Cervical Cancer- second most common cancer in women

Risk Factors - HANNAHS

History of cervical dysplasia

Age of first intercourse
Number of partners
History of iNfection  - Human papillomavirus or Herpes simplex virus 2

Age of patient
HIV positive
Smoking

Identify normal female anatomy, including the location of Skene's and Bartholin's glands.

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Skene's glands - periurethral

Bartholin's glands - usually not visible, their opening is located between th elabia minora and the hymen; function: to secrete mucous for lubrication

Skene's glands - Place index finger with palm upwards into the vagina; Exerting upward pressure, milk the Skene gland by moving the finger outward; repeat on opp. side

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Bartholin's glands - Palpate the posterolateral portion of the labia majora; Palpate individually bilaterally
Bartholin cyst is due to chronic inflammation

Acute Bartholin abscess is usually due to gonorrhea or staphylococcus

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Prolapse - esp. in older women

cystocele - causes buldging of the anterior vaginal wall

rectocele - causes buldging of the posterior vaginal wall

uterine prolapse - causes cervical protrusion

At the start of sexual activity

At age 18

At the discretion of the physician for complaints of severe dysmenorrhea, menorrhaghia, etc.

In the United States there are 10,500
diagnoses annually of invasive cervical cancer & 3900 annual deaths.

Prior to the institution of screening, cervical
cancer was the number one cancer in U.S.
women

1. Empty her bladder

2. Patient's Permission First!

3. Chaperone must be present

4. Dorsal lithotomy position

5. Have patient move down until her buttocks are at the edge of the table.

6. Patient as comfortable as possible

7. Raise the head of bed to maintain eye contact

8. Position drape across the knees in a way that will allow you to see the patient's face

9. Let legs fall open

10. Start with neutral touch

Inspection:

I. Hair distribution - look for Tanner staging, possible lice

Labia majora - look for swelling, excoriation, rashes or growths

Labia minora - separate the labia majora with the gloved fingers of one hand in order to inspect. Palpate the labia minora between thumb and second finger

Clitoris - look for enlargement that may indicate excess masculine hormones

Urethra -

Vaginal introius

Perineum

Skene's glands

Bartholin's glands

 

II. Observe for prolapse

 

Speculum Examination

1. Lubricate speculum

2. Ask patient to relax the vagina

3. Place finger into the vaginal introitus and apply gentle pressure down on the perineum. Insert the speculum gently over your finger with inward and slightly downward movement.

4. Place a finger into the vaginal introitus and apply gentle pressure down on the perineum. Insert the speculum gently over your finger with inward and slightly downward movement.

5. Avoid touching the clitoris, or pinching skin or hair.

6. Open speculum once fully inserted.

7. Once cervix is in view, lock the speculum blades.

Pap Smear

1. Insert long end of spatula into the cervical os and rotate 360 degrees.

2. Spread the specimen onto a glass slide.

3. Inssert the cytobrush into the cervical os and rotate one-half to one full turn.

4. Roll the brush onto a glass slide and apply fixative.

5. Thin prep Pap smear - rinse spatula into the solution vial by swirling it 10 times.Insert the endocervical brush and rotate one-half to one turn. Rinse the brush in the solution 10 times.

 

Gonococcal Culture Specimen Collection

1. Insert a sterile cotton swab into the cervical os.

2. Hold it for 10-30 seconds.

3. Spread the swab in a z-pattern over the culture media. Culture media must be kept refrigerated.

4. A specimen for culture may be obtained from the rectum too.

5. THe DNA probe is more commonly used than the culture.

DNA probe - fast and sensitive test for gonorrhea and chlamydia

1. The DNA probe involves constructing a nucleic acid sequence (the probe) that will match to a sequence in the DNA or RNA of the target tissue.

2. Use a Dacron swab with a plastic or wire shaft.

3. Insert the swab into the cervical os and rotate it for 30 seconds.

4. Place the swab into a tube containing the specimen reagent.

Wet Mount- used to detect Trichomonas vaginalis, bacterial vaginosis, and sometimes Candidiasis.

1. Obtain a swab of the vaginal discharge.

2. Smear the swab on a glass slide, and add a drop of normal saline.

3. Place a coverslip on the slide and view under the microscope.

KOH prep

1. collect specimen as for the wet mount

2. smear specimen on the slide.

3. Add KOH to the specimen.

4. Place a cover slip and view under the microscope.

5. The KOH dissolves epithelial cells and facilitates visualization of the mycelia of a fungus.

Speculum Withdrawal

1. Note vaginal walls while withdrawing the speculum.

2. Normal secretions are thin, clear, or cloudy. Secretions are abnormal if frothy, curdy, gray, green or yellow. They should not be malodorous.

3. As you withdraw the speculum maintain downward pressure to avoid urethral trauma. Inspect the vaginal walls as you withdraw the speculum.

Bimanual exam

1. Explain to the patient what will happen during the bimanual exam. Change your gloves.

2. Palpate the vaginal walls as you insert your fingers.

3. Palpate for cysts, nodules, masses or growths.

4.

Speculum Examination

1. Lubricate speculum

2. Ask patient to relax the vagina

3. Place finger into the vaginal introitus and apply gentle pressure down on the perineum. Insert the speculum gently over your finger with inward and slightly downward movement.

4. Place a finger into the vaginal introitus and apply gentle pressure down on the perineum. Insert the speculum gently over your finger with inward and slightly downward movement.

5. Avoid touching the clitoris, or pinching skin or hair.

6. Open speculum once fully inserted.

Ways to visualize cervix: gently reposition the speculum until the cervix is visualized. Sometimes you will need to completely withdraw the speculum, and re-insert it at a different angle. Rarely it is necessary to locate the cervix by palpation prior to the speculum examination.

