Episode 18 - Cervical Polyps

Episode 18: Cervical Polyps

The sun rises over the San Joaquin Valley, California, today is June 26, 2020.

As our nation continues to battle the OPIOID epidemic (along with other epidemics), our good, old-fashioned aspirin at high doses (900 to 1300 mg) was found to be effective and safe to treat acute migraine headaches. Further research is needed to recommend aspirin as a prophylactic therapy, but it’s promising. Findings of this research were published in November 2019 by Dr Biglione and collaborators in The American Journal of Medicine (1,2). Aspirin keeps giving us surprises after more than 120 years on the market! 

Also, the Food and Drug Administration has approved the first over-the-counter ibuprofen and acetaminophen combination drug for the U.S. It’s called Advil Dual Action which contains 250 mg of ibuprofen and 500 mg of acetaminophen. It will be available later in 2020 (3).

Talking about epidemics, have you heard that diabetes is a surgical disease? Some experts support the cure of diabetes with bariatric surgery, and yes, it may not be the first choice, but it is effective when used appropriately. However, according to a research presented during Endo Online 2020, Dr Yingying Luo, stated that having bariatric surgery BEFORE developing type 2 diabetes results in a greater weight loss, especially within the first 3 years after surgery. The probability of achieving BMI less than 30, and the chance of reaching excess weight loss of more than 50%, is higher in patients WITHOUT diabetes before surgery(4). Diabetes prevention is another good reason to send your patients to bariatric surgery in a timely manner when they meet criteria. 

Welcome to Rio Bravo qWeek, the podcast of the Rio Bravo Family Medicine Residency Program, recorded weekly from Bakersfield, California, the land where growing is happening everywhere.

The Rio Bravo Family Medicine Residency Program trains residents and students to prevent illnesses and bring health and hope to our community. Our mission: To Seek, Teach and Serve. 

Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care to patients throughout Kern and Fresno counties since 1971. 

“A good head and good heart are always a formidable combination. But when you add to that a literate tongue or pen, then you have something very special.” ― Nelson Mandela

I always thought that having a good brain and a good heart were enough to be wise, but Mr Mandela taught me that having a good tongue or pen makes than person even more special. Do you get it? Being wise and compassionate, and being able to communicate that information to others is very important. That’s why we have this exercise called Rio Bravo qWeek– to learn how to transfer information from our head and our hearts to our co-residents and patients. I hope we can become better communicators every day. 

Before I introduce our guest today, I want to take a minute to correct myself. In episode 15, I said “more higher”, I noticed my mistake, and I correct it now: It is not “more higher”, it’s just “higher”. Also, I hope you heard the beautiful quote we used at the end of our episode 17. I want to clarify that we do not have any political affiliation, but we have the same values and principles we shared with the good people of America, including politicians, artists, NGOs, religions, and other groups. I encouraged you to “examine what is said, not him who speaks” (Arab proverb), especially in this podcast. We have a very pleasant and clever resident who has some things to say today. Welcome, Dr Yodaisy Rodriguez.

Question Number 1: Who are you?

My name is Yodaisy Rodriguez Acosta. I graduated from medical school in Cuba. Before moving to the US, I worked in Honduras and in Venezuela as part of Medical collaboration programs. I love outdoor activities, gardening, crafting, movies, and dogs. My perfect day is having a picnic with my family.

Question number 2: What did you learn this week? 

I learned about cervical polyps this week. 

Clinicians may encounter normal variants and benign neoplasms of the cervix on pelvic examination. It is important, as family medicine doctors, to become familiar with a normal cervix, so we can identify what looks ABNORMAL.

Cervical polyp definition

-A cervical polyp is a growth or tumor found in the cervical canal. It is a lobular or tear-shape growth, red or purple, it can also be very vascularized. After you see a couple of them you learn to recognize them. 

-They present more commonly in post-menarche and pre-menopausal women who have been pregnant. 

- It is included in the Cervical Noncystic lesions.

-The etiology is unknown. Chronic inflammation of the cervical canal may be the cause. Hormonal factors may also play a role, since endometrial hyperplasia and cervical polyps coexist. 

-Differential diagnosis includes an endometrial polyp or prolapsed leiomyoma.

-Malignancy in polyps is uncommon.

What to do when you see a cervical polyp

Polyps should always be removed if they are symptomatic (eg, bleeding, excessive discharge), large (≥3 cm), or appear atypical. Polypectomy is usually a small procedure done in the office. 

Malignancy is rarely found in a cervical polyp, however, polyps that are removed should be submitted to the laboratory for histological study.

Question number 3: Why is that knowledge important for you and your patients?

Because cervical cancer is very common. Every year, nearly 13,000 cases of cervical cancer are diagnosed, with more than 4,000 deaths. Cervical cancer is typically asymptomatic. We should become familiar with the screening and management of cervical diseases. Having the right information will help us answer our patient’s concerns.

 

 

Question number 4: How did you get that knowledge?

I learned because I had a patient with a cervical polyp. When you receive an abnormal pap result, you normally look up the next step by using the ASCCP app, but what do you do when the cervix looks abnormal during the physical exam? How do you perform a polyp removal? Thanks to my OBGYN attendings, and thanks to my gynecology rotations, I have improved my knowledge and abilities in managing abnormal cervix. 

I learned that if a patient has a grossly visible cervical lesion, biopsy should be performed. If biopsy cannot be performed at that visit, cervical cytology should be collected, and the patient should have a biopsy as soon as possible. 

