Disorders of the cervix Flashcards
1
Q
Are disorders of the cervix usually sx or asx? Early detection helps prevent what?
A
- asx
- early detection of abnormal cell changes and presence of HPV leads to tx that prevents the progression to cervical cancer
2
Q
Why is the SCJ so impt?
A
- this is where cancer is most likely to arise
3
Q
What cells are affected in cervicitis? Etiologies?
A
- primarily affects columnar epithelial cells
- can cause visible changes of ectocervix
etiologies: often caused by STIs - often asx local trauma malignancy, radiation therapy, chemical irritation (changing the pH), systemic inflammatory disease (Behcet's syndrome) idiopathic
4
Q
What is impt about sexual activity to ask in hx?
A
- number of partners
- use of condoms
- hx of STIs (women under 25 - 1/3 have chlamydia)
- use of pessiary, diaphragm, douches
- specific sxs (post-coital bleeding, deep pain, spotting)
- constitutional sxs (fever, malaise)
5
Q
Sxs of cervicitis?
A
- purulent or mucopurulent d/c from vagina
- intermenstrual or postcoital bleeding
- dysuria or urinary frequency
- dysparuenia
- vulvovaginal irritation
- pain and fever are atypical in the absence of upper tract infection
6
Q
PE appearance of cervicitis?
A
- purulent d/c on surface and/or exuding from the canal
- minor trauma from insertion from a cotton swab - bleeding (friability)
- diffuse vesicular lesions suggest HSV
- punctate hemorrhages consistent with trichomonas infection
- cervical motion tenderness is sign of coexisting PID
7
Q
Tx fo GC and Chlamydia?
A
- Rocephin IM and Azithro PO
- test for other STIs and HIV
8
Q
What is pathognomic for trichomonas infection?
A
- strawberry cervix (rare)
9
Q
Diff b/t primary and secondary outbreaks of genital herpes?
A
- primary: much more severe, more vesicles
- recurrence: won’t be as severe
- if you want - can test for abs (will have if recurrent)
10
Q
Dx of cervicitis?
A
- from exam and determination of risk - also test for gonorrhea, chlamydia, HSV if indicated
- tx empirically to cover gonorrhea, chlamydia, and trichomonas:
ceftriaxone, doxy, and flagyl - all pts eval for STIs should be offered counseling and testing for HIV
- if exam shows minor erythema and low risk person, or cultures are negative then other etiologies might be in play - then there may be an offending agent that needs to be stopped
11
Q
Tx of cervicitis?
A
persistent disease:
- if persists after initial round of abx then repeat testing w/ most sensitive dx tests
- re-examine possible exposure to chemical irritatants
- have sex partner(s) be examined and tested for STIss
12
Q
What are cervical polyps? Result of? May be assoc with? Most common in?
A
- benign, pedunculated growths of varying size that extend from the ectocervix of endocervical canal
- may occur singularly or may be multiple
- etiology is unknown
- believed to result from chronic inflammation
- may be assoc with hyperestrogen states
- found commonly with endometrial hyperplasia
- MC among multiparous women in their 30s and 40s
- MC benign neoplastic growth of the cervix
- occurs in 4% of all gyn pts
13
Q
When do cervical polyps commonly occur? How common are malignant changes?
A
- commonly occur during reproductive years
- usually arise from endocervical canal
- etiology is unkown
- malignant change is rare-about 1% will show neoplastic changes
- removed fairly esaily
- always send to path
14
Q
Sxs of cervical polyps?
A
- usually asx
- thick leukorrhea
- postcoital bleeding
- intermenstrual bleeding
- menorrhagia
- post-menopausal bleeding
- mucopurulent or blood tinged vaginal d/c
15
Q
PE of cervical polyps?
A
- single or multiple pear shaped growths may protrude from the cervix into the vaginal canal
- usually smooth, soft, reddish purple to cherry red
- may readily bleed when touched
- may be small or very large
16
Q
DDx for cervical polyps?
A
- endometrial polyps
- small prolapsed myomas
- cervical malignancy
17
Q
Tx of cervical polyps?
A
- tie off base
- twist off at base with forceps
- may need to cauterize site
- recurrence low
18
Q
What are nabothian cysts?
A
- mucous filled cyst on surface of the cervix
- most often caused when stratified squamous epithelium of ectocervix grows over the simple columnar epithelium of endocervix
- tissue growth can block the cervical crypts and trap mucous inside the crypts
19
Q
How do nabothian cysts appear? Are they worrisome?
A
- appear as firm bumps on the surface
- considered harmless and usually resolve on their own
- appearance may be related to menses
- not considered problematic unless they grow really large and present secondary sxs
- may be removed by electrocautery or cryotherapy
20
Q
How common is Cervical cancer? Is it increasing or decreasing?
A
- 3rd most common gyn malignancy and COD in women in US
- in past 45 yrs its incidence has decreased from 45 to 15/100,000 women due to screening from pap smears
- in US represents 1.3% of cancer deaths in women and in developed countries 75% decrease in incidence and mortality over 50 yrs
- in developing countries 2nd MC cause of cancer related morbidity and mortality among women
21
Q
Pathology of cervical cancer?
