The Cervix in Health and Disease

Question 1

What is the cervix?

Answer 1

• lower part of the uterus
• superior to the vagina
• facilitates the passage of sperm whilst maintaining a sterile environment in the upper female reproductive system

Question 2

Label the key parts of the cervix using the labels below”

external os
internal os
uterine part of endocervix
vaginal part of endocervix
isthmus

Answer 2

1 - isthmus
2 - external os
3 - uterine part of endocervix
4 - vaginal part of endocervix
5 - internal os

Question 3

Generally where is the location of the cervix in the pelvis?

Answer 3

• midline

Question 4

Using the labels below, label the organisation of the female reproductive system:

fundus
body of uterus
vagina
cervix
isthmus

Answer 4

fundus
body of uterus
isthmus
cervix
vagina

Question 5

The internal and external os are the openings between what and the cervix?

Answer 5

• internal os = isthmus and cervix

- external os = cervix and vagina

Question 6

What is the endocervix and ectocervix?

Answer 6

• endocervix = opening of the cervix that leads into the uterus
• ectocervix = outer part of the cervix that joins the vagina

Question 7

What cells line the endocervix and what do they secrete?

Answer 7

• columnar epithelial cells

- produce mucus

Question 8

What cells line the ectocervix and what do they secrete?

Answer 8

• mature squamous epithelial cells

Question 9

What is the squamocolumnar junction?

Answer 9

• junction where columnar (endocervix) and squamous (ectocervix) cells meet

Question 10

What is the transformation zone?

Answer 10

• where columnar and squamous cells meet

- sub columnar cells multiply and differentiate into immature squamous epithelium through a process called metaplasia

Question 11

What is metaplasia?

Answer 11

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

Question 12

What are 3 basic things that can affect the shape of the cervix?

Answer 12

• age
• hormonal state
• parity

Question 13

In the image below which image shows nulliporous (not have given birth previously) and multiporous (several pregnancies)?

Answer 13

• top is nulliporous (barrel shaped with small external os)

- bottom is multiporous (bulky and external os appears slit like)

Question 14

What are the 4 main functions of the cervix?

Answer 14

1 - produces mucus to facilitate sperm migration
2 - acts as a barrier to ascending infection
3 - holds a developing pregnancy in place
4 - effaces and dilates to enable vaginal birth

Question 15

The cervix effaces during birth. What does this mean?

Answer 15

• stretches and gets thinner

- works alongside dilation

Question 16

During pregnancy does the cervix hypertrophy or atrophy?

Answer 16

• hypertrophy

- becomes softer though

Question 17

During pregnancy what happens to the blood supply to the cervix?

Answer 17

• increases in vascularity

- venous congestion occurs

Question 18

During pregnancy the glands of the cervix distend with mucus, forming what?

Answer 18

• mucus plug

Question 19

During pregnancy the cervical canal grows onto the outside of the cervix, called glandular cells. What is this process called?

Answer 19

• cervical ectropion

- driven by estrogen

Question 20

During pregnancy the cervical canal grows onto the outside of the cervix, called glandular cells in a process called cervical ectropion, which is driven by estrogen. Why is this important?

Answer 20

• cells that grow on the outside of the cervix are more sensitive
• increased sensitivity can cause pain, bleeding and discharge

Question 21

During pregnancy the cervical canal grows onto the outside of the cervix, called glandular cells in a process called cervical ectropion, which is driven by estrogen. This is important because cells that grow on the outside of the cervix are more sensitive and can cause pain, bleeding and discharge. Is this generally treated?

Answer 21

• no

- usually disappears in 3-6 months

Question 22

Cervical diseases are one of the most common pathologies in women of different ages. Inflammatory cervical disease, also called cervicitis can be divided into 2 categories, what are the 2 categories?

Answer 22

• infectious

- non-infectious

Question 23

Cervical diseases are one of the most common pathologies in women of different ages. Inflammatory cervical disease, also called cervicitis can be divided into 2 categories, infectious and non-infectious. What are the 5 most common microorganisms that can cause infection through sexual transmission?

