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Cervical Pathology

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A Normal Cervix

Cervical Cancer

Cervical cancer is cancer that starts in the cervix, the lower part of the uterus (womb) that opens at the top of the vagina.

Causes

Worldwide, cervical cancer is the third most common type of cancer in women. It is much less common in the United States because of routine use of Pap smears.

Cervical cancers start in the cells on the surface of the cervix. There are two types of cells on the cervix's surface: squamous and columnar. The majority of cervical cancers are from squamous cells.

The development of cervical cancer is usually very slow. It starts as a pre-cancerous condition called dysplasia. This pre-cancerous condition can be detected by a Pap smear and is 100% treatable. That is why it is so important for women to get regular Pap smears. Most women that are diagnosed with cervical cancer today have not had regular Pap smears or they have not followed up on abnormal results.

Undetected, pre-cancerous changes can develop into cervical cancer and spread to the bladder, intestines, lungs, and liver. It can take years for pre-cancerous changes to turn into cervical cancer. Patients with cervical cancer do not usually have problems until the cancer is advanced and has spread.

Almost all cervical cancers are caused by HPV (human papilloma virus). HPV is a common virus that is spread through sexual intercourse. There are many different types of HPV, and many do not cause problems. However, only certain strains of HPV actually lead to cervical cancer. (Other strains may cause genital warts.)

Cervical Cancer

Other risk factors for cervical cancer include:

* Having sex at an early age
* Multiple sexual partners
* Sexual partners who have multiple partners or who participate in high-risk sexual activities
* Women whose mothers took the drug DES (diethylstilbestrol) during pregnancy in the early 1970s to prevent miscarriage
* Long-term use of birth control pills (more than 5 years)
* Weakened immune system
* Infections with genital herpes or chronic chlamydia infections
* Poor economic status (may not be able to afford regular Pap smears)

Symptoms

Most ot the time, early cervical cancer has no symptoms. Symptoms that may occur can include:

* Continuous vaginal discharge, which may be pale, watery, pink, brown, bloody, or foul-smelling
* Abnormal vaginal bleeding between periods, after intercourse, or after menopause
* Periods become heavier and last longer than usual
* Any bleeding after menopause

Symptoms of advanced cervical cancer may include:

* Loss of appetite
* Weight loss
* Fatigue
* Pelvic pain
* Back pain
* Leg pain
* Single swollen leg
* Heavy bleeding from the vagina
* Leaking of urine or feces from the vagina
* Bone fractures

Exams and Tests

Pre-cancerous changes of the cervix and cervical cancer can not be seen with the naked eye. Special tests and tools are needed to spot such conditions.

Pap smears screen for pre-cancers and cancer, but do not offer the final diagnosis. If abnormal changes are found, the cervix is usually examined under magnification. This is called colposcopy. Pieces of tissue are surgically removed (biopsied) during this procedure and sent to a laboratory for examination.

Other tests may include:

* Endocervical curettage (ECC) to examine the opening of the cervix
* Cone biopsy

If the woman is diagnosed with cervical cancer, the health care provider will order more tests to determine how far the cancer has spread. This is called staging. Tests may include:

* CT scan
* Cystoscopy
* MRI
* Chest x-ray
* Intravenous pyelogram (IVP)

Treatment

Treatment of cervical cancer depends on the stage of the cancer, the size and shape of the tumor, the age and general health of the woman, and her desire to have children in the future.

Early cervical cancer can be cured by removing or destroying the pre-cancerous or cancerous tissue. There are various surgical ways to do this without removing the uterus or damaging the cervix, so that a woman can still have children in the future.

Types of surgery for early cervical cancer include:

* LEEP (Loop Electrosurgical Excision Procedure) -- uses electricity to remove abnormal tissue
* Cryotherapy -- freezes abnormal cells
* Laser therapy -- uses light to burn abnormal tissue

A hysterectomy (removal of the uterus but not the ovaries) is not often performed for cervical cancer that has not spread. It may be done in women who have repeated LEEP procedures. However, in more advanced disease, a radical hysterectomy may be performed. This type of hysterectomy removes the uterus and much of the surrounding tissues, including internal lymph nodes and upper part of the vagina. In the most extreme surgery, called a pelvic exenteration, all of the organs of the pelvis, including the bladder and rectum, are removed.

Radiation may be used to treat cancer that has spread beyond the pelvis, or cancer that has returned. Radiation therapy is either external or internal. Internal radiation therapy uses a device filled with radioactive material, which is placed inside the woman's vagina next to the cervical cancer. The device is removed when she goes home. External radiation therapy beams radiation from a large machine onto the body where the cancer is located. It is similar to an x-ray.

