Cervical Disorders

Question 1

What are cervical polyps?

Answer 1

Benign growths protruding from the inner surface of the cervix.
Typically asymptomatic, but a small minority can undergo malignant change.
2-5% of women.

Question 2

Describe the pathophysiology of cervical polyps.

Answer 2

Focal hyperplasia of the columnar epithelium of the endocervix.

Question 3

What are the possible causes of cervical polyps?

Answer 3

Chronic inflammation
Abnormal response to oestrogen (revival polyps associated with endometrial hyperplasia)
Localised congestion of the cervical vasculature

Question 4

What are the risk factors for cervical polyps?

Answer 4

Muligravidae

50-60 years

Question 5

What are the clinical features of cervical polyps?

Answer 5

Often asymptomatic (identified incidentally via routine cervical screening)
Abnormal vaginal bleeding (menorrhagia, IMB, PCB, PMB)
Increased vaginal discharge
If growth large enough to block cervical canal - infertility
Speculum - polyploid growths projecting through the external os.

Question 6

What are the differentials for cervical polyps?

Answer 6

Cervical ectropion/cancer
STIs
Fibroids
Endometritis
Pregnancy-related bleeding 
Always exclude endometrial cancer in post-menopausal women
Endometrial polyp

Question 7

What are the investigations for cervical polyps?

Answer 7

Definitive diagnosis - histological examination after removal
Triple swabs (endocervical and high vaginal) - rule out infection
Cervical smear - rule out cervical intraepithelial neoplasia (CIN) - if cannot be done remove polyp and then smear

Question 8

What should be done if bleeding still persists after removal of a cervical polyp?

Answer 8

Cervical polyps are associated with endometrial polyps, especially in post-menopausal women.
Do a USS to assess the endometrial cavity.

Question 9

What is the management for cervical polyps?

Answer 9

Small polyps - removed in primary care using polypectolmy forceps and twisting several times. Any bleeding can be cauterised with silver nitrate.
Larger polyps - removed by diathermy loop excision in colposcopy clinic/under GA if the base is broad
Excised polyps sent for histological examination to exclude malignancy

Question 10

What is the recurrence rate of cervical polyps?

Answer 10

6-12%

Question 11

What are the complications of polyp removal?

Answer 11

Infection
Haemorrhage
Uterine perforation (very rare)

Question 12

What is cervical ectropion?

Answer 12

Version of the endocervix, exposing the columnar epithelium of the vaginal milieu.
AKA cervical erosion.
It is a benign condition, commonly seen on examination of the cervix in adolescents, in pregnancy and in women taking oestrogen containing contraceptives.

Question 13

What needs to be excluded when suspecting cervical ectropion?

Answer 13

Cervical cancer

CIN

Question 14

What are the 2 regions of the cervix?

Answer 14

Endocervix/endocervical canal

Ectocervix

Question 15

Describe the endocervix.

Answer 15

The proximal and inner part of the cervix.

Lined by mucus secreting simple columnar epithelium.

Question 16

Describe the ectocervix.

Answer 16

The part of the cervix that projects into the vagina.

Lined by stratified squamous non-keratinised epithelium.

Question 17

Describe the pathophysiology of cervical ectropion.

Answer 17

The stratified squamous cells of the ectocervix undergo metaplastic change to become simple columnar epithelium.
Thought to be induced by high levels of oestrogen.
The columnar epithelium contains mucus-secreting glands = vaginal discharge.
PCB as it contains fine blood vessels which are easily broken during intercourse.

Question 18

What are the risk factors for cervical ectropion?

Answer 18

COCP
Pregnancy
Adolescence
Mestruating age

Question 19

What are the clinical features of cervical ectropion?

Answer 19

Mostly asymptomatic
PCB, IMB
Increased vaginal discharge (non-purulent)
Speculum - exerted columnar epithelium has a reddish appearance - usually arranged in a ring around the external os.

Question 20

What are the differentials for cervical ectropion?

Answer 20

Cervical cancer
CIN
Cervicitis
Pregnancy

Question 21

What are the investigations for suspected cervical ectropion?

Answer 21

It is a clinical diagnosis, but need to exclude differentials
Pregnancy test
Triple swabs (infection)
Cervical smear (rule out CIN) - biopsy if a frank lesion

Question 22

What is the management for cervical ectropion?

Answer 22

No treatment if asymptomatic
Stop oestrogen-containing medications (COCP)
Cryotherapy/electrocautery to ablate columnar epithelium (results in higher vaginal discharge until healing complete)
Medication to acidity vaginal pH e.g. boric acid pessaries

Question 23

What is cervical cancer?

Answer 23

Neoplasia arising from the cervix.

3rd most common cancer worldwide (12th in UK)

Question 24

What age group does cervical cancer affect?

