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Gynaecology > Cervical Disorders > Flashcards

Cervical Disorders Flashcards

1
Q

What are cervical polyps?

A

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

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2
Q

Describe the pathophysiology of cervical polyps.

A

Focal hyperplasia of the columnar epithelium of the endocervix.

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3
Q

What are the possible causes of cervical polyps?

A

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

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4
Q

What are the risk factors for cervical polyps?

A

Muligravidae

50-60 years

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5
Q

What are the clinical features of cervical polyps?

A

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.

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6
Q

What are the differentials for cervical polyps?

A 
Cervical ectropion/cancer
STIs
Fibroids
Endometritis
Pregnancy-related bleeding 
Always exclude endometrial cancer in post-menopausal women
Endometrial polyp
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7
Q

What are the investigations for cervical polyps?

A 
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
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8
Q

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

A

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

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9
Q

What is the management for cervical polyps?

A

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

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10
Q

What is the recurrence rate of cervical polyps?

A

6-12%

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11
Q

What are the complications of polyp removal?

A

Infection
Haemorrhage
Uterine perforation (very rare)

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12
Q

What is cervical ectropion?

A

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.

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13
Q

What needs to be excluded when suspecting cervical ectropion?

A

Cervical cancer

CIN

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14
Q

What are the 2 regions of the cervix?

A

Endocervix/endocervical canal

Ectocervix

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15
Q

Describe the endocervix.

A

The proximal and inner part of the cervix.

Lined by mucus secreting simple columnar epithelium.

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16
Q

Describe the ectocervix.

A

The part of the cervix that projects into the vagina.

Lined by stratified squamous non-keratinised epithelium.

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17
Q

Describe the pathophysiology of cervical ectropion.

A

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.

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18
Q

What are the risk factors for cervical ectropion?

A

COCP
Pregnancy
Adolescence
Mestruating age

19
Q

What are the clinical features of cervical ectropion?

A

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.

20
Q

What are the differentials for cervical ectropion?

A

Cervical cancer
CIN
Cervicitis
Pregnancy

21
Q

What are the investigations for suspected cervical ectropion?

A

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

22
Q

What is the management for cervical ectropion?

A

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

23
Q

What is cervical cancer?

A

Neoplasia arising from the cervix.

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

24
Q

What age group does cervical cancer affect?

A

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

Peak 25-29 with another peak at 80.

25
Q

Describe the pathophysiology of cervical cancer.

A

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.

26
Q

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

A

Lung
Liver
Bone
Bowel

27
Q

What is the aetiology of cervical cancer?

A

Caused by persistent HPV infection

28
Q

What is the human papilloma virus?

A

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

29
Q

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

A

6 and 11 - low risk - cause genital warts

16 and 18 - high risk

30
Q

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

A

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

31
Q

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

A

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

32
Q

What are the risk factors for cervical cancer?

A

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

33
Q

What are the clinical features of cervical cancer?

A

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

34
Q

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

A

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

35
Q

What are the differentials for cervical cancer?

A 
STI
Cervical ectropion
Polyps
Fibroids
Pregnancy-related bleeding
Endometrial carcinoma must always be ruled out in the post-menopausal population
36
Q

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

A

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

37
Q

Describe the procedure of colposcopy and biopsy.

A

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

38
Q

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

A

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

39
Q

Are cervical smears used to detect cervical cancer?

A

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

40
Q

Roughly describe the staging for cervical cancer.

A

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

41
Q

Describe the surgical management of cervical cancer.

A

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

42
Q

Describe the radiotherapy used in the management o cervical cancer.

A

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

43
Q

Describe the use of chemotherapy in cervical cancer management.

A

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

44
Q

Describe the follow-up in cervical cancer.

A

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

Gynaecology (12 decks)

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