Pathology of the Cervix, Vagina & Vulva

Question 1

What type of epithelium lines the ectocervix? [1]

Answer 1

non-keratinising stratified squamous epithelium

Question 2

What type of epithelium lines the endocervix? [1]

Answer 2

columnar (glandular) epithelium

Question 3

Describe the changes in the cervix after puberty [2]

Answer 3

1. with the growth of the cervix, the squamo-columnar junction is everted into the vagina
2. the squamous epithelium adapts to the vaginal environment by squamous metaplasia in the transformation zone

Question 4

What happens to the pubertal changes of the cervix at menopause? [1]

Answer 4

they get reversed

Question 5

Where do most cervical neoplasia develop?

Answer 5

transformation zone

(zone of unstable differentiation)

Question 6

Describe the process and role of cervical cytological screening? [2]

Answer 6

1. samples cells from the cervical transformation zone using a speculum 5/6 times turn clockwise in cervix
2. used to detect changes associated with HPV infection and cervical intraepithelial neoplasia

Question 7

What is dyskaryosis and what is it suggestive of? [2]

Answer 7

1. dyskaryosis = nuclear abnormalities
2. suggestive of cervical intraepithelial neoplasia (CIN) and prompts referral to colposcopy clinical for biopsy

Question 8

Describe the age ranges for cervical screening [2]

Answer 8

1. women aged 25-50 every 3 years
2. women aged 50-65 every 5 years

Question 9

What are the 4 steps involved in colposcope examination? [4]

Answer 9

1. cervix visualised
2. washed with acetic acid
3. iodine is applied + green light filter
4. abnormal area can be biopsed or treatment given at the time or at a further appointment

Question 10

List the 5 colposcopic features of micro-invasive lesions of the cervix [5]

Answer 10

1. densely staining acetowhite lesion & often large volume lesions
2. atypical vessels, suspicious of invasion
3. “Pollarded” vessels → thick calibre with no visible branching on the surface
4. poor iodine uptake
5. may bleed easily

Question 11

What are the prevalent strains of HPV in Scotland? [4]

Answer 11

1. HPV 16 + 18 = cervical cancer
2. HPV 6 + 11 = genital warts

Question 12

Describe the 2 types of HPV genes and their actions [5]

Answer 12

1. early genes E1-E7
   
   • interact with intracellular molecules to interfere with cell proliferation machinery to replicate the virus
2. late genes L1+L2
   
   • encode capsid proteins
   • disruption of cell cycle checkpoints may contribute to accumulation of oncogenic mutations and carcinogenesis

Question 13

What are the symptoms of cervical cancer? [5]

Answer 13

1. post-coital bleeding
   
   • bleeding from vagina after sex
2. intermenstrual bleeding
3. irregular vaginal bleeding
4. pain
5. can be asymptomatic

Question 14

Describe the relation between CIN and development of cancer [2]

Answer 14

1. invasive squamous carcinoma of the cervix almost always develops from a pre-existing CIN, but not all CIN will be squamous cancer
2. CIN II and CIN III are more likely to progress than CIN I

Question 15

Atrophic Vaginitis

1. Cause? [1]
2. Signs & Symptoms? [5]

Answer 15

1. caused by low oestrogen after menopause (not cancer)
2. signs & symptoms:
   
   • discomfort
   • dyspareunia (painful sex)
   • bleeding
   • polyps
   • cysts

Question 16

What cancers can develop in the vagina? [3]

Answer 16

1. VAIN (vaginal intraepithelial neoplasia)
2. squamous carcinoma
3. primary cancers of cervix or vulva can also involve the vagina

Question 17

List 5 infections that can develop in the vagina [5]

Answer 17

1. yeast (candida, thrush)
2. bacterial vaginosis
3. C. trichomonas vaginalis
4. actinomyces
5. herpes simplex

Question 18

Name 5 skin conditions that can affect the vulva [5]

Answer 18

1. inflammatory dermatoses and skin tumours occurring at other sites may also occur in the vulva
2. skin tags
3. melanocytic nevi
4. benign cysts

Question 19

What can candidiasis (thrush) in the vulva be associated with? [2]

Answer 19

1. pregnancy
2. diabetes

Question 20

How can Bartholin’s vestibular gland cysts get infected? [1]

Answer 20

1. they may become infected with abscess formation

Question 21

Name 2 non-infective inflammatory conditions that can develop in the vulva and name which one is associated with anogenital skin in females and vulval squamous carcinoma [3]

Answer 21

1. Lichen planus
2. Lichen sclerosus
   
   • associated with anogenital skin in females (genital warts) and vulval squamous carcinoma

Question 22

Describe the features of squamous cell carcinoma (SCC) associated with vulval interepithelial neoplasia (VIN) [4]

Answer 22

1. occurs in females <60yrs
2. assoicated with high incidence of lower genital tract neoplasia, particularly
   
   • CIN
   • invasive cervical cancer
3. usually related to high risk type HPV 16/18
4. warty or basaloid cancers

Question 23

Describe the features of SCC associated with Dermatoses [4]

Answer 23

1. occurs in females >60yrs
2. most of the cancer is well-differentiated and keratinising
3. not associated with HPV infection or VIN
4. adjacent squamous hyperplasia and/or lichen sclerosis is common