Cervical Disease and STIs -> Flashcards
(139 cards)
1
Q
What happens at the transformation zone of a normal cervix?
A
Physiologic replacement of columnar epithelium with squamous cell epithelium
2
Q
The squamocolumnar junction in the cervix changes with _____.
A
age
3
Q
Where is the squamocolumnar junction in younger women?
A
on the ectocervix
4
Q
With age, how does the squamocolumnar junction move?
A
Toward the external os through process of squamous metaplasia
5
Q
What is squamous metaplasia?
A
Columnar epithelium gradually converts to squamous epithelium
6
Q
By age 50, where has the squamocolumnar junction receded to?
A
Endocervical canal (ectocervix is completely covered in squamous epithelium)
7
Q
How may squamous metaplasia cause nabothian cysts?
A
Crypts/clefts of columnar epithelium are bridged over/may block glands –> mucous secretions may build up
8
Q
How common are nabothian cysts?
A
very common
9
Q
How would nabothian cysts appear on PE?
A
Yellow/translucent cysts on cervix that range from 2mm-3cm
10
Q
Treatment for nabothian cysts?
A
None required
11
Q
What are cervical polyps?
A
Small (<3 cm) pedunculated neoplasms of the cervix
12
Q
Are cervical polyps common?
A
Yes
13
Q
Are cervical polyps concerning for malignancy?
A
Most benign (<1% malignant)
14
Q
S/sx of cervical polyps?
A
Typically asx, but if sx:
intermenstrual/post-coital bleeding MC, leukorrhea (white/yellow secretions), menorrhagia
15
Q
How do cervical polyps appear on speculum exam?
A
Smooth, red, fingerlike projections from cervical canal
16
Q
Can cervical polyps be felt bimanually?
A
Not usually (too soft)
17
Q
Ddx of cervical polyps?
A
Endometrial cancer, endometrial polyp
18
Q
Treatment for cervical polyps?
A
Polypectomy: office if small, OR if large w/ testing of cervical discharge if present
19
Q
What is cervical stenosis?
A
Narrowing of cervical canal
20
Q
Complications of cervical stenosis?
A
Hematometra (accumulation of blood in uterus), pain, dysmenorrhea, endometriosis
21
Q
Causes of cervical stenosis?
A
Congenital, secondary to surgery/trauma, radiation, cervical cancer, menopause
22
Q
How to dx cervical stenosis?
A
Clinical dx w/ inability to pass small cervical dilator
23
Q
Treatment for cervical stenosis?
A
Dilation w/ small dilators followed by large dilators progressively
24
Q
What is DES?
A
Synthetic, non-steroidal estrogen (used in 1940-71 for prevention of premature birth, miscarriage, or OB complications)
25
How can DES exposure affect the fetus?
Passes placenta --> affects reproductive tract differentiation --> structural abnormalities of cervix/uterus
26
What may be a cause of vaginal clear cell carcinoma in female offspring?
DES exposure
27
Women who were exposed to DES in the womb/develop cervical abnormalities are more at risk for what?
Infertility, pregnancy complications (miscarriage, ectopic, premature delivery), vaginal clear cell carcinoma, CIN (cervical neoplasia cell changes)
28
What are the screening guidelines for females affected by DES in utero?
Annual pelvic exam & pap, no stopping age for exams determined
29
What is CIN?
Cervical intraepithelial neoplasia
30
Screening method for CIN and cervical cancer?
Pap smear
31
What Bethesda system (cervical cytology classification) is ASC-US?
Atypical squamous cells of undetermined significance
32
What Bethesda system (cervical cytology classification) is ASC-H?
Atypical squamous cells - high grade lesion cannot be excluded
33
What Bethesda system (cervical cytology classification) is LSIL?
Low grade squamous intraepithelial lesion (consistent w/ CIN I)
34
What Bethesda system (cervical cytology classification) is HSIL?
High grade squamous intraepithelial lesion (consistent w/ CIN II/III)
35
First and last Bethesda System cervical cytology classifications?
First: normal
Last: invasive carcinoma
36
Normal histologic classification (biopsy results)?
No abnormal cells
37
CIN I histologic classification (biopsy results)?
Mild dysplasia (disordered growth of lower 1/3 epithelial lining)
38
CIN II histologic classification (biopsy results)?
Moderate dysplasia (disordered growth of lower 2/3 epithelial lining)
39
CIN III histologic classification (biopsy results)?
