OFFICE GYNECOLOGY

Loida S. Ponio, M.D., FPOGS, MHA MPI-Medical Center Muntinlupa

OBJECTIVE

To refresh us with the different diagnostic procedures, practical and cost effective that can guide us in most of our office gynecology practice

The diagnostic procedures that we should do and request must be based on a working impression gathered through a complete, thoughtfully elicited and thorough history and PE

In patients with no apparent symptoms referable to the pelvic organs, the following information should be included:

Inquiry regarding abnormal bleeding or discharge menstrual irregularities, pelvic discomfort, changes in or abnormality of bowel or bladder function, pruritus or lesions of the vulva. Careful general exam should include survey of the neck, breast, axilla, abdomen, groin, and legs. Complete pelvic exams:

Inspection and palpation of the external genitalia Bimanual and vaginal exam Speculum exam of the cervix and vagina Rectal exam including recto-vaginal exam

DIAGNOSTIC PROCEDURES

PAP SMEAR

Single diagnostic screening technique which has had the longest impact into the reduction of mortality in cervical cancer

Ideal Target population: Screening all sexually active women and all women above 18 years.

PAP SMEAR

High Risk Group: 1. Early sexual activity 2. Early child bearing 3. Multiple sex partners 4. HPV and Herpes Simplex Virus II infection 5. Immunosuppressed patients 6. Smoking

7. Decreased dietary intake of vitamin A

CONVENTIONAL PAP SMEAR

Sampling of specimen:

1. Endocervix (transformation zone) 2. Lateral mid vaginal wall 3. Vaginal pool

Fixation use:

1. 95% alcohol 2. Ether and alcohol 3. Hair spray 4. Air drying

CONVENTIONAL PAP SMEAR

Factors that influence accuracy of PAP smear:

1. Appropriate volume of screening material 2. Adequate sampling of the epithelium at risk 3. Careful preparation of cytologic material

4. Accurate diagnostic methods in the cytopathology laboratory

CONVENTIONAL PAP SMEAR

Information from PAP smear:

1. Diagnosis of cervical CA, dysplasia and CIN

2. Suggest carcinoma arising from other pelvic organs and elsewhere in the peritoneal cavity.

3. Suggest etiology of cervico-vaginal infection

4. Quantitative assessment of estrogen status(MI)

CONVENTIONAL PAP SMEAR

Rough guide:
Superficial 1-10% 10-30% Estrogen Effect slight moderate

30%

marked

Other basis for MI:

50% or more Basal - low estrogen effect

90% or more Intermediate

- suppression of estrogen by progesterone as in pregnancy

CONVENTIONAL PAP SMEAR

Importance of MI:

1. Rough guide for HRT among menopausal patients 2. Postmenopausal women without estrogen supplement with increased estrogen effect may suggest the possibility of existing estrogen secreting granulosa cell or theca cell tumor of origin. 3. Children with precocious puberty.

CONVENTIONAL PAP SMEAR

Limitations of MI:

1. Inflammation disturbs the cornification pattern and render it unreliable as an index of estrogen effect. 2. Postmenopausal women taking Digitalis and related glycosides for more than 2 years may increase MI.

LIQUID BASED CYTOLOGY OR LIQUID-BASED PAP TESTING

A newer method called liquid-based cytology, or liquid-based pap testing can remove some of the mucus, bacteria, yeast, and pus cells in a sample and can spread the cervical cells more evenly on the slide. Instead of being directly placed on a slide, the sample is placed into a special preservative solution.
This new method, also known by brand names ThinPrep or Autocyte, also prevents cells from drying out and becoming distorted.

LIQUID BASED CYTOLOGY OR LIQUID-BASED PAP TESTING

Recent studies show that liquid-based testing can slightly improve detection of precancers, and reduce the number of tests that need to be repeated. This method is more expensive than a usual PAP smear. HPV exam can be done simultaneously.

LIQUID BASED CYTOLOGY OR LIQUID-BASED PAP TESTING

USA statistics
At 50 years of age ~ 80% with (+) genital HPV 5% of females of cervical Ca are between 35-55 years >20 years of age account for 63% of genital warts

Type 16 &18 70% associated with cervical Ca

Type 6 & 11 90% associated with genital warts Women between 25-54 20% will have at least 1

abnormal pap smear test.