Answer 23

1 - Chlamydia trachomatis
2 - Ureaplasma urealyticum
3 - T. vaginalis, 
4 - Neisseria gonorrhoeae
5 - HumanPapillomaVirus (HPV)

Question 24

What are cervical polps?

Answer 24

• non-cancerous growths that usually appear on the cervix where it opens into the vagina
• generally cherry-red to reddish-purple or grayish-white

Question 25

What is the cervical condyloma and what causes it?

Answer 25

- non cancerous genital warts - can grow on cervix and vagina - caused by the human papillomavirus (HPV)

Question 26

What is dysplasia?

Answer 26

- mature growth cells enter the cell cycle - undergo mitosis creating 2 identical daughter cells - if replication continues faster than the body needs - causes abnormal number and shape of cells

Question 27

Dysplasia is when mature growth cells enter the cell cycle and undergo mitosis creating 2 identical daughter cells, but replication continues faster than the body needs them is called dysplasia. Why is dysplasia important?

Answer 27

- precursor for cancer

Question 28

What are the 5 most common causes of cervical patholgies?

Answer 28

``` 1 - hormonal disorders 2 - injury to cervix 3 - infectious diseases 4 - viral diseases, including human papillomavirus (HPV) 5 - weak immune system ```

Question 29

What are some of the most common methods that can help diagnose cervical pathologies?

Answer 29

- vaginal examination - urogenital swab to assess microflora and presence of pathological bacteria - cytology (analysis of single cells to screen for cancer) - colposcopy (magnifying camera of cervix)

Question 30

Some basic cervical pathologies which can be treated such as erosion and inflammatory process are generally not dangerous. But left untreated, what can they develop into?

Answer 30

- cancer

Question 31

In the cervix where do tumours most commonly arise from?

Answer 31

- transformation zone

Question 32

What is the most common cause of pre-cancer and cervical cancer?

Answer 32

- human papillomavirus (HPV) | - transmitted through sex

Question 33

What are the 5 most common predisposing risk factors of pre-cancer and cervical cancer?

Answer 33

- smoking - multiple sexual partners - male partner with multiple previous sexual partners - immuno compromise (HIV, organ transplant) - low socio-economic status

Question 34

What is the human papillomavirus (HPV)?

Answer 34

- group of non-enveloped DNA viruses | - specifically infect human epithelial cells

Question 35

The human papillomavirus (HPV) has the ability to infect different cellular types ultimately to produce a successful infection. What is this ability called?

Answer 35

- viral tropism | - HPV has viral tropism for immature squamous epithelial cells

Question 36

The human papillomavirus (HPV) has the ability to infect different cellular types ultimately to produce a successful infection. This ability is called viral tropism, where the HPV has viral tropism for immature squamous epithelial cells. Do HPV infections always lead to cancer?

Answer 36

- no | - can be transient and eliminated by the host

Question 37

The human papillomavirus (HPV) has the ability to infect different cellular types ultimately to produce a successful infection. This ability is called viral tropism, where the HPV has viral tropism for immature squamous epithelial cells. Not all HPV infections lead to cancer, but those that do cause what to occur?

Answer 37

- cause squamous cervical intraepithelial lesions/neoplasia (CIN) - precursor for cervical carcinomas

Question 38

How does the human papillomavirus (HPV) replicate in immature basal squamous cells of the cervix?

Answer 38

- uses host cells DNA polymerase to replicate its genome

Question 39

The human papillomavirus (HPV) replicate in immature basal squamous cells of the cervix by using host cells DNA polymerase to replicate its genome. 2 specific proteins are able to ensure that the basal cells continually replicate, called E6 and E7 proteins. E6 is able to inhibit p53 and E7 inhibits etinoblastoma (RB). What are p53 and RB and why is this important?

Answer 39

- p53 and RB are tumour suppressor genes | - E6 and E7 inhibit these genes and allows tumours to develop

Question 40

The human papillomavirus (HPV) replicate in immature basal squamous cells of the cervix by using host cells DNA polymerase to replicate its genome. There are over 100 forms of HPV, but which 2 are high risk and account for aprox 70% of squamous intraepithelial lesions and cervical carcinomas?

