1. Benign and premalignant disease of the cervix
Dr. Lubna maghur MRCOG

2. Introduction
Benign diseases of the cervix are common and are unusually asymptomatic or cause minor symptoms but must be differentiated from malignancy.
Cervical cancer is the second commonest cancer in women. It is proceeded by a premalignant form years before its invasion.
Screening for premalignant disease of the cervix markedly reduces the deaths from cervical cancer.

3. objective To understand the normal cervical epithelium
To be able to define metaplasia and dysplasia.
To understand the concept of cervical screening.
To outline the principles of colposcopy.
To outline the management of CIN

4. Epithelium of the cervix

5. Transformational zone: The area of cervix between the old and new squamo- columnar junction. It is the area of risk of developing premalignant and malignant disease of the cervix.

6. Benign diseases of the cervix
Cervical ectropion.
Nabothian follicle.
Genital warts.

7. Cervical ectropion (erosion)
Physiological presence of columnar epithelium on the ectocervix.
Increases in pregnancy and OCP.
May lead to vaginal discharge and PCB.
Management includes reassurance, exclude other cause, and if distressing coagulation.

8. Nabothian follicle
Endocervical glands in the transformational zone become covered with squamous cells and forms mucus filled cysts.

9. Premalignant disease of the cervix
HPV infection
CIN I
CIN II
CIN III
Cervical
cancer
Normal cervix

10. HPV infection DNA virus.
Over 100 different types and subtypes of this virus.
Common infection effecting epithelial surface.
Genital HPV is divided into
Low risk type (HPV 6,11) cause genital warts.
High risk types (HPV 16, 18, 31, 33, 45, 56).
HPV is a common infection while cervical cancer is a rare disease.

11. Factors that increase risk of transmission:
Smoking.
Increasing parity.
Early age of intercourse.
Oral contraceptive pills.
Immunity.

12. Cervical intraepithelial neoplasia
Metaplasia: change of epithelium from one cell lining (columnar) to another (squamous).
Dysplasia: abnormal epithelial cells that fail to maturate. (hyperchromasia, larger, variable size, mitosis).
it may be mild, moderate or severe

13. CIN 2 (moderate dysplasia) (severe dysplasia/CIS)
Classification of CIN
CIN1
Normal
CIN 1
(condyloma)
(mild dysplasia)
CIN 2 (moderate dysplasia)
CIN 3
(severe dysplasia/CIS)
Invasive cancer
Histology of squamous cervical epithelium1

14. Bethesda system
Low grade squamous intraepithelial lesion (LSIL); HPV infection, CIN I.
High grade squamous intraepithelial lesion (HSIL); CIN II, CIN III.

15. Outcome of CIN
Spontaneous regression.
Progression to invasive cancer.
Progression from one stage to another takes years.
Detection and treatment of CIN prevents cancer cervix.

16. Screening for CIN cervical smear
Screening for dyskariosis by obtaining cervical cytology.
Cervical screening should be carried out every 3-5 years in all sexually active women from years of age.
There is a % chance of false positive or false negative results.

17. Management of cytology results
Smear
Risk of having HSIL
Management
If next smear is negative
Normal
0.1%
Repeat in 3-5 years
Routine
Inflammatory
<6%
Borderline
20-30%
Repeat 6 months
Repeat 1 year then 2 then routine.
Colposcopy if 3 borderline.
Mild dyskaryosis
30-50%
Repeat in 3 months
Or refer for colposcopy
moderate dyskaryosis
50-70%
Colposcopy
Repeat after treatment
Severe dyskaryosis
80-90%
Invasion suspected
50% invasion
Urgent colposcopy

18. Colposcopy
Is the inspection of the cervix with a low powered microscope.
Magnifies the cervix 4-20 times.
The patient is put in lithotomy position.
Passing a bivalve speculum gently into the vagina.

19. Inspection of the cervix and its vasculature.
Green filter may help studying vasculature.
Abnormal vascular structure includes punctuation and mosaicism.
Acetic acid test: application of 3% acetic acid stained the abnormal area. The degree of staining correlates with severity of the lesion.
Schiller test: application of Lugol’s iodine stains the normal cervix brown.
Colposcopy gives a clinical diagnosis.
Punch biopsy from the abnormal area gives a histopathological diagnosis.

20. Management of abnormal colposcopy
CIN II,CIN III. ?CIN I.
Techniques for treatment:
Excisional: LLETZ, laser cone, knife cone, hysterectomy.
Ablative: radical electrodiathermy, cold coagulation, cryocautery, laser.
90-95% cure rate

21. Adenocarcinoma insitu
Less common than squamous intraepithelial neoplsia.
Has same risk factors.
Can not be reliably screened by colposcopy.
Does not have particular colposcopic features.
Divided into high grade and low grade.
Characterized by skip lesions.
Treatment by large cone biopsy.

22. Human papilloma virus vaccine
The first vaccine that intends to prevent cancer.
2 forms of vaccine are available
Bivalent 16, 18
Quadrevalent 6, 11, 16, 18.
Now licensed in a number of countries.

23. Summary
Benign diseases of cervix are harmless but malignancy should be excluded.
Cervical intraepithelial neoplasia proceedes cancer cervix by years.
Screening for CIN reduces mortality from cancer cervix.
Those with positive screening test should be referred to colposcopy for diagnosis and treatment.