Cervical disorders

Question 1

What is a cervical polyp? Ax and PPx?

Answer 1

• Cervical polyps are benign growths protruding from the inner surface of the cervix, they are typically asymptomatic but a very small minority can undergo malignant change.
• They develop due to focal hyperplasia of the columnar epithelium in the endocervix.
  Ax: Chronic inflammation, congestion of vasculature, abnormal response to oestrogen (associated with endometrial hyperplasia).
• Common with multigravidae (peak in incidence between 50-60).

Question 2

Clinical features of cervical polyps?

Answer 2

• OFTEN ASYMPTOMATIC (identified via routine screening)
• Cervical polyps often associated with endometrial polyps (especially in post-menopausal patients).

1) Abnormal vaginal bleeding (menorrhagia, inter-menstrual, post-coital, post-menopausal)
2) Polyps can cause increased vaginal discharge
3) RARELY - grow large enough to block cervical canal causing infertility.
4) On speculum - polypoid growths projecting through external os.

Question 3

Investigations for cervical polyps?

Answer 3

1) Definitive diagnosis for cervical polyp is HISTOLOGICAL examination after the polyp has been removed.
2) Triple swabs - if suggestion of infection - such as purulent discharge (high vaginal swabs and endocervical)
3) Cervical smear - to exclude cervical intraepithelial neoplasia, if polyp prevents smear repeat swab after removal.
IF bleeding persists after removal of polyps - an ultrasound scan taken to assess endometrial cavity for further polyps.

Question 4

Management of cervical polyps?

Answer 4

• Cervical polyps have small risk of malignant transformation - common practice to remove when identified.
  1) Small polyps: removed in primary care - polypectomy forceps + twisted, polyp avulsed as pedicle twisted. Resulting bleeding can be cauterised with silver nitrate.
  2) Large polyps: diathermy loop excision in colposcopy clinic, or under general anaesthesia if the base of the polyp is broad.
  Any excised polyps should be sent for histological examination to exclude malignancy.

Question 5

Complications of polyp removal?

Answer 5

1) Infection
2) Haemorrhage
3) Uterine perforation (very rare) - only remove easily visible polyps in outpatient clinic (not from within cervical canal or intrauterine).

Question 6

What is cervical ectropion?

Answer 6

• Cervical ectropion occurs when there is eversion of the endocervix - exposing the columnar epithelium to the vaginal milieu. It’s also known as cervical erosion (although no erosion occurs).
• Benign condition usually seen on cervical examination in adolescents, pregnancy and women taking oestrogen containing contraceptives.
• Cervical cancer and cervical intraepithelial neoplasia NEED TO BE EXCLUDED.

Question 7

Ax and PPx of cervical ectropion?

Answer 7

• Cervix composed of two regions, ectocervix and endocervical canal.
  Endocervical canal - more proximal, and the inner part of the cervix lined by a mucous-secreting simple columnar epithelium.
  Ectocervical canal - the part of the cervix that projects into the vagina normally lined by stratified squamous non-keratinised epithelium.
• In cervical ectropion the stratified squamous cells of the ectocervix undergo metaplastic change to become simple columnar epithelium (same as endocervix) - due to high levels of oestrogen.
• Fine vessels within this simple columnar epithelium prone to rupture during intercourse (post-coital bleeding), and mucus secreting glands in this epithelium (may present with vaginal discharge).

Question 8

Risk factors of cervical ectropion?

Answer 8

• Induced by high levels of oestrogen, Therefore factors that increase ectropion risk:
  1) COCP
  2) Pregnancy
  3) Adolescence
  4) Menstruating age (uncommon post-menopause)

Question 9

Clinical features cervical ectoprion?

Answer 9

• Usually asymptomatic
  1) Vaginal discharge (NON-PURULENT)
  2) Post-coital bleeding, intermenstrual bleeding
  On speculum:
• Everted columnar epithelium has a reddish appearance - usually in a ring around the external os.

Question 10

Investigations of cervical ectoprion?

Answer 10

Clinical diagnosis - investigations to exclude other diagnosis:

1) Pregnancy
2) Triple swabs - if any suggestion infection (such as purulent discharge), endocervical and high swabs should be taken.
3) Cervical smear - to rule out cervical intraepithelial neoplasia. If a frank lesion is observed a biopsy should be taken (not performed as routine)

Question 11

Management of cervical ectoprian?

