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Flashcards in Disorders of the Cervix Deck (60)
1

ABNORMAL CONDITIONS OF THE CERVIX
3

1. Cervicitis
2. Polyps
3. Nabothian Cysts

2

Disorders of the Cervix
1. Infections often present how?

2. Early detection of abnormal cell changes and the presence of HPV leads to treatment that prevents the progression to what?

1. asymptomatic

2. cervical cancer

3

Cervisitis
1. Primarily affects what cells?
2. Can cause visual changes of the what?

3. Etiologies? 4

Cervicitis
1. Primarily affects the columnar epithelial cells
2. Can cause visible changes of the ectocervix

3. Etiologies
-Often caused by STIs—often asymptomatic
-Local trauma
-Malignancy, radiation therapy, chemical irritation, systemic inflammatory disease (Behcet's syndrome)
-Idiopathic

4

Hx questions for Cervisitis?
6

Sexual hx
1. # of partners
2. use of condoms
3. Hx of STIs (women under 25…1 out of 3 have chlamydia)‏

4. Use of pessiary, diaphragm, douches etc.
5. Specific symptoms
6. Constitutional symptoms

5

Symptoms of cervisitis?
6

1. Purulent or mucopurulent discharge from the vagina

2. Intermenstrual or postcoital bleeding

3. Dysuria or urinary frequency

4. Dyspareunia

5. Vulvovaginal irritation

6. Pain & fever are atypical in the absence of upper tract infection

6

Physical exam
Cervitis may appear how?
5

1. Purulent discharge on the surface and/or exuding from the canal

2. Minor trauma from insertion from a cotton swab—bleeding (friability)‏

3. Diffuse vesicular lesions suggest HSV

4. Punctate hemorrhages consistent w/ trichomonas infection

5. Cervical motion tenderness is a sign of coexisting PID

7

Gonnorrhea tx?

Chlamydia tx?

250 mg Rocephin bid

1000mg Azithro

8

What is pathogonomic for Trchomonas infection?

Strawberry spots

9

1. Dx how?

2. Treat empirically to cover gonorrhea, chlamydia and trichomonas: Which abx? 3

3. All patients evaluated for STIs should be offered counseling and testing for what?

4. If exam shows what then other etiologies might be in play; then there may be an offending agent that needs to be stopped? 3

1. From exam and determination of risk— test for gonorrhea and chlamydia, HSV if indicated

2.
-Ceftriaxone
-Doxycycline
-Metronidazole

3. HIV!!!

4.
-minor erythema and
-low risk person, or
-cultures are negative

10

Treatment for persistant cervisitis?
3

1. If persists after initial round of antibiotics then repeat testing w/ most sensitive diagnostic tests

2. Re-examine possible exposure to chemical irritants

3. Have sex partner(s) be examined and tested for STIs

11

What is the most common benign neoplastic growth of the cervix?
-occurs in 4% of all gynecologic patients

Cervical Polyps

12

1. Cervical Polyps
are what?
2. In what numbers can they present?
3. Believed to be a result of what?
4. May be associated with what?
5. Found commonly in what dz process?
6. Most common amoung what population?

1. Benign, pedunculated growths of varying size that extend from the ectocervix or endocervical canal

2. May occur singularly or may be multiple

3. Etiology is unknown
-Believed to result from chronic inflammation

4. May be associated with hyperestrogen states

5. Found commonly with endometrial hyperplasia

6. Most common among multiparous women in their 30s and 40s

13

Cervical Polyps
1. Commonly occur in what years?
2. Usually arise from where?
3. How common is malignant change?

4. Removed Easily. Always do what with this?

1. Commonly occur during reproductive years

2. Usually arise from the endocervical canal

3. Malignant change is rare-about 1% will show neoplastic changes

4. Removed fairly easily
Always send to pathology

14

Cervical Polyps: Symptoms

7

1. Usually asymptomatic
2. Thick leukorrhea
3. Postcoital bleeding
4. Intermenstrual bleeding
5. Menorrhagia
6. Post-menopausal bleeding
7. Mucopurulent or blood-tinged vaginal discharge

15

Cervical Polyps: Physical Exam
findings?
4

1. Single or multiple pear-shaped growths may protrude from the cervix into the vaginal canal

2. Usually smooth, soft, reddish purple to cherry red

3. May readily bleed when touched

4. May be small or very large

16

Cervical Polyps: Differential Diagnoses
3

1. Endometrial polyps
2. Small prolapsed myomas
3. Cervical malignancy

17

Cervical Polyps-
Treatment
4

1. Tie off base
2. Twist off at base with forceps
3. May need to cauterize site
4. Recurrence low

18

1. Nabothian Cysts are what?
2. Most often caused when what?
3. Tissue growth can cause what complications?

1. Mucous filled cyst on the surface of the cervix

2. Most often caused when stratified squamous epithelium of the ectocervix grows over the simple columnar epithelium of the endocervix

