178 Gynecologic Cancers for the PANCE: Endometrial, Ovarian, Cervical & Vulvar

Hello and welcome to episode 178 of the physician assistant exam review podcast. This week we are going to be covering gynecological cancers, including endometrial, ovarian, cervical and vulvar. As always, we’re going to start with our priming questions to get your brain moving and to get you thinking as we go through this. I don’t want you just passively listening. We want to be moving and talking and thinking. So number one, a thin white figure of eight skin around the vulva and anus points to what diagnosis thin white figure of a skin around the vulva and anus points to what diagnosis after menopause and endometrial stripe of how many millimeters needs a biopsy.

After menopause and endometrial stripe of how many millimeters needs a biopsy. Why is it suspected ovarian cancer never biopsy? I’m sorry. Why is a suspected ovarian cancer never biopsied with a needle? Why is a suspected ovarian cancer never biopsied with a needle? Why don’t you ever biopsy a suspected ovarian cancer with a needle, a visible cervical mass and a normal Pap? What do you do next? A visible cervical mass and a normal Pap smear. What do you do next?

All right. My name is Brian Wallace. I’m the host and creator here at physician assistant exam review and I’ve been here behind the microphone for over 15 years now helping PA students get through PA school, get the most out of it and pass the PANCE. During this show, we don’t just teach medicine. We teach how to think about it so that it sticks in your brain for longer. Not just tricks and tips still make it last a week, but we’re building it so that you have it for your EORs, for your PACKRAT, for your EOC and then finally for the PANCE. Last week we covered trauma in pregnancy and the postpartum mood disorders. Today we’re going to finish up reproduction with the four cancers we talked about before and then next week we’re going to start renal.

That’s basically where we’re at. You can find all the notes as always, any of the tables, images, pictures. I’ve been putting some more pictures and tables onto the website. If you want to find those and you can follow along a little bit more clearly, that’s going to be episode 178. physicianassistantexamreview.com, a 178 or you can see the slides over on YouTube as you go through them.

We’re going to begin with endometrial cancer and endometrial cancer is cancer of the uterine lining. Okay? So just the inside part of the uterus and this is the most common gynecological cancer in the United States. Most causes are driven by unopposed estrogen. Estrogen is what creates the uterine liner, causes it to proliferate and then progesterone is what causes it to shed, right? So if you get unopposed estrogen, you get proliferation of the uterine lining and at some point that turns over and turns over and turns over and you wind up with endometrial cancer. Endometrial hyperplasia is the overgrowth of uterine lining from unopposed estrogen and it runs on a spectrum toward cancers.

So basically you have without atypia and with atypia, right? With typical cells or with atypical cells. So without atypia, you get extra lining of the endometrium, but the cells are all normal. This is a low cancer risk. You have some overgrowth, but there’s no dysfunctional cells. Atypical hyperplasia is extra lining and abnormal cells. This is a precursor to cancer and usually cancer is probably already present when you see this, but give atypical cells and you have this overgrowth, atypical hyperplasia. Both present the same way. You get abnormal bleeding and a thickened stripe on ultrasound. How do you tell them apart? Well, we’re going to get to that in a second, but the answer is going to be an endometrial biopsy.

What are risk factors for endometrial cancer? Well, anything that means estrogen without progesterone, sorry, we just said before that unopposed estrogen is our problem. So risk factors are going to be the things you consider that are going to increase estrogen and decrease progesterone. So let me run through a few. Obesity is going to be on this list. So fat tissue turns other hormones into estrogens, definitely fat is active. It is not just stored energy. It is active. PCOS, you get no ovulation, so no progesterone, estrogen only hormone therapy and a woman with a uterus, right? So if you’re only getting estrogen, you’re adding an estrogen that can be a problem and then more lifetime estrogen.

