STANFORD/FOOTHILL PRIMARY CARE ASSOCIATE PROGRAM CLASS OF 2002 | home
OBJECTIVES
Colposcopy
Visualization of cervical, vaginal, or vulvar epithelium under 5-50x magnification to identify abnormal areas requiring biopsy. Used to identify genital warts on males as well as females. An office procedure. The minimum goal of every colposcopic procedure should be to rule out the presence of invasive cancer. In order to do this, the clinician must have an appropriate understanding of the anatomy of the cervix, with particular emphasis on the area where cancer is likely to occur, the transformation zone (TZ). Approximately 90% of cervical carcinomas occur in this small anatomic region. The TZ typically is a 2-6 mm band of epithelium around the external cervical os.
Pap Smear results and when indicated for colposcopy
Atypical squamous cells of undetermined significance (ASCUS)
Low-grade squamous intraepithelial neoplasia (LGSIL)
High-grade squamous intraepithelial neoplasia (HGSIL)
Most practitioners recommend colposcopic evaluation for all women with Pap findings of HGSIL or worse. There is no consensus on the need for routine colposcopy for patients with a single ASCUS or LGSIL result.
Contraindications: There are no absolute contraindications to the performance of a colposcopic exam. The patient’s ability to tolerate a standard speculum examination is the only true limiting factor. Active cervicitis should be treated before undertaking the exam as inflamed tissues can alter the ability to obtain an accurate assessment and also can make the discomfort of the exam markedly worse.
From Current and emedicine journal excerpts
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Primary Diagnoses- Fertility awareness
Identification of the days when fertility will result.
The sperm live for five days, and the female egg
lives for 24 hours post ovulation, therefore fertility
can be considered for six days; the four days prior to
ovulation, the ovulation day and the 24 hours
post-ovulation onset. (Risky business to cut it too
close)
Accurate prediction or indication of ovulation is
essential to the success of birth control using the
rhythm method and for couples use combined methods of
barrier or withdrawal during fertile time. Also natural
family planning, when couples abstain during the fertile
times.
Calendar method, predicts the day of ovuation by means of
a formula based on the menstrual cycle recorded over
months. Ovulation occurs 14 days before the first day of
the next period. The fertile interval should be assumed
to extend from at least 2 day before ovulation to no less
than 2 days after ovulation.
Temperature method. The vaginal or rectal temperature is
recorded daily upon awakening. There is a slight often
undetected drop in temperature 24-36 hours after
ovulation. Temperature then rises abruptly about .5-.7
degrees F., and continues on this plateau for the
remainder of the cycle. The third day after the onset of
elevated temperature is considered to be the end of the
fertile period.
Cervical Mucus Method. Changes in cervical mucus
secretions due to hormonal alterations predict ovulation.
Starting several days before and until just after
ovulation, the mucus becomes thin and watery, whereas at
other times the mucus is thick and opaque. Evaluate
daily.
Fertility awarness is used for the following purposes:
to conceive, to avoid pregnancy, to detect impaired
fertility, to relieve premenstrual syndrom, to detect a
need for medical attention.
Emergency Contraception:
Preven is one of 6 emergency contraceptive kets allowed
by the FDA. The medication must be prescribed within 72
hours and repeated in 12 hours. Mechanism of action of
the ppostcoital estrogen pregnancy prevention unknown.
It produces a premature fall in corpus luteum
progesterone production and changes in the endometrium,
which may provide an unacceptable implantation site for
the fertilized ovum. The Yuzpe regimen is the most
studied. Consists of 2- 50 mg tablest of ethinyl
estradio and .5 mg of norgestrel within 72 hours and a
repeated dosage 12 hours after the first dosages. Unse
of the gigh dose estrongen progestin combinations may
cause menstrual cycle disruption, and if so a sensitive
pregnancy test should be done. On evidence that the
above treatment affects the fetus or pregnancy. Used
only as emergency treatment as no long term studies of
side effects etc.
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_ORAL CONTRACEPTIVES:
Mechanism of action: prevent pregnancy by suppressing ovulation through the combined actions of an estrogen (ethinyl estradiol or mestranol) and a progestin (norethindrone, norgestrel etc.).
Effectiveness: Among “perfect” (miss no pills) users only 1 in 1,000 is expected to become pregnant within the first year. Among typical users 1 in 20 will become pregnant within the first year.
Advantages: Effective, safe, most women can safely use Ocs throughout their reproductive years, reversible, decreases menstrual cramps, PMS symptoms and number of days of bleeding, improves hirsutism, prevents ovarian and endometrial cancer, prevention of functional ovarian cysts, decreased risk for benign breast disease, ectopic pregnancy prevention, acne improvement, enhanced sexual enjoyment (decreases worry about pregnancy), may protect against osteoporosis, endometriosis and rheumatoid arthritis, can be used as emergency hormonal contraception, prevents atherogenesis and decreases risk of symptomatic PID.
