Gynecology 5th year, 9th lecture (Dr. Hanaa)

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The lecture has been given on Apr. 6th, 2011 by Dr. Hanaa.

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  • Click on the image to run a 2-minute video clip showing Pap smear technique. It covers the concepts of proper patient positioning, inspection of the vulva, painless insertion of the speculum, using an Ayers spatula and cytobrush, removal of the speculum, preparing the smear, and spraying the slide with fixative.
  • Gently spread the labia apart and inspect the vulva, looking for lesions, masses, drainage, or discolorations of the skin. Explain what you are doing to the patient to keep her relaxed.
  • Keep in mind the basic anatomy of the vulva.
  • The vaginal speculum consists of two blades. When closed, the speculum is inserted into the vagina. Then the blades are opened, revealing the cervix at the end of the vagina. Thin-bladed Pederson speculums are most comfortable for most women. For women who have had babies, the wider Grave’s speculum may be needed for good visualization of the vagina and cervix.
  • Warm the vaginal speculum. Running water works well for this as it also lubricates the speculum. Some health care providers use a heated drawer or heating pad to keep the speculums warm. Do not overheat as a speculum that is too hot is just as uncomfortable as one that is too cold. Never use K-Y Jelly(r), Surgilube(r), Petroleum Jelly or other lubricant to moisten the speculum as it will likely make your Pap smears unreadable under the microscope.
  • After warming the speculum, separate the labia and keep them apart. Insert the speculum into the vagina, letting the speculum follow the path of least resistance. Some vaginas go straight back, parallel to the floor. Other vaginas tilt slightly downward toward the floor as the speculum advances. Others angle upward, away from the floor. Keep the speculum blades closed until the speculum is completely inserted. Open the speculum and usually the cervix is immediately visible. If not, the cervix is usually just below the lower blade or just above the upper blade. Rocking the speculum downward and upward usually causes the hidden cervix to drop into view. Lock the blades in the open position, wide enough apart to allow complete visualization of the cervix but not to far open as to be uncomfortable for the patient. With practice, insertion of the speculum should generally be totally painless. .
  • In obtaining the Pap smear, it is important to sample the "Squamo-columnar Junction." This is the circular area right at the opening of the cervix where the pink, smooth skin of the cervix meets the fiery-red, fragile, mucous-producing lining of the cervical canal. If there is going to be a problem with cancer or precancerous changes, it is this area that is most likely to be effected. This area is also known as the SQJ, or transition zone.
  • The Ayers spatula is specially designed for obtaining Pap smears. The concave end (curving inward) fits against the cervix, while the convex end (curving outward) is used for scraping vaginal lesions or sampling the "vaginal pool," the collection of vaginal secretions just below the cervix. The spatula is made of either wood or plastic. Both give very satisfactory results.
  • The concave end of the spatula is placed against the cervix and rotated in circular fashion so that the entire area around the cervical opening (os) is sampled. Usually this can be done without causing any discomfort, although some women are sensitive to the sensation and may experience minor cramping. Sometimes, obtaining this sample causes some bleeding. In this case, reassure the patient that: 1. although she may have some minor bleeding or spotting for a few hours, it is not dangerous, 2. it will stop spontaneously and promptly 3. it is caused by the Pap smear.
  • Push the cytobrush into the canal, no deeper than the length of the brush (1.5 cm - 2.0 cm). Rotate the brush 180 degrees (half a circle) and pull the cytobrush straight out. Don't keep spinning the brush round and round or you will cause bleeding. Even the 180 degree rotation may cause a little bleeding but usually it doesn't.
  • Label the slide with pencil on the frosted end. Two slides may be made, one for the spatula and one for the brush (“two-slide” technique). Alternatively, a single slide may be used (the “one-slide” technique) in which the brush is spread on one half the slide and the spatula is used on the other half. Both techniques give good results.
  • Allow the slides to dry completely before placing them in the Pap smear container. Once dry and packaged, it is best to send them out promptly for interpretation. When operational circumstances disallow prompt sending of the slides, they can be held for weeks to months without significant loss of readability. Make sure the slides are properly labeled and that important clinical information is included with the requisition. Telling the cytologist that the patient has had a hysterectomy will save considerable amounts of time in evaluating the smear. For women who have had a hysterectomy, Pap smears are obtained by using the convex end of the Ayers spatula, scraping it horizontally across the top of the vagina. Then the cytobrush is used to reach into the the right and left top corners of the vagina.
