Cervical Disorders Flashcards
What are cervical polyps?
Benign growths protruding from the inner surface of the cervix.
Typically asymptomatic, but a small minority can undergo malignant change.
2-5% of women.
Describe the pathophysiology of cervical polyps.
Focal hyperplasia of the columnar epithelium of the endocervix.
What are the possible causes of cervical polyps?
Chronic inflammation
Abnormal response to oestrogen (revival polyps associated with endometrial hyperplasia)
Localised congestion of the cervical vasculature
What are the risk factors for cervical polyps?
Muligravidae
50-60 years
What are the clinical features of cervical polyps?
Often asymptomatic (identified incidentally via routine cervical screening)
Abnormal vaginal bleeding (menorrhagia, IMB, PCB, PMB)
Increased vaginal discharge
If growth large enough to block cervical canal - infertility
Speculum - polyploid growths projecting through the external os.
What are the differentials for cervical polyps?
Cervical ectropion/cancer STIs Fibroids Endometritis Pregnancy-related bleeding Always exclude endometrial cancer in post-menopausal women Endometrial polyp
What are the investigations for cervical polyps?
Definitive diagnosis - histological examination after removal Triple swabs (endocervical and high vaginal) - rule out infection Cervical smear - rule out cervical intraepithelial neoplasia (CIN) - if cannot be done remove polyp and then smear
What should be done if bleeding still persists after removal of a cervical polyp?
Cervical polyps are associated with endometrial polyps, especially in post-menopausal women.
Do a USS to assess the endometrial cavity.
What is the management for cervical polyps?
Small polyps - removed in primary care using polypectolmy forceps and twisting several times. Any bleeding can be cauterised with silver nitrate.
Larger polyps - removed by diathermy loop excision in colposcopy clinic/under GA if the base is broad
Excised polyps sent for histological examination to exclude malignancy
What is the recurrence rate of cervical polyps?
6-12%
What are the complications of polyp removal?
Infection
Haemorrhage
Uterine perforation (very rare)
What is cervical ectropion?
Version of the endocervix, exposing the columnar epithelium of the vaginal milieu.
AKA cervical erosion.
It is a benign condition, commonly seen on examination of the cervix in adolescents, in pregnancy and in women taking oestrogen containing contraceptives.
What needs to be excluded when suspecting cervical ectropion?
Cervical cancer
CIN
What are the 2 regions of the cervix?
Endocervix/endocervical canal
Ectocervix
Describe the endocervix.
The proximal and inner part of the cervix.
Lined by mucus secreting simple columnar epithelium.
Describe the ectocervix.
The part of the cervix that projects into the vagina.
Lined by stratified squamous non-keratinised epithelium.
Describe the pathophysiology of cervical ectropion.
The stratified squamous cells of the ectocervix undergo metaplastic change to become simple columnar epithelium.
Thought to be induced by high levels of oestrogen.
The columnar epithelium contains mucus-secreting glands = vaginal discharge.
PCB as it contains fine blood vessels which are easily broken during intercourse.
What are the risk factors for cervical ectropion?
COCP
Pregnancy
Adolescence
Mestruating age
What are the clinical features of cervical ectropion?
Mostly asymptomatic
PCB, IMB
Increased vaginal discharge (non-purulent)
Speculum - exerted columnar epithelium has a reddish appearance - usually arranged in a ring around the external os.
What are the differentials for cervical ectropion?
Cervical cancer
CIN
Cervicitis
Pregnancy
What are the investigations for suspected cervical ectropion?
It is a clinical diagnosis, but need to exclude differentials
Pregnancy test
Triple swabs (infection)
Cervical smear (rule out CIN) - biopsy if a frank lesion
What is the management for cervical ectropion?
No treatment if asymptomatic
Stop oestrogen-containing medications (COCP)
Cryotherapy/electrocautery to ablate columnar epithelium (results in higher vaginal discharge until healing complete)
Medication to acidity vaginal pH e.g. boric acid pessaries
What is cervical cancer?
Neoplasia arising from the cervix.
3rd most common cancer worldwide (12th in UK)
What age group does cervical cancer affect?
Disease of the young - half of cases diagnosed before 47.
Peak 25-29 with another peak at 80.
