The Cervix in Health and Disease Flashcards
Function of the Cervix
- Its function is as a consequence of where it is (junction between the uterus and Vagina)
- Neck of womb
Embryology of Cervix
- …-… weeks - during embryogenesis
- … epithelium involutes to form 2 sets of tubes:
- Wollfian duct - … duct
- Müllerian duct - … duct
- In Women - Müllerian duct fuse in midline to form uterus, cervix, vagina, cranial end of fallopian tubes
- 6-8 weeks - during embryogenesis
-
Coelomic epithelium involutes to form 2 sets of tubes:
- Wollfian duct - mesopnephric duct
- Müllerian duct - paramesonephric duct
- In Women - Müllerian duct fuse in midline to form uterus, cervix, vagina, cranial end of fallopian tubes
What is visible here?
- Uterus specimen - looking from behind
- above - cervix
- Ovaries on either side
- fallopian tubues on top of each ovary
Congenital abnormalities of cervix: Agenesis and Dysgenesis
- Diagram A = ?
- Diagram B = ?
- Diagram C = ?
- Diagram D = ?
- Diagram A = Cervical - complete agensis (no cervix)
- Diagram B = Uterus and cervix formed, no connection with vagina
- Diagram C = Cervical dysgenesis
- Diagram D = Cervical dysgenesis
What is Cervical Agenesis?
Cervical agenesis is a congenital disorder of the female genital system that manifests itself in the absence of a cervix, the connecting structure between the uterus and vagina.
What is Cervical Dysgenesis?
Milder forms of the condition Cervical Agenesis, in which the cervix is present but deformed and nonfunctional, are known as cervical atresia or cervical dysgenesis.
Anatomy of the Cervix
- The cervix consists of 2 regions: the Endocervical Canal and the Ectocervix
- The Ectocervix is the portion of the cervix that projects into the …
- The … Os marks the transition between the ectocervix and endocervical canal
- The Endocervical canal is the more ‘…’ part of the cervix.
- The endocervical canal ends, and the uterine cavity begins, at a narrowing called the … Os.
- Where the Columnar epithelium of endocervical canal meets the Ectocervix (stratified squamous epithelium) = … junction (SCJ)
- The cervix consists of 2 regions: the Endocervical Canal and the Ectocervix
- The Ectocervix is the portion of the cervix that projects into the vagina
- The External Os marks the transition between the ectocervix and endocervical canal
- The Endocervical canal is the more ‘inner’ part of the cervix.
- The endocervical canal ends, and the uterine cavity begins, at a narrowing called the Internal Os.
- Where the Columnar epithelium of endocervical canal meets the Ectocervix (stratified squamous epithelium) = Squamocolumnar junction (SCJ)
The cervix consists of 2 regions: the … and the …
The cervix consists of 2 regions: the Endocervical Canal and the Ectocervix
Nulliparous women are…
Nulliparous is the medical term for a woman who has never given birth either by choice or for any other reason.
Parous women are…
Women who have given birth one or more times.
The appearance of the cervix varies widely with 1) …, 2) … …, 3) ….
The appearance of the cervix varies widely with age, hormonal state and parity
Appearance of the Cervix - Nulliparous vs Parous women
- In the nulliparous female it is … shaped with a small … external os at the center of the cervix
- In parous women, cervix is … and the external os becomes …-like
- In the nulliparous female it is barrel shaped with a small circular external os at the center of the cervix
- In parous women, cervix is bulky and the external os becomes slit-like
Histology of the Normal Cervix
- The … is covered by non-keratinizing, stratified squamous epithelium. either native or metaplastic in continuity with the vaginal epithelium.
- The squamous epithelium is composed by multiple layers: basal, parabasal, intermediate and superficial layer.
- The … is lined by a simple columnar epithelium that secretes mucus
- Mucinous columnar epithelium lines the surface and the underlying glands.
- The ectocervix is covered by non-keratinizing, stratified squamous epithelium. either native or metaplastic in continuity with the vaginal epithelium.
- The squamous epithelium is composed by multiple layers: basal, parabasal, intermediate and superficial layer.
- The endocervix is lined by a simple columnar epithelium that secretes mucus
- Mucinous columnar epithelium lines the surface and the underlying glands.
Histology of the Normal Cervix - Endocervix
- The endocervix is lined by a simple … epithelium that secretes …
- The endocervix is lined by a simple columnar epithelium that secretes mucus
- Mucinous columnar epithelium lines the surface and the underlying glands.
