Gynaecology Thrissur

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Articles for the practicing clinician.

 Fibroids

Ovarian cysts 

Vaginal discharge

Endometriosis  

Dysfunctional uterine bleeding 

Infertility  

Anovulation   Contraception   Menopause   Chronic pelvic pain 

 

Physiological causes of leucorrhoea:

 The term leucorrhoea is used to denote a simple increase in normal vaginal secretions, but currently it is used to describe every white discharge of a non-purulent nature.  The physiological causes of leucorrhoea are

a)                Ovulation: when the high peak of estrogen provokes the endocervical glands into excessive secretions.

b)    As a result of sexual stimulation.

c)                Premenstrual congestion.

d)    During pregnancy.

 

 Leucorrhoea in the premenarchal age group:

  Any foreign body should be looked for and removed.

In infective leucorrhoea, a course of anti-infective agents could be given.

 A proper cleaning of the vulval region followed by application of estrogen cream helps to increase the thickness of the vaginal epithelium and reduces the vulnerability of the vulval region to infection. 

Low dose estrogen tablets of Estriol (Evalon)1mg for 10 days or estradiol (Lynoral) 0.01mg daily for 3-4 days is also helpful.

 

Causes of leucorrhoea in the reproductive age group:

Broadly, the causes of vaginal discharge could be classified into

1)                Infectious causes: These include bacterial vaginosis, vulvovaginal candidiasis, trichomonas vaginitis, mucopurulent cervicitis, gonorrhea, condyloma accuminata, herpes type2 virus and cytolytic vaginosis.

2)     Normal discharge secondary to hormonal changes: These could occur due to physiologic leukorrhea (midcycle cervical mucus/postintercourse) or atrophic vaginitis.

3)     Other causes: There may be chemical/allergic vaginitis, foreign body, desquamative inflammatory vaginitis, chronic cervicitis, cervical ectropion, cervical polyps, cervical and endometrial cancer and collagen disorders.

 

Vaginal discharge in a postmenopausal woman:

A:  In women who are not on estrogen replacement therapy, there is relative lack of estrogen effect in postmenopausal women. Hence in postmenopausal women, most cases of vulvo- vaginitis are due to atrophic vaginitis. This is changing with an increasing trend to use estrogens in postmenopausal women for the prevention of osteoporosis and general sexual well being.  In senile vaginitis, or atrophic vaginitis, a purulent and often slightly bloodstained discharge is evident.  The vagina is inflamed and oedematous.  Vulva is inflamed, tender and excoriated.  The raw inflamed areas may become adherent and produce an obliteration of the canal, causing the infection to spread upwards into the cervix and endometrium, leading to pyometra.  Senile vaginitis can mask a hidden cancer of the endocervix or endometrium.  Hence it must be investigated by doing a diagnostic curettage.Mainstay of treatment in senile vaginitis is to improve the resistance of the vaginal epithelium by giving estrogen.  Estrogen also raises the glycogen content of the vagina and lowers the vaginal pH, making it more acidic and inhibits the growth of organisms.  Estrogen creams applied locally twice is effective in these cases.

 

Bacterial vaginosis:

Bacterial vaginosis is the most common cause of vaginal discharge.  In this condition, there is bacterial overgrowth, primarily anaerobes, without signs of inflammation.

Presentaion: The patient may present with a fishy-smelling increased vaginal discharge not accompanied by leukorrhea, vulvar burning, or pruritis.

Aetiology:Its presence represents a change in the vaginal ecosystem, specifically a decrease in lactobacilli, which is part of the normalflora; a proliferation of pathogenic inhabitants of the vagina; and an elevation of pH (>4.5).

Sexual transmission:Whether BV is sexually transmitted remains unsettled. The majority of observations, suggests that BV is probably not sexually transmitted.

Diagnosis:  The diagnosis of BV requires the presence of at least 3 of the following 4 criteria: 1.A homogenous noninflammatory discharge (not many WBCs).

Treatment: The various modalities are:

1.Metronidazole 2g PO as single dose or 500mg PO twice daily for 7 days. 2..Metronidazole gel given as suppository b.i. d for 7 days.

3.Cindamycin 300mg PO b.i.d for 7 days.

4.2% clindamycin cream b.i.d for 7 days.

5. Ampicillin had been suggested in the past for bacterial vaginosis, but is not effective.

6. In pregnancy, the recommended regimen is metrondazole in the dose of 250mg three times daily for 7 days.  It is contraindicated in first trimester. Alternative regimens in pregnancy are with 2g single dose orally, or local cream.