Describe the pathophysiology of cervical cancer.
70% squamous cell carcinoma; 15% adenocarcinoma; 15% mixed
Develops as a progression from CIN
Occurs over 10-20 years (though most cases of CIN spontaneously regress)
Invasive cancer occurs when the basement membrane of the epithelium has been breached.
What are the most common sites of metastases from cervical cancer?
Lung
Liver
Bone
Bowel
What is the aetiology of cervical cancer?
Caused by persistent HPV infection
What is the human papilloma virus?
It is a sexually transmitted virus which affects the skin and mucous membranes
Highly prevalent
What are the high and low risk serotypes of HPV implicated in cervical cancer?
6 and 11 - low risk - cause genital warts
16 and 18 - high risk
Why are HPV serotypes 16 and 18 thought to be high risk for cervical cancer?
They produce proteins which inhibit the tumour suppressor protein p53 in cervical epithelial cells.
Allows for uncontrolled cell division.
Why is the incidence of cervical cancer low in comparison to some other countries?
National HOV vaccination programme protects against HPV 16, 18, 6 and 11.
Regular screening - smear tests
What are the risk factors for cervical cancer?
Smoking
Other STIs
Long-term COCP use (>8 years)
Immunodeficiency e.g. HIV
What are the clinical features of cervical cancer?
Abnormal vaginal bleeding
Vaginal discharge (blood stained, foul-smelling)
Dyspareunia
Pelvic pain
Weight loss
Asymptomatic in early stages - found on routined screening
Advanced (cancer invades nearby structures) - oedema, loin pain, rectal bleeding, radiculopathy, haematuria
What clinical examinations should be done when suspecting cervical cancer and what might you find?
Speculum - bleeding, discharge, ulceration
Bimanual - pelvic masses
GI - hydronephrosis, hepatomegaly, rectal bleeding, mass on PR
What are the differentials for cervical cancer?
STI Cervical ectropion Polyps Fibroids Pregnancy-related bleeding Endometrial carcinoma must always be ruled out in the post-menopausal population
What are the investigations that need to be done when suspecting cervical cancer?
Pre-menopausal - test for chalmidya - if negative/symptoms persist refer for colposcopy and biopsy
Post-menopausal - urgent colposcopy and biopsy
Describe the procedure of colposcopy and biopsy.
Colposcope used to produce a magnified view of the cervix.
Acetic acid used to stain dysplastic areas.
Biopsy taken.
If the diagnosis of cervical cancer is confirmed, what further investigations are needed?
Baseline bloods
CT CAP - looking for mets
Further staging e.g. MRI pelvis, PET
+/- examination under anaesthesia with further biopsies
Are cervical smears used to detect cervical cancer?
No, they aim to detect CIN (pre-invasive disease)
Roughly describe the staging for cervical cancer.
FIGO staging
Stage 0 - in situ
Stage 1 - confined to cervix
Stage 2 - beyond cervix, but not pelvic sidewall/vagina but not lower third
Stage 3 - extends to pelvic sidewall/involves lower third of vagina/hydronephrosis not explained by another cause
Stage 4 - extends to bladder/rectum/mets
Describe the surgical management of cervical cancer.
Stage 1 - radical trachelectomy (removal of cervix and upper vagina) if needs fertility-preservation, otherwise laparoscopic hysterectomy with pelvic lymphadenectomy
Stage 2 - radical hysterectomy - curative
Stage 4/recurrent - anterior/posterior/total pelvic exteneration
Describe the radiotherapy used in the management o cervical cancer.
Combination of external beam therapy and intracavity brachytherapy
Alternative to surgery in early disease
In conjunction with chemotherapy over a 5-8 week course
Additional hysterectomy offers no benefits in terms of survival in the early stages
Therefore, for these stages chemo radiation therapy is gold standard
Describe the use of chemotherapy in cervical cancer management.
Cisplatin-based
Before surgery/radiotherapy (neoadjuvant) or after (adjuvant)
Mainstay in palliative setting
Describe the follow-up in cervical cancer.
Reviews by a gynaecologist every 4 months after treatment for the first 2 years
Then every 6-12 months for the subsequent 3 years
All follow-ups involve physical examination of the vagina and cervix if not removed