Histology of the Normal Cervix - Ectocervix
- The Ectocervix is covered by non-keratinizing, … … epithelium. either native or metaplastic in continuity with the vaginal epithelium.
- The Ectocervix is covered by non-keratinizing, stratified squamous epithelium, either native or metaplastic in continuity with the vaginal epithelium.
- The squamous epithelium is composed by multiple layers: basal, parabasal, intermediate and superficial layer.
Ectocervix - The squamous epithelium is composed by multiple layers: …, …, … and superficial layer.
The squamous epithelium is composed by multiple layers: basal, parabasal, intermediate and superficial layer.
Endocervix - … columnar epithelium lines the surface and the underlying glands
Endocervix - Mucinious columnar epithelium lines the surface and the underlying glands
The Transformation Zone
- Red lining - represents … epithelium
- Pink lining - represents … epithelium
- Transformation Zone - Area where … meets … - area of actively dividing cells which undergo continuous …
- Area more prone to … infection
- Red lining - represents columnar epithelium
- Pink lining - represents squamous epithelium
- Transformation Zone - Area where columnar meets squamous - area of actively dividing cells which undergo continuous metaplasia - columnar to squamous as columnar undergoes metaplastic change when exposed to acidic pH
- Area more prone to HPV infection
The Transformation Zone - After the Menopause
- Arrow below the red area represents … which has receeded upwards into the canal
- The white represents … which is located in the … rather than the …
- What causes this?
- Arrow below the red area represents the SCJ - receeds upwards into canal
- White represents Transformation zone located in the endocervical canal rather than on the ectocervix
- Why? - After menopause - relative deficiency in oestrogen
- Patients with abnormal smear test in menopause - can be harder to access for any precancerous changes
What happens to the transformation zone after menopause?
Recedes upwards into the endocervical canal (all squamous, no columnar visible)
The stroma of the cervix
- Made up of:
- Mostly … connective tissue
- Approx …% smooth muscle fibres
- Made up of:
- Mostly Collagenous connective tissue
- Approx 15% smooth muscle fibres
Blood Supply of the Cervix
- …. artery, (arises from the internal iliac artery), … branch
- (This artery is only found in females)
- Venous drainage follows the arteries
-
Uterine artery, (arises from the internal iliac artery), descending branch
- (This artery is only found in females, supplying the uterus and other parts of the female reproductive system. Developmentally, the uterine artery is thought to be a female equivalent to the artery to ductus deferens in the male.)
- Venous drainage follows the arteries
Lymphatic drainage of the Cervix
- Lymph nodes in … (on either side of cervix), Drainage follows from … to obturator, internal …, external …, common … towards aorta
- Lymph nodes in Parametrium (on either side of cervix), Drainage follows from parametrium to obturator, internal iliacs, external iliacs, common iliacs towards aorta
Nerve Supply to the Cervix
- Pain fibres with the … to S2, S3, S4 (uterine to T11 and T12 in addition)
- Pain fibres with the parasympathetics to S2, S3, S4 (uterine to T11 and T12 in addition)
Nerve Supply to the Cervix
- Pain fibres with the parasympathetics to …,…,… (uterine to T11 and T12 in addition)
- Pain fibres with the parasympathetics to S2, S3, S4 (uterine to T11 and T12 in addition)
Functions of the Cervix
- Produces … to facilitate sperm …
- Acts as a … to ascending …
- Holds a developing … in place
- … and … to enable vaginal birth
- Produces mucus to facilitate sperm migration
- Acts as a barrier to ascending infection
- Holds a developing pregnancy in place
- Effaces (stretch and thin) and dilates to enable vaginal birth
Examination of the Cervix
- What do we use?
A speculum is a device used to look inside in the vagina and observe the cervix.
The Cervical Mucous
Cervical mucus is fluid or gel-like discharge from the cervix. Throughout a woman’s menstrual cycle, the thickness and amount of cervical mucus changes. This is because of hormone levels fluctuating throughout your cycle. Hormones stimulate glands in the cervix to produce mucus.
Physiological Changes in Pregnancy (Cervix)
- …, but not as much as the uterus
- Becomes ….
- Increased …/venous congestion, “purple tinge”
- Glands distended with …, “… plug”
- Prominent …
- Remains … until the onset of labour
- Hypertrophies, but not as much as the uterus
- Becomes softer
- Increased vascularity/venous congestion, “purple tinge”
- Glands distended with mucus, “mucus plug”
- Prominent ectropion
- Remains elongated until the onset of labour
The Cervix in pregnancy
- What is happening at each stage?
