Week 5 - FGS Flashcards
STIs, Cervical Cancer, PAP Test, Uterine Disorders (100 cards)
1
Q
What is post-coital bleeding suggestive of?
A
cervical cancer
2
Q
What is the most common cause of post-menopausal bleeding?
A
endometrial cancer
3
Q
What is the commonest cause of pre-pubertal vaginal bleeding?
A
trauma
also:
-foreign body
-rare malignancy (sarcoma botryoides)
4
Q
What is the commonest cause of vaginal bleeding in pregnancy?
A
- placenta praevia
- miscarriage
- ectopic pregnancy
5
Q
What is the commonest cause of abnormal menstruation?
A
DUB - dysfunctional uterine bleeding
- psychological, hormonal, hemostasis disorders
- local –> fibroids, polyps, endometriosis
6
Q
What is the cause of white cheesy discharge?
A
candida
7
Q
What is the cause of clear/watery discharge?
A
- trichomonas
- gardnarella
- chlamydia
- eczema
8
Q
What is the cause of pus/purulent discharge?
A
gonococcal, bacteria
9
Q
What is the cause of bloody discharge?
A
- infections
- trauma
- malignancy
10
Q
What are the 2 embryonic ducts and what do they give rise to?
A
Mullerian duct
- fallopian tubes
- uterus
- cervix
- vagina
Mesonephric duct
-ovaries
11
Q
What is the site of cervical cancer?
A
transformation zone
12
Q
What happens to the cervix during puberty?
A
- endocervix comes out (pre-pubertay –> endocervix is inside)
- columnar cells are exposed (v. sensitive cells)
- sexual activity can increase risk of infection
13
Q
What is the transformation zone?
A
- post-puberty, the exposed columnar cells of the endocervix undergo squamous metaplasia
- site of cervical cancer
14
Q
What type of epithelium is endocervix vs. ectocervix?
A
endocervix = columnar ectocervix = stratified squamous
15
Q
What is sarcoma botryoides?
A
high grade connective tissue sarcoma in young children (1-5yrs)
16
Q
What is bartholin cyst?
A
-reasonably common cysts that occur due to obstruction and infection of vaginal glands
17
Q
What is vaginal adenosis?
A
-chronic inflammation of vagina leading to increased mucous glands
18
Q
How does vulvo-vaginitis present?
A
vaginal discharge
19
Q
What are causes of vulvo-vaginitis?
A
Contact dermatitis
-urine, soaps, antiseptics, deodorants, creams, foreign body, etc –> oozing + crusting papules (children common)
Infections
-chlamydia, herpes, candida, trichomonas, syphillis, HPV –> common in sexually reproductive ppl
Inflammations + Atrophy
-lichen sclerosis –> atrophic, hyperplastic
20
Q
What are the investigations for STIs?
A
- tested for multiple STI organisms
- endocervical + high vaginal swab (males urethral swab)
- first pass urine
- nucleic acid amplification test (NAAT)
21
Q
What is the standard test for STIs?
A
NAAT
- nucleic acid amplification test
- standard molecular genetic technique (PCR, RT-PCR, etc)
- detects pathogen earlier than antibody tests –> because Abs take time to develop (window period)
22
Q
What is contained in the transport media for STI swabs?
A
sucrose phosphate
-UTM-RT (universal transport media)
23
Q
What is cervicitis secondary to?
A
common - secondary to vaginal infections
- STIs –> gardnerella, chlamydia, trichomonas, candida, etc
- *plenty of inflammatory cells on PAP smear
24
Q
What does chronic cervical inflammation lead to?
A
endocervical polyps (benign) -plenty of inflammatory cells in PAP smear
25
What % of chlamydia in females is asymptomatic?
80%
26
What long term complications can arise from chlamydiasis in females?
PID, infertility, ectopic pregnancy, etc
27
Why is mycoplasma genitalium resistant to penicillin and what does this lead to?
- organisms have NO cell wall
| * *leads to recurrent + chronic STIs
28
True or False?
| you can use antibiotics to treat trichomonas vaginalis
False
| -it is a flagellate protozoa (NOT a bacteria)
29
What would you suspect if there was clear watery to white/yellow BUBBLY discharge?
trichomonas vaginalis
30
What is strawberry cervix?
