DO of the Cervix and Uterus Flashcards by MA CARMELA CONCEPCION SALES

______ are fingerlike growths that start on the surface of the cervix or endocervical canal.

These small, fragile growths hang from a stalk and push through the cervical
opening.

Cervical polyps

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Causes of cervical polyps

They may be associated with chronic inflammation, an abnormal response to increased levels of estrogen, or
thrombosed cervical blood vessels.

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What is the hx of cervical polyp

The history is usually positive for vaginal bleeding, often after intercourse. This bleeding occurs between normal menstrual periods

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PE of pts with cervical polyp

Speculum examination reveals smooth, red or purple, fingerlike projections from the
cervical canal

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Mx of cervical polyp

Polyps can be removed by gentle twisting or by tying a surgical string around the base
and cutting it off.

Removal of the polyp’s base is done by electrocautery or with a laser.

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A ______is a mucus-filled cyst on the surface of the uterine cervix.

The cervical canal is lined by glandular cells that normally secrete mucus

nabothian cyst

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PE of Nabothian Cyst

Pelvic examination reveals a small, smooth, rounded lump (or collection of lumps)
on the surface of the cervix.

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Mx of Nabothian cysts

They can be easily cured through electrocautery or cryotherapy. Both procedures can be done in the doctor’s office

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The most common finding is mucopurulent cervical discharge and a friable
cervix. This diagnostic finding is confirmed by endocervical bleeding easily induced by passage of a cotton swab through the cervical os

Cervicitis

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Findings of cervicitis

Routine cervical cultures are positive for chlamydia or gonorrhea. WBC and ESR are normal

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Mx of Cervicitis

Oral azithromycin in a single dose or oral doxycycline BID for 7 days.

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The progression from premalignant to invasive cancer has been reported to be approximately ______

8–10 years

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HPV_________ are the most common

HPV types associated with premalignant and cancerous lesions of the cervix

16, 18, 31, 33, and 35

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HPV 6 and 11 are the most common HPV types associated with ______

benign condyloma acuminata.

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RF for Cervical Neoplasia

These include early age of intercourse, multiple sexual partners, cigarette smoking,
and immunosuppression. The mediating factor for all these conditions is probably HPV

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What cytologic screening methods can be used for cervical neoplasia

conventional method

thin-layer, liquid-based cytology

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Pap smear should be started at the following ages:
• Age <21: ________
• Age 21: _____

no Pap test or screening for HPV, regardless of sexual activity

Start Pap test with cytology alone without HPV testing; the recommendation is the same whether HPV vaccinated or not

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The frequency of recommended Pap smear is as follows:

• Age 21–29: _____

repeat Pap every 3 years with cytology alone; do not perform HPV testing in this age group

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The frequency of recommended Pap smear is as follows:

• Age 30–65:

repeat Pap every 3 years with cytology but no HPV testing OR repeat Pap
every 5 years if both cytology and HPV testing (the recommended option in this age
group)

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Pap smears should be discontinued:

After age 65 if_________
Any age if________

negative cytology and/or HPV tests for past 10 years AND no history of CIN 2, CIN 3 or cervical carcinoma

total hysterectomy AND no history of cervical neoplasia

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Pap Smear Classification

________is the current classification used in the United States.

The Bethesda system

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Negative for intraepithelial lesion or malignancy; comments may report 
1
2
3
4
5

trichomoniasis, candida, BV, HSV, or atrophy

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Pap Smear

________: changes suggestive
of but not adequate to label LSIL

ASC-US (atypical squamous cells of undetermined significance)

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Pap Smear

_______: biopsy is expected to show histologic findings of HPV, mild dysplasia, or CIN 1

LSIL (low-grade squamous intraepithelial lesion)

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________: changes suggestive of but not | adequate to label HSIL

ASC-H (atypical squamous cells can’t rule out HSIL)

________: biopsy is expected to show histologic findings of moderate–severe dysplasia, CIN 2, CIN 3, or CIS

HSIL (high-grade squamous intraepithelial lesion)

Examples of Abnormal endocervical cells (1% of abnormal Pap smears) 1 2 3 4

– AGC-NOS (atypical glandular cells, not otherwise specified) – AGC-neoplastic (atypical glandular cells, can’t rule out neoplasia): changes suggestive of but not adequate to call AIS or cancer – AIS (adenocarcinoma in situ) – Adenocarcinoma

Diagnostic Approach to Abnormal Pap Smears This is an option for findings of ASC-US in patients of any age, and the preferred option with either ASC-US or LSIL in patients ages 21-24.Repeat the Pap in 12 months.

Accelerated repeat Pap.

Mx of repeated pap – If repeat cytology is negative,____ – If repeat cytology is anything other than negative, _______

repeat Pap in another 12 months. proceed to colposcopy and biopsies

Diagnostic Approach to Abnormal Pap Smears _______This is the preferred option for findings of ASC-US in patients age ≥25.It is acceptable but not preferred in patients ages 21-24

HPV DNA testing.