ENDOMETRIAL CYTOLOGY

Procedure

Aspiration and brush lavage of endometrial cavity

Advantage

Simple and less expensive way to diagnose endometrial pathology

ENDOMETRIAL CYTOLOGY

Disadvantages

There is difficulty in identifying pre-malignant changes of the endometrial cells on cytopathological material It is difficult to differentiate secretory endometrium, hyperplastic and endometrial hyperplasia
Sensitivity and specificity of endometrial cytology is less than desirable

ENDOMETRIAL CYTOLOGY

Conclusion

Disadvantages outweigh the advantages, thus it cannot be recommended as a routine screening.

WET SMEAR & GRAM STAINING

Cervicitis and vaginitis are the most frequent complaints evaluated by the gynecologist

Organisms most often associated with cervicitis:

Chlamydia trachomatis (most common) Neisseria gonorrhea

Herpes simplex II

WET SMEAR & GRAM STAINING

In vaginitis, the most common offending organisms can be easily diagnosed by simple wet smear with the use of NSS

Candidiasis Candida albicans Trichimoniasis Trichomonas vaginalis Bacterial Vaginosis Gardnerella vaginalis and anaerobic bacteria

WET SMEAR & GRAM STAINING

TRICHOMONAS VAGINALIS

The organism seen are actively motile, normally moving with the direction of flagella.

WET SMEAR & GRAM STAINING

GARDNERELLA VAGINALIS

Will show the typical clue cells which consists of epithelial cells that appear stippled or granulated. Mobilinus species will appear as highly motile curved bacterial rods with cork-screw spinning action which is seen in approximately 50% of cases.

WET SMEAR & GRAM STAINING

CANDIDA ALBICANS

Typical hyphae and spore formation is also seen in wet smears. It is however, better visualized with KOH smears.

Bacterial vaginosis can also be diagnosed by adding KOH in the discharge. This produces a fishy amine odor which is the basis for the Whiff test.

WET SMEAR & GRAM STAINING

In Gram staining of discharge from patients with bacterial vaginosis. It will show presence of clue cells with few polymorphonuclear cells (PMN). There will be few lactobacilli and small pleomorphic gram (-) rods. In Gardnerella vaginitis, minute rod-shaped gram (-) bacilli will be seen. Gonococcal infection will manifest gram (-) diplococci in the cytoplasm of PMNs.

CULTURE & SENSITIVITY STUDIES

Routine bacterial culture of the vaginal discharge may be misleading and of no diagnostic value In herpes and Chlamydia infection, proper media and transport vials are necessary. It is however indicated in the following:

1. Recurrent infection 2. Abscess of vulva, groin, and pelvis

CULTURE & SENSITIVITY STUDIES

The following culture media are suggested:

1. Gonococcal infection Thayer Martin

2. Trichomonal infection Freiberg, Whiethylin, or diamonds media culture however are seldom necessary.

3. Candida albicans Wickersons and Saborauds media

4. Gardnerella vaginitis Casmans blood agar Colonies are identified by different beta hemolysis produced.

CERVICAL MUCUS ARBORIZATION TEST

Formation of fern patterns

Directly dependent on the ovarian hormonal status of the patient at the particular time

Seen in its typical form with the presence of adequate estrogens.

Progesterone inhibits or completely abolishes ferning formation even with the presence of sufficient estrogen

CERVICAL MUCUS ARBORIZATION TEST

Procedure:

A sample of endocervical mucus is spread on a clean dry slide. Air dry for 20-30 minutes

Read under the microscope

CERVICAL MUCUS ARBORIZATION TEST

Result

(+) - presence of arborization with crystallization indicative of predominance of estrogen effect (-) - cellular pattern without crystallization and arborization; indicative of little or no estrogen or suppression of estrogen by progesterone False (-) results presence of blood, or if the sample was spread too thinly.