Chemotherapy uses drugs to kill cancer. Some of the drugs used for chemotherapy for cervical cancer include 5-FU, Cisplatin, Carboplatin, Ifosfamide, Paclitaxel, and Cyclophosphamide. Sometimes radiation and chemotherapy are used before or after surgery.

Support Groups

National Cervical Cancer Coalition - http://www.nccc-online.org/

Outlook (Prognosis)

Many factors influence the outcome of cervical cancer. These include:

* The type of cancer
* The stage of the disease
* The age and general physical condition of the woman

Pre-cancer conditions are completely curable when followed up and treated properly. The chance of being alive in 5 years (5-year survival rate) for cancer that has spread to the inside of the cervix walls but not outside the cervix area is 92%.

However, the 5-year survival rate falls steadily as the cancer spreads into other areas.

Possible Complications

* Some types of cervical cancer do not respond well to treatment.
* The cancer may come back (recur) after treatment.
* Women who have treatment to save the uterus have a high risk of the cancer coming back (recurrence).
* Surgery and radiation can cause problems with sexual, bowel, and bladder function.

When to Contact a Medical Professional

Call your health care provider if you:

* Are a sexually active woman who has not had a Pap smear in the past year
* Are at least 20 years old and have never had a pelvic examination and Pap smear
* Think your mother may have taken DES when she was pregnant with you
* Have not had regular Pap smears (ask your health care provider how often you should have one performed)

Prevention

A new vaccine to prevent cervical cancer is now available. In June 2006, the U.S. Food and Drug Administration approved the vaccine called Gardasil, which prevents infection against the two types of HPV responsible for the majority of cervical cancer cases. Studies have shown that the vaccine appears to prevent early-stage cervical cancer and precancerous lesions. Gardasil is the first approved vaccine targeted specifically to prevent any type of cancer.

Practicing safe sex (using condoms) also reduces your risk of HPV and other sexually-transmitted diseases. HPV infection causes genital warts. These may be barely visible or several inches wide. If a woman sees warts on her partner's genitals, she should avoid intercourse with that person.

To further reduce the risk of cervical cancer, women should limit their number of sexual partners and avoid partners who participate in high-risk sexual activities.

Getting regular Pap smears can help detect pre-cancerous changes, which can be treated before they turn into cervical cancer. Pap smears work very well in spotting such changes, but they must be done regularly. Annual pelvic examinations, including a pap smear, should start when a woman becomes sexually active, or by the age of 20 in a non-sexually active woman. If abnormal changes are seen, a colposcopy with biopsy should be performed.

See also: Physical exam frequency.

If you smoke, quit. Cigarette smoking is associated with an increased risk of cervical cancer.


Cervical Inflammation


Definition

Cervicitis is swelling (inflammation) of the end of the uterus (cervix).

Causes

Cervicitis is most often caused by an infection. However, in a few cases it may be due to:

* A device inserted into the pelvic area such as:
o Cervical cap
o Device to support the uterus (pessary)
o Diaphragm
* An allergy to spermicides used for birth control or to latex in condoms
* Exposure to a chemical

Cervicitis is very common, affecting more than half of all women at some point during their adult lives. Risks include:

* High-risk sexual behavior
* History of sexually transmitted disease (STD)
* Many sexual partners
* Sex (intercourse) at an early age
* Sexual partner(s) who have engaged in high-risk sexual behavior or have had an STD

STDs that can cause cervicitis include:

* Chlamydia
* Gonorrhea
* Herpes virus (genital herpes)
* Human papilloma virus (genital warts)
* Trichomoniasis

Bacteria (such as staphylococcus and streptococcus) and too much growth of normal bacteria in the vagina (bacterial vaginosis), can also cause cervicitis.

Symptoms

* Abnormal vaginal bleeding
o After intercourse
o After menopause
o Between periods
* Unusual vaginal discharge
o Does not go away
o Gray, white, or yellow color
o May have an odor
* Painful sexual intercourse
* Pain in the vagina
* Pressure or heaviness in the pelvis

Note: There may be no symptoms.

Exams and Tests

A pelvic examination may show:

* Discharge from the cervix
* Redness of the cervix
* Swelling (inflammation) of the walls of the vagina

Tests:

* Inspection of the discharge under a microscope (may show candidiasis, trichomoniasis, or bacterial vaginosis)
* Pap smear
* Tests for gonorrhea or chlamydia

Treatment

Treatments include:

* Cryosurgery
* Electrocauterization
* Hormonal therapy (especially in postmenopausal women)
* Laser therapy
* Medication (antibiotics or antifungals)

Outlook (Prognosis)

Simple cervicitis usually heals with treatment if the cause is found and there is a treatment for that cause.

Possible Complications

Cervicitis may last for months to years. Cervicitis may lead to pain with intercourse (dyspareunia).