Alternative regimens in pregnancy are with 2g single dosing orally, local cream applications or Clindamycin 300mg b.i.d for 7 days. The cost of therapy for Clindamycin comes to about Rs.160/day in India.It is safe in pregnancy. 

Complications: Infection with BV has been associated with an increased risk of septic abortion, premature rupture of amniotic membranes, preterm labor, preterm delivery, post-Cesarean endomyometritis, and post-hysterectomy pelvic cellulitis.

 

Trichomonial vaginitis:

A: Trichomonal vaginitis is caused by the protozoan Trichomonas vaginalis, a motile organism with four flagella,It accounts for 10 to 25 percent of vaginal infections.It is sexually transmitted and may be identified in 30 to 80 percent of the male sexual partners of infected women. Trichomoniasis is associated with and may act as a vector for other venereal diseases. Studies indicate that this infection increases the transmission rate of the human immunodeficiency (AIDs) virus. 

Presentation: There is copious, malodorous, yellow-green (or discolored) discharge,pruritus and vaginal irritation.  There may be no symptoms in 20 to 50 percent of affected women.  On examination there may be vulvar and vaginal edema and erythema.  The cervix may have a strawberry appearance in 25% of women. The vaginal pH is elevated (>4.5) Microscopic examination will show many trichomonads and many polymorphonuclear cells.

 

 Treatment:

1.Metronidazole 2g orally in a single dose.

2. Metronidazole could be given in the the dose of 500mg twice daily for 7 daily as an alternative.

3. Clotrimazole, another nitro-imidazole compound similar to metronidazole, has been reported to attain nearly a 50% cure rate when given as an intravaginal cream. 

3.Sexual partners should be treated simultaneously even if they are asymptomatic.

 4. Recurrences should be treated with 2gm daily for 3-5 days. 

 

Vaginal candidiasis:

Vulvovaginal candidiasis is a common cause of vaginitis in women. In 80-90% of cases, the causative organism is Candida albicans.

Predisposing factors: Risk of this infection is increased in women who use oral contraceptive pills, a diaphragm and spermicide, or an IUD. Other risk factors include young age at first intercourse, intercourse more than four times per month and receptive oral sex. The risk of vulvovaginal candidiasis is also increased in some women who have diabetes, are pregnant or are taking antibiotics.

Presentation: Women with vulvovaginal candidiasis frequently complain of pruritus, vaginal irritation and dysuria. In vulvovaginal candidiasis, the discharge is usually white and thick, with no odor and a normal pH. Women with candidiasis can have vulvar and vaginal erythema and, occasionally, scaling and fissures of vulvar tissue.

Diagnosis:  Microscopy of the discharge with 10% KOH will often reveal hyphae or budding yeast in 50%-70% of cases C albicans organisms are easiest to identify, as they have long hyphae with blastospores along their length and a terminal cluster of chlamydia spores.                                                      

 Treatment:Vulvovaginal candidiasis could be treated with intravaginal creams or pessaries or oral drugs.   Recommended intravaginal agents are:

1.   Butoconazole 2% cream, 5 g intravaginally for 3 days.

2.   Clotrimazole 1% cream, 5 g intravaginally for 7 to 14 days.

3.   Clotrimazole 100 mg vaginal tablet daily for 7-10 days.

 4.  Clotrimazole 100 mg vaginal tablet, two tablets daily for 3 days.

5 .  Clotrimazole 500 mg vaginal tablet, one tablet in a single application.

6    Miconazole   2% cream, 5 g intravaginally for 7 days

7.   Miconazole 200-mg vaginal suppository, one daily for 3 days.

8.   Miconazole 100-mg vaginal suppository, one daily for 7 days.

9    Nystatin   100,000-unit vaginal tablet, one   daily for 14 days

10. Tioconazole 6.5% ointment, 5 g intravaginally in a single application.

11. Terconazole (Terazole) 0.4% cream, 5 g intravaginally for 7 days

12 Terconazole 0.8% cream, 5 g   intravaginally for 3  days

13. Terconazole 80-mg vaginal suppository, one daily for 3 days.

 Recommended oral agents:

 Fluconazole 150-mg tablet taken orally in a single dose or itraconazole 200 mg orally in a single dose.

Complications& sexual transmission: Complications of vulvovaginal candidiasis are rare. Chorioamnionitis in pregnancy and vulvar vestibulitis syndrome have been reported.  Candidal organisms are not transmitted sexually, and episodes of vulvovaginal candidiasis do not appear to be related to the number of sexual partners.  Treating the male partner is unnecessary unless he is uncircumcised or has inflammation of the glans of the penis.