Disadvantages: Does not protect against STIs, must take daily, high cost, menstrual cycle changes (spotting, breakthrough bleeding), nausea, vomiting, headaches, may increase depression, may cause deficiency of Vitamin B6, decreased libido, increased risk for cervical ectopy and chlamydia infection, increased risk of cardiovascular disease (example: DVT), possible increased glucose level, gallbladder disease acceleration, increased risk for bening liver tumors. The present consensus is that Ocs can lead to breast CA, but the risk is small and resulting tumors spread less aggressively than usual. The risk of cervical cancer appears to be increased slightly in women using oral contraceptives, particularly long term users.
MINIPILLS (progestin only pills): Contain only levonorgestrel and may also be used as emergency contraceptive pills; they cause less vomiting or nausea than do regimens using combined oral contraceptives. Progestin only pills are generally less effective than combined Ocs. Among typical users 5% probability of pregnancy. Among perfect users 0.5% women would become pregnant in the first year. Advantages are similar to combined Ocs and also they are less confusing to take (same color and hormone content). Can be used in breastfeeding women. Disadvantages:
Certain drugs will affect the effectiveness of low dose contraceptives. Minipills must be taken close to the same hour each day.
INJECTABLES:
Mechanism of action: Inhibition of ovulation, thickened and decreased cervical mucus and decreased receptivity of endometrium to blastocyst.
Effectiveness: Among perfect users 1st year failure rate is 0.3%
Advantages: No estrogen, scanty menses or no menses, less anemia, decreased menstrual cramps and pain, suppression of pain associated with ovulation, decreased risk of endometrial cancer, ovarian cancer and PID, management of pain associated with endometriosis, reversibility, long term effective, low risk of ectopic pregnancy, not coitally dependent, no drug interaction, decreased frequency of seizures. Can be used in breastfeeding women, older women and women who cannot take estrogen.
Disadvantages: Does not protect against STIs, menstrual irregularity, breast tenderness, depression, weight gain, no immediate discontinuation, return visits every 12 weeks, lowers HDL lipids, allergic reaction may occur, bone density decrease. Studies have shown that Depo-provera may accelerate the presentation of breast cancer in young women, perhaps acting as a promoter in the late stages of carcinogenesis, but other studies have failed to demonstrate a significantly increased risk.
IMPLANTS:
Mechanism of action: Inhibition of ovulation, thickened and decreased cervical mucus and decreased receptivity of endometrium to blastocyst.
Effectiveness: 1st year failure rate is 0.05%
Advantages: No estrogen, scanty menses or no menses, less anemia, decreased menstrual cramps and pain, suppression of pain associated with ovulation, decreased risk of endometrial cancer, ovarian cancer and PID, management of pain associated with endometriosis, reversibility, long term effective, low risk of ectopic pregnancy, high continuation rate 88%, not coitus dependent.
Disadvantages: Does not protect against STIs, menstrual irregularity, breast tenderness, depression, difficult removal requiring minor surgical procedure, higher initial cost, extremely low-dose contraceptive, local inflammation or infection at site of implant, ovarian cysts.
INTRAUTERINE DEVICES (IUDs):
Mechanism of action: Current evidence does not support the common belief that the IUD is an abortifacient. The IUD appears to work primarily by preventing sperm from fertilizing ova. Progestin IUDs have a primarily hormonal method of action.
Effectiveness: First yr. Failure rate among perfect users 1.5% for progesterone T, 0.6% for Copper T 380A, 0.1% for LNg 20. Among typical users: 2.0% for progesterone T, 0.8% for Copper T 380A, 0.1% for LNg 20.
Advantages: easy to use, no systemic side effects, effective, safe, long acting, reversible, does not interfere with lactation, decreased risk of PID (LNg 20)
Disadvantages: risk of developing PID if exposed to STIs, between 2-10% can be expulsed spontaneously within 1st yr. Must be removed as soon as possible if woman becomes pregnant.
BARRIER METHODS ( REFER TO CLASS NOTES FOR A GOOD SUMMARY)
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Uncommon Diseases: 3 & 4
Cytomegalovirus (CMV) is a beta herpes-virus, occurring congenitally, post-natally, or at any age, ranging from inconsequential silent infection to disease manifested by fever, hepatitis, pneumonitis, and in newborns, severe brain damage, stillbirth, or perinatal death. Almost two-thirds of the U.S. population is sero-positive from exposure in childhood or early adulthood. Populations at risk are neonates, transplant recipients, and AIDS patients.
Signs and Symptoms:
Congentital
Abortion, asymptomatic Cytomegalovirus, hemorrhage, anemia, jaundice, signs of CNS damage Aquired (acute infection in a normal or immunocompromised host)
May be asymptomatic, fatigue, nausea, vomiting, bone pain, chills, fever, diarrhea, jaundice, hepatomegaly, splenomegaly, dyspnea Infections in Transplant patients Pneumonitis with cough, fever, chills and chest pain Infections in AIDS patients Retinitis, esophogeal, gastic, small bowel and colonic ulcerations, pneumonitis, CNS with radiculopathy or encephalitis 5 Minute Clinical Consult, 2000 Ed.
