Vaginal Cancer Cheatsheet

Cheatsheet Content

Exam-teller summary Common benign cervical conditions include cervicitis (inflammation), polyps (growths), ectropion (eversion of glandular tissue), and Nabothian cysts (mucus retention cysts). Often asymptomatic or present with non-specific symptoms like abnormal bleeding or discharge. Diagnosis is usually clinical, confirmed by colposcopy and biopsy if malignancy is suspected. Management ranges from observation to targeted treatment based on symptoms and pathology. Definition and pathophysiology Cervicitis: Definition: Inflammation of the uterine cervix. Can be acute or chronic. Pathophysiology: Often due to infection (e.g., Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, HSV), but can also be non-infectious (e.g., chemical irritants, allergic reactions, mechanical trauma, foreign bodies like pessaries). Leads to hyperemia, edema, and inflammatory cell infiltration of the cervical stroma. Cervical Polyps: Definition: Benign pedunculated (stalked) or sessile (broad-based) growths originating from the endocervical canal. Pathophysiology: Thought to arise from focal hyperplasia of the endocervical epithelium and stroma due to chronic inflammation, hormonal influences (estrogen), or local vascular congestion. Most are fibrovascular polyps covered by endocervical epithelium. Cervical Ectropion (Ectopy/Eversion): Definition: Condition where the columnar (glandular) epithelium from the endocervix extends outwards onto the ectocervix, replacing the normal squamous epithelium. Pathophysiology: The squamocolumnar junction (SCJ) shifts outwards. This is a physiological phenomenon influenced by estrogen levels (puberty, pregnancy, oral contraceptive use). The columnar epithelium is thinner and more delicate, making it more prone to irritation and bleeding. Nabothian Cysts: Definition: Mucus-filled cysts on the surface of the cervix, typically benign. Pathophysiology: Form when the normal stratified squamous epithelium of the ectocervix grows over and blocks the opening of an endocervical gland duct. Mucus produced by the gland accumulates, leading to cyst formation. Common after metaplasia or chronic cervicitis. Epidemiology and risk factors Cervicitis: Epidemiology: Very common. Prevalence varies with population and risk factors for STIs. Risk factors: Multiple sexual partners, unprotected intercourse, history of STIs, young age at first intercourse, douching. Cervical Polyps: Epidemiology: Very common, affecting 2-5% of women. Most common in multiparous women aged 40-60 years. Rare before menarche. Risk factors: Chronic inflammation, high estrogen levels (pregnancy, peri-menopause), chronic cervicitis. Cervical Ectropion: Epidemiology: Extremely common, especially in young women, pregnant women, and those on oral contraceptives. Considered physiological. Risk factors: High estrogen states (adolescence, pregnancy, combined oral contraceptive pills). Nabothian Cysts: Epidemiology: Extremely common, found in up to 70% of women. More common in reproductive age and postmenopausal women. Risk factors: Chronic cervicitis, childbirth, cervical trauma, cervical metaplasia. Clinical features (with red flags) Cervicitis: Typical: Vaginal discharge (mucopurulent), intermenstrual or postcoital bleeding, dyspareunia, pelvic pain. Atypical: Often asymptomatic (especially Chlamydia). Red flags: Fever, chills, severe lower abdominal pain (suggests Pelvic Inflammatory Disease - PID). Cervical Polyps: Typical: Often asymptomatic. Abnormal uterine bleeding (intermenstrual, postcoital, postmenopausal), menorrhagia, leukorrhea (white vaginal discharge). Atypical: Large polyps may cause pressure symptoms. Red flags: Any postmenopausal bleeding (always warrants investigation for malignancy). Cervical Ectropion: Typical: Often asymptomatic. Increased vaginal discharge (physiologic), postcoital bleeding (due to delicate columnar epithelium). Atypical: Rarely causes significant issues. Red flags: Persistent or heavy bleeding, especially if not explained by physiological ectropion. Nabothian Cysts: Typical: Almost always asymptomatic. Appear as small, smooth, yellowish-white nodules on the cervical surface during speculum exam. Atypical: Rarely, very large cysts may cause pressure or obstruction of cervical os, though this is exceedingly rare. Red flags: If lesion is firm, irregular, or rapidly growing (suggests malignancy). Investigations (with criteria/scores) First-line/Bedside: Speculum examination: Must order for all conditions to visualize the cervix. Bimanual examination: Must order to assess for uterine/adnexal tenderness (suggests PID with cervicitis), or uterine pathology. Labs: Cervicitis: STI