Severe dysplasia (disordered growth >2/3 or full thickness epithelial lining)
40
What is full thickness dysplasia?
Carcinoma in situ (CIS) confined to surface of cervix
41
When is dysplasia considered invasive cervical cancer?
When it spreads to local tissues
42
What will a pap report show (Bethesda system reporting process)?
Specimen type, specimen adequacy, interpretation/result
43
Specimen types for pap smear report?
Conventional or liquid based thin prep
44
Specimen adequacy for pap smear report?
Satisfactory or unsatisfactory for evaluation
45
Interpretations/results for pap smear report?
Negative for intraepithelial lesion/malignancy or epithelial cell abnormalities (squamous cell or glandular cells)
46
Squamous cell abnormalities that can be detected by pap?
ASC-U, ASC-H, LSIL (CIN I), HSIL (CIN II/III, moderate and severe dysplasia), SCC
47
Glandular cell abnormalities that can be detected by pap?
Atypical, endocervical adenocarcinoma in situ (CIS), adenocarcinoma
48
When is an annual pap recommended?
HIV pts (twice 1st year, then anually), hx of HSIL (CIN II/III), cancer (for 20yrs post-dx), DES exposure in utero, immunosuppressed
49
How common is cervical cancer?
3rd most common GYN cancer in the US
50
Prevalence of cervical cancer depends on what?
Socioeconomic factors
51
High grade lesions are typically diagnosed in women of what age?
25-35
52
Cervical cancer is more common after what age?
40, typically 8-13 yrs after high grade lesion dx
Avg age = 50
53
Causes of CIN/Cancer?
HPV (16&18) MC, 70-75% squamous cell carcinoma (HPV 16), 20-25% are different kinds of adenocarcinoma
54
Risk factors for CIN/Cervical cancer?
HPV***, smoking, multiple partners, early onset of sexual activity, high risk partner, STI hx, HIV/AIDS, immunosuppression, multiparity
55
Low risk types of HPV?
6, 11, 42, 43, 44
56
High risk types of HPV?
16, 18
57
Most new HPV infections clear within what time?
6-12 mos
58
S/sx of CIN?
Asx, usually found on abnormal pap
59
S/sx of cervical cancer?
Abnormal bleeding MC, leukorrhea (may be blood stained, odorous, prurulent), post-coital bleeding
Advanced disease: pelvic pain (unilateral, radiating to hip)
Late disease: weakness, weight loss, anemia
60
PE for CIN?
+/- obvious cervical lesion (if noticed must have bx)
61
PE for cervical cancer?
Enlarged/irregular/firm cervix, deep necrotic ulcerations as advances
62
90% of cervical cancer lesions occur where?
within 1 cm of the squamocolumnar junction (SCJ)
63
How to diagnose CIN?
Pap & HPV testing, confirmed by colposcopy or endocervical sampling
64
How to diagnose cervical cancer?
Bx aided by colposcopy
65
Characteristics of colposcopy procedure?
Acetic acid brings out areas of dysplasia, magnified view of cervix, visualizes extent/location of CIN, directed biopsy
66
Cervical cancer stage IB?
Cancer tissue within cervix
67
Cervical cancer stage IIB?
Cancer spreads outside of cervix
68
Treatment of CIN?
Destroy abnormal cells (prevent progression): electrocautery, cryotherapy, laser therapy, conization, LLEP or large-loop excision of transitional zone
69
Treatment of cervical cancer?
Depends on stage: possible surgery (radical hysterectomy w/ pelvic lymph node resection), radiation, chemo
70
Prognosis of cervical cancer?
35% will be recurrent/persistent post-tx, 50% of deaths 1st year after tx --> 25% after 2nd year --> 15% in third year
***POST TX FOLLOW UP RECOMMENDED FREQUENTLY INITIALLY AFTER TX
71
Most common causes of cervicitis?
Neisseria gonorrhea, Chlamydia trachomatis, Herpes simplex, Trichomoniasis, BV
72
S/sx of cervicitis?
Often asx, MC vaginal discharge
*discharge appearance depends on organism
73
Screening for cervicitis is more important in which patients?
High risk
74
Complications of cervicitis?
PID, infertility, ectopic pregnancy, chronic pelvic pain mostly w/ gonorrhea/chlamydia infection
75
Most cases of genital herpes are caused by which virus?
HSV-2 (HSV-1 less common)
76
S/sx of herpes simplex?
