Pathology of the Female Reproductive Tract Part 1

Question 1

What is the 3rd most common death worldwide?

Answer 1

• cervical cancer

Question 2

Cervical cancer is the 3rd most common cause of death worldwide. Why does it have a higher prevalence in developing countries?

Answer 2

• poorer screening

Question 3

What is human papillomavirus (HPV)?

Answer 3

• a very common group of viruses

- can cause genital warts or cancer

Question 4

The human papillomavirus (HPV) is a very common group of viruses that can cause genital warts or cancer. What are some common risk factors for contracting HPV?

Answer 4

• multiple sexual partners without protection
• prolonged infection
• immunosuppression
• smoking (twice as likely to have cervical cancer if smoking)
• prolonged use of COCP > 5 years
• having many children >3
• low socio economic background

Question 5

Which of the following are risk factors for the development of cervical/vulval intraepithelial neoplasia?

• intraepithelial = abnormal cells present on the surface epithelial tissue of the cervix and have not grown past that surface layer
• neoplasia = abnormal growth of cells

1 = HPV infection				 
2 = High Fat diet 				
3 = Early age of first intercourse	
4 = Multiple sexual partners		
5 = Excessive alcohol consumption	
6 = Smoking

Answer 5

1 = HPV infection (type of HPV virus)			 
4 = Multiple sexual partners			
6 = Smoking

Question 6

If you contract the human papillomavirus (hpv) what are the initial outcomes that could occur?

Answer 6

• body fight infection and tissue returns to normal
• body contracts HPV again and fights infection and tissue returns to normal
• body contracts HPV again fights infection but tissue becomes pre-cancerous

Question 7

If you contract the human papillomavirus (hpv) multiple times and the tissues becomes pre-cancerous, does that mean it will automatically become cancerous?

Answer 7

• no

- could become cancerous or just remain with the infection, but not pre-cancerous

Question 8

If you contract the human papillomavirus (hpv) multiple times what can determine if the cervical tissue then becomes cancerous?

Answer 8

• polymorphisms in major histocompatibility complex

Question 9

If you contract the human papillomavirus (hpv) multiple times the presence of polymorphisms in major histocompatibility complex can determine if the cervical tissue then becomes cancerous. What risk factors can then determine if the pre-cancerous tissues then becomes cancerous?

Answer 9

1 - HPV infection	
2 - multiple sexual partners		
3 - smoking
4 - nutrition
5 - multi-parity (multiple child births)

Question 10

What is cervical intraepithelial neoplasia (CIN)?

Answer 10

• abnormal growth of cells from the basal epithelial of the cervix
• could potentially lead to cervical cancer
• CIN I-III determines the level of affected epithelial cells of the cervix

Question 11

Which of the following are risk factors for the development of cervical intraepithelial neoplasia?

BRCA mutation positive		
Sun exposure			
Immunocompromise		
Tampon use				
Low socioecomonic status		
Lack of physical exercise

Answer 11

3 - Immunocompromised

5 - Low socio-economic status

Question 12

What is the basic cell type of the ectocervix?

Answer 12

• non-keratinising stratified squamous epithelial cells

- resistant to low pH of the vagina

Question 13

What is the basic cell type of the endocervix?

Answer 13

• columnar epithelial cells

- secrete mucus

Question 14

The basic cell type of the endocervix is columnar epithelial cells that secrete mucus. What happens to the columnar epithelial cells if they are exposed to the acidic pH of the vagina?

Answer 14

• undergo metaplasia

Question 15

What is metaplasia?

Answer 15

• replacement of one differentiated somatic cell type with another differentiated somatic cell type in the same tissue
• cervix cells turn from columnar to squamous

Question 16

The basic cell type of the endocervix is columnar epithelial cells that secrete mucus. If the columnar epithelial cells are exposed to the acidic pH of the vagina they undergo metaplasia, which is the change from one cell type to another (columnar to squamous). Alternatively, if a patient is infected with human papillomavirus (hpv), what can happen to the cells of the cervix?

