Cervical disease Flashcards
(101 cards)
1
Q
What 3 periods of life can a cervix change from columnar to stratified squamous?
A
As a fetus
adolescence
during 1st pregnancy
2
Q
What is a Nabothian cyst
A
develops when crypts and clefts of columnar epithelium are bridged over and become occluded, blocking mucous resulting in a formation of a cyst
3
Q
how common are naothian cysts
A
very common
4
Q
what will a nabothian cyst look like on exam
A
yellow or translucent in color and range from 2mm-3cm
5
Q
what is the Tx for a nabothian cyst
A
nothing
6
Q
what are cervical polyps
A
small, pedunculated neoplasms of the cervix
7
Q
how often do cervical polyps appear?
A
common
rare before menarche
more common in multigravidas over 20 years of age
8
Q
when a cervical polyp is noted on exam what should be done?
A
most are benign, but should be removed and biopsied to rule out malignancy
<1% incidence
9
Q
what 2 types of cervical polyps are there
A
endocervical: red, flame shaped, fragile, range from a few millimeters to 2-3cm
ectocervical: pale, flesh colored, smooth and rounded or elongated, less likely to bleed
10
Q
what are the signs and symptoms of cervical polyps
A
intermenstrual or postcoital bleeding is most common, Leukorrhea (white or yellow mucous secretions) menorrhagia
11
Q
what is the Tx for cervical polyps
A
r/o infection w/ cultures, polpectomy
12
Q
what is cervical stenosis
A
narrowing of cervical canal
13
Q
what are some complications of cervical stenosis
A
obstruct menstrual flow, pelvic pain, endometrosis, infertility
14
Q
what is the etiology of cervical stenosis
A
may be present from birth secondary to cervical surgery Trauma Radiation therapy cervical cancer menopause
15
Q
how is cervical stenosis diagnosed
A
clinical, you are not able to pass a small cervical dilator
16
Q
what is the treatment for cervical stenosis
A
dilation of cervical canal
17
Q
what is DES or Diethylstilbestrol
A
synthetic non-steroidal estrogen
used b/w 1940-1971 to prevent premature birth, miscarriages and other complications
18
Q
what was the result of using DES
A
is passed the placenta resulting in structural changes of the cervix, uterus and was a cause of vaginal clear cell carcinmoa in fm offspring
19
Q
using DES put the offspring at risk for what following complications
A
offspring were at increased risk of infertility, complicated pregnancies (miscarriage, ectopic, and premature delivery) and vaginal clear cell carcinoma
20
Q
what is CIN cervical intraepithelial neoplasia
A
disordered growth and development of the epithelial lining of the cervix
21
Q
what are the 2 classification systems
A
histologic classification (based off biopsy alone) bethesda system (cytologic classification based on pap smear results)
22
Q
what is the classification that uses biopsy alone?
A
Histologic classification
23
Q
what is the CIN 1 classification?
A
Mild (disorders growth of lower 1/3 of epithelial lining)
24
Q
what is the CIN 2 classification?
A
moderate (disordered growth of lower 2/3 of epithelial lining)
25
what is the CIN 3 classification?
severe (more than 2/3rds of epithelial thickness)
26
carcinoma in situ is what thickness of the cervical tissue?
full thickness dysmaturity
27
what is the classification based of cytologic classification?
bethesda system
28
what is the ASC-US classification?
atypical squamous cells of undetermined significance
29
what is the ASC-H classification?
atypical squamous cells high grade lesions cannot be excluded
30
what is LSIL classification
low grade squamous intraepithelial lesions consistent w/CIN I
31
what is the HSIL classification
high grade squamous intraepithelial lesions consistent with CIN II/III
32
What are the recommendations for pap smear screening based on ACS, ASCCP and ASCP-2012?
For ages less than 21
ages 21-29
age<21=no screening
21-29=screening every 3 years (cytology only)
-If cytology negative or HPV-neg repeat cytology in 3 years
33
What are the recommendations for pap smear screening based on ACS, ASCCP and ASCP-2012?
For ages 30-65
30-65 year:
-HPV and cytology every 5 years or cytology alone 3 years after 3 consecutive normal pap smears
-HPV positive, cytology negative: repeat co-testing in 12months or test for HPV 16 or 18 genotypes. If positive colposcopy, If neg. repeat co-testing in 12 months
If both cytology and HPV neg repeat screening 3-5 years
34
What are the recommendations for pap smear screening based on ACS, ASCCP and ASCP-2012?
for ages >65
No screening if > 3 normal paps in a row and no CIN in last 10 years
If hx of CIN II/III, continue routine screening for at least 20 years
After hysterectomy
No screening in women w/o a cervix and without a hx of CIN II or more severe diagnosis in the past 20 years
35
when is the annual pap smear recommended?