screening: Must order. Nucleic acid amplification tests (NAATs) for Chlamydia trachomatis, Neisseria gonorrhoeae from cervical swab or urine. Wet prep for Trichomonas, bacterial vaginosis, candidiasis. Culture: For specific resistant organisms if initial treatment fails. Cervical Polyps, Ectropion, Nabothian cysts: Cervical cytology (Pap test): Must order. Routine screening. Abnormal results (ASCUS, LSIL, HSIL) warrant colposcopy. HPV testing: Must order. Co-testing with Pap for women $>30$ years or reflex testing for ASCUS. Imaging: Generally not required for diagnosis of these benign conditions. Transvaginal ultrasound: Consider. If large Nabothian cysts are causing concern, or to rule out other uterine/adnexal pathology, or if polyp appears to extend into the uterus. Diagnostic criteria: Cervicitis: Mucopurulent discharge from the endocervix, easily induced cervical bleeding, or cervical friability on speculum exam. Definitive diagnosis requires identification of pathogen or histological inflammation. Cervical Polyps: Visual identification on speculum exam, confirmed by histological examination after removal. Cervical Ectropion: Visual identification of everted columnar epithelium on speculum exam, often appearing red and granular. Nabothian Cysts: Visual identification of smooth, glistening, yellowish-white cysts on the cervix. Management Immediate stabilisation (ABCDE): Not applicable for these benign conditions unless severe infection (e.g., PID with sepsis) is present. Disease-specific acute and definitive therapies: Cervicitis: Infectious: Treat underlying cause. Chlamydia: Doxycycline 100 mg PO BID for 7 days (CDC 2021). Gonorrhea: Ceftriaxone 500 mg IM single dose (CDC 2021). Trichomonas: Metronidazole 2g PO single dose (CDC 2021). Non-infectious: Remove irritant, treat underlying inflammation. Pregnancy-safe alternatives: Azithromycin 1g PO single dose for Chlamydia; Ceftriaxone 500 mg IM for Gonorrhea (CDC 2021). Metronidazole 2g PO single dose for Trichomonas. Cervical Polyps: Removal: Polypectomy (twisting off at the base with forceps or ligating and excising) is recommended for symptomatic polyps, those $>1$ cm, or those with suspicious features (e.g., friable, irregular, atypical appearance). Specimen must be sent for histopathology to rule out malignancy (NICE 2017). Observation: Asymptomatic, small polyps may be observed, but removal is generally preferred to rule out malignancy and prevent future symptoms. Cervical Ectropion: Observation: Asymptomatic ectropion requires no treatment as it is physiological. Treatment: For symptomatic ectropion (e.g., bothersome discharge or persistent postcoital bleeding), ablation techniques like cryotherapy or electrocautery can be used to destroy the columnar epithelium and allow squamous metaplasia (NICE 2017). Nabothian Cysts: Observation: No treatment required as they are benign and asymptomatic. Rarely: If very large and causing symptoms (e.g., cervical obstruction), drainage or excision may be considered, but this is uncommon. Disposition and follow-up criteria: Cervicitis: Follow-up to ensure symptom resolution. Partner treatment for STIs. Repeat STI testing in 3 months for Chlamydia/Gonorrhea (CDC 2021). Cervical Polyps: Histopathology report review. Routine cervical screening as per guidelines. Ectropion/Nabothian Cysts: Routine cervical screening. No specific follow-up needed unless symptoms persist or worsen. Resource-limited adaptations: Cervicitis: Syndromic management for STIs if NAATs unavailable. Polyps: Clinical removal and visual inspection if histopathology unavailable, but with awareness of missed malignancy risk. Complications and prognostic markers Cervicitis: Complications: Ascending infection leading to Pelvic Inflammatory Disease (PID), endometritis, salpingitis, infertility, ectopic pregnancy, chronic pelvic pain. Increased risk of HIV acquisition. Prognosis: Good with appropriate treatment, but recurrence possible if risk factors persist. Cervical Polyps: Complications: Rarely, malignant transformation (adenocarcinoma in situ or invasive adenocarcinoma) can occur, hence the importance of histopathology. Recurrence after removal. Prognosis: Excellent, almost always benign. Cervical Ectropion: Complications: Increased susceptibility to STIs due to delicate columnar epithelium. Rarely, causes persistent bothersome discharge or bleeding. Prognosis: Excellent, physiological condition. Nabothian Cysts: Complications: Extremely rare, may rarely cause cervical obstruction if very large, or be mistaken for other cervical pathology. Prognosis: Excellent, entirely benign. Differential diagnosis (with discriminators) Cervicitis vs. Vaginitis: Discriminator: