Cervix

Question 1

What is the cervix?

Answer 1

Part of uterus below the internal os

Question 2

What area of uterus is most predisposed to malignant change?

Answer 2

Transition zone

Question 3

What is the transition zone?

Answer 3

Squamo-columnar junction between endocervical canal and vaginal cervix

Question 4

Histology of vaginal cervix?

Answer 4

Squamous epithelium

Question 5

Histology of endocervical canal?

Answer 5

Columnar epithelium

Question 6

What is cervical ectropion/ erosion ?

Answer 6

Endocervical epithelium extends outside cervical canal to vaginal portion of cervix

Question 7

What are nabothian cysts?

Answer 7

Mucus retention cysts on the cervix - harmless

Question 8

What are cervical polyps?

Answer 8

Benign tumours of endocervical epithelium. May cause bleeding

Question 9

Treatment of cervical polyps?

Answer 9

In young women - avulsed

In peri/postmenopausal women - TVS +/- hysterectomy

Question 10

Consequence of cervicitis?

Answer 10

Infertility if Fallopian tube damage

Question 11

Causes Of cervicitis?

Answer 11

Chlamydia
Gonococci
Herpes simplex
If chronic may be mixed infection

Question 12

How often are HIV +ve smeared?

Answer 12

Every year

Question 13

How often are age 25-50 year olds smeared?

Answer 13

Every 3 years

Question 14

How often are aged 50-64years old smeared?

Answer 14

Every 5 years

Question 15

If smear is normal, next action?

Answer 15

Repeat in 3 years

Question 16

If smear shows inflammation, next actions?

Answer 16

Repeat in 6 months
Swabs
Colposcopy after 3 abnormal p

Question 17

If smear borderline, next actions?

Answer 17

High risk HPV test - if positive refer for colposcopy. If negative repeat in 3 years

Question 18

If smear shows mild dyskaryosis, next actions?

Answer 18

High risk HPV test - if positive refer for colposcopy. If negative repeat in 3 years

Question 19

If smear shows moderate-severe dyskaryosis, next actions?

Answer 19

Refer to colposcopy

Question 20

If smear shows suspected invasion, next action?

Answer 20

Urgent colposcopy

Question 21

If smear shows abnormal glandular cells, next action?

Answer 21

Urgent colposcopy

Question 22

What is CIN?

Answer 22

Cervical intraepithelial neoplasia.

Pre-invasive stage of cervical cancer

Question 23

Features of CIN?

Answer 23

Dysplasia of squamous cells
Nuclear abnormalities - increased nucleocytoplasmic ratio
Excess mitotic activity

Question 24

Where does CIN occur?

Answer 24

Transformation zone

Question 25

Risk factors for CIN?

Answer 25

Persistent high risk HPV infection (16,18) Exposure to HPV by having multiple partners Smoking Immunocompromised Decreased use of barrier contraceptives and increased use of oral contraceptives

Question 26

Changes in CIN I?

Answer 26

Abnormal cells in basal 1/3 of epithelium Increased number of mitotic figures in lower 1/3 Surface cells quite mature but nuclei abnormal

Question 27

Changes in CIN II?

Answer 27

Abnormal cells extend to middle 1/3 Mitosis in middle 1/3 Abnormal mitotic figures

Question 28

Changes in CIN III?

Answer 28

Abnormal cells occupying full thickness of epithelium. | Mitosis, often abnormal, in upper 1/3

Question 29

Management of CIN?

Answer 29

Colposcopy - punch biopsies taken to get histological diagnosis. LLETZ

Question 30

Management of CIN I?

Answer 30

May regress spontaneously | If HPV +ve, offer 6 monthly colposcopy and LLETZ if persistent

Question 31

Treatment of CIN II and III?

Answer 31

Excision with LLETZ

Question 32

What does cervical cancer have a strong association with?

Answer 32

HPV | Preexisting CIN

Question 33

When does cervical cancer occur?

Answer 33

2 peaks: - 30-39 years old - >70 years old

Question 34

Symptoms and signs of cervical cancer?

Answer 34

On smear- invasion Post-coital/ postmenopausal bleeding Advanced disease - heavy vaginal bleeding, uteric obstruction, weight loss, bowel disturbance , pain

Question 35

Investigations of cervical cancer?

Answer 35

``` FBC, U&Es, LFTs Punch biopsy for histology CT abdo and pelvis MRI pelvis Cystoscope, hysteroscopy, PR/PV exam ```

Question 36

Cervical cancer on colposcopy?

Answer 36

Irregular cervical surface Abnormal vessels Dense uptake of acetic acid

Question 37

Speculum exam of cervical cancer?

Answer 37

Irregular mass - often bleeds on contact

Question 38

Cervical cancer on bimanual exam?

Answer 38

Cervix feels roughened and hard. | If advanced - loss of fornices and cervix fixed

Question 39

Staging of cervical cancer?

Answer 39

``` 1a1 - <3mm depth, <7mm width 1a2 - <5mm depth, <7 mm width 1b - confined to cervix II - spread to adjacent organs III - involvement of pelvis wall IV - distant mets/ involvement of rectum / bladder ```

Question 40

Treatment of stage 1a1 cervical cancer?

Answer 40

Excision or hysterectomy

Question 41

Treatment of stage 1a2 or 1b cervical cancer?

Answer 41

Lymphadenectomy and hysterectomy

Question 42

Treatment of stage II or III cervical cancer?

Answer 42

Combined chemoradiotherapy

Question 43

Treatment of stage IV cervical cancer?

Answer 43

Chemoradiotherapy, lymohadenectomy, wertheims hysterectomy