Cervical Disorders

Question 1

Epidemiology of cervical cancer

Answer 1

3rd most common cancer worldwide – 15 in 100,000 in the UK
Two peaks – late 20s and 80s
70% are squamous cell carcinomas

Question 2

Risk factors for cervical cancer

Answer 2

Usually progresses from CIN and predominantly caused by persistent HPV infection
Risk factors include
- HPV
- Smoking
- Other STIs
- Long term COCP use (>8years)
- Immunodeficiency

Question 3

Features of cervical cancer

Answer 3

Blood stained vaginal discharge, dyspareunia, pelvic pain and weight loss
Often asymptomatic and picked up through routine screening

Question 4

Investigations for cervical cancer

Answer 4

Pre-menopausal women – test for chlamydia trachomatis and perform colposcopy and biopsy if negative
Post-menopausal women should be referred for an urgent colposcopy and biopsy

Question 5

Cervical cancer staining

Answer 5

Stage 0 – carcinoma in situ
Stage 1 – confined to cervix
- A – identified only microscopically
- B – gross lesions, clinical identifiable
Stage 2 – beyond cervix but not pelvic sidewall/ involves vagina but not lower 1/3
- A – no parametrial involvement
- B – obvious parametrial involvement
Stage 3 – extends to pelvic sidewall / lower 1/3 of vagina
- A – no extension to sidewall
- B – extension to sidewall and/or hydronephrosis
Stage 4 – extends to bladder or rectum or metastases
- A – involves bladder/rectum
- B – involves distant organs

Question 6

Management of cervical cancer

Answer 6

Surgery
- Stage 1a – radical trachelectomy or laparoscopic hysterectomy
- Stage 1n/2a – radical hysterectomy and lymphadenectomy
- Stage 4a/recurrent disease – anterior/posterior/total pelvic exenteration
Radiotherapy
- Combination of external beam therapy and intracavity brachytherapy
- Stage 1b to 3 – conjunction with chemotherapy for 5-8 wks
- Chemoradiation is gold standard
Chemotherapy
- Cisplatin-based
- Mainstay in palliative setting

Question 7

Features of cervical screening

Answer 7

National UK screening programme
Women 25-49 every 3 years and 50-64 every 5 years
Small sample of cells taken from ectocervix using brush

Question 8

Mangement of cervical screening sample

Answer 8

Tested for presence of HPV strains
If detected check for presence of abnormal cells
Decide to monitor or treat

Question 9

Define cervical ectropion

Answer 9

Eversion of endocervix exposing columnar epithelium to vaginal milieu
- benign condition but must exclude cervical cancer and CIN

Question 10

Pathophysiology of cervical ectropion

Answer 10

Stratified squamous cells of the ectocervix undergo metaplastic change -> simple columnar epithelium
Columnar epithelium contains mucus-secreting glands so may experience increased discharge and fine blood vessels present may lead to post-coital bleeding

Question 11

Risk factors for cervical ectropian

Answer 11

High levels of oestrogen

• use of COCP
• pregnancy
• adolescence
• menstruating age

Question 12

Clinical features of cervical ectropian

Answer 12

Usually asymptomatic
Can present with PCB, IMB or excessive discharge (non-purulent)
On speculum everted columnar epithelium has reddish appearance

Question 13

Differential diagnosis for cervical ectropion

Answer 13

Cervical cancer
CIN
Cervicitis
Pregnancy

Question 14

Investigations for cervical ectropion

Answer 14

Pregnancy test
Triple swabs - if suggestion of infection
Cervical smear - rule out CIN, biopsy if frank lesion

Question 15

Management of cervical ectropion

Answer 15

Normal variant - no treatment unless symptomatic
Stop oestrogen containing medications - COCP
Ablation of columnar epithelium - significant vaginal discharge until healing completed

Question 16

Define CIN

Answer 16

Pre-cancerous condition in which abnormal cells grow on the surface of the cervix

Question 17

Categories of CIN

Answer 17

Low grade - dysplasia involving 1/3 thickness of epithelium
CIN 2 - abnormal changes 1/3 to 2/3 depth
CIN 3 - affects more than 2/3 depth

Question 18

Features of CIN

Answer 18

Usually symptomatic - abnormal cells found on cervical smear

can have IMB, PCB or abnormal discharge

Question 19

Causes of CIN

Answer 19

HPV 16 + 18
Increasing age
Smoker
Immunosuppressant drugs
Multiple partners

Question 20

Investigations for CIN

Answer 20

Smear test
Colposcopy
Biopsy

Question 21

Management of CIN

Answer 21

Depends on severity

• low - watch and wait
• LETZ - loop electrosurgical excision procedure
• conization
• hysterctomy

Question 22

Define cervical polyps

Answer 22

Benign growths protruding from the inner surface of cervix

- very small minority can undergo malignant change

Question 23

Aetiology of cervical polyps

Answer 23

Result of focal hyperplasia of the columnar epithelium of endocervix
- chronic inflammation
- abnormal response to oestrogen
- localised congestion of cervical vasculature
More common in multigravidae and peak incidence between 50-60 years

Question 24

Clinical features of cervical polyps

Answer 24

Often asymptomatic
- identified via routine screening
Abnormal vaginal bleeding
- menorrhagia, IMB, PCB, PMB
Increased vaginal discharge
Infertility - due to blocked cervical canal

Question 25

`Differential diagnosis of cervical polyps

Answer 25

Cervical extropian or cancer
STI
Fibroids
Endometritis
Pregnancy- related bleeding
Endometrial carcinoma - PM
Endometrial polyp

Question 26

Investigations for cervical polyps

Answer 26

Histological examination post removal for definitive diagnosis
Exclude other diagnosis
- triple swabs
- cervical smear

Question 27

Management of cervical polyps

Answer 27

Remove when identified - due to malignant transformation risk

• polypectomy forceps for small
• colposcopy clinic for larger