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Testing conditions for Helicobacter pylori

Quality statement

Adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for Helicobacter pylori if they are receiving proton pump inhibitor therapy.

Rationale

To improve the accuracy of Helicobacter pylori (H pylori) testing it is important to have a 2-week washout period after using a proton pump inhibitor (PPI). Improving the accuracy of the test will ensure that treatment for H pylori infection is given only if needed. Treatment for H pylori infection is complex and there is concern that treatment without an accurate diagnosis may lead to increasing antimicrobial resistance. In addition, treatment for H pylori can be unpleasant for the patient and has an increased risk of antibiotic-associated diarrhoea and enteric infections such as Clostridium difficile.

Quality measures

Structure

Evidence of local arrangements to ensure that adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for H pylori if they are receiving PPI therapy.

Data source: Local data collection.

Process

Proportion of adults with dyspepsia or reflux symptoms receiving PPI therapy who are tested for H pylori who had a 2-week washout period before the test.

Numerator - the number in the denominator who had a 2-week washout period before the test.

Denominator - the number of adults with dyspepsia or reflux symptoms receiving PPI therapy who are tested for H pylori.

Data source: Local data collection.

Outcome

H pylori antimicrobial resistance rate.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (general practices and hospitals) ensure that adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for H pylori if they are receiving PPI therapy.

Healthcare professionals ensure that adults with dyspepsia or reflux symptoms have a 2-week washout period before testing for H pylori if they are receiving PPI therapy.

Commissioners (clinical commissioning groups and NHS England area teams) commission services that ensure that adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for H pylori if they are receiving PPI therapy.

What the quality statement means for patients, service users and carers

Adults with indigestion or heartburn may need to have a test for an infection called Helicobacter pylori (H pylori for short), which can cause stomach and duodenal ulcers (the duodenum is the section of intestine immediately after the stomach). H pylori infection is detected using a breath or stool test, or sometimes a blood test. If the person is taking a medicine called a proton pump inhibitor (PPI) for their indigestion or heartburn symptoms, their GP will tell them if they need to stop taking the PPI or any other medicine before the H pylori test.

Source guidance

Definitions of terms used in this quality statement

Proton pump inhibitor (PPI)

Proton pump inhibitors inhibit gastric acid secretion by blocking the hydrogen-potassium adenosine triphosphatase enzyme system (the 'proton pump') of the gastric parietal cell. PPIs include esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole.

Test for H pylori

Use a carbon-13 urea breath test, a stool antigen test or laboratory-based serology where its performance has been locally validated to test for H pylori. Ensure that no antibiotics have been taken for any infection in the 4 weeks before the test.

If laboratory-based serology is to be used, its performance should be locally validated to test for H pylori. The serology test should have high positive predictive value in the intended population, or positives should be confirmed with a second test. Validation is an evidence-based assessment of how a test performs in the laboratory, and demonstrates suitability for intended purpose. Local validation will provide documentary evidence that a commercial serology kit is performing within the manufacturer's specifications. This will include results of experiments to determine its accuracy, sensitivity, reliability and reproducibility. Local validation should meet the requirements set out in the UK Standards for Microbiology Investigations.

Equality and diversity considerations

Serological tests are less reliable in older people and therefore, where laboratory-based serology tests are used, their suitability for people over 65 should be carefully considered.

It is important to use an accurate test for H pylori for people from ethnic minority groups because resistance rates are higher than in the general population. Where laboratory-based serology tests are used, their suitability for people from ethnic minority groups should be carefully considered.

Effective interventions library

Effective interventions library

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.

Pathway created: June 2015 Last updated: August 2018

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Suspected cancer recognition and referral overview

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Quality statement Adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for Helicobacter pylori if they are receiving proton pump inhibitor therapy. Rationale To improve the accuracy of Helicobacter pylori (H pylori) testing it is important to have a 2-week washout period after using a proton pump inhibitor (PPI).

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Daisy

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http://teachmeobgyn.com/gynaecology/cervix/cervical-cancer/

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Disease profile of CIN and cervical cancer - NICK

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Disease profile of CIN and cervical cancer - NICK

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https://almostadoctor.co.uk/encyclopedia/cervical-cancer-and-cin#Investigations-2

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Julia

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Cervical changes in response to hormones 

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Cervical changes in response to hormones 

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Julia

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CHLAMYDIA trachomatis is the most common bacterial sexually transmitted disease (STD). In women, chlamydial infection usually presents as cervicitis. Asymptomatic or mildly symptomatic infections occur in up to 70% of cases. Estimates of chlamydial infection range from 3% to 5% in asymptomatic women to 20% in women examined at STD clinics. Chlamydial infection is implicated in up to 30% to 50% of pelvic inflammatory disease episodes, many of which are subclinical. Pelvic inflammatory disease has significant reproductive sequelae, such as tubal infertility and ectopic pregnancy.

Oral contraceptive (OC) use and cervical ectopy have been associated with an increased risk of chlamydial infection. Cervical ectopy is defined as the presence of endocervical columnar epithelium on the ectocervix. C trachomatis preferentially infects columnar cells; thus, ectopy may increase exposure of susceptible cells to infection. Alternatively, presence of endocervical cells on the ectocervix may result in improved detection of C trachomatis. The increased risk of chlamydial infection with OC use has been hypothesized to be caused by induction of ectopy, an increased number of partners, or by a direct affect of OCs either on the genital immune response or on the susceptibility of host cells. The interrelationship of cervical ectopy and OC use is especially important to discern in young or adolescent females when ectopy is highly prevalent, chlamydial infection rates are highest, and when OCs are the most common pharmacologic intervention.

