Routine GYN Screening

Group C
Morgan Del Principe, Julia Badalov, Brandon Harvison, Ashlee
Osier, Lauren Hoyos, Jacqueline Jamison, Trysha Hicks,
Carolina Ley, and Alyssa Parker
What is mammography?
● Breast imaging that uses low-dose X rays to detect cancer early and before
women experience symptoms (when it is most treatable)
● Diagnostic and screening tool
● Patient’s breast is placed on flat support plate and compressed with a parallel
plate (paddle)
● Top and side views are taken
● Images produced = mammograms
● Majority of abnormal mammograms are false positives

https://www.cancer.org/healthy/find-cancer-
early/cancer-screening-guidelines/american-cancer-
society-guidelines-for-the-early-detection-of-
cancer.html#written_by
What are the most current recommendations regarding
mammograms?
● Women ages 40-44: should have the choice to start annual breast
cancer screening with mammograms if they would like
● Women ages 45-54: should get mammograms every year
● Women 55 and older: should get mammograms every 2 years or can
continue yearly screening
● Screening should continue as long as woman is in good health and is
expected to live 10 or more years
● These recommendations are for women with average risk for breast
cancer
● Women at high risk should begin screening earlier and more often
https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-
detection/mammograms/mammogram-basics.html
What is a breast self exam?
A breast self exam (BSE) is a technique used to examine one’s breasts for any
visual or physical changes. The exam is often utilized as an early indicator for
breast cancer.
● It has been recommended for both women and men to do a BSE at least
once a month starting between the ages of 18-20.
● Approximately 80% of lumps found during BSE are non-cancerous.
Most current recommendations regarding BSE

● The most recent recommendation statement from the U.S.

Preventative Services Task Force (USPSTF) regarding screening
for breast cancer was released in 2016, but the recommendation on
clinicians teaching breast self exams remained the same from their
2009 recommendation statement.
Most current recommendations regarding BSE
(cont.)
● USPSTF recommends AGAINST teaching breast self-examinations
(BSE)
○ Evidence suggests that BSE does not reduce breast cancer
mortality
○ Potential harms of BSE include: false-positive results that lead to
anxiety, and unnecessary visits, imaging and biopsies
○ Grade D recommendation: discourage the use of this service
Know Yourself: Do a BSE

● But we should all know our normal!

○ Size
○ Color
○ Nipples
○ Lumps
○ Veins
http://www.cliffordgelmanmd.com/br-
selfexam.html

http://www.breastcancer.org/symptoms/test
ing/types/self_exam/bse_steps
Correct Procedures for BSE

1) In the shower
a) Pads of fingers in circular motion
from outside to inside
b) Feel for anything outside of your
normal: new lumps, lumps that
are hardening, thickening, etc.

http://www.nationalbreastcancer.org/breast-self-exam
Correct Procedures for BSE

2) In front of a mirror
a) Arms by side
b) Look for indentations,
dimpling, redness, change in
nipples, etc.
c) Arms overhead & repeat
d) Arms pressed on hips & repeat

http://www.nationalbreastcancer.org/breast-self-exam
Correct Procedures for BSE

3) Lying down
a) Place pillow under shoulder and
place arm behind head
b) Small, circular motions with pads
of fingers
c) Squeeze nipple, checking for
discharge

http://www.nationalbreastcancer.org/breast-self-exam
What is a pap smear?
● A pap smear is a test that uses
a swab to scrape cells from the
opening of the cervix to check
for abnormalities that may be
indicative of cervical cancer

http://www.differencebetween.net/science/health/the-
difference-between-pelvic-exam-and-pap-smear/
What are the current recommendations regarding
getting a pap smear?
1. A woman should begin getting pap smears at 21 years of age
2. They should get a pap smear every 3 years
3. After 30 years old they can opt to get a combination testing of the pap
smear and HPV testing every 5 years (recommended), or continue
with just getting the pap smear every 3 years
4. Many women can stop getting pap smears around the age of 65 as
long as they have had 3 consecutive negative tests, or 2 consecutive
negative co-tests in the past 10 years
How is a pap smear done?
A pap smear is performed with the
woman lying on an examination
table with her feet in stirrups. A
speculum is placed in the woman’s
vagina so that the provider can see
inside and visualize her cervix. Then
cells are gently scraped from the
cervix with a swab and are sent out
for testing.

http://www.wikihow.com/Deal-with-an-Abnormal-Pap-
Smear
Are pap smears effective at preventing cervical
cancer?
● Pap smears are a proven way to prevent cervical cancer
● If the test shows precancerous cells it can be treated before it
becomes cancerous
● Most cervical cancers that are invasive are found in women who have
not had their regular pap smears
Identify key teaching to be done prior...
The following should be avoided for 48 hours PRIOR to getting a pap smear:
1. Using a tampon.
2. Douching.
3. Inserting any creams, suppositories, or medications into the vagina.
4. Using vaginal lubrication.
5. Using vaginal sprays or powders.
6. Having sex.