When to Contact a Medical Professional

Call your health care provider if you have symptoms of cervicitis.

Prevention

Ways to reduce the risk of cervicitis include:

* Avoid chemical irritants such as douches and deodorant tampons.
* Avoid using spermicidal contraceptives, if possible (however, if they are the only form of contraceptive available to you, it is better to practice safer sex by using them). If you use a barrier method of birth control (diaphragm, condoms, cervical caps) with spermicidal jelly, see your health care provider to discuss other methods of birth control before stopping your current method.
* Begin sexual activity at a later age.
* Have sex with just one person (monogamy).
* Make sure that any foreign objects that you insert into your vagina (such as tampons) are placed properly. Be sure to follow the guidelines as to how long to leave the object in, how often to change it, or how often to clean it.
 

Cervical Inflammation

Cervical Dysplasia

Cervical dysplasia is the abnormal growth of cells on the surface of the cervix. Although this is not cancer, this is considered a precancerous condition.

Cervical dysplasia is grouped into three categories:

* CIN I -- mild dysplasia (a few cells are abnormal)
* CIN II -- moderate to marked dysplasia
* CIN III -- severe dysplasia to carcinoma-in-situ (precancerous cells only in the top layer of the cervix)

Causes

Most cases of cervical dysplasia occur in women aged 25 to 35.

The cause is unknown. However, the following may increase your risk:

* Multiple sexual partners
* Becoming sexually active before age 18
* Giving birth before age 16
* If your mother took a drug called diethylstilbestrol (DES) during pregnancy
* Sexually transmitted infections, especially HIV or HPV (genital warts)

Symptoms

There are usually no symptoms.

Exams and Tests

A pelvic examination is usually normal.

A Pap smear shows abnormal cells. A colposcopy-directed biopsy is done to confirm the condition and determine its severity.

Other tests may be done to find out if the abnormal cells have spread outside the cervix:

* Endocervical curettage
* Cone biopsy

Treatment

Treatment depends on the degree of dysplasia. Mild dysplasia may go away on its own . You may only need careful observation by your doctor with repeat Pap smears every 3 to 6 months.

Treatment for moderate to severe dysplasia or dysplasia that does not go away may include:

* Cryosurgery
* Electrocauterization
* Laser vaporization to destroy the abnormal tissue
* Surgery to remove the abnormal tissue

Women with dysplasia need consistent follow-up, usually every 3 to 6 months or as recommended by their provider.

Outlook (Prognosis)

Early diagnosis and prompt treatment cures nearly all cases of cervical dysplasia.

Without treatment, 30-50% of cases of severe cervical dysplasia may lead to invasive cancer. The risk of cancer is lower for mild dysplasia.

Possible Complications

The condition may return.

When to Contact a Medical Professional

Call for an appointment with your health care provider if you are a woman who is sexually active or aged 20 or older and you have never had a pelvic examination and Pap smear.

See: Physical exam frequency

Prevention

To reduce the chance of developing cervical dysplasia:

* Wait until you are 18 or older before becoming sexually active
* Practice monogamy and use condoms during intercourse

Cervical Dysplasia

Cervical Polyps

Cervical polyps are fingerlike growths on the lower part of the uterus that connects with the vagina (cervix).

Causes

The cause of cervical polyps is not completely understood. They may occur with:

* An abnormal response to increased levels of the female hormone, estrogen
* Chronic inflammation
* Clogged blood vessels in the cervix

Cervical polyps are common, especially in women over age 20 who have had children. Polyps are rare in young women who have not started their period (menstruation).

Most women have only one polyp, but some women have two or three.

Symptoms

* Abnormally heavy periods (menorrhagia)
* Abnormal vaginal bleeding
o After douching
o After intercourse
o After menopause
o Between periods
* White or yellow mucus (leukorrhea)

Polyps may not cause symptoms.

Exams and Tests

During a pelvic examination, the health care provider will see smooth, red or purple, fingerlike growths on the cervix. A cervical biopsy will show cells that are mildly abnormal and signs of infection.

Treatment

The health care provider can remove polyps during a simple, outpatient procedure. Gentle twisting of a cervical polyp may remove it, but normally a polyp is taken out by tying a surgical string around the base and cutting it off. The polyp's base is removed with electrocautery or a laser.

Because many polyps are infected, you may have to take an antibiotic after the removal, even if there are no signs of infection. Although most cervical polyps are not cancerous (benign), the removed tissue should be sent to a laboratory and checked further.

Outlook (Prognosis)

Typically, polyps are not cancerous (benign) and easy to remove. Polyps do not usually grow back.

Possible Complications

Some cervical cancers may first appear as a polyp. Infections may occur after removal.

Cervical Polyp  

    
       

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