# Anatomy and whatever

● Vulva nerve innervation:

Most → Pudendal n.
Ant to urethra → IlioInguinal n. & GenitoFemoral n.

Pudendal n block wont affect the area ant to urethra, so in case of ParaUrethral Tear a
SubCut anesthesia will be needed

cercix

vagina

Hymen

vestibule

Labia minora

Posterior part of ​vestibule ​= fourchette

4 ​Uterus Ligaments 4 ​Uterus folds

Round VesicoUterine

Uterosacral RetroUterine

Cardinal (Mackenrodt) Mesosalpinx x2

Pubocervical

● Fallopian tube anatomy

Interstitial portion​ (Cornual ect preg happens here)
Isthmus​ & its ​narrow par​t
Ampulla​ \
Infundibulum ​ |- are mobile bc mesosalpinx
Fimbriae​ / doesn't cover it
● Pfannenstiel incision
separate Ant. rectus sheath from Rectus Abd muscle then cut in linea alba, Now we
have a mobile Rectus to move aside and reach the pelvis
This is bc below Arcuate line Rectus is connected to sheath only on Ant part
We like it bc:
# no cut of the muscle → less risk for hernia
# cosmetically good bc scar covered by pubic hair

● Cherney incision
Like pfannenstiel, but w/ cut of Tendineous part of Pubis symphysis

● Maylard incision
Transverse cut of Rectus m. along Langer lines (so kinda good cosmetically)
Important to take care of Inf. Epigastric a.
Ligate - if u need more view
(or)
Retract

● Langer’s lines
Lines according to Collagen orientation (usually ┴ to muscles)
Incision along these lines are cosmetically better

● Vertical incision
For big exploration (eg. Cancer)

● Nagele [Neygel] Rule

By knowing Last Menstruation Date we can estimate the Date of Delivery
LMP + 7 days - 3 months + 1 year (or) LMP + 7 days + 9 months
LMP = first day of Last Menstruation Period

● Signs of pregnancy
Presumptive signs of Pregnancy (skin)
# Chadwik sign - Dark discoloration on vulva
# Pigmentation on the skin
Linea neagra - on lower abdomen
Cholasma - under the eyes (can also be OCP SE)
Probable signs of pregnancy (by Labs or Uterus)
# Piskacek sign - enlargement of 1 cornu (horn of uterus)
# Hegar sign - compression of connection bw fundus and cervix by palpation
# hCG tests
Positive sign (by USG)
# Gest sac - 3-4 wks
# Embryo in the sac - 5 wks
# cardiac activity - 6 wks
# movement - 8 wks
● Dysmenorrhea = pain during menses
Mittelshmitz = pain in Mid-Cycle due to ovulation, it’s normal

hyperTrichosis Hirsutism

All over the body Androgen specific areas: Chest, Face,

Back, Linea alba, Medial thigh

● ParaRectal stomach metastasis = Schnitzler metastasis

Originally was found by palpation of Douglas pouch on Bimanual Exam
#1 Lecture: History, Examinations, symptoms

● Perform breast exam only at follicular phase (right (A) menses) as the breast may be
rigid/tender at luteal phase

● w/ breast palpation its important to palpate the lymph nodes as well

Supra- & Infra-Clavicular, Axillary

● Episiotomy = cut the vagina down during delivery if its a difficult delivery

● Pain = tubal disease

Uterus isnt painful

● Rectovaginal exam for children, virgins, elderly

● Amenorrhea Progesterone Challange

10 mg PO daily for 7-10 dd
(or)
Once IM 100-200 mg
+ test = bleeding in 1-2 wks

… ‫יש עוד שיטות ל‬AMENORREA ‫בהרצאה‬

● Schiller test [colposcopy]

Introduce Schiller Iodine solution (or) Lugol Iodine solution to cervix
Normal cervix cells contain Glycogen and with Iodine itll stain brown
If areas appear pale → suspect cancer (so take biopsy)

● Pelvimetry
Need to know steps and what to measure (from e-mail)

● Symphyseal-Fundal height
SFH ~ wks of Gestation ​+/- 2
[cm] ~ [wks]
#2 Lecture: Menstruation and Ab(N) Uterine Bleeding