Granuloma Inguinale (Donovanosis) a sexually transmitted, progressive infection of the genital skin acused by intra-cellular bacterium, Calymmatobacterium granulomatis.
Signs and Symptoms:
The incubation period varies from 1 to 12 weeks. The initial lesion is a painless, beefy-red nodule that slowly enlarges as an elevated, velvety, malodorous, granulating ulcerative plaque. Sites of infection are the scrotum, groin, and thighs in men; the vulva, vagina and perineum in women; the anus and buttocks in homosexual men; and the faces of both sexes. Lymphadenopathy is absent, and the disease spreads by contiguity and autoinoculation. Lesions progress slowly but eventually cover the genitalia. Healing is slow with scarring. Secondary infection is common and can cause gross tissue distruction. Hematogenous dissemination to bones, joints, or liver occurs occasionally, and anemia, cachexia, and death may follow in neglected cases.
Merck Manual, 17th Edition
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SYPHILIS
PATHO-PHYSIOLOGY: Primary mode of transmission: direct contact with infectious exudates from obvious or concealed lesions of the skin and mucous membranes, or body fluids, and secretions (semen, saliva, blood, vaginal secretions), additionally may be transmitted transplacentally, and intravenously. ETIOLOGY:Treponnema pallidum, a spirochete. Humans are the only host of T. Pallidum.
RISK FACTORS: Multiple sexual partners, intravenous drug users, commercial sex worker, young age, incarcerated, blacks and Hispanics.
SIGNS AND SYMPTOMS: Syphilis has been divided into 5 stages.
Primary Syphilis: painless lesion (Chancre) appears 2-6 weeks after exposure. Initially appears as a painless papule (usually singular), quickly erodes into an indurated ulcer (well marginated) Localized painless lymphadenopathy. Usually on genital region (site of inoculation or may appear on the tongue, buccal mucosa, and lips. Healing of the chancre is spontaneous.
Secondary Syphilis: Appears 2-6 months after primary syphilis. Infection has progressed from the regional type to the systemic one. Most common sign is skin lesions. Syphilitic lesions may imitate several conditions ( varicella, pityriasis rosea, tinea versicolor) and may be transitory or persist for several months. Any lesions appearing on the palms of the hands, soles of the feet should be considered syphilitic in nature. Lesions primarily present in the genital and rectal areas (condylomatalata), skin and mucous membranes (highly contagious), and hyper tropic painless papules in the intriginous areas. Alopecia, sore throat, fever, chills, headache, weight loss, anorexia, and lymphadenopathy are present. Uncommon: arthritis, ostetitis, meningitis, iritis, and hepatitis. With or without treatment all clinical signs resolve spontaneously.
Late Latent syphilis: Patient is asymptomatic but diagnostic testing is positive (usually found incidentally). Two stages: Early latent stage lasts up to 1 year. Late latent stage occurs after 1 year without symptoms. Unless the patient develops tertiary symptoms, patient will remain in latent syphilis throughout his or her life.
Tertiary syphilis: Is a chronic inflammatory disease that can affect any organ system.
Cardiovascular syphilis (10%): artistes, aortic insufficiency, and aneurysms.
Neurosyphilis (10%): 40% asymptomatic, symptomatic: stroke, seizures, paresis and tabes dorsalis (posterior destruction of the spinal cord), psychiatric and neurological manifestations Tabes Dorsalis
Ataxia, decreased vibratory sensation, decreased DTR’s, incontinence, cranial nerve palsies, AgryII, Robertson pupils, peripheral neuropathies.
General Paresis tremors, personality changes, hyperactive reflexes, speech disorders. Stroke syndromes, seizures
Gummatous syphilis: (15%): development of gummas (slowly enlarging, benign granulomatous lesions on the skin, bone, and respiratory tract.
Investigative: Dark field exam of cutaneous lesions specimens should show T pallidum. Silver staining can be used in difficult cases as T pallidum does not stick around very long Diagnosis is usually obtained with serologic tests which become positive after the primary lesion appears. Nontreponemal tests, VDRL test is widest used, become positive 3-6 weeks after infection or 2-3 weeks after primary lesion appears. Can have false positives. Also used to monitor therapeutic progress of treatment.
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Disease: Epididymitis
Patho- Physiology: This is an inflammation of the epididymis, usually caused by bacteria, but other factors may be the cause. These include viruses, trauma or chemical agents.
Etiological Agents: Chlamydia trachomatis 70% of cases. Less common: Neisseria gonorrhoeae. Males over 35 typical causes are E. Coli and Pseudomonas areugainosa. H. Influenza in boys 5 yr old and younger.
Major Risk factors: Prior infection of the Urethra. Unprotected vaginal or anal sex. Concern is that this infection can spread to the testis and spermatic cord.