CERVICAL MUCUS ARBORIZATION TEST

Diagnostic Uses

Indirect quantification of estrogen effect

Ferning can be graded according to the branching of the ferning pattern upon crystallization GRADE I GRADE II GRADE III GRADE IV primary branching secondary branching tertiary branching quarternary branching

Index of ovulation and normal corpus luteum function (shifting from (+) to (-) ferning test)

CERVICAL MUCUS ARBORIZATION TEST

Diagnostic Uses

Timing of post coital test Diagnosis of pregnancy vs anovulatory cycles Disorders of early pregnancy

Patients with (+) ferning during early pregnancy were found to have higher incidence of abortion

TOLUIDINE BLUE STAIN TEST

Procedure

Toluidine blue 1% is applied liberally to the vulva and perineal area. Dry for 2-3 minutes Decolorize with acetic acid Acetic acid enhances the diagnostic capabilities and augmentation or recognition of white or hyperpigmented lesions

SCHILLERS TEST

Basis

Glycosylated squamous epithelium takes up iodine based atain.

For cervical dysplasia in which the nuclearcytoplasm ratio is increased and therefore the glycogen is diminished, the epithelium will not take up stain and may appear as light yellow

Indication

Guide for surgical biopsy

SCHILLERS TEST

Procedure
Schillers solution (1 part iodine + 2 parts KI + 300 parts water) is applied in the vagina and upper cervix with cotton pledget

SCHILLERS TEST

Result

(-) mahogany brown (normal epithelium) (+) light yellow , as in

Dysplasia Traumatized tissue Cervicitis Columnar epithelium

NUCLEAR SEX CHROMATIN

Basis

Nuclear sex chromatin recognition of a chromatin mass (sex chromati body) in individual with 2x chromosomes as in normal females. It is present in 65-75% female tissue and absent in around less than 4% in males

NUCLEAR SEX CHROMATIN

Procedure

Specimen taken from oral buccal smear is commonly employed

Chromatin mess or sex chromosome body is recognized in the cell nucleus adjacent to the nuclear membrane in the female

NUCLEAR SEX CHROMATIN

Indication

Primary amenorrhea in apparent female Ambiguous external genitalia at any age Prepubertal girls with pronounce shortness of stature Male infertility Mental retardation and or psychotic or antisocial behavior in either male and female Aggressive, antisocial behavior in males with excessive height

CULDOCENTESIS

Aspiration of fluid from posterior cul-de-sac (pouch of Douglas) by needle placed through posterior fornix of the vagina

Usually done in office with local or no anesthesia

CULDOCENTESIS

Indications

Most commonly performed for confirmation of suspected hemoperitoneum (finding of non clotting blood) Can help diagnose ectopic pregnancy, hemorrhagic ovarian cyst or upper abdominal pathology If WBC count > 30,000/ml of peritoneal fluid, suspect pelvic inflammatory disease (normal WBC count <1000/ml) Identification of possible ovarian carcinoma

CULDOCENTESIS

Benefits

Allows rapid diagnosis of a life-threatening condition

Office procedure Allows culture of organisms for treatment of PID

CULDOCENTESIS

Risks

Does not distinguish between sources of intraabdominal bleeding

Painful for patient

Bleeding, infection risks minimal

COLPOSCOPY
COLPOSCOPE

Use of a magnifying instrument to

identify abnormal (precancerous, cancerous) areas of cervical mucosa

Usually performed at 10-20x

magnification

COLPOSCOPY

Must be observed
Squamo-columnar

junction is noted for color, topography of epithelial surface and vascular architecture as punctuation or mosaicism

Vascular pattern may be described

White discoloration or oyster shell

appearance

COLPOSCOPY

3 to 5% acetic acid applied to cervix

Normal mucosa appears smooth, opaque pink Abnormal mucosa appear white due to increased nuclear-cytoplasmic ratio Abnormal vascular patterns

Mosaicism Punctation

Atypical (compatible with cancer)

Result from neovascularization of neoplasia

Satisfactory exam must be able to see:

Transition zone in its entirety (360)

All margins of the lesions, i.e. doesnt extend into canal beyond view If unsatisfactory, invasive cancer not ruled out