  • Gynecology 5th year, 9th lecture (Dr. Hanaa)

    1. 1. <ul><li>Premalignant conditions of the cervix </li></ul>
    2. 3. <ul><li>Transformation zone </li></ul><ul><li>Is that part of the cervix that extend from the widest part of the skin that was originally columnar epithelium into the current SCJ </li></ul><ul><li>This is characterized by Nabothian follicles (retention cyst s of endocervical glands that have covered by advancing squamous epithelium. </li></ul><ul><li>The ectocervix is covered by squamous stratified epithelium </li></ul><ul><li>The canal of the cervix , is lined by single columnar epithelium, the point where these two epithelium meet is called squmocolumnar junction. </li></ul><ul><li>The SCJ during infancy lies just at the external os </li></ul><ul><li>At puberty & pregnancy the SCJ is said to roll out onto the ectocervix.to be seen (red area) </li></ul>
    3. 5.
    4. 6. <ul><li>Transformation zone </li></ul>
    5. 7. Terminology Dysplasia and cervical intraepithelial neoplasia (CIN) are different terms or names for the same condition. Dysplasia simply means abnormal tissue development ; while dysplasia is still sometimes used to mean CIN, the term is not used as frequently as in the past. Squamous intraepithelial lesions (SIL) is another term that is used with regard to CIN, and describes the type of cervical cells that undergo changes in 80% of cervical neoplasia. Both terms--dysplasia and CIN--remain in use today. Cervical intraepithelial neoplasia (CIN) is now used to describe what was once called dysplasia
    6. 8. <ul><li>Cervical intraepithelial neoplasia (CIN) is now used to describe what was once called dysplasia </li></ul><ul><li>CIN I = minimal dysplasia </li></ul><ul><li>CIN II = moderate dysplasia </li></ul><ul><li>CIN III = severe dysplasia or carcinoma in situ </li></ul><ul><li>CIN III, severe dysplasia and carcinoma in situ are all different names for the same thing--early cervical cancer. While approximately one-third of all cases of CIN I will resolve in time, the rest will progress. All degrees of CIN, however, require immediate colposcopy . </li></ul>
    7. 9. <ul><li>Introduction </li></ul><ul><li>Cervical intraepithelial neoplasia (CIN) is a condition characterized by new growth (neoplasia) in the normal tissue (epithelium) of the cervix. A diagnosis of CIN means that abnormal tissue has been detected in a woman's cervix. In addition to CIN, other types of lower genital tract neoplasias reported in women with HIV include vulvar intraepithelial neoplasia (VIN) and perianal intraepithelial neoplasia (PIN or AIN, anal intraepithelial neoplasia). </li></ul>
    8. 10. <ul><li>CIN is much more common than the other types of genital neoplasia in women with HIV. The tissue changes that signify CIN are premalignant, or precancerous; CIN is essentially a precursor to invasive cervical cancer. CIN may be mild, moderate or severe. </li></ul><ul><li>The abnormal tissue of CIN is collectively composed of cells that have undergone abnormal, individual changes, and which have formed lesions in the cervix. Cervical lesions can regress (grow smaller and disappear), persist or progress to early cervical cancer, more formally called cervical carcinoma in situ, and finally invasive cervical cancer. Moderate or severe CIN (high-grade SIL, CIN II-III) is more likely to persist or progress. Mild CIN (low-grade SIL, CIN I) often regresses without any treatment, overcome by a successful immune system defense. </li></ul>
    9. 11. <ul><li>Signs and Symptoms </li></ul><ul><li>Cervical dysplasia often produces no symptoms and is usually discovered during an annual Pap smear. Occasional signs and symptoms of the condition can include: </li></ul><ul><li>Genital warts </li></ul><ul><li>Abnormal bleeding </li></ul><ul><li>Spotting after intercourse </li></ul><ul><li>Vaginal discharge </li></ul><ul><li>Low back pain� </li></ul><ul><li>It is important to note that these symptoms are not unique to cervical dysplasia and they may indicate a different problem. </li></ul>
