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Gynecology Screening

Group C
Morgan Frank, Jenny Garred, Alyssa Hall, Rachel Lima,
Lauren Powell, Clay Sensibaugh, Leah Silver, Emily St.
Germain, Holly Zuehlke-Frazelle

Current Screening
Holly Zuehlke-Frazelle

What is mammography?

Mammography is an x-ray exam of the
breast that is used to detect and
evaluate changes within the breast

Today’s mammography equipment uses
far less radiation than machines of the

Image quality has also improved greatly
compared to past technologies.

(American Cancer Society, 2015d)

What are the types of imaging testing?

Screening exams: Mammograms are done to aid in detection of early
breast tissue changes. This is performed when there are no breast
symptoms, and no previous history of abnormal results.

The goal is to catch cancer in its earliest stages.

Diagnostic exams: Are used to investigate potential problems. These are
done when abnormal breast conditions (like finding a lump or nipple
discharge) or as a follow up to a screening mammogram that indicated an
abnormal area.

They may also be done as follow up testing on women who have had a
history of breast cancer.

(American Cancer Society, 2015d)

Current recommendations on
mammography testing.

Recommendations for women at average risk of breast cancer.

Women aged 45-54 should be screened annually.

Women aged 55 and older should transition to biennial screening or have the
opportunity to continue with annual screening.

Women aged 40-44 should have the opportunity to begin annual screening.

Women should continue mammogram screenings as long as their overall health is
good and they have a life expectancy of 10 years or longer.

The American Cancer Society does not recommend clinical breast examination for
breast cancer screening among average-risk women at any age.

(Oeffinger et al., 2015)

Current recommendations on
mammography testing.
• Recommendations for women with a higher risk for breast cancer.
• Women at a higher risk for breast cancer based on certain factors
should have a yearly mammogram and MRI.
• Risk factors include
• Have a lifetime risk of breast cancer of about 20-25%, based mainly
on family history of breast cancer.
• Have a known BRCA1 or BRCA2 mutation.
(American Cancer Society, 2015d).

Current recommendations on
mammography testing.

• Risk factors, continued. . .

• Have a first degree relative (parent, brother, sister, child) with a
BRCA1 or BRCA2 gene mutation, and you yourself have not had
genetic testing.
• Had radiation therapy to the chest when they were between 10-30
years old.
• Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-RileyRuvalcaba syndrome, of have first degree relatives with these

Breast Self Exam & Most
Jenny Garred

BSE - What is it?
• BSE are a way for women to familiarize themselves with how their
breasts look and feel so that they can alert their healthcare
provider if they begin to notice any changes.
• According to John’s Hopkins Medical Center, “forty percent of
diagnosed breast cancers are detected by women who feel
a lump, so establishing a regular breast self-exam is very

(National Breast Cancer Foundation, INC, 2015a)

BSE - Current Recommendations

Despite the previous statement put forth by
John’s Hopkins Medical Center, the American
Cancer Society revised its guidelines
regarding BSE as of 10/20/2015 stating:

“Research does not show a clear benefit of
physical breast exams done by either a
health professional or by yourself for breast
cancer screening. Due to this lack of
evidence, regular clinical breast exam
and breast self-exam are not
recommended. Still, all women should be
familiar with how their breasts normally look
and feel and report any changes to a health
care provider right away.”

BSE Procedure and
Patient Teaching
Morgan Frank

Performing a BSE
• Although breast self-exam is no longer
recommended as part of breast cancer screening,
it is still important to be familiar with the way
your breasts normally look and feel.
• Knowing what is normal for your body can help you see or feel any changes
in your breasts.
• A self breast exam should be performed monthly, and should be performed
in the shower, in front of a mirror, and laying down.

Source: Susan G. Komen, 2015

Performing a BSE: In the Shower

Raise right arm

Use pads of fingers on left hand

Feel around entire right breast in a circular pattern
moving from the outside to the center of the breast.

Check entire breast and armpit area of both

Feel for lumps, thickening, or hardened knots.

Repeat with left breast

Source: National Breast Cancer Foundation, INC, 2015b

Performing a BSE: In Front of a Mirror
1. Stand with arms by your sides and look at your breasts.
2. Next, raise arms above your head and look at your breasts.