● The Dominant Follicle is 2cm in size so can be seen on USG & helps determine
ovulatory phase

● Ab(N) bleeding:
Heavy (PALM COIEN)
Precoucious puberty (< 9 yo)
Post Menopausal (Menopause = 1 year w/o menses)

● Menstrual cycle characteristics

Frequency 24~38 dd
Regularity +/- 7~9 dd
Duration of bleeding < 8 dd
Volume < 80 ml [Avg = 35 ml]

● Disorders naming:
↑ Vol = Heavy
Defined not by volume, but by How it affects quality of life:
Physically (eg. Anemia and shock)
Socially & Emotionally (eg. cant go to city pool)
Material (eg. got fired bc she missed work due to bleed)
Regularity: Irregular (or) Absent
Frequency: Frequent (or) Infrequent
Duration: Prolonged (or) Short
Ovulation
Dysmennorrhea

● Classification systems
#1: by description of bleeding (frequency,regularity, volume, duration)
#2: PALM COEIN
PALM Dx by USG, histology …
COEIN Dx by ​order ​of CIONE:
1. Check coagulopathies
2. Iatrogenic (OCP, GnRH analogs, IUD, carbamazepine, rifampin)
3. Ovulatory esp. Anovulation in young kids / Premenopausal
Mechanisms​:
# Persistent dominant follicle makes too much Est.
# Follicular atresia
 (no selection of 1 follicle, many follicles make lots of Est)
4. Not otherwise specified
Rare diseases like: Chronic Endometriosis, AV malf.
5. Endometrial dysfunc.
Dx by exclusion
Problem w/: Fibrinolysis, PG, Inflamm mediators

#3 Lecture: PID

● How to describe PID?

Upper Genital Tract inf.​ ​ hat m/o​ (N.gono/C.tracho)
W ​Stage

● Clinical ▲:
Lower Abd tenderness
Adnexal tenderness & Cervical motion tenderness (chandelier sign)
Fever

● Criteria, staging, grading in Lecture

● Bacterial Vaginosis ​Amsel Criteria ​2/4

White discharge
Clue cells
pH >4.5
Fishy odor on whiff (KOH) test
There’s Nugent criteria by bacteriology
Usually Bacterial vaginosis doesnt go up causing PID and endometritis but can in case
when some procedures are done, like IUD

T. vaginalis Candida

Strawberry cervix Cottage cheese and Itching

Purulent discharge pH < 4.5

Dx: NAAT test & wet mount Dx: microscopy

● How do Chlamydia and Gono go up to cause PID?

They infect sperms which move up then get to Tubes and infect them
● Tx: BV (vs) T.vaginalis
 Gardenella & anaerobes Trichomonas

Metronidazole 0.5g twice daily for 7 dd

Clindamycin Tinidazole (clinda wont work)

Dont Tx partner Tx partner

● Gonococci can be Tx by:

Ceftriax + Azithro
(Azithro not for Chlamydia but for ceftriax resistant gono)
Or
Ceftriax + Doxy

Out px In px

Cefoxitin & III gen Cephalosporine Cefotetan Cefoxitin Clinda

Ceftriax probenecid + 2g IV every 12 hh 2g IV every 6 hh 0.9g every 8 hh
+ + Doxy + + +
Doxy Doxy + Doxy Doxy Genta*
+ + Metro
Metro Metro

Ceftriaxone - 0.25 g IM Doxy - 0.1 g every 12 hh

Doxycycline - 0.1 g twice a day for 14 dd Gentamycin* - loading dose 2mg/kg
Metronidazole - 0.5 g twice a day for 14 dd Maintenance dose 1.5 mg/kg every 8 hh

● PID can be caused by:

Chlamydia trachomatis
N. gonorrhea
G+ flora
G- flora
Anaerobes
That's why we use Broad spectrum antibiotics as in the table above

● TubOvarian Abcess
#1 try antibiotics
Works in 75% of cases and wont dmg fertility
#2 Laparoscopic (or) Percutaneous drainage
Laparoscopic is better bc ↓ risk for relapse
#4 Lecture: Amenorrhea