HIV (twice in the 1st year then annually)
Hx of CIN 2 or 3 or cancer (for 20 yrs after dx
DES in utero exposure
Immunosuppressed
36
Epidemiology of CIN/Cervical cancer?
Prevalence varies depending on socioeconomic factors
-CIN is most common detected in women in their 20's
-Peak Incidence of CIS is 25-35yrs
Incidence of cervical cancer rises after age of 30
37
What is the Etiology of CIN/Cervical cancer
```
CIN: primarily HPV
Cancer:
-all cancers start at CIN, grows slowly
-70-75% are squamous cell carcinoma
-20-25% are different types of adenocarcinoma
```
38
what are the primary risk factors for CIN/Cervical cancer?
HPV is prime risk factor (16,18)
low risk (6,11,42,43,44)
-90% of immunocompetent women will have spontaneous resolution over a 2 year period
-5% will develop CIN
39
what are other risk factors for CIN/cervical cancer?
```
multiple sex partners
Early onset of sexual activity
High risk sexual partner
Hx of STI
Smoking
HIV/AIDS
Immunosupressed
Multiparity
Long term OCP use
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40
What are signs of CIN?
asymptomatic, typically found on a routine pap smear that comes back abnormal, followed by a biopsy
41
what are signs of cervical cancer?
abnormal vaginal bleeding most common
Leukorrhea (whitish yellow discharge)
Pelvic pain-unilateral and radiating to hip suggest advanced dz
Weakness, weight loss and anemia are signs of late stages of dz
42
what does CIN look like on PE?
may or may not see an obvious lesion
43
what does cervical cancer look like on PE?
Normal w/ preclinical dz
enlargement, irregularity and firm consistency of cervix
Ulcerations
90% occurs within 1cm of the squamocolumnar junction (SCJ)
44
How is CIN/cancer dx?
CIN-pap screening and HPV testing.
confirmed by:
colposcopy directed cervical biopsy or edocervical sampling
Cancer-Biospy aided by colposcopy
30-40% of CIN-III actucally progress to cancer
45
How is acetic acid used when preforming colposcopy?
it brings out areas of dysplasia
46
What is the Tx for CIN?
destroy abnormal cells to prevent progression
Electrocautery, cryocautery, laser therapy, conization, large loop excision of transitional zone or loop Electrodiathermy excision procedures (LEEP)
47
What is the Tx of Cancer?
depends on the stage of the dz which may include surgery, radiation, chemotherapy
48
What is the prognosis for patients with cervical cancer?
35% of pts w/ invasive cervical cancer will have recurrent or persistent dz after therapy
50% of deaths occur in the 1st year after tx
25% in the 2nd year after treatment
15% in the 3rd year
***therefore post- Tx follow up recommended more frequently initially
49
How many females are diagnosed with cervicitis
3 million annually
50
what are the most common causes of cervicitis?
Gonorrhoeae, Chlamydia, HSV, HPV, trichomoniasis, bacterial vaginosis
Can also occur in the absence of vaginal disease through sexual contact
51
```
what are the signs/symptoms of cervicitis?
for each of the pathogens
Gonorrhea
Chlamydia
Trichomonas
Candidiasis
BV
```
```
Purulent vaginal d/c is a primary sign and symptom
Bleeding after intercourse
intermenstrual bleeding
Vulvar burning and itching
Gonorrhea: thick and creamy
Chlamydia: +/- purulent discharge
Trichomonas: foamy and greenish white
Candidiasis: white curd like
Bacterial vaginosis: thing and gray (+ whiff test)
```
52
What will the PE look like for a female with cervicitis?
Gonorrhea
Chlamydia
Trichomonas
Chlamydia: reddened, congested cervix or w/o signs
Gonorrhea: acutely inflamed and edematous cervix w/ purulent d/c form external os
Trichomonas: strawberry-like appearance of ectocervix that may extend to vagina
53
What are the labs you would want to order with a patent who you suspect of cervicitis?
PCR is most widely used d/t high sensitivity
Gram stains, saline wet preps and cultures are not used routinely d/t either low sensitivity for chlamydia/gonorrhea: however may detect trichomonas, BV and candidiasis
Cervical Cytology can also aid in dx
54
what is the Tx for cervicitis
depends on the pathogen causing the infx
55
what is a Chancroid
caused by gram-neg rod Haemopgilus ducreyi (highly infectious)
56
What are the S/S of chancroid?
Red papule that evolves into a pustule-Ulcer surrounded by an inflammatory wheal. Multiple lesions may be present and coalesce
- lesion are very tender and produces a foul smelling d/c that is contagious
- confined to genital region
- Painful inguinal lymphadenopathy in 50% of cases
57
Hoe is the Dx of chancroid made?
