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

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

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

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)

Rough guide: Other basis for MI: Superficial Estrogen Effect 1-10% slight 10-30% moderate 30% marked 50% or more Basal - low estrogen effect 90% or more Intermediate - suppression of estrogen by progesterone as in pregnancy

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.

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.

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.

USA statistics At 50 years of age ~ 80% with (+) genital HPV 5% of females of cervical Ca are between 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  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

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

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

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.

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.

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 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.

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

Procedure: A sample of endocervical mucus is spread on a clean dry slide. Air dry for minutes Read under the microscope

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.

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) GRADE I primary branching GRADE II secondary branching GRADE III tertiary branching GRADE IV quarternary branching

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

SCHILLER’S TEST Basis Indication
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

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

SCHILLER’S 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 Allows rapid diagnosis of a life-threatening condition
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 intra- abdominal 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 Vascular pattern may be described as punctuation or mosaicism 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. doesn’t extend into canal beyond view If “unsatisfactory,” invasive cancer not ruled out

COLPOSCOPY CIN Invasive Cell Ca
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 Benefits
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 To the naked eye With colposcopy
Evaluation of a cervical lesion visible To the naked eye With colposcopy

CERVICAL BIOPSIES Bleeding from biopsy site
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 False negative results may be due to: Sampling error – Inadequate colposcopic skills

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

Diagnosis

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 o’clock 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 Treatment of cervical intraepithelial neoplasia
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)

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

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

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

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

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

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 Precautions 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 antecedent disease in around 50% of cases.

Indication: Infertility work up Treatment plan for gynecological disorders such as abnormal uterine bleeding. Asherman’s 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

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.

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 patient’s 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 

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

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

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