This review defines ectopy and summarizes the literature on the changes in ectopy due to exposure to endogenous and exogenous reproductive hormones at different stages in a woman's life, and describes how ectopy decreases over time by different processes. The understanding of the physiology of ectopy, which involves a complex interplay of morphology and histology, is crucial to the study of the effect of exogenous hormones on infection risk.

Review of Cervical Anatomy and Physiology

In this review, we use the following standard anatomical or histologic definitions: the uterine cervix superior to the vagina is termed the endocervix, whereas the inferior portion is termed the ectocervix (or portio vaginalis); the external os is the area where the endocervical canal joins the vagina, and the internal os is the area where the endocervical canal joins the endometrium.

The types of epithelia that line the two parts of the cervix are affected differently by estrogen and progesterone, and are susceptible to infection by different organisms. For example, columnar epithelium (typically on the endocervix) is susceptible to chlamydial and gonococcal infection, whereas squamous epithelium is susceptible to human papillomavirus infection.

Columnar Epithelium

A monolayer of columnar epithelium, which is composed of tall, mucin-secreting cells, lines the endocervical canal and the underlying "glandular" structures. Unlike true glands, these structures are actually cleft-like infoldings that develop when the surface columnar epithelium invaginates into the underlying stroma to increase surface area. When columnar epithelium extends out onto the ectocervix, it is defined by colposcopists as cervical ectopy; however, no strict definition exists ( Figure 1). Basal to the columnar cells are several subcolumnar cells, or "reserve cells," that multiply and differentiate into squamous epithelium, thereby replacing the overlying columnar epithelium under certain conditions in a process called squamous metaplasia.

Squamous Epithelium

Well-differentiated squamous epithelium line the vagina and part of the ectocervix. Normal, stratified squamous epithelium is arranged in three layers: (1) basal cells; (2) parabasal cells and intermediate cells; and (3) superficial (mature) cells. Intermediate cells and mature squamous cells do not divide. The three layers respond differently to hormonal stimulation. Estrogen induces proliferation, complete maturation of all layers of epithelium, and desquamation. Progesterone causes thickening of intermediate layers but does not lead to complete maturation. When the ratio of progesterone to estrogen is increased (e.g., during pregnancy or during the secretory phase of the menstrual cycle), intermediate cells predominate; however, when this ratio is reversed (e.g., during the proliferative phase of the menstrual cycle or during administration of exogenous estrogen), superficial cells predominate. Without such hormonal stimulation the squamous epithelium is largely undifferentiated or atrophic, and glycogen is absent.

Developmental Aspects of Ectopy

The Squamocolumnar Junction

The original (neonatal) position of the squamocolumnar junction changes as a result of hormonal influences in utero, at puberty, during pregnancy, and after menopause. The endocervical mucosa is fixed to the muscular wall and is stable in length. Movement of the endocervix, including "glandular structures" and stroma, onto the ectocervix occurs when the underlying muscle wall increases in volume under the influence of reproductive hormones. Because of anatomical constraints, the only direction for expansion of the endocervix in this situation is downward onto the ectocervix. This results in exposure of the endocervical mucosa to the vaginal environment (cervical ectopy) ( Figure 1).

The position of the original squamocolumnar junction, which is determined in utero, has been studied at different ages and at different points in a women's life using autopsy specimens, biopsy specimens, and colposcopy. The findings are inconsistent, perhaps owing to the two techniques that are used. Histology may be more sensitive than colposcopy in detecting the original and the neosquamocolumnar junction. An abrupt transition from columnar to squamous epithelium is rarely seen because of the presence of a transformation zone where cells are undergoing change. These demarcations may not be evident from a colposcope or by unaided visual assessment.

Squamous Metaplasia and Squamous Epitheliazation

Cervical ectopy is decreased in area over time by two processes: squamous metaplasia and squamous epitheliazation ( Figure 2). Squamous metaplasia is a normal and irreversible physiologic process in which ectocervical simple columnar epithelium is replaced by squamous epithelium. Multiple physiologic factors are involved. The lower pH (4.5) of the ectocervix most likely destroys the buffering action of the mucus that protects columnar cells. Metaplasia is most pronounced when the progesterone/estrogen ratio is high (e.g., during late fetal life, during pregnancy, with OC use).

Squamous metaplasia is multifocal and begins in distinct areas within the columnar epithelium, usually around "gland" openings, where the histologic borders to the surrounding columnar epithelium are distinct. The process of metaplasia can be arrested and resumed at any stage for reasons that are currently unclear. These foci eventually fuse, remodeling the zone of ectopy. This squamous epithelium is virtually indistinguishable from original squamous epithelium on the ectocervix except for the presence of clefts or retention cysts ("glands") in the underlying stroma, which remain from the time when the layer was composed of mucosal columnar epithelium.

Transformation Zone

The area in which squamous metaplasia replaces columnar epithelium is termed the transformation zone. Hamperl identifies the original squamocolumnar junction by the "gland" furthest from the external os, which can be determined histologically but not always colposcopically. As metaplasia progresses, the transformation zone moves from the original squamocolumnar junction toward the external os, and the area of ectopy decreases. A new border, the neosquamocolumnar junction, is created between the squamous cells that result from metaplasia and columnar cells.

