OFFICE GYNECOLOGY

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

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

3. 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

4. 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

5. DIAGNOSTIC PROCEDURES

6. 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.

7. 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

8. 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

9. 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

10. 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)

11. CONVENTIONAL PAP SMEAR Rough guide: Other basis for MI:

12. 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.

13. 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.

14. LIQUID BASED CYTOLOGY or LIQUID-BASED PAP TESTING A newer method called liquid-based cytology, or liquid-based pap testingcan 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.

15. 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.

16. LIQUID BASED CYTOLOGY orLIQUID-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.

17. ENDOMETRIAL CYTOLOGY Procedure Aspiration and brush lavage of endometrial cavity Advantage Simple and less expensive way to diagnose endometrial pathology

18. 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

19. ENDOMETRIAL CYTOLOGY Conclusion Disadvantages outweigh the advantages, thus it cannot be recommended as a routine screening.

20. 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

21. 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

22. WET SMEAR & GRAM STAINING TRICHOMONAS VAGINALIS The organism seen are actively motile, normally moving with the direction of flagella.

23. 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.

24. 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.

25. 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.

26. 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

27. CULTURE & SENSITIVITY STUDIES The following culture media are suggested: 1. Gonococcal infection – Thayer Martin 2. Trichomonal infection – Freiberg, Whiethylin, or diamond’s media culture however are seldom necessary. 3. Candida albicans – Wickerson’s and Saboraud’s media 4. Gardnerella vaginitis – Casman’s blood agar Colonies are identified by different beta hemolysis produced.

28. 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

29. 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

30. 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.

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

32. 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

33. 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

34. SCHILLER’S TEST • Basis • Glycosylated squamous epithelium takes up iodine based atain. • For cervical dysplasia in which the nuclear-cytoplasm 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

35. SCHILLER’S TEST • Procedure Schiller’s solution (1 part iodine + 2 parts KI + 300 parts water) is applied in the vagina and upper cervix with cotton pledget

36. SCHILLER’S TEST • Result • (-) mahogany brown (normal epithelium) • (+) light yellow , as in • Dysplasia • Traumatized tissue • Cervicitis • Columnar epithelium

37. 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

38. 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

39. 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

40. 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

41. 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

42. CULDOCENTESIS • Benefits • Allows rapid diagnosis of a life-threatening condition • Office procedure • Allows culture of organisms for treatment of PID

43. CULDOCENTESIS • Risks • Does not distinguish between sources of intra-abdominal bleeding • Painful for patient • Bleeding, infection risks minimal

44. COLPOSCOPY colposcope • Use of a magnifying instrument to identify abnormal (precancerous, cancerous) areas of cervical mucosa • Usually performed at 10-20x magnification

45. COLPOSCOPY • Must be observed • Squamo-columnar junction is noted for color, topography of epithelial surface and vascular architecture • Vascular pattern may be described as punctuation or mosaicism • White discoloration or “oyster shell” appearance

46. 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. doesn’t extend into canal beyond view • If “unsatisfactory,” invasive cancer not ruled out

47. 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

48. 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

49. 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

50. 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