Comment: We had a patient recently with an abnormal cervical exam. It was described as a “cavity” between 3 and 6 o’clock. The resident explained to me that “he has never seen any cervix like that”. Our patient had weight loss and abdominal pain, along with bilateral hydronephrosis. The cervical biopsy was done at the time of the placement of bilateral ureter stents in the OR. The biopsy resulted in squamous cell carcinoma of the cervix. So, I agree with you, grossly abnormal cervix should prompt us to perform a biopsy in a timely manner.

Cervical cytology became the standard screening with the introduction of the Papanicolaou (Pap) smear in 1941. Now we start screening for cervical cancer at age 21 regardless of sexual activity. Cultural concerns should be addressed and respected when possible. A patient at age 21 may decline pelvic exam, you have to be culturally sensitive and discuss the matter with the patient and encourage pap smear with tact, but respect patient’s preferences.

Question number 5: Where did that knowledge come from? 

1) Up To Date. 

2) Cervical Cancer: Evaluation and Management by Jennifer Wipperman and collaborators, published in the American Family Physician in 2018.

3) FP notebook app 

4) American Society for Colposcopy and Cervical Pathology (ASCCP) app 

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Speaking Medical: Pioikilothermia
by Edvard Davtyan, MS4

Good afternoon, my name is Edvard Davtyan, I am a 4th year medical student. I will be presenting the word of the week, Poikilothermia. This may sound like a phrase used in the world of thermodynamics. However, this phrase is more commonly used in the realm of Biology and Medicine. 

The term poikilothermia means “cool extremity”. It is originated from the word poikilothermwhich is used to describe animals or organisms whose internal temperature varies considerably with the temperature of its surroundings. These animals are also referenced by the common vernacular “cold-blooded.” The term is derived from Greek poikilos,meaning “varied”, and thermos, meaning “heat.”

In Medicine, the loss of thermoregulation in humans is referred to as poikilothermia. This is seen in states of sedation (esp. REM sleep), effects of hypnotic drugs and acute limb ischemia. Poikilothermia is 1 of the 6 P’s in clinical presentation of acute limb ischemia: Pain, Pallor, Paresthesia, Pulselessness, Poikilothermia, and Paralysis. 

Hope this has been interesting for you, remember, if your patient has poikilothermia, it doesn’t mean they are cold-blooded, it just means you should probably check their ankle-brachial index (ABI).

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Espanish Por Favor: Chorro
by Dr Claudia Carranza

(Recorded Previously on 6/10/2020)

Hi this is Dr Carranza on our section Espanish Por Favor. This week’s word is chorro. Chorro means jet or stream; some patients use this word to describe their bowel movement. Patients can come to you with the complaint: “Doctor, tengo chorro”, which means “Doctor, I have the runs” or in other words, “I’m having diarrhea”. This is more common in the Spanish-speakers coming from Mexico. You can then continue the interview and ask about how often, for how many days and if it’s bloody or melanotic, etc. Chorro can also mean a ton or lots; so, a patient might say “Doctor, tengo un chorro de problemas” which means “Doctor, I have a ton of problems”. 

Now you know the Spanish word of the week, “CHORRO”.

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For your Sanity (Medical Joke of the Week): ***
by Dr Steven Saito and Dr Lisa Manzanares

A cosmetic surgeon sign says: “If life gives you lemons, a simple surgery will give you melons”.

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Now we conclude our episode number 18 “Cervical Polyps”. Dr Rodriguez recommended us to get used to a normal cervix. If a cervix looks odd, do not hesitate to or perform a biopsy schedule patient for biopsy. If you see a cervical polyp, a polypectomy can be easily performed in the office. Remember to send that sample to pathology. Edvard explained that Poikilothermia refers to cold-blooded animals, but it also refers to a “cold limb” as a sign of acute limb ischemia. Chorro was explained by Dr Carranza as a “less elegant” way to say diarrhea in Spanish. 

This is the end of Rio Bravo qWeek. We say good bye from Bakersfield, a special place in the beautiful Central Valley of California, United States, a land where growing is happening everywhere.

If you have any feedback about this podcast, contact us by email [email protected], or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. 

Our podcast team is Hector Arreaza, Yodaisy Rodriguez, Claudia Carranza, Edvard Davtyan, Lisa Manzanares, and Steven Saito. Audio edition: Suraj Amrutia. See you soon! 

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References:

The American Journal of Managed Care, https://www.ajmc.com/newsroom/aspirin-effective-in-treating-acute-migraine-preventing-recurrent-migraine-review-finds.Biglione B, Gitin A, Gorelick PB, et al. Aspirin in the treatment and prevention of migraine headaches: possible additional clinical options for primary healthcare providers [published online November 8, 2019]. Am J Med. doi: 10.1016/j.amjmed.2019.10.023.“FDA approves combination ibuprofen-acetaminophen drug for U.S.”, ADA News, March 02, 2020, https://www.ada.org/en/publications/ada-news/2020-archive/march/fda-approves-combination-ibuprofen-acetaminophen-drug-for-us“Bariatric surgery may be less beneficial in diabetes”, Family Practice News, Vol 50, No. 4, April 2020, page 11. “Benign cervical lesions and congenital anomalies of the cervix” by Marc R Laufer, MD, UptoDate, Last updated on May 28, 2020. https://www.uptodate.com/contents/benign-cervical-lesions-and-congenital-anomalies-of-the-cervix?search=cervical%20polyp&sectionRank=1&usage_type=default&anchor=H16&source=machineLearning&selectedTitle=1~28&display_rank=1#H16, accessed on June 22, 2020.“Cervical Cancer: Evaluation and Management” by Jennifer Wipperman, MD, MPH; Tara Neil, , MD; and Tracy Williams, MD, Am Fam Physician. 2018 Apr 1;97(7):449-454. https://www.aafp.org/afp/2018/0401/p449.html American Society for Colposcopy and Cervical Pathology (ASCCP), App.