Cervix and cervical screening

Question 1

Where is the cervix located? Histology? Where do cancers tend to arise?

Answer 1

Part of uterus below the internal os
Endocervical canal lined with mucous columnar epithelium
Vaginal cervix with squamous
Transitional zone between them - squamo-columnar junction is are predisposed to malignant change

Question 2

What is cervical ectropion

Answer 2

Red ring around os because endocervical epithelium has extended its territory over the paler epithelium of the ectocervix

On the ectocervix there is a transformation zone where the stratified squamous epithelium meets the columnar epithelium of the cervical canal.

Elevated oestrogen levels (ovulatory phase, pregnancy, combined oral contraceptive pill use) result in larger area of columnar epithelium being present on the ectocervix

Question 3

What does ectropion predispose to? Features?

Answer 3

Bleeding
Excess mucus production
Infection

Vaginal discharge
Post-coital bleeding

Question 4

What is treatment for ectropion?

Answer 4

No treatment if asymptomatic, pregnant or pubertal
f taking hormonal contraception consider changing to non-hormonal methods
Cautery with diathermy if required

Question 5

What are cervical polyps?

Answer 5

Peculated benign tumours of endocervical epithelium
May cause increased mucus discharge or PCB

Treated by avulsion
Hysteroscopy in peri and postmenopausal women to exclude intrauterine polyps

Question 6

What is CIN? What are the types?

Answer 6

Cervical intra-epithelial neoplasia is a pre-invasive phase of cervical cancer

CIN I affects the lower basal third of cervical epithelium and will regress to normal in 60% within 2 years

CIN II affects <2/3 of the full thickness of epithelium and is likely to regress in 43% within 2 years

CIN III affects > 2/3 of the full thickness of epithelium and is likely to regress in 32% within 2 years

Question 7

What is CIN associated with?

Answer 7

HPV 16, 18, 31, 33

Oncogenic

Question 8

What is a smear test?

Answer 8

Collection of cervical cells for microscopy for dyskaryosis (abnormalities which reflect CIN)

Question 9

Who is cervical screening offered to?

Answer 9

Women aged 25-64
25-49: 3 yearly screening
50-64: 5 yearly screening

Question 10

When is cervical screening done in pregnancy?

Answer 10

Usually delated until 3 months post-partum unless missed screening or abnormal smears

Question 11

How is cervical screening performed?

Answer 11

Pap smear

• Cervix visualised with speculum
• cells are scraped from the squamo-columnar transformation zone

Liquid based cytology

• sample is raised in preservative or simply removed into sample bottle containing preservative
• reduced rate of inadequate smears

Take cervical smear around mid-cycle

Question 12

What are risk factors for CIN?

Answer 12

Persistent high-risk HPV infection
Exposure to HPV increased by multiple partenrs
Smoking
Immunocompromised (HIV, transplant, immunosuppressed)
Oral contraceptive - probably due to reduced use of barrier contraception

Question 13

What should be done if smear shows inflammatory changes?

Answer 13

Repeat in 6 months
Swabs
Colposcopy after 3 abnormal

Question 14

What should be done if borderline mild dyskaryosis?

Answer 14

High risk HPV test -16,18,31,33
If positive refer for colposcopy
If negative repeat in 3 years

Question 15

What should be done if moderate dyskaryosis?

Answer 15

Refer for colposcopy uregent

Question 16

What would be done in severe dyskaryosis?

Answer 16

Refer for urgent colposcopy (2 weeks)

Question 17

What should be down if suspected invasion?

Answer 17

Urgent colposcopy (2 weeks)

Question 18

What should be done if abnormal glandular cells?

Answer 18

Urgent colposcopy (2 weeks)

Question 19

When should screening be carried out after pregnancy?

Answer 19

3 months post delivery

Cervix undergoes changes due to hormones that can be misinterpreted as dyskaryosis