Preventive Measures: Use a condom during sex. Treat urethritis quickly and aggressively with antibiotics.
Signs and Symptoms: Dull aching pain and swelling of the epididmyis. The pain will sometimes radiate to the spermatic cord and the lower abdomen and flank. The pain begins slowly and builds over time, unlike testicular torsion, which is an abrupt onset. Some dysuria and pain at the tip of the penis. Fever is sometimes associated.
Differential Dx: Testicular Torsion Abscess, fungal infection.
Investigative Measures: Gram stain of an urethral smear, ( pt should not urinate 2 hours before the swab) UA is indicated. Culture or non-culture test for N. Gonorrhea
And C. Trachomatis. CBC will show a left shift.
Management of Disease: Rocephin 250 mg IM, single dose. Doxycycline or ofloxcin, and Cipro are all used.
Patient Education: If sexually acquired, discuss safe sex practices, as well as testing for other STDS. Also discuss heavy lifting and trauma issues regarding their effects on this disease.
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Renal Stone (Nephrolithiasis) (from Currents '01)
pathophys. - Calcium, magnesium or uric acid crystalize and precipitate in the renal pelvis leading to stones. Likely due to increased concentration (supersaturation) of the stone's constituents in the urine. 75% stones are Calcium oxalate +/- calcium phosphate. Usu. unilateral.
etiology/risk factors - men 4:1, 30-40 yo's, sedentary lifestyle, diet (high sodium/protien), frequent bacterial infection, urinary retention, alkaline or acidic urine, diminished protective factors (magnesium, citrate, pyrophosphate, etc.), hot/humid climate, drugs (diuretics, thyroid hormones), fam. hx, obesity, fasting
preventative - avoidance of risk factors
s/sxs - if in renal pelvis - asymptomatic. If obstructing, present with colic (pain with pt. constantly oving as opposed to acute abdomen), sudden, severe and may awaken from sleep. Flank pain may radiate to abdoen or ipsilateral testis or labium as moves down the ureter. Assoc with N/V, fever/chills. May c/o urgency and urinary frequency. Hematuria. Flank tenderness. Size of stone does not correlate with sx severity.
Diffs - different types of stones, pyelonephritis, prostatitis, gallstones, diverticulitis, IBS, PID, appendicitis, ulcers, etc
Investigative - urinalysis (usu. microscopic or gross hematuria) - clean catch/24h urine, urine pH, CBC, abd. plain film, spiral CT, renal US, IVP
Mgmt - Stones < 6mm on x-ray usu. pass spontaneously, observe for 6 weeks with pain meds (Demerol, NSAIDS). If no spontaneous passage after 6 weeks or uncontrolled pain, fever, persistent N/V, social requirements - consider Tx. ESWL (extracorporeal shock wave lithotripsy) or uretoscopic stone extraction. (No ESWL if female of childbearing age). Med Tx depending on etiology of stones (Allopurinol, thiazide, potassium citrate, potassium-magnesium citrate) to prevent formation.
Pt Ed. - increase fluid intake - @ meals, 2 h. post meals and @ bedtime (double previous fluid intake), avoid soda, grapefruit juice, other risk factor modification
Recurrent Urinary Tract Infections
Def - In about 20% of cases after a first episode of UTI, infections recur usually a few months apart. The recurrence is often defined as either reinfection or relapse.
Reinfection. A reinfected UTI is caused by introduction of new bacteria from fecal matter, usually several weeks after antibiotic treatment has cleared up the initial episode. Reinfection occurs in 80% of those who experience recurring urinary tract infections.
Relapse. Relapse, the less common form of recurrent urinary tract infection, occurs within two weeks of treatment when the same organism reappears in the same site as the previous infection. It usually occurs in kidney infection (pyelonephritis) or is caused by obstructions such as kidney stones, structural abnormalities, or, in men, chronic prostatitis.
Etiol/Risk Factors - Almost 20% of all women who recover from a bout of cystitis experience recurrent episodes. The major groups of women who are at highest risk for recurrent infections are young highly sexually active women and postmenopausal women. It might be argued that nearly all women who have a urinary tract infection are at risk for another, particularly if they are not treated for the first one. Why urinary tract infections become chronic and recurring in many women is not entirely clear, but researchers are identifying certain lifestyle factors that may increase the risk in specific women:
Having more than four sexual intercourse episodes a month. Having a new sexual partner in the past year. Having a mother with a history of UTIs. Having a first UTI before age 15. Use of spermicides. Some women may also have biologic factors that increase the risk: Having a shorter than average distance between the urethra and the anus. Certain women may carry a compound called sialosyl galactosyl globoside (SGG) on the surface of kidney cells, which is a highly powerful receptor for E. coli bacteria. Some women who carry the blood group P1 tend to have large numbers of vaginal and urethral cells that attract and bind a strain of E. coli that is resistant to normal infection-fighting mechanisms. (This does not seem a significant risk factor except possibly in certain older women.) Certain women may be deficient in human beta-defensin-1 (HBD-1), believed to be a naturally occurring antibiotic. Mgmt - All women with an initial episode of UTI should use hygienic measures to prevent recurrences. Antibiotics are typically used for recurrence, although concern over increasing strains of bacteria resistant to common antibiotics is causing physicians to reassess standard regimens.