    10. 12. <ul><li>Risk Factors The following may increase an individual's risk for developing cervical dysplasia: </li></ul><ul><li>Human papilloma virus (HPV) infection </li></ul><ul><li>Genital warts </li></ul><ul><li>Smoking </li></ul><ul><li>Early onset of sexual activity (younger than 18 years old) </li></ul><ul><li>Multiple sexual partners </li></ul><ul><li>Having a partner whose former partner had cervical cancer </li></ul><ul><li>History of one or more sexually transmitted diseases, such as genital herpes or HIV </li></ul><ul><li>Other causes of immunosuppression, such as HIV or the use of chemotherapeutic medications to treat cancer </li></ul><ul><li>Long-term use (5 or more years) of birth control pills </li></ul><ul><li>Being born to a mother who took diethylstilbestrol (DES) to become pregnant or to sustain pregnancy (this drug was used many years ago to promote pregnancy but it is no longer used for these purposes) </li></ul>
    11. 13. <ul><li>Dysplasia </li></ul><ul><li>The process of metaplasia can be disrupted by external influences& can lead to disordered squamous epithelium called dysplastic epithelium ( HPV ,smoking , immune suppression may act as coagent </li></ul><ul><li>Dysplasia </li></ul><ul><li>*Lack of normal maturation of cell as they move from basal layer to superficial layer </li></ul><ul><li>*Large nuclei more variable in size &shape </li></ul><ul><li>* more actively dividing nuclei . </li></ul><ul><li>Dysplasia are now referred to as cervical intraepithelial neoplasia ( CIN) </li></ul><ul><li>CIN graded mild ,moderate or sever depending on </li></ul><ul><li>1- severity of atypia </li></ul><ul><li>2- thickness of epithelium involved </li></ul><ul><li>CIN1 ,deepest 1/3 of the epithelium from the basal layer is involved . </li></ul><ul><li>CIN2 affects 2/3 of the thickness of the epithelium </li></ul><ul><li>CIN3 no maturation throughout the full thickness. </li></ul><ul><li>Simpler classification ( Bethsda system) </li></ul><ul><li>Low grade squamous intraepithelial lesion (LSIL) CIN1 </li></ul><ul><li>High grade squamous intraepithelial lesion ( HSIL) CIN2 ,CIN3 </li></ul>
    12. 14. <ul><li>Cytology </li></ul><ul><li>Exfoliative cervical cytology is a technique developed by Papanicolaou to collect the cells that had been shed from the skin of the cervix ,spread them on a glass slide & stain them . </li></ul><ul><li>Normal squamous epithelium have small nuclei that flattened & pyknotic. </li></ul><ul><li>Abnormal ( dysplastic cells ) having </li></ul><ul><li>*large nuclei </li></ul><ul><li>*cytological atypia </li></ul><ul><li>*high N/C ratio </li></ul><ul><li>this can be put in </li></ul><ul><li>1-mild dyskariosis (smear should be repeated) </li></ul><ul><li>2-moderate dyskariosis (colposcopy ) </li></ul><ul><li>3-sever dyskariosis (colposcopy ) </li></ul><ul><li>Three normal smears are required before a women can be returned to routine screening after a smear showing mild dyskaryoisis </li></ul><ul><li>Abnormal changes in glandular cells or borderline nuclear changes in glandular cells , such women are always referred to colposcopy </li></ul>
    13. 15. Pap Smear Technique Video
    14. 16. Inspect <ul><li>Spread labia </li></ul><ul><li>Discharge </li></ul><ul><li>Ulcers </li></ul><ul><li>Growths </li></ul>
    15. 17. Anatomy
    16. 18. Vaginal Speculum
    17. 19. Warm Speculum <ul><li>Warm water </li></ul><ul><li>Not too hot </li></ul><ul><li>Lubricates speculum </li></ul>
    18. 20. Insert Speculum <ul><li>Spread labia </li></ul><ul><li>Keep labia apart </li></ul><ul><li>Blades remain closed until fully inserted </li></ul>
    19. 21. Squamo-Columnar Junction <ul><li>Junction of pink cervical skin and red endocervical canal </li></ul><ul><li>Inherently unstable </li></ul><ul><li>Key portion of the cervix to sample </li></ul><ul><li>Most likely site of dysplasi a </li></ul>
    20. 22. Ayers Spatula <ul><li>Concave end to fit the cervix </li></ul><ul><li>Convex end for vaginal wall and vaginal pool scrapings </li></ul>
    21. 23. Sample Cervix <ul><li>Use concave end </li></ul><ul><li>Rotate 360 degrees </li></ul><ul><li>Don’t use too much force (bleeding, pain) </li></ul><ul><li>Don’t use too little force (inadequate sample ) </li></ul>