So early menarche, late menopause or nulliparity, so never being pregnant will increase lifetime estrogen and increase the risk for endometrial cancer. Tamoxifen blocks estrogen in breast but acts like estrogen in the uterus, so that can be an issue. Diabetes and hypertension can be risk factors. Lynch syndrome, which we’ll get to a little bit, it’s an inherited risk factor for endometrial cancer and colon cancer. Clinical presentation is going to be postmenopausal bleeding. This is the first sign in most cases, but this is the big key. Any bleeding after menopause is endometrial cancer until proven otherwise and it must be worked up. This is really, really important.

Before menopause, what does it look like? Well, you get heavy or between period bleeding. At 45 or older or younger with obesity and PCOS, you’re going to have to sort of put those pieces together, but you apply the risk factors in the situation, but it tends to be bleeding, tends to be the number one indication. What’s your question stem going to look like here? There’s a couple of different ways that this can present, but let’s say an obese 62-year-old with diabetes and light spotting four years after menopause, that 100% is endometrial cancer until proven otherwise, until you can’t see it any other way. What do you do to diagnose this? Well, there’s no routine screening.

We don’t do any screening for this. Once you think you are concerned and you’re going to do the workup, you’re going to start with a transvaginal ultrasound, and you’re going to look for an endometrial stripe of four millimeters or less. Sometimes I don’t think dosages are important. Sometimes I don’t think certain numbers are important. That one I would probably hold on to. Four millimeters or less is a low risk. More than four millimeters, what are you going to do? Well, if you get an ultrasound, which is a relatively non-invasive test, and it comes back concerning, what do you think the next step is? What do you think happens next? Well, we’re going to get a biopsy.

We’re going to actually look at that tissue and see what’s going on. Now after that, if the bleeding continues or we have an issue with the biopsy or we can’t read it, are there some kind of other problem? The next step is going to be a hysteroscopy and perhaps a D&C. So treatment is going to be driven by the biopsy and by what the cell types come back as. So hyperplasia without atypia. So we get overgrowth, but no atypical cells, we can treat that with progestin. Hyperplasia with atypia, so we have abnormal cells in there. This is precancerous and we’re going to go ahead and do a hysterectomy. If it comes back as straight endometrial cancer, well, then we’re going to do a total hysterectomy with a bilateral salpingo-oophorectomy and staging.

So what we’re going to do is we’re going to take the uterus out, and when we say total hysterectomy, that includes the cervix. We’re going to take both tubes and ovaries out, and then we’re going to look at some lymph nodes to see if this has traveled anywhere. So that’s straight endometrial cancer versus hyperplasia with atypia versus hyperplasia without atypia, right? I would know each and every one of these and how you would follow it. Again, this isn’t that complicated, build out a little table, I’ll have one for you on the website, and I think you’ll be able to go through this really, really fast. Your question stem would be something like, there’s a woman starting estrogen for hot flashes, estrogen alone is the trap, she needs progestin to protect that lining.

Exam keys here, bleeding after menopause equals endometrial cancer until proven otherwise, the stripe of over four millimeters gets a biopsy, and then atypia on a biopsy gets a hysterectomy.

Okay, so that’s endometrial cancer. One of the things I want to talk about is when we go through these, we’re always looking at how questions get built, right? We’re thinking about them in relation to each other. We’re not just thinking about them on their own. So here, we’re going to compare and contrast the different cancers for sure, but we’re also going to compare and contrast, what are the things that we’re going to have to know just within endometrial cancer? Well, we’re going to have to know age, we’re going to have to know the workup, so from ultrasound to biopsy, right? Then we’re going to have to know the difference between hyperplasia without atypia, hyperplasia with atypia and endometrial cancer, and how we’re going to handle each one of those situations.

So there’s a lot to know just within endometrial cancer, then you need to compare it to the other things so you know when a patient walks through the door, what you’re looking for, what they’re probably going to have. So I want you to always be thinking about how you’re going to build out questions, how they’re going to write the questions to ask you these things, how they’re going to go through it with you on the exam. Remember, our point here is to study for the test. I know you all want to be amazing clinicians, and I want you to be amazing practitioners. But before that, you have to pass your test coming up this week, you have to pass your EOR, you have to pass your PANCE, you have to do all of those things.

