Cervical Screening and STI Flashcards
(36 cards)
What questions do you want to ask about discharge?
- Colour
- Consistency
- Blood
- Duration
- Timing - cyclical/constant (cyclical more likely period related)
- Odour - infective cause
- Previous hx
- Sexual and menstrual hx
What are the infective causes of discharge?
Non-sexually transmitted: - Bacterial vaginosis - Candida Sexually transmitted: - Chlamydia trachomatis - Neisseria gonorrhoeae - Trichomonas vaginalis - HSV
What are non-infective causes of discharge?
- Foreign bodies e.g. retained tampons, condoms
- Cervical polyps and ectopy
- Genital tract malignancy
- Fistulae
What are post-coital bleeding questions?
- Timing? Duration? Previous hx?
- Dyspareunia
- IMB
- Menstrual hx
- Smear hx
- Any other symptoms
What is ectropion?
Cells that line the inside of the cervix grow on the outside - these are redder and more sensitive. Exam would show a reddened area around the external os.
What is bacterial vaginosis (BV)?
Refers to an overgrowth of anaerobic bacteria in the vagina. It is caused by a loss of the lactobacilli (produce lactic acid to keep pH <4.5) “friendly bacteria” in the vagina. It can increase the risk of women developing STIs.
What are examples of anaerobic bacteria that can cause BV?
- Gardnerella vaginalis (most common)
- Mycoplasma hominis
- Prevotella species
What are risk factors for BV?
- Multiple sexual partners
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent abx
- Smoking
- Copper coil
What is a classic presentation of BV?
Fishy-smelling watery grey or white vaginal discharge, half are asymptomatic
What investigations can be done for BV?
- Speculum can be performed to confirm discharge, high vaginal swab and exclude other causes of symptoms
- Vaginal pH with swab and pH paper (normal 3.5-4.5)
- Charcoal vaginal swab - clue cells on microscopy, gardnerella vaginalis (epithelial cells from cervix with bacteria stuck inside
What is the managemet for BV?
- Metronidazole - PO or vaginal gel
- Clindamycin is an alternative but less optimal
- Always assess risk of additional pelvic infections with swabs for chlamydia and gonorrhoea
- Asymptomatic BV does not require treatment
- Provide advice about measures to reduce the risk of further episodes e.g. avoid vaginal irrigation or cleaning with soaps
- When prescribing metronidazole, advise patient to avoid alcohol for duration of treatment - n+v, flushing, sometimes shock and angioedema
What are complications of BV in pregnant women?
- Miscarriage
- Preterm delivery
- Premature rupture of membranes
- Chorioamnionitics
- LBW
- Postpartum endometritis
What is candidiasis?
Otherwise known as ‘thrush’, candida may colonise the vagina without causing symptoms. It then progresses to infection when the right environment occurs e.g. during pregnancy or after treatment with broad-spectrum abx that alter flora.
What are risk factors for candidiasis?
- Increased oestrogen (increased in pregnancy, decreased in pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression e.g. coricosteroids
- Broad spectrum abx
What are the symptoms for candidiasis?
- Thick, white discharge that does not typically smell
- Vulval and vaginal itching, irritation or discomfort
- More severe infection - erythema, fissures, oedema, dyspareunia, dysuria, excoriation
What is the management for candidiasis?
- Candidiasis pH <4.5
- Oral anti-fungal tablets i.e. fluconazole 150mg
- Anti-fungal cream i.e. clotrimazole - into vagina with applicator (5g of 10% cream at night)
- Anti-fungal pessary i.e. clotrimazole (500mg at night or 3 doses with 200mg total)
What is dyskariosis?
This is not a histological diagnosis, it is a description of how abnormal the cells on the surface of the cervix appear from a smear test. It often corresponds with CIN i.e. mild dyskaryosis CIN1, moderate CIN2 etc., but smear cannot diagnose CIN. A biopsy must be taken to assess the depth of invasion and therefore the grade of CIN.
It is not cancer, abnormal cells often return to normal cells on their own, but if left untreated, these changes may develop into cancer in future.
Describe low grade dyskariosis
Indicated by the presence of dyskariotic cells with a nuclear : cytoplasmic diameter ratio of <50%. Such cells may also show koilocytosis, indicated by the presence of a large sharply defined, clear perinuclear halo, surrounded by a condensed rim of cyanophilic or eosinophilic cytoplasm.
Describe high-grade dyskariosis (moderate)
Dyskariotic cells are present with a nuclear : cytoplasmic diameter ratio of >50% but <75%. Distinguishing precisely between high-grade dyskariosis (moderate) and high-grade dyskariosis (severe) is difficult.
Describe high-grade dyskariosis (severe)
Dyskariotic cells with nuclear : cytoplasmic diameter ratio >50% and probably >75%.
Basically the nucleus is outgrowing the cytoplasm, which shouldn’t happen and the bigger the nucleus is compared to the cytoplasm, the more concerning it is.
What investigations should be done based on the smear result?
- Borderline/mild dyskaryosis: test for HPV. If HPV -ve, go back to routine call. If +ve, refer for colposcopy.
- Moderate/severe dyskaryosis: urgent colposcopy within 2 wks
- Suspected invasive cancer: urgent colposcopy (within 2 wks)
- Inadequate: repeat smear within 3 months (if 3 inadequate samples, assess by colposcopy)
Why is HPV testing done?
- HPV is the 1st line cervical screening tool
- If a smear is negative for HPV, it is very unlikely that cervical cancer will develop so further screening at 3 or 5 years depending on the woman’s age
- If the smear is positive for HPV, cytological exam is carried out on the sample. Follow up pathways are dependent on cytology.
What is HPV?
HPV is the virus associated with genital warts, there are >100 types but some types are more associated with genital warts and some with cervical cancer. The ones associated with cancer are the ones more termed ‘high risk HPV’. HPV is sexually transmitted but can lay dormant without symptoms for many years. It is estimated that >75% of sexually active women have been infected with one or more type of HPV.
How do you triage HPV?
- Borderline or mild dyskaryosis > test for HPV. A positive result will be referred to colposcopy and negative will be returned to routine recall.
- If HPV positive, but on cytology the cells are normal, then follow-up screen in 12 months time to check if the virus has cleared.