Painful genital ulcers w/ prodromal sx (burning, parasthesia, numbeness), dysuria, +/- fever
77
PE for herpes simplex?
Multiple, shallow, tender ulcers in grouped vesicles on an erythematous base, inguinal lymphadenopathy
78
Are recurrent infections w/ herpes simplex as severe as the first?
No, often less severe
79
How to diagnose herpes simplex?
PCR (test of choice), viral cultures
80
Treatment for herpes siimplex?
PO antivirals (Acyclovir, Valacyclovir, Famciclovir), IV for severe dz
81
Pregnant women with herpes simplex may require what?
Suppressive therapy at 36 wks
82
What causes chancroid?
Haemophilus ducreyi (highly infectious gram neg rod bacteria)
83
Incubation period of Haemophilus ducreyi (chancroid)?
4-10 days
84
Is chancroid a reportable disease?
Yes
85
How is chancroid transmitted?
sexually, but cutaneous transmission reported
86
Development of chancroid?
Begins as erythematous papule --> pustule --> ulcer (~1-2cm)
87
S/sx of chancroid?
ulcer w/ erythematous base & gray/yellow purulent exudate/bleeds when scraped, painful, heavy/foul smelling discharge that is contagious, painful inguinal lymphadenopathy more common in men
88
How to diagnose chancroid?
Special media culture (has limitations) --> if unavailable: clinical dx (adenopathy w/ negative tests for other ulcer lesions like syphilis/HSV)
89
Treatment for probable or confirmed cases of chancroid?
Antimicrobial: Azithromycin PO x1, Ceftriaxone IM x1, Cipro BID x3d, or Erythromycin TID x7d
*Tx all partners w/in 10 days of sx onset
90
Screening for those with chancroid?
HIV screen
91
Re-examine cases of chancroid how many days?
3-7 days
92
What causes lymphogranuloma venereum (LGV)?
Aggressive serotype of chlamydia trachomatis
93
Where is LGV most common?
Tropical/subtropical nations, Southeastern US
94
Is LGV most common in men or women?
Men > women 6:1
95
What is LGV strongly associated with?
HIV infection
96
Is LGV a reportable disease?
Yes
97
S/sx of LGV?
MC: tender, unilateral inguinal/femoral lymphadenopathy
Primary infection --> mild, painless blister that resolves @ site of inoculation
Secondary stage (2-6wks) --> tender, unilateral inguinal lymphadenopathy & hard tender masses (buboes) +/- fould smelling discharge
98
How to diagnose LGV?
Clinical suspicion/exclusion of other etiologies, culture of lesions/lymph nodes (direct immunofluorescence or nucleic acid detection)
99
Tx for LGV?
Abx: Doxy BID x21d or Erythromycin QID x21 days
Surgical: buboes may need aspiration to prevent inguinal/femoral ulcers
100
Test those w/ LGV for what?
Other STIs
101
When should sexual partners of those w/ LGV be examined/tested/treated?
w/in 60 days
102
What is PID comprised of?
Spectrum inflammatory disorders of the upper female tract: any combo of endometriosis, salpingitis, tubo-ovarian abscess, pelvic peritonitis
103
Causes of PID?
N. gonorrhoea and C. trachomatis MC, other vaginal flors microorganisms
In the setting of IUD: Actinomyces israelii
104
Prevention measures for PID?
Screening/tx of pts and sexual partners for chlamydia/gonorrhea reduces risk, early dx/tx to prevent complications
105
S/Sx of PID?
Subtle/mild (delays dx), lower abdominal/pelvic/back pain/pressure, purulent vaginal discharge, abnormal bleeding, dyspareunia, nausea, +/- vomiting, fever, general malaise
106
PE for PID?
Abdominal tenderness in lower quadrants, distended abdomen, hypoactive/absent bowel sounds
Pelvic exam: +/- purulent d/c, chandelier sign, tenderness on palpation of ovaries/uterus
107
What is chandelier sign?
Extreme cervical motion tenderness
108
DDx for PID?
Anything causing R/L lower quadrant pain
109
Complications of PID?
Peritonitis, prolonged ileus, septic pelvic thrombophlebitis, abscess, infertility/scarring, intestinal adhesions, obstructions
RARE: bacteremia/shock
110
Labs for PID?
Normal or abnormal (supportive evidence only): leukocytosis w/ L shift, elevated ESR/CRP, endocervical swabs +/- gonorrhea/chlamydia, endometrial biopsy (endometriosis), HCG
111
Imaging for PID?
