Womens health continued Flashcards
what is cervical cancer strongly associated with
HPV - 16 and 18
how does HPV predispose someone to cancer
P53 and pRb are tumour suppressor genes. They have a role in suppressing cancers from developing. HPV produces two proteins (E6 and E7) that inhibit these tumour suppressor genes. The E6 protein inhibits p53, and the E7 protein inhibits pRb. Therefore, HPV promotes the development of cancer by inhibiting tumour suppressor genes.
what are risk factors for cervical cancer
Increased risk of catching HPV
Later detection of precancerous and cancerous changes (non-engagement with screening)
Smoking
HIV (patients with HIV are offered yearly smear tests)
Combined contraceptive pill use for more than five years
Increased number of full-term pregnancies
Family history
Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)
what are increased risks of catching HPV
Early sexual activity
Increased number of sexual partners
Sexual partners who have had more partners
Not using condoms
how does cervical cancer present
may be detected during cervical smears in otherwise asymptomatic women
abnormal vaginal bleeding
vaginal discharge
pelvic pain
dyspareunia
what are appearances which may suggest cervical cancer
Ulceration
Inflammation
Bleeding
Visible tumour
what are the grades of cervical intraepithelial neoplasia
CIN I: mild dysplasia, affecting 1/3 the thickness of the epithelial layer, likely to return to normal without treatment
CIN II: moderate dysplasia, affecting 2/3 the thickness of the epithelial layer, likely to progress to cancer if untreated
CIN III: severe dysplasia, very likely to progress to cancer if untreated
what are notable exceptions for the smear test
Women with HIV are screened annually
Women over 65 may request a smear if they have not had one since aged 50
Women with previous CIN may require additional tests (e.g. test of cure after treatment)
Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant)
Pregnant women due a routine smear should wait until 12 weeks post-partum
when are women called to the cervical screening programme
Every three years aged 25 – 49
Every five years aged 50 – 64
what are the different cytology results someone can get
Inadequate
Normal
Borderline changes
Low-grade dyskaryosis
High-grade dyskaryosis (moderate)
High-grade dyskaryosis (severe)
Possible invasive squamous cell carcinoma
Possible glandular neoplasia
what is the management for different smear results based on the public health england guidelines
Inadequate sample – repeat the smear after at least three months
HPV negative – continue routine screening
HPV positive with normal cytology – repeat the HPV test after 12 months
HPV positive with abnormal cytology – refer for colposcopy
what is colposcopy
it is when a speculum is inserted and uses a colposcope to magnify the cervix which allows the epithelial lining of the cervix to be examined
stains such as acetic acid and iodine solution can be used to differentiate abnormal areas
what is acetic acid
causes abnormal cells to appear white. This appearance is described as acetowhite. This occurs in cells with an increased nuclear to cytoplasmic ratio (more nuclear material), such as cervical intraepithelial neoplasia and cervical cancer cells.
what is schillers iodine test
involves using an iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain.
what is large loop excision of the transformation zone
it is a procedure called a loop biopsy which can be performed with local anaesthetic during colposcopy, which involves using diathermy to remove abnormal epithelial tissue of the cervix
what is a cone biopsy
it is a treatment for cervical intraepithelial neoplasia and very early stages of cervical cancer. The surgeons removes a cone shaped piece of cervix
what are the main risks of a cone biopsy
Pain
Bleeding
Infection
Scar formation with stenosis of the cervix
Increased risk of miscarriage and premature labour
what is the staging used for cervical cancer
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage cervical cancer:
Stage 1: Confined to the cervix
Stage 2: Invades the uterus or upper 2/3 of the vagina
Stage 3: Invades the pelvic wall or lower 1/3 of the vagina
Stage 4: Invades the bladder, rectum or beyond the pelvis
what is the management of cervical cancer
Cervical intraepithelial neoplasia and early-stage 1A: LLETZ or cone biopsy
Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
Stage 2B – 4A: Chemotherapy and radiotherapy
Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
what is the five year survival for cervical cancer
The 5-year survival drops significantly with more advanced cervical cancer, from around 98% with stage 1A to around 15% with stage 4
what is pelvic exenteration
an operation that may be used in advanced cervical cancer. It involves removing most or all of the pelvic organs, including the vagina, cervix, uterus, fallopian tubes, ovaries, bladder and rectum. It is a vast operation and has significant implications on quality of life.
what is Bevacizumab
monoclonal antibody that may be used in combination with other chemotherapies in the treatment of metastatic or recurrent cervical cancer. It is also used in several other types of cancer. It targets vascular endothelial growth factor A (VEGF-A), which is responsible for the development of new blood vessels.