Self Treatment. A number of studies now suggest that many, if not most, women with recurrent UTIs can accurately self-diagnose an infection and self treat recurrent UTIs without going to a physician:
As soon as the patient develops symptoms, she takes the antibiotic. Infections that occur less than twice a year are usually treated as if they were an initial attack, with single dose or three-day antibiotic regimens. At that time, she also performs a clean-catch urine test and sends it to the physician for culturing to confirm the infection. A physician should be consulted under the following circumstances: If there is no improvement. If there is a change in symptoms. If the patient suspects that she is pregnant. If the patient has more than four infections a year. Women who are not good candidates for self-treatment are those with impaired immune systems, previous kidney infections, structural abnormalities of the urinary tract, or a history of infection with antibiotic-resistant bacteria.
Other Regimens for Recurrent Infections. Other regimens for recurrent infections may vary depending on the circumstances:
If reinfection occurs three or more times in a year, the physician may prescribe preventive low-dose antibiotics for six months to a year. Typical regimens include one dose of nitrofurantoin (50 mg), 1/2 tablet of TMP-SMX, or cephalexin (250 mg). Taking the antibiotic at bedtime may be most effective. If the infection is related to sexual activity and episodes recur more than three times a year, a single preventive dose of an antibiotic such as ciprofloxacin taken immediately after intercourse has proven to be very effective in many cases. In elderly people with frequent recurrences, half doses of trimethoprim are beneficial. ____________________________________________________________________________________
CERVICITIS
Infection of the cervix must be distinguished from physiologic ectopy of columnar epithelium, which is common in young women. Mucopurulent cervicitis is characterized by a red edematous cervix with a purulent yellow discharge.The infection may result from a sexually transmitted pathogen such as Neisseria gonorrhoeae, chlamydia, or herpesvirus (which presents with vesicles and ulcers on the cervix during a primary herpetic infection), though in most cases none of these organisms can be isolated. Mucopurulent cervicitis is an insensitive predictor of either gonorrheal or chlamydial infection and in addition has a low positive predictive value.Treatment should be based on microbiologic testing.Presumptive antibiotic treatment of mucopurulent cervicitis is not indicated unless there is a high prevalence of either N. gonorrhoeae or chlamydia in the population or if the patient is unlikely to return for treatment. Three months after Tx, approximately 20% of women will have persistent or recurrent mucopus in the cervix, not explained by relapse or reinfection.( Current Dx&Tx 2002,p750)
CANCER OF CERVIX **Essentials of Dx:- Abnormal uterine bleeding and vaginal discharge.
- Cervical lesion may be visible on inspection as a tumor
or ulceration.
- Vaginal cytology usually positive,and must be confirmed by
biopsy.
**Clinical findings: Pts present with abnormal bleeding or postcoital spotting or
menometrorrhagia or intermenstrual bleeding . Vaginal discharge, low back
pain, and urinary Sx may also be present.
**Staging : Staging is clinical and consists of a pelvic exam under anesthesia with cystoscopy and proctoscopy. CXR, IV pyelography, and abdominal CT are used to search for metastases .
Stage:
|
Cervix |
5-Year Survival, % |
0
|
Carcinoma in site
|
100
|
I
|
Confined to uterus
|
85
|
II
|
Invades beyond uterus but not pelvic wall
|
60
|
III
|
Extends to pelvic wall and/or lower third of vagina, or hydronephrosis
|
33
|
IV
|
Invades mucosa of bladder or rectum or extends beyond the true pelvis
|
7
|
**Screening: Women should begin screening when they begin sexual activity or at age 20. After two consecutive annual Pap smears, the test should be repeated every 3 years. Abnormal smears dictate the need for a cervical biopsy, usually under colposcopy, with the cervix painted with 3% acetic acid, which shows abnormal areas as white patches. If there is evidence of carcinoma in situ, a cone biopsy is performed, which is therapeutic.
**Treatment:
Carcinoma in situ is cured with cone biopsy. Stage I disease may be treated with
radical hysterectomy or radiation therapy. Stages II-IV disease are usually treated
with radiation therapy, often with both brachytherapy and teletherapy, or
combined modiality therapy. Pelvic exenteration is used uncommonly to control
the disease, especially in the setting of centrally recurrent or persistent disease.
Women with locally advanced (Stage IIB to IVA) disease usually receive
concurrent chemotherapy and radiation therapy. The role of chemotherapy is to
act as a radiosensitizer. Hydroxyurea, 5-fluorouracil (5-FU), and cisplatin have
shown all the promising results given concurrently with radiation therapy.
Cisplatin 75 mg/m2 IV over 4 h on day 1 and 5-FU 4 g given by 96-h infusion on
days 1-5 of radiation therapy in a common regime.
