Definition of cervical intraepithelial neoplasia (CIN)
- Premalignant transformation and dysplasia of squamous cells on the surface of cervix
Management of CIN
> Low grade
- Conservative mx: close f/u with colposcopy and cytology 6 months after initial dx
- Cryotherapy
> High grade
- Loop diathermy
- Cone biopsy
Indication for pap smear
- Screening program for early cervical cancer
- Sexually active at age 20-65
- History of STD
- Abnormal PV bleeding/ discharge
- Follow-up procedure following treatment of CIN
Function and result of acetic acid and Lugol’s iodine in colposcopy
> Acetic acid
- Causes nucleoprotein within cells to coagulate temporarily
- Area of high cell turnover -> white
> Lugol’s iodine (Schiller’s test)
- Stains area of normal cells (having glycogen) BROWN
- Areas of CIN lacks glycogen -> YELLOW
Risk factor for cervical Ca
- Persistent HPV infection - Type 16, 18, 31, 33
- Abnormal cervical cytology: CIN
- Immunocompromise (HIV)
- Multiple sexual partner
- Multiparous women
- Cigarette smoking
Clinical presentation of cervical Ca
> Early stage
- Post-coital bleeding
- Intermenstrual bleeding
- Blood stained vaginal discharge
- LOW, LOA
> Advance
- Pain (lower abdominal, back if vertebral mets)
- Anemia (chronic vaginal bleeding)
- Renal failure (ureteric blockage)
Management of cervical Ca
> Stage 0 (CIN)
- Cryosurgery
- Cone biopsy
- Loop diathermy
> Stage 1a
- Complete local excision
- Loop biopsy
- Cone biopsy
> Stage 1b
- Pre-menopausal: radical hysterectomy, Wertheim’s hysterectomy, radical trachelectomy
- Post-menopausal: radiotherapy
> Stage 2-4
- Radiotherapy with or without chemotherapy
Characteristic of cervix tumor in speculum examination
- Fungating
- Ulceration
- Cauliflower
- Contact bleeding
- Friable
- Stony hard
Investigation for cervical Ca
> Blood test
- FBC
- BUSE/ Cr: exclude ureteral obstruction
- LFT: exclude liver mets
> Staging
- Ultrasound
- Chest XR
- CT/ MRI
- Cystoscopy/ Sigmoidoscopy
- IV Urogram
FIGO staging for cervical Ca
0: CIN
Stage 1: Confined to cervix
- 1a: microscopic
- 1b: macroscopic
Stage 2: Beyond the cervix
- 2a: involve upper 2/3 of vagina
- 2b: infiltrate parametrium
Stage 3
- 3a: involving lower 1/3 of vagina
- 3b: extending to pelvic wall and/ or hydronephrosis due to ureteric obstruction
Stage 4
- 4a: Involving mucosa of bladder/ rectum and/ or extending beyond the true pelvis
- 4b: Spread to distant organ
Type of endometrial Ca
> Type 1
- Endometrial adenocarcinoma
- More common (90%)
- A/w: unopposed estrogen, obesity, HPT, DM
- Prognosis good
> Type 2
- Serous papillary carcinoma, clear cell, malignant mixed Mullerian tumor
- A/w: atrophy, thin physique
- Prognosis poor
Cause of endometrial Ca
- Hyperestrogenism
(Endogenous: obesity, PCOS; Exogenous: ERT, Tamoxifen therapy) - HNPCC
Risk factors for endometrial Ca
- Obesity
- Diabetes (IGF function as a mediator of estrogen actions through paracrine/autocrine mechanisms)
- Nulliparous
- Late menopause
- Unopposed estrogen therapy
- Tamoxifen therapy
- HRT
- Family history of colorectal/ ovarian Ca
- OCP/ POP reduce the risk
Clinical features of endometrial Ca
> Post-menopausal
- Irregular vaginal bleeding
> Pre-menopausal
- Intermenstrual bleeding
- Blood-stained vaginal discharge
- Heavy menstrual bleeding
- Lower abdominal pain
- Dyspareunia
Investigation for endometrial Ca
> Blood test
- FBC
- BUSE/ Cr: exclude ureteral obstruction
- LFT: exclude liver mets
> Imaging (assessment of metastases)
- CXR
- Ultrasound abdomen
- CT/ MRI
- Cystoscopy
- Barium studies
- Sigmoidoscopy
> Diagnosis
- Transvaginal ultrasound scan: assessment of endometrial thickness
- Hysteroscopy: if endometrial thickness >5mm (allow direct visualization, direct biopsy)
- Endometrial sampling: pipelle, dilation and curettage, hysteroscopy guided biopsy
Management of endometrial Ca
- Stage 1A: TAHBSO
- Stage 1B: TAHBSO + Radiotherapy
- Stage 2: Radical hysterectomy + pelvic and aortic LN dissection (Wertheim hysterectomy)
- Stage 3: Surgical debulking +- radiotherapy prior surgery
- Stage 4: Systemic chemotherapy/ hormonal therapy
Management of endometrial hyperplasia
> Premenopausal
- Progestin therapy (eg: IUCD, COCP)
> Postmenopausal
- Progestin therapy
- Hysterectomy
Risk factor for endometrial polyp
- Tamoxifen
- Hormone replacement therapy
- Obesity
Management for endometrial polyp
> Premenopausal
- Managed expectantly if removal not indicated
- Removal of symptomatic polyps, or RF for endo hyperplasia or Ca, >1.5cm, multiple or prolapsed, infertile patient
> Postmenopausal
- Removal of all polyp
Clinical features of atrophic vaginitis
- Vulvovaginal dryness
- Decreased vaginal lubrication during sexual activity
- Dyspareunia
- Vulvar or vaginal bleeding
- Decreased arousal, orgasm, or sexual desire
- Vulvovaginal burning, irritation, or itching
- Vaginal discharge
- Urinary tract symptoms
