Womens Health-cervix, uterus Flashcards
Where is the uterus located?
Between the urinary bladder anterior to the rectum posteriorly
How long and thich is the uterus?
About 8 cm long, 5 cm across and 4 cm thick
What are the three main parts of the uterus?
Fundus, body and cervix
What is the portioVagninalis?
Is the portion of the cervix that is in the vagina
What are some common positions of the uterus?
Typical, Retroversion, Retroflexed and prolapsed
What are the three layers of the uterus?
o Inner layer- Endometrium
o Middle layer: Myometrium
Outer Layer: Serosa or perimetrium
Which layer is most active and responds to cyclic ovarian hormone change?
The endometrium
What layer is essential to menstruaral and reproductive function?
Endometrium
What layer composed the majority of the uterine volume?
The Myometrium
What is the myometrium composed of?
Primarily smooth muscle
What is the Perimetrium composed of?
Epithelial cells that envelope the uterus
What are some of the muellerian abnormalities of the uterus?
o Septate- complete or partial
o Uterus didelphys
o Bicornuate uterus
o Uterus unicornis
What is a Uterus unicornis?
the uterus is formed from one only of the paired Müllerian ducts while the other Müllerian duct does not develop or only in a rudimentary fashion.
What is a Uterus didelphys?
the uterus is present as a paired organ as the embryogenetic fusion of the mullerian ducts failed to occur. As a result there is a double uterus with two separate cervices, and often a double vagina as well. Each uterus has a single horn linked to the ipsilateral fallopian tube that faces its ovary
what is a Septate- complete or partial uterus?
the uterine cavity is partitioned by a longitudinal septum;
what is a Bicornuate uterus?
A bicornuate uterus is a uterus that has two horns and a heart shape. The uterus has a wall inside and a partial split outside.
Anatomy of the Cervix
Anatomy of the Cervix
What does the cervix connect?
The vagina and the uterus
What is the cervix composed of?
Composed of cartilage covered by smooth moist tissue
What is the size of the cervix?
About 1 in across
The shape of the cervical os varies, explain?
o Nulliparous: Small and Circular
o Post partum: Slit like
o Post Menopause: May narrow down to a pin point
What are the two main portions of the cervix?
The Ectocervix and Endocervix
What is the Ectocervix
It extends from the Squamocolumnar junction to the vaginal fornices
What is the extocervix covered in?
Non keratinizing stratified squamous epithelium
Is the Ectocervix Hormone sensitive?
Yes
What is the Endocervix (endocervical canal)?
Tunnel though the cervix which extends from the isthmus (internal os to the ectocervical canal)
What is the endocervix covered with?
Lined by mucous secreting columnar epithelium
What is the Squamocolumnar Junction (SCJ)?
The location where the columnar epithelium and the squamous speitheulim meet
When doing a PAP smear it is important to swab what area?
The SCJ because it is an area of transition so high risk of CA
Cervical Dysplasia:
Cervical Dysplasia:
How is Cervical Dysplasia ranked?
Mild dysplasia CIN I: only a few cells are abnormal
Moderate Dysplasia CIN II: Abnormal cells involve abut ½ of the thickness of the surface lining of the cervix
Severe Dysplasia CIN III: Entire thickness of cells is disordered, abnormal cells have not yet spread below the surface still carcinoma in situ (in place)
What happened if CIN II is not treated?
Often it will grow into a invasive cervical CA
What does ASCUS stand for?
Atypical cells of undetermined significance
What does ASCUS mean?
That some cells are slightly abnormal in appearance but not enough to call dysplasia
What is the follow up for CIN I?
Cytology Q 6 mo and 12 Mo if it is normal then go back to normal screening
What is the follow up for CIN II and CIN III?
Cytology/ Colposcopy and cytology repeated ever 4-6 mo for 2 years
What is a Colposcopy?
A gynecological procedure that illuminates and magnifies the vulva/vagina walls and uterine cervix
What is done during a Coloscopy?
Specialized test such as acetic acid wash and biopsy sampling
What is a culdoscopy?
Insertion of an instrument though the wall of the vagina in order to view the pelvic area behind the vagina
What is the treatment of Cervical dysplasia?
o Cryotherapy o Laser o Leep o Cone biopsy o Hysterectomy
Explain how Cryotherapy works in the treatment of Cervical Dysplaisa?