COLPOSCOPY

CIN
Appears as white lesion and a minor alteration

of surface contour
Vascular pattern may be prominent with

mosaicism and punctuation

Invasive Cell Ca
Abnormal surface contour with heavy vessels

COLPOSCOPY

Indications

In abnormal pap smear, it determines the site of abnormal cells and thus eliminate hazards of diagnostic conization Atypical squamous cells of undetermined significance (ASCUS - H or + high risk HPV)

Low grade squamous intraepithelial lesion (LGSIL) High grade squamous intraepithelial lesion (HGSIL)

Carcinoma in-situ or invasive carcinoma

Repeated (>2) atypical pap smears Atypical glandular cells

COLPOSCOPY

Indications

(+) ECC
Radiation changes

Following radiation , pap smear is occasionally abnormal. Colposcompy can locate white epithelium due to radiation changes

HPV and Herpes infection DES exposed offspring Pregnant patients can undergo colposcopy, as well

COLPOSCOPY

Risks

minimal risk, since colposcopy is not invasive

Benefits

Allows better visualization of cervical tissue than the naked eye Without biopsies, no more uncomfortable for patient than a Pap Identifies areas of concern for dysplasia Defines histologic diagnosis, severity of disease, extent/location of disease Information obtained guides management/treatment choices

CERVICAL BIOPSIES

Removing a small (2-3mm) sample of cervical tissue Usually done under colposcopic guidance

Usually fixed in formalin, in separate containers

Instruments (Tischler or Kevorkian biopsy forceps)

CERVICAL BIOPSIES

Indications

Evaluation of a cervical lesion visible

To the naked eye

With colposcopy

CERVICAL BIOPSIES

Risks

Bleeding from biopsy site

Usually minimal, hemostatics applied p.r.n. May be more significant with increased vascularization

Pregnancy

Neovascularization of severe dysplasia and cancer

Infection rare, as tissue is well vascularized and heals easily Misdiagnosis

False positive results may be due to:

Improperly oriented specimen Inflammatory changes in the tissue Sampling error Inadequate colposcopic skills

False negative results may be due to:

CERVICAL BIOPSIES

Benefits

Allows specific dysplasia diagnosis and treatment plan to be made based on tissue sample (histology), not screening test (Pap, cytology)
Can also diagnose infections such as herpes, syphilis and chronic cervicitis No anesthesia required

D IAGNOSIS

CONE BIOPSY

Excision of transformation zone in a cone shape (T-zone area at greatest risk for cervical neoplasia) Anesthesia required local, regional or general

Can be performed in OR using a scalpel, cold knife cone or CO2 laser

Can be performed in the office setting
Loop electrosurgical excision Not recommended for cervical lesions high in the canal Not recommended for large or wide lesions Local anesthesia is usually sufficient

CONE BIOPSY

Technique of cold knife cone biopsies

Adequate anesthesia
Sutures at 3 and 9 oclock of lateral cervix for better hemostasis Can use intracervical injections of vasopressin for hemostasis Locate endocervical canal and transformation zone Circumferential excision of transformation zone in cone shape Ablation of base with cauterization

Perform endocervical curettage

Ensure hemostasis with sutures if necessary

CONE BIOPSY

Indications

Treatment of any high grade dysplastic lesion (CIN II or III) or abnormal endocervical curettage Evaluation of high grade lesion seen on an unsatisfactory colposcopic exam (e.g. lesion extends into the cervical canal)

Rule out invasive cancer (suspected by Pap or colposcopy, but unable to confirm by office biopsy)
Resolve discrepancy between Pap finding and cervical biopsy findings Suspicion of glandular neoplasia (by Pap or colpo) Microinvasive cancer on biopsy rule out frank invasion, as therapy differs

CONE BIOPSY

Benefits

Often done as day surgery Provides tissue for further analysis by pathology Not as destructive to specimen as electrocautery or laser procedures Ablation of base may destroy residual, neoplastic disease

CONE BIOPSY
Risks

Bleeding Infection

Future pregnancy loss due to loss of cervical competence

Inability to remove all disease

Recurrence of disease

CRYOTHERAPY

Rapid expansion of carbon dioxide or nitrous oxide in a probe placed against cervix causing freezing of cervical tissue

Freezing process usually performed twice during procedure to ensure destruction of tissue