There is an additional process of cervical remodeling called squamous epitheliazation. Metaplastic epithelium cannot always be differentiated colposcopically from squamous epitheliazation (sometimes called ascended healing), which also remodels the ectocervix. Tongues of squamous epithelium from the native squamous epithelium of the portio are thought to grow beneath the adjacent columnar epithelium, which are then sloughed off. This process is thought to replace areas of true erosion, and to be a reactive change due to inflammation or regeneration. This epithelium does not originate from subcolumnar cells, as in metaplasia. It is unclear, however, the degree to which metaplasia and squamous epitheliazation independently modify the area of ectopy or to what extent low pH, hormones, trauma, chronic irritation, semen, and cervical infection initiate and maintain each of these processes independently. Thus, the effects of repeated or chronic infection with C trachomatis, for example, on decreasing cervical ectopy are unknown. If chlamydial infection is dependent on an area of susceptible tissue, then susceptibility could decrease with increased remodeling of the ectocervix.

The position of the neosquamocolumnar junction is especially important to recognize, because it aids in the location of the area of columnar epithelium on the ectocervix. This area decreases with age. It is also important for colposcopists looking for abnormal precancerous squamous tissue, which is most prevalent near the neosquamocolumnar junction.

The Cervix at Different Stages of Development

The cervix in fetal life. During late fetal development, the fetus is exposed to maternal hormones that are believed to stimulate hyperactivity of columnar epithelium and produce ectopy. In a postmortem examination of 88 female infants, the prevalence of columnar cells on the ectocervix (ectopy) was less frequent in premature infants (29%) than in infants younger than 1 month (68%). The decreased frequency of ectopy in the premature infants may be due to the unresponsiveness of immature tissue. Infants with ectopy exhibited more mucus production, reserve cell activity, and growth of the endocervix and ectocervix. This growth might explain the shift downward in the position of the endocervical columnar epithelium and related stroma onto the ectocervix. In another study, 70% of mature autopsied fetuses presented with the squamocolumnar junction located on the ectocervix. Maternal estrogen exposure is thought to increase metaplasia. A significant transformation zone with metaplasia was observed in 39% of fetuses born after 36 weeks, but was present in fewer younger fetuses. These observations illustrate the effect of hormones in producing ectopy and metaplasia early in life.

The cervix in childhood. The influence of maternal hormones on the cervical mucosa diminishes after the first month of life. With the loss of maternal estrogen and progesterone and low levels of endogenous estrogen throughout the prepubertal period, some investigators believe that the ectopy produced in late fetal life retracts into the endocervix within the first year of life. Histologic studies by Hamperl and Kaufmann showed that the most prevalent pattern in childhood was an endocervical position of the original squamocolumnar junction. Similarly, Sersiron found that none of the 2,210 infants or juveniles observed during gynecologic examination showed ectopy. Madile found that ectopy was more common in infants than in children (2 out of 3 infants versus 1 out of 3 children) and argues that retraction of the ectopy occurs because columnar cell activity is low, the portio vaginalis shortens, and the lengthening of the endocervical mucosa pulls the ectocervical mucosa upward.

The cervix in adolescence and hormones at puberty. Significant hormonal events occur at puberty. Puberty is marked by a rise in secretions of luteinizing hormone followed by increased ovarian secretions of estrogen. The body and cervix of the uterus begin to increase in volume 2 to 3 years before menarche. Newly secreted ovarian hormones at puberty are believed to cause increased intracervical edema. Because of anatomical constraints, the enlarged endocervix can only expand downward and outward, which causes eversion, thereby exposing more endocervical columnar cells on the ectocervix. A zone of ectopy is thus created. During menarche, changes in the vaginal environment include a drop in pH, which stimulates metaplasia. Several histologic and colposcopic studies support the notion of ectopy occurring at menarche, resulting in a new position of the squamocolumnar junction.

Histology and colposcopy of the adolescent cervix. Ectopy is more common after puberty than in prepubescent females. Hamperl and Kaufmann found temporal changes in the positions of columnar and squamous epithelium on the cervix from childhood through early adulthood. Using histologic specimens, they found an equal percentage of 13- to 15-year-old females who had columnar cells on the ectocervix as females who exhibited no columnar cells on the ectocervix (an endocervical position of the squamocolumnar junction). However, younger females 9 to 11 years infrequently had columnar cells on the ectocervix (10%), whereas most women 21 to 23 years (90%) had an ectocervical position of the squamocolumnar junction. This finding illustrates the changes that occur around puberty. Similarly, in another study that examined colpophotographs of autopsied cervices, the frequency of females with the squamocolumnar junction within the endocervix dropped from 28% in females younger than the mean age of menarche to 12% in females older than that age. Histologic sections of the same specimens supported the colposcopic observations. Additionally, more columnar epithelium was found ectocervically in the postmenarchal than in the premenarchal females. In conclusion, adolescents have increased rates of cervical ectopy that are related to increasing hormone levels at puberty.

Ovarian hormones also stimulate metaplasia, probably through a direct effect on reserve cells and by lowering vaginal pH. In one study, postmenarchal women had greater amounts of recently formed metaplastic epithelium than premenarchal women, but the amount of mature epithelium of fetal origin was the same in both groups.