Damaged cells will shead over the next month in a heavy watery discarge, it is a simple inexpensive procedure
What are the draw backs of Cryotherapy for the treatment of Cercial Dysplasia?
The depth cannot be precisely controlled
High failure rates
How does laser treatment of dysplasia work?
Uses a tiny beam of light to vaporize the abnormal cells, this can usually be done in the office with no or very little discomfort.
What are some advantages of Laser treatment of cervical dysplasia?
The laser can be directed thought the colposcope, and the area and depth of treatment can be controlled precisely
What is the healing process after laser treatment?
It is much faster than cryotherapy because dead tissue is not left behind. The SCJ heals correctly and is easily evaluated in the future.
What are some disadvantages of Laser therapy?
Requires sophisticated Equipment, and cost a lot, not in a lot of offices
What is the Leep procedure for cervical dysplasia?
It is a loop electrosurgical excision procedure (LEEP) a fine wire loop with electrical energy flowing though it to remove the abnormal area of the cervix. The removed tissue is then sent to the lab for examination.
What is a major advantage of the LEEP procedure?
It can often be used to treat and diagnose at the same time
What is the Cone Biopsy procedure for cervical dysplasia?
It removes a cone shaped or Cylinder shaped piece of the cervix the while SCJ is revoved
Where are Cone Biopsys usually performed?
In the OR.
What are the complications and advantages of cone biopsy?
It has higher success rate but also has higher complications- can interfere with childbearing
Who is a Hysterectomy for the treatment of cervical dysplasia recommended for?
For patients who do not want to bear children in the future.
What are some advantages and disadvantages of Hysterectomy?
It has the lowest recurrence rate of any other treatment but it is a major surgical procedure. NOTE: even after hysterectomy, dysplsia can come back on the vagina, therefore it is essential that PAPs be cont.
What are the different types of Hysterectomies?
Partial: just the Uterus
Total: Uterus and cervix
Radical: Take everything, fallopian tubes ovaries, uterus, cervix
Where do the secretions from the cervix originate?
Secretion of columnar epithelium lining the upper portion of the cervical canal
Cervical Cancer:
Cervical Cancer:
What makes a pt at increased risk for developing Cervical Cancer?
Having HIV and High risk HPV (16 and 18), Smoking, Decreased Vitamin A
What are some early signs of Cervical Cancer?
Watery vaginal discharge, intermittent spotting or postcoital bleeding
What are some clinical findings of cervical cancer ( not early)
Metrorrhagia (bleeding at irregular times) cervival ulceration, postcoital spotting, bloody/purulent/odorous non putitic discharge, bladder and rectal dysfunction or fistulas and pain
How is Cervical Cancer Diangosed?
Cervical lesions may be visible on inspection as a tumor or ulceration, vaginal cystology is usually positive but either way it must be diagnosed by biopsy
What cell type is the majority of cervical cancers?
85% is SCC
What are some complications of Cervical CA?
Mets to regional lymph nodes
Ureters are often obstructed: 2/3 with untreated CA die of uremia when bilateral ureteral obstruction
Back pain- sistribution of lumbosacral plexus- indicative of neurologic involvment
Gross edema of the legs – Indicative of vascular and Lymphatic stais due to tumor
Vaginal fistula to rectum and urinary tract
What can be used for prevention of cervical CA?
Quadravalent HPV 6/11/16/18 L1 virus like particle vaccine : Gardasil
Bivalent HPV 16/18 vaccine: CERVIX
What is the 5 year survival rate for Cervical cancer
Around 60% survival in 5 years,
Cervical Secretions
Cervical Secretions
Do the secretions from the cervix stay consistent though menstrual cycle?
No they change in appearance and consistency thought-out the menstrual cycle.
What will the secretions look like as ovulation approaches?
Increasing amounts of sticky cloudy white or yellowish secretions are seen
What will the secretions look like as the time of ovulation?
The volume and mucus increases and becomes more clear and slippery and elastic. This is known to resemble the uncooked white of an egg
What will secretions look like after ovulation?
The mucus becomes cloudy, thick, sticky and progressively les perfuse until menstruation supervenes and begins the cycle again
What are the most common causes of Cervicitis?
o Neisseria Gonorrhea o Chlamydia trachomoatis o Herpes simples virus o Human Papillomavirus o Trichomoniasis o Bacterial Vagnosis o Cytomegalovirus
What are the common symptoms of Cervicitis?
