benign n pre malignant diseases of cx

Benign diseases of the cervix are common and are unusually asymptomatic or cause minor symptoms but must be differentiated from malignancy.

Cervical cancer is the second commonest cancer in women. It is proceeded by a premalignant form years before its invasion.

Screening for premalignant disease of the cervix markedly reduces the deaths from cervical cancer.

Transformational zone: The area of cervix between the old

and new squamo-columnar junction. It is the area of risk of developing

premalignant and malignant disease of the cervix.

1) Cervical ectopy (erosion)2) Cervical eversion (ectropion)3) Cervical tears4) Cervical cyst5) Endocervical polyp.6) Inflammatory conditions of cervix

CLINICAL FEATURESSymptoms-Vaginal discharge -Contact bleeding-Associated cervicitis may

produce backache, pelvic pain

Signsp/s bright red area extending

beyond external os.Neither tender nor bleeds on

touch.Outer edge clearly

demarcatedThe feel is soft, granular and

gives rise to grating sensation

aetiology

DIAGNOSISIt can be confused with-ectropion-early carcinoma (indurated, friable and bleeds to

touch)-primary chancre (ulcer has a punched out

appearance.-tubercular ulcer (indurated with caseation at base) MANAGEMENTAll cases should be subjected to cytological

examination to exclude dysplasia and malignancyIn symptomatic cases-Pill should be stopped and barrier method is

advised.-persistent ectopy with troublesome discharge thermal cautrisation cryosurgery laser vaporisation

In chronic cervicitis there is marked thickening of cervical mucosa with underlying tissue edema. These thickened tissue tend to push out through the ex. Os along direction of least resistance.

More marked if cx already lacerated As a result lips of cx curl upwards and

outwards exposing red looking endocervix

It frequently occurs during vaginal delivery.

One or both sides of cx may be torn, or it may b irregular (stellate) type

If these is no infection the torn surfaces approximate and heal leaving a notch if infection persists it causes eversion.

Non obstetric causes include lacerations due to operative procedures of DNC

Postmenopausal atrophy or chronic cervicitis also predisposes to tear.

These include1. Nabothian cyst2. Endometriotic cyst3. Mesonephric cyst

Endocervical glands in the transformational zone become covered with squamous cells and forms mucus filled cysts.

As this benign process continues, smooth, clear or yellow glandular elevations are visible during routine examination

Nabothian cyst warrants no further therapy..

ENDOMETRIOTIC CYST

Situated in portio vaginalis part of cx.

It is small reddish and <1cm dia.

Implantaion of endometrium due to surgery or during labour occurs giving rise to cyst

Symptoms-PCB, intermenstrual

bleeding-DysmenorrhoeaTreatmentDestruction by

cauterisationRarely excision

MESONEPHRIC CYST

Usually situated in outer side of cervical stroma

Seldom increase 2.5cm.Lined by cuboidal

epithelium. They are

asymptomatic .Warrants no further

treatment

It is one of the most common neoplasms It is a hyperplastic projection of the endocervical

folds. These lesions are commonly found and may be

associated with leukorrhea and post coital spotting

If it has a slender stalk it is removed my continuous twisting using a ring forceps. Twisting leads to occlusion of supporting vessels and avulsion of mass

A thick pedicled polyp needs surgical excision Excised cervical polyps require pathologic

evaluation to rule out malignancy

ACUTE CERVICITISUsually follows child birth,

abortion or any operative procedure on cervix.

Responsible organisms aregonococcal, chlamydia, thrichomonal vaginosis, mycoplasma and HPV.

Clinical features-Painful vaginal examination-Tender, Oedematous and

congested cx-Muco purulent discharge seen

at osPrognosis-Resolve completely.-infection spreads to adjacent

structures.-becomes chronicTreatment -high vaginal endocervical swab

to be taken for bacteriological examination

-treat with appropriate antibiotics.

CHRONIC CERVICITISFollows attack of acute cervicitisEndocervix ia a potential

reservoir of infection with N. gonorrhoeae, chlamydia, HPV, bacterial vaginosis.

Clinical features-asymptomatic-excessive mucoid discharge

might be present-h/o contact bleeding might be

thereOn examination-Cx is tenderOn p/s mucopurulent discharge

escaping ex. OsTreatment1) No role of antimicrobial

therapy except in gonococcal2) Diseased tissue destroyed by

electo or diathermy cauterisation or laser cryosurgery.