A
- squamous cell (69%)
- adenocarcinoma (25%)
- adenosquamous, rare types (sarcomas) (6%)
22
Q
Sxs of cervical cancer?
A
- frequently asx
- abnormal vaginal bleeding
- postcoital spotting
- vaginal d/c - can be watery, mucoid or purulent and malodorous
23
Q
RFs for cervical cancer?
A
- early onset of intercourse (b/f 18)
- 3 or more sexual partners
- male partner who has had other partners or is uncircumcised
- hx of STIs (chlamydia, herpes)
- first child prior to age 20 and multiparity (more than 3 term pregnancies)
- cigarette smoking (SCC)
- immunosuppression
- OCP - especially long term
- low socioeconomic status (not getting screened)
- daughter of a mother who took DES
- HPV exposure
24
Q
Why are the effects of race and social economic status controversial?
A
- higher rates among black and especially foreign born hispanic women
- higher rates among women of lower social economic status
- unclear whether related to access to pap smears and other medical care or other undetected confounding variables
25
Protective factors for cervical cancer?
- virginity
- long term celibacy
- life long mutual monogamy
- long term use of condoms
- obtaining regular pap smears
26
What is the role of HPV in cervical cancer?
- at least 80% of sexually active women will have acquired a genital HPV infection by 50
most HPV infections are transient but:
- over 50% are cleared in 6-18 months
- 80-90% will have resolved w/in 2-5 yrs
- HPV can be detected in 99.7% of cervical CAs
- generally HPV alone can't cause cervical cancer - it usually takes about 15 yrs from time of infection to presentation of cervical cancer
27
Neoplastic transformation from HPV? Major factors assoc with development of HGL and cervical cancer?
- HPV integrates into human genome and can result in abnormal high grade lesions and cancer
- major factors assoc with development of HGL and cervical cancer are:
HPV subtype: 18 and 16 (bulk of cervical cancers)
persistence: age, duration, oncogenic subtypes
enviro factors: cigarette smoking, infection with HIV, gonorrhea and chlamydia, HSV and OCPs
28
Pathogenesis of cervical cancer - early on?
- earliest SCC is confined to epithelial layers:
intraepithelial neoplasia
preinvasive carcinoma (carcinoma in situ)
- the disease remains confined to mucous membrane for several years b/f invading the subjacent stroma
- CIS occurs most frequently in 40s
- invasive carcinoma is encountered most often in women b/t 40-50
29
Pathogenesis of HPV infection to cancer?
- oncogenic HPV infection at transformation zone (SJC)
- persistence of infection
- progression of a clone of epithelial cells from persistent viral infection to precancerous cells
- development of carcinoma and invasion through the basement membrane
30
Dx genital HPV?
- pap smears prepared from cervical or anal scrapings often show cytologic evidence of HPV infection
- persistent or atypical lesions should be bx and examined by routine histologic methods
- the most sensitive and specific methods of virology dx - use techniques such as PCR or hybrid capture assay to detect HPV nucleic acids and to ID specific virus types
31
How can we prevent HPV?
- vaccinate!
- recently developed vaccines dramatically reduce rates of infection and disease produced by HPV types in vaccines
- gardisil:
recommended by CDC for girls and boys 11-26
32
Administration of gardisil?
- admin in 3 separate intramuscular injections in deltoid region of upper arm or in higher anterolateral area of thigh
- over a 6 mo period with first dose at elected date
- 2nd dose 2 mo after 1st
- 3rd dose 6 months after first
- $180 for dose of gardisil 9
33
Comfort of pt - positioning?
- privacy
- have buttocks just off table
- good lighting
- drape
- assistant/chaperone
34
Inserting speculum for pelvic exam?
- spread labia
- keep labia apart
- alternate method -
insert 2 fingers in base of vagina - then press down and insert speculum over tops of fingers
- blades remain closed until fully inserted
- squeeze handle to open speculum and visualize cervix
35
What is the squamo-columnar jxn?
- jxn of pink cervical skin and red endocervical canal
- inherently unstable
- key portion of cervix to sample
- most likely site of dysplasia
36
How do you sample cervix when doing a pap smear?
- use concave end
- rotate 360 degrees
- don't use too much force (bleeding, pain)
- don't use too little force (inadequate sample)
37
What is the definition of a satisfactory pap?
- proper amt of squamous cells
- proper labeling
- endocervical cells present
not satisfactory if:
scant cellularity
not properly labeled
cells obscured by blood or inflammation (menses could ruin pap)
38
Normal results for a pap smear?
- if no abnormal cells are seen, the test is normal
| - if only benign changes are seen, usually resulting from inflammation or irritation, then the test result is normal
39
Abnormal results for a pap smear?
- atypical cells of undetermined significance (ASCUS, AGUS)
- low grade squamous intraepithelial lesions or cervical intraepithelial neoplasia (CIN) 1. these are mild, subtle cell change, and most go away w/o tx
- high grade sqaumous intraepithelial lesions (HSIL) or CIN 2 or 3. Moderate or severe cell changes which reqr further testing or tx
- carcinoma
40
Cervical intraepithelial neoplasia grades?
