Aboubakr Elnashar

Benha university Hospital,

Egypt

Aboubakr Elnashar

Contents 1. Terminology & Definition

2. Causes

3. Evaluation

4. Treatment

Aboubakr Elnashar

Abnormal-looking cervix

Unhealthy looking cervix

Aboubakr Elnashar

DEFINE

It is the cervix which has one or more of the following:

1. White or red patches

2. Polyps

3. Nodular cervix with retention cyst

4. Hypertophied cervix

5. Ulcer

6. Purulent, or persistent discharge

7. Bleeding on touch or PCB (Sammour et al, 1985; Aboloyoun et al, 1990; Abdelshafy,1997; Chong, 2003;

Milingos et al, 2010; Darwish et al, 2013) Aboubakr Elnashar

Aboubakr Elnashar

Women presented with suspicious cervix during

routine pelvic examination should be referred for

appropriate diagnosis mainly to exclude underling

preinvasive or invasive cervical lesions.

Proper diagnoses and management of cervical

lesions are the cornerstone for cervical cancer

prevention in settings where there is no or

disorganized cervical cancer screening program, like

Egypt

Aboubakr Elnashar

CAUSES

1. Inflammatory:

Mechanical

Traumatic

Infections.

2. Dystrophic:

Hormonal or

Nutritional

3. Neoplastic:

Benign

Premalignant

Malignant Aboubakr Elnashar

Clinically suspicious cervix does not mean CIN, but

mostly, it is caused by benign and inflammatory

conditions:

Cervicitis

Ectopy, Ectropion

infected Nabothian cysts

polyp, or

true ulcers (Chong, 2003)

Aboubakr Elnashar

Ectopy

Ectropion, erythroplakia, macula rubra , erosion.

single-layered secreting columnar epithelium (which

usually covers the cervical canal, i.e. the

endocervix), beyond the external cervical orifi ce.

multilayered squamous epithelium typically found in

the vagina and exocervix are replaced.

Aboubakr Elnashar

1. sex hormones (particularly oestrogen) that

encourage the growth of columnar epithelium

over the ectocervix

2. common in pregnant

3. taking the COC

Aboubakr Elnashar

PCB Causes (Sahu etal,2007)

Ectopy: 34%

Cervical polyp: 5-13%

Chlamydia infection: 2%

CIN: 7-17%

Invasive cervical cancer: 0.6-4%.

No specific cause: 50% .

Aboubakr Elnashar

Cervical

Polyps

Carcinoma

Ectropion

Trauma Cervicitis

Genital warts

Vaginal

Carcinoma

Vaginitis

* Atrophic

* Infective

Endometrial

Polyps

Carcinoma

Usually, the bleeding originates from the vagina, or

cervix, rather than the endometrium.

Aboubakr Elnashar

Cervical polyps

can also bleed and can also normally be visualised

on examination.

Aboubakr Elnashar

Cervicitis

: vaginal discharge, bleeding.

STI:

Chlamydia

gonorrhoea

occasionally herpes.

Aboubakr Elnashar

Invasive

cancer

CIN Total Year

19 (0.9%)

244 (11.9%) 2049 2000 Elnashar

4 (4%) 15 (16%) 95 2010 Milingos et al

Pre invasive and Invasive cancers

PCB

asymptomatic

speculum examination and refer urgently if

suspicious

Patients with a clinically suspicious cervix are

more likely to develop CIN and should have

priority in any extended screening programs.

CIN & invasive cancer in suspicious cervices

Aboubakr Elnashar

Diagnosis

History

Speculum examination

Laboratory Tests: Infection screen

Nucleic acid amplification testing (NAAT) for N.G,

C.T, and T. V

Wet mount: most cost-effective means

of diagnosing TV, the overall sensitivity is low

and is dependent on the inoculum size; thus, NAAT

testing has become popular due to its relatively high

sensitivity and specificity.

Aboubakr Elnashar

Cytology.

HPV.

VIA

Colposcopy

Aboubakr Elnashar

Pap smear used for ≥50 y all across the globe. widely used for in most developed countries

Meets all the requirements for mass screening:.

