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1 Cervix
1 Cervix
Treatment
To reduce the ectropion and associated symptoms women should be changed from
oestrogen-based hormonal contraceptives.
The other option is cervical ablation where the visible glandular producing columnar cells
are ablated,
usually with cryocautery, as an outpatient.
Prior to treatment end, cervical and lower genital tract swabs are taken to exclude
chlamydia and other sexually-transmitted infections and normal cervical cytology should be
confirmed to exclude cervical premalignancy and malignancy
Nabothian follicles
Sometimes the columnar glands within the transformation zone become sealed over,
forming small, mucus-filled cysts visible on the ectocervix.
These are termed ‘nabothian follicles’ and are of no pathological significance.
No treatment is usually required although extremely large ones can be drained using a
large-bore needle .
Cervical polyps
Cervical polyps are benign tumours arising from the endocervical epithelium and may be
seen as smooth,reddish protrusions.
They are usually asymptomatic, being identified incidentally during a routine cervical
smear, but as with a cervical ectropion they can cause vaginal discharge, IMB and PCB. They
are easily removed by avulsion with polyp forceps as an outpatient
Cervical stenosis
Cervical stenosis refers to pathological narrowing of the endocervical canal and is usually an
iatrogenic phenomenon caused by a surgical event.
Treatment of premalignant disease of the cervix using a cone biopsy or loop diathermy can
cause cervical stenosis, as can endometrial ablation affecting the os.
The ensuing trapped blood in the uterus (haematometra) causes cyclical dysmenorrhoea
with no associated menstrual bleeding.
Treatment is by surgical dilatation of the cervix under ultrasound or hysteroscopic
guidance.
premalignant disease of the cervix
Cervical screening has been shown to reduce both the incidence and the number of deaths
from cervical cancer in higher income countries.
It has been estimated that cervical screening prevents around 5,000 deaths every year in
the UK alone.
Pap smear
Many countries, including the UK, are now moving towards primary HPV screening; that is,
testing all cervical cytology specimens for high-risk HPV first, and carrying out reflex
cytological assessment on those that test positive. This will reduce the costs of the
screening programme, since HPV testing is automated and achieves a high throughput,
while cytological assessment is manual and requires a skilled workforce
The National Cervical Screening Programme
Since 1988, the UK has offered population-based cervical screening. Women aged 25–64
are invited every 3–5 years to take part in the screening programme.
25 to 49 every 3yr ,50-64 every 5yr.
Colposcopy
Colposcopy is the examination of the magnified cervix using a light source . It is used for
both diagnosis and treatment.
The woman undresses and places her legs in the semi-lithotomy position.
A speculum is placed in the vagina and the cervix examined with a light source, under
magnification (5–20-fold)
The application of acetic acid and iodine solutions highlights abnormal areas of the cervix
that can be biopsied.
Acetic acid causes nucleoproteins within cells to coagulate temporarily; therefore, areas of
increased cell turnover, including CIN, appear white
Areas of CIN lack intracytoplasmic glycogen and fail to stain brown when iodine is applied
CIN is a preneoplastic process and the process of angiogenesis (new blood vessel
formation) is apparent in CIN when viewed through the colposcope If CIN is present, the
colposcopist determines whether the appearances are low or high grade.
The latter can be treated in the clinic on the same visit (known as ‘see and treat’); the
former can be monitored with a subsequent colposcopy and cytology 6 months later.
A biopsy usually helps make the decision if unsure (‘select and treat’)
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.
Patients who have received treatment for CIN undergo a ‘test of cure’ 6 months later.
This includes a high-risk HPV test and cytological assessment.
If negative, the woman is returned to routine recall; that is, cervical screening in 3 years
time .
If positive, repeat colposcopy is indicated to identify any residual, untreated CIN.
A woman with a history of CIN has an increased life-time risk of recurrent CIN and cervical
cancer.
HPV vaccination
HPV vaccines have been shown to be safe and effective at preventing persistent high-risk
HPV infection CIN.
School-based immunization in the UK is aimed at 12–13-year-old girls so it will take many
years to know if HPV vaccination can reduce deaths from cervical cancer.
The bivalent vaccine prevents persistent infection with HPV types 16 and 18, which
together are responsible for more than 70% of cases of cervical cancer.
In 2011, the bivalent vaccine was replaced by the quadrivalent vaccine, which additionally
protects against HPV types 6 and 11, the main perpetrators of genital warts.
Current vaccination strategies are unlikely to result in the eradication of cervical cancer
because other high-risk HPV types are not included and uptake is not universal.
Future strategies will increase efficacy by vaccinating adolescent boys and the development
of new polyvalent vaccines that provide protection against more high-risk HPV types.