● Causes:
Hypothal
Kallman ,
functional
Pituitary -
adenoma ,
Sheehan
Endocrine -
↑/↓ Thyroidism ,
↑Androgens
Ovary -
gonadal dysgenesis,
gonadal failure,
PCOS (aka) Stein-Leventhal synd.
Outflow tract obstruction
Mayer Rikotansky Kuster Hauser synd (aka) Mullerian agenesis [MRKH]
w/o Uterus
Imperf. Hymen
Cervical agenesis
Transverse Vaginal septum
Asherman synd
w/ uterus

● Problems:
→ Infertility
→ No 2° sexual charact.
→ ↓Estrogen - osteoporosis, vaginal atrophy
EuEstrogen - ↑Risk for Endomet Carcinoma

● Estrogens → Thelarche
Androgens → Pubarche
GnRH--------------┐
LH/FSH |- any problem here causes 1 Amenorrhea
Est & Progest |
Outflow tracts ---┘

No Breast = No Estrogen
 & Dx at 14 years old (sooner, (vs) at 16 when breast is present)
No Uterus = ♂ (or) MRKH

● 4 subtypes:

B&U B & ​U
Always XX ♂ w/ CAIS
Outflow Tract Obst. (or)
Dx at 16 ♀ w/ MRKH
Check USG &/or MRI Dx at 16
Usually easy to Tx Check karyotype

B​ & U XY CAIS XX MRKH

Central
(or)
Ovarian
Dx at 14
Check FSH

↑ ↓ ​Central problem *** Testes have to be Male ​pyelogram ​as

HyperGonadotropic HypoGonadotropic removed ​(risk for MRKH is associated w/
HypoGonadism HypoGonadism Gonadoblastome) renal and ureter Ab(N)
Check Karyotype** Check MRI &
begin Hormone
# ​Turner (N) MRI Replacement Therapy
Streak gonads # ​Kallman synd (with Estrogens)
w/ Short stature & somatic # ​func ​Hypothal
Ab(N) Wont have kids of their own
Dx at delivery Ab(N) MRI Sexual life possible with surgery (vaginoplasty)
# ​Pure Gonadal # ​cong​. Defects
Dysgenesis # CNS tumors B ​& ​U
Streak gonads Esp. Always XY
No somatic Ab(N) Craniopharyngioma Enzyme def
Can be:
XX (or) Swyer Synd
# ​Mosaicism​ XX/XY 17-hydroxylase def 5a reductase def
# ​17a Hydroxylase def ​in No Testosterone Testosterone present
XX No DHT (Normal ♂ int. genitalia)
No DHT
w/ ↑MC [HTN & ↑K]

For ​Turner ​& ​Pure G dysg Kallman synd Tx

- in Swyer synd and - Hormone
mosaicism gonads should Replacement (Est &
be removed *** Progest) *
- Wont have kids of their - Later Ovulation
own induction with
- Hormone Replacement Leuprolide ​for
Therapy (w/ Est. & pregnancy
Progest) * Can have own kids
- can carry Pregnancy w/
ovum donation

No Breast = ​B
No Uterus = ​U

* [Progest to prevent Endomet cancer]

** ↑GonadoTropic ↓Gonadism check Karyotype to determine XX/XY/XO/mosaicism

(for mosaicism karyotype to >35 WBCs)

*** every XY with ♀ Ext. Genitalia testes should be removed to prevent:

Gonadoblastoma (benign) → Dysgerminoma (malignant)

● 2 Amenorrhea = when absent for 6 months

● PCOS Criteria 2/3:

↑ Androgens - Clinical (Hirsutism) or Biochemical
Anovulation
Polycystic ovaries on USG/Laparoscopy

● Hirsutism = ♀ with hair in Androgen sensitive areas like: Face, Back, inner thigh, chest

● 2 amenorreah causes:
Pregnancy
Ashemann
↓Est:
Hypothal.-Pituit. Dysfunc
↓ FSH/LH
↑/↓ Thyroidism
↑Prolact
Premature Ovarian failure
↑ And:
CAH
PCOS
HAIR-AN synd [HyperAnd Insulin Resistance Acanthosis Nigricans]