Puberty is not the only event that appears to accelerate the process of metaplasia, sexual activity has been associated with increased metaplastic activity. Whether this results from exposure to semen, sexually transmitted organisms, or other factors is not known. Semen is an attractive hypothesis because it is alkaline and has many immunosuppressive effects that could, theoretically, promote progression of STDs in the female genital tract. In colposcopic photographs of virginal and sexually active adolescent women, the latter had a larger proportion of new metaplastic activity than virgins. The original metaplastic area remained equivalent in the virgins and sexually active females of the same age. These observations are supported by Gotardi et al, who found that older sexually active females were more likely to have atypical transformation zones. In contrast to the virgins whose atypical zones did not vary by age, the atypical zones were larger in the older age groups among the sexually active females. Atypical areas could indicate immature metaplasia, response to inflammation, or human papillomavirus infection, which is highly prevalent among adolescents. A report by Coppleson et al suggested that sexual activity might cause some retraction of the ectocervix into the endocervix because the total transformation zone area is smaller in sexually active adolescents. The researchers speculate that either factors in semen (prostaglandins) or muscular contractions during intercourse may promote this phenomenon. In summary, there appears to be an increase in the prevalence of ectopy at puberty exposing columnar epithelium on the ectocervix. The ectopy gradually decreases with increasing amounts of metaplasia stimulated by hormones, decreased pH, and sexual activity.

The cervix in pregnancy. During pregnancy, the endocervical epithelium is everted onto the ectocervix due to hyperplasia of the columnar epithelium and by hyperemia and stromal edema, both stimulated by reproductive hormones. Late in pregnancy, mechanical venous obstruction may be a factor. Severe hyperplasia resembles a polyp, which can protrude through the external os (microglandular hyperplasia). Larger eversions are associated with larger increases in volume of the cervix from distended columnar villous processes and an increase in fibromusculature.

Eversion begins early in pregnancy and is most marked during the second and early third trimester. It is more pronounced in the primigravida than in the multigravida female. The process of metaplasia begins early in pregnancy in the primigravida female with exposure to the low vaginal pH. In multigravida females, metaplasia is mostly seen in the third trimester when eversion is also most common. Metaplasia also occurs on endocervical cells exposed through gaping of the pregnant cervical os, especially in multigravida females. Postpartum, the cervix diminishes in volume and the columnar epithelium frequently revert back into the endocervix. After pregnancy, it is uncommon to see evidence of lesions on the cervix due to delivery. Denuded areas appear to be replaced with squamous epithelium.
The cervix in the childbearing years through menopause.
With age there are increasing amounts of mature metaplastic epithelium initiated by sexual activity, infections, or hormones (including elevated hormone levels during pregnancy), which therefore decrease the amount of ectopy.

Menopause begins when the ovary can no longer release ova. Luteinizing hormone and follicle-stimulating hormone increase in the absence of ovarian estrogen feedback. In the postmenopausal years, some investigators believe that there is retraction of the transformation zone into the endocervical canal because of the reduced or absent exposure to ovarian hormones. Pharmacologically, however, the cervix is still responsive. Three of six recently postmenopausal women experienced displacement of the squamocolumnar junction from an endocervical to an ectocervical position after mestranol and norethisterone were administered sequentially.

Estrogen and progesterone receptors in cervical tissue. Estrogen and progesterone bind to specific high-affinity protein receptors and estrogen-responsive proteins in cervical tissue to regulate cervical growth and the production of mucus.

The proliferation and maturation of squamous epithelium is stimulated by estrogen, whereas progesterone inhibits complete maturation. The estrogen receptor and the estrogen-responsive or estrogen-regulated proteins are found with variability in basal, parabasal cells and in intermediate cells throughout the cycle and during pregnancy, with a small increase in receptors in the follicular phase. Progesterone receptors are present in the parabasal cells during the luteal phase and during pregnancy.

The cervix in hormonal contraceptive users and with hormone therapy. Hormonal contraceptives are categorized into oral (short-acting) and long-acting formulations. OCs are typically a combination of a progestin and an estrogen. Long-acting contraceptive preparations include depot medroxyprogesterone acetate (DMPA), which is an injectable progestin, and levonorgestrel, which is a progestin implant.

The gross appearance of the uterine cervix of OC users resembles the cervix during "early" pregnancy. Both groups exhibit hyperplasia and hypersecretion of endocervical glands, increased metaplasia and stromal edema, hyperemia, and ectopy. It is difficult to separate the effects of estrogen and progesterone on these processes. Compared with pregnant women in the third trimester and with women taking continuous progestin therapy, fewer OC users exhibited the aforementioned changes. Among the three groups, the changes were most common in pregnant women, and the differences were attributed to increasing progestin exposure. Because current OCs contain lower hormone levels, the extent of cervical changes may be less pronounced than those previously seen.

Summary

Cervical physiology is extremely complex and changes during different stages of development. Columnar cells of the endocervix protrude onto the ectocervix under the stimulation of reproductive hormones during late gestation, puberty, and pregnancy. Exogenous effects, such as hormonal contraception and sexual activity, also affect cervical morphology and physiology. The area of cervical ectopy undergoes changes over time through metaplasia and epitheliazation, whereby squamous epithelium replace columnar epithelium under the influence of low pH and repair. Cervical ectopy decreases with age as these processes progress.

Results of studies of the association between ectopy and chlamydial infection or other outcomes are conflicting. Relevant variables or confounders have not been adequately addressed across studies. In addition, misclassification of ectopy may be an important reason for discrepancies across studies because ectopy has not been assessed by standardized criterion and because the age and parity of participants vary. Furthermore, few studies have evaluated longitudinally the impact of estrogen or progestin use on changes in ectopy. Because chlamydial infection is the most common bacterial STD, especially among adolescents, and because the infection can cause significant reproductive sequelae, it is important to gain a better understanding of the etiology and evolution of ectopy at different stages of development.