So we teach this in a method that is designed to help it stick in your brain for your tests. That’s the goal, right? And along with that, I just want to let you know that on Tuesday, November 10th and Thursday, November 12th at 8pm Eastern time, I’m going to be hosting a free Master Class on eight new ways to get the most out of your question bank. So I want you to be looking at questions and doing questions. And when you do your notes, and when we go through the podcast, I want you to be thinking about questions and test questions and how they’re going to come and what they’re going to look like. But I also want you to be reviewing questions with some intention with some style with some ways of thinking about it that are going to help it stick long term so you get the most out of the question banks you’re already using.

If you’re interested in figure in finding out more about how to turn that time into more points, go to physicianassistantexamreview.com backslash Master Class to register again, it’s November 12th. I’m sorry, November 10th and November 12th, 8pm Eastern time, and if you come live, I am releasing for the first time ever, a brand new question bank, that’s 3116 questions and it has explanations that will help you to understand why you got things wrong, not just from a content, but from a test taking perspective. So more of how to get more out of your question banks. That’s really the key here. So again, physicianassistantexamreview.com backslash Master Class, okay, let’s jump into ovarian cancer.

The ovarian cancer is the most likely gynecological cancer to be fatal. That’s going to be ovarian cancer. It’s not because it’s much worse than anything else. It’s just because it’s found so much later. I think of it like esophageal cancer. Esophageal cancer isn’t particularly deadly. The problem is nobody finds it, nobody sees it until it’s too late. The ovarian cancer works the same way. You get these vague symptoms and there’s no screening test, right? So the symptoms, we’ll get to in just a second, but are just kind of like weird GI stuff. So they just gets this long workup that doesn’t really go anywhere and there’s no screening test for it.

So risk factors are, number one is age. Risk rises with age and most cases fall after menopause. But if you have someone with a BRCA1 or BRCA2, the bracket mutations, they can certainly get this at a younger age, 30s, mid 30s, it’s not unreasonable. Family history and Lynch syndrome are also risk factors. So we’re going to want to be keeping close eye on those people. More lifetime ovulations is riskier. So if you have nulliparity, early first periods, early menarche or late menopause, that will put you at risk here. And then same thing, what’s protectable? Anything that stops ovulation. So oral contraceptives, pregnancy, breastfeeding, tying or removing tubes.

And over the past few years, just as a side note here in the GYN universe, we have moved towards if someone wants their tubes tied, we remove the tubes. We don’t just fulgurate them or tie them off. We actually remove the entire tubes on both sides. And the reason is that there has been some new literature that shows that ovarian cancer might stem from the tubes. So we removed them. So again, this is a vague, but persistent symptoms. You get all these weird GI stuff. So there’s bloating, there’s early satiety, there’s nausea, there’s indigestion, there’s change in bowel habits, there’s all this stuff. So the patient’s uncomfortable, so you have this like, let’s call it 60 year old female with these GI symptoms.

And that’s kind of what they come in looking like. They can have some pelvic or abdominal pain and maybe some urinary urgency, but really that’s just kind of the picture. So that’s why this gets missed is because it isn’t, there’s no bright red flashing, you know, rash or something. There’s nothing that makes it stand out. They can get ascites later, they can get some weight loss, they can get their belly can be distended. They can get, you can maybe palpate and an adnexal mass, but the reality is the symptoms are super vague. So your question is, like I said, it’s going to be like a 60 year old with months of bloating, early satiety, and you can feel an an adnexal mass.

If you’re thinking about this as IBS or reflux or something else as a GI problem, that’s where you’re going to fall into a trap. You’ve got to be thinking of ovarian cancer in this, in this population. So what are you going to do to diagnose this? Well, what’s our first step in diagnosing a, an issue of GYN cancer in most cases here? Well, it’s going to be a transvaginal ultrasound. We’re going to be looking for the mass. We’re going to be investigating here. So this is going to be a complex mass. So parts of it will be solid. You may have walls on the inside of it, that kind of thing, instead of a, a simple cyst, which is just fluid filled, and you can see that really clearly on an ultrasound.