Look for changes in contour, swelling, dimpling of the skin, or changes in nipples.

3. Then, place your palms on your hips and press firmly
to flex chest muscles.

Left and right breasts will not match exactly.

Look for any dimpling, puckering, or changes.
Source: National Breast Cancer Foundation, INC, 2015b

Performing a BSE: Lying Down

Lying down (in a supine position) allows the breast tissue to spread out evenly along the chest


Place a pillow under right shoulder and put right arm behind head.


Use left hand and feel with pads of fingers around your right breast in small, gentle, circular


Cover entire breast and armpit area.


Use light, medium, and firm pressure.


Squeeze nipple to check for discharge and lumps.


Repeat with left breast!
Source: National Breast Cancer Foundation, INC, 2015b

Patient Teaching
• BSE is NOT recommended for breast cancer screening
• However, when combined with regular medical care and appropriate
guideline-recommended mammography, BSE’s can help patients know what
is normal for their body so changes or lumps can be promptly reported to a
healthcare provider.
• Women should perform a BSE at the same time each month because of
hormonal changes that affect breast tissue
• Patients should be educated about proper technique and positioning for
performing a BSE.
Sources: National Breast Cancer Foundation, INC, 2015b
Johns Hopkins Medicine, 2015

Pap Smear - Purpose,
Efficacy, and
Rachel Lima

Pap Smear

A Pap (Papanicolaou) test is a screening test for
cervical cancer.

A speculum is inserted into the vagina and a synthetic
fiber brush or plastic spatula is used to swab the cervix
to obtain the specimen.

Specimens taken from the cervix and vagina undergo
microscopic examination to assess for the presence of
abnormal cells. Abnormal results require follow-up.

Although it is not 100% effective, it is currently the
most effective form of cancer screening.

Limitation: inability for a person to inspect every
cell in a sample containing hundreds of thousands
of cells.

Source: Chapman & Durham, 2014b

Pap Smear - Recommendations
● Women of any age should NOT be screened yearly by any method.
● 21 years old: screen ALL women
● 21-29 years old: screen every 3 years
● 30-65 years old: combine a Pap test with an HPV test every 5 years, aka “cotesting”
● Over 65…
○ Stop screening if they’ve had regular screening over the past 10 years
and have not had an abnormal result in the past 20 years.
○ Screening should continue for 20 years after any abnormal results have
been found.
Source: American Cancer Society, 2014

First Pap Smear - Patient
Leah Silver

What is a Pap Smear?
● Screening procedure to detect abnormal cells in and around the cervix
● Early detection of cervical cancer - identified through microscopy often prior to symptoms
● Does not screen for uterine or ovarian cancer
● Inform of risks (To be discussed by Lauren)
● Procedural instructions

Speculum inserted into vagina

Wipes thin brush on cervix to take cell sample

Cells placed in liquid preservative and sent to lab

(MD Anderson Cancer Center, 2011)

How do you prepare for the test?
• Schedule an appointment five days after stopping menstrual period
• 48 hours before procedure, avoid:
• Tampons
• Contraceptive or vaginal foams
• Douching
• Sexual Intercourse

Common Misconceptions about Pap
• “Once I have a pap smear, I will no longer be a virgin”
• “A Pap smear test will tell me if I have HIV”
• “Only girls that sleep around or aren’t virgins need Pap

(MD Anderson Cancer Center, 2011)

Cervical Cancer
Risk factors, Signs, and
Lauren Powell

Cervical Cancer

Cervical cancer is a cancer arising from
the cervix. It is due to the abnormal
growth of cells that have the ability to
invade or spread to other parts of the

Rated as the 14th leading cause of
cancer related deaths

Decrease in cervical related death can be
attributed to women getting Pap tests,
which aids in detecting cervical cancer at
an early stage.

(Chapman & Durham, 2014a)

Cervical Cancer cont.
• The human papillomavirus
(HPV) is the primary cause of
cervical cancer.
• HPV is a skin infection,
spread through skin-to-skin
contact with a person who
has the virus.
(Chapman & Durham, 2014a)

Cervical Cancer - Risk Factors

Pregnancy: women who have had three or more full-term pregnancies, or who had their first full-term
pregnancy before age 17, are twice as likely to get cervical cancer.

