Cervical Conditions
  • Cervical Ectropion

A condition in which simple columnar epithelium (lining the endocervix) is present on the ectocervix.
– This type of epithelium is more fragile than the stratified squamous epithelium that usually lines the ectocervix and may bleed after sexual intercourse
– Ectropion can also lead to increased vaginal discharge as simple columnar cells are mucus-producing,
– It is diagnosed clinically after ruling out other more sinister pathologies like cervical cancer.

Causes
– Raised oestrogen levels (e.g. pregnancy, COCP)

Symptoms:
Mostly asymptomatic but may cause: – Post-coital bleeding
– An increase in vaginal discharge
– Pain/bleeding during cervical screening
– On examination -> red, velvety area on the ectocervix

Investigations:
– Swabs and smear to rule out infection and CIN/cervical cancer

 

Management
– Do not treat unless it is symptomatic
– If on COCP, consider switching to another COCP with a lower dose of oestrogen or to the POP
– Can do silver nitrate cauterisation or cold coagulation of the columnar epithelium

  • Cervical Polyps

These are benign growths on the cervix which result from hyperplasia of the columnar epithelium – Usually benign but carry a risk of malignant transformation and so must be removed

Symptoms
– May be asymptomatic and found incidentally on speculum examination or may cause: – Abnormal vaginal bleeding (menorrhagia, IMB, PCB, PMB)
– Abnormal vaginal discharge
– Difficulty taking smear sample

Investigations
– Do swabs and smear to rule out infection/cervical cancer

Management
– Remove polyp + send for histological evaluation to exclude malignancy

N.B. Some recommend only removing symptomatic polyps as risk of malignant change in asymptomatic polyps may be so low that removal is unnecessary

  • Cervical Cancer

This is an invasive carcinoma of the cervical epithelium, which usually present as post-coital bleeding – It is usually seen in 30-year olds (more sexually active) and >50 years old (less immune surveillance)

Cervical carcinoma is characteristically preceded by Cervical Intraepithelial Neoplasia (CIN)
– CIN is characterized by nuclear changes and increased mitosis in the transformation zone (the junction between the endocervix and ectocervix)

Divided into 3 grades according thickness of dysplastic cells:
– CIN 1 < 1/3 thickness of epithelium
– CIN 2 < 2/3 thickness of epithelium
– CIN 3 < complete thickness of epithelium
– Carcinoma in situ (CIS) = involves entire thickness

– It can then become invasive when it begins to invade through the basement membrane.
– CIN classically progresses in stepwise fashion through the grades to full carcinoma, but can regress

Risk factors:
– The main risk factor is infection with Human Papilloma Virus (HPV) types 16 + 18
– These make proteins E6 (inhibits p53) and E7 (affect RB) increasing risk of cancer.
– Increase HPV infection –> Many sexual partners, age at first sexual intercourse, condom use – Increase progression –> Smoking, COCP use, high parity, co-infection with other STIs
– Increase both –> HIV or immunosuppressed patients

Symptoms:
Most are asymptomatic and detected on screening:
– Intermenstrual bleeding, postcoital bleeding, postmenopausal bleeding
– Blood-stained, mucoid or purulent vaginal discharge
– Pelvic pain/dyspareunia

Screening:
Currently a Pap smear screening program for women aged 25-64
– A brush inserted in cervical os to gain sample of the transformation zone
– The best time to take a smear test is mid-cycle
– 25-49 years = 3-yearly screening –
50-64 years = 5-yearly screening
– Sample is screened for the presence of high risk variants of HPV (hrHPV)
– If this is positive, then you carry out cytological examination of the cells

The results of the smear test are one of 3:

i) Inadequate -> due to problems, must repeat the smear test within 3 months.
    – If you have 2 consecutive inadequate samples, refer for colposcopy

ii) Patient is hrHPV negative -> return to routine 3-year screening

iii) Patient is hrHPV positive -> cytology (look for cellular abnormalities) can give the following:
• Borderline changes
• Low-grade dyskaryosis
• High-grade dyskaryosis
• Invasive squamous cell carcinoma
• Glandular neoplasm

 

–  If borderline or low grade dyskaryosis ➔ repeat HPV test in 12 months

If negative after 12 months –> return to routine 3 years

   • If HPV positive after 12 months + cytology negative –> repeat at 12 months
   • If HPV positive again at this time –> arrange colposcopy

–  If high grade dyskaryosis or suspected carcinoma ➔ refer for urgent colposcopy

Diagnosis
– Colposcopy and biopsy, used to definitively measure degree of CIN

Treatment
(from CRUK3) – this depends on the extent of CIN
– If CIN2/CIN3 
➔ large loop excision of the transformation zone (LLETZ)
  – This gives short term risk of bleeding, infection and pain
– Long term can result in dyspareunia and pre-term labour (as cervix is weaker) so women as given a progesterone pessary to keep the cervix more intact

– Full cervical carcinoma (confined to the cervix or only extending to the top of vagina):                

– Surgery = Radical hysterectomy +/- removal of lymph nodes

-Warn the patient about damage to the obturator nerve as can affect adductors in legs

– If advanced –> options include chemotherapy, radiotherapy or palliative care

There are special management options for patients with cervical cancer who still want to get pregnant:
– If stage 1A 
➔ do a radical trachelectomy or cone biopsy
– If stage 2/3 cancer ➔ brachy-therapy (radiotherapy source inside the or close cancer)
– It is not a definitive cure and they will need a hysterectomy after giving birth

Vaccination
– To reduce the incidence of CIN, there is a school vaccination programme for HPV
– Offered to all 12- and 13-year olds (girls and boys) in School Year 8, given as 2 doses

 

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