Answer 16

• cells change in a gene mutated manner

- called dysplasia (abnormal development of cells)

Question 17

What is the name of the junction where the endocervix and ectocervix meet?

Answer 17

• squamocolumnar junction

Question 18

The junction where the endocervix and ectocervix meet is called the squamocolumnar junction. What happens to the position of this junction as a woman ages?

Answer 18

• changes from foetal life to menopause

Question 19

Metaplasia is the term used to describe when one cell type changes into another, and this occurs when the columnar cells become squamous cells when exposed to the acidic vaginal pH. This causes the the squamocolumnar junction (where endocervical (columnar) and ectocervix (squamous) meet to move throughout a woman’s life. What is the movement of the squamocolumnar junction called?

Answer 19

• eversion

Question 20

Metaplasia is the term used to describe when one cell type changes into another, and this occurs when the columnar cells become squamous cells when exposed to the acidic vaginal pH. This causes the the squamocolumnar junction (where endocervical (columnar) and ectocervix (squamous) meet to move throughout a woman’s life, which is called eversion. What is the name of the zone where the cells of the endocervix (columnar) undergo metaplasia and become squamous cells?

Answer 20

• transformation zone

- only location in the acidic part of the vagina

Question 21

What is the most common site for development of cervical squamous neoplasia?

Answer 21

• transformation zone

Question 22

What is dyskaryosis?

Answer 22

• abnormal cytologic (cell examination) changes of squamous epithelial cells
• characterised by hyperchromatic (darker than usual) nuclei and/or irregular nuclear chromatin

Question 23

Cervical intraepithelial neoplasia (CIN) is abnormal growth of cells from the basal epithelial of the cervix that could potentially lead to cervical cancer. CIN I-III determines the level of affected epithelial cells of the cervix and ranges from mild to moderate. What levels of cells are affected in CIN1, CIN II and CIN III?

Answer 23

• CIN I = changes in basal 1/3 of epithelial layer of cervix
• CIN II = changes in basal 2/3 of epithelial layer of cervix
• CIN III = changes in most or all of the epithelial layer of cervix

Question 24

In a woman who has persistent human papillomavirus (hpv) what % do the following for cervical intraepithelial neoplasia (CIN) I?

regress
persist
progress
become invasive carcinoma

Answer 24

• regress = 57%
• persist = 32%
• progress = 11%
• become invasive carcinoma = 1%

Question 25

In a woman who has persistent human papillomavirus (hpv) what % do the following for cervical intraepithelial neoplasia (CIN) II? regress persist progress become invasive carcinoma

Answer 25

- regress = 43% - persist = 35% - progress = 22% - become invasive carcinoma = 5%

Question 26

In a woman who has persistent human papillomavirus (hpv) what % do the following for cervical intraepithelial neoplasia (CIN) III? regress persist become invasive carcinoma

Answer 26

- regress = 32% - persist = 56% - become invasive carcinoma = >12%

Question 27

Does a cervical screening diagnose cancer?

Answer 27

- no - just identifies the pre-malignant phase - not 100% sensitive

Question 28

At what age do women begin getting cervical smear tests for screening?

Answer 28

- 25y/o

Question 29

How often does cervical screening occur for the following: - women - 25-49 y/o - women - 49-64 y/o

Answer 29

- women - 25-49 y/o = every 3 years | - women - 49-64 y/o = every 5 years

Question 30

The findings from a smear test can be scored by cytology, and this falls into 3 categories, what are they?

Answer 30

1 - inadequate (not enough sample, blood interferred etc..) 2 - negative = no abnormalities 3 - abnormal

Question 31

The findings from a smear test can be scored by cytology can be scored as inadequate, negative and abnormal. What are the categories of abnormal?

Answer 31

- borderline changes in squamous or endocervical cells - low-grade dyskaryosis - high-grade dyskaryosis (moderate) - high-grade dyskaryosis (severe) - invasive squamous cell carcinoma - glandular neoplasia

Question 32

If patients test positive for human papillomavirus (HPV) but they have a negative cytology report from their smear test, what should happen to the future test for HPV?