 

Recurrent candidal vaginitis:

  Recurrent infections may be treated with a weekly administration of fluconazole 150mg for up to 12 consecutive weeks. An alternative topical maintenance regimen consists of clotrimazole vaginal suppositories 500 mg weekly. When infection is related to menstruation, 100-mg clotrimazole vaginal suppositories nightly for several days preceding menstruation may be effective. But it must be remembered that 15% of women harbour yeast organisms in their GI tract and for these women, local treatments may not be effective and oral preparations may be the only solution.  It is important to avoid douching and wearing tight underclothings to prevent recurrences. Tight undergarments tend to retain moisture in the vaginal secretions.Immunosuppressive factors like diabetes should be looked for and treated.

As a preventive measure, it has been found useful to give two additional doses of Fluconazole on days 14 and 35 to women having severe infections with Candida Albicans.

 

Cytolytic vaginitis:

A: Cytolytic Vaginosis is a condition thought to be caused by an overgrowth of lactobacilli and possibly other bacteria, which causes cytolysis of vaginal epithelium and a frothy white discharge. Symptoms, which usually increase during the second half of the menstrual cycle, include dyspareunia, vulvar pruritus, and dysuria. Physical examination is remarkable for the presence of white frothy discharge and a pH level between 3.5 and 4.5.

Diagnostic criteria:

The four diagnostic criteria observed on wet mount are:

1.Absence of Trichomonas, bacterial vaginosis, and Candida;

2. Few leukocytes;

3.Increased lactobacilli;

4. Cytolysis of vaginal epithelial cell.

Patients with cytolytic vaginosis are frequently misdiagnosed as having chronic yeast infections and treated unsuccessfully with various antifungal medications, especially when the health care provider relies on the patient’s symptoms and not on a thorough examination of the wet mount.  This is treated with sodium bicarbonate douches two to three times a week and then once or twice a week as needed to increase the pH of the vagina and decrease the amount of lactobacilli. The recommended douching solution should include 30 to 60 g of sodium bicarbonate to 1 L of warm water.

 

Cervical ectropion:

Cervical ectropion is the new terminology for what was previously known as erosion of the cervix.  It indicates migration of endocervical epithelium over the surface of the cervix. This lesion is usually symmetric about the os and is not particularly friable. It is accompanied by a mucoid cervical discharge. Ectropion is more common in women taking oral contraceptives, and the increased amount of exposed columnar epithelium may contribute to the greater risk of chlamydial infection among women taking oral contraceptives. It is often impossible on clinical grounds alone to differentiate ectropion from true infection. Levofloxacin once-a-day therapy can be useful for uterine cervicitis.

 

Q: What are the causes, presentation and treatment of mucopurulent cervicitis?

A: Normal cervical discharge is clear and mucoid. Purulent or mucopurulent discharge is associated with gonococcal or chlamydial infection. Chlamydial infection of the cervix is usually associated with hypertrophic cervicitis.  On examination the cervix may appear normal or exhibit edema, erythema, and hypertrophy with a mucopurulent discharge from the os . Mucopurulent cervicitis caused by Chlamydia trachomatis is characterized by a thick yellow-white discharge coming from the cervical os in conjunction with 10 or more leukocytes per microscopic field (high-power oil immersion) on Gram’s stain examination. Because the diagnostic tests and treatments for cervicitis are different from those for vaginitis, it is important to differentiate these conditions. Several clues can help to rule out cervical infection as the cause of a vaginal discharge. Almost 90 percent of symptomatic or asymptomatic women with chlamydial cervicitis meet at least two of the following criteria: (1) younger than 24 years, (2) sexual intercourse with a new partner in the previous two months, (3) presence of mucopurulent cervicitis, (4) cervical bleeding induced by swabbing the endocervical mucosa and (5) no form of contraception. 

 Treatment:

 1.Doxycycline (100 mg twice a day for 7 days)

2.Erythromycin (500 mg four times a day for 7 days), with treatment of the partner and follow-up culture 1 week after completed treatment.

3. Azithromycin 1gm as a single dose is as effective as Doxycycline 100mg /day for seven days, but is more expensive.

4. Levofloxacin 250mg once -a-day for 7 days can also be useful on uterine cervicitis.

 

Gonococcal cervicitis:

 In typical cases of gonococcal cervicitis the cervical os is reddened and produces a purulent discharge.