It is often asymptomatic (think nerve innervations)
What happens if cervicitis is left untreated?
It may lead to pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pelvic pain
Clinical findings of ACUTE cervicitis
Purulent:
Thick and Creamy:
Foamy and greenish:
White and curd like:
Thin and gray, smells like fish:
Strayberry appearance on the cervix:
Discharge:
Purulent: Chlamydia trachomoatis
Thick and Creamy: Neisseria Gonorrhea
Foamy and greenish: Trichomoniasis
White and curd like: Canidiasis
Thin and gray, smells like fish: Bacterial Vaginosis
Strayberry appearance on the cervix: Trichomoniasis
Acute cervicitis may also be associated with what symptoms?
Possible vaginal bleeding(post coitis) Freq, urgency and dysuria (with Gonorrhea and Chlamydia ) may also be vuvlar burning and pruritus
What are the Clincial findings of CHRONIC cervicitis?
Leukorrhea may be the chief symptom Discharge may causes vulvar irritation Lower abd pain Lumbosacral back pain Dysmenorrhea Dyspareunia Urinary Freq, urgency and dysuria
What are some lab findings and treatment of cervicitis?
Dependent of etiology and infection
Diseases of the Uterus
Diseases of the Uterus
Leiomyoma (Fibroid Tumor)
Leiomyoma (Fibroid Tumor)
What is a Leiomyoma?
Benign smooth muscle and connective tissue tumor that appears as an enlargement of the uterus
Discrete, round and firm
What do Leiomyoma present with?
May be asymptomatic, but can have heavy or irregular vaginal bleeding, dysmenorrheal
acute and recurrent pelvic pain if the tumor becomes twisted on its pedicle infracted
Symptoms due to pressure on Juxtapositional organs
Do Leiomyomas respond to hormonal fluctuations?
Yes, with rapid growth in high estrogen states, when the women enters menopause it will generally stop growing and can induce atrophy
What is the etiology of Leiomyoma?
Chromosomal abnormalities
How are Leiomyoma classified?
o Intramural o Submucous o Intraligamentous o Parasitic o Vervical
what type of Leiomyoma may become pedunculated and descend though cervic into the vagina?
Submucous
What are some lab finding of Leiomyomas?
Iron Deficiency (Blood loss) Polycythemia ( tumor production of erythropoietin)
What imaging is done for Leiomyoma?
o Ultrasounds- confirm the presence and monitor the growth
o MRI- delineate intramural and submucous myomas
o Hysterography/Hysteroscopy- confirm cervical or submucosal myomas
Steps to dx of Leiomyoma?
o Histroy
o PE- Lungs, heart, abd, pelvic
o Test- Preg, Urinalysis, abd and pelvic ultrasound, endometrial biopsy, “sound the uterus”, consider hysteroscopy, CT, MRI, ect…
What is the treatment of a Leiomyoma
o Reassurance that its not CA!
o Symptomatic treatment: Nothing if no difficulties with ADLs, Intermittent progestin supplimentation, BCP
o Myomectomy if fertility or pregnancy is compromised ( fibroma >8 cm or near the fallopian tubes
o Hysterectomy
Medical Treatment:
o GnRH receptor agonist
o Danazol
o Myolysis efficacy is not known
o UAE ( uterine artery embolization) cut off the blood supply
o MRI- guided focused ultrasound surgery- raised the temp so sound waves can burn it off.
What happens if the Leiomyoma occurs during pregnancy-
o If the fibroids are small its no problem
o If greater than 3 cm there is an increased incidence of preterm labor, placentral abruption, pelvic pain and C-section
o Myomas may also increase so much in size during pregnancy that they will outgrow the blood supply and die off.
What is the treatment of Leiomyoma during pregnancy?
Generally can treat symptoms with bed rest and pain control with strong analgesics
Leiomyoscarcoma: Cancer
Leiomyoscarcoma: Cancer
What is a Leiomyoscarcoma?
It is a rare cancer of the smooth muscle it is not a degeneration of fibroids
What do the tumors look like?
Heterologous, mixed tumors that contain other sarcomatous tissues found in other ears of the body.
Adenomyoma
Adenomyoma
What is a Adenomyoma?