Transvaginal US/MRI: thickened fluid filled tubes +/- free pelvic fluid/tubo -ovarian complex, Doppler studies, Laparoscopy: adjunct only when dx in question
*imaging may be normal in early dz
112
How to diagnose PID?
Can be clinical/empiric tx started if:
-Pt has lower abdominal/pelvic pain
-No cause of illness other than PID
-1 or more present: cervical motion tenderness, uterine tenderness, adnexal tenderness
113
Empiric tx for PID?
Broad spectrum Abx covering most likely pathogens ASAP) gonorrhea & chlamydia --> neg screenings don't r/o upper infection)
114
Admit patients w/ PID if...?
Severely ill, pregnant, surgical emergency not r/o, no response to outpt tx, non-compliance/unable to follow through w/ tx, tubo-ovarian abscess
115
Abx for PID (outpt)?
Ceftriaxone 500mg or 1G (weight dependent) IM + x1 & Doxy 100mg PO BID x14d + Metro 500mg PO BID x 14d
If no response in 72 hrs: re-eval/admit
116
Inpatient tx for PID?
IV Abx
117
What are tubo-ovarian abscesses (TOA) preceded by?
PID, or one acute episode of salpingitis (but often seen w/ recurrent infection)
118
What occurs in TOA?
Fallopian tube necrosis/epithelial damage by bacterial pathogens --> anaerobic invasion/growth (polymicrobial)
119
Is TOA primarily unilateral or bilateral?
Unilateral
120
When is TOA most common?
Young age (females) but can occur at any age
121
TOA in a postmenopausal female is highly indicative of what?
Concurrent malignancy
122
S/Sx of TOA?
Ranges from asx -> shock
Usually pelvic/abdominal pain, fever, N/V over a week
123
PE for TOA?
Abd tenderness/guarding, pelvic exam limited d/t tenderness - adnexal mass may be present, if rupture: acute surgical abdomen/may develop septic shock sx
124
Labs for TOA?
CBC varies (leukopenia -> leukocytosis), UA +/-abnormal, elevated ESR or CRP
* all suggestive of TOA if adnexal mass
125
Imaging for TOA?
Pelvic US modality of choice: usually complex adnexal mass obscuring normal structures
CT: recommended if r/o appendicitis/diverticulitis
126
Tx for unruptured TOA?
Similar to inpt tx for PID w/ longer duration depending on abscess size/response to tx
-24 hr inpatient obs
-If no improvement: surgical management (extent of resection depends on extent of dz) - laparoscopy, drainage, oophrectomy, hysterectomy
127
Tx for ruptures TOA?
Life threatening emergency!!!
Immediate surgery w/ abx: total hysterectomy & bilateral bilat salpingo-oophrectomy (TAH-BSO)
-Post-op SICU obs of VS and UO
128
Complications of unruptured TOA?
May rupture, sepsis, re-infection, bowel obstruction, infertility, ectopic preg d/t adhesions
129
Complications of ruptured TOA?
Septic shock, intra-abd abscess, septic emboli w/ renal, lung, brain abscess
130
Prognosis of unruptured TOA?
Excellent (yet inc. risk of infertility/ectopic preg)
131
Prognosis of ruptured TOA?
Mortality <2% w/ medical/surgical therapy
132
What bacteria causes toxic shock syndrome?
S. aureus
133
Who does TSS commonly affect?
Menstrual females (use of tampons, diaphragm, post-delivery)
134
Risk factors for TSS?
High absorbent tampons, continuous tampon use for more days than cycle, single tampon in place for long period of time
135
S/Sx of TSS?
Rapid: fever, hypotension, tachycardia, skin manifestations, chills, malaise, HA, myalgia, fatigue, N/V/D, abd pain, orthostasis/syncope
136
PE for TSS?
If tampon present -> remove
+/-mucosal/skin involvement
137
How to diagnose TSS?
Culture for S. aureus (not required for dx though), clinical s/sx + organ dysfunction on lab w/u in abence of other cause
138
Labs for TSS may reveal what?
Shock/organ failure
139
Tx for TSS?
-Admit to ICU
-Supportive tx mainstay: fluids, vasopressors, packed RBCs, coagulation factors, mechanical vent, hemodialysis
-Abx: Vanco IV + Clindamycin IV + Cefepime IV and then tailor to culture results