Laboratory detection: Polymorphonuclear cells are normally present in the endocervix, but abnormally increased numbers are suggestive of gonococcal cervicitis.  This can be detected crudely on a Gram stain of the endocervical material. After the endocervixhas been cleaned off, a swab is inserted into the cervix and gently rotated, and therecovered material is applied to a microscope slide by rolling the swab over an areaabout 1 × 2 cm. The specimen is then Gram stained. Observation of 10 to 30 PMNs

per oil-immersion field in the densest portion of the slide correlates statistically with the presence of gonococci or chlamydiae.

Treatment: One of four initial regimens-are recommended as initial therapy:

1) Ceftriaxone, 125 mg IM.(this drug probably aborts incubating syphilis also)

2) Cefixime, 400 mg orally.

3) Ciprofloxacin, 500 mg orally.

 4) Ofloxacin, 400 mg orally.

The major drawback of Ceftriaxone is the necessity for intramuscular administration. Ciprofloxacin and Ofloxacin should be avoided in pregnant women, and because they lack activity against Treponema pallidum, these drugs will not abort incubating syphilis. The efficacy of cefixime against incubating syphilis is uncertain.  Although cross-reactions between penicillin and the cephalosporins appear to be uncommon in persons treated for gonorrhea and although many clinics routinely use ceftriaxone, cefixime, or other cephalosporins to treat gonorrhea in patients with histories of penicillin allergy, the safest approach in such circumstances would be to use an oral fluoroquinolone. Regardless of the single-dose regimen chosen, the initial treatment should be followed by a regimen active against C. trachomatis. In addition to treating chlamydial infection, along with an attendant reduction in the risk of postgonococcal urethritis and salpingitis, giving a second drug may reduce the potential for selection of gonococci with increased antimicrobial resistance. The recommended regimens are doxycycline, 100 mg orally twice daily for 7 days, or a single oral dose of azithromycin 1.0-g.  The latter is highly effective against genital chlamydial infection.  A single dose of 2.0 g azithromycin is effective against both gonorrhea and chlamydial infection, but cost and gastrointestinal intolerance limit its utility. Erythromycin, in a divided-dose regimen totaling 2.0 g/day orally, is acceptable as follow-up therapy if neither azithromycin nor a tetracycline can be given.

 Pregnant women with uncomplicated gonorrhea should not be treated with quinolones or tetracyclines.

Spectinomycin is effective and safe but is less acceptable because of the increased likelihood of pharyngeal gonorrhea during pregnancy.  The efficacy of azithromycin in eradicating chlamydial infection has not been determined in pregnant women, and most authorities recommend following ceftriaxone with a 7- to 10-day course of erythromycin.

 

Infectious vaginal discharge: Treatment:
A: In most centers in India, gynaecology health providers do not take endocervical swabs for gram staining or do tests to detect chlamydia.  Treatment is essentially empirical.  In this scenario it is useful to remember that all fluoroquinolones are active against N. gonorrhoeae, and ofloxacin (but not ciprofloxacin) is active against C. trachomatis.  Neither ciprofloxacin nor ofloxacin is highly active against anaerobic bacteria. A regimen consisting of 14 days of treatment with oral ofloxacin plus metronidazole provides comprehensive coverage for all likely pathogens. Several studies have demonstrated good short-term outcomes in women with mild to moderate PID treated with ofloxacin alone,  and some investigators believe that most outpatients with acute PID can be safely treated without providing coverage for anaerobic bacteria(i.e, there is no need to add metronidazole to the regiment).  However, most authorities agree that it is prudent to routinely add metronidazole (or clindamycin) to improve coverage for anaerobic pathogens.

 

Herpetic cervicitis:

  Herpetic cervicitis may be present without external lesions. Cervicitis is seen on physical examination in about 90% of women whose cervical cultures are positive for herpes simplex virus.  The cervix usually displays diffuse friability and, less frequently,frank ulcers or necrosis.  Cervical discharge is usually mucoid, but it is occasionally mucopurulent, and in one series herpetic cervical infection caused 8% of cases of mucopurulent cervicitis.  Affected patients may have lower abdominal pain, but inguinal adenopathy is rare unless the disease is accompanied by lesions of the external genitalia because lymphatic drainage of the cervix involves the external iliac rather than the inguinofemoral nodes. First-episode primary genital herpes is characterized by fever, headache, malaise, and myalgias. Pain, itching, dysuria, vaginal and urethral discharge, and tender inguinal lymphadenopathy are the predominant local symptoms. Widely spaced bilateral lesions of the external genitalia are characteristic Lesions may be present in varying stages, including vesicles, pustules, or painful erythematous ulcers. The cervix and urethra are involved in more than 80% of women with first-episode infection.