- commonly seen in trichomonas vaginalis infections
| - inflammation of cervix leads to multiple erythematous spots (looks like a strawberry)
31
Why is there increased risk of HIV and other STIs in trichomonas vaginalis?
- it produces proteolytic enzymes, complement, neutrophils which breaks down mucosal defence
* PID, preterm birth = longterm complications
32
What is the microscopy of trichomonas vaginalis?
-flagellate leaf-shaped cells (motile)
33
What populations are more affected by candida albicans?
candida vulvovaginitis (thrush)
- pregnancy
- diabetes
- immunodeficiency
- HIV
34
What are the features of candida vulvovaginitis (thrush)?
- itchy, sore, burning, bright red rash
| - thick, white cheesy discharge
35
How is candida vulvovaginitis diagnosed?
vaginal swab/PAP smear
36
What is characteristic microscopy of candida vulvovaginitis?
branching hyphae + budding yeast forms
37
Where would you see cowdry A inclusions on microscopy?
genital herpes
| -large intranuclear inclusions (cowdry A) + multinucleated giant cells
38
What is the common clinical presentation of genital herpes?
asymptomatic in majority
| *clusters of multiple, painful vesicles --> ulcers
39
What are Tzanck smears?
-simple smears of genital herpes lesions for testing (do NOT distinguish between VZV + HSV infections) --> NAAT for Dx confirmation
40
What is condyloma accuminatum?
- soft, moist, papillomatous/warty lesions
| - STI - HPV serotypes 6 + 11 (low malig. risk)
41
What are the microscopic features of HPV?
- koilocytosis (perinuclear halo)
- hyperkaratosis
- parakeratosis
- papillomatosis
- dyskeratosis + dysplasia
- intact basement membrane (benign)
42
Which HPV serotype is responsible for vulval carcinoma?
HPV 16
43
What is paget's disease of vulva?
* same as breast*
| - eczematous lesion due to malignant cells spreading to skin
44
Compare lichen sclerosus et. atrophicus and lichen simplex chronicus
Lichen sclerosus et. atrophicus
- immune, T cell mediated
- atrophy/thinning of epidermis
Lichen simplex chronicus
- AKA squamous hyperplasia - chronic irritation
- excess proliferation of skin (opposite)
*BOTH present as whitish scar-like patches
45
What is the pathogenesis of pelvic inflammatory disease (PID)?
- chronic complication of many STDs (esp. chlamydia/mycoplasma)
- organism enters uterus and spreads through fallopian tube to peritoneal cavity --> chronic inflammation --> spreads to pelvic organs with chronic inflammation --> pain, fever, mass, fallopian tube obstruction (INFERTILITY) + interorganal adhesions (due to chronic inflamm. and scarring --> pelvic organs become one inflammatory mass)
46
What is the first cancer to get a vaccine?
cervical ca.
47
What type of cancer is cervical cancer?
squamous cell carcinoma
| -STD due to HPV (16 + 18)
48
What is the etiology of cervical cancer?
1. HPV (initiator) - DNA virus
- multiple partners - STI; mucosal contact
- high risk (16 + 18) - bind to cell DNA
2. estrogens (promoter)
- early menarche, late menopause, lack of pregnancy, HRT, obesity, hyperestrogenemia (endometrial polyps, hyperplasia, etc)
3. other factors
- FHx, smoking/other carcinogens
49
What is CIN?
cervical intraepithelial neoplasia --> prolonged pre-cancer dysplsia (10yrs)
- dysplastic cells can be seen in PAP smear 2yrs prior to cancer
- NOT all CIN progress to cancer
50
What is 5yr survival of cervical cancer?
stage 1 --> 80%
stage 4 --> 10%
*early detection saves lives!
51
How many genes does HPV have and which ones are the ones that lead to cancer?
8 genes in total (categorised as late (L) or early (E))
* E6 - binds p53
* E7 - binds Rb
- -> tumour suppressor genes
52
What cancers can HPV cause (other than cervical)?
-oropharynx, vulva, vaginal, penis, scrotum, rectum, perineum
53
What does the Gardasil vaccine target against?
- quadrivalent vaccine
| - against HPV strains 6+11 (warts - benign) and strains 16+18 )cancer)
54
What % of high grade vs low grade lesions lead to cervical cancer?
LSIL <5%
| HSIL >70%
55
What is the pathogenesis of HPV causing cervical cancer?
