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Benign diseases of the cervix are common and are unusually asymptomatic or cause minor symptoms but must be differentiated from malignancy.
Cervical cancer is the second commonest cancer in women. It is proceeded by a premalignant form years before its invasion.
Screening for premalignant disease of the cervix markedly reduces the deaths from cervical cancer.
Transformational zone: The area of cervix between the old
and new squamo-columnar junction. It is the area of risk of developing
premalignant and malignant disease of the cervix.
1) Cervical ectopy (erosion)2) Cervical eversion (ectropion)3) Cervical tears4) Cervical cyst5) Endocervical polyp.6) Inflammatory conditions of cervix
CLINICAL FEATURESSymptoms-Vaginal discharge -Contact bleeding-Associated cervicitis may
produce backache, pelvic pain
Signsp/s bright red area extending
beyond external os.Neither tender nor bleeds on
touch.Outer edge clearly
demarcatedThe feel is soft, granular and
gives rise to grating sensation
aetiology
DIAGNOSISIt can be confused with-ectropion-early carcinoma (indurated, friable and bleeds to
touch)-primary chancre (ulcer has a punched out
appearance.-tubercular ulcer (indurated with caseation at base) MANAGEMENTAll cases should be subjected to cytological
examination to exclude dysplasia and malignancyIn symptomatic cases-Pill should be stopped and barrier method is
advised.-persistent ectopy with troublesome discharge thermal cautrisation cryosurgery laser vaporisation
In chronic cervicitis there is marked thickening of cervical mucosa with underlying tissue edema. These thickened tissue tend to push out through the ex. Os along direction of least resistance.
More marked if cx already lacerated As a result lips of cx curl upwards and
outwards exposing red looking endocervix
It frequently occurs during vaginal delivery.
One or both sides of cx may be torn, or it may b irregular (stellate) type
If these is no infection the torn surfaces approximate and heal leaving a notch if infection persists it causes eversion.
Non obstetric causes include lacerations due to operative procedures of DNC
Postmenopausal atrophy or chronic cervicitis also predisposes to tear.
These include1. Nabothian cyst2. Endometriotic cyst3. Mesonephric cyst
Endocervical glands in the transformational zone become covered with squamous cells and forms mucus filled cysts.
As this benign process continues, smooth, clear or yellow glandular elevations are visible during routine examination
Nabothian cyst warrants no further therapy..
ENDOMETRIOTIC CYST
Situated in portio vaginalis part of cx.
It is small reddish and <1cm dia.
Implantaion of endometrium due to surgery or during labour occurs giving rise to cyst
Symptoms-PCB, intermenstrual
bleeding-DysmenorrhoeaTreatmentDestruction by
cauterisationRarely excision
MESONEPHRIC CYST
Usually situated in outer side of cervical stroma
Seldom increase 2.5cm.Lined by cuboidal
epithelium. They are
asymptomatic .Warrants no further
treatment
It is one of the most common neoplasms It is a hyperplastic projection of the endocervical
folds. These lesions are commonly found and may be
associated with leukorrhea and post coital spotting
If it has a slender stalk it is removed my continuous twisting using a ring forceps. Twisting leads to occlusion of supporting vessels and avulsion of mass
A thick pedicled polyp needs surgical excision Excised cervical polyps require pathologic
evaluation to rule out malignancy
ACUTE CERVICITISUsually follows child birth,
abortion or any operative procedure on cervix.
Responsible organisms aregonococcal, chlamydia, thrichomonal vaginosis, mycoplasma and HPV.
Clinical features-Painful vaginal examination-Tender, Oedematous and
congested cx-Muco purulent discharge seen
at osPrognosis-Resolve completely.-infection spreads to adjacent
structures.-becomes chronicTreatment -high vaginal endocervical swab
to be taken for bacteriological examination
-treat with appropriate antibiotics.
CHRONIC CERVICITISFollows attack of acute cervicitisEndocervix ia a potential
reservoir of infection with N. gonorrhoeae, chlamydia, HPV, bacterial vaginosis.
Clinical features-asymptomatic-excessive mucoid discharge
might be present-h/o contact bleeding might be
thereOn examination-Cx is tenderOn p/s mucopurulent discharge
escaping ex. OsTreatment1) No role of antimicrobial
therapy except in gonococcal2) Diseased tissue destroyed by
electo or diathermy cauterisation or laser cryosurgery.