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Histologic Development of Cervical Ectopy: Relationship to... : Sexually Transmitted Diseases

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e the production of ectopy during late fetal life, puberty, pregnancy, and with use of oral contraceptives. Ectopy is modified over time by squamous metaplasia and epitheliazation, low pH, trauma, and possibly by cervical infection. Study Design: The authors review the histologic development of ectopy from late fetal life to menopause to understand STD risk.

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julia
https://geekymedics.com/cervical-smear-test/

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Cervical screening (previously known as a smear test) frequently appears in OSCEs. You'll be expected to competently perform the procedure and demonstrate appropriate communications skills with the patient or mannequin. This cervical screening test OSCE guide provides a clear step by step approach to performing the procedure. Check out the cervical screening OSCE mark scheme here.

Check out our focused speculum examination OSCE guide here.

Wash your hands

Confirm the patient's details (e.g. name and date of birth)

Ask if the patient could currently be pregnant

Explain the procedure (as shown below)

Assess the patient's current understanding:

"I've been asked to perform a speculum examination."

"Do you understand what this procedure involves?"

Explain the procedure:

"What the procedure will involve is me inserting a small plastic device called a speculum into the vagina. This will allow me to visualise the neck of the womb."

"I will then place a very small brush into the vagina and take a sample of cells from the neck of the womb."

"The procedure shouldn't be painful however it will feel a little uncomfortable."

"If at any point you want me to stop the procedure, please let me know. You may also experience some light vaginal bleeding after the procedure."

Explain the need for a chaperone:

"For this examination, another staff member will be present, acting as a chaperone."

"Are you happy for a chaperone to be present?"

"Do you have any preference on the gender of the chaperone?"

Check the patient's understanding and gain consent:

"Do you understand everything I've explained?"

"Do you have any questions?"

"Are you happy for me to perform the procedure?"

Ask if the patient would like to go to the toilet to empty their bladder before the examination.
The patient should be positioned supine on a bed with their underwear removed and their abdomen exposed (a modesty cloth should be provided):

"I need you to go behind the curtain and remove your underwear. Could you please then get onto the bed and cover yourself with the cloth provided."
Position the patient in the modified lithotomy position:

"Bring your heels towards your bottom and then let your knees fall to the side."

Preparation

Inspect the vulva

Ulcers (e.g. genital herpes)

Abnormal vaginal discharge (e.g. chlamydia or gonorrhoea)

Scars from previous surgery (e.g. episiotomy)

Vaginal atrophy (secondary to post-menopausal changes)

Masses (e.g. Bartholin's cyst)

Varicosities (varicose veins secondary to venous disease/obstruction in the pelvis)

Cervical screening test

Inserting the speculum

1. Warn the patient you are about to insert the speculum

3. (blades closed, angled downwards and backwards)

4. (so that the handle is facing upwards)

5. Open the speculum blades until an optimal view of the cervix is achieved

6. Tighten the locking nut to fix the position of the blades

Inspect the cervix

External os (note if open or closed)

Cervical erosions (e.g. ectropion)

Masses (e.g. cervical malignancy)

Ulcers (e.g. genital herpes)

Abnormal discharge (e.g. bacterial vaginosis)

Obtaining the cervical screening sample

1. Insert endocervical brush through speculum into the endocervical canal

3. Remove endocervical brush, avoiding touching the speculum as you do so

4. Deposit the tip of the endocervical brush into the liquid-based cytology container

Removing the speculum

2. Rotate the speculum 90 degrees, back to its original insertion orientation

3. Gently remove the speculum, inspecting the walls of the vagina as you do so

To complete the procedure...

Thank the patient

Allow the patient time to get re-dressed

Label the sample

Document the procedure in the medical notes including the details of the chaperone

"On examination of Mrs Smith, a 29-year-old female, there were no abnormalities of the vulva noted on inspection. Speculum examination revealed a healthy cervix, with the external os closed and no abnormal masses or discharge present."

Suggest further assessments and investigations
REVIEWED BY
Mr Isaac Magani

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Cervical screening test (smear test) - OSCE Guide | Geeky Medics

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Cervical screening (previously known as a smear test) frequently appears in OSCEs. You'll be expected to competently perform the procedure and demonstrate appropriate communications skills with the patient or mannequin. This cervical screening test OSCE guide provides a clear step by step approach to performing the procedure.

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Muntasha

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Thomas

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A hysterectomy is the surgical removal of the uterus. It is a very common procedure, performed for a variety of indications.

In this article, we shall look at the classification, indications and complications of a hysterectomy.

Classification

A hysterectomy can be classified by the amount of tissue resected:

Total hysterectomy - removal of the uterus and cervix.

Sub-total hysterectomy - removal of the body of the uterus only, leaving the cervix behind.

Total hysterectomy and bilateral salpingo-oophorectomy - removal of the uterus, cervix, fallopian tubes and ovaries.

Radical hysterectomy - removal of the uterus and cervix, the parametrium, a vaginal cuff and part of or the whole of the fallopian tubes.

This procedure is carried out in selected cases of cervical cancer.

The ovaries may be removed or may be left behind, depending on the patient's age.

There are three main approaches to a hysterectomy. The principles and steps for each approach are the same (but in a different order).

Abdominal - via an incision in the abdomen.

Vaginal - via incision through the superior part of the vagina.

Laparoscopic - via small incisions in the abdomen, and using laparoscopes and a uterine manipulator.

Mobilisation should be encouraged as soon as possible. Discharge is usually after 1-2 days for vaginal and laparoscopic hysterectomy, and 2-5 days for abdominal hysterectomy (depending on the type of incision - generally longer stay if midline incision).