Answer 24

Disease of the young - half of cases diagnosed before 47.

Peak 25-29 with another peak at 80.

Question 25

Describe the pathophysiology of cervical cancer.

Answer 25

70% squamous cell carcinoma; 15% adenocarcinoma; 15% mixed Develops as a progression from CIN Occurs over 10-20 years (though most cases of CIN spontaneously regress) Invasive cancer occurs when the basement membrane of the epithelium has been breached.

Question 26

What are the most common sites of metastases from cervical cancer?

Answer 26

Lung Liver Bone Bowel

Question 27

What is the aetiology of cervical cancer?

Answer 27

Caused by persistent HPV infection

Question 28

What is the human papilloma virus?

Answer 28

It is a sexually transmitted virus which affects the skin and mucous membranes Highly prevalent

Question 29

What are the high and low risk serotypes of HPV implicated in cervical cancer?

Answer 29

6 and 11 - low risk - cause genital warts | 16 and 18 - high risk

Question 30

Why are HPV serotypes 16 and 18 thought to be high risk for cervical cancer?

Answer 30

They produce proteins which inhibit the tumour suppressor protein p53 in cervical epithelial cells. Allows for uncontrolled cell division.

Question 31

Why is the incidence of cervical cancer low in comparison to some other countries?

Answer 31

National HOV vaccination programme protects against HPV 16, 18, 6 and 11. Regular screening - smear tests

Question 32

What are the risk factors for cervical cancer?

Answer 32

Smoking Other STIs Long-term COCP use (>8 years) Immunodeficiency e.g. HIV

Question 33

What are the clinical features of cervical cancer?

Answer 33

Abnormal vaginal bleeding Vaginal discharge (blood stained, foul-smelling) Dyspareunia Pelvic pain Weight loss Asymptomatic in early stages - found on routined screening Advanced (cancer invades nearby structures) - oedema, loin pain, rectal bleeding, radiculopathy, haematuria

Question 34

What clinical examinations should be done when suspecting cervical cancer and what might you find?

Answer 34

Speculum - bleeding, discharge, ulceration Bimanual - pelvic masses GI - hydronephrosis, hepatomegaly, rectal bleeding, mass on PR

Question 35

What are the differentials for cervical cancer?

Answer 35

``` STI Cervical ectropion Polyps Fibroids Pregnancy-related bleeding Endometrial carcinoma must always be ruled out in the post-menopausal population ```

Question 36

What are the investigations that need to be done when suspecting cervical cancer?

Answer 36

Pre-menopausal - test for chalmidya - if negative/symptoms persist refer for colposcopy and biopsy Post-menopausal - urgent colposcopy and biopsy

Question 37

Describe the procedure of colposcopy and biopsy.

Answer 37

Colposcope used to produce a magnified view of the cervix. Acetic acid used to stain dysplastic areas. Biopsy taken.

Question 38

If the diagnosis of cervical cancer is confirmed, what further investigations are needed?

Answer 38

Baseline bloods CT CAP - looking for mets Further staging e.g. MRI pelvis, PET +/- examination under anaesthesia with further biopsies

Question 39

Are cervical smears used to detect cervical cancer?

Answer 39

No, they aim to detect CIN (pre-invasive disease)

Question 40

Roughly describe the staging for cervical cancer.

Answer 40

FIGO staging Stage 0 - in situ Stage 1 - confined to cervix Stage 2 - beyond cervix, but not pelvic sidewall/vagina but not lower third Stage 3 - extends to pelvic sidewall/involves lower third of vagina/hydronephrosis not explained by another cause Stage 4 - extends to bladder/rectum/mets

Question 41

Describe the surgical management of cervical cancer.

Answer 41

Stage 1 - radical trachelectomy (removal of cervix and upper vagina) if needs fertility-preservation, otherwise laparoscopic hysterectomy with pelvic lymphadenectomy Stage 2 - radical hysterectomy - curative Stage 4/recurrent - anterior/posterior/total pelvic exteneration

Question 42

Describe the radiotherapy used in the management o cervical cancer.

Answer 42

Combination of external beam therapy and intracavity brachytherapy Alternative to surgery in early disease In conjunction with chemotherapy over a 5-8 week course Additional hysterectomy offers no benefits in terms of survival in the early stages Therefore, for these stages chemo radiation therapy is gold standard

Question 43

Describe the use of chemotherapy in cervical cancer management.

Answer 43

Cisplatin-based Before surgery/radiotherapy (neoadjuvant) or after (adjuvant) Mainstay in palliative setting

Question 44

Describe the follow-up in cervical cancer.

Answer 44

Reviews by a gynaecologist every 4 months after treatment for the first 2 years Then every 6-12 months for the subsequent 3 years All follow-ups involve physical examination of the vagina and cervix if not removed