● NeoVagina creation (aka) Vaginoplasty

2 methods
Both should be done by the time the px plans to have Sexual intercourse
Frank method​ - takes wks~months to dilate the vagina
McIndoe vaginoplasty​ - uses skin graft
 ● Primary Ovarian Failure​ can be caused by ​Autoimmune ​attack but it’s a ​Dx of
exclusion
Exclude: Turner(XO) and Mosaicism(XX/XY) by Karyotyping & USG of ovaries

Autoimmune Mosaicism / turner

On USG Follicles are present No follicles

Prognosis May still have kids Cant have own kids

Perform Oophrectomy to
prevent Gonadoblastoma

● In Premature ovarian failure <30 yo always do Karyotyping

But in <40 yo px we will still do karyotyping to exclude mosaicism & Dx Autoimmune

● 2 Amenorrhea Algorithm

#1 check bhCG

(-) → #2 (+) → ​Pregnancy

Antenatal Care

#2 ​Endocrinopathies
Check Prolactin
check TSH

↑/↓ TSH → check free T4 Prolactin > 20 microg/L

Determine 1 (or) 2 Hyper-/Hypo-Thyroidism Repeat when px takes no Drug​s
If still High → ​MRI

#3 Progesterone Challenge

w/drawal bleeding No w/drawal bleeding

(Estrogen is present) check Estrogen test
check LH/FSH ratio No Bleeding → ​Outflow Tract Obstruction
LH/FSH > 2.5 → suspect ​PCOS ​(check criteria)
(N) ratio → ​Anovulation Bleeding → ​check LH & FSH

↑ FSH & LH ↓ FSH & LH

Primary Gonadal failure Central problem
check Karyotype GnRH stim test
Clomiphene test
To identify Secondary
(or) Tertiary cause
[Pituit (or) Hypothal]
 MRI
To identify Organic (or)
Functional cause
●

# Dysmenorrhea

● Primary Dysmenorrhea

#1 NSAIDS #2 OCPs If #1 && #2 dont work If Laparoscopy shows nothing

Mefanamic acid No ovulation → no pain Dx Laparoscopy Psychiatric consultation

Ibuprofen (bc pain is during
Naproxen Ovulatory phase)

● How to stop AUB medically:

- Estrogen then Progesteron
or
- only Progest
or
- Est + Progest

● Before Misoprostol administration for abortion use Ibuprofen to ↓ pain

# Pregnancy

● Gestational sac diameter on USG can estimate Gest Age

S ac diameter [mm] + 30 ± 3 = Gest. Age [days]

Crown-Ramp Length (CRL) is when embryo is seen

C RL [mm] + 42 ± 3 = Gest. Age [days]

At 6+ wks ♥ should be seen when embryo (CRL) is 5 mm

● Abortion 1st trimester

3 methods:
Vacuum
 D&C
Medical
# Procedural steps:
Paracervical Block​***​ → Cannula ​*** ​→ Mannual Vaccum Aspiration
Or
D&C
Vaccum is preferred over D&C
Always done <12 wks
# Medical
Misoprostol - Sublingually (or) vaginally
[bc orally will cause diarrhea and 1st pass will ↓concentration]
Mifepristone

***​ cannula diameter in mm ~ wks of pregnancy

4 wks use 4 mm cannula
5 use 5
…
12 wks use 12 mm cannula
***​ Paracervical Block
Use Lidocaine
But its toxic dose is >200mg
According to our teacher they use 3 times 2 ml of 2% lidocaine (which is 120mg
total)
Also be aware of complication - always aspirate before introduction to avoid
lidocaine in blood (will cause cardiac arrest/block or whatever)
He sent a video of this on email

● Abortion 2nd trimester

Dilation & Evacuation (w/ forceps & then curretage)
Or
Medical

● 1st trimester is considered until 14 wks

But 1st trimester abortions do untill 12 wks
2nd trimester is considered until 28 wks
But 1st trimester abortions do untill 24 wks
Why? Idk he said so…

● So, Abrtion in general

1st trimester 2nt trimester

Medical
or
 Manual Vaccum aspiration surgical D&E

Local anesthesia General anesthesia

[Paracervical Block]

Lidocaine induced ♥arrest Risks Most common cause of

death of abortion
(even more than
thrombosis, infection)