Answer 40

- HPV types 16 and 18

Question 41

Squamous intraepithelial lesions (SIL) are abnormal growth of epithelial cells on the surface of the cervix, commonly called squamous cells. This condition can lead to cancer. There are 2 types of SIL, what are they?

Answer 41

1 - low-grade squamous intraepithelial lesion (LSIL), still often referred to as cervical intraepithelial neoplasia I (CIN I), and 2 - high-grade squamous intraepithelial lesion (HSIL), encompassing cervical intraepithelial neoplasia II and III (CIN II and III)

Question 42

Squamous intraepithelial lesions (SIL) are abnormal growth of epithelial cells on the surface of the cervix, commonly called squamous cells. This condition can lead to cancer. There are 2 types of SIL: 1 - low-grade squamous intraepithelial lesion (LSIL), still often referred to as cervical intraepithelial neoplasia I (CIN I), and 2 - high-grade squamous intraepithelial lesion (HSIL), encompassing cervical intraepithelial neoplasia II and III (CIN II and III) Do they both lead to cancer?

Answer 42

- LSIL = no, generally regress, small % may progress to cancer - HSIL = yes, treated as high risk to become cancerous

Question 43

On histology what can we expect to see in low-grade squamous intraepithelial lesion (LSIL)?

Answer 43

- dysplastic changes in the lower third of the squamous epithelium - koilocytotic change in the superficial layers of the epithelium

Question 44

What are koilocytes?

Answer 44

- a squamous epithelial cell that has undergone a number of structural changes - changes are caused by human papillomavirus (HPV) - on histology we can tell if a patient has had HPV

Question 45

On histology what can we expect to see in high-grade squamous intraepithelial lesion (HSIL) CNII?

Answer 45

- dysplasia extends to the middle third of the epithelium in the form of variation in cell and nuclear size - superficial layer of cells in CIN II still shows differentiation and occasional koilocytotic changes

Question 46

On histology what can we expect to see in high-grade squamous intraepithelial lesion (HSIL) CNIII?

Answer 46

- complete loss of differentiation - large variation in cell and nuclear size - almost all layers of the epithelium are affected - Koilocytotic change usually is absent

Question 47

The image below shows cytology of some tissues samples. Which image is: normal tissue low-grade squamous intraepithelial lesion (LSIL) high-grade squamous intraepithelial lesion (HSIL) CNII and CNIII

Answer 47

A = normal B = low-grade squamous intraepithelial lesion (LSIL) C and D = high-grade squamous intraepithelial lesion (HSIL) CNII and CNIII

Question 48

Squamous intraepithelial lesions (SIL) can be detected on smear tests and followed up by colposcopy. How would the following be treated: low-grade squamous intraepithelial lesion (LSIL) high-grade squamous intraepithelial lesion (HSIL) CNII and CNIII

Answer 48

- LSIL = monitored with observation - HSIL and persistent LSIL = surgical excision (cone biopsy) - If HSIL patients will have follow up smears and remain at risk of HPV and associated cervical, vulvar, and vaginal cancers

Question 49

How common is cervix cancer?

Answer 49

-worldwide 2nd most common cancer amongst women

Question 50

How many cases of cervix cancer and deaths from cervix cancer each year?

Answer 50

- incidence = 430,000 | - deaths = >200,000

Question 51

What are the most common types of cervix cancer?

Answer 51

``` 1st = squamous cell carcinoma 2nd = adenocarcinoma ```

Question 52

What are the most common risk factors for cervix cancer?

Answer 52

- mutations in suppressor genes and human papillomavirus (HPV) together - smoking - HIV

Question 53

What is the only reliable way to monitor the disease course of cervix cancer?

Answer 53

- frequent physical examination with pep smears

Question 54

In the cervix, what is the most common location for invasive carcinoma to develop?

Answer 54

- transformation zone

Question 55

What are some common clinical presentations of cervix cancer?

Answer 55

- vaginal bleeding and discomfort - foul smelling vaginal discharge - pain in groin (hydronepherosis) - constipation - pelvic pain (lymph nodes)

Question 56

How can cervix cancer be treated?

Answer 56

- surgically remove the tumour - uterus and lymph nodes may need to be removed - radiation - chemotherapy