3. Tissue growth can block the cervical crypts and trap mucous inside the crypts

19

Nabothian cysts
1. Appear how?
2. Prognosis?
3. Appearance may be related to what?
4. Not considered problematic unless what?
5. May be removed how? 2

1. Appear as firm bumps on the surface

2. Considered harmless and usually resolve on their own

3. Appearance may be related to menses

4. Not considered problematic unless they grow very large and present secondary symptoms

5. May be removed by electrocautery or cryotherapy

20

Cervical Cancer
1. Pathology in order of prevalence? 3

2. Symptoms? 4

1. Pathology:
-Squamous cell—69%
-Adenocarcinoma—25%
-Adenosquamous, rare types (sarcomas)—6%

2. Symptoms:
-Frequently asymptomatic
-Abnormal vaginal bleeding
-Postcoital spotting
-Vaginal discharge—can be watery, mucoid or purulent and malodorous

21

What does an adenocarcinoma of the cervix look like?

An elevated white and dense lesion overlying columnar epithelium with coarse punctation

22

Risk Factors for Cervical Cancer
10

1. Early onset of intercourse (3 term pregnancies)

6. Cigarette smoking (for squamous cell CA)

7. Immunosuppression

8. Oral contraceptive use—especially long term (?)

9. Low socioeconomic status (?)

10. Daughter of a mother who took diethylstibestrol (DES) (1970s)

23

Protective Factors for cervical cancer?
5

1. Virginity
2. Long-term celibacy
3. Life-long mutual monogamy
4. Long-term use of condoms
5. Obtaining regular Pap smears

24

Most HPV infections are transient—but:
1. Over 50% are cleared in ____ months

2. 80-90% will have resolved within ___ years

3. ____ can be detected in 99.7% of cervical CAs!

4. Generally HPV alone cannot cause cervical CA—it usually takes about ____ from time of infection to presentation of cervical CA

1. 6-18
2. 2-5

3. HPV

4. 15 yrs

25

How does HPV cause cancer?

HPV integrates into the human genome & can result in abnormal high grade lesions and cancer

26

Major factors associated w/ development of HGL and cervical Cancer are?
3

1. HPV subtype: 18 & 16 (involved in the bulk of cervical CAs)

2. Persistence: age, duration, oncogenic subtypes

3. Environmental factors: cigarette smoking, infection w/ HIV, gonorrhea & chlamydia, herpes simplex virus, OCP

27

1. The earliest squamous cell carcinoma is confined to the epithelial layers: What are these?

2. The disease remains confined to the mucous membrane for several years before invading the what?

3. Carcinoma in situ (CIS) occurs most frequently in the _____ decade

4. Invasive carcinoma is encountered most often in women between age what?

1.
-intraepithelial neoplasia
-preinvasive carcinoma (carcinoma in situ)

2. subjacent stroma

3. fourth

4. 40 and age 50

28

1. Oncogenic HPV infection at the what?

2. This leads to what?

3. Progression of a what from persistent viral infection to precancerous cells?

4. Development of carcinoma & invasion through the what?

1. transformation zone

2. Persistence of the infection

3. clone of epithelial cells

4. basement membrane

29

Diagnosis of Genital HPV
3

1. Papanicolaou (Pap) smears prepared from cervical or anal scrapings often show cytologic evidence of HPV infection

2. Persistent or atypical lesions should be biopsied and examined by routine histologic methods

3. The most sensitive and specific methods of virology diagnosis, use techniques such as the
-polymerase chain reaction or
-the hybrid capture assay to detect HPV nucleic acids and to identify specific virus types

30

Prevention of HPV: Vaccination

1. Which vaccine?

2. Who should receive it and what ages?
-boys
-girls

Recently developed HPV vaccines dramatically reduce rates of infection and disease produced by the HPV types in the vaccines

1. Currently, one quadrivalent product (Gardasil, Merck):
Recommended by the Centers for Disease Control

2.
-Vaccination in boys and men 9 through 26 years of age for the prevention of genital warts caused by HPV types 6 and 11

-Vaccination in people ages 9 through 26 years for the prevention of anal cancer and associated precancerous lesions due to human papillomavirus (HPV) types 6, 11, 16, and 18


As of December 2014 Gardisil 9 was approved by the FDA

31

Dosing schedule for Gardasil?
3

1. Over a 6-month period with the first dose at an elected date

2. The second dose 2 months after the first dose

3. Third dose 6 months after the first dose

COST—for Gardisil 9--$180 a dose

32

How should we prepare the speculum before the pap?
2

1. Warm water
-Not too hot

2. Lubricates speculum
-May use a small amount of gel on plastic speculums

33

When inserting the speculum what are the steps?
4

1. Spread labia
2. Keep labia apart
3. Blades remain closed until fully inserted
4. Squeeze handle to open speculum and visualize cervix

34

1. What is the Squamo-Columnar Junction?

2. What is important to know about this area?

1. Junction of pink cervical skin and red endocervical canal

2. Most likely site of dysplasia
-Key portion of the cervix to sample

35

Ayers Spatula
1. Concave end to fit the what?
2. Convex end for what?