Uterrine thickening due to the endometrial tissue moving into the outer muscular walls of the uterus – cells grow directly into the uterine walls
What happened to Adenomyoma during menstration?
Since it is made out of endometrial tissue, the Adenomyoma will bleed just like the endometrial tissue does. This bleeding will be directly into the muscle and cause pain
As the Adenomyoma bleeds into the muscle and the blood begins to accumulate what happened?
The surrounding muscles will swell and forms fibrous tissue in response to the irritation.
How do mild to servere Adenomyoma presen like?
May be asymptomatic
More severe forms:
may lead to heavy bleeding and severe cramps during menstrual period
Adenomyoma are found in what percent of women?
10%
How do you diagnose Adenomyoma?
Suspected in uterine enlargment and tenderness to palpation, may be suggested by the apperance of the uterus on sonoram (MRI is better at detecting adenomyosis, but the test is $$), Also Surgical excision: onced removed the tissue can be examined under the microscope and the uterine lining cells can be seen within the muscle wall.
How do you treat Adenomyomas?
Lupron or synarel: can cause cessation of periods and associated menstral crampine, lead to shrinkage of the swelling associated with adenomyomas. The only true cure is surgery (small sxr or hysterectomy depending on the size)
What is Lupron or Synarel?
Modifications of the natural GnRH.
Endometriosis
Endometriosis
What is Endometriosis?
Presence of abnormal growth of tissue, histologically resembling the endometrium present in locations other than the uterine lining
Who is common to have Endometriosis?
6-10% of females, almost exclusive to women of reproductive age, most common in nulliparous women
What is the Etiology of Endometriosis?
Pathogenesis and natural cause is not fully understood, may be from retrograde menstruation( most accepted cause) can also be from vascular and lumphatic dissemination, coelomic metaplasia of multipotential cells in the peritoneal cavity may develop into functional endometrium.
What will decrease the risk for Endometriosis?
Multiple births, extended intervals of lactation and late menarche (after 14)
What will increase the risk of Endometriosis?
Nulliparity, early menarche/late menopause, short menstrual cycles, prolonged menses, mullerian anomalies, associated with taller and thinner habitus and lower body mass index
What are the clinical manifestations of Endometriosis?
Variable and unpredictable in presentation and course, severity of pain may be inversely related to anatomic extent of the disease. Symptoms may include dysmenorrheal, chronic pelvic pain, dyspareunia and possibly asymptomatic.
What will the pelvic findings in a patient with Endometriosis?
Tender nodules in cul-de-sac or retrovaginal septum
Urerine retroversion with decreased uterine mobility
Cervical motion tenderness
Adnexal mass or tenderness
Most will have normal pelvic examinations
How do you diagnose Endometriosis?
Imaging: limited value : useful only in the presence of pelvic or adenxal mass, use transvaginal ultrasound 9used to detect deeply penetrating endometriosis of rectum or rectovaginal septum) MRI (reserved for equivocal cases of retrovaginal or bladder endometriosis
Definite diagnosis: Histology of lesions excised by surgical interventions
What is the treatment of Endometriosis?
NSAIDs- just for pain relief
Hormonal Treatment- effective in alleviation of pain- designed to inhibit ovulation over 4-9 mo and lower hormone levels.
Surgery
What hormone treatment is available for Endometriosis?
OC, contraceptive patch or vaginal rings- prolongs suppression of ovulation inhibiting further simulation of residual endometriosis.
Progestins- specifically norethindrone acetate and subcutaneous DMPA) approved by the FDA for treatment of Endometriosis.
GnRH agonists- Nafarelin nasal spray or long acting injectable leurolide acetate- suppresses ovulation, its highly effetive in reducing pain associated with endometriosis. Not superiour to other methods as first line therapy, side effects include vasomotor symptoms and bone demineralization
Danazol- androgenic drug- use it for 4-6 mo in lowest dose necessary to suppress menstruation, s/e of androgenic side effect
Intrauterine progestin with levonorgesttrel intrauterine system
Aromatase Inhibitors- Anastrozole or Letrozole- Promising but insufficient data
What is the surgical treatment of Endometriosis:
Effective in both reducing pain and in promoting fertility.
Laproscopic ablation of endometrial implants along with uterine nerve
Ablation of implands (+/- removal of ovarian endometriomas) enhance fertility.