This would be complex, right? You’d have, again, parts that are solid, parts with thickened walls, it’d be different across it. This would be concerning. You can do a CA 125. It’s not a screening test as a problem. You’re going to order it once you have symptoms or a pelvic mass, and it’s going to help you to follow treatment. And it’s less useful before menopause because it can indicate a lot of different things. So that’s why it’s not really a screening test. You’re not going to do a needle biopsy here because there’s concern about spilling the cancer cells into the abdomen. So what you are going to do, if you have concerns, is you’re going to surgically remove the ovary.

That’s going to be the next step. And it’s also going to be the treatment, right? So surgery with a gynecological oncologist, we’re going to stage it and remove it. We’re going to remove anything that looks visibly like a tumor, and then we may do chemotherapy to follow that up. If you have someone who’s BRCA positive, once they’re done having children, you may consider removing the tubes and ovaries. Exam keys here. So bloating plus just GI issues. And if you have an adnexal mass, for sure, in an older female, you’re thinking of ovarian cancer. In a BRCA positive patient, you’re thinking about removing tubes and ovaries. And if you think it’s ovarian cancer, we’re going to do surgery.

We’re not going to biopsy it. All right.

Let’s talk about cervical cancer. Cervical cancer, this is cancer of the cervix, almost always from persistent high-risk HPV type 16 to 18, 16 and 18. This is usually a squamous cell carcinoma. Adenocarcinoma maybe is the second most likely, but usually it’s squamous cell. It starts out as cervical dysplasia and moves on because it was not seen. So your risk factors are not being screened. That’s a major, major risk factor, not being screened. This grows very slowly and takes years to develop. So screening will catch this. HPV exposure is another risk factor. So early first intercourse, multiple sexual partners, smoking, HIV and other immunosuppression will make this a faster moving and more likely to happen situation.

So those are risk factors, clinical presentation. There’s usually no symptoms, right? We said this is really slow moving. There’s usually no symptoms until there are. And once there are, it would be things like bleeding after sex, right? So post-coital bleeding, bleeding between periods, foul discharge, maybe, and then late, late, late would be pelvic or back pain. You could even get hydronephrosis I came across and that’s because the tumor gets so large that it blocks the ureter. Your question stem here would be a 45 year old with no Pap smear in the last 15 years. And she has bleeding after sex and a friable, and a friable cervical mass, right?

That friable cervical, if you see a cervical mass, you need to be considerate there. What are we going to do to diagnose this? Well, if you see a visible mass, what are we going to do? We’re going to biopsy it. We want to take a look at what’s actually going on there. The Pap smear is what’s going to be our ongoing surveillance, but it only scrapes surface cells. So if you’re going to need a biopsy, you’re going to need a biopsy. If you have an abnormal Pap smear with no visible lesions, you may want to follow that up with a colposcopy and a biopsy of any abnormal areas.

Okay. So now most women with cervical disease don’t walk in with a mass, right? They walk in with an abnormal Pap smear. That’s sort of the issue at hand. You catch this in screening typically, and the exam is going to want you to talk through or work through what to do. You know, first of all, is when are you going to screen? And second of all is what are you going to do when you get those results back? So we’re going to do two screening tests and both come back from one swab, right? We do a speculum and a small brush to sweep the cells of the cervix. And then the lab runs a Pap smear, which is cervical cytology. So the pathologist looks at the cells under the microscope and it says, do these cells look abnormal?

Is there a problem here? We also can run the HPV test, which the lab checks the same sample for DNA of high risk HPV, which hopefully you guys know is 16 and 18. Those are the worst. All right. So like I said, they’re going to want to know who is going to get screened. So this, I would absolutely know no one under 21 gets screened. Doesn’t matter when they become sexually active. Doesn’t matter any of that stuff. They may have HPV, but it can also clear on its own. Your immune system could clear the virus and it’s also really slow moving. So we don’t really have to go out of our way to screen under 21. I would absolutely hold onto that number.

