Colposcopy and Cervical Intraepithelial Neoplasia(CIN)

Question 1

DEFINITIONS(CIN):

1. CIN I
2. CIN II
3. CIN III
4. Microinvasion

*33% of women with CIN II-III progress to develop cervical cancer over the next 10y if untreated

Answer 1

• presence of atypical cells within squamous epithelium

1. Mild dysplasia
   - atypical cells in lower 1/3 of epithelium
2. Moderate dysplasia
   - atypical cells in lower 2/3 of epithelium
3. Severe dysplasia
   - atypical cells in full thickness of epithelium without invasion
4. Abnormal cells penetrated the basement membrane

Question 2

EPIDEMIOLOGY:

Answer 2

• 90% CIN III in women <45y

- peak incidence: 25-29y

Question 3

AETIOLOGY AND RISK F:

Answer 3

1. Aetiology: HPV
   - 16, 18, 31, 33 most commonly associated
2. Risk f:
   - Multiple sexual partners
   - COCP
   - Smoking
   - Immunocompromised states(eg HIV and long-term steroids)

Question 4

INTERPRETATION OF CERVICAL CANCER SCREENING RESULTS:

1. Borderline/mild dyskaryosis
2. Moderate dyskaryosis
3. Severe dyskaryosis
4. Suspected invasive cancer
5. Inadequate
6. Abnormal columnar cells(suspicion of CGIN)

Answer 4

1. Test for HPV
   - If positive, refer for colposcopy(within 8w)
   - If negative, back to routine recall
2. Consistent with CIN II, refer for colposcopy(within 4w)
3. Consistent with CIN III, Refer for colposcopy(within 4w)
4. Urgent colposcopy(within 2w)
5. Repeat cervical cytology in 3/12. If 3 consecutive inadequate samples, refer for colposcopy
6. Colposcopy and endocervical curettage/cone biopsy
   - Hysteroscopy if cause of abnormal cells still unclear.

Question 5

HPV VACCINATION:

1. Targets
2. Administration
3. Adverse effects

Answer 5

1. HPV 6, 11, 16, 18
2. • Gardasil vaccine offered to girls aged 12-13y
     - Administered at school usually
     - Can receive despite going against parental wishes
     - 2 doses with 2nd dose being given 6-24 months after the first.
     - If first dose after 15y, will need 3 doses. 2nd dose at ≥1/12 after 1st dose and 3rd dose at ≥3 months after 2nd dose.
3. Injection site reactions

Question 6

CERVICAL CANCER SCREENING:

1. Who gets screening and how often?
2. Impact

Answer 6

1. a) 25-49y; every 3y
   b) 50-64y; every 5y
   * usually at around mid-cycle
2. Prevents 1000-4000 deaths/year
   * Cervical adenocarcinoma accounting for 15% cases is frequently undetected.

Question 7

COLPOSCOPY:

Answer 7

1. Microscope to view cervix
2. Stained with acetic acid
   - Abnormal areas appear white and are iodine negative.
3. Loop excision of the transformation zone(LETZ)
   - Local anaesthesia
   - 95% effective
   - Repeat smear and HPV after 6/12. If negative, routine smear in 3y
4. Complications:
   - Bleeding 1-2%
   - Infection, treated with augmentin(amoxicillin clavulanate)
   - Cervical stenosis 1-2%
   - LETZ depth >10 mm associated with increased incidence of preterm labour

Question 8

MILD ABNORMALITIES:

Answer 8

1. Minimal risk of cancer progression
2. Conservative management
   - Biopsy and annual smears for 2y
   - If abnormality persists, LETZ followed by smear and HPV 6/12 post LETZ