7. Once cervix is in view, lock the speculum blades.

In speculum examination:

based on the position of the uterus (whether anteverted or retroverted) the cervix may or may not be in the midline.

Conventional pap smear - cells in dry form

thin-prep pap smear - cells in liquid form

human papillomavirus testing - identify the presence of high risk strains of HPV in specimen

Sensitivity of detecting High grade Squamous Epithelial lesions:

Conventional Pap - 70%

Thin Prep Pap - 90%

Conventional Pap and HPV Testing - 99%

Specificity of detection of High Grade Squamous Epithelial II lesions:

Conventional Pap - 95%

Thin prep - 93%

Conventional Pap & HPV testing - 86%

Convetional Pap - Annual

Thin Prep - every other year

DC at age 70 if prior paps normal

Younger than 30 y/o: annual

>30 y/o w/ 3 normal pap tests: once every 2-3 years

65-70: 3 normal paps, no abnormal paps in 10 years: dc

Yearly at any age especially if:

1. Pt. is immunocompromised ecause of orga ntransplant, chemotherapy, or steroid use

2. maternal history of diethylstilbestrol (DES) use while pregnant

3. HIV-positive; if HIV positive, get pap tests 6 months apart, then if normal, switch to annual

Seventy-five percent of sexually active females and males become HPV infected in their lifetime
Prevalence varies by age:

Child to 10 years old - 1%
Teenager - 20%
20 to 29 years old - 40%
Then decreases with age

Gonococcal Culture Specimen Collection

1. Insert a sterile cotton swab into the cervical os.

2. Hold it for 10-30 seconds.

3. Spread the swab in a z-pattern over the culture media. Culture media must be kept refrigerated.

4. A specimen for culture may be obtained from the rectum too.

5. THe DNA probe is more commonly used than the culture.

DNA probe - fast and sensitive test for gonorrhea and chlamydia

1. The DNA probe involves constructing a nucleic acid sequence (the probe) that will match to a sequence in the DNA or RNA of the target tissue.

2. Use a Dacron swab with a plastic or wire shaft.

3. Insert the swab into the cervical os and rotate it for 30 seconds.

4. Place the swab into a tube containing the specimen reagent.

Wet Mount- used to detect Trichomonas vaginalis, bacterial vaginosis, and sometimes Candidiasis.

1. Obtain a swab of the vaginal discharge.

2. Smear the swab on a glass slide, and add a drop of normal saline.

3. Place a coverslip on the slide and view under the microscope.

KOH prep

1. collect specimen as for the wet mount

2. smear specimen on the slide.

3. Add KOH to the specimen.

4. Place a cover slip and view under the microscope.

5. The KOH dissolves epithelial cells and facilitates visualization of the mycelia of a fungus.

Move cervix from side to side 1-2cm. Should cause minimal discomfort

If tenderness ocurs, this is indicative of pelvic inflammatory disease, or ruptured tubal pregnancy.

In bimanual examination:

Place your intravaginal fingers in the anterior fornix

Push down and forward with the flat surface of the fingers of your abdominal hand
Push inward and upward with the fingers of your intravaginal hand

If the uterus is anteverted or anteflexed you will feel the fundus between the fingers of your two hands

If you are unable to feel the uterus with the previous maneuver, place your intravaginal fingers behind the cervix (in the posterior fornix)
Press firmly down with the abdominal hand while pressing up against the cervix with the intravaginal hand
A retroverted or retroflexed uterus should be felt with this maneuver.

Labia majora are flatter and smaller
The urethra may be located more posteriorly
The vagina is narrower and shorter. 
Rugation are absent

The cervix will be smaller and paler
The ovaries are rarely palpable due to atrophy
The uterus is also smaller
Check closely for urinary incontinence and possible prolapse

adolescents

Always take a complete history
Always ask about sexual activity without the parents present
Always address confidentiality
Always ask about condom use and contraception

Along with the Pap smear, a DNA probe for Chlamydia is usually done
Do not forget to ask about other high risk behavior
Be nonjudgmental
Issues of consent

older patient

evaluate for possible prolapse; ask about urinary incontinence

Pelvic examinations may be safely done in pregnancy
A complete history and physical is essential
If a woman has not had a pap smear, it should be done
Late in pregnancy, care must be taken not to introduce infection

In early pregnancy, the cervix, vagina, and vulva acquire a bluish color
The cervix softens
Increased vaginal secretions occur

Obstetrical history

G = total # of pregnancies (don't forget current one)

P = # of pregnancies carried past 20 weeks (viable)

A = # of fetal losses (spontaneous and induced)

L = # of living children

Cervical dilation = usually occurs just prior to delivery; measured in cm (ranges from 0 (closed) to 10 (complete dilation)

Effacement = refers to thinning of the cervix that occurs when uterine contractions pull the cervix upward

Station = position/location of the fetus in relation to the mother's ischial spines, recorded in cm. Positive (+) cm recording tells you the baby's presentin part is below the ischial spines. Negative (-) cm recording tells you that the baby's presenting part is above the ischial spines. Thus, a +2 station is much closer to delivery than a -2 station.

Endometrial Cancer  - most common gynecologic maligancy secondary to excess exposure to exogenous or endogenous estrogens

Risk Factors: CALF OPEN

Chronic Anovulation

Late menopause

Family history

Obesity

Postmenopausal
Early menarche
Nulliparity

Ovarian cancer - insidious and difficult to diagnose during early stages; present with non-specific symptoms (bloating, abdominal discomfort)

Risk Factors - BIN LADEN

Breast cancer patients - Family/personal history

Infertility (RR 2.8)

Nulliparity (RR 1.6)

Late menopause

Age of patient
 Drug (fertility) use - history

Early menarche

No Prolonged use oral contraceptives