when is the HPV vaccine given and what does it protect you against
12-13 yrs before sexual activity
The current NHS vaccine is Gardasil, which protects against strains 6, 11, 16 and 18:
Strains 6 and 11 cause genital warts
Strains 16 and 18 cause cervical cancer
what is the most common type of endometrial cancer
adenocarcinoma
it is an oestrogen sensitive cancer
what is endometrial hyperplasia
precancerous condition involving thickening of the endometrium. The risk factors, presentation and investigations of endometrial hyperplasia are similar to endometrial cancer. Most cases of endometrial hyperplasia will return to normal over time
what are the two kinds of endometrial hyperplasia
hyperplasia without atypia
atypical hyperplasia
how is endometrial hyperplasia treated
progestogens, with either:
Intrauterine system (e.g. Mirena coil)
Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel)
what are risk factors for endometrial cancer
unopposed oestrogen
Increased age
Earlier onset of menstruation
Late menopause
Oestrogen only hormone replacement therapy
No or fewer pregnancies
Obesity
Polycystic ovarian syndrome
Tamoxifen
type 2 diabetes
hereditary nonpolyposis colorecta cancer/lynch syndrome
for endometrial protection what should women with PCOS be given
one of:
The combined contraceptive pill
An intrauterine system (e.g. Mirena coil)
Cyclical progestogens to induce a withdrawal bleed.
what are protective factors against endometrial cancer
Combined contraceptive pill
Mirena coil
Increased pregnancies
Cigarette smoking
how does smoking affect the risk of endometrial cancer
it reduces the risk of it as it is anti-oestrogenic
Oestrogen may be metabolised differently in smokers
Smokers tend to be leaner, meaning they have less adipose tissue and aromatase enzyme
Smoking destroys oocytes (eggs), resulting in an earlier menopause
how does endometrial cancer present
postmenopausal bleeding
Postcoital bleeding
Intermenstrual bleeding
Unusually heavy menstrual bleeding
Abnormal vaginal discharge
Haematuria
Anaemia
Raised platelet count
what is the referral criteria for endometrial cancer
The referral criteria for a 2-week-wait urgent cancer referral for endometrial cancer is:
Postmenopausal bleeding (more than 12 months after the last menstrual period)
NICE also recommends referral for a transvaginal ultrasound in women over 55 years with:
Unexplained vaginal discharge
Visible haematuria plus raised platelets, anaemia or elevated glucose levels
what investigations are done for suspected endometrial cancer
Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause)
Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer
Hysteroscopy with endometrial biopsy
what are the stages of endometrial cancer
The International Federation of Gynaecology and Obstetrics (FIGO) staging system is used to stage endometrial cancer:
Stage 1: Confined to the uterus
Stage 2: Invades the cervix
Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes
Stage 4: Invades bladder, rectum or beyond the pelvis
how is endometrial cancer treated
The usual treatment for stage 1 and 2 endometrial cancer is a total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO
other treatment options include:
A radical hysterectomy involves also removing the pelvic lymph nodes, surrounding tissues and top of the vagina
Radiotherapy
Chemotherapy
Progesterone may be used as a hormonal treatment to slow the progression of the cancer
what are the types of ovarian cancers
Epithelial cell tumours
dermoid cysts/germ cell tumours
sex cord stromal tumours
metastasis
what is an epithelial cell ovarian tumour
Epithelial cell tumours (tumours arising from the epithelial cells of the ovary) are the most common type. Subtypes of epithelial cell tumours include:
Serous tumours (the most common)
Endometrioid carcinomas
Clear cell tumours
Mucinous tumours
Undifferentiated tumours
what are dermoid cysts/germ cell ovarian tumours
These are benign ovarian tumours. They are teratomas, meaning they come from the germ cells. They may contain various tissue types, such as skin, teeth, hair and bone. They are particularly associated with ovarian torsion. Germ cell tumours may cause raised alpha-fetoprotein (α-FP) and human chorionic gonadotrophin (hCG).
what are sex cord stromal ovarian tumours
These are rare tumours, that can be benign or malignant. They arise from the stroma (connective tissue) or sex cords (embryonic structures associated with the follicles). There are several types, including Sertoli–Leydig cell tumours and granulosa cell tumours.
what is a Krukenberg tumour
a metastasis in the ovary, usually from a gastrointestinal tract cancer, particularly the stomach. Krukenberg tumours have characteristic “signet-ring” cells on histology, which look like signet rings on under a microscopy.
what are risk factors for ovarian cancer
Age (peaks age 60)
BRCA1 and BRCA2 genes (consider the family history)
Increased number of ovulations
Obesity
Smoking
Recurrent use of clomifene
early onset periods
late menopause
no pregnancies