Answer 11

Does not need treatment unless symptomatic:

1) Stop any oestrogen containing medication (COCP) - usually effective
2) If symptoms persist - columnar epithelium can be ablated - cryotherapy or electrocautery: SIGNIFICANT vaginal discharge until healing is completed
3) Boric acid pessaries to acidify vaginal pH (??)

Question 12

What is cervical cancer? Ax and PPx?

Answer 12

• Refers to neoplasia arising from cervx - primarily disease of YOUNG - weak age of diagnosis between 25-29.
• Majority are squamous cell carcinomas, remained are adenocarcinomas or mixed.
• Cervical cancer develops as a progression from cervical intraepithelial neoplasia (over the course of 10-20 years) although most regress spontaneously.
• Invasive cervical cancer - basement membrane of epithelium has been breached - most common metastasis sites: lung, liver, bone and bowel.
• VAST MAJORITY of cervical squamous cell carcinoma caused by HPV infection - contain HPV DNA within cancerous cells.
• HPV 16 and 18 most common high risk serotypes - protected by national HPV vaccination programme.

Question 13

Risk factors for Cervical cancer?

Answer 13

1) Infection with HPV
2) Smoking
3) Other STIs
4) Long-term (>8 years) COCP use
5) Immunodeficiency (HIV)

Question 14

Clincal features of Cervical cancer?

Answer 14

1) MOST COMMON - Abnormal vaginal bleeding (post-coital, intermenstrual or PMB)
2) Vaginal discharge (blood stained, foul smelling
3) Dyspareunia
4) Pelvic pain
5) Weight loss
OFTEN Asymptomatic - detected through routine screening

Advanced disease: oedema, loin pain, rectal bleeding, radiculopathy and haematuria.

• Speculum - bleeding, discharge, ulceration.
• Bimanual - pelvic masses
• GI - hydronephrosis, hepatomegaly, rectal bleeding, mass on PR.

Question 15

Investigations for cervical cancer?

Answer 15

• Pre-menopausal: Test for chlamydia trachomatis infection (treat if positive) - if symptoms persist after positive test, or if test is negative - colposcopy and biopsy is performed.
• Post-menopausal: urgent colposcopy and biopsy

If cervical cancer confirmed:

1) FBC, LFT, U+E
2) CT chest-abdomen-pelvis (metastasis)
3) MRI Pelvis/PET
4) Examination under anaesthesia with further biopsies

Question 16

What is colposcopy?

Answer 16

Colposcope (modified microscope) produced magnified view of cervix - acetic acid used to stain dysplastic areas and a biopsy is taken.

Question 17

Staging of cervical cancer?

Answer 17

Stage 0 - Carcinoma-in-situ
Stage 1 - Confined to cervix (a - only microscopically identified, b - gross lesions clinically identifiable.)
Stage 2 - Beyond cervix but not pelvic sidewall/involves vagina but not lower 1/3rd (a - no parametrial involvement, b - obvious parametrial involvement)
Stage 3 - Extends to pelvic sidewall/ involves lower 1/3rd vagina/hydronephrosis not explained by another cause. (a - no extension to sidewall, b - extension to sidewall and/or hydronephrosis)
Stage 4 - Extends to bladder or rectum, or metastasis (a - involves bladder/rectum, b - involves distant organs).

Question 18

Surgical management of cervical cancer?

Answer 18

Surgical:

• 1a) Radical trachelectomy if fertility-preservation is a priority - involved removal of cervix and upper vagina. Laproscopic hysterectomy with pelvic lymphadenectomy is offered if preservation of fertility is not a requirement.
• 1b/2a) Radical (Wertheim’s) hysterectomy as a curative treatment modality - removal of uterus, vagina and parametrial tissues up to the pelvic sidewall plus lymphadenectomy.
• 4a or recurrent disease) Anterior/posterior/total pelvic externteration. Removal of all pelvic adnexal plus bladder (anterior)/rectum (posterior or both (total)).

Question 19

Chemoradiation therapy of cervical cancer?

Answer 19

Radiotherapy - often combination of external beam therapy and intracavity brachytherapy - in stage 1b to 3, offered in conjunction with chemotherapy over a 5-8 week course. Evidence suggests additional hysterectomy offers no benefits in terms of survival in these stages. CHEMORADIATION therapy is GOLD STANDARD.

Chemotherapy - Cisplatin based. Given before treatment by surgery/radiotherapy (neoadjuvant chemotherapy). Chemotherapy is the mainstay in a palliative setting

Should be reviewed every 4 months after treatment for the first 2 years, and every6-12 months for the subsequent 3 years.