Total abdominal hysterectomy and bilateral salpingoopherectomy (TAH-BSO)- definitate treatment, will need hormone replacement.
What is the prognosis of endometriosis?
Reproductive function in early or moderately advanced Endometriosis appears to be good with conventional therapy.
Endometrial (Cervical and Uterine) Polyps
Endometrial (Cervical and Uterine) Polyps
What is an Endometrial Polyp?
Hyperplastic overgrowth of the endometrial glands and troma that foams a projection (sessile or pedunculated) from the surface of the endometrium.
Where do the majority of Endometrial Polyps?
Most originate from endocervix
What are the findings (symptoms) of Endometrial Polyp?
Intermenstrural or postcoital bleeding, soft red pedunculated protrusion from the cervical canal at the external os, microscopic examination confirms the diagnosis of benign polyps
Who is likely to have Endometrial Polyps?
Over the age of 20 and nulliparous, it is rare in prepubescent
If a patient has one Endometrial Polyp are they likely to have more?
Typically only have one
What is the size of Endometrial Polyps?
Range in diameter from mm to several cm
Are Endometrial Polyp cancerous?
Majority are benign- but malignancy does occur in some women.
What causes Endometrial Polyps?
Not completely understood may be with:
•An abnormal respince to increased levels of estrogen
•Chronic inflammation
•Occluded blood vessels in the cervix
•Tamoxifen- 2-36% develop usually larger or multiple
•Obesity
•Post menopausal hormones
What is the physical exam findings of absence of a prolapsed polyp?
No PE findings associated with Endometrial Polyp
What is the physical exam findings of prolapsed polyps?
visualized during a speculum examination, typically as a globular, friable, pedunculated lesion protruding from the external cervical os.
How do you dx Endometrial Polyp?
Transvaginal ultrasound
Sonohysterography – aka saline infused sonogram- used in uncertain findings on ultrasound alone or who are canidates for expectant management
Hysteroscopy- Direct visualization of the lesion
How is a Sonohysterography done?
Fluid is put into the uterine cavity transcercially to enhance endometrial visulation during TVUS
Endometrial Cancer
Endometrial Cancer
Endometrial Cancer is known as what?
The most common diagnosed Gynecological malignancy in the US
When is Endometrial Cancer likely to occur?
between 50-70 yo peak in 7th decade
Endometrial Cancer accounts of ____% of postmenopausal bleeding?
15-25% due to cancer
what is the cell type of most Endometrial Cancers?
Adenocarcinomas
What is the presenting sign of Endometrial Cancer in 80% of the cases?
Abnormal bleeding
What will the pap smear of Endometrial Cancer show?
Freq negative
What is needed for dx?
A biopsy of Enometrial tissue.
What are the two types of Endometrial Cancer?
Type I or Estrogen dependent
Type II or estrogen Independent
What is more common Type I or Type II Endometrial Cancer?
Type I estrogen dependent
What causes Type I estrogen dependent Endometrial Cancer?
Excess of unopposed estrogen, leading to low-grade nuclear atypia
What causes type II estrogen dependent Endometrial Cancer?
It is spontaneous, begins in the atrophic endometrium
What type I or II has the best prognosis?
Type I has favorable prognosis where Type II has a worse prognosis
Where are Endometrial Cancer mets likely to go?
Generally from the inside of the uterus outward, more likely to spread hematogenously than ovarian CA
What are the risk factors for Endometrial Cancer?
Exactly the same as for uterine hyperplasia
What are the symptoms of Endometrial Cancer?
Abnormal bleeding, Postmenopausal bleeding, Menorrhagia, metrorrhagia, pelivic discomfort or pressure ( usually in advanced cases)
Endometrial Carcinoma
Endometrial Carcinoma
What is the most common type of endometrial carcinoma?
Adenocarcinoma (80%) malignant glands
What are the other types of endometrial carcinoma?
Adenocarcinoma with squamous differentiation
Serous
Clear cell
What is the treatment of endometrial carcinoma?
Total Hysterectomy and bilateral salpingo—oophorectomy
Radiation for metastatic disease
Palliative care
What is the prognosis of endometrial carcinoma?
Early dx: 5 year survival is 80-90%
Stage I depth of myometiral invasion- strongest predictor of survival ( less than 66%= 98% 5 eyar survival, over 66% 78% 5 year survival)