CRYOTHERAPY

Indications

Treatment of cervical intraepithelial neoplasia

In theory, dysplasia cure rate should be ~ 90% for all grades

Some report high failures with carcinoma in situ and higher-grade lesions Wide transformation zones may be difficult to cover with probe Cryotherapy is usually recommended for CIN I-II with no endocervical involvement Treatment of chronic cervicitis done historically, not currently recommended

CRYOTHERAPY

Benefits

No anesthesia needed In-office procedure Minimal cramping No bleeding

CRYOTHERAPY

RISKS

No pathologic specimen obtained for review (all tissue destroyed) must rule out cancer via colposcopy As above, cryotherapy cannot extend to vaginal margins or into canal; therefore large lesions or endocervical lesions may not be cured.

Cryotherapy may not extend into glands to destroy intra glandular dysplasia.
Cervical stenosis postoperatively is a rare possibility Colposcopic follow-up may be more difficult Cannot be used on vaginal lesions due to varying thicknesses of tissue and possible intra-abdominal organ damage Contraindicated in pregnancy

ELECTROSURGICAL EXCISION OF CERVIX

Loop electrosurgical wire (unipolar) with cutting/coagulation current used to excise entire cervical transformation zone Tissue sent to pathology for definitive diagnosis, rule out invasive cancer Base of cervix can then be ablated for hemostasis and destruction of residual disease Local anesthesia used (cervical block)

ELECTROSURGICAL EXCISION OF CERVIX

Indications

Diagnosis and removal of high-grade cervical dysplasia

Evaluation of lesions seen on unsatisfactory colposcopy, where a larger tissue sample which includes some endocervical canal is needed Rule out invasive cancer

ELECTROSURGICAL EXCISION OF CERVIX

Benefits

Gives tissue diagnosis, rule out cancer Office procedure Minimal discomfort for patient

ELECTROSURGICAL EXCISION OF CERVIX

Risks

Bleeding intraoperative or late

Infection Not recommended for:

Wide lesions which cover ectocervix Lesions high in canal

Bleeding disorders, anticoagulants

High risk of invasive cancer cold knife cone preferred Pregnancy

ENDOCERVICAL CURETTAGE

Sampling of endocervical canal by curette scraping

Usually performed with colposcopy

ENDOCERVICAL CURETTAGE

Indications

Squamous or glandular dysplasia on Pap Evaluation of cervical lesion in canal

Should be performed even if transformation zone entirely visible at first colposcopic exam; may not be needed subsequently
Used to stage endometrial cancer by determining cervical involvement

ENDOCERVICAL CURETTAGE

Benefits

Allows evaluation of areas not visible by colposcopy Helps determine treatment for dysplasia conization or loop excision indicated if positive for squamous or glandular disease

No anesthesia needed

ENDOCERVICAL CURETTAGE
Risks

Minimal spotting Possible cramping during procedure Contraindicated in pregnancy

ENDOMETRIAL BIOPSY

Indications

Diagnosis of ovulation Follow up of medically managed endometrial pathology cases Endometrial dating and diagnosis of luteal phase defects Abnormal uterine bleeding

ENDOMETRIAL BIOPSY

Diagnosis of Luteal Phase Defects

Discrepancy of 3 days or more between the histology date of the endometrium and that of the cycle. Correlation of histology with luteal length as defined by the serum LH spikes or ultrasound evidence of ovulation Low serum progesterone Short luteal phase Basal Body Temperature

ENDOMETRIAL BIOPSY

Benefits

Low risk of uterine perforation (1/1000) Gives tissue for diagnosis Sensitivity for diagnosing neoplasia similar to D&C Minimal bleeding Unlike D&C, no anesthesia needed

ENDOMETRIAL BIOPSY

Contraindications

Pregnancy Acute pelvic inflammatory disease

Precautions

Cardiac patients must receive prophylactic antibiotics to prevent possible bacteremia

HYSTEROSALPINGOGRAPHY

Radiographic delineation of the uterus and fallopian tubes using contrast material introduced at the uterus via the cervical canal.

It is done 2-6 days after cessation of menstrual flow.

