hysteroscopy
Most accurate way to diagnose uterine fibroids if diagnosis is uncertain is what?
MRI
List the main points of Leiomyoma Treatment
1) Medications : NSAIDS
2) First Tier: Myomectomy + Hormonal Treatment
3) Second Tier: Leuprolide + Uterine artery embolization
4) Third Tier: Endometrial ablation + Hysterectomy
Leiomyoma Tx:
1) What med can be used?
2) What are the 2 parts of the first tier of Tx?
1) NSAIDS
2) Myomectomy (risk of uterine rupture, but everyone who wants to preserve fertility should get this) or hormonal Tx
Leiomyoma Tx:
1) What is the second tier (for those not wanting to preserve fertility)?
2) What is the third tier (for those not wanting to preserve fertility)
1) Leuprolide or uterine artery embolization
2) Endometrial ablation
Hysterectomy
Most common reason for hysterectomy is what?
Leiomyoma
Endometriosis:
1) Most common in __________ women
2) Most commonly found on the __________ (typically bilateral)
1) nulliparous
2) ovaries
Endometriosis:
1) What is the main Sx?
2) Are any ppl asymptomatic?
3) What will the PE show?
4) What is the hallmark finding on PE?
1) Cyclical premenstrual pelvic or low back pain
2) Many are ASYMPTOMATIC
3) Physical Exam: nonspecific
4) Hallmark finding: “uterosacral nodularity”
Gold standard/Definitive Diagnosis for endometriosis is what?
Laparoscopy
Laparoscopy for endometriosis allows you to visualize what hallmark Sx?
(common PANCE q)
“Chocolate” cysts or “powder burn marks”
Often the first line for pain associated with endometriosis is what?
Combined OCPs + NSAIDs
Give 2 main Sx of adenomyosis
1) Menorrhagia + Dysmenorrhea
2) Dyspareunia not as common as with endometriosis
If the uterus is described as boggy or globular on a bimanual exam, what is the likely Dx?
Adenomyosis
What is the first line for evaluation of an enlarged uterus, pelvic pain, and/or abnormal bleeding?
TVUS (transvaginal ultrasound)
Adenomyosis:
1) What is the only definitive Tx?
2) What is the main Tx for pts that still want kids?
1) Total hysterectomy
2) NSAIDs and hormones (particularly a levonorgestrel-releasing IUD)
What is the pathophys of Endometrial Hyperplasia?
High Unopposed Estrogen
True or false: PCOS can lead to endometrial hyperplasia
True
Name one of the main Sx of endometrial hyperplasia
Post-menopausal bleeding
Endometrial stripe >4mm on TVUS is indicative of what?
Endometrial hyperplasia
What allows for definitive diagnosis of endometrial hyperplasia?
Endometrial biopsy
Endometrial Hyperplasia Treatment depends on what? Explain.
Biopsy results:
1) Biopsy shows endometrial hyperplasia without atypia: Synthetic progesterone and repeat biopsy in 3-6 months
2) Biopsy shows endometrial hyperplasia with atypia: Hysterectomy
What are some adjunct therapies for endometrial hyperplasia to use adj. to synthetic progesterone or hysterectomy?
GnRH analogues (Leuprolide)
Androgens (Danazol)
NSAIDs
Most common genital tract malignancy is what?
Endometrial Carcinoma
1) 4th most common cancer (after breast, lung, and colorectal carcinoma) is what?
2) What is this cancer the cause of 5-10% of?
3) What is the most common treatment for this CA?
1) Endometrial carcinoma
2) Postmenopausal bleeding
3) A total abdominal hysterectomy with bilateral salpingo-oophorectomy
Endometrial Cancer: List the 2 main etiologies & which is more common
1) Type I: estrogen-dependent (80-90%)
2) Type II: estrogen-independent
Endometrial Cancer Type 1:
1) Is caused by unopposed or excessive continuous ___________ exposure to the endometrium
2) This proliferative effect must be counteracted by what?
1) estrogen
2) Progesterone
BMI >__________= 2.6- fold increase of endometrial cancer risk
> 30
Long-term hormone replacement (estrogen w/o progesterone) is a risk factor for what type of CA?
Endometrial Carcinoma Type I
American Cancer Society recommends focusing on __________ lifestyles to reduce endometrial CA risk
healthy
Adipose tissue produces continuous high levels of circulating estrogen from the ________________ of ________________ to estrone
aromatization; androstenedione
What is the most common type of endometrial carcinoma?
Adenocarcinoma– 75%
Adenocarcinoma of the endometrium:
1) Most common, typically post_______________
2) Associated with excessive __________ exposure
3) Often diagnosed with endometrial _____________
1) postmenopausal
2) estrogen
3) hyperplasia
What is the main Sx of endometrial CA?
Abnormal Uterine Bleeding; especially Postmenopausal Bleeding
1) In High-Risk Patients (obese, PCOS, genetic) for endometrial CA, what should you do?
2) What abt for atypical endometrial hyperplasia?
1) Annual endometrial sampling and transvaginal ultrasonography beginning at age 30 to 35
-Oral contraceptives (COCs)
2) Risk-reducing hysterectomy
Women with Lynch syndrome:
1) Lifetime risk for _____________ and ___________ cancers increased compared to general population.
2) 40% risk of _________ cancer.
3) These pts make up 2 - 5 % of all ____________ carcinomas.
1) endometrial and ovarian
2) colon
3) endometrial
Screening & prevention of endometrial cancer in women w Lynch syndrome includes what 3 things?
1) Annual endometrial sampling and TVUS
2) Risk-reducing hysterectomy
3) Oral contraceptives
List 3 genetic factors predisposing to endometrial CA
1) Lynch syndrome
2) Cowden syndrome
3) BRCA gene mutations
List 3 important parts of an endometrial CA workup
1) Pelvic exam
2) +/- CA-125 marker
3) Transvaginal Ultrasound to evaluate endometrial lining
List the main stages of endometrial CA
1- Endometrium
2- Body of uterus into the cervix
3- Local and/or regional spread of the tumor
4- Bladder and/or Bowel mucosa, and/or distant mets
1) What is the main surgical Tx for endometrial CA?
2) Women with ______________ disease often treated with surgery alone & have high cure rates
1) Hysterectomy
2) stage 1, grade 1
Endometrial CA: ____________ and _______________ are commonly added for more advanced stage and high-risk features
Radiation and chemotherapy
True or false: Endometrial CA is usually diagnosed at early stage with better outcome than cervical or ovarian cancer.
True
Uterine Sarcoma:
1) What is the 5yr prognosis?
2) Sarcomas (about 5% of uterine cancers) have generally poor prognosis if they have >_____mitoses per 10 HPF (mitotic count)
1) 29-76% survival
2) 10
List 3 risk factors of uterine sarcoma
1) Tamoxifen (>5yrs)
2) Pelvic radiation
3) Hereditary conditions
Uterine Sarcoma: List 2 reasons for clinical suspicion
1) Rapidly enlarging “fibroids” and uterine enlargement
2) Postmenopausal bleeding
Up to ___% of sarcomas have metastasized outside the uterus at time of diagnosis (spread via lymphatics and bloodstream
50
Uterine Sarcoma:
1) What are 3 Txs?
2) What should be scheduled?
1) TAH, BSO, and surgical staging
2) Endometrial biopsy