*Be sure not to schedule your pap smear while on your period.
Identify risk factors for cervical cancer...
- Human Papillomavirus (HPV)
- Family history of cervical cancer
- Smoking
- Having a weakened immune system
- Chlamydia Infection
- Diet low in fruits and vegetables
- Being overweight
https://www.cancercouncil.com.au/research-
- Long term use of oral contraceptives old/reports-and-publications/state-of-cancer-
control-in-australia-1987-2007/results-by-
- Economic status cancer-type/cervical-cancer-c53/
Signs and symptoms of cervical cancer
- Early cervical cancers/precancers:
- Usually no symptoms
- Once the cancer becomes invasive and grows into nearby tissue:
- Abnormal vaginal bleeding
- Any unusual discharge from vagina
- Pelvic pain
- Advanced cervical cancer:
- Weight loss
- Fatigue
- Back pain
- Leg pain or swelling
- Leakage of urine or feces from the vagina
- Bone fractures
How are abnormal pap smear results classified?

● New classification system known as Bethesda System--allows

pathologists to describe what they see rather than assigning a number
● No abnormalities= “negative for intraepithelial lesion or malignancy”

A negative result can also describe infection, inflammation or

satisfactory specimen.

● Distinguished abnormalities between squamous cell and glandular

cells separately.
https://www.google.nl/patents/WO2011036173A1?cl=en
Squamous cell abnormalities
● Atypical Squamous Cells (ASC)-most common abnormal finding in
Pap smears
ASC-US: atypical squamous cells of undetermined significance
ASC-H: atypical squamous cells, also have undetermined
significance, but have a higher chance of being precancerous
than ASC-US
● Low grade squamous intraepithelial lesions (LSIL): mild
abnormalities caused by HPV infection. Early changes in the size and
shape of the cells. Intraepithelial refers to the layer that forms the
surface of the cervix. Can be further classified as mild dysplasia or
cervical intraepithelial neoplasia, grade 1 (when biopsied)
Squamous cell abnormalities cont.
● High grade squamous intraepithelial lesions (HSILs): more severe
abnormalities with a higher likelihood of progressing to cancer if
untreated. More evident changes in size/shape of abnormal-
precancerous cells. Under microscope changes could be classified as
moderate or severe dysplasia. Also reveal carcinoma in situ.
● Squamous cell carcinoma: cervical cancer. Abnormal squamous cells
invaded more deeply into cervix, other tissues/organs. Rare to find
cancer in cervical screenings if well-screened populations.
Glandular Cell Abnormalities
Abnormal changes in glandular tissue of the cervix

● Atypical glandular cells (AGC): cells do not appear normal, but

uncertain the extent and meaning.
● Endocervical adenocarcinoma in situ (AIS): severely abnormal cells,
but limited to glandular tissue and have not yet spread
● Adenocarcinoma: cancer of the endocervical canal and has possibly
spread further.
http://clinicalgate.com/cervical
-squamous-intraepithelial-
lesions/
If a woman has an abnormal pap smear what is
the likely treatment/follow-up?
● Normal pap smear with positive HPV test:
○ Return in a year for repeat screen
○ Get test for HPV-16 and HPV-18 (most common cause of cervical
cancer)
■ If either is present → colposcopy
● Abnormal pap smear with negative HPV test:
○ If ASC-US result: return in 3-5 years
○ If LSIL result: recommend colposcopy or return in one year
Treatment/follow-up continued...
● Abnormal pap smear with positive HPV test:
○ Considered high risk HPV type → colposcopy
● Pap smear alone
○ ASC-US result: test for high risk types
■ If negative: estrogen cream for low hormone levels
■ Usually self-limiting
Progression of HPV Lesions

http://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(07)61416-0/fulltext?_eventId=login
Treatment procedures
● Biopsy- removal of cells and tissue from cervix to examine
under microscope for abnormalities
● Excision- removal of tissue to be examined in laboratory
○ Loop electrosurgical excision procedure (LEEP)
○ Conization
● Ablative- destruction of tissue that requires no further
analysis in laboratory
○ Cryotherapy
○ Laser therapy
Other components of the routine gynecologic
exam.
● Pelvic exam
○ External exam
○ Speculum exam
○ Internal exam
● Clinical breast exam
● STI testing

http://www.etsu.edu/com/colormyworld/womenshealth.ph
p
Pelvic Exam
● External
○ Inspect external genitalia
○ Structures, distribution of hair, signs of infection
○ Education: Anatomy, signs of infection, reassure of what is normal
● Speculum
○ Insert speculum into vagina
○ Inspect vagina & cervix, pap, & STI swab
● Internal
○ Bimanual palpation of uterus & adnexa
○ Start at umbilicus to assess for masses, pain, structural abnormalities, etc.
○ Optional if asymptomatic (decision made by patient & provider)
○ May be necessary if: Abnormal bleeding, dysmenorrhea, infertility, etc.
Clinical Breast Exam
● Current recommendations
○ Before 40: every 1-3 years
○ 40+: every year
● False positives
● Opportunity for education!!!!!
○ Encourage breast self-knowledge
○ Reassure of what is normal
http://www.nationalbreastcancer.org/clinical-breast-exam
STI Testing: Current Recommendations
● High risk behavior
○ Exchanging sex for money, multiple partners, inconsistent use of
barrier methods (condom or dental dam)
○ Chlamydia, gonorrhea, HIV, & syphilis
● Age < 25
○ Increased risk due to immature anatomy & non-monogamous
relationships
○ Chlamydia & gonorrhea
Question #1
What age should women start getting pap smears?

A. 25
B. 18
C. 21
D. 16
Answer:
What age should women start getting pap smears?

A. 25
B. 18
C. 21
D. 16
Question #2
Where should individuals complete breast self exams?

A. In the shower
B. In front of a mirror
C. Lying down
D. All of the above
Answer:
Where should individuals complete breast self exams?

A. In the shower
B. In front of a mirror
C. Lying down
D. All of the above
References
American Cancer Society. (2015). American cancer society guidelines for the early detection of cancer. Retrieved from https://www.cancer.org/healthy/find-cancer-
early/cancer-screening-guidelines/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html#written_by

American Cancer Society (2016). Can Cervical Cancer Be Prevented? Retrieved from https://www.cancer.org/cancer/cervical-cancer/causes-risks-
prevention/prevention.html

American Cancer Society. (2016). HPV and HPV testing. Retrieved from https://www.cancer.org/cancer/cancer-causes/infectious-agents/hpv/hpv-and-hpv-testing.html

American Cancer Society. (2016). Mammogram basics. Retrieved from https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-

detection/mammograms/mammogram-basics.html

American Cancer Society (2016). What are the risk factors for cervical cancer? Retrieved from https://www.cancer.org/cancer/cervical-cancer/causes-risks-
prevention/risk-factors.html

American College of Obstetricians and Gynecologists. (2013). New Guidelines for Cervical Cancer Screening. Retrieved from http://www.acog.org/-/media/For-
Patients/pfs004.pdf?dmc=1&ts=20170416T2158248438

Byrd, I. (2017). Pap test. Retrieved from http://medlineplus.gov/ency/article/003911.htm

Cancer Treatment Centers of America. (n.d). Cervical cancer signs and symptoms. Retrieved from http://www.cancercenter.com/cervical-cancer/symptoms/
References
Chi, E. (2016). Laser Therapy. Retrieved from http://www.healthline.com/health/laser-therapy#overview1

National Breast Cancer Foundation. (2016). Breast Self-Exam. Retrieved from http://www.nationalbreastcancer.org/breast-self-exam

National Cancer Institute at the National Institutes of Health. (2014). Pap and HPV testing. Retrieved from https://www.cancer.gov/types/cervical/pap-hpv-testing-fact-
sheet#q8

Thomas, D. B., Gao, D. L., Ray, R. M., Wang, W. W., Allison, C. J., Chen, F. L., …Porter, P. (2002). Randomized trial of breast self-examination in Shanghai: Final Results.
Journal of the National Cancer Institute, 94(19), 1445-1447.

Unger, J. G. (2015). Cryotherapy. Retrieved from http://emedicine.medscape.com/article/1125851-overview#a2

U.S. Preventative Services Task Force. (2009). Breast cancer: Screening. Retrieved from
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening

U. S. Preventative Services Task Force (2017). Gynecological conditions: Periodic screening with pelvic examination. Retrieved from
https://www.uspreventiveservicestaskforce.org/Page/Document/ClinicalSummaryFinal/gynecological-conditions-screening-with-the-pelvic-examination

U. S. Preventative Services Task Force. (2017). USPSTF recommendations for STI screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-
recommendations-for-sti-screening