The cervix and its disorders

Question 1

What cells line the endo- and exo-cervix? Where do they meet?

Answer 1

Endocervix = columnar
Exocervix = squamous
Meet at the squamocolumnar junction.

Question 2

What causes the transformation zone?

Answer 2

The lower pH of the vagina - causes the columnar epithelium to undergo metaplasia to squamous epithelium. This is at the squamocolumnar junction.

Question 3

What is cervical ectropion?

Answer 3

When columnar cells of the endocervix are visible as a red area around the os on the surface of the cervix.

Question 4

What causes cervical ectropion?

Answer 4

Eversion.

Normal in younger women, particularly those who are pregnant or taking the pill.

Question 5

What are possible symptoms of cervical ectropion?

Answer 5

Post-coital bleeding, vaginal discharge.

Question 6

How is cervical ectropion treated and what must you do first?

Answer 6

Treated with cryotherapy (no anaesthetic) after a smear test (and colposcopy if possible) to exclude cervical carcinoma.

Question 7

What can cause acute cervicitis?

Answer 7

STI, severe prolapse when it protrudes or held back with a pessary.

Question 8

What is the most common cause of chronic cervicitis?

Answer 8

Chronic infection or inflammation, often of an ectropion. This can also cause inflammatory smears.

Question 9

What is the treatment for chronic cervicitis?

Answer 9

Cryotherapy +/- antibiotics

Question 10

Who are cervical polyps most common in?

Answer 10

Over 40 years old

Question 11

What are the most common symptoms of cervical polyps?

Answer 11

Inter-menstrual bleeding, post-coital bleeding. They can be asymptomatic.

Question 12

What is the treatment for cervical polyps?

Answer 12

Avulsion. Sent to histology.

Question 13

What are nabothian follicles?

Answer 13

These are when squamous epithelium has formed by metaplasia over the endocervical cells. Columnar cell secretions are trapped and form retention cysts, which appear as white or opaque swellings on the ectocervix.

Question 14

What is cervical intraepithelial neoplasia (CIN)?

Answer 14

Pre-malignant condition of the cervix with atypical dyskaryotic cells with larger nuclei and frequent mitoses.

Question 15

What are the differences between CIN 1-3?

Answer 15

CIN1 = mild dysplasia (atypical cells only in the lower 1/3 epithelium)
CIN2 = moderate dysplasia
CIN3 = severe dysplasia
If untreated, 1/3 women with CIN2 or 3 will develop cervical cancer in the next 10 years.
CIN1 can progress but commonly regresses spontaneously.

Question 16

What virus can cause CIN/cervical cancer?

Answer 16

HPV (strains 16, 18, 31, 33 being most frequently associated)

Question 17

What are the risk factors for CIN/cervical cancer?

Answer 17

Smoking
Oral contraceptive pill
HPV - sexual intercourse
Steroids/HIV (immunosuppression)

Question 18

What is the pathology of HPV cervical cancer?

Answer 18

As columnar epithelium undergoes metaplastic change to squamous cells in the transformation zone, HPV is taken up into cells. This virus suppresses certain tumour suppressor gene products, pushing the cell into the cell cycle.

Question 19

What is the screening for cervical cancer?

Answer 19

Smear tests.

CIN is not symptomatic and it is the predisposing factor to cervical cancer so needs to be screened for.

Question 20

What age and how often is cervical screening?

Answer 20

From age 25 and above (or first sexual intercourse if later) and every 3 years until 49, then every 5 years.

Question 21

Why is cervical screening started at a certain age?

Answer 21

Because under 25, women have abnormal cervical changes and risk is very low. It saves excessive referrals to colposcopy clinics.

Question 22

What is tested for if a smear comes back abnormal?

Answer 22

Presence of high risk HPV. If there is not HPV and it is low-grade, they are entered back into the national screening and not seen more regularly.

Question 23

What is colposcopy?

Answer 23

Speculum and microscope used to visualise the cervix. CIN is looked for after cervix has been stained with 5% acetic acid. Biopsy taken.

Question 24

Treatment of CIN II or III?

Answer 24

Transformation zone is excised with cutting diathermy under local anaesthetic (loop excision).

Question 25

What are the 2 types of cervical cancer?

Answer 25

Squamous carcinoma (HPV) 
Adenocarcinoma (rarer but harder to treat)

Question 26

Is cervical cancer familial?

Answer 26

No

Question 27

What are the symptoms of cervical carcinoma and what is seen on examination?

Answer 27

Symptoms: post-coital bleeding, IMB, offensive discharge. Later stages can cause uraemia, haematuria, rectal bleeding/pain.
Examination: early stages appears normal. Can progress to a visible or palpable mass on cervix.

Question 28

Staging of cervical carcinoma

Answer 28

Stage 1 - cervix
Stage 2 - Invasion into vagina, not pelvic side wall
Stage 3 - Invasion into lower vagina or pelvic wall, or causing urinary obstruction.
Stage 4 - Invasion of bladder or rectal mucosa, or beyond the true pelvis

Question 29

Treatments for cervical carcinoma

Answer 29

1. Cone biopsy (younger) or simple hysterectomy (older)
2. Laparoscopic lymphadenectomy and radical trachelectomy (removal of 80% cervix and the upper vagina)
3. Radical hysterectomy or chemo-radiotherapy
4. chemo-radiotherapy alone

Question 30

What is a side effect of previous cone biopsy and trachelectomy in pregnancy?

Answer 30

Premature labour

Question 31

Overall survival rate for cervical cancer?

Answer 31

65% 5 year survival