Abdominal Hysterectomy

An abdominal hysterectomy may be performed through a low transverse incision, or through a midline incision. This depends on the indication and the size of the uterus - for example, a large fibroid uterus may necessitate a midline incision.

The steps for a simple total hysterectomy, after the abdomen is opened are as follows:

The round ligaments are divided.

If the tubes and ovaries are to be removed, the infundibulopelvic ligaments are ligated and tied (the ureters should be identified first).

The uterovesical peritoneal fold is divided and the bladder reflected down past the cervix.

The parametrial tissue is divided.

The uterine vessels and ligated and tied.

The paracervical tissue and uterosacral ligaments are ligated and tied.

The vagina is opened and the uterus and cervix removed.

The vagina is usually closed with an absorbable suture.

Haemostasis is confirmed at all pedicles.

The abdomen is closed.

Laparoscopic Hysterectomy

The above steps are identical for a total laparoscopic hysterectomy, except that the procedure is performed through several very small incisions, using a laparoscope and laparoscopic instruments. The specimen (uterus, cervix +/- tubes and ovaries) is removed through the vagina.

Bipolar energy may be used for coagulation of blood vessels with scissors for dissection, or more modern energy devices may be used. The vaginal vault may be closed laparoscopically or vaginally. It can also be performed using a robotic platform (available in some parts of the UK).

A general anaesthetic is required for abdominal and laparoscopic hysterectomy.

Vaginal Hysterectomy

For a vaginal hysterectomy, no abdominal incisions are made and the procedure is performed entirely through the vagina.

The steps are as follows:

Local anaesthesia is infiltrated around the cervix (front and back, not laterally).

A circumferential incision is made around the cervix.

The bladder is dissected off the cervix and reflected upwards.

The anterior peritoneum is opened by cutting the utero-vesical peritoneal fold.

The Pouch of Douglas is opened.

The uterosacral ligaments are ligated and tied.

The uterine arteries and ligated and tied.

The round ligaments are ligated and tied.

The tubes and ovaries may be taken in this pedicle, or may be preserved.

The uterus and cervix are removed.

The vagina is normally closed or the edges sutured to ensure haemostasis.

The uterosacral ligaments may be fixed to the upper vagina to prevent prolapse of the vaginal vault.

Vaginal hysterectomy may be performed under regional anaesthesia (spinal/ epidural). A general anaesthetic is not required.

Indications

A hysterectomy has a number of possible indications. The following are the most common, but this is not an exhaustive list:

Heavy menstrual bleeding

Pelvic pain

Uterine prolapse (vaginal hysterectomy)

Gynaecological malignancy (usually ovarian, uterine or cervical)

Risk reducing surgery, usually in cases of BRCA 1 or 2 mutations, or Lynch syndrome.

Hysterectomy may also be performed as a life saving procedure in the management of major postpartum haemorrhage.

Complications

There are some potential complications of a hysterectomy. As for any surgical procedure, the general complications include risk of haemorrhage, infection and pain. There is also a general anaesthetic risk.

The specific complications of hysterectomy include:

Damage to the bladder and/or the ureter (seven women in every 1000) and/or long-term disturbance to the bladder function (uncommon)

Damage to the bowel: four women in every 10 000 (rare)

Haemorrhage requiring blood transfusion, 23 women in every 1 000 (common)

Return to theatre because of bleeding/wound dehiscence, and so on: seven women in every 1000 (uncommon)

Pelvic abscess/infection: two women in every 1000 (uncommon)

Venous thrombosis or pulmonary embolism, four women in every 1000 (uncommon)

Risk of death within 6 weeks, 32 women in every 100 000 (rare). The main causes of death are pulmonary embolism and cardiac disease.

If the ovaries are conserved, menopause may occur earlier (by 1-2 years) due to a change in the blood supply to the ovaries.

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Hysterectomy - Procedure - Indications - Complications - TeachMeObGyn

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A hysterectomy is the surgical removal of the uterus. It is a very common procedure, performed for a variety of indications. In this article, we shall look at the classification, indications and complications of a hysterectomy. A hysterectomy can be classified by the amount of tissue resected: Total hysterectomy - removal of the uterus and cervix.

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Thomas

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Cervical Cancer Progression And Staging - Manipal Hospital

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First page is a good summary of the causes and management- Thomas

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Octavi

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Genital warts - Symptoms, diagnosis and treatment | BMJ Best Practice

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Very common STI. Caused by human papillomavirus (HPV) infection, most commonly HPV types 6 and 11. Peak incidence of genital HPV infection occurs in 16- to 25-year-olds. Diagnosis is made based on clinical presentation. Generally has a benign course and is not often associated with oncogenic pote...

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https://www.cancer.gov/about-cancer/diagnosis-staging/staging

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Daisy

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Daisy

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Daisy

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Muntasha

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Skip to main content

© 2017 American Association for Clinical Chemistry, republished from Lab Tests Online.*

Descriptions of clinical laboratory tests were originally prepared for use on Lab Tests Online, an award-winning patient education website on clinical laboratory testing. Lab Tests Online is produced by the American Association for Clinical Chemistry (AACC), a global scientific and medical professional organization dedicated to clinical laboratory science and its application to healthcare. The Lab Tests Online website is developed in collaboration with other laboratory professional societies and is funded in part through corporate sponsorships.

Please click to see a complete list of the site's collaborating partners or corporate sponsors.

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Skip to main content © 2017 American Association for Clinical Chemistry, republished from Lab Tests Online.* Descriptions of clinical laboratory tests were originally prepared for use on Lab Tests Online, an award-winning patient education website on clinical laboratory testing.