    22. 24. Cytobrush <ul><li>Insert ~ 2 cm (until brush is fully inside canal) </li></ul><ul><li>Rotate only 180 degrees (otherwise will cause bleeding) </li></ul>
    23. 25. Make Pap Smear <ul><li>As thin as possible </li></ul><ul><li>Properly labeled </li></ul>
    24. 26. Spray with Fixative <ul><li>Within 10-15 seconds </li></ul><ul><li>Allow to fully dry before packaging </li></ul><ul><li>Cytologic Fixative (hairspray works acceptably also) </li></ul>
    25. 28. <ul><li>The sensitivity of cervical cytology is about 50% but, because CIN takes about 10 years, missed lesions are detected on second or 3 rd subsequent sample . </li></ul><ul><li>The specificity of cervical cytology is about 90%. </li></ul><ul><li>Colposcopy </li></ul><ul><li>Binocular operative microscope with magnification of 5-20 X . It has been used to examine the cervix in detail to identify CIN & premalignant invasive cancer. </li></ul><ul><li>the cervix is first examined for </li></ul><ul><li>1- abnormal vessel pattern ( punctate, mosiasim) </li></ul><ul><li>2-acetic acid (3-5%) </li></ul><ul><li>3- Schiller`s test </li></ul><ul><li>Normal epithelium take the dye brown colour. </li></ul>
    26. 29. <ul><li>Schiller`s test is negative </li></ul><ul><li>1- columnar epithelium </li></ul><ul><li>2- abnormal squamous epithelium </li></ul><ul><li>3- immature normal squamous epithelium </li></ul><ul><li>Usually colposcopic derived biopsy will be taken from the most abnormal epithelium to confirm the diagnosis . </li></ul><ul><li>if the transformation zone extends up to the canal out of the view colposcopy is unsatisfactory </li></ul><ul><li>ENDOCERVICAL CURETTAGE (ECC) </li></ul><ul><li>ECC is sampling the cells inside the cervix (i.e. the endocervical canal), higher than the colposcopist can see. This involves scraping inside the cervical canal with a small sharp instrument and collecting the cells, mucus, and bloody material in preservative for histological analysis. Some colposcopists sample the endocervix with an endocervical brush instead, or may use an endocervical brush to remove the tissue, if an ECC is done. </li></ul>
    27. 30. <ul><li>Treatment for CIN </li></ul><ul><li>Ideally, the natural immune response would be powerful enough to eradicate any low-grade CIN or tissue abnormalities. </li></ul><ul><li>Observation and repeat Pap smears and biopsies can confirm such spontaneous self-correction. Currently, there is no treatment per se for CIN I, which either resolves or progresses to CIN II, which is treated. </li></ul><ul><li>If CIN does not resolve but instead progresses, or is detected at CIN stage II or III, treatment is needed to prevent the development of invasive disease. </li></ul><ul><li>CIN lesions may be treated on an outpatient or inpatient basis . </li></ul>
    28. 31. <ul><li>Outpatient techniques include </li></ul><ul><li>*laser vaporization or excision </li></ul><ul><li>** loop electrosurgical excision procedure (LEEP); </li></ul><ul><li>Inpatient techniques include </li></ul><ul><li>*cone biopsy or cervical (cold knife) conization, which involves removing a cone-shaped portion of the cervical tissue, </li></ul><ul><li>** simple hysterectomy. </li></ul><ul><li>Some strategies, like LEEP or cone biopsy, combine diagnosis and treatment by removing all abnormal tissue. CIN II-III often can be treated with outpatient techniques; higher-grade CIN likely requires inpatient treatment. </li></ul>
    29. 32. Fig. 6 Punctation seen with carcinoma-insituand microinvasion. Fig. 8 Loop diathermy apparatus
    30. 33. <ul><li>If a hysterectomy is performed because of abnormal smears, annual vault smears should be performed. </li></ul><ul><li>There is growing evidence to suggest psychosexual morbidity following investigation. Patients need to be approached with confidence and sensitivity. </li></ul><ul><li>CIN III </li></ul><ul><li>The recurrence rate about 9% after 10 years & 4 times invasive carcinoma than normal population. </li></ul><ul><li>Smears should be repeated every year in the 1st 10 years after treatment </li></ul>
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