Family History:

Women with a sister or mother who had cervical cancer are two to three times more likely

to develop cervical cancer.

Sexual History: HPV infection (most important risk factor). Sex before age 16, sex with multiple partners
and sex with someone who has had multiple partners. Studies also show a link between chlamydia infection
and cervical cancer.


Oral Contraceptive Use: Women who take oral contraceptives for 5 or more years has an increased risk

A woman who smokes doubles her risk of cervical cancer.

of cervical cancer, but this risk returns to normal within a few years after the pills are stopped.

(Chapman & Durham, 2014a)

Other Conditions
• HPV: Though infection of the cervix with human papillomavirus
(HPV) is the most common cause of cervical cancer, having
HPV does not mean you will get cancer.
• The majority of women who contract HPV clear the virus or
have treatment so the abnormal cells are removed.
• Routine Pap screening is important to check for abnormal cells
in the cervix, so they can be monitored and treated as early as

(Chapman & Durham, 2014a)

Signs and Symptoms of Cervical Cancer
In most cases, cervical cancer does not
cause noticeable symptoms in the early
stages of the disease.
• Vaginal bleeding: This includes
bleeding between periods, after
sexual intercourse or postmenopausal bleeding.
• Unusual vaginal discharge: A watery,
pink or foul-smelling discharge is
• Pelvic pain: Pain during intercourse
or at other times may be a sign of
abnormal changes to the cervix.

Cervical cancer may spread (metastasize )
within the pelvis, to the lymph nodes or
elsewhere in the body. Signs of advanced cervical
cancer include:

Weight loss
Loss of appetite

Back pain

Leg pain or swelling

Leakage of urine or feces from the vagina

Bone fractures

(Chapman & Durham,

Classification of
Abnormal Pap Smear
Clay Sensibaugh

Quick Refresher
The Pap test is a screening test for malignant and
premalignant changes of the cervix. A positive result
indicates that there may be a problem and that
further diagnostic procedures must be done. The Pap
test is not a diagnostic test. It cannot be used to
exclude a cancer of the cervix for a person who has
symptoms that could be due to a cervical cancer
(Pfenninger, 2011).

Classification of Pap Test Results
Class I (Negative)


Class II (Atypical)

Atypical, inflammation of uterine cells

Class III (Low-grade squamous
intraepithelial lesion)

Dysplastic, mild, moderate, or severe

Class IV (High-grade squamous
intraepithelial lesion


Class V (Cancer)

Suspicious for an invasive cancer

Source: American Cancer Society, 2014b

Negative (Class I)
•Indicates that there are no abnormal cells
•The smear is clean and clear of any
inflammatory cells.
•Signs of infection with yeast, herpes or
Trichomonas vaginalis.

Source: (Pfenninger, 2011)

Atypical (Class II)
•Abnormal cells were present within the
sample, but there is no evidence
indicative of cancer, infection or irritation.
•There may be evidence of cervical cell
regeneration or cellular changes r/t
Source: (Pfenninger, 2011)

Low-grade squamous intraepithelial
lesion (Class III)
•Abnormal cells that have mild
- Dysplasia is a precancerous change,
which prompts further evaluation.
- Cells typically tend to go away on
Source: (Pfenninger,
their 2011)

High-grade squamous
intraepithelial lesion (Class IV)
•High degree of precancerous change.
•Colposcopy is mandated.
•Warrants cryotherapy treatment or removal of
area of concern.

Source: (Pfenninger, 2011)

Cancer (Class V)

•Indicative of a high possibility of cancer.
•Prompts a complete assessment to
determine the extent of the issue.
•Carcinoma-in-situ: A cancerous lesion
that is confined to a given area and has
yet to metastasize.
Source: (Pfenninger, 2011)

Atypical Glandular Cells
•Used to describe when the glandular
cells do not look normal, but do not have
cancerous qualities
•Follow-up treatments are recommended

Source: (Pfenninger, 2011)

Other malignant neoplasms
•Rare cancers of the cervix.
•Malignant melanoma, sarcoma and

Source: (Pfenninger, 2011)

Treatment/Follow-Up of
Abnormal Pap Smear
Alyssa Hall

So what happens next…?
If your Pap smear shows you
have a definite or possible low
grade abnormality, your doctor
will usually recommend a repeat
Pap smear in 12 months time.