Cervicitis involves cervical inflammation; vaginitis involves vaginal inflammation. Both can cause discharge, but cervicitis often has mucopurulent discharge from the os, cervical friability. Cervical Polyps vs. Cervical Cancer: Discriminator: Polyps are typically soft, mobile, and smooth. Cancer is often firm, irregular, friable, and fixed. Histopathology is definitive. Cervical Ectropion vs. Cervical Cancer/Dysplasia: Discriminator: Ectropion is a smooth, red, symmetrical eversion of glandular tissue. Cancer/dysplasia may present with irregular, friable, or ulcerated areas. Colposcopy and biopsy differentiate. Nabothian Cysts vs. Cervical Cancer/Tumor: Discriminator: Nabothian cysts are typically smooth, round, yellowish, and mobile under the surface. Malignant lesions are usually firm, irregular, and may be ulcerated. Uterine Fibroids/Endometrial Polyps: Discriminator: These are intrauterine lesions causing abnormal bleeding, but originate from the uterus, not the cervix. Transvaginal ultrasound differentiates. OSCE and SBA traps OSCE traps: Failing to perform a thorough speculum exam. Not offering STI screening in a patient with cervicitis symptoms. Dismissing postmenopausal bleeding due to a benign polyp without further investigation for malignancy. SBA traps: Choosing observation for a symptomatic cervical polyp without recommending removal and histology. Incorrectly identifying a physiological ectropion as a pathological condition requiring treatment. Missing the appropriate antibiotic regimen for common STIs causing cervicitis. Common pitfalls: Assuming all abnormal cervical appearances are sinister without proper investigation. Inadequate follow-up for infectious cervicitis. Examiner buzzwords: "Mucopurulent discharge," "strawberry cervix" (Trichomonas), "postcoital bleeding," "physiological ectropion," "histopathology." Counseling points/safety-netting lines "Many changes on the cervix are benign and quite common. We'll investigate to ensure it's nothing serious." "For conditions like cervicitis, it's important to treat the infection and ensure your partner is also treated to prevent re-infection." "Cervical polyps are usually harmless, but we remove them and send them to the lab to be absolutely sure." "Cervical ectropion is a normal variation, especially in young women or during pregnancy. It rarely needs treatment unless it's causing bothersome bleeding or discharge." "Nabothian cysts are like little pimples on the cervix, filled with mucus, and are completely normal and don't need treatment." "Always come back if your symptoms change, worsen, or new symptoms appear." "Regular cervical screening (Pap tests) is vital to catch any serious changes early." Mnemonics and memory hooks Cervical Polyps: "P" for "Polyp, Pedunculated, Postcoital Bleeding, Pathology." Ectropion: "E" for "Estrogen, Everted, Epidermalization." Nabothian Cysts: "N" for "Normal, No treatment, Nodule (smooth)." Rapid algorithm (ASCII) for assessment and initial management PATIENT PRESENTS WITH CERVICAL SYMPTOMS (Bleeding, Discharge, Pain) OR ABNORMAL CERVICAL FINDING | v 1. CLINICAL ASSESSMENT: HISTORY & PHYSICAL EXAM - History: Symptoms (type, duration, severity), sexual history, contraception, obstetric history, Pap history. - Speculum Exam: Visualize cervix (discharge, friability, lesions, ectropion, cysts, polyps). - Bimanual Exam: Tenderness, masses. | v 2. INITIAL INVESTIGATIONS - Cervical Cytology (Pap test) & HPV testing (if indicated) - STI Screening (NAATs for Chlamydia/Gonorrhea, wet prep for Trichomonas/BV/Candida) | v 3. DIAGNOSIS & MANAGEMENT PLAN +---------------------------------------------------------------------------------------------------+ | FINDING: CERVICITIS | | - Symptoms: Mucopurulent discharge, friability. | | - Labs: Positive STI test. | | - Tx: Treat specific STI (e.g., Doxycycline for Chlamydia, Ceftriaxone for Gonorrhea). | | Partner treatment. Follow-up STI test in 3 months. | +---------------------------------------------------------------------------------------------------+ | FINDING: CERVICAL POLYP | | - Appearance: Pedunculated/sessile growth from os. | | - Symptoms: Often asymptomatic, intermenstrual/postcoital bleeding. | | - Tx: Polypectomy (remove and send for histopathology). | +---------------------------------------------------------------------------------------------------+ | FINDING: CERVICAL ECTROPION | | - Appearance: Red, granular area around os, eversion of columnar epithelium. | | - Symptoms: Often asymptomatic, increased discharge, postcoital bleeding. | | - Tx: Observation (if asymptomatic). Ablation (cryotherapy/electrocautery) if