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Cervical Screening and Colposcopy Update April 2019
- 2. Sarawak Gynaecology referral Pathways When&What to do Dr. Chai MC
- 3. • Standardised guidance •Evidence-based management • Fast and easy to refer • Simple and comprehensive • Enhance familiarization of management Pathways
- 5. 1. Cervical Screening& Colposcopy Pathways 2. Management of Cervical Cancer Pathways 3. Management of Endometrial Hyperplasia Pathways 4. Management of OvarianTumour Pathways 5. Management of Pregnancy of Unknown Location Pathways SGH Gynaecological Management Pathways
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- 7. 1.Cervical screening andreferral 2.Abnormal uterine bleeding and referral 3.Ovarian tumour and referral Content
- 10. Cervical Screening Cervical ScreeningIntervals A sexually active woman aged ≥ 25 years old should be offered yearly cervical screening initially, and if she has consecutive yearly normal cervical smears x2, routine screening (3 yearly/ 5yearly based on the age) is required thereafter. Age Group (Years) Routine Screening Intervals 25-49 3 yearly 50-65 5 yearly >65 Only screen those who have not been screened since age of 50 and who have had a recent abnormal smear
- 11. Cytology Regression at24 months Progression to HGSIL at 24 months Progression to invasive cancer at 24 months ASCUS 68.2% 7.1% 0.3% LGSIL 47.4% 20.8% 0.2% HGSIL 35.0% 23.4% (persistence) 1.4% CIN Regression Persistence Progression to CIN3 Progression to invasive cancer CIN 1 57% 32% 11% 1% CIN 2 43% 35% 22% 1.5% CIN 3 32% 56% - 12% Natural History of Abnormal Cytology Natural History of Cervical Intraepithelial Neoplasia (CIN)
- 12. Terminologies • Cervical smear •Pap smear, liquid based cytology • To detect precancerous cells • HPV triage • Virology testing to detect high risk HPV virus (16, 18, 31, 45) • Colposcopy • Examination under magnification • Cervical intraepithelial neoplasia (CIN) • Histology diagnosis (Biopsy) of the premalignant transformation of cervix
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- 17. Treatment for AbnormalOrganisms • BacterialVaginosis • T. Metronidazole 400mg BD x 1/52 • Trichomonas vaginalis • T. Metronidazole 400mg BD x 1/52 • Treat the partner • Vaginal candidiasis • Clotrimazole pessary 200mg ON x 3/7
- 18. General Rules for Managementof Abnormal Cervical Smear Squamous Cell Abnormalities Glandular Cell Abnormalities • Unsatisfactory smear Repeat in 3 months, if still unsatisfactory → colposcopy (non-urgent) • Inflammatory smear Treat infection or atrophy Repeat in 6 months If inflammatory smear x 3 → colposcopy (non-urgent) • Atypical squamous cells of undetermined significance (ASCUS) HPV triage/repeat smear in 6 months/colposcopy (non- urgent) • Low-grade squamous intraepithelial lesion (LGSIL) Colposcopy (non-urgent) • High-grade squamous intraepithelial lesion (HGSIL) Colposcopy (urgent) • Atypical squamous cells – cannot exclude HGSIL (ASC – H) Colposcopy (urgent) • Squamous cell carcinoma Refer gynae-oncologist urgent • Atypical glandular cells not otherwise specified (AGC – NOS) Colposcopy (non-urgent) + endocervical curettage ± endometrial sampling • Atypical glandular cells favour neoplasia Colposcopy (urgent) + cone biopsy + hysteroscopy and endometrial curettage • Endocervical adenocarcinoma-in-situ Colposcopy (urgent) + cone biopsy • Adenocarcinoma Refer gynae-oncologist urgent 5-yr cancer risk: 8% 5-yr cancer risk: 2% 1/3 – 2/3 are non-HPV related
- 19. WHENEVERTHERE ISAN ABNORMAL SUSPICIOUSLOOKING GROWTH OVERTHE CERVIX, REFER O&G SPECIALIST URGENT FOR ASSESSMENTAND BIOPSY!!!!! (DO NOT PROCEEDWITH PAP SMEAR ONLY)
- 20. Case Scenario • 35year-old woman went to KK for routine pap smear. Speculum showed a mass 2x2 cm over anterior lip of cervix. Pap smear was done.
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- 22. • Heavy menses •Irregular menses • Prolonged menses • Inter-menstrual bleed • Post-coital bleed • Post-menopausal bleed Abnormal Uterine Bleeding (AUB)
- 23. PALM-COEIN Classification Make surerule out PREGNANCY!!!
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- 25. HISTORY Menstrualhistory Associated Symptoms: Compressive symptoms, Anaemia symptoms, Symptoms suggestive of systemic causes (hypothyroid, bleeding disorders, polycystic ovarian syndrome), PID Cervical smear history Contraception history Sexual history and fertility desire Family history of malignancy/bleeding disorders Past medical history Past surgical history Drug history: over-the-counter or natural/herbal remedies (may interfere ovulation/associated with bleeding) – anticoagulants, antidepressants, antipsychotic, corticosteroids, Tamoxifen, ginseng
- 26. PHYSICAL EXAMINATION General: pale,bruises, body mass index (BMI), blood pressure, pulse rate Abdomen: mass/uterus Speculum: cervix/vagina mass Bimanual examination of uterus and adnexal structures INVESTIGATIONS Urine pregnancy test Full blood count Coagulation profile Anaemic workup: peripheral blood film, serum iron + ferritin, serum folate, serum B12, Hb electrophoresis Hormonal profile Transabdominal/vaginal scan: uterus size, fibroids, endometrial thickness, polyps, ovarian cyst, hydrosalpinx Cervical smear Endometrial sampling (pipelle sampling can detect over 90% of endometrial cancer) o Age >40, o Younger women with risk factors (BMI>30, nulliparity, PCOS, DM, HNPCC, oligomenorrhoea suggestive of anovulation) o Failure of medical treatment, o Intermenstrual bleed,
- 27. 1. Structural abnormalityrequiring surgery (polyps, big fibroids) 2. Suspecting malignancy (postmenopausal bleed, thickened ET, cervical mass) 3. Failed to response to medical treatment 4. Endocrinology disorders: Refer medical team When do you refer??
- 28. RED FLAGS!!! –REFER!!! •Non-cyclical PV bleed •Intermenstrual Bleed •Post-coital bleed
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- 30. 1. Bilateral 2. Multilocular 3.Solid Areas 4. Ascites 5. Metastasis Criteria for complex ovarian tumour
- 31. Simple cyst <5cmis likely to be physiological and almost always resolve within 3 menstrual cycle
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