Laboratory diagnosis: The diagnosis of herpetic cervicitis may be made cytologically by observing multinucleated giant cells, often with intranuclear inclusions.

 

Treatment of genital herpes:

A:  Acyclovir, Famcyclovir and Valacyclovir are useful in the treatment of genital herpes The dosage schedule for Acyclovir is given below:

First episode:

Acyclovir:    PO 200 mg 5 times daily for 7 days or 400mg tid for 10 days.

 Recurrence:

 Acyclovir: PO 200 mg 5 times daily or 400 mg tid for 5 d.

Suppression:

Acyclovir: PO 400-mg bid or 200 mg tid for up to 5 y.

 

Cervicitis: Aetiology:

Human papillomavirus, particularly certain subtypes, frequently infects the cervix.  It  has been observed since 1837 that cancer of the cervix behaves epidemiologically as if it were a sexually transmitted disease. The strongest infectious association with cancer of the cervix has been established for some types of human papillomavirus. Other organisms occasionally considered causes of cervicitis include adenovirus, measles virus, cytomegalovirus, Enterobius vermicularis, amoebae,M. tuberculosis, group B streptococci, N. meningitidis, and actinomycetes, the last usually in association with the use of intrauterine contraceptive devices. The chancre of syphilis sometimes manifests as a cervical lesion.

Herpes in pregnancy:
 In general, the clinical manifestations of recurrent genital herpes, including the frequency of subclinical versus clinical infection and the duration of lesions, pain, and constitutional symptoms are similar in pregnant and nonpregnant women. Recurrences appear to increase in frequency over the course of pregnancy. Among women who are HSV-2 seropositive entering pregnancy, several clinical series and a recent study indicates that there is no effect of recurrent clinical infection on neonatal outcome, including birth weight and gestational age. First-episode infections in pregnancy have more severe consequences to mother and infant.  Visceral dissemination during the third trimester occasionally occurs and prematurity or intrauterine growth retardation, or both, may be seen. The acquisition of primary disease in pregnancy carries the risk of potential transplacental transmission of virus to the neonate.Primary

HSV infection in pregnancy can result in spontaneous abortion, albeit this appears to be relatively uncommon.

 

Chronic cervicitis: Treatment:

 Chronic cervicitis is one of the common disorders encountered in daily practice. To overcome this problem,the first step should be antibiotic therapy in the acute phase. If this fails, the infection becomes chronic and may spread to internal genital organs leading to pelvic inflammatory disease and eventually to infertility. Chronic form of infection may lead to  the development of dysplasia and neoplasm. Hence if the patient does not improve after 2-3 months, minor surgical therapy is indicated.  Various methods such as electrocautery, loop diathermy, cryotherapy or laser are used to destroy the inflamed area if the chronic cervicitis is accompanied by ectropion.

1.The procedure should be done in the first half of the cycle, as there is the danger of ascending infection and postoperative infection in the premenstrual period.  But puncture biopsy of nabothian cysts may be done at any time during the cycle. 

2. A vaginal cytology, and if possible a colposcopy should be done to know if there is cervical intraepithelial neoplasia. Carcinoma of the cervix or endometrium is a contraindication.

3.Pregnacy should be ruled out.

4. Any acute inflammation of the cervix should be treated, as doing the procedure on the cervix in the acutely inflammed state would produce spread of infection into the parametrial tissues.

Electocoagulation: Electocauterisation is done with either a thermal or a spark-type electrocautery n a radial strip fashion.  Because there are very few nerve endings carrying pain sensation from the cervix, this can be done in the office without anesthesia. After the procedure, the patient should be administered local creams or vaginal suppositories to aid healing.

Cryosurgery: Cryosurgery destroys tissue by freezing.  The refrigerants (carbondioxide, Freon,nitrous oxide, or nitrogen- all in liquid state) are passed through a hollow probe placed in the cervical canal and against the external os.  The advantages are the ease of administration and lack of discomfort as compared with thermal or electrocauterization.  This tratment method has the disadvantage of causing a profuse vaginal discharge for 2-3 weeks following its application. 

Laser: In laser (light amplification by stimulated emission of radiation) therapy, a high-energy beam of light in the infrared spectrum is directed to the cervix, resulting in complete vaporization of cells. As a result, there is no necrotic tissue slough and no resulting leukorrhea.  Disadvantages are the relatively large size and high cost of the equipment as well as the special training required.