symptomatic. | +---------------------------------------------------------------------------------------------------+ | FINDING: NABOTHIAN CYSTS | | - Appearance: Smooth, yellowish-white, subepithelial cysts. | | - Symptoms: Almost always asymptomatic. | | - Tx: Observation. No treatment needed. | +---------------------------------------------------------------------------------------------------+ | v 4. FOLLOW-UP - Ensure symptom resolution. - Review histopathology (for polyps). - Routine cervical screening. - Counsel on prevention (safe sex, contraception). Practice items (SBAs, OSCE checklists, viva) SBA-style stems A 28-year-old sexually active woman presents with a 2-week history of yellow vaginal discharge and postcoital spotting. On speculum examination, the cervix is erythematous and friable, with mucopurulent discharge from the os. A Pap test is normal. Which of the following is the most appropriate next step in management? A. Reassure and observe B. Prescribe topical estrogen cream C. Perform cervical cryotherapy D. Order Nucleic Acid Amplification Tests (NAATs) for Chlamydia and Gonorrhea E. Refer for colposcopy Answer: D. The symptoms and signs are highly suggestive of infectious cervicitis, requiring STI screening. A 55-year-old multiparous woman presents with intermittent spotting for 3 months. Speculum examination reveals a 1.5 cm soft, reddish, pedunculated growth protruding from the external cervical os. Her last Pap test 6 months ago was normal. What is the most appropriate management? A. Reassure and observe, as it's likely benign B. Prescribe broad-spectrum antibiotics C. Remove the polyp and send for histopathology D. Perform immediate cervical biopsy without removal E. Refer for urgent colposcopy Answer: C. Cervical polyps, especially if symptomatic or >1cm, should be removed and sent for histology to rule out malignancy. A 20-year-old woman using combined oral contraceptive pills presents for routine check-up. Her Pap test is normal. On speculum exam, the area around the external os appears red and granular, extending onto the ectocervix. She has no symptoms. What is the most likely diagnosis? A. Early cervical cancer B. Cervical ectropion C. High-grade cervical intraepithelial neoplasia D. Nabothian cyst E. Severe cervicitis Answer: B. Cervical ectropion is a physiological finding common in young women and those on OCPs, often asymptomatic. OSCE station checklists Counseling a patient newly diagnosed with Chlamydial cervicitis: Explain Diagnosis: "You have an infection called Chlamydia in your cervix, which is a common sexually transmitted infection." Treatment Plan: Explain antibiotic course (e.g., Doxycycline 100mg BID for 7 days). Partner Treatment: Emphasize importance of partner treatment to prevent re-infection. Abstinence: Advise abstinence from sexual intercourse until both patient and partner(s) have completed treatment and symptoms have resolved. Follow-up: Advise repeat STI testing in 3 months. Prevention: Discuss safe sex practices (condoms) and future screening. Safety Net: "Come back if symptoms worsen, you develop fever, or new abdominal pain." Performing speculum and bimanual examination for a patient with abnormal vaginal bleeding: Preparation: Introduce self, explain procedure, gain consent, ensure chaperone present, position patient. Speculum Exam: Insert speculum correctly, visualize cervix fully. Inspect for discharge (color, consistency), lesions (polyps, ulcers), friability, ectropion, Nabothian cysts. Obtain Pap smear/HPV and STI swabs if indicated. Bimanual Exam: Remove speculum. Palpate cervix (consistency, tenderness, mobility), uterus (size, position, masses), adnexa (masses, tenderness). Documentation: Clearly describe findings. Patient Comfort: Ensure minimal discomfort, explain findings, answer questions. Rapid-fire viva prompts "What's the most common cause of infectious cervicitis?" Chlamydia trachomatis. "When should you always send a cervical polyp for histology?" Always, to rule out malignancy, especially if symptomatic or postmenopausal. "Is cervical ectropion a pathological condition?" No, it's a physiological finding, especially in young women and those on OCPs. "What's a Nabothian cyst and does it need treatment?" A mucus-filled cyst on the cervix due to blocked endocervical glands; typically benign and needs no treatment. "What's a key complication of untreated cervicitis?" Pelvic Inflammatory Disease (PID), which can lead to infertility. Guideline anchors and year Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines 2021 National Institute for Health and Care Excellence (NICE) Guidelines for Abnormal Vaginal Bleeding 2017 American College of Obstetricians and Gynecologists (ACOG) Practice Bulletins (various)