- Prelabour
- Effacement (thin and stretch)
- Dilatation
Physiological changes on cervix - Oestrogen
- The presence of glandular columnar cells on the ectocervix is known as Cervical … or “E…”
- effect of oestrogen
- Thinning, drying and inflammation of the vaginal walls is known as A… “C…”
- lack of oestrogen
- The presence of glandular columnar cells on the ectocervix is known as Cervical Ectopy “Erosion”
- effect of oestrogen
- Thinning, drying and inflammation of the vaginal walls is known as Atrophic “Cervicitis”
- lack of oestrogen
What is Atrophic “cervicitis”? (atrophic vaginitis)
is thinning, drying and inflammation of the vaginal walls that may occur when your body has less oestrogen.
What is Cervical Ectopy? (Erosion)
A cervical ectopy happens when the inner lining of the cervical canal (columnar cells) comes out onto the outer surface of the cervix. It can be seen during a speculum examination and appears red and velvet like. This is because the columnar cells are much thinner than squamous cells and the underlying blood vessels show through more easily.
Cervical infections (4)
- Chlamydia
- Gonorrhoea
- Trichomonas Vaginalis
- HPV
Gonorrhoea
Gonorrhoea is a sexually transmitted infection (STI) caused by Neisseria gonorrhoeae.
Chlamydia
What causes chlamydia? Chlamydia is an infection with Chlamydia trachomatis bacteria. When an infection is present, the bacteria can be present in the cervix
HPV - Human papillomavirus
- HPV is the name of a very common group of viruses. They do not cause any problems in most people, but some types can cause genital warts or cancer.
Causes of Pre-cancer and Cervix cancer
-
H…
- … factors:
- S…
- … … partners
- … compromise
- Low ..-.. status
- … factors:
-
HPV
-
Predisposing factors
- Smoking
- Multiple sexual partners
- Immune compromise
- Low socio-economic status
-
Predisposing factors
HPV infection
- HPV is a … … infection which is easily transmitted through close sexual contact
- Acquisition can occur via …. contact in the genital area
- Up to ….% of sexually active women will be infected with HPV at some point in their lives
- … reduce the risk of infection but are not fully protective
- HPV is a very common infection which is easily transmitted through close sexual contact
- Acquisition can occur via skin to skin contact in the genital area
- Up to 95% of sexually active women will be infected with HPV at some point in their lives
- Condoms reduce the risk of infection but are not fully protective
HPV infection
- The number of … cancers in women is rising of which an increasing proportion are HPV related
- Male partners of women with cervix cancer have higher rates of … and … cancer
- … cancer rates are higher in women with CIN and their male partners
- The number of oropharyngeal cancers in women is rising of which an increasing proportion are HPV related
- Male partners of women with cervix cancer have higher rates of tongue and tonsil cancer
- Anal cancer rates are higher in women with CIN and their male partners
HPV infection
- HPV infection cannot cause problems as long as it sits outside cell and immunity to virus is present
- has to gain entry into cell to change it
Diagram of … infection
HPV infection
- Mild - Cin 1 (lowest 1/3 of the squamous epithelium of cervix that undergoes change)
- Moderate - Cin 2 (2/3 thickness)
- Higher grade - Cin 3 (full thickness)
- Highest grade - Cin 4 (basement membrane breached - cervical cancer)
Cervical Intraepithelial Neoplasia
- Cervical intraepithelial neoplasia (CIN) is a … condition in which … cells grow on the surface of the cervix.
- CIN-1 (low-grade) involves the lower … or less of the epithelium, whereas the more significant CIN-2 and CIN-3 (high-grade) progress to include the … … of the epithelium.
- Dysplasia becomes cancer when it invades the …
- Cervical intraepithelial neoplasia (CIN) is a precancerous condition in which abnormal cells grow on the surface of the cervix.
- CIN-1 (low-grade) involves the lower 1/3 or less of the epithelium, whereas the more significant CIN-2 and CIN-3 (high-grade) progress to include the entire thickness of the epithelium.
- Dysplasia becomes cancer when it invades the basement membrane.
Low-grade neoplasia (CIN 1) refers to dysplasia that involves about … … of the thickness of the epithelium
Low-grade neoplasia (CIN 1) refers to dysplasia that involves about one-third of the thickness of the epithelium
CIN 2 refers to abnormal changes in about … to … of the epithelial layer.
CIN 2 refers to abnormal changes in about one-third to two-thirds of the epithelial layer.
CIN 3 (the most severe form) describes a condition that affects more than … of the epithelium.
CIN 3 (the most severe form) describes a condition that affects more than two-thirds of the epithelium.