Now from 21 to 29 years of age, you’re going to want to get a Pap smear every three years and you’re not necessarily going to, you’re not necessarily, you’re not going to get an HPV test because HPV can be very common and temporary. Like I said, that you can clear it. Your immune system can clear it. So you’re not want to be really aggressive about treating it because it can be cleared, but you do want to make sure we don’t have changes in the cell structures. From 30 to 65, you’re going to want to do any one of three screenings. You can do an HPV test alone every five years. You can do a Pap alone every three years, or you can do both every five years.

And then over 65, you’re going to stop testing. See if she’s been normal and she is in high risk. And obviously if the patient has had a hysterectomy and doesn’t have a cervix anymore, we’re not going to run these tests, right? That kind of makes sense. The other question that comes up is if you’re vaccinated, what do you do? We’re going to still continue to screen for vaccinated patients because the vaccine doesn’t cover every high risk type. It doesn’t cover everything. So we’re still going to do the Pap smear. So here’s where it got complicated for me in PA school and what I struggled with is the report on the Pap smear, right? So there are five results you can come up with, and the PANCE is going to ask you to understand them and then want to know what you’re going to do with them.

The first is atypical squamous cells of undetermined significance, ASC-US. This is where a few cells look slightly off, but not enough to definitively make a decision. This is the most common abnormal result and usually means nothing. Then you have low grade squamous intraepithelial lesion, LSIL, and this is mild changes, usually an HPV infection that will clear. High grade squamous intraepithelial lesion, these cells look like pre-cancer. And then you get to atypical squamous cells can exclude high grade, unclear, but HSIL can’t be ruled out. So it’s handled like HSIL. So we’re thinking this is pre-cancer. And then the last one is atypical glandular cells.

These abnormal cells are glandular, so they’re inside the cervical canal, not the squamous surface. Most abnormal results will wind up with a colposcopy. So we’re going to do a magnified look at the cervix with a biopsy of anything that doesn’t look right. Now the exam is going to look for the exceptions, right? It’s not going to say list all the details. It’s going to say, are we going to do, what are we going to do for an ASC-US or ASC-US what’s going to happen next? Well, we’re going to do a reflex HPV test. Reflex means the lab automatically runs the HPV test on the same sample when the Pap reads ASC-US. No second swab, no second visit, right?

Does that make sense? So if the, you’re not going to run the HPV test because you might not want to see the results, right? Because you don’t want to be treating something that’s not causing a problem, but when we do a reflex HPV test, what happens is they use the same swab, that same sample. They look at it to see if there are atypical cells, and if they come back as indeterminate like this, then they’re going to run the HPV test on that sample. So the patient doesn’t have to come back and do everything again. If HPV is positive at that point, we’re going to do a colposcopy. If HPV is negative, then we’re thinking that it probably wasn’t because of HPV.

So we’re going to go back to screening and repeating in three years. Okay. Now, for age 21 to 24, ASC-US or L-S-I-L, we’re going to repeat the Pap in one year. We’re not going to do the colposcopy. It usually takes care of itself. For A-S-C-H or H-S-I-L, we’re going to do the colposcopy and not just repeat the Pap. Remember, these are a little bit more concerning. And for AGC, colposcopy plus a sample from inside the canal. Remember, these are glandular. So we’re going to want to get that as well as an endometrial biopsy, especially if she’s older, 35 or older, or has endometrial cancer risk factors because those cells may be coming from the uterus.

We’re not sure. We want to investigate that. Again, all of these notes will be over on the website, physicianassistantexamreview.com slash 178, with a, I’ll put together a really nice chart for you there so you can see everything. A normal Pap, but HPV positive 30 and older is our next category. Here if it’s HPV 16 or 18, then we’re going to do a colposcopy because those types carry the highest risk and anything else, we’re going to repeat the co-test in about a year. All right. Let’s talk about colposcopy. A colposcopy positions the patient in stirrups with a speculum, just like the Pap smear. But here we’re using a scope to magnify inside of the vagina.