• Fairly tolerated by patients, Easy to administer

• Reasonable sensitivity & specificity.

• Detection of endocervical lesions.

• It has resulted in a substantial reduction in both the morbidity & mortality of cervical cancer.

Aboubakr Elnashar

Aboubakr Elnashar

In developed countries: Continue to be the mainstay of cervical cancer

organized program settings

adequate coverage optimal frequency. refresher training continued supplies

Infrastructure

laboratory quality assurance

In developing countries:

impractical approach

Not appropriate or adequate

Visual inspection with acetic acid (VIA)

Effects of acetic acid:

.It coagulates the proteins of the nucleus &

cytoplasm & makes the protein opaque & white.

.It dehydrates the cells, the cytoplasmic volume is

reduced & the reflection is increased.

Duration:

appears after 20 seconds

disappears after 2 minutes.

Aboubakr Elnashar

Aboubakr Elnashar

Procedure

1.Wash the cervix with a 3%–5% acetic acid

solution.

2.Carefully inspect the cervix, especially the TZ,

with the naked eye.

Aboubakr Elnashar

Category Clinical Findings

Negative

No acetowhite lesions or

faint acetowhite lesions;

polyp,

cervicitis, inflammation,

Nabothian cysts.

Positive Sharp, distinct, well-defined,

dense (opaque/dull or oyster white) acetowhite with

or without raised margins touching SCJ;

leukoplakia and

warts.

Suspicious

for cancer

ulcerative, cauliflower-like growth or

ulcer; oozing and/or bleeding on touch. Aboubakr Elnashar

Aboubakr Elnashar

Negative

Positive

Suspicious for cancer

Aboubakr Elnashar

VIA Performance:

Source: Adapted from Gaffikin, 2003

Sensitivity Specificity

Pap 47-62 60-95

VIA 76-84 79-83

Aboubakr Elnashar

Management:

VIA: Negative:

follow-up after 3-5 ys acc to the decided policy.

VIA test: positive

Offer to treat immediately. or

Refer for colposcopy and biopsy and then offer tt if a

precancerous lesion is confirmed.

VIA : suspicious for cancer:

Refer for colposcopy and biopsy and further

management

Aboubakr Elnashar

WHO guidelines for screening and tt of CIN, 2013

In developing counteries, where screening with an HPV

test is not feasible: screen with VIA and treat.

Use a strategy of screen with VIA and treat, over a

strategy of screen with cytology followed by colposcopy

(with or without biopsy) and treat.

Screen-and-treat strategies involve tt with

cryotherapy, or LEEP when the patient is not eligible for

cryotherapy.

Aboubakr Elnashar

Aboubakr Elnashar

Colposcopy

Indications 1. Part of any gynecologic examination 2. Primary screening for cervical cancer. 3. Clinically suspicious cervix. 4. Abnormal Pap smear 5. Evaluation & treatment of CIN. 6. Follow up after conservative therapy of CIN. 7. Postcoital bleeding. 8. Patients with external vulval warts 9. Evaluation of sexual assault victims. 10. Patients with history of DES exposure

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Swede score

Aboubakr Elnashar

Swede score of 4 and above: Punch biopsies of the cervix

Swede score 6 and above:

immediate treatment with cold coagulation under visualisation with the Gynocular and local anaesthesia. patients not suitable for cold coagulation or with biopsies revealing microinvasive cervical disease or worse: appropriate diagnostic workup and management protocol.

Aboubakr Elnashar

Aboubakr Elnashar

TREATMENT

Of the cause

Cervicitis

Ectopy, Ectropion

Infected Nabothian cysts

Polyp

True ulcers

CIN

Aboubakr Elnashar

Cervicitis.

CT:

Doxycycline 100mg twice daily for 7 days or

Azithromycin 1gm orally stat dose.

Gonorrhoea

Ceftriaxone 250mg IM stat dose or

Cefixime 400mg oral stat dose.

Aboubakr Elnashar

Cervical Ectropion.