Aim: The aim of these methods is destruction of infected tissues with subsequent healing by fibroblastic proliferation and reepithelialization.  Complete healing may take up to 6 weeks.  The cervix should be inspected again at the end of this time to be certain that healing is satisfactory.  If cauterization must be repeated, it should be done 1-2 months after the initial tratment to encourage healing.

Complications:  Reactivation of salpingitis may occur if treatment is done in the presence of acute cervicitis.  Cervical stricture may follow deep cauterization carried high into the endocervical canal.  Cauterization or freezing of a cervix that contains an unrecognized malignant tumour will mask the neoplastic process, resulting in further delay in its recognition and perhaps serious consequences. 

 

Cervical intraepithelial neoplasia:

 Cervical intraepithelial neoplasia is a premalignant lesion of the cervix.There is abnormality of cervical epithelium displaying proliferation of parabasal cells with disordered polarity, loss of cellular junctions, coarse nuclear chromatin clumping, abnormal nuclear cytoplasmic ratio, and high mitotic index. Reported as grades I (low grade) to Ill (high grade, including carcinoma in situ) dysplasia  It remains asymptomatic and can be diagnosed only on routine screening. McIndoe (1984) concluded that women with cytological evidence of continuing neoplasia afer initial diagnosis of carcinoma in situ of the cervix had an 18% chance of developing invasive cancer of the cervix or vaginal vault at 10 years and a 36% chance at 20 years.  Routinely screening women with vaginal cytology and coloposcopy can pick up these women and prevent them from progressing to carcinoma cervix.

 

 Pap smear:

A: Pap smear is vaginal cytology, where exfoliated cells from the vagina are examined for various purposes. It was introduced by Papanicolou and can be used to screen women for premalignant lesions of the cervix.  It is important to remember that it is only a screening procedure and not a diagnostic procedure.  Suspicious cases found on Pap smear need further evaluation with colposcopy, simple biopsy or cone biopsy. The physician cannot rely on the Pap smear alone to be diagnostic for that particular lesion.

Pre-procedure precautions: The Pap smear is best performed during midcycle. The patient should avoid douching, vaginal medications, and intercourse for 24 hours prior to the procedure. Reschedule the examination if the patient is actively menstruating.

Procedure: 1.Clarify the patient’s risk factors for cervical dysplasia by history.

2. Label the end of a glass slide with the patient’s name and other identifying data as necessary.

3. Insert speculum and adjust it to obtain adequate visualization of the cervix.

4. Determine whether the vagina or cervix appears inflamed or infected. Avoid rubbing or otherwise traumatizing the cervix.

5. Identify cervical landmarks, including the transformation zone with its squamocolumnar junction. Note the nature of the cervical mucus. Excess mucus or discharge may be gently blotted, not rubbed, from view. Note any gross cervical lesions such as erosions, leukoplakia, nabothian cysts, or condylomata

Examine the vaginal fornices for obvious abnormalities

6. Obtain the Pap smear by using an endocervical sampling device(Cytobrush,Papette,or Cervexbrush). If the two-sample method of obtaining cells is used,first insert the Cytobrush into the canal and rotate 90 to 180 degrees. Follow this by a gentle smear of the entire transformation zone with a spatula device, fitting the contour of the patient’s remaining transformation zone.Sampling the vaginal pool has little advantage during Pap smear screening unless the patient has had a hysterectomy. In this instance, be sure to sample the vaginal cuff. If vaginal abnormalities are seen, another Pap smear of these areas (using a spatula) may be submitted on a separate slide. Areas that appear abnormal on visualization will

   ultimately require colposcopy and biopsy.

7.The preparation is evenly applied to its appropriate slide immediately after sampling and then the slide is sprayed or dipped in preservative within 5 seconds and sent to the histopathologylaboratory.

8. Make sure the Pap smear requisition form includes all pertinent data regarding the patient. Be sure to include clinical findings, patient risk factors, or yourconcerns as part of this “referral”.

Interpretation and further management: All Pap smears reported as abnormal require some form of intervention. A report of dysplasia warrants colposcopy. Many clinicians recommend colposcopy for reports of atypia also, especially in patients with numerous risk factors.

Papanicolou classification and Approximate Comparative Nomenclature of Cervical Smears with CIN class;

 Class I: normal smear; no abnormal cells (CIN Class- normal)                    

 Class II: atypical cells; no neoplasia (CIN class-reparative or atypical)                    

 Class III: smear contains abnormal cells consistent with dysplasia

(CIN class- CIN I or II mild,moderate dysplasia)

Class IV: smear contains abnormal cells consistent with carcinoma in situ (CIN class- CIN III, CIS)

Class V: smear contains abnormal cells consistent with carcinoma of squamous origin                      

CIN class- carcinoma

* CIN = cervical intraepithelial neoplasia.