Culture (special culture media)
If culture media not available Dx is made on clinical presentation, adenopathy and negative testing for other ulcerative lesions
58
What is the treatment of a chancroid?
Local symptomatic treatment (sitz bath, good hygiene)
Abx (Azithromycin po, Ceftriaxone IM, Cipro po, Erythromycin po)
Treat partner
59
what is lymphogranuloma Venereum?
caused by aggressive serotype of Chlamydia trachomatis
60
where is lymphogranuloma Venereum most common?
in tropical and sub tropical nations but is seen in South east US.
Strongly associated with HIV infection
61
What are the S/S of Lymphogranuloma Venereum?
Initial exposure:Mild blister like formation which is unnoticed
Following months: ulcerations of the vaginal, rectal or inguinal areas that are painful
Tender UNILATERAL inguinal and or femoral lymphadenopathy and hard tender masses (buboes)
Rectal exposure-proctocolitis- discharge, pain, constipation, fever or tenesmus
62
How is Lymphogranuloma Venereum Dx?
based on clinical suspicion and exclusion of other etiologies
63
what is the Tx of Lymphogranuloma Venereum?
Doxycycline 100mg bid x21 days
Erythromycin 500mg po qid x21 days
Surgical Tx of complications
64
what causes syphilis?
treponema pallidum
65
how is syphilis contracted?
sexually transmitted and can be transmitted in utero after 10th wk of pregnancy
Known as great imitator
66
what are the clinical findings of syphilis?
primary syphilis: painless genital sore at site of inoculation associated w/ painless regional lymphadenopathy
Secondary: may involve skin, mucous membranes,eye, bone, kidneys, CNS, liver
Tertiary: gummatous lesions involving skin, bones, and viscera
67
How is syphilis Dx?
serologic testing
Non-treponemal test:
VDRL and RPR become positive 4-6 weeks after infection
positive in 99% of cases of primary and secondary syphilis but may be negative in late disease
False positive can occur in autoimmune dz
Treponemal Test: Use live or killed T. pallidum as Ag to detect specific Ab
FTA-ABS (fluorescent absorption test) most widely used
Accurate in most paitents w/primary syphilis and in all pts w/secondary syphilis
Tertiary syphilis includes LP, joint fluid analysis or biopsy
68
what is the Tx for syphilis?
Benzathine Penicillin G 2.4mill Units IM tx of choice
Penicillin allergy options:
doxycycline 14 days
Tetracycline 14 days
Neurosyphilis is treated with aqueous penicillin G IV
**Treat all partners even in absence of symptoms
Recommended screening and Tx of other STI d/t high risk of other STI
69
What is the Jarisch-Herxherimer rxn?
Fever, toxic state- can occur when there is a sudden destruction of spirochetes
-Prevented by giving antipyretics during 1st 24 hours
70
What is Gonorrhea
gram negative diplococcus
71
what are the S/S of Gonorrhea?
most are asymptomatic
symptoms are localized to lower GU tract
Vaginal d/c, urinary frequency, rectal discomfort, purulent urethral d/c
vaginitis and cervicitis are common
bacteremia is associated with peripheral skin lesions
72
what is the lab/dx of Gonorrhea?
gram stain d/c typicall shows gram neg. diplococci
| Culture, PCR through urine or vaginal cervical swab test
73
what is the Tx of Gonorrhea
dual therapy for chlamydia is recommended for all pt's due to co-infection.
tx all partners
Uncomplicated:
Ceftriaxone, cefixime, axithromycin, doxycycline
Disseminated Infx:
hospitilization and ceftriaxone IV or Cefoxtamin
74
What is the most reported infectious disease in the US
Chlamydia
Highest prevalence in ≤25 years
Increased risk if patient has had multi sexual partners and lower socioeconomic status
75
what are the S/S of chlamydia?
Often asymptomatic
| may have mucopurulent d/c in the setting of a cervical infection
76
how is chlamydia diagnosis made?
culture and PCR through Urine sample or cervical/vaginal swabs can be performed
77
What is the Tx for Chlamydia?
Dual therapy to cover gonorrhea is required d/t high rates of co-infection
treat sexual partners
Recommendations:
Azithromycin 1g po x 1, or
Doxycycline 100mg po bid x 7days, plus Gonorrhea coverage
In pregnancy:
Amoxicillin
Re-screen them 3 months after treatment or w/in 12 months of Tx
78
What is Pelvic Inflammatory Disease?