● Doderlein bacilli = Lactobacilli

● Late Prepuberty process (7-10 yo) → Puberty process caused by it

Adrenarche → Pubarche
Gonadarche → Telarche

● Gonadarche - when theres ↓ sens of GnRH cells to Estrogen (-) feedback

So theres ↑GnRH which is pulsatile but chaotic and ​nocturnal
LH is more sensitive to GnRH than FSH so in Gonadarche LH is the
characteristic gonadotropic hormone
LH/FSH ratio > 0.3
This process also continues to early Puberty 11-12 years

● Mid Puberty 12-14 yo

GnRH release transforms from pulsatile nocturnal to Adult type release (pulsatine
not just at night)
This causes ↑FSH which leads to:
Follicular maturation (↑Estrogens)
Sexual characteristics

# Ectopic pregnancy

● Clinical ​△:
Missed menses
Vaginal bleeding (usually Spotting)
Abdominal pain (usually lower adb)
● There are a lot of risks
The one with the highest OddsRatio is ​History of Ectopic Pregnancy
Other risks include: Salpingitis, Endometriosis, ruptured appendicitis, prior surgery …
Also associated with: Smoking, Infertility,​ IUD & OCP ***
***​Generally contraceptive ↓Risk for pregnancy but if Contraception fails and pregnancy
occurs it has a higher risk to be Ectopic
[bc Progesterone ↓ Tubal peristalsis]
● 3 Presentations of Ect Preg:

Acutely Ruptured Probable Ect Preg Possible Ect Preg

Sudden severe pain Typical clinical triad: Most common presentation

Dizziness & syncope Hemodynamically stable (+) Preg test w/ mild
Hypotension (+) Preg test symptoms
Anemic pale px Pelvic pain and Spotting

Acute Abdomen Peritoneal DDx: Initially Dx as PUL and

signs: Abortion (see algorithm) further investigation will be
Blumberg (rebound tend) Luteal Cysts needed
Abd Guarding Acute PID
Adnexal torsion
Shoulder pain is possible Leiomyoma
bc Acute Abdomen phrenic Appendicitis
n irritation Pancreatitis
Pyelonephritis

Surgical Emergency Surgery is recommended

Laparoscopy​ if
HemoDynamically stable
Laparotomy ​if HD
unstable

● Arias-Stella reaction
Thickening of Endometrium in response to hCG
● Possible pregnancies [(+) Preg test]
(N) Preg = IntraUterine Yolk sac (or) Embryo seen in Gest sac
AnEmbryonic Preg​*​ = Gest sac with nothing inside when hCG > Discriminatory Zone
Embryonic demise​*​ = Embryo is seen but no ♥ activity at 6 wks
Incomplete Abortion = placenta still inside
Complete Abortion = Nothing remains inside; hCG goes down normally
Ectopic Preg = Empty uterus with ExtraUterine Gest sac
PUL (Preg of Unknown Location) = Empty uterus with no Gest sac found yet
* ​- are considered Ab(N) IntraUterine pregnancies (see Algorythm)
● Discriminatory zone DZ = hCG levels at which embryo should already be seen
IntraUterine on USG (usually bw 1500~2000 IU/mL)
● Repeated hCG tests every 48 hh help determine Ab(N)ities
(N) ↑ in hCG = ↑ by > 35 %
(N) ↓ in hCG = ↓ by > 20 %
(N) ↓ in hCG using MTX for abortion = ↓ by > 15 %
● USG “double ring” sign of (N) Preg can be confused with ​Pseudodecidual Sac​ in Ect
Preg
To avoid confusion wait till u see Gest sac with yolk sac or Embryo inside
 ● Culdocentesis = aspiration from Douglas pouch
can be used if we know there’s IntraPeritoneal fluid but dont know what fluid exactly
Blood → Ect Preg
Pus → PID or whatever infection
Transudate → Ovarian cyst rupture
● Laparoscopy will be used as Emergency Dx in Acute Rupture presentation or PUL to find
the pregnancy
● Hacker p309 Algorythm
For​ Probable Ect Preg​ presentation

***
Definitive - Extrauterine Gest sac with yolk sac or embryo
Probable - Inhomogenous adnexal mass
free fluid in cul-de-sac

● Rupture Presentation will occur earlier in case of Ectopic Pregnancy in Isthmus