    CIS = carcinoma in situ.  

 

1.The American College of Obstetricians and Gynecologists (ACOG) recommends that all women who have been sexually active or are at least 18 years old undergo an annual Papanicolaou test (vaginal cytology) and pelvic examination. The ACOG and the US PreventativeService Task Force agree that if three annual Papanicolaou screens are normal,screening may be performed less frequently than yearly at the discretion of the physician based on the woman’s risk factors. Some clinicians will screen a subset of women with low risk factors every 3 years providing that there are three negative yearly Pap smears and the risk factors do not change.

High-risk groups for CIN are as follows: Genital HPV infection, Positive HIV status, Multiple sexual partners,Early age of intercourse,High parity,Cigarette smoking,Low socioeconomic status and History of prior sexually transmitted disease other than HPV.

2. Any visible or palpable lesion of the cervix. Follow precaution that Pap smear is not diagnostic and further assessment may be necessary.

3.Any abnormal vaginal bleeding or discharge.

4. Posthysterectomy (hysterectomy for benign disease): Every 3 years if patient’s risk for cancer remains low.

5. Posthysterectomy (hysterectomy for dysplasia, carcinoma): annually after three to four normal Pap smears at 4- to 6-month intervals.

6. Posttreatment for cervical dysplasia, malignancy: Every 4 months for three visits; every 6 months for two visits; annually thereafter.

7. Victims of rape, incest, abuse: As part of initial work-up. Repeat in 6 to 12 months.

8. Currently it is not considered necessary to continue screening beyond the age of 64 years, provided that: the woman has had three consecutive negative smears,the most recent one was done no more than three years previously.

Contraindications: There are no absolute contraindications to obtaining a Pap smear. Relative

contraindications include clinical circumstances where sample collection is difficult to obtain or difficult to interpret (e.g., active vaginitis or cervicitis, pelvic inflammatory disease [PID], or menses). The clinician must weigh the benefits versus the risk of obtaining the screening Pap smear under these circumstances. For instance, if a woman presents with abnormal vaginal bleeding, a Pap smear is advised, despite the presence of blood. This contrasts with a patient who comes in for a routine Pap smear screening and has begun to menstruate. In the later instance, the Pap smear can be deferred to a

more favorable time.

 

Atypical/ premalignant lesions of  the cervix: Management:

The following treatment modalities are useful in patients with CI N.

1) Chemical :Topical concentrated trichloroacetic acid (TCA 50% to 85%) or bichloracetic acids are desiccant acids that have been used to treat CIN.

2) Cold Coagulation: Cold coagulation is also a highly effective ablative treatment for CIS. The name iscounterintuitive: that is, this method involves heat destruction of tissue, although the amount of heat is less than that used with other coagulation methods. A 100°C Teflon probe is applied directly to the cervical tissue.

3) Cryotherapy: Cryotherapy is a relatively safe, easy, and inexpensive ablative treatment for CIN. As is true in any method of treatment for cervical dysplasia, the goal is destruction of the lesion, including the abnormal transformation zone.

4) Electrocoagulation: Cervical lesions have been treated with monopolar electrocoagulation for years with good success reported. With this method, there is a continuous flow of electrons from the generator to the handpiece tip back to the generator via the grounding pad and the patient. The electron flow is highly “channeled” through the small surface area of the handpiece tip and spread over a large-area grounding pad as the electrons make the circuit. The result is a concentrated thermal effect at the handpiece tip and no thermal effect at the grounding pad. At 45°C, irreversible tissue damage occurs that is notusually visible to the naked eye. At 100°C, desiccation occurs. At greater than 100°C, vaporization and carbonization occur. The most efficient way to obtain deep thermal damage at the tissue level is a low continuous current (e.g., cutting current) with a large-surface-area handpiece tip (e.g., a ball electrode). The ball should be used in contact mode (placed directly on the tissue) and held in place long enough to obtain deep penetration into the cervical glands. Firm pressure on the tip against the surface is essential to achieve the broad surface contact.

5)Laser Vaporization :Carbon dioxide laser vaporization continues to be used widely, with excellent success rates for treating CIN.

6)Excisional techniques: Excisional techniques have been an effective treatment for CIN for many years.