DYSPLASIA OF THE CERVIX (Current 2002,p751))There are varying degrees of dysplasia, defined by the degree if cellular atpia; all types must be observed and treated if they persist or become more severe. Classification systems for Papanicolaou smears
Numerical
|
Dysplasia
|
CIN
|
Bethesda system
|
1
|
Benign
|
Benign
|
Normal
|
2
|
Benign with inflammation
|
Benign with inflamation
|
Normal
|
3
|
Mild dysplasia
|
CIN I
|
Low-Grade SIL
|
3
|
Moderate dysplasia
|
CIN II
|
|
3
|
Severe dysplasia
|
CIN III
|
High-Grade SIL
|
4
|
Carcinoma in situ
|
|
|
5
|
Invasive cancer
|
Invasive cancer
|
Invasive cancer
|
CIN = cervical intraepithelial neoplasia SIL = squamous intraepithelial lesion
*Clinical findings: No specific Sx or S.All visibly abnormal cervical lesions should be
biopsied.
*Dx: -_Cytologic exam(Pap smear).
Colposcopy Biopsy *Prevention:
-Regular cytologic screening
-Using a diaphragm or condom for coitus.
-Limiting the # of sexual partners.
-Stopping smoking.
*Tx:
-Cauterization or Cryosurgery
-CO2 Laser
-Loop Resection
-Conization of the Cervix
-F/U: Vaginal cytologic exam should be repeatd @3mths intervals for @ least 1 yr.
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CRYOSURGERY: The use of either hot cauterization or freezing(cryosurgery) is effective for noninvasive small lesions visable on the cervix without endocervical extension. Involves less discomfort to the patient than electrocautization ot thermal cauterization, but is followed by a heavy, watery discharge for 4-6 weeks. Furthermore, the rate of cell destruction falls off rapidly at a depth of 3-4 mm, so dysplasia in the deeper tunnels and crypts of the transformation zone may not be controlled. The failure rate of cryotherapy in the more severe forms of cervical epithelial neoplasia is about 20%.
CONIZATION OF THE CERVIX Conization of the cervic is surgical removal of the entire transformation zone and endocervical canal. It should be reserved for cases of severe dysplasia or cancer in situ(CIN III), particularly those with endocerival extension. The procedure can be performed with the scalpel, the CO2 laser, or by large loop excision.
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Spontaneous Abortion
DESCRIPTION Abortion is the separation of products of conception from the uterus prior to the potential for fetal survival outside the uterus. Gestationally, the point at which potential fetal viability exists has been the subject of much legal and scientific debate, and definitions vary from state to state; however, a "potentially viable" fetus generally weighs at least 500 grams and/or has a gestational age over 20 weeks.
Spontaneous abortion: refers to expulsion of all (complete abortion) or part (incomplete abortion) of the products of conception from the uterus prior to the 20th completed week of gestation. The placenta, either in whole or in part, can be retained and leads to continuing vaginal bleeding (sometimes profuse). Abortion is "threatened" when vaginal bleeding occurs early in pregnancy, with or without uterine contractions, but without dilatation of the cervix, rupture of the membranes, or expulsion of products of conception. Cervical dilation, rupture of membranes or expulsion of products in the presence of vaginal bleeding portends "inevitable abortion." Differentiation between threatened and inevitable abortion is desirable since management differs. Missed abortion: Failed first trimester pregnancy but without the usual signs and symptoms such as bleeding or cramping. Term blighted ovum replaced with anembryonic gestation. Ultrasound findings of "empty sac." Induced abortion: refers to the evacuation of uterine contents/products of conception by either medical or surgical methodology Infected abortion: infection involving the products of conception and the maternal reproductive organs Septic abortion: dissemination of bacteria (and/or their toxins) into the maternal circulatory and organ system Habitual spontaneous abortion: three or more consecutive spontaneous abortions. Risk of another spontaneous abortion is approximately 25-30% with 70% rate of successful pregnancy in subsequent pregnancy. DIFFERENTIAL DIAGNOSIS
Ectopic pregnancy: a potentially life-threatening complication, difficult to distinguish from threatened abortion. Transvaginal ultrasonography can identify intrauterine gestational sacs at 32 days of gestation (at serum HCG levels of 1500-2000 IU). The absence of transvaginal ultrasound evidence of an intrauterine gestation with serum HCG over 2000 IU/L should be considered an ectopic pregnancy until proven otherwise. 