Bc ↓ diameter of isthmus makes it unable to distend
Other than that rupture in Ect Preg in Tubes will occur in ~ 7 wks

● MTX as Tx steps

Use 50 mg/m2

7 days later → hCG test for (N) ↓ w/ MTX (>15%)

(N) decline Ab(N) decline Undetectable hCG

Repeat dose & check in 7 dd ↑ MTX dose You have successfully

aborted the babyk

MTX containd:
HemoDyn unstable
Amnestic px (or) for whatever reason may not return to visit (to check hCG decline)
Known sensitivity to MTX (of course)
Immunodef
Liver, Kidney, Hematologic, Lung​ diseases
Peptic Ulcer
Breastfeeders
Preg related contraind
Gest sac > 3.5~4 cm
♥ activity on USG
hCG > 6K~15K

● Surgical Tx
We can use Salpingectomy (or) Salpingostomy
To determine which is better take in consideration these:
#1 check for Tubal dmg
Lot of dmg → Ectomy
Little dmg → Ostomy
#2 check for contralat Tube
Normal contralat tube → Ectomy is good
Damaged contralat tube → Ostomy to preserve fertility

After -ostomy u have to check hCG lvls to see if everything was removed successfully
# Infertility

● Infertility = no pregnancy after 1 year of frequent and regular Sexual intercourse

Subfertility = ↓ fertility but no absence
Sterility = inability to become fertile
Fecundity = the probability of​ live birth​ in 1 menstrual cycle

● Check:
Urine LH → Luteal function duration
Mid-luteal Progesterone → Luteal phase levels of function
USG → to visualized changes
● LH surge until menses takes >= 12 days
● Progest > 5 ng/mL → ovulation occurs
● Always check ​these ​before this Tx of ovulation induction
TSH, Prolactin, USG (for PCOS)

Ovulation induction
PCOS → clomiphene
GnRH problem → Leuprolide
Pituitary problem → hCG (or) hMG
HyperProlact → Bromocriptine / Cabergoline
For PCOS can use:
Clomiphene
Metformine
Letrozole
Ovarian drilling
---------------------
If Clomiphene doesnt work → may be a result of (N) FST & ↓ LH
[follicle matures but doesnt rupture]
Use hCG at time of rupture (know the time but USG)
If no follicle maturation
Use hMG to ↑FSH

hCG hMG

Acts like ​LH ​> FSH Acts like ​FSH ​> LH

● HyperStim Synd
PostOvarian induction Tx
Ovarian enlargement & Exudation into peritoneal cavity (douglas)
Cysts, multiple gestations are possible
Prevent with Estradiol
 ● Infertility causes:

Male 30% Female 60% Unexplained 10%

AntiSperm Ab Ovulation problem

Azoospermia Anatomic
Peritoneal
Cervical Mucus

● For males with infertility problems suggest

Not to go to sauna, hot dush...
● Dx - Sims Huhner test
2-12 hh after sex take mucus
Assess sperm there and mucus
If sperm is (N) → mucus problem
But this shit isnt used anymore cuz whos gonna have sex at the docs office
● Female factors:

Cervical Anatomic Peritoneal Tubal defects

Mucus changes thickening Myoma Endometriosis Salpingitis

will prevent sperm from Polyps Adhesions Endometriosis
passing through it surgery
Mucus isnt ​Spinnbarkeit [according to ​Hacker [according to ​teacher’s
classif] + tubal defects classif] + tubal defects

Tx: Dx: Dx: Dx:

Infection → Doxy HysteroSalpingography Laparoscopy HysteroSalpingography
IntraUterine Insemenation Laparoscopy with dye
Indigo carmine

Spinnbarkeit ​= watery mucus few dd before ovulation with pH > 6.5

This isn't the type of mucus in cervical mucus disorders

● Unexplained factors
Tx:
IUI
IVF
# Cancer: General Things

● Dont give chemotherapy when:

WBC < 1500/mm3
Platelets < 100,000/mm3
1-2 weeks after initiation of chemo:
Take CBC
Check Renal and Liver Func Tests

● Radioresistance
Bc radioTx needs O2 to work, Hypoxic areas are resistant
Bulky tumors are less vascularized so less O2 means RadioResistant