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Muntasha

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ON THIS PAGE: You will learn about how doctors describe a cancer's growth or spread. This is called the stage. Use the menu to see other pages.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to find out the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer. For cervical cancer, the staging system developed by the International Federation of Obstetrics and Gynecology (Federation Internationale de Gynecologie et d'Obstetrique or FIGO) is used.

FIGO stages for cervical cancer

Doctors assign the stage of the cancer by evaluating the tumor and whether the cancer has spread to lymph nodes and other parts of the body.

Stage I: The cancer has spread from the cervix lining into the deeper tissue but is still just found in the uterus. It has not spread to lymph nodes or other parts of the body. This stage may be described in more detail (see below).

Stage IA: The cancer is diagnosed only by microscopy, which is viewing cervical tissue or cells under a microscope. No lymph nodes are involved, and there is no distant spread.

Stage IA1: There is a cancerous area of 3 millimeters (mm) or smaller in depth and 7 mm or smaller in length. No lymph nodes are involved, and there is no distant spread.

Stage IA2: There is a cancerous area larger than 3 mm but not larger than 5 mm in depth and 7 mm or smaller in length. No lymph nodes are involved, and there is no distant spread.

Stage IB: In this stage, the doctor can see the lesion, and the cancer is found only in the cervix. Or there is a lesion that can be seen using a microscope, and it is larger than a stage IA2 tumor (see above). The cancer may have been found through a physical examination, laparoscopy, or other imaging method (see Diagnosis). No lymph nodes are involved, and there is no distant spread.

Stage IB1: The tumor is 4 centimeters (cm) or smaller. No lymph nodes are involved, and there is no distant spread.

Stage IB2: The tumor is larger than 4 cm. No lymph nodes are involved, and there is no distant spread.

Stage II: The cancer has spread beyond the cervix to nearby areas, such as the vagina or tissue near the cervix, but it is still inside the pelvic area. It has not spread to lymph nodes or other parts of the body. This stage may be described in more detail (see below).

Stage IIA: The tumor has not spread to the tissue next to the cervix, also called the parametrial area. No lymph nodes are involved, and there is no distant spread.

Stage IIA1: The tumor is 4 cm or smaller. No lymph nodes are involved, and there is no distant spread.

Stage IIA2: The tumor is larger than 4 cm. No lymph nodes are involved, and there is no distant spread.

Stage IIB: The tumor has spread to the parametrial area. No lymph nodes are involved, and there is no distant spread.

Stage III: The tumor has spread to the pelvic wall, and/or involves the lower third of the vagina, and/or causes swelling of the kidney, called hydronephrosis, or stops a kidney from functioning. No lymph nodes are involved, and there is no distant spread.

Stage IIIA: The tumor involves the lower third of the vagina, but it has not grown into the pelvic wall. No lymph nodes are involved, and there is no distant spread.

Stage IIIB: The tumor has grown into the pelvic wall and/or affects the kidneys, but it has not spread to the lymph nodes or distant sites. Or, the cancer has spread to lymph nodes in the pelvis, but not distant sites, and the tumor can be any size.

Stage IVA: The cancer has spread to the bladder or rectum and may or may not have spread to the lymph nodes, but it has not spread to other parts of the body.

Stage IVB: The cancer has spread to other parts of the body.

Recurrent: Recurrent cancer is cancer that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.
Information about the cancer's stage will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. You may use the menu to choose a different section to read in this guide.

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ON THIS PAGE: You will learn about how doctors describe a cancer's growth or spread. This is called the stage. Use the menu to see other pages.Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.

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A blog but recently medically reviewed - Julia
https://www.stdcheck.com/blog/everything-about-chlamydia-and-chlamydia-testing/

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Chlamydia is a bacterial sexually transmitted disease that is caused by Chlamydia trachomatis. It is a common STD that is contracted during vaginal, anal or oral sex. Chlamydia can also be spread by sharing unclean sex toys. The Centers for Disease Control and Prevention (CDC) estimates that there are approximately 2.86 million chlamydia infections annually, making it the most frequently reported bacterial STD in the U.S.

Often, people with chlamydia do not show any signs or symptoms of the infection. Therefore, chlamydia can be spread easily, since chlamydia carriers typically do not realize they have it. Which is why getting tested for chlamydia is so important. If symptoms appear, they typically occur within 2-21 days after exposure.

Chlamydia most frequently infects the cervix, urethra, or rectum, but it can also be spread to the throat during oral sex. The infection can spread to the eye if an infected area is touched and then the eye is touched. Pregnant women with chlamydia can pass the infection to their babies during childbirth. Chlamydia is especially harmful to infants and can cause infections that result in pneumonia and even blindness.

Symptoms of chlamydia sometimes differ between men and women.

Symptoms in men can include:

Discharge from the penis

Burning/itching sensation during urination

Pain/swelling in one or both testicles (less common)

Rectal pain or bleeding (when contracted in the rectum)

Symptoms in women can include:

Abnormal vaginal discharge

Burning sensation during urination

Pain during intercourse (less common)

Abdominal pain (less common)

Bleeding between periods (less common)

Rectal pain or bleeding (when contracted in the rectum)

For both men and women, chlamydia is commonly asymptomatic, meaning that it displays no symptoms at all.
Who is at risk for chlamydia?

This STD is particularly common in young people. According to a CDC report, "chlamydia prevalence among sexually active persons aged 14-24 years is nearly three times the prevalence among those aged 25-39 years." It is more prevalent among young women because at that age the cervix is still developing and is much more susceptible to the bacteria. Additionally, the vagina and cervix provide more surface area than the penis, which makes it easier for women to contract the bacteria.