Cervical polyps, neoplasias, and/or inflammatory conditions can cause vaginal bleeding. This bleeding is not usually associated with pain/cramping and is apparent on speculum exam. Hydatidiform mole pregnancy usually ends in abortion prior to the 20th week of pregnancy. Bloody discharge prior to abortion is common. An intrauterine grape-like appearing mass on the ultrasound is diagnostic (a "snow storm" appearance). Human chorionic gonadotropin (HCG) is often high. Membranous dysmenorrhea: characterized by bleeding, cramps and passage of endometrial casts can mimic spontaneous abortion. HCG is negative. HCG secreting ovarian tumor LABORATORY
Cultures - gonorrhea and chlamydia CBC Rh type Human chorionic gonadotropin (HCG) Serial ß-HCG measurements can assess viability of the pregnancy. Normal gestations have an approximate 67% increase over 2-day interval. Abnormal gestations do not rise appropriately, plateau, or decrease in level before the eighth week of gestation. PATHOLOGICAL FINDINGS
Products of conception, placental villi
SPECIAL TESTS
Progesterone levels > 25 ng/mL are consistent with normal intrauterine pregnancy and are rarely seen in ectopic and/or non-viable pregnancy. A progesterone of < 5 ng/mL is an indicator of a nonviable intrauterine gestation or an ectopic pregnancy.
IMAGING
Ultrasound examination for fetal viability and to rule out ectopic pregnancy Ultrasound imaging can be sensitive enough to confirm an intrauterine pregnancy in the fourth or fifth gestational week from last menstrual period DIAGNOSTIC PROCEDURES
Viable intrauterine pregnancy with fetal cardiac activity detected between 5-8 weeks from last menstrual period on transvaginal ultrasound Transvaginal ultrasound criteria for nonviable intrauterine gestation include: 5 mm fetal pole without cardiac activity, or 16 mm gestational sac without a fetal pole Fetal heart tones can be auscultated with doppler starting between 10-12 weeks gestation from last menstrual period for a viable pregnancy Consider a diagnosis of spontaneous abortion in a woman, of childbearing age, presenting with abnormal vaginal bleeding MENOPAUSEDESCRIPTION The cessation of spontaneous menstrual cycles
Perimenopause: Period of time where there is a decline in ovarian function. Although a woman may continue to have periodic uterine bleeding, such cycles may be anovulatory. During this time estrogen production diminishes and a woman may experience early signs of estrogen deficiency. Postmenopause: The period after menopause usually accounting for more than a third of a woman's total life. Premature menopause: occurring before age 30 and may be associated with sex chromosome abnormalities DIFFERENTIAL DIAGNOSIS
Pregnancy Polycystic ovarian disease Microadenoma of pituitary Hypothalamic dysfunction Asherman's syndrome Obstruction of uterine outflow tract LABORATORY
Usually none is required because patient's age and symptoms readily establish the diagnosis If the diagnosis is questionable in a young patient, an elevated serum FSH indicates ovarian failure (FSH greater than 40 mIU/mL [100 IU/L]). Measurement of LH is not necessary. Estradiol (E2) levels will be less than 30 pg/mL. Peripheral blood karyotype if age < 30 Drugs that may alter lab results:
Estrogens Androgens Hormonal contraceptives Disorders that may alter lab results: Temporary, reversible cessation of ovarian function, e.g., during chemotherapy
PATHOLOGICAL FINDINGS
Atrophy of endometrium - virtually 100% if untreated. The uterus may seem smaller on bimanual examination. Atrophy of vagina - loss of rugae, appearance of petechiae - virtually 100% after several years if untreated Atrophy of urethra Osteoporosis - approximately 2% loss of bone mass/year. Most common in Caucasians and Orientals and least common in African-Americans. Arteriosclerosis Ovarian stroma only - or only a few inactive oocytes SPECIAL TESTS
Endometrial biopsy and/or D&C in patients who have intermenstrual or postmenopausal bleeding - may be accompanied by hysteroscopy. Investigation for endometrial cancer is necessary even in the presence of an atrophic vagina (usually the cause of the bleeding). Bleeding may also be evaluated by vaginal sonography; if double wall thickness of endometrial stripe is less than 5 mm, endometrial carcinoma is highly unlikely IMAGING
None for physiologic menopause MRI scan of head if pituitary tumor suspected DIAGNOSTIC PROCEDURES
Endometrial sampling if intermenstrual or post menopausal bleeding occurs Pap smear Bimanual pelvic examination Mammography annually Bone density determination
Hormone Replacement Therapy
Hormone replacement therapy (HRT) is treatment with estrogen or a combination of estrogen and progesterone, to replace the loss of these natural hormones after menopause. Estrogen can be administered as a pill taken daily or as a skin patch worn every day. Progesterone can be taken as a pill or as a vaginal suppository or cream.
Originally, the purpose of HRT was to relieve the symptoms of menopause. However, it has become clear that HRT has other major long-term benefits, though it also carries some risks. The time to consider starting HRT is in the perimenopausal period. The longer you take HRT, the more benefits you receive. It is never too late to benefit from HRT. When women stop HRT, they lose many of its beneficial effects, but they also avoid some of the risks.
Reducing menopausal symptoms Taking HRT during menopause improves a variety of menopausal symptoms. In women who still have their uterus, progesterone is added to estrogen to protect against endometrial cancer (see Cancer of the Endometrium). In women who have had a hysterectomy (removal of the uterus), estrogen alone is usually given.