 Total Hysterectomy :Historically, hysterectomy was a mainstay of excisional therapy for CIS. With theadvent of more sensitive outpatient diagnostic modalities and less invasive treatmentmodalities, hysterectomy is now rarely indicated for CIN. Hysterectomy might beconsidered for (1) patients who have high-grade lesions who have failed conservativetreatments, (2) patients who have high-grade lesions who desire sterilization, (3) patientswho have high-grade lesions who cannot be treated adequately with local therapies, and(4) patients who have high-grade lesions who have no access for follow-up diagnosticprocedures after a conservative therapy. Disadvantages of hysterectomy are the

requirement for hospitalization, the requirement for regional or general anesthesia, theincreased surgical risk, and the risk for complications. It is sometimes more difficult diagnostically to follow-up vaginal neoplasia that occurs posthysterectomy.

Cold-Knife Conization :Excisional conization is the treatment of choice for patients with CIN and an unsatisfactory colposcopic examination. The cold-knife procedure involves surgical excision with a scalpel and requires an operating room and regional or general anesthesia. Cold-knife conization is largely being replaced with LEEP conization.

: LEEP/LLETZ : Loop electrical excision procedure and large loop excision of the transformation zone

(LLETZ) are relatively simple outpatient treatments for CIN. Indications for LLETZ are as follows: Unsatisfactory colposcopic examination

Treatment of biopsy-proven CIN 2, CIN 3, and CIS

Suspicion of squamous microinvasive disease or adenocarcinoma in situ

Persistent CIN 1 for 1 year or noncompliant patient.

Two-grade discrepancy between the cytologic, colposcopic, or histologic diagnos

Symptomatic cervical ectropion.

Reference:

Byrne.P,Nava.G., Premalignant lesions of the lower genital tract:Dtudd.J,Progress in Obstetrics in Obstetrics & Gynaecology: Vol6., 1987,Churchill Livingstone

Cervical smears., Internet article: http://www.allvitalpoints.com/Medical3/Cervical.htm.

 Dalgic H; Kuscu NK., Laser therapy in chronic cervicitis: Arch Gynecol Obstet 2001 May;265(2).

Egan.M.E., Diagnosis of vaginitis:American Family Physician:Vol 62 • NO 5 • September 1, 2000.

Flowers.L.C, Mccall.M.A., Diagnosis and management of cervical intraepithelial neoplasia: Obstetrics and Gynecology Clinics: Vol 28 • NO 4 • December 2001.

Goroll: Approach to a patient with vaginal discharge: Goroll: Primary Care Medicine, 4th ed., Copyright © 2000 Lippincott Williams & Wilkins.

Griffith.H.W.,  Complete Guide to Symptoms, Illness & Surgery, 1995 The Putnam.Berkley  Group, Inc.; electronic rights by Medical Data Exchange.

Hill.E.c., Disorders of the uterine cervix: Benson.R.C.,Current Obstetric & Gynecologic Diagnosis & Treatment. 5th ed,1984.Lange Medical Publications, California.

Jones.RB,Batteiger.B.E.,Chlmydia trachomatis:Mandell: Principles and Practice of Infectious Diseases, 5th ed., Copyright © 2000 Churchill Livingstone, Inc.

Gary R, Newkirk.G.R.,The Pap smear : Screening for Cervical Cancer: Pfenninger: Procedures for Primary Care Physicians, 1st ed., Copyright © 1994 Mosby-

Mikamo H – Effects of levofloxacin in once-a-day therapy on uterine cervicitis:Jpn J Antibiot - 01-Jul-1999; 52(7): 511-6 .

Nyrjese.P., Chronic vulvovaginal candidiasis: American Family Physician

Vol 63 • NO 4 • February 15, 2001.

Rein.M.F., Kapernick.P.S,et al., Vulvovaginitis and cervicitis: Mandell: Principles and Practice of Infectious Diseases, 5th ed.,

 Sobel.J.D., Treatment of complicated Candida vaginitis: Comparison of single and sequential doses of fluconazole:Am J Obst & Gyn :Vol 185 • NO 2 • August 2001.

Sparling.P.F,Handsfield.H., Neisseria gonorrhoeae: Mandell: Principles and Practice of Infectious Diseases, 5th ed.,

Tan HH; Chan RK: An open label comparative study of azithromycin and doxycycline

in the treatment of non-gonococcal urethritis in males and Chlamydia trachomatis cervicitis in female sex workers in an STD clinic in Singapore Singapore Med J - 01-Aug-1999; 40(8): 519-23 .

Woodward pharm.C., Drug treatment of common STD’s: Part II Vaginal infections,Pelvic inflammatory disease and genital warts: American Family Physician:Vol60 • NO 6 • October 15, 1999.    

    

 

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