1. cervix

2. vaginal wall and vaginal pool scrapings

36

1. For a sample of the cervix what end of the spatula should we use?
2. Rotate how much?

1. Use concave end

2. Rotate 360 degrees

37

Describe the prepartion of the pap smear?
3

1. As thin as possible
-Properly labeled
2. Spray with a fixative within 10-15 seconds
3. Allow to fully dry before packaging

38

Definition of a Satisfactory pap? 3

Not satisfactory if what? 3

1. Proper amount of squamous cells
2. Proper labeling
3. Endocervical cells present!!!

NOT Satisfactory if:
1. Scant cellularity
2. Not properly labeled
3. Cells obscured by blood or inflammation

39

Categories for Pap test results:

What is categorized as a normal result? 2

Abnormal? 4

Normal results:
1. If no abnormal cells are seen, then the test result is normal

2. If only benign changes are seen, usually resulting from inflammation or irritation, then the test result is normal

Abnormal results:
1. Atypical cells of undetermined significance (ASCUS, AGUS)

2. Low-grade squamous intraepithelial lesions (LSIL) or cervical intraepithelial neoplasia (CIN) 1. These are mild, subtle cell changes, and most go away without treatment

3. High-grade squamous intraepithelial lesions (HSIL) or CIN 2 or 3. Moderate and severe cell changes which require further testing or treatment

4. Carcinoma

40

Cervical Intraepithelial Neoplasia
1. CIN 1—low grade lesion?
2. CIN 2—high grade lesion?
3. CIN 3—high grade lesion?

4. Incidence:
High grade lesions more commonly a disease in women ______ while invasive cancer disease women > ___?

1. mild atypia, 1/3
2. moderate atypia, 2/3
3. severe atypia, >2/3

4. 25-35, 40

41

Describe the following stages of cervical cancer:
1. Stage 0?
2. Stage I?
3. Stage II?
4. Stage III?
5. Stage IV?

1. Carcinoma in-situ
2. Confined to cervix
3. Disease beyond cervix but not to pelvic wall or lower 1/3 of the vagina
4. Disease to pelvic wall or lower 1/3 of vagina
5. Invades bladder, rectum, or metastasis

42

Routes of spread of Cancer

1. Can spread by direct extension

2. Any pelvic lymph node groups may be sites of metastasis

3. Hematogenous spread

43

Cervical Cancer: Hematogenous spread often to where?
3

1. Lungs
2. Liver
3. Bone

44

Cervical Cancer screening
1. Treatment according?
2. Treatment modalities? 3

1. According to staging system-

2. Treatment modalities:
-Early stage disease: surgery or chemo-radiation
-Locally advanced disease: chemo-radiation
-Disease w/ distant metastases: chemotherapy (Palliative care with radiation and chemotherapy)

45

HIV Infection and
Cervical Cancer Risk of morbidity and mortality prevention?

4

1. Pap smears at least annually

2. Baseline colposcopic evaluation at time of initial diagnosis of HIV

3. Colposcopy after single reading of ASCUS or SIL Pap

4. Aggressive treatment of cervical disease will prolong life in most cases

46

1. When should we start screening for cervical cancer?
2. Critical that adolescents who may not need yearly Pap smears
obtain other yearly preventative health care: What does this include? 4

1. At age 21

2.
- Assessment of Health Risks
- Contraception
- Prevention Counseling
- Screening and treatment of STIs

47

Young women who are infected with HIV and/or
immunocompromised should have Pap smears 1.______ in the
first year after diagnosis and if normal—2.______ thereafter

1. twice

2. annually

48

1. Screening intervals for paps?

2. For women over 30? 2

3. When to stop? 2

1. Every 3 years from 21 to 30 a pap smear

2. For women over 30:
-Every 3 years with a pap smear
-Every 5 years with a pap smear and HPV test as long as the first set were negative

3. When to stop:
-At 65
-As long as the woman had 2 consecutive tests negative prior to stopping

49

You performed a routine Pap smear on a 24 yo female. The result is “within normal limits with a missing endocervical component.”