(Cancer Institute NSW, 2015)

Will be needed if:

A low grade abnormality that
continues over several Pap

High grade abnormality is
found on your Pap smear

Any glandular abnormality that
is found on your Pap smear

The specialist uses a colposcope
(large microscope). This allows
the specialist to have a
magnified view of the cervix to
check the extent and nature of
any abnormality.


During the colposcopy
examination, a sample of
tissue is taken from any
abnormal looking areas of the

The sample will be sent to a
laboratory for testing and will
take up to two weeks for

(Cancer Institute NSW,

•If a colposcopy and biopsy show a high grade abnormality, your specialist will recommend
that you have treatment.
•The purpose of treatment is to remove the abnormal cells
–One of the following methods will be recommended:
•Wire loop excision
•Cone biopsy
•After treatment
–A Pap smear and colposcopy should be done four to six months later.
–Yearly Pap smear and an HPV test until both tests are negative two years in a row.
–These follow ups are done to make sure the treatment has worked.
(Cancer Institute NSW,

Cervical Cancer
•It is rare that a Pap smear result will show cells suggestive of cervical
cancer, because cervical cancer is a rare disease. If this does happen,
your doctor will recommend you see a specialist who will perform a
colposcopy and further tests to determine how serious the changes are.
•If a biopsy shows that cancer is present, your doctor may order certain
tests to see how far the cancer has spread including:
–Cystoscopy, proctoscopy, and examination under anesthesia
–Imaging studies
•Chest x-ray, CT, MRI, PET scans

(American Cancer Society,

Cervical Cancer Treatment
•Treatment will depend on the stage of the cancer.
–Common treatments for cervical cancer:
–Cryosurgery, laser surgery, conization, and hysterectomy

–External beam radiation and brachytherapy

(American Cancer Society,

Other Components of
Routine Gynecologic
Emily St. Germain

Gynecological History
A routine gynecological exam begins with a complete gynecological
This consists of:

Presenting problem
Medical and surgical history
Medications & allergies
Menstrual history
Sexual history
Obstetric history
Last pap smear
Intimate partner violence screening
Family history
Urologic history

(Lentz, 2012)

Physical Exam
A complete physical exam may be performed for every patient at the
first visit and at each check up
Breast exam

visual examination of chest and skin

palpation of breast tissue and nipples

Pelvic exam

external examination

speculum examination

bimanual examination

● Gynecological visits and
exams vary in emphasis
depending on the patient’s
age and history
○ when a woman comes in
for a routine
gynecological exam, this
is an opportunity to
screen for illnesses in all
organ systems

(Lentz, 2012)

Pelvic Exam
External Examination
Visual inspection of external
genitalia for any lesions,
discoloration, or abnormalities

(Lentz, 2012)

Speculum Examination

A speculum is placed in the patient’s
vagina to allow visualization of the

Once placed, the blades are slowly
opened and the surface of the cervix
is assessed

observed for secretions and any
abnormalities such as ulcers or

Any symptomatic, colored, or foul
smelling discharge is sampled from
the vaginal wall for microscopic

A pap smear is performed

Pelvic Exam
Bimanual Examination

Palpation of the cervix
- usually firm and non-tender

One or two fingers are inserted into the cervix and
gently pushed upward

- the other hand is placed on the abdomen to palpate
the uterus
size, shape, consistency, and position of uterus is

Palpation of the ovaries
Palpation of the anterior fornix for assessment of the
bladder wall
(Lentz, 2012)

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Cancer Institute NSW (2015). What is an abnormal Pap smear test? Retrieved from

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nursing: The critical components of nursing care (2nd ed.) (pp. 527-529). Philadelphia, PA: F.A. Davis Company.
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nursing care
(2nd ed., pp. 492-493). Philadelphia, PA: F. A. Davis Company.
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Lentz, G.M. (2012). History, physical examination, and preventative health care. In G.M. Lentz, R.A. Lobo, D.M. Gershenson,
V.L. Katz (Eds.), Comprehensive gynecology (6th ed.) (pp. 113-128). Philadelphia, PA: Elsevier Mosby.
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