- HPV strains 16+18 infect immature squamous cells of transformation zone
- HPV proteins E6 (bind p53) and E7 (bind Rb) which are both tumour suppressor genes --> loss of growth suppression --> low grade dysplasia --> high grade dysplasia --> cancer
56
What are cervical cancer investigations?
1. colposcopy
- metaplastic cells of transformation zone lack epithelial maturation --> therefore cells don't have glycogen
2. PAP smear
- nuclear shape and irregularity
3. biopsy
- tissue infiltration/depth of cancer
57
Outline colposcopy method + principles
1. saline
- observe BV pattern - mosaic = abnormal
2. acetic acid
- whitening of dysplastic + columnar area (acetowhite = dysplastic)
3. iodine
- dark brown = normal
- unstained = dysplastic (same region that appeared white after adding acetic acid) --> due to lack of glycogen
58
Outline PAP smear appearance of normal and CIN 1-3
normal --> small and pyknotic nuclei
LSIL (1) --> bigger nucleus, smooth border
HSIL (2/3) --> very large irregular nucleus with chromatin clumping
59
What is the first step in microscopy of HPV infections causing dysplasia?
koilocytes --> epithelial cells loaded with HPV viral particles + perinuclear halo
60
Outline cervical cancer staging/progression
- CIN (stage 0) --> dysplasia with intact basement membrane
- stage 1 --> limited to cervix
- 1a-1 --> <3mm
- 1a-2 --> 3-5mm
- 1b --> >5mm (still confined to cervix)
- stage 2 --> beyond cervix (upper 1/3 vagina)
- stage 3 --> to pelvic wall/lower 1/3 vagina
- stage 4a --> bladder/rectum involvement
- stage 4b --> beyond pelvis (metastases)
61
What are the microscopic features of cervical cancer?
* squamous cell carcinoma*
- pleomorphic squamous cells
- keratin pearls
62
True or False?
| PAP smear can Dx cervical cancer
False
| -only suspect
63
What cells are seen on a normal PAP smear?
- superficial, mature pink cells (estrogen effect)
- intermediate, blue cells (progesterone effect)
- basal cells/metaplastic cells
- smooth small to pyknotic nuclei
- few bacilli/neutrophils in background
* increase neutrophils/basal cells --> inflammation
* pleomorphic/hyperchromatic cells --> ?cancer
64
What smears are involved in a PAP smear?
1. high vaginal smear
- from the fornix
- to detect infections
2. cervical smear
- from transformation zone
- to detect carcinoma
65
When is optimal PAP smear timing and why?
- soon after menstrual period when estrogen effect is maximal to ensure ample superficial pink mature cells (small nuclei) present to increase likelihood of detecting any early dysplasia (bigger nuclei)
- later in the cycle, nuclei are normally bigger anyway --> progesterone effect - intermediate blue cells (therefore difficult to detect dysplasia)
66
What are clue cells?
-vaginal squamous epithelial cells coated with bacteria causing bacterial vaginosis
N.B. - can be normal
67
When do you refer a patient for a colposcopy?
* suspicion of cervical ca. (post-coital bleeding) --> do NOT do a PAP smear (it is only a screening tool for normal patients)
* abnormal PAP smear:
- any glandular abnormality
- HSIL definite/possible
- LSIL definite/possible + >30 with no Hx. of negative cytology in previous 2-3yrs (colposcopy or repeat PAP smear in 6mths)
- LSIL definite/possible + <30yrs --> repeat PAP at 12mths --> if still LSIL definite/possible --> colposcopy
68
What do you do if there are fluctuating repeat smear results?
-refer for colposcopy women with >/= 2 low grade smear reports (at least 12mths apart) within a 3yr time frame
69
What is the myometrium and endometrium composed of?
myometrium --> smooth muscle
| endometrium --> glands in stroma
70
What happens to endometrium glands in proliferative vs secretory phase?
proliferative phase --> glands are small and round with plenty of stroma
secretory phase --> larger glands with secretions and less stroma
71
What are the disorders of the myometrium?
ONLY tumours
- benign --> leiomyoma (fibroid) --> submucosal, intramural, subserosal
- malignant --> leiomyosarcoma
72
What is the cause of endometrial hyperplasia?
hormone-induced (estrogen)
| -polypoid + diffuse
73
What is endometriosis?