This is indicated for evaluation of LSIL in patients age ≥25, and all patients with ASC-H and HSIL.

Colposcopy

Satisfactory or adequate colposcopy is diagnosed if

the entire T-zone is visualized and no lesions disappear into the endocervical canal

All nonpregnant patients undergoing colposcopy which shows metaplastic epithelium entering the endocervical canal will undergo an

ECC to rule out endocervical lesions.

If the Pap smear is worse than the histology (suggesting the site ofabnormal Pap smear cells was not biopsied), then a________ is performed

cone biopsy

SSx of Invasive Cervical Cancer

Patients with invasive cervical cancer can present with postcoital vaginal bleeding. Other symptoms of cervical cancer include irregular vaginal bleeding and, in advanced stage, lower extremity pain and edema.

_________ is the third most common gynecologic malignancy with a mean age at diagnosis of 45 years

Cervical carcinoma

Work-up for cervical CA

Cervical biopsy. Metastatic workup Imaging studies

Patients with these findings are offered adjuvant therapy (radiation therapy and chemotherapy).

These include metastatic disease to the lymph nodes, tumor size >4 cm, poorly differentiated lesions, or positive margins

Mx Stage Ia1: ______ Stage Ia2:_______

Total simple hysterectomy, either vaginal or abdominal Modified radical hysterectomy

Mx Stage IIB, III, or IV: ________

Radiation therapy and chemotherapy for all ages.

All patients with invasive cervical cancer should be followed up with Pap smear ________ after treatment, and then ___________

every 3 months for 2 years every 6 months for the subsequent 3 years

Patients who have a local recurrence can be treated with ________; if they had received radiation previously, they might be considered candidates for a _______

radiation therapy pelvic exenteration.

Patients with distant metastases should be considered for chemotherapy treatment. The most active chemotherapeutic agent for cervical cancer is _______

cisplatinum

Uterine anomalies may result from 3 mechanisms: Stage 1: ________ Stage 2: ________ Stage 3: ________

failure of one or both of the 2 müllerian ducts to form failure of the 2 ducts to fuse completely failure of the 2 fused mullerian ducts to dissolve the septum that results from fusion

MU¨ LLERIAN ANOMALIES Failure to Form

Hypoplasia/Agenesis | Unicornuate Uterus

When one of the müllerian ducts fails to form, a single-horn (banana-shaped) uterus develops from the healthy müllerian duct. This single-horn uterus may stand alone.

Unicornuate Uterus

Problem with Unicornuate Uterus

a girl may have monthly pain during adolescence because there is no outlet for the menses from this rudimentary horn

There is a risk that a pregnancy will implant in this rudimentary horn, but because of space limitations, _______

90% of such pregnancies rupture

A double uterus results from the complete failure of the 2 Müllerian ducts to fuse together (stage 1 of development). So each duct develops into a separate uterus, each of which is narrower than a normal uterus and has only a single horn

Didelphys Uterus

In 67% of cases, a didelphys uterus is associated

with 2 vaginas separated by a thin wall

Didelphys Uterus Cx

Preterm delivery is common if pregnancy occurs in these patients.

A ______results from a problem in stage 2 or 3 of uterine development. The two müllerian ducts fused normally; however, there was a failure in degeneration of the median septum.

septate uterus

If this failure was “complete,” a median septum persists in the entire uterus, separating the uterine cavity into______

two single-horned uteri that share one cervix

If this failure was “partial,” resorption of the lower part of the median septum occurred in stage 2 but the top of the septum failed to dissolve in stage 3. Thus, there is a __________

single cervix and uterine cavity at the bottom, but at the top that cavity divides into two distinct horns.

This type of uterus is essentially normal in shape with a small midline indentation in the uterine fundus, which results from failure to dissolve the median septum completely.

Arcuate Uterus

The daughters of mothers exposed to diethylstilbestrol (DES) during pregnancy are predisposed to ______ and _______

uterine abnormalities and clear cell carcinoma of the vagina

It is a benign smooth muscle growth of the myometrium. It is the most common benign uterine tumor. It is 5 times more common in black women than white women.

Leiomyoma Uteri

The most common location of a leiomyoma is within the wall of the uterus.

Intramural.

These myomas are located beneath the endometrium and can distort the uterine cavity. The distorted overlying endometrium may not respond appropriately to the normal hormonal fluctuations, resulting in unpredictable, often intermenstrual, bleeding

Submucosal.

______ is the most common symptom of a submucosal | myoma and can result in anemia

Abnormal vaginal bleeding

These are located beneath the uterine serosa. As they grow they distort the external contour of the uterus causing the firm, nontender asymmetry

Subserosal.