Cervical intraepithelial neoplasia (CIN) - another name is cervical …
cervical dysplasia
Investigate Precancer and Cancer - Cervix
- Cytology (known as … test)
- Colposcopy (m..)
- Histology (b…)
- Cytology (smear test)
- Colposcopy (magnification)
- Histology (biopsy)
Cytology: The NHSCSP (The National Health Service Cervical Screening Programme)
- Women are invited for cervical smears (… triage)
- 25 - 49yrs … yearly
- 50 – 65yrs … yearly
- Referred for c… if cytological abnormalities
- Women are invited for cervical smears (HPV triage)
- 25 - 49yrs 3 yearly
- 50 – 65yrs 5 yearly
- Referred for colposcopy if cytological abnormalities
Different methods of performing…
smear tests (left = old method)
George Papanicolaou
- What was named after him?
‘PAP’ smear (Cervical smear)
Normal cytology findings
- minimum number of endocervical cells, squamous cells and metaplastic cells to be assessed - if minimum number normal - adequate and normal smear test result
Smear test slide
- … on left
- moderate … on right
Normal on left, moderate dyskaryosis on right
Hans Hinselmann invented what?
He invented colposcopy. Hans Hinselmann introduced colposcopy for early diagnosis of cervical cancer in the nineteen twenties.
What is this?
Colposcope - visualisation of cervix - magnification 8-16x - identify abnormal areas with acetic acid and iodine
Worldwide Cervical cancer is the … most common cancer amongst women
Worldwide Cervical cancer is the 2nd most common cancer amongst women
Cervix Cancer, Global incidence
Cervical Cancer
- Worldwide Cervix cancer is the … most common cancer amongst women
- …. cases each year
- >…. deaths
- …% occur in LEDC’s
- Worldwide Cervix cancer is the 2nd most common cancer amongst women
- 430,000 cases each year
- >200,000 deaths
- 80% occur in LEDC’s (low socio-economic developed countries)
Age-specific incidence of cervical cancer in screened (UK) and unscreened (Brazil) populations
Age-specific incidence
- The difference in incidence of cervical cancer between countries with routine mass screening and those with no organised screening programme is very clear. This slide shows the impact that screening has on the UK population, compared directly with the figures for Brazil, which has no national screening programme
Cervix Cancer, current treatment
- Stage 1a cone … / …
- Stage 1b radical … / radical …
- Stage >1b2 …-…therapy
- 1a cone biopsy / excision
- 1b radical hysterectomy / radical trachelectomy
- >1b2 chemo-radiotherapy
Loop excision /cone biopsy of Cervical Cancer
- used in what stage?
1a stage of cervical cancer
Cervical Cancer - Radical Trachelectomy
- What is it?
- What stage of cancer?
- Can you still have children after?
- A radical trachelectomy is an operation to remove cancer from the cervix (neck of the womb). It involves removing the cervix and the upper third of the vagina.
- Stage 1b cancer
- Yes - fertility-sparing technique
Cervical Cancer - Radical Hysterectomy
- What is it?
- What stage of cancer?
- Fertility?
- A hysterectomy is a type of surgery that remove the womb (uterus) and cervix. It aims to remove all the cervical cancer.
- Preferred option in advanced stage 1 and some early stage 2 cervical cancers (1b)
- Not fertility sparing (It is not usually possible to become pregnant or carry a pregnancy after treatment with radical hysterectomy and/or chemoradiation therapy.)
Patiens who have a tumour greater than 4cm or if it has spread (If Cervical Cancer is >1b2 stage), they are offered a combination of
chemo-radiotherapy
Jade Cerisa Lorraine Goody
- Who is she?
- Jade died of advanced cancer of the cervix
- Mother of 2
- Died aged 27yrs London UK
- 22/03/09 (Mothers Day)
The Jade Goody Effect
- 3 years after death - significant increase in request for smear test
- now only 6/10 attend for smear test - remind young patients to attend
- Home testing for HPV is rolling out gradually - currently in london
Henrietta Lacks
- Who is she?
- Cancer of the cervix
- Mother of 5
- Died 1951 aged 31yrs
- Johns Hopkins Baltimore USA
- Her cells were dividing not changing - used in research, cancer trials, vaccines and more recently in covid vaccine tests
- No consent obtained at the time - family not aware - they now have a trust to progress research
Cervix in Health and Disease - Summary
- Embryology explains the anatomy of the cervix
- Its function is as a consequence of where it is (junction between the uterus and Vagina)
- Physiological changes occur throughout life
- The Physiological changes expose it to pathological events