It is normal for some vaginal spotting to occur in the first few months after starting HRT. However, tell your doctor about any new vaginal spotting or bleeding or change in your usual pattern that occurs after the first 6 months.
Progesterone can cause side effects such as mood changes, nausea, breast tenderness, weight gain, and bloating. Many of these side effects can be minimized by using low doses, and the side effects often disappear after a few months.
Progesterone may also be taken as a vaginal suppository or cream on a daily basis or in an intrauterine device (IUD) changed yearly. These alternative forms minimize side effects and limit the growth of the endometrium. It is not certain, however, that these forms decrease the risk of endometrial cancer as much as the oral form.
The debate about HRT Is HRT right for you? It produces benefits and risks, because both estrogen and progesterone have a wide spectrum of different effects on the body. HRT is right for you if the benefits are greater than the risks. There are many good studies that allow women and their doctors to estimate both the benefits and risks of HRT, but none of the studies is ideal.
The results of a study of a very large group of women, the Women’s Health Initiative, will formally test the benefits and risks of HRT and are expected sometime between 2005 and 2010. In the meantime, learn more about HRT, and talk to your doctor about what approach is best for you.
What causes the benefits? Estrogen replacement eases menopausal symptoms that are caused by the reduction in your body’s natural supply of estrogen. The most important potential benefit of taking estrogen is reducing your chance of coronary heart disease. In postmenopausal women, heart disease is by far the most common cause of death. Estrogen has beneficial effects on cholesterol. It increases HDL (good cholesterol) and lowers LDL (bad cholesterol) and appears to slow atherosclerosis and narrowing of the arteries.
Estrogen definitely reduces your chance of getting osteoporosis and of the complications of osteoporosis, such as hip and spine fractures, by enhancing the activity of the cells that make new bone. It is thought that estrogen may reduce the risk of colon cancer, Alzheimer disease, and Parkinson disease, but these theories have not yet been proved.
What causes the risks? Estrogen stimulates the growth of cells in the lining of the uterus (endometrium). Constant stimulation over a long period of time can increase the risk of getting cancer of the endometrium eight- to tenfold. However, taking progesterone with estrogen protects against the development of cancer of the endometrium.
In a similar manner, constant stimulation by estrogen may cause cancer to develop in cells of the breast. After taking estrogen for 10 years, the risk of developing breast cancer may increase 15% to 30% above your normal risk. Women who have a mother, sister, or daughter with endometrial cancer or breast cancer may have an increased risk of those cancers if they take HRT. Progesterone does not have the same protective effect against the development of breast cancer that it has against the development of cancer of the endometrium.
Women taking HRT have almost twice the risk of developing gallstones of women who do not take hormones. In some women, HRT may also increase blood pressure or make migraine headaches occur more frequently.
Newer forms of HRT Other medicines--called selective estrogen receptor modifiers or "designer estrogens"--are being developed to achieve the beneficial effects of estrogens while avoiding the risks. Early results are promising, but much more research is needed before it will be clear if these medications will be successful.
One of the newer medicines, raloxifene (approved only to prevent osteoporosis as of 1998), reduces bone loss and has beneficial effects on blood cholesterol levels without affecting the estrogen receptors in breast tissue or in the uterus. Raloxifene may protect women from osteoporosis and heart disease without increasing the risk of breast cancer (but this has not been demonstrated conclusively). Other, similar drugs are under development
cystocele
A condition where the bladder herniates into the vaginal canal. This usually results in stress incontinence. This condition is seen with increased frequency with aging and multiparity. A cystocele (SIS-tuh-seal) occurs when the wall between a woman's bladder and her vagina weakens and lets the bladder droop into the vagina. This condition may cause discomfort and problems with emptying the bladder. A cystocele may result from muscle straining while giving birth. Other kinds of straining--such as heavy lifting or repeated straining during bowel movements--may also cause the bladder to fall. The hormone estrogen helps keep the muscles around the vagina strong. Treatment options range from no treatment for a mild cystocele to surgery for a serious cystocele. If a cystocele is not bothersome, the doctor may only recommend avoiding heavy lifting or straining that could cause the cystocele to worsen. If symptoms are moderately bothersome, the doctor may recommend a pessary--a device placed in the vagina to hold the bladder in place. Large cystoceles may require surgery to move the bladder back into a more normal position and keep it there.bartholin's glandsPaired glands situated on each side of the vaginal orifice. ____________________________________________________________________________________
The Bartholin's glands are paired glands located at the vaginal opening, one on the right and one on the left. They are the size of a pea and secrete a liquid that lubricates the tissues at the vaginal opening. The opening of the gland may become blocked, causing swelling. Most often this swelling is due to the normal secretions not being able to drain (a Bartholin's gland cyst), but it may be due to infection as well (an abscess). A cyst usually develops slowly and, while it may be very large, is most often not painful. An abscess usually develops over the course of a few days and is very painful.