Cervical Disorders

Question 1

What are the clinical features of cervical polyps?

Answer 1

Often asymptomatic
Can cause abnormal vaginal bleeding
On speculum exam:
- polypoid growths projecting through external os

Question 2

How are cervical polyps managed?

Answer 2

Removed due to small risk of malignant transformation

• polypectomy forceps in GP is small
• diathermy loop excision in colposcopy clinic if larger
• always send for histology

Question 3

What is a cervical ectropion?

Answer 3

Eversion of the endocervix, exposing the columnar epithelium to the vaginal milieu

Question 4

What are the risk factors for cervical ectropion?

Answer 4

COCP
Pregnancy
Adolescence
Menstruating age

Question 5

What are the clinical features of an ectropion?

Answer 5

Asymptomatic
Post-coital bleeding
Intermenstrual bleeding
Excessive discharge
Red ring around external os

Question 6

What is the management for an ectropion?

Answer 6

Doesn’t require treatment unless symptomatic
Stopping COCP is usually effective
Ablation with cryotherapy of electrocautery

Question 7

Where on the cervix does metaplasia tend to occur?

Answer 7

Transformation zone
–> where the columnar epithelium of endocervix meets squamous epithelium of ectocervix

(where cervical smear is taken from)

Question 8

What is CIN?

Answer 8

Cervical intraepithelial neoplasia –> preinvasive phase of squamous cervical cancer

Question 9

What are the risk factors for cervical cancer?

Answer 9

HPV 16 + 18
Smoking
Other STIs/multiple partners
Long term (>8 years) COCP use
Immunodeficiency e.g. HIV

Question 10

What is CGIN?

Answer 10

Cervical glandular intraepithelial neoplasm –> preinvasive phase of endocervical adenocarcinoma
(harder to diagnose on smear)

Question 11

What age of women get cervical screening?

Answer 11

Age 25-65

women on routine recall for abnormal results are invited up to age 70

Question 12

What happens to the sample obtained at smear test?

Answer 12

First tested for high risk HPV

• if positive –> cytology testing
• if negative –> cytology not required

Question 13

What happens following the smear test?

Answer 13

If sample HPV negative:
–> recalled for screening in 5 years

If sample HPV positive but cytology negative:
–> repeat screening in 1 year

If HPV positive and cytology positive:
–> colposcopy (regardless of grade of dyskaryosis)

Question 14

What happens at colposcopy?

Answer 14

Squamocolumnar junction visualised
Acetic acid applied –> abnormal epithelium shows up white
Biopsies then taken

Question 15

What is the difference between dyskaryosis and CIN?

Answer 15

Dyskaryosis is a cytological diagnosis from cells collected on smear
CIN is a histological diagnosis from biopsy taken at colposcopy

Question 16

Which finding, indicating HPV infection, is often seen on histology in CIN?

Answer 16

Koilocytosis

Question 17

How is CIN classified?

Answer 17

CIN I = abnormal mitoses occupying 1/3 of basal epithelium
CIN II = abnormal cell extend to middle third
CIN III = abnormal cells span full thickness of epithelium

Question 18

What is the management of CIN I?

Answer 18

Usually regresses spontaneously - follow up with repeat colposcopy

Question 19

What is the management of CIN II/III?

Answer 19

Excision at time of colposcopy or after biopsy results
–> large loop excision of transformational zone (LLETZ)
Thermal ablation also an option if no features of invasion

Question 20

What are the clinical features of cervical cancer?

Answer 20

Post-coital bleeding
Intermenstrual bleeding
Menorrhagia
Pelvic pain
Offensive discharge

If advanced disease:

• backache
• leg pain
• haematuria
• weight loss
• anaemia
• altered bowel habit

Question 21

Which type of cervical cancer is most common?

Answer 21

Squamous (75-95%)

Question 22

Where does cervical cancer most commonly spread?

Answer 22

Adjacent structures and via lymphatics

- pelvic + para-aortic nodes

Question 23

What is the management for cervical cancer stage IA1-IA2?

Answer 23

IA1:

• local excision with LLETZ/cone biopsy with close follow up if fertility required
• hysterectomy if fertility not required

IA2:

• hysterectomy + pelvic nodes
• adjuvant RT if nodes positive

Question 24

What is the management for cervical cancer stage IB1-IIA?

Answer 24

Radical hysterectomy + pelvic nodes

or radical RT + cisplatin chemotherapy

Question 25

What is the management for cervical cancer stage IIB-IV?

Answer 25

Radical RT + chemotherapy

Question 26

If you see a patient and suspect cervical cancer, what should be done to investigate?

Answer 26

Urgent referral for colposcopy + biopsy