-spread of endometrium outside of the uterus
74
What is adenomyosis?
-spread of endometrium into the uterus in the myocardium
75
True or False?
| Leiomyoma (fibroid uterus) are estrogen responsive
TRUE
76
What gene mutation is commonly seen in fibroid uterus (leiomyoma)?
MED12 gene mutations in 70% cases
77
What is microscopy of leiomyoma?
bundles of smooth muscle, well demarcated (benign)
78
What are the clinical features of leiomyoma?
- usually asymptomatic**
| - DUB, abortion, malpresentation, post-partum haemorrhage, torsion/strangulation, etc
79
What are the differences between leiomyoma and leiomyosarcoma?
Leiomyoma:
- small, well-demarcated, slow growing
- non-invasive, non-metastatic, well differentiated
Leiomyosarcoma:
- large, poorly demarcated, rapidly growing with haemorrhage and necrosis
- locally invasive, metastatic, poorly differentiated
80
What is the common cause of acute endometritis?
STIs - neutrophilic
- chlamydia = 1
- gonorrhea = 2
81
What is the common cause of chronic endometritis?
- TB
- PID
* lymphocytic
82
What are the complications of endometritis?
-DUB, infertility, ectopic pregnancy
83
What are the 3 types of endometrial hyperplasia + polyp?
1. simple
- simple and cystic galnds
2. complex
- branching glands
3. atypical/dysplastic
- irregular glands --> incr. risk of malignancy
84
How does endometrium spread beyond uterus in endometriosis?
1. regurgitation --> via fallopian tube into pelvic cavity
| 2. vascular/lymphatic spread
85
What are the causes of endometriosis?
- hyperoestrogenemia
| - increased PGE2
86
What is chocolate cyst?
-result of endometriosis where endometrium spreads to ovary with resultant bleeding and increasing tumour
87
What are the clinical features of endometriosis?
- severe cyclic pain
- pelvic inflammation --> fibrosis
*PID, infertility = complications
88
What is Tx for endometriosis?
COX2 inhibitors
89
What is adenomyosis caused by and what are the Sx?
-myometrial invasian by endometrium (internal endometriosis) --> hyperplasia
-etiology = hyperestrogenemia (+/- polyps)
Sx --> cyclic pain, DUB, uterine hypertrophy
90
What type of cancer is endometrial cancer?
adenocarcinoma (estrogen related) --> pleomorphic cells forming closely packed irregular endometrial glands with scanty stroma
91
Why is there early detection of endometrial cancer?
common cause of post-menopausal bleeding
92
What are the 2 types of endometrial cancer?
type 1: - 80% (most common)
-assoc. with excess estrogens, obesity, DM, HTN
type 2: - 15%
- thin, atrophic uterus, serous ca.
- familial type
93
When is dysfunctional uterine bleeding diagnosed?
-after excluding any other lesion (infection, inflamm., polyps, cancer)
94
What is menorrhagia and metorrhagia?
menorrhagia = increased blood during cycle
metorrhagia = irregular bleeding between periods
95
What is etiology of DUB?
ovulation failure** commonest **
-ends of reproductive period, early menarche, increased estrogen, endocrine disorders, nutrition, obesity, psychological, stress, etc
luteal phase failure; contraceptive-induced bleeding, etc
96
What is microscopy of DUB?
- proliferative, abnormal cystic glands
- no secretory phase
- scanty stroma --> breakdown of endometrial tissue --> bleeding
97
What is Mx of DUB?
- rule out any pathology
| - then D+C (dilatation + curettage) --> cervix is dilated and a special instrument is used to scrape the uterine lining
98
What is microscopy of LSIL?
1. dysplastic (blue) cells in lower 1/2 sq. epithelium (dysplastic cells >1/3)
2. mature (pink) cells in superficial area
3. endocervical mucous gland in submucosa
4. stroma shows inflammatory infiltrate
99
What is microscopy of HDIL?
1. full thickness dysplasia (blue cells) of epithelium
2. no mature (pink cells)
3. endocervical mucous gland in submucosa
4. stroma shows inflammatory infiltrate
100
What is microscopy of endometrial carcinoma type 1?
1. pleomorphic cells forming irregular glands (adenoca.)
| 2. scanty stroma (closely packed cells)