Indications:

Routine tt is not recommended

To relieve symptoms

No tt unless PCB is persistent

Further studies to test that tt: protection against

cervical cancer

Prior tt, ruled out underlying malignancy

Aboubakr Elnashar

Methods:

1. Cervical ablation: with either

Cryotherapy

Electrocautery

microwave tissue coagulation laser cauterisation Side effects:

copious vaginal discharge until healing is complete

cervical stenosis

Aboubakr Elnashar

2. An alternative therapy

Acidifying agents: boric acid suppositories 600mg

vaginally at bedtime

Alpha interferon suppository Polydeoxyribonucleotide vaginal suppositories.

Aboubakr Elnashar

Polyps.

Removal

1. Symptomatic

2. Suspicious

Often performed in the office without sedation

{Most are pedunculated and detach easily and

painlessly).

more persistant, or larger polyps, which are more

likely to bleed

electrosurgical excision

hysteroscopic polypectomy if they appear to be

coming from the endocervix or higher.

should be sent to pathology to be evaluated for

malignancy Aboubakr Elnashar

Vaginal Atrophy.

1. Vaginal moisturizers and lubricants

prior to and during intercourse (Avetrix gel)

not have any direct effect on improving atrophic

changes.

2. Vaginal estrogen therapy.

PCB despite lubricants

most effective: thickens the vaginal epithelium and

decreases dryness.

1st line tt for postmenopausal women.

Aboubakr Elnashar

CIN: WHO Recommendation 2014. CIN 1:

(i) immediate tt

(ii) follow the woman and then tt if the lesion is

persistent or progressive after 18 to 24 months.

CIN 2 and CIN 3:

cryotherapy or LEEP.

AIS (adenocarcinoma in situ)

CKC

Aboubakr Elnashar

Cryotherapy Cryotherapy relies on a steady supply of compressed refrigerant gases (N2O or CO2) in transportable cylinders. Cryotherapy is not adequate to treat lesions involving the endocervix. If excellent contact between the cryoprobe tip and the ectocervix is achieved, N2O-based cryotherapy will achieve –89°C and CO2-based system will achieve –68°C at the core of the ice ball and temperatures around –20°C at the edges. Cells reduced to –20°C for one or more minutes will undergo cryonecrosis.

Aboubakr Elnashar

Aboubakr Elnashar

Cryotherapy should consist of

two sequential freeze-thaw

cycles, each cycle consisting of

3 min of freezing followed by 5

minutes of thawing (3min

freeze-5 min thaw-3 min

freezethaw).

Adequate freezing has been

achieved when the margin of

the ice ball extends 4-5 mm

past the outer edge of the

cryotip. This will ensure that

cryonecrosis occurs down to at

least 5 mm depth.

Aboubakr Elnashar

Advantages

Favorable safety profile

Outpatient procedure

No anesthetic requirements

Ease of procedure

Low-cost equipment with minimal maintenance

Bleeding complications rare

No proven adverse reproductive effects

Acceptable primary cure rate

Aboubakr Elnashar

Disadvantages

No tissue specimen for histopathology evaluation

Cannot treat lesions with unfavorable sizes or

shapes

Uterine cramping

Potential for vasovagal reaction

Profuse vaginal discharge postprocedure

Cephalad migration of squamocolumnar junction

Adapted from Martin-Hirsch, 2010, with permission.

Video

Aboubakr Elnashar

LEEP

Technique

• Colposcopy & lesion outlined

• Patient grounded with pad return electrode

•Inject anaesthetic just beneath & lateral to the lesion

•Set cut/blend to 25-50 watts & excise lesion using the LEEP

•Coagulate the base of the cone by the ball electrode(60 W) even if no apparent bleeding

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Aboubakr Elnashar

Advantages Favorable safety profile

Ease of procedure

Outpatient procedure using local anesthesia

Low costs of equipment

Tissue specimen for histopathology evaluation

Disadvantages

Thermal damage may obscure specimen margin

status

Special training required

Risk of postprocedure bleeding

Theoretical risk of vapor plume inhalation

Aboubakr Elnashar

Video

Aboubakr Elnashar

Thanks

Aboubakr Elnashar