Cervicalcancer
Normal cervix
DNA virus. Over 100 different types and subtypes of this
virus. Common infection effecting epithelial surface. Genital HPV is divided into Low risk type (HPV 6,11) cause genital warts. High risk types (HPV 16, 18, 31, 33, 45, 56). HPV is a common infection while cervical
cancer is a rare disease.
Factors that increase risk of transmission:
Smoking. Increasing parity. Early age of intercourse. Oral contraceptive pills. Immunity.
Metaplasia: change of epithelium from one cell lining (columnar) to another (squamous).
Dysplasia: abnormal epithelial cells that fail to maturate. (hyperchromasia, larger, variable size, mitosis).
It may be mild, moderate or severe
CIN1 Normal
CIN 1(condyloma
)
CIN 1(mild
dysplasia)
CIN 2 (moderate dysplasia)
CIN 3(severe dysplasia/CIS) Invasive cancer
Histology of squamous cervical epithelium1
Low grade squamous intraepithelial lesion (LSIL); HPV infection, CIN I.
High grade squamous intraepithelial lesion (HSIL); CIN II, CIN III.
Squamous cell Glandular cell
Atypical squamous cell (ASC) Atypical glandular cells (AGC) Endocervical, endometrial, or not otherwise specified
ACS of undetermined significance(ASCUS)
Atypical glandular cells, favour neoplastic or not otherwise specified
ACSH cannot exclude HSIL
Low grade sq. intraepithelial lesion(LSIL)
Endocervical adenocarcinoma in situ
adenocarcinomaH SIL
Sq cell carcinoma
Outcome of CIN Spontaneous regression. Progression to invasive cancer. Progression from one stage to another
takes years. Detection and treatment of CIN
prevents cancer cervix.
Screening for dyskariosis by obtaining cervical cytology.
Cervical screening should be carried out every 3-5 years in all sexually active women from 20-60 years of age.
There is a 10-15 % chance of false positive or false negative results.
Smear Risk of having HSIL
Management If next smear is negative
Normal 0.1% Repeat in 3-5 years
Routine
Inflammatory <6% Repeat in 3-5 years
Routine
Borderline 20-30% Repeat 6 months Repeat 1 year then 2 then routine.Colposcopy if 3 borderline.
Mild dyskaryosis 30-50% Repeat in 3 monthsOr refer for colposcopy
Repeat 1 year then 2 then routine.Colposcopy if 3 borderline.
moderate dyskaryosis
50-70% Colposcopy Repeat after treatment
Severe dyskaryosis
80-90% Colposcopy Repeat after treatment
Invasion suspected
50% invasion
Urgent colposcopy
Is the inspection of the cervix with a low powered microscope.
Magnifies the cervix 4-20 times. The patient is put in lithotomy position. Passing a bivalve speculum gently into
the vagina.
Inspection of the cervix and its vasculature. Green filter may help studying vasculature. Abnormal vascular structure includes
punctuation and mosaicism. Acetic acid test: application of 3% acetic
acid stained the abnormal area. The degree of staining correlates with severity of the lesion.
Schiller test: application of Lugol’s iodine stains the normal cervix brown.
Colposcopy gives a clinical diagnosis. Punch biopsy from the abnormal area gives
a histopathological diagnosis.
CIN II,CIN III. ?CIN I.Techniques for treatment:Excisional: LEEP (loop electrosurgical
excision procedure) CO2 laser cone, knife cone, hysterectomy.
Ablative: radical electrodiathermy, cold coagulation, cryocautery, laser.
90-95% cure rate
Less common than squamous intraepithelial neoplsia.
Has same risk factors. Can not be reliably screened by colposcopy. Does not have particular colposcopic
features. Divided into high grade and low grade. Characterized by skip lesions. Treatment by large cone biopsy.
The first vaccine that intends to prevent cancer.
2 forms of vaccine are available Bivalent 16, 18 (cervarix) Quadrevalent 6, 11, 16, 18.(gardasil) Now licensed in a number of countries.
Benign diseases of cervix are harmless but malignancy should be excluded.
Cervical intraepithelial neoplasia proceedes cancer cervix by years. (CIN 1 to CIN 3 twenty years)
Screening for CIN reduces mortality from cancer cervix.
Those with positive screening test should be referred to colposcopy for diagnosis and treatment.