What would you do?

ASCCP (American Society Colposcopy and Cervical Pathology) have published recommendations stating Pap can be repeated in 1 year if this was a routine screening Pap
Earlier screening at 6 months required if there was a previous abnormal Pap without 3 normal f/u Pap smears
Or… patient is immunosuppressed; patient has not had regular screening; a prior Pap revealed glandular abnormalities; a high risk HPV + result was obtained in the past year then it should be repeated now

50

2001 Bethesda System-
used for reporting Pap smears
What are the squamous cell types? 4

1. Atypical squamous cells (ASC)

2. Low-grade squamous intraepithelial lesions (LSIL)
-Encompassing human papillomavirus (HPV), mild dysplasia, and cervical intraepithelial neoplasia (CIN) 1

3. High-grade squamous intraepithelial lesions (HSIL)
-Encompassing moderate and severe dysplasia, carcinoma in situ, CIN 2, and CIN 3

4. Squamous Cell carcinoma

51

2001 Bethesda System-
used for reporting Pap smears
What are the glandular types?
4

1. Atypical glandular cells (AGC) (specify endocervical, endometrial, or not otherwise specified)

2. Atypical glandular cells, favor neoplastic (specify endocervical or not otherwise specified)

3. Endocervical adenocarcinoma in situ (AIS)

4. Adenocarcinoma

52

Management options if the Pap test result is abnormal:
1. For women with low-grade squamous abnormalities (ASCUS or LSIL)?

2. Women with glandular abnormalities (AGUS)?

3. Women with HSIL?

1. give periodic Pap tests until the abnormality resolves, or a colposcopy referral for persistent lesions

2. usually are referred for colposcopy

3. are referred for colposcopy

53

HPV is VERY COMMON, occurring at least once over a 3-year period in 60% of young women
1. Lifetime cumulative risk is at least ___%

2. What increases the risk of CIN? 2

3. ________ DOUBLES the risk of progression to CIN 3 in HPV positive patients

1. 80

2.
-The longer HPV is present
-the older the patient,

3. Smoking

54

1. Vast majority clear the virus or suppress it to levels not associated w/ _______, and for most women this occurs promptly

2. The duration of HPV positivity is shorter and the likelihood of clearance is higher in ________ women

3. Only 1 in 10 to 1 in 30 HPV infections are associated w/ what?

4. Only 15% of women w/ negative cytology reports and positive HPV will have_______________ within 5 years

5. The risk of cervical cancer in women who do not harbor what is extremely low?

6. The time course from CIN 3 to invasive cancer averages between what range of years?

1. CIN 2/3+

2. younger

3. abnormal cervical cytology

4. abnormal cytology

5. oncogenic HPV

6. 8.1 and 12.6

55

Likelihood of regression to normal:
CIN 1: ?
CIN 2: ?

1. 60%
2. 40%

56

Cytology vs. Cytology + HPV testing:
Describe the differences?
3

1. Cytology alone low sensitivity

2. Cytology + HPV testing much higher sensitivity

3. HPV testing especially helpful in patients > 30 years old

57

Cytology normal/HPV positive
1. If combined testing is normal, repeat combined testing only every ?

2. If pap normal and HPV positive then what? 2

1. 3 years

2.
-repeat pap and HPV testing in 12 months,
-then colposcopy if either is positive

58

1. What is colposcopy?

2. Application of a what?

3. obtain colposcopically directed biopsies of all lesions suspected of representing what?

4. Need to visualize all of the what?
Up to 10% of lesions more severe than anticipated

1. Examination of the cervix with a colposcope:

2. 3-5% acetic acid solution


3. neoplasia

4. SCJ!

59

Is excision or ablation better?
1. Name three ablation techniques?
2. What must you do if an ablation is planned?
3. When can you not perform an ablation?
4. If you can't, then what is preferred?

1.
-Laser,
-LEEP,
-cryotherapy: all ablation techniques

2. MUST perform endocervical sampling if ablation is planned

3. Do not perform ablation if dysplasia on endocervical curettage

4. Then cold knife conization is preferred or LEEP

60

Care and follow-up during/after pregnancy
1. What is the only thing that alters management?
2. Colposcopy should have what as its primary goal?
3. Higher grade results: then what management is indicated? 3

1. Only the diagnosis of invasive cancer alters management

2. Colposcopy should have as its primary goal the exclusion of invasive cancer

3. Higher grade test results:
-colposcopy without endocervical sampling
-Biopsy only if colposcopic appearance consistent w/ CIN 3, AIS, or cancer
-Repeat colposcopy each trimester w/ biopsy only if progression of disease is suggested or cytology is suggestive of invasive cancer