Includes a combination of endometritis, salpingitis, tubo-ovarian abscess and pelvic peritonitis
79
what is the etiology of PID
In the setting of IUD-Actinomyces israelii
N. gonorrhea, C. trachomatis are a common cause but other organism that compromise the vaginal flora are associated and are often polymicrobial in nature
80
How is PID prevented?
screening and treating patients and their sexual partners for chlamydia/gonorrhea reduces risk
early diagnosis and treatment to prevent complications
81
What are S/S of PID?
May be subtle or mild which delays diagnosis and treatment
Insidious or acute onset of lower abdominal and pelvic pain, usually b/l
Sensation of pelvic pressure or back pain
May have associated purulent vaginal discharge
Nausea w/ or w/o vomiting
Fever, headache and general malaise
82
What will the PE be like with PID
Abdominal tenderness in lower quadrants
Abdomen may be distended
BS may be hypoactive or absent
Pelvic exam:
Inflammation of Skene or Bartholin glands may be present
Purulent cervical d/c,
Cervical motion tenderness as well as tenderness w/ palpation of uterus/ovaries
83
What will the labs for PID be like?
may be normal or abnormal but used as supportive evidence only
Leukocytosis w/left shift
Elevated ESR
Endocervical swabs may be + gonorrhea/chlamydia
Endometrial biopsy showing endometrosis
84
What type of imaging would you want for PID?
trans-vaginal US or MRI will show thickened, fluid filled tubes w or w/o free pelvic fluid or tubo-ovarian complex or doppler study showing tubal hyperemia
Only use Laparoscopy when diagnosis is in question
85
How is PID Dx
can be made clinically and empiric tx started if patients is experiencing pelvic or lower abdominal pain
no cause for the illness other than PID can be identified
And if 1 or more of the following minimum criteria is present:
CMT
Uterine tenderness
Adnexal tenderness
86
What is the Tx for PID?
```
empiric broad spectrum Abx
Ceftriaxone IM x 1 plus Doxy with or w/o metronidazole
covering most likely pathogen Asap
Tx as inpatient if:
Severely ill
Pregnant
Surgical Emergency cannot be r/o
have not responded to outpatient oral therapy
non-compliant pts
tubo-ovarian abscess is present
```
87
What precedes a Tubo-ovarian abscess?
PID
| usually polymicrobial, usually unilateral but can be b/l
88
Who is TOA more common in?
Younger females but can occur at any age
| ***Presence of TOA in a postmenopausal femal is highly indicative of concurrent malignancy
89
what are S/S of TOA?
Pelvic and abdominal pain, fever, nausea and vomiting developing over a week or so
90
what will the PE look like for TOA?
Abdominal tenderness and guarding
Pelvic exam- limited d/t tenderness, but adnexal mass may be present
If ruptured, presents w/ signs/symptoms of an acute surgical abdomen and may develop signs of septic shock
91
What will the labs for TOA look like?
CBC- varies from leukopenia to leukocytosis
U/A- pyuria w/o bacteriuria
Elevated ESR or CRP
*All suggestive of TOA in the setting of an adnexal mass
92
what is the imaging of choice with TOA?
U/S
| CT-recommended if trying to r/o appendicitis or divertivulitis
93
What is the treatment for an unruptured TOA
Similar to inpatient tx of PID w/ a longer duration of therapy depending on the size of the abscess and clinical response to tx
Minimally invasive radiologic guided drainage of abscesses for large abscess if not improving
Surgical management if still no improvement
94
what is the Tx for a ruptured TOA?
life threatening emergency, and therefore required immediate surgery w/ antibiotic therapy
TAH-BSO is the procedure of choice
(total abdominal hysterectomy-Bilteral saplingo oophorectomy
95
what is the prognosis for TOA
unruptured: excellent though increased risk of infertility and ectopic pregnancy
rupture mortality rate <2%
96
What is Toxic Shock Syndrome
rare infection caused by Staphylococcus aureus
| occurs in menstrual females
97
what is toxic shock syndrome associated with?
tampon use
98
what are the risk factors for toxic shock syndrome
use of high absorbancy tampons
Continuous tampons use for more days of their cycle
keeping a single tampon in a place for longer period of time
99
what are S/S of Toxic shock syndrome
develops rapidly
Fever, Hypotension and skin manifestations
Chills, malaise, HA, ST, myalgias, fatigue, vomiting, diarrhea, abdominal pain, orthostatic, myalgias, fatigue, vomiting, diarrhea, abdominal pain and orthostatic dizziness
100
what will the PE be like for Toxic shock syndrome?
tampon present remove
mucosal lesions may be present
culture should be performed for S. aureus
101
What is the Tx for toxic shock syndrome?
```
supportive therapy is mainstay of Tx:
aggressive fluid resuscitation
vasopressors, packed red blood cells, coagulation factors
Antimicrobial therapy x10-14 days
Vanco or Clindamycin
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