So we can see the cervix and we can get a good look for anything that looks abnormal. We’re looking at the transformation zone, the ring where the squamous cells of the outer cervix meet the glandular cells of the canal because that’s where the changes start. And then we do one, we can do two things, right? We can do two stains. If nothing stands out initially that we want to biopsy that can make abnormal tissue stand out. So we can use acetic acid. We paint that onto the cervix and an abnormal areas turn white. All blood vessels show up and look like punctate lesions and you get some mosaicism or a tile like pattern. You could also use Lugol’s iodine.

Normal cells are full of glycogen and stain dark brown, abnormal cells don’t stain and stay pale. So this is just a way to identify things that look that may not stand out normally. But when you use those two solutions, you can get a better idea. And then you’re going to biopsy anything that doesn’t look good. You can also do endocervical curettage, so scraping the cells from inside the canal where the scope can’t quite see. Something kind of interesting then comes up in as a question. I doubt it’ll be on your PANCE, but if the patient is pregnant, colposcopy and biopsy are perfectly safe. You’re not going to do endocervical curettage though, right?

We don’t want to be too aggressive, but we’re not going to do anything as far as treating until after delivery, unless we have a really invasive issue. Okay. So now we get to the biopsy. So this is what’s hard, right? You have to separate the Pap findings from the biopsy findings. So again, to me, I’m building out a chart for this and I’m going through it and I’m learning it that way. So first on the biopsy, remember you need to have two separate categories. Pap findings, biopsy findings. With the Pap smear findings, we just walk through the steps of what you do depending on what they look like. Now biopsy is going to be more invasive, right? The Pap smear is just getting the, brushing the cervix to get those cells at the top level.

Now we’re actually going to go a little bit deeper and get a biopsy and see what’s really going on. So the first one we come across is cervical intraepithelial neoplasia, CIN. This is pre-cancer of the cervix. The abnormal cells are confined to the surface lining and haven’t broken through into deeper tissue, right? That’s always the worst case scenarios. When we break through the deeper tissue or start to spread. Once they break through, that’s called cancer. So it means inside the lining, neoplasia, abnormal or new growth, right? So if we get LSIL and HSIL, that’s talking about those cells, right? So then we’re going to go ahead and get a biopsy.

Now we’re going to answer the question of, is this actually a problem? And the biopsy is going to answer that for us. So the CIN is graded by how much of the lining is thickness is abnormal, CIN1 is the bottom third, it’s mild, usually clears on its own, CIN2 is up to two-thirds, it’s moderate. CIN3 is the full thickness, and this is severe, also called carcinoma in situ, cancer cells that haven’t yet invaded. And then the, so that’s the stepwise as to how we categorize it, but why do we categorize it? Well, we categorize it because we want to know what to do with it. That’s really what the categories are for. If we put things into a category, then we know how to treat it.

So CIN1, we just watch and repeat the testing in a year. CIN2 or 3, we’re going to remove the transformation zone. You can do that a couple of different ways, a LEEP, cold knife. LEEP is a loop electro-surgical excision procedure. So essentially it’s a thin wire on a loop with an electric current, and you can use that to sort of cut through the cervical tissue and remove it. A cold knife is a, where you use a scalpel, removes a cone shaped piece of the cervix in the operating room, very similar to a, to a LEEP, LEEP’s a little bit easier to perform. Under 25 years old with CIN2, watching is acceptable because it does often regress. CIN3, we’re going to have to treat that no matter what.

Now one thing to remember is that after a LEEP or a cone biopsy, she’s going to have higher risk of preterm birth and later pregnancy because we removed part of the cervix, right? So again, the Pap smear asks if the cells look okay or if there’s a problem. The HPV test asks if the virus is there. Then we move on to, if we get something we don’t like, then we do a colposcopy to take a look. We do a biopsy to see if we actually have abnormal growth. We watch CIN1, CIN2 or 3 get a LEEP. It’s actually not super complicated, but it does take some understanding because we’re so many abbreviations, so many different pieces here.