Answer 32

- screened again in 12 months

Question 33

If patients test positive for human papillomavirus (HPV) but they have a negative cytology report from their smear test, they should have a further HPV tests at 12 months. If that test then comes back negative, what should happen to their screening for HPV and smear test routine?

Answer 33

- return to normal routine recall based on their age

Question 34

If patients test positive for human papillomavirus (HPV) but they have a negative cytology report from their smear test, they should have a further HPV tests at 12 months. If that test remains positive, and the cytology is inadequate or negative, what test should they be referred for?

Answer 34

- colposcopy

Question 35

If patients test positive for human papillomavirus (HPV) but they have a negative cytology report from their smear test, they should have a further HPV tests at 12 months. If that test remains positive, and the cytology is borderline dyskaryosis or worse at 12 or 24 month follow up, what test should they be referred for?

Answer 35

- colposcopy

Question 36

All patients who are positive for human papillomavirus (hpv) and have abnormal cytology should be referred for what test?

Answer 36

- colposcopy

Question 37

During a colposcopy a speculum will be placed inside the vagina. A citric solution will then be sprayed onto the cervix. We may see some tissue then become white. Why would the tissue become white?

Answer 37

- increased uptake of citric acid - abnormalities are present - high mitotic cells replication and glycogen stores so citric acid is taken up causing them to become white

Question 38

What are glandular cells of the cervix?

Answer 38

- cells that makes mucus | - located on the inner part of the cervix

Question 39

Glandular cells of the cervix are cells that make mucus that are located on the inner part of the cervix. What is cervical glandular intraepithelial neoplasia 1?

Answer 39

- abnormality of the glandular cells | - rare, but requires colposcopy immediately

Question 40

Glandular cells of the cervix are cells that make mucus that are located on the inner part of the cervix. Cervical glandular intraepithelial neoplasia 1 is an abnormality of the glandular cells, that is rare, but requires colposcopy immediately. What are the main types of human papillomavirus (hpv) that cause this?

Answer 40

- HPV 18 | - occurs in older women

Question 41

What is the main form of transmission of human papillomavirus (hpv)?

Answer 41

- sexually transmitted

Question 42

The human papillomavirus (hpv) is a small, non-enveloped deoxyribonucleic acid (DNA) virus that infects skin or mucosal cells. How many genes does the HPV contain?

Answer 42

- 8

Question 43

Which 2 forms of the human papillomavirus (HPV) are low risk with the NHS, but can still cause warts and respiratory papillomatosis?

Answer 43

- 6 and 11

Question 44

Which 2 forms of the human papillomavirus (HPV) are high risk with the NHS and can lead to cervical head, neck and anogenital cancer?

Answer 44

- 16 and 18 - account for 70% of cervical cancers - 99% of cervical cancers are because of HPV virus

Question 45

The vulva is the outer part of the female genitals. The vulva includes the opening of the vagina (sometimes called the vestibule), the labia majora (outer lips), the labia minora (inner lips), and the clitoris. What is Vulvar Intraepithelial Neoplasia?

Answer 45

- abnormal cells develop in the surface layers of the skin covering the vulva - divided into HPV related (subdivided to wart, baseloid and mixed), and differentiated, which has nonviral aetiology

Question 46

A 27-year-old nulliparous woman is seen in colposcopy following a smear report of severe dyskaryosis. Colposcopy reveals a transformation zone with large areas of dense acetowhite epithelium consistent with cervical intraepithelial neoplasia III. What is the most appropriate management for this patient? ``` 1 - repeat Smear in 6 months 2 - HPV testing 3 - loop excision of transformation zone 4 - single punch biopsy of TZ 5 - repeat colposcopy in 12 months ```

Answer 46

3 - loop excision of transformation zone

Question 47

A severely dyskaryotic smear is associated with the colposcopic finding of high-grade cervical intraepithelial neoplasia (CIN) II or III in what % of cases? 1 - 80–90% of cases 2 - 50–60% of cases 3 - 10–20% of cases 4 - 100% of cases

Answer 47

1 - 80–90% of cases