● Estrogen Exposure → ↑ER && PR

Progest exposure → ↓ in these Rs

● PARP-Is
New class of ChemoTx used in BRCA-1 & 2 cancers
They affect DNA repair mechanism

# Cancer: Cervical cancer

● Most common GYN cancer worldwide C > E > O

But less common in developed countries due to screening E > O > C
● Vaccines:
Quadrivalent - Gardasil
6, 11, 16, 18
Bivalent - Cervarix
16, 18
● Pap smear

2 methods

Traditional Brush on smear directly

Liquid Brush into liquid

Centrifuge sorts the cells (WBCs, Ep cells…)
https://www.youtube.com/watch?v=w_kZNiF8akg
https://www.youtube.com/watch?v=_9AjC_xLWWg

Check the CUSIM instructions for Pap (the Prep, the procedure….)

F(-) for high-grade CIN = 20%

Liquid based has ↓F(-) so ↑Sensitivity
 DNA testing for papilloma (vs) Pap

sensitivity >>

specificity <<

● In Israel

https://www.clalit.co.il/he/your_health/womens/Pages/pap_test_gardasil_cervarix.aspx

○ Pap smear recommendations

25+ yo every 3 years until 65 yo
○ Vaccine recommendations
Women: 11 ~ 45 yo
Men: 11~ 26 yo
Since 2015 women do Gardasil 9 in schools in 8th grade

● Transformation Zone
Area of metaplastic Sq ep.
Bw existing SqColumnar Junc and early SqCJunc

SqCJ is a circle
TZ is an area

● Ectocervix can have an area red in color

This isnt pathology, its just means that SqCJ in in Ectocervix
Bc columnar ep is thin [(vs) Sq stratified ep which is thicker] so we see vessels under it
● CIN = Cervical IntraEp Neoplasia

LSIL HSIL 35%​ of cases Invasive

10%​ of cases w/in 10 years cancer
CIN1 → CIN 2 (or) 3 →

⅓ Atypia > ⅔ Atypia

● Nabothian follicle / cyst

Mucus secretion cysts in TZ
Seen on speculum exam in TZ but its normal
● Dyskaryosis
Dys - change
Karyo - nucleus
Changes in nuclei that help pathologists identify LSIL/HSIL on Pap
● Pap can show:
A lot of things - see Bethesda system
ASCUS = cant determine CIN grade [Atypical Sq Cells of Undetermined Significance]

If shows ASCUS

Do again in 6 month If again ASCUS

Colposcopy

● Bethesda system
3 Points

#1 Adequacy How is the specimen?

 #2 Categorization Generally what do you see?

Atypia (or) Not

#3 Interpretation

Atypia No atypia

SqCell CIN 1/2/3 +/- m/o

ASCUS +/- inflamm

glandular cells AGC (atypical gland cells)

AIS (adenocarc. In situ)

Other Endometrial cells

● Iodine is used to see pathology

Glycogen is present in Ep cells, these cells interact with Iodine making them brown
Ab(N) cells won't take up iodine and will appear white
● Ab(N) Pap smear algorithm & Cone Biopsy indications|

ECC = EndoCervical Curretage

Cone biopsy indications

1. ​High Grade Pap && unsatisfactory Colposcopy (cant see TZ)
2. ​High Grade Pap && punch biopsy not high grade
3. ​ECC is High grade
4. Pap shows AIS (glandular)
5. ​Punch biopsy shows microinvasion​ (stage IA)
 ● CIN Tx options

Excisional Ablative

LLETZ (Large Loop of the TZ) Semms coagulation

Laser conization Cryoablation

Cold knife conization Laser Ablation

● Invasive Cancer: Rectovaginal exam is important

Bc cancer size is more easily determined via rectum

● Staging of Invasive Cancer

○ Status of ParaAortic lymph node is important
Occurs in 20% of Stage II
And 30% if Stage III
Detected by PET
○ MRI and CT aren’t useful in detecting ParaAortic nodes
○ MRI can be used to determine the degree of 1’ Invasion (to UB, colon..)

Stage features Dx

Stage I Cancer only in cervix Based on Cone Biopsy only

Stage IA Deepest <= 5 mm By microscopy

Largest <= 7 mm

IA1 Deepest <= 3 mm

IA2 Deepest 3 > mm (<= 5)

Stage IB Clinically visible clinically

IB1 Visible lesion <= 4 cm

IB2 > 4 cm

Stage II Invasion (but not to: Pelvic wall or Lower vagina)

Stage IIA w/o Parametrium inv.