Okay. So that’s pre cancer and that’s how we catch it. Once it’s actually cancer, the treatment’s a little bit different. So treatment for cervical cancer, uh, it’s, if it’s early and still confined to the cervix, then we do a radical hysterectomy. Here we take the uterus, the cervix, plus the tissue besides the cervix and the top of the vagina. We want to make sure that we get good margins here, but the ovaries can stay. So the LEEP removes the transformation zone for pre cancer. A radical hysterectomy is for invasive cancer. If it’s locally advanced, so if it’s spread beyond the cervix into the tissue around it, then we’re going to have to include chemo and radiation together.

We’re less likely to do surgery because we can’t clear all that tissue. And again, the HPV vaccine is going to be, and screening is how we’re going to prevent this. So exam keys bleeding after sex, plus a friable cervical mass equals cervical cancer. Visible lesions, we’re going to biopsy them no matter what I don’t care what the Pap says. I don’t care what the HPV test says. If you see a visible lesion, that’s going to get biopsy abnormal Pap with no lesion. We can do a colposcopy. Again, that’s for ASC-US. We get the reflex HPV test first, CIN two or CIN three. We do a LEEP for invasive cancer. We’re doing a radical hysterectomy or chemo radiation.

Our last one for today is vulvar cancer, which is cancer of the external genitalia. This is mostly squamous cell carcinoma in older women. In older women, it tends to come from a lichen sclerosus in younger women from HPV infections. Risk factors here. So that lichen sclerosus is a chronic itchy skin disease of the vulva. This is where you get that thin white crinkled skin, often in a figure eight around the vulva and the anus. This peaks in postmenopausal women and prepubertal girls. Biopsy is going to confirm it and it’s going to be treated with high potency topical steroid. And you’re going to watch this for life because it raises the risk of cancer.

And then we said also that HPV can cause this. So we’re going to do the same things. We have HPV, we have smoking, we have immunosuppression as our risk factors there. Clinical presentation. This would be, again, in the lichen sclerosus one. This is long-standing vulva itching, often for years. They may have a lump or an ulcer or a whiter red patch, usually on the labia majora. Question stem here would be something like a 70-year-old with years of itching treated with antifungal creams who now has a raised lesion. And another round of cream isn’t going to make it better. How do we diagnose this? Well, again, stop and think. What would you do to diagnose vulvar cancer?

If you see an area with white skin that looks kind of funny and there’s a lesion, what do you think we’d do next? We’re going to get a punch biopsy, right? We’re going to take a look at what that is. If we have itching, it doesn’t respond to treatment or we have a lesion, we should probably send that to pathology and find out what’s going on here if it’s not responding to treatment. Treatment ultimately is going to be surgical excision and we can look to the groin lymph nodes to evaluate further.

Okay, let’s run through top to bottom real fast. Well, I’ll put this together for you on the website, physicianassistantexamreview.com backslash 178 so if you’re out for a jog or you’re in the car, you don’t have to memorize this off the top of your head, I’m going to put this all together for you so it looks really nice and you can go take a look at the tables over there. But where you’re going to want to start is what does she walk in with? How does she look when she walks through the door? What’s the initial presenting symptoms? So you have bleeding after menopause. This is endometrial cancer. You do an ultrasound or a biopsy. If we have an older 60s, whatever female with GI symptoms, bloating, change in bowel habits, nausea, early satiety, we’re looking at ovarian cancer.

We’re going to do an ultrasound and a CA125. If we have bleeding after intercourse, we’re thinking cervical cancer as a possibility and we’re going to look, take a look and we’re going to do a biopsy. If a patient comes in complaining of years of itching and now has a lesion, we’re thinking vulvar cancer and we’re going to do a biopsy. A couple other things to note, only cervical cancer has a screening test, right? That’s our Pap smear.

