Cervical Disorders Flashcards
Epidemiology of cervical cancer
3rd most common cancer worldwide – 15 in 100,000 in the UK
Two peaks – late 20s and 80s
70% are squamous cell carcinomas
Risk factors for cervical cancer
Usually progresses from CIN and predominantly caused by persistent HPV infection Risk factors include - HPV - Smoking - Other STIs - Long term COCP use (>8years) - Immunodeficiency
Features of cervical cancer
Blood stained vaginal discharge, dyspareunia, pelvic pain and weight loss
Often asymptomatic and picked up through routine screening
Investigations for cervical cancer
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
Cervical cancer staining
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
Management of cervical cancer
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
Features of cervical screening
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
Mangement of cervical screening sample
Tested for presence of HPV strains
If detected check for presence of abnormal cells
Decide to monitor or treat
Define cervical ectropion
Eversion of endocervix exposing columnar epithelium to vaginal milieu
- benign condition but must exclude cervical cancer and CIN
Pathophysiology of cervical ectropion
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
Risk factors for cervical ectropian
High levels of oestrogen
- use of COCP
- pregnancy
- adolescence
- menstruating age
Clinical features of cervical ectropian
Usually asymptomatic
Can present with PCB, IMB or excessive discharge (non-purulent)
On speculum everted columnar epithelium has reddish appearance
Differential diagnosis for cervical ectropion
Cervical cancer
CIN
Cervicitis
Pregnancy
Investigations for cervical ectropion
Pregnancy test
Triple swabs - if suggestion of infection
Cervical smear - rule out CIN, biopsy if frank lesion
Management of cervical ectropion
Normal variant - no treatment unless symptomatic
Stop oestrogen containing medications - COCP
Ablation of columnar epithelium - significant vaginal discharge until healing completed
Define CIN
Pre-cancerous condition in which abnormal cells grow on the surface of the cervix
Categories of CIN
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
Features of CIN
Usually symptomatic - abnormal cells found on cervical smear
can have IMB, PCB or abnormal discharge
Causes of CIN
HPV 16 + 18 Increasing age Smoker Immunosuppressant drugs Multiple partners
Investigations for CIN
Smear test
Colposcopy
Biopsy
Management of CIN
Depends on severity
- low - watch and wait
- LETZ - loop electrosurgical excision procedure
- conization
- hysterctomy
Define cervical polyps
Benign growths protruding from the inner surface of cervix
- very small minority can undergo malignant change
Aetiology of cervical polyps
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
Clinical features of cervical polyps
Often asymptomatic - identified via routine screening Abnormal vaginal bleeding - menorrhagia, IMB, PCB, PMB Increased vaginal discharge Infertility - due to blocked cervical canal
`Differential diagnosis of cervical polyps
Cervical extropian or cancer STI Fibroids Endometritis Pregnancy- related bleeding Endometrial carcinoma - PM Endometrial polyp
Investigations for cervical polyps
Histological examination post removal for definitive diagnosis
Exclude other diagnosis
- triple swabs
- cervical smear
Management of cervical polyps
Remove when identified - due to malignant transformation risk
- polypectomy forceps for small
- colposcopy clinic for larger