IIA1
Like IB 1/2
IIA2
IIB w/ Parametrium invasion

Stage III Invasion to:

Pelvic wall
Lower ⅓ vagina
Hydronephrosis or signs of Renal F.

IIIA Lower vagina

IIIB pelvic wall or Renal inv.

Stage IV Metastasis beyond pelvis (of the cancer no edema)

IVA Adjacent metastasis

IVB Distant metastasis

 ● We can use Ulipristal (‫ )גלולות חירום “אלה” בארץ‬for Myoma
● Dont use ECC when Cervical Papilloma is in Pregnant woman

# Vulvar & vaginal cancer

● Vulvar cancers can be:

SqCC - most common
In young women → due to HPV
In older women → due to Lichen Sclerosis
Melanoma
Adenocarcinoma - eg. bartholin cancer
 *** Paget disease of the vulva is Adenocarcinoma In Situ
PAS (+) cells
Not associated with invasive cancer [(vs) Paget of breast always associated
with invasive Ductal cancer]

# Endometrial cancer

● Type I - Estrogen related ​Endometrioid ​type

Type II - Estrogen unrelated
● Risks for type I
Obesity
Granulosa-Theca tumor
PCOS
Late menopause
taking Estrogen HRT with intact uterus
Tamoxifen
Lynch synd

*** ​High Risk women

●

● Staging

Stage I Only in uterine body

IA No invasion (or) invasion < 0.5 myometrium

IB Invasion >= 0.5 myometrium

Stage II Cervix invasion

 Stage III Local & regional invasion

IIIA Invasion to serosa &/or Adnexa

IIIB Invasion to Vagina or Parametrium

IIIC Lymph nodes

IIIC1 1- Pelvic nodes (ParaAortic are clear)
IIIC2 2- ParaAortic nodes

Stage IV

IVA UB or colon invasion

IVB Distant metastasis (or) Inguinal lymph node involvement

● In comparison with Cervical Cancer, Endometrial cancer staging depends on CT and

MRI findings
CT is useful to detect:
Lymph involvement
Liver / Lung / Adrenal metastasis
Hydronephrosis
MRI
To differentiate Superficitial or Deep invasion into myometrium
[Staging IA or IB]
To detect cervical involvement [Stage II]
● All Stages can be subclassified by the Grading
Grades 1, 2 or 3 - all depend on Glandular architecture and nuclear atypia (dyskaryosis)
Grade 1 = well differentiated
Grade 3 = undifferentiated

● Tx:
Stage I
- Surgical [Laparoscopy / Laparotomy]
Total Hysterectomy + Bilat Salpingoophrectomy
Peritoneal washing → send to pathology (used to be part of Staging)
Open Retroperitoneum → enlarged ParaAortic / Pelvic nodes should be removed
Grade 3 / serous / Clear cell / Stage IB and II cancers →
at least Pelvic lymphadenectomy has to be done
- Radiation depending on Surgical staging
- Hormone Therapy - use for early stage Grade 1 in px who doesn't want Hysterectomy
Medroxyprogesterone acetate 200mg twice daily for several months
may regress the tumor but recurrence is common so keep monitoring
Stage II
If cervical invasion detected Histologically → same as stage I
If not (eg. Grossly large cervix) →
 Radical Hysterectomy + Bilat SalpOphrectomy + Pelvic & ParaAortic
lymphadenectomy + Radiation therapy depending on Lymph nodes
Stages III+
Individualized
The ChemoTx mostly effective are ​Platinum based

● A point he mentioned in the practic

3 differences bw cervical and endometrial cancers

Cervical (vs) Endometrial

Hysterectomy Total Hyst.ectomy

Or Bilat SOectomy
Conization Tx of Stage IA Lymph.ectomy
[no lymph removal] +
[no SOectomy] RadioTx (as Adjuvant)

Not useful Hormonal therapy Useful

In some stages RadioTx can RadioTx Radio is always adjuvant to

be used as​ Primary​ Tx surgical Tx