Okay. Marvelous. So we just finished up all of reproduction, including these last four cancers. So we are now done. We will be moving on to renal next week. I’m super excited to be doing that. But I want to close out this talking a little bit about a study tip that’s great for closing out an entire section. So you’ve heard me talk about active versus passive studying before. There’s a lot of ways to do this and everyone just kind of sticks with flashcards when they talk about it, but there’s so much more. So one I want to talk about today is just pulling out a blank sheet of paper and then marking down the left hand side with your diagnoses on the left hand side, then make a column that says what test it would be to diagnose it.

And then I’d make another column that says, what would the treatment be real, real simple. Then you can pull the diagnoses from any book or anywhere you want or any list like the NCCPA blueprint and then fill in the rest of the chart from memory. This is the hard part. This is the work. Do it from memory. Don’t look it up. Don’t check it. Let’s try one now. So if you have endometrial cancer, what’s the first test? How do we diagnose it? We do a transvaginal ultrasound or endometrial biopsy. What’s the treatment? It’s a hysterectomy with both tubes and ovaries. Let’s go back further. What if you have an ectopic pregnancy or you’re considering an ectopic pregnancy?

What’s the test that proves it? Transvaginal ultrasound or an HCG, right? What’s the treatment? Well, if it’s smaller, it’s methotrexate. If the HCG is higher, it’s bigger, it’s surgery. Or if she’s unstable. But for this exercise, you don’t need every minute detail. Just real fast. Can you list out the diagnoses? Can you list out the test? Can you list out the treatments from memory? That’s the key. Now I get it. Now some of these don’t have a single test, right? So if you’re looking at something like placenta previa, you don’t have a treatment, right? You have an ultrasound. It’s going to be your test. And then what? Well, what are you going to do?

If you have placenta previa, you’re going to monitor the mom, no pelvic exams, et cetera. So you have to do this with a little bit of an eye toward what makes sense and what doesn’t make sense. But then go back and check. See where you have gaps. See where you have holes. One of the things I love about using methods like this is there’s no hiding. You can’t say like, oh, I just didn’t understand the question. Oh, I just wasn’t sure. Oh, you know, you have to look at what you got right and what you know and what you don’t know. And that’s one of the reasons I absolutely love doing exercises like this. Whiteboards are good for this. Working with friends is really good for this in a small group.

But pulling the information from your head and coming up with different ways to do that, really, really valuable. So flashcards are one, building out charts, writing out things on whiteboards, that kind of thing. But this is a simple exercise that I promise you will lock in so much more of what you’re doing.

All right, cool. Next week, we’re going to start with renal. Like I said, we’re about to get to the answers for our priming questions, which hopefully will be a little bit easier now. I do just want to quick remind you, you can find the notes and charts and illustrations over at physicianassistantexamreview.com backslash or forward slash 178. And then I am also doing the free Master Class on Tuesday, November 10th and Thursday, November 12th. It’s going to be fantastic where we’re going to go through how to answer questions, how to use your question banks in a way that’s going to help you actually hold on to information more and understand test taking more.

It’s going to be an absolute blast. Your scores are going to go up just from this one class. There’s no doubt about it. So that’s at physicianassistantexamreview.com slash Master Class. Please I’d love to have you come and share it with your classmates because it’s going to be really, really valuable. All right. Let’s jump into the priming, the answers to our priming questions and then we’ll wrap

up for today. A thin white figure of eight skin around the vulva and anus points to what diagnosis. This was lichen sclerosus and vulvar cancer. Your menopause and endometrial stripe over how many millimeters needs a biopsy for four millimeters was our number. Why is a suspected ovarian cancer never biopsied with a needle? Do you remember? It can rupture and then spread the cancer cells through in the abdomen, a visible cervix, a visible mass on the cervix and a normal Pap. What do you do? A visible mass on the cervix and a normal Pap. What do you do? You’re going to get a biopsy, right? If you see a mass on the cervix, you’re going to biopsy.

Perfect.

All right. Great. Well, thank you guys so much for joining me today. This has been absolutely always my pleasure. I look forward to hearing from you during the week, how your exams are going. And then, um, as always, I’ll be back again next week. We’ll cover it. We’ll begin renal and that’ll be a whole new section for us to dive into. All right. Take care. Have a great week.