Whether chlamydia symptoms are present or not, untreated chlamydia can travel to the upper genital tract and cause serious health problems. In women, chlamydia can lead to pelvic inflammatory disease (PID) and cause permanent damage leading to infertility or potentially fatal ectopic pregnancy. In men, untreated cases can lead to epididymitis, which can, but very rarely does, cause sterility.

Chlamydia can be Treated and Cured with Antibiotics

Individuals diagnosed with chlamydia should abstain from sexual activity for one week after finishing antibiotics. Keep in mind that it is possible to become reinfected with chlamydia after receiving treatment. This is why it is crucial for partners of those who have chlamydia to also get tested and treated if found positive. Chlamydia often occurs along with gonorrhea (another bacterial STD). If you have one of these STDs, you might have the other because the risk factors and symptoms are very similar. Getting tested for both is important.

Whether or not symptoms are present, testing or screening for chlamydia can be done as early as 24 hours after exposure. The incubation times vary from person-to-person; for the most accurate results, get tested two weeks after initial exposure. If you test positive for chlamydia, it is advised to get retested two weeks after completing treatment to be sure that all of the Chlamydia trachomatis bacteria is cleared from your system.

How do you test for chlamydia?

Nucleic Acid Amplification (NAA)
The three NAA tests described below (urine, swab, and DFA) work by finding the DNA of chlamydia bacteria. Because NAA tests search for the bacteria's genetic material, it is very unlikely that a false-positive test result will occur. The incubation period for chlamydia is 1-5 days, so wait at least five days after potential chlamydia exposure before getting tested to ensure the most accurate results possible.
Urine samples (recommended test method)

Testing via urine samples needs to consist of first-catch urine (approximately 20-30mL of the initial urine stream). Patients should not include more than the first-catch in the collection cup to avoid diluting the sample.

Patients should not urinate for at least one hour prior to providing a sample.

Female patients should not cleanse the labial area prior to providing the specimen.

Swab cultures

Endocervical swab

Male urethral swab

Vaginal swab

Rectal swab

Pharyngeal swab (throat swab) if the throat is infected

Direct Fluorescent Antibody (DFA)

Swab cultures

Endocervical swab

Male urethral swab

Rectal swab

Neonates conjunctival swab

Why shouldn't you get tested for chlamydia via a blood test?

Testing chlamydia with a blood test requires that a small blood sample is drawn and then tested for antibodies to the chlamydia bacteria: Chlamydia trachomatis. Chlamydia is not a blood-borne disease or infection, but the body creates antibodies to respond to various diseases and infections, and these can be found in the blood. The test can detect if antibodies to chlamydia are present, but these antibodies could be the result of a previous chlamydia infection. This would result in a false positive. Because chlamydia blood tests cannot tell for certain if an individual has chlamydia at the time of the test, only whether or not the individual has had it in the past, this type of test should not be used to diagnose chlamydia.
Enzyme-linked immunosorbent assay (ELISA); Antibodies, IgM

IgM antibodies are found mainly in the blood and lymph fluid; they are the first antibody to be made by the body to fight a new infection.

This blood sample's results should not be used as a diagnostic procedure without confirmation of the diagnosis by another medically established diagnostic product or procedure.

Enzyme immunoassay (EIA); Antibodies, IgG

IgG antibodies are the most abundant type of antibody; they are found in all body fluids and protect against bacterial and viral infections.
Cell Culture and Subsequent Detection of Chlamydia by Fluorescent Antibody Test Method

A culture allows the chlamydia bacteria to grow, but results take longer (typically 5 to 7 days) than the other tests and must be done in a lab.

The fastest results possbile - available in 1 to 2 days
Get Tested Today

Although culture is the legal standard, it is not the gold standard for the detection of Chlamydia trachomatis.

Women should not douche or use vaginal creams/medicines for 24 hours before having a chlamydia test.

Test options for cell cultures include:

Conjunctival swab

Cervical swab

Rectal swab

Posterior nasopharynx/throat swab

Urethral swab

Key Takeaways:

Chlamydia is the most common bacterial STD in the United States.

Chlamydia is a curable bacterial STD that doesn't usually show signs or symptoms.

Chlamydia can cause infertility in women and sterility in men if left untreated.

Chlamydia can be transmitted to newborns during delivery and cause serious health complications like blindness and pneumonia.

Chlamydia is particularly common in young people (aged 14-24) and is especially prevalent among young women.

Co-infection of chlamydia and gonorrhea is common.

Chlamydia can infect the genitals, rectum, throat, and eyes.

Nucleic Acid Amplification (NAA), via either urine or swab, is considered the best option in testing for chlamydia.

Get tested for chlamydia! It is curable and easily treated.

Read Section 4 on Gonorrhea and Gonorrhea Testing

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Chlamydia Test: Chlamydia Blood & Urine Testing Information | STDCheck.com

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Chlamydia is a bacterial sexually transmitted disease that is caused by Chlamydia trachomatis. It is a common STD that is contracted during vaginal, anal or oral sex. Chlamydia can also be spread by sharing unclean sex toys.

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Includes info on the histology and lots of images- Daisy

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Daisy

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Your browser does not support iFrames. Please visit http://www.bashhguidelines.org.

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Cervical screen results guidelines - Octavi 

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Cervical screen results guidelines - Octavi 

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The NICE Clinical Knowledge Summary (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories