Colposcopy and Treatment of Cervical Intraepithelial Neoplasia - RHO

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Management that provides continuity of care for women screening programme, if one is on-going in the region (which is not the case in many developing countries!). Otherwise, she may be advised to undergo a repeat screening examination after three to five years. Reproductive tract infection If a woman is diagnosed with reproductive tract infection, prompt treatment should be instituted following the WHO guidelines (WHO, 2001). The Table 11.1 Treatment for reproductive tract infections Reproductive tract infection Non-pregnant women Treatment guidelines Pregnant women T. vaginalis (Trichomoniasis) Metronidazole 400 mg orally, 2 times a day, for 7 days or tinidazole 500 mg orally, 2 times a day, for 7 days or a single dose of metronidazole 2 g orally or tinidazole 2 g orally. 1 st trimester: Metronidazole gel, 0.75%, 5 g, 2 times a day intravaginally, for 7 days; 2 nd and 3 rd trimester: same as non-pregnant women. Candidiasis Clotrimazole or miconazole, 200 mg intravaginally, daily for 3 days or Fluconazole, 150 mg orally, as a single dose. Clotrimazole or miconazole, 200 mg intravaginally, daily for 3 days. Bacterial vaginosis Metronidazole 400 mg orally, 2 times a day, for 7 days. Metronidazole gel, 0.75%, 5 g, 2 times a day intravaginally, for 7 days or clindamycin, 300 mg orally, 2 times daily, for 7 days. Chlamydial infection Doxycycline 100 mg orally, 2 times a day, for 7 days or azithromycin, 1 g orally, as a single dose. Erythromycin 500 mg orally, 4 times daily, for 7 days or amoxycillin, 500 mg orally, 3 times daily, for 7 days. Gonococcal infection Ciprofloxacin, 500 mg, orally, as a single dose or azithromycin 2 g orally as a single dose. Cefixime, 200 mg orally, as a single dose or ceftriaxone, 125 mg intramuscularly, as a single dose. Syphilis Benzathine penicillin, 2.4 million IU, by intramuscular injection, as a single treatment; in penicillin-allergic patients, doxycycline, 100 mg orally, 2 times a day, for 15 days Benzathine penicillin, 2.4 million IU, by intramuscular injection, as a single treatment; in penicillin-allergic patients, erythromycin 500 mg orally, 4 times daily, for 15 days. Lymphogranuloma venereum Doxycycline, 100 mg orally, 2 times daily, for 14 days or erythromycin 500 mg orally, 4 times a day, for 14 days. Erythromycin 500 mg orally, 4 times a day, for 14 days. Chancroid Ciprofloxacin, 500 mg orally, 2 times a day, for 3 days or erythromycin 500 mg orally, 4 times a day, for 7 days or a single dose of azithromycin, 1 g orally. Erythromycin 500 mg orally, 4 times a day, for 7 days. Granuloma inguinale Azithromycin, 1 g orally, as a single dose or doxycycline, 100 mg orally, 2 times daily, for 14 days Erythromycin 500 mg orally, 4 times a day, for 7 days. Genital herpes Acyclovir, 400 mg orally, 3 times daily, for 7 days or famciclovir, 250 mg orally, 3 times daily, for 7 days. - Pelvic inflammatory disease (PID) Ceftriaxone 250 mg as a single intramuscular injection plus doxycycline 100 mg orally, 2 times a day, for 14 days or cefixime 800 mg orally as a single dose plus doxycycline as above or Ciprofloxacin 500 mg orally as a single dose plus doxycycline as above. Erythromycin 500 mg orally, 4 times a day, for 14 days. 91
Chapter 11 treatment policies for pregnant and non-pregnant women, diagnosed with reproductive tract infection, are outlined in Table 11.1. Use of oral metronidazole is contraindicated during the first trimester of pregnancy, but can be safely used in the second and third trimesters. Patients taking oral metronidazole should be cautioned not to consume alcohol while they are taking the drug or up to 24 hours after taking the last dose. Patients with advanced syphilis may require prolonged treatment with antibiotics. There is no known cure for genital herpes infections, but the course of symptoms can be modified if systemic therapy with acyclovir or its analogues is initiated. Leukoplakia (hyperkeratosis) Leukoplakia should be biopsied and submitted for histopathological examination, to rule out underlying cervical neoplasia. Condyloma Condylomata should be biopsied and localized ectocervical exophytic lesions may be treated with ablative treatment by cryotherapy or electrofulguration or with excisional treatment such as LEEP. CIN 1 If the final diagnosis in a woman is CIN 1, the clinical management may take one of the following courses: either to (a) to immediately treat the lesion or (b) follow the woman cytologically or colposcopically and then treat if the lesion is persistent or progressive after 18 to 24 months, and, if regression occurs, discharge her from the colposcopy clinic. In the context of developing countries, a decision may be made to treat the woman, as many fail return for a follow-up visit. If the decision is made to treat the woman with cryotherapy or LEEP, at least one follow-up visit should be scheduled at 9 to 12 months from the date of treatment (see Chapters 12 and 13). After cryotherapy and LEEP, healing of the cervix is grossly apparent by three to four weeks; cytological and colposcopic appearances will continue to reflect healing or regenerative effects for approximately three months. If the follow-up visit reveals no evidence of persistent disease, the woman can be discharged from the colposcopy clinic and advised to participate in the screening programme, if one is on-going in the region. Otherwise, she may be advised to undergo a repeat screening examination after three to five years. If persistent disease is found during the follow-up visit, appropriate investigations and appropriate treatment with cryotherapy, LEEP or cold-knife conization should be carried out. Table 11.2: Indications for cold-knife conization • The lesion extends into the endocervical canal and it is not possible to confirm the exact extent. • The lesion extends into the canal and the farthest extent exceeds the excisional capability of the LEEP cone technique (maximum excisional depth of 1.5 cm). • The lesion extends into the canal and the farthest extent exceeds the excisional capability of the colposcopist. • The cytology is repeatedly abnormal, suggesting neoplasia, but there is no corresponding colposcopic abnormality of the cervix or vagina on which to perform biopsy. • Cytology suggests a much more serious lesion than that which is seen and biopsy-confirmed. • Cytology shows atypical glandular cells that suggest the possibility of glandular dysplasia or adenocarcinoma. • Colposcopy suggests the possibility of glandular dysplasia or adenocarcinoma. • Endocervical curettage reveals abnormal histology. 92
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Colposcopy and Treatment of Cervica
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INTERNATIONAL AGENCY FOR RESEARCH O
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Published by the International Agen
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Contents 11 Management that provide
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Acknowledgements The authors gratef
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Preface Health care providers have
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Chapter 1 An introduction to the an
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An introduction to the anatomy of t
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Chapter 2 An introduction to cervic
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An introduction to cervical intraep
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Chapter 3 An introduction to invasi
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An introduction to invasive cancer
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Chapter 4 Table 4.1: Indications fo
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Chapter 4 FIGURE 4.2: Colposcope wi
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Chapter 4 FIGURE 4.6: Endocervical
Page 47 and 48:
Chapter 4 Table 4.2: Preneoplastic
Page 49 and 50: Chapter 5 between the two ocular le
Page 51 and 52: Chapter 5 Obtain specimens for labo
Page 53 and 54: Chapter 5 FIGURE 5.2: Biopsy techni
Page 55 and 56: Chapter 5 tissue tends to mimic inv
Page 57 and 58: Chapter 6 invasive carcinoma. Even
Page 59 and 60: Chapter 6 ages (Figures 1.7d, 1.7e,
Page 61 and 62: Chapter 6 FIGURE 6.7: The colour ch
Page 63 and 64: Chapter 6 Crypt openings Immature s
Page 65 and 66: Chapter 6 a FIGURE 6.17: An area of
Page 67 and 68: Chapter 7 The colposcopic diagnosis
Page 69 and 70: Chapter 7 appears as individual sma
Page 71 and 72: Chapter 7 acid stain is correlated
Page 73 and 74: Chapter 7 FIGURE 7.15: Moderately d
Page 75 and 76: Chapter 7 FIGURE 7.23: A dense acet
Page 77 and 78: Chapter 7 FIGURE 7.30: Mustard yell
Page 79 and 80: Chapter 7 We recommend that the stu
Page 81 and 82: Chapter 8 highlights this responsib
Page 83 and 84: Chapter 8 Appearance before applica
Page 85 and 86: Chapter 8 diagnosis of AIS and aden
Page 87 and 88: Chapter 8 a ↑ FIGURE 8.10: Adenoc
Page 89 and 90: Chapter 9 Inflammatory lesions of t
Page 91 and 92: Inflammatory lesions of the uterine
Page 93 and 94: Inflammatory lesions of the uterine
Page 95 and 96: Chapter 10 Table 10.1: Common sourc
Page 97 and 98: Chapter 10 Table 10.2 (cont.): A su
Page 99: Chapter 11 FIGURE 11.1: Flow chart
Page 103 and 104: Chapter 11 Vaginal delivery can be
Page 105 and 106: Chapter 12 involvement increases wi
Page 107 and 108: Chapter 12 Table 12.1: Eligibility
Page 109 and 110: Chapter 12 a b c d e f FIGURE 12.6:
Page 111 and 112: Chapter 12 during the follow-up in
Page 113 and 114: Chapter 13 (2) (1) FIGURE 13.2: Ele
Page 115 and 116: Chapter 13 (1) (2) (3) (4) (5) (8)
Page 117 and 118: Chapter 13 Once the specimen has be
Page 119 and 120: Chapter 13 in the endocervical cana
Page 121 and 122: Chapter 14 Decontamination, cleanin
Page 123 and 124: Decontamination, cleaning, high-lev
Page 125 and 126: References Herrero, R. (1997) Preva
Page 127 and 128: Further reading Suggestions on furt
Page 129 and 130: Appendix Leukoplakia Condylom
Page 131 and 132: Appendix regardless of your pregnan
Page 133 and 134: Appendix Monsel’s paste Ingredien
Page 135 and 136: Appendix 5 The modified Reid colpos
Page 137 and 138: Index Acetowhitening . . . . . . .
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