Cervicalcancer

Normal cervix

DNA virus. Over 100 different types and subtypes of this

virus. Common infection effecting epithelial surface. Genital HPV is divided into Low risk type (HPV 6,11) cause genital warts. High risk types (HPV 16, 18, 31, 33, 45, 56). HPV is a common infection while cervical

cancer is a rare disease.

Factors that increase risk of transmission:

Smoking. Increasing parity. Early age of intercourse. Oral contraceptive pills. Immunity.

Metaplasia: change of epithelium from one cell lining (columnar) to another (squamous).

Dysplasia: abnormal epithelial cells that fail to maturate. (hyperchromasia, larger, variable size, mitosis).

It may be mild, moderate or severe

CIN1 Normal

CIN 1(condyloma

)

CIN 1(mild

dysplasia)

CIN 2 (moderate dysplasia)

CIN 3(severe dysplasia/CIS) Invasive cancer

Histology of squamous cervical epithelium1

Low grade squamous intraepithelial lesion (LSIL); HPV infection, CIN I.

High grade squamous intraepithelial lesion (HSIL); CIN II, CIN III.

Squamous cell Glandular cell

Atypical squamous cell (ASC) Atypical glandular cells (AGC) Endocervical, endometrial, or not otherwise specified

ACS of undetermined significance(ASCUS)

Atypical glandular cells, favour neoplastic or not otherwise specified

ACSH cannot exclude HSIL

Low grade sq. intraepithelial lesion(LSIL)

Endocervical adenocarcinoma in situ

adenocarcinomaH SIL

Sq cell carcinoma

Outcome of CIN Spontaneous regression. Progression to invasive cancer. Progression from one stage to another

takes years. Detection and treatment of CIN

prevents cancer cervix.

Screening for dyskariosis by obtaining cervical cytology.

Cervical screening should be carried out every 3-5 years in all sexually active women from 20-60 years of age.

There is a 10-15 % chance of false positive or false negative results.

Smear Risk of having HSIL

Management If next smear is negative

Normal 0.1% Repeat in 3-5 years

Routine

Inflammatory <6% Repeat in 3-5 years

Routine

Borderline 20-30% Repeat 6 months Repeat 1 year then 2 then routine.Colposcopy if 3 borderline.

Mild dyskaryosis 30-50% Repeat in 3 monthsOr refer for colposcopy

Repeat 1 year then 2 then routine.Colposcopy if 3 borderline.

moderate dyskaryosis

50-70% Colposcopy Repeat after treatment

Severe dyskaryosis

80-90% Colposcopy Repeat after treatment

Invasion suspected

50% invasion

Urgent colposcopy

Is the inspection of the cervix with a low powered microscope.

Magnifies the cervix 4-20 times. The patient is put in lithotomy position. Passing a bivalve speculum gently into

the vagina.

Inspection of the cervix and its vasculature. Green filter may help studying vasculature. Abnormal vascular structure includes

punctuation and mosaicism. Acetic acid test: application of 3% acetic

acid stained the abnormal area. The degree of staining correlates with severity of the lesion.

Schiller test: application of Lugol’s iodine stains the normal cervix brown.

Colposcopy gives a clinical diagnosis. Punch biopsy from the abnormal area gives

a histopathological diagnosis.

CIN II,CIN III. ?CIN I.Techniques for treatment:Excisional: LEEP (loop electrosurgical

excision procedure) CO2 laser cone, knife cone, hysterectomy.

Ablative: radical electrodiathermy, cold coagulation, cryocautery, laser.

90-95% cure rate

Less common than squamous intraepithelial neoplsia.

Has same risk factors. Can not be reliably screened by colposcopy. Does not have particular colposcopic

features. Divided into high grade and low grade. Characterized by skip lesions. Treatment by large cone biopsy.

The first vaccine that intends to prevent cancer.

2 forms of vaccine are available Bivalent 16, 18 (cervarix) Quadrevalent 6, 11, 16, 18.(gardasil) Now licensed in a number of countries.

Benign diseases of cervix are harmless but malignancy should be excluded.

Cervical intraepithelial neoplasia proceedes cancer cervix by years. (CIN 1 to CIN 3 twenty years)

Screening for CIN reduces mortality from cancer cervix.

Those with positive screening test should be referred to colposcopy for diagnosis and treatment.