A history of PID, septic abortion, IUD use, ruptured appendix, tubal surgery, or ectopic pregnancy alerts the physician to the possibility of tubal damage. However cases eventually found to have tubal damage, and or pelvic adhesions have no apparent history of

HYSTEROSALPINGOGRAPHY

Indication:

Infertility work up Treatment plan for gynecological disorders such as abnormal uterine bleeding. Ashermans syndrome or uterine synechiae Pre-operative evaluation prior to myomectomy, and tubal reconstruction surgery. Post-operative assessment of the uterus and tubal integrity. Documentation that the tubes were lighted in cases where histologic documentation was not previously done. Cervical incompetence diagnosis Mullerian Duct abnormalities Women exposed to DES Endometrial pathology diagnosis

HYSTEROSALPINGOGRAPHY

Contraindication:

Pregnancy Menstruation Acute PID Hypersensitivity to the dye

Precautions:

For suspected cases with Pelvic Infection

Water soluble rather than oil dye should be used for better absorption. Sedimentation rate is done. If elevated, give antibiotics and request sedimentation rate after 1 month.

HYSTEROSALPINGOGRAPHY

Therapeutic uses of hysterosalpingogram:

It may effect mechanical lavage of the tube and dislodged mucus plug
It may strengthen the tube and then break down peritoneal adhesions. It may provide stimulatory effect for the cilia of the tubes. It may improve the cervical mucus Iodine may exert as a bacteriostatic effect on the mucus membrane. Ethiodiol decreases the phagocytic capability of macrophages and this could decrease the infection of the sperm.

ULTRASOUND

Noninvasive imaging technique utilizing acoustic waves similar to sonar Ultrasound is approximately 90% accurate in recognizing the presence of a pelvic mass, but does not establish a tissue diagnosis.

ULTRASOUND

Disadvantage:

Poor penetration of bone and air, thus the pubic symphysis and air-filled intestines and rectum often inhibit visualization.

Advantages:

Real time nature of the image Absence of radiation Ability to perform the procedure in the office during or immediately after a pelvic examination Ability to describe the findings to the patient while she is watching Absence of adverse clinical effects from the energy levels used in diagnostic studies.

ULTRASOUND

Ultrasound evaluation of endometrial pathology involves measurement of the endometrial thickness or stripe.

The normal endometrial thickness is 4mm or less in a postmenopausal woman not taking hormones. The thickness varies in perimenopausal women at different times of the menstrual cycle. The endometrial thickness is measured in the longitudinal plane, from outer margin to outer margin, at the widest part of the endometrium

ENDOVAGINAL ULTRASOUND

During the examination, the woman is in a dorsal lithotomy position and has an empty bladder. Because the transducer is closer to the pelvic organs than when a transabdominal approach is employed, endovaginal resolution is usually superior. If the pelvic structures to be studied have expanded and extend into the patients abdomen, the organs are difficult to visualize with an endovaginal probe.

TRANSABDOMINAL ULTRASOUND

A sector scanner is preferable because it provides greater resolution of the pelvis and an easier examination than the linear array.

It is helpful for the patient to have a full bladder, this serves as an acoustic window for the high-frequency sound waves.

DOPPLER ULTRASOUND

Assess the frequency of returning echoes to determine the velocity of moving structures. Measurement of diastolic and systolic velocities provides indirect indices of vascular resistance. Muscular arteries have high resistance Newly developed vessels, such as those arising in malignancies, have little vascular wall musculature and thus have low resistance.

COLOR FLOW DOPPLER

A technique that usually displays shades of red and blue that delineate blood flow within an ovarian neoplasm
Benign ovarian lesions have little color flow

When a color flow doppler scan does demonstrate vascularity, the vascular resistance can be calculated.
Low resistance is associated with malignancy, and high resistance usually is associated with normal tissue or benign disease. Highly sensitive in evaluating ovarian malignancy

SONOHYSTEROGRAPHY

In women with abnormal vaginal bleeding, transcervical injection of saline outlines the uterine cavity

A thin catheter, a pipelle or intrauterine insemination catheter, is inserted through the cervical os and 3 to 10 cc of saline are slowly injected into the uterine cavity. Also helpful in the evaluation of uterine septae
It does not make a tissue diagnosis.

THANK YOU