- CIN 1 - low grade lesion: mild atypia, 1/3
- CIN 2 - high grade lesion: moderate atypia, 2/3
- CIN 3 - high grade lesion: severe atypia, greater than 2/3
- incidence: high grade lesions more commonly a disease in women 25-35, while invasive cancer disease affects women over 40 more
41
Natural hx of cervical cancer?
- impt to manage precursor lesions
- it is crucial to realize that not all lesions begin as condyloma (genital warts) or CIN1
- cervical cancer may present at any pt in the spectrum depending on assoc. HPV type and other host factors
42
Routes of spread of cervical cancer?
- can be spread by direct extension
- any pelvic lymph node groups may be sites of mets
- hematogenous spread:
lungs
liver
bone
43
Tx of cervical cancer?
```
- according to staging system
tx modalities:
- early stage disease: surgery or chemo
- locally advanced disease: chemo-rad
- disease with distant mets: chemo (palliative care with rad and chemo)
```
44
What screening should be done if a pt is HIV positive?
- pap smears at least annually
- baseline colposcopic eval at time of initial dx of HIV
- colposcopy after single reading of ASCUS or SIL Pap
- aggressive tx of cervical disease will prolong life in most cases
45
Stats of screening and cervical cancer link?
- 50% of cervical cancer dx in US is found in women who haven't been screened
- another 10% occur in women who have not been screened for 5 yrs
46
When should women start to get screened for cervical cancer?
- at age 21
- critical that adolescents who may not need yearly pap smears obtain other yearly preventative health care:
assess. of health risks
contraception
prevention counseling
screening and tx for STIs
47
Why does screening not start until 21?
- because there is a low risk of missing an impt cervical lesion until 3-5 yrs after initial exposure to HPV
- earlier screening may result in over-dx of cervical lesions
- these usually regress spontaneously but may lead to inappropriate intervention
- young women who are infected with HIV and or immunocompromised should have pap smears twice in the first yr after dx and if normal - annual thereafter
48
Screening intervals for Cervical cancer?
- q 3 yrs from 21-30 a pap smear
- for women over 30:
q 3 yrs with a pap smear
or
q 5 rys with a pap smear and HPV test as long as first set were negative
- when to stop:
at 65
as long as woman had 2 consecutive tests negative prior to stopping
49
What should you do if you have a pt with a pap within normal limitis with a missing endocervical component?
- ASCCP have published recommendations stating that a pap can be repeated in 1 yr if it was just a screening pap
- earlier screening at 6 mo is rqd if there was a previous abnormal pap w/o 3 normal f/u paps or -
pt is immunocompromised, pt hasn't had regular screening, a prior pap revealed glandular abnormalities, a high risk HPV + result was obtained in past yr then it should be repeated now
50
Management options if pap test result is abnormal?
- for women with low grade squamous abnormalities (ASCUS or LSIL) give periodic pap tests until the abnormality resolves or colp referral for persistent lesions
- women with glandular abnormalities (AGUS) usuall are referred for colp
- women with HSIL are referred for colp
51
HPV and the risk of CIN?
- HPV is very common, occurring at least once over a 3 yr period in 60% of young women
- lifetime cumulative risk is at least 80%
- the longer HPV is present and the older the pt, the greater the risk of CIN
- smoking doubles the risk of progression to CIN3 in HPV positive pts
- the vast majority clear the virus or suppress it to levels not assoc with CIN2/3, and for most women this occurs promptly
- duration of HPV positivity is shorter and the likelihood of clearance is higher in younger women
- only 1/10 to 1/30 HPV infections are assoc with abnormal cervical cytology
- the risk of cervical cancer in women who don't harbor oncogenic HPV is extremely low
- time coures from CIN 3 to invasive cancer averages b/t 8.1 and 12.6 yrs
52
Likelihood of CIN regression to normal?
- CIN 1: 60%
| - CIN 2: 40%
53
Type of testing done for cervical cancer?
- cytology alone has low sensitivity
- cytology + HPV testing much higher sensitivity
- HPV testing especially helpful in pts over 30
- if combined testing is normal, repeat combined testing only q 3 yrs
- if pap normal and HPV positive repeat pap and HPV testing in 12 months then colp if either is +
54
What is a colposcopy?
- examining the cervix with a colposcope
- application of 3-5% acetic acid soon
- obtain colposcopically directed bx of all lesions suspected of representing neoplasia
- do endocervical curettage
- need to visualize all of SCJ
- up to 10% of lesions more severe than anticipated
55
Is excision or ablation better?
- laser, LEEP, and cryotherapy are all ablation techniques
- must perform endocervical sampling if ablation is planned
- don't perform ablation if dysplasia on endocervical curettage
- then cold knife conization is preferred or LEEP
56
Care and F/U during and after pregnancy?
- only the dx of invasive cancer alters management
- colp should have as its primary goal the exclusion of invasive cancer
higher grade test results:
- colp w/o endocervical sampling
- bx only if colposcopic appearance consistent w/ CIN2, AIS, or cancer
- repeat colp each trimester w/ bx only if progression of disease is suggested or cytology is suggestive of invasive cancer