Subserosal myoma If they are pedunculated, attached to the uterus by a stalk, they can become ____

parasitic fibroids

Estrogen receptors are increased in leiomyomas resulting in rapid enlargement during times of high estrogen levels, such as ______

pregnancy

During times of rapid growth, myomas may outgrow their blood supply, resulting in ______

ischemic degeneration of a fibroid

Common myoma degenerations that are | seen include ______, ______ and ______

hyaline, calcific, and red degeneration

______can cause such extreme, acute pain that the patient requires hospitalization and narcotics. This is most common during pregnancy.

carneous | degeneration,

_______is helpful for identifying submucosal myomas by instilling 5–10 mL of saline into the uterine cavity before visualizing the uterine cavity with an endovaginal sonogram probe.

Saline infusion sonography

Submucosal myomas may be identified by visualizing them directly with ______

hysteroscopy

Most leiomyomas can be managed

conservatively and followed expectantly | with regular pelvic examinations

After 3–6 months of_______ with resultant hypoestrogenic state, a 60–70% reduction in size of the fibroids can be expected.

GnRH analog therapy,

Thus, GnRH analogs cannot be used for definitive cure, but they can be used in the_______

adjuvant setting with surgical therapy

This is a surgical procedure performed if the patient desires to maintain fertility. The uterus is incised and the myoma removed through either a laparoscopic or laparotomy approach

Myomectomy

If the myomectomy incision entered the endometrial cavity, delivery of any subsequent pregnancy should be by cesarean section because of i________

increased risk of scar rupture in labor

This is an invasive radiology procedure in which a catheter is placed into the vessels supplying the myoma. Microspheres are injected, causing ischemia and necrosis of the myoma.

Embolization.

If the patient has completed her childbearing, definitive therapy is an

abdominal or vaginal hysterectomy.

Ectopic endometrial glands and stroma are located within the myometrium of the uterine wall. The most common presentation is diffuse involvement of the myometrium

Adenomyosis

The lesion is known as an _______if the involvement is focal, surrounded by a pseudocapsule.

adenomyoma

Dx of adenomyosis

In most cases the diagnosis is made clinically by identifying an enlarged, symmetric, tender uterus in the absence of pregnancy. The only definitive diagnosis is by histologic confirmation of the surgically excised tissue

PE of adenomyosis

The uterus is globular and diffusely up to 2–3 times the normal size. Tenderness is most common immediately before and during menses

Imaging of adenomyosis

Ultrasound study or MRI imaging shows a diffusely enlarged uterus with cystic areas found within the myometrial wall.

Mx of adenomyosis

Medical treatment includes the levonorgestrel (LNG) intrauterine system (IUS), which may decrease heavy menstrual bleeding. Surgery, in the form of hysterectomy, is the definitive treatment

________ is the most common gynecologic malignancy, occurring in 1% of women. The mean age at diagnosis is 61 years

Endometrial carcinoma

A patient is considered to be in menopause after 1 2

3 continuous months of cessation | of menses and elevated gonadotropins.

Although the most common cause of postmenopausal bleeding is ______ or _____, the most important diagnosis to rule out is endometrial carcinoma

vaginal or | endometrial atrophy

The mediating factor for most endometrial carcinomas appears to be ______

unopposed estrogen. This results from excessive hyperstimulation of the endometrium without the stabilizing effect of progesterone

RF for endometrial CA

These include obesity, hypertension, and diabetes mellitus. Other risk factors include nulliparity, late menopause, and chronic anovulation conditions, such as PCO disease

MC Stage at Dx

Spread limited to the uterus (most common stage at diagnosis)

Stages of Endometrial CA

Stage I: Spread limited to the uterus (most common stage at diagnosis) Stage II: Extension to the cervix but not outside the uterus Stage III: Spread adjacent to the uterus Stage IV: Spread further from the uterus

If the endometrial histology sampling reveals atrophy and no evidence of cancer, it can be assumed the patient is bleeding from atrophy and can be treated with _______

hormone replacement therapy

With hormone replacement therapy, estrogen and progesterone should be given to the patient. If estrogen is given alone, the risk of ______

endometrial cancer increases

The mainstay of treatment of endometrial carcinoma is a

total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO), pelvic and para-aortic lymphadenectomy, and peritoneal washing

An evaluation of the postoperative pathology report will classify patients into poor or good prognosis. Patients with poor prognosis should be considered for______

radiation therapy

``` Poor prognostic factors include 1 2 3 4 ```

metastasis to lymph nodes, >50% | myometrial invasion, positive surgical margins, or poorly differentiated histology

Postmenopausal patients taking estrogen replacement therapy must be also treated with ______ to prevent unopposed estrogen stimulation, which may lead to endometrial cancer.

progestins

Reproductive age women who have chronic anovulation, such as_______ should also be treated with progestins to avoid endometrial hyperplasia from unopposed estrogen

PCO syndrome,

DO of the Cervix and Uterus Flashcards

(95 cards)