Cervix and its disorders

Question 1

what are the two areas of the cervix

Answer 1

endo and ectocervix

Question 2

what kind of epithelium covers the ectocervix

Answer 2

squamous epithelium

Question 3

what kind of epithelium covers the endocervix

Answer 3

glandular epithelium

Question 4

why is there two different types of cervix and why is it a high risk area for malignant change

Answer 4

partial eversion occurs in puberty exposing to the different pH of the vagina leading to squamous metaplasia which has a risk for cancerous change

Question 5

what is the lymphatic drainage of the vagina/uterus

Answer 5

obturator and internal/external iliac nodes to common ilial and paraaortic

Question 6

what is a cervical ectropion

Answer 6

erosion of the cervix revealing columnar epithelium, particularly common in younger people taking the pill/that are pregnant

Question 7

what are the symptoms of a cervial ectropion

Answer 7

post-coital bleeding

vaginal discharge

Question 8

how do you manage cervical ectropion

Answer 8

smear to exclude cancer

cryotherapy is curative

Question 9

what is acute cervicitis and what are the clinical features

Answer 9

rare, complication of STIs, ulceration and infection with severe prolapse

Question 10

what is chronic cervicitis and how do you treat it

Answer 10

most common form of vaginal discharge, usually from an ectropion, treat as an ectropion

Question 11

what is a cervical polyp

Answer 11

benign tumours of endocervical epithelium

Question 12

what is the most common age group for cervical polyps

Answer 12

> 40

Question 13

what are symptoms of cervical polyps

Answer 13

post coital bleeding

vaginal discharge

Question 14

how do you manage cervical polyps

Answer 14

smaller ones may be excised but any bleeding/large lesions may need to be investigated for cancer

Question 15

what are nabothian follicles

Answer 15

squamous epitheloum growth over the columnar secretory epithelium, secretions get trapped under the epithelium forming cyst like structures - appearing like opaque like swelling on the ectocervix

Question 16

what is cervical intraepithelial neoplasia

Answer 16

the presence of abnormal cells in the squamous epithelium

Question 17

how are CIN cells described

Answer 17

dyskaryotic due to increased nuclear:cytoplasm ratio

Question 18

what is the grading of CIN and how does that relate to the chance of cancerous progression in 5-15 years

Answer 18

CIN 1 = mild (abnormal cells only found in lower 1/3 of epithelium 20% chance of progressing to cervical cancer in 5-15 years

CIN 2 = moderate (abnormal cells in lower 2/3 of epithelium) 50% chance in 5-15 years

CIN 3 = full thickness atypical presentation
80% chance of progression in 5-15 years

Question 19

What are the peak ages for CIN

Answer 19

25-29

95% are <49

Question 20

what is the aetiology of CIN

Answer 20

HPV
sexual contact at an early age 
smoking
OCP
immunocompromisation

Question 21

what is the pathology of HPV in the context of CIN

Answer 21

Transformational zone metaplasia is interrupted by viral DNA incorporating itself into the cellular DNA, inactivating key tumour suppressor genes which pushes the cell into mitosis

Due to increased cellular turnover, mutations can accumulate

Viruses can also cause changes to avoid the immune system which is why immunocompromised patients are at risk

Question 22

how do you diagnose CIN

Answer 22

CIN is asymptomatic so smears are the only way to catch it

Question 23

what is the cervical smear screening regime

Answer 23

25-49 every 3 years
49-65 every 5 years
<25 not done
>65 only done if theyve had previous abnormal smears. or if theyre only been screened from 50

Question 24

what is the role of colposcopy in cervical smears

Answer 24

normal/ borderline hpv -ve smears are not followed up
HPV +ve borderlines are followed up
moderate+ are followed up

Question 25

how do you treat CIN

Answer 25

CIN2/3 = large loop excision of transformation zone via diathermy

Question 26

what are the complications of CIN treatment

Answer 26

they're rare haemorrhage preterm delivery in the future

Question 27

what are the peak ages of cervical cancer

Answer 27

30s and 80s

Question 28

what kind of cancer are cervical cancers usually

Answer 28

squamous cell carcinoma 90-95% 5-10% are adenocarcinomas originating from the columnar epithelium

Question 29

what are clinical features of cervical cancers

Answer 29

``` post-coital discharge offensive vaginal discharge intermenstrual bleeding post-menopausal bleeding pain (late) uraemia (late) rectal bleeding (late) ulcer/mass visible to naked eye (late) ```

Question 30

how does cervical cancer spread

Answer 30

``` locally to parametrium and vaginal wall lymphatic spread is early rarely there is ovarian spread blood-bourne spread is late staging is clinical ```

Question 31

how do you stage cervical cancer

Answer 31

1a(i) + 1a(ii) are microscopic and differ by invasion lateral spread 1b(i) - clinically visible <4cm 1b(ii) = clinically visible >4cm stage 2 = vaginal invasion but not pelvic side wall 2a (i) = <4cm with involvement of upper 2/3 of vagina 2a(ii) = >4cm 2b = invasion of parametrium stage 3 = lower vaginal/pelvic side wall invasion stage 4 = invasion of bladder or rectal mucosa, beyond true pelvis

Question 32

how do you investigate suspected cervical cancer

Answer 32

biopsy Vaginal and rectal examination is done under GA to determine local spread Cystoscopy detects bladder involvement MRI detects local spread and lymph node involvement

Question 33

how do you treat cervical cancer

Answer 33

stage 1a(i) - cone biopsy as lymph node spread risk is very low (0.5%) 1a(ii)-2a - chemoradiotherapy or radical abdominal hysterectomy 2b+ - chemoradiotherapy with platinum agents, paliation for bone pain/haemorrhage done via radiotherapy

Question 34

what are the complications for radical abdominal hysterectomy

Answer 34

Haemorrhage Fistula Ureteric and bladder damage Voiding problems Lymph accumulation

Question 35

what is involved in a radical abdominal hysterectomy for cervical cancer

Answer 35

pelvic node clearance, hysterectomy , removal of parametrium and upper 1/3 of the vagina ovaries are left in young women to prevent menopause

Question 36

what is a radical trachelectomy

Answer 36

Conserves fertility Laparoscopic pelvic lymphadenectomy first performed and biopsies are done, chemo-radiotherapy is performed if the biopsy is +ve 80% of cervix and upper vagina is removed, with cervical sutures put in place to prevent an increased risk of preterm delivery

Question 37

what is the review programme for cervical cancer

Answer 37

3 months, 6 months and the every 6 months for 5 years

Question 38

what are poor prognostic indicators for cervical cancer

Answer 38

``` lymph involvement advanced clinical stage large primary tumour poor differentiation early recurrence ```

Question 39

what does death usually occur from in cervical cancer

Answer 39

uraemia due to ureteric obstruction