1. Ateneo School of Medicine and Public Health 16 November 2011
Cervical Lesions
Maria Julieta V. Germar, FPOGS, FSGOP
Section of Gynecologic Oncology
UP College of Medicine-Philippine General Hospital
The Medical City
Ateneo School of Medicine and Public Health 16 November 2011

2. Lecture Outline 2011 updates Review: Anatomy
Benign Lesions of the Cervix
Clinical Presentation, Diagnosis
Management
Infectious Conditions:Cervicitis
Cervical Cancer
Prevention
Diagnosishhhh
Staging
2011 updates

3. The cervix
corresponds to the narrow stalk end of the pear shaped uterus
a cylindrical-shaped muscular structure , about 3-5cm in length and partly lies in the upper vagina, extending superiorly into the retroperitoneal space behind the bladder and in front of the rectum.

4. The cervix
The length and width of the endocervical canal varies; it is usually 2.5 to 3 cm in length The width of the canal varies with the parity of the woman and changing hormonal levels.

5. A single layer of columnar epithelium lines the endocervical canal and the underlying glandular structures. This specialized epithelium secretes mucus, which facilitates sperm transport.

6. An abrupt transformation usually is seen at the junction of the columnar epithelium of the endocervix and the nonkeratinized stratified squamous epithelium of the portio vaginalis The stratified squamous epithelium of the exocervix is identical to the lining of the vagina.

7. Speculum examination of the vagina and cervix

8. Benign Lesions of the Cervix
Endocervical Polyp
Nabothian Cyst
Cervical Myoma

9. Endocervical Polyps Most common benign neoplasm of the cervix
Usually found in the 4th to 6th decade of life.
May be single or multiple and may be pedunculated lesion on a stalk of varying length.
May be cervical/ectocervical or endocervical

10. Endocervical polyps
Polyps may arise from either the endocervical canal (endocervical polyp) or ectocervix (cervical polyp).
Endocervical polyps are more common than are cervical polyps.
Polyps whose base is in the endocervix usually have a narrow, long pedicle and occur during the reproductive years, whereas polyps that arise from the ectocervix have a short, broad base and usually occur in postmenopausal women.

11. Endocervical polyps Etiopathogenesis:
abnormal focal responsiveness to hormonal stimulation or local inflammation
The color of the polyp depends in part on its origin, with most endocervical polyps being cherry red and most cervical polyps grayish white.

12. Endocervical Polyps CLINICAL PRESENTATION Polyps bleed easily to touch
Usually asymptomatic but may also present as abnormal bleeding: post coital bleeding, menorrhagia, postmenopausal bleeding
DIAGNOSIS
Speculum examination then Biopsy
MANAGEMENT
Polypectomy, surgical dilatation and curettage, hysteroscopic polypectomy

13. Benign Lesions of the Cervix
Endocervical Polyps
Nabothian Cyst
Cervical Myoma

14. Nabothian Cysts
mucus-filled lesions ,multiple translucent or opaque, white or yellow lesion ranging from 2mm to 10mm in size.
retention cysts of endocervical columnar cells occurring where a tunnel or cleft has been covered by squamous metaplasia.
These cysts are so common that they are considered a normal feature of the adult cervix

15. Nabothian cysts
The area of the transformation zone of the cervix is in an almost constant process of repair, and squamous metaplasia and inflammation may block the cleft of a gland orifice.
The endocervical columnar cells continue to secrete, and thus a mucous retention cyst is formed.

16. Nabothian Cysts asymptomatic CLINICAL PRESENTATION
tend to occur following natural tissue regrowth after minor trauma or after childbirth.
DIAGNOSIS
Clinical, Speculum exam
MANAGEMENT
usually asymptomatic and need no treatment.

17. Benign Lesions of the Cervix
Endocervical Polyps
Nabothian Cyst
Cervical Myoma

18. Cervical Myoma A cervical myoma is usually a solitary growth
Because of the relative paucity of smooth muscle fibers in the cervical stroma, the majority of myomas that appear to be cervical actually arise from the isthmus of the uterus.
CLINICAL PRESENTATION:
Vaginal Bleeding
dysuria,urgency, obstruction and dyspareunia

19. Cervical Myoma DIAGNOSIS Speculum, Pelvic examination, Biopsy
MANAGEMENT
if reproductive age : GnRH agonists ( to shrink myoma), excision
If completed family size: Hysterectomy

20. Infectious Conditions of the Cervix
Condyloma
Gonococcal Cervicitis
Chlamydial cervicitis

21. Condyloma acuminata, cervix
CLINICAL PRESENTATION
The warts may be raised or flat, single or multiple, small or large. Some may cluster to form a cauliflower-like shape.
Condyloma acuminatum is the most common viral sexually transmitted disease of the vulva, vagina, rectum, and cervix

22. Condyloma acuminata, cervix
Genital warts are caused by the human papillomavirus (HPV). Most commonly
HPV 6,11
HPV is easily spread during oral, genital, or anal sex with an infected partner.

23. Condyloma acuminata, cervix
The virus can be shed from both macroscopic and microscopic lesions.
It is highly contagious, with 25% to 65% of sexual partners developing the infection.
Studies have demonstrated condoms offer only modest protection against HPV transmission.
The average incubation period is 3 months, with a wide range of 1 to 8 months.
peak incidence occurs between the ages of 15 and 25 years.

24. Condyloma acuminata, cervix
DIAGNOSIS
Speculum exam, biopsy, colposcopy
MANAGEMENT
ablative
Cryosurgery (freezing)
electrocautery
Laser treatment
PREVENTION
Abstinence
HPV Vaccine

25. Infectious Conditions of the Cervix
Condyloma
Gonococcal Cervicitis
Chlamydial cervicitis

26. Gonococcal Cervicitis
MICROBIOLOGY:
Etiologic agent: Neisseria gonorrhoeae
Gram-negative intracellular diplococcus
Infects mucus-secreting epithelial cells

27. Gonococcal Cervicitis
CLINICAL MANIFESTATIONS:
Cervicitis – inflammation of the cervix
Non-specific symptoms: abnormal vaginal discharge, intermenstrual bleeding, dysuria, lower abdominal pain, or dyspareunia
Clinical findings: mucopurulent or purulent cervical discharge, easily induced cervical bleeding
60% of women with clinical cervicitis have no symptoms
symptoms may occur within 10 days of infection

28. Gonococcal Cervicitis
DIAGNOSIS
Culture
Non-culture tests
Polymerase chain reaction (PCR) (Roche Amplicor)
Gram stain
All patients tested for gonorrhea should be tested for other STDs, including chlamydia, syphilis, and HIV.
MANAGEMENT
Antibiotic treatment of patient and partner (within the past 60 days)

29. Treatment for Uncomplicated Infections of the Cervix, Urethra, and Rectum
Recommended Regimens* Ceftriaxone 250 mg IM in a single dose. If there's an oropharyngeal component this is preferred    OR Cefixime400 mg orally in a single dose    OR Ciprofloxacin 500 mg orally in a single dose*    OR Ofloxacin 400 mg orally in a single dose*    OR Levofloxacin250 mg orally in a single dose*    PLUS TREATMENT FOR CHLAMYDIA IF
CHLAMYDIAL INFECTION IS NOT RULED OUT
2011 updates
*Contraindicated in pregnancy and children. Not recommended for infections acquired in California, Asia, or the Pacific, including Hawaii. 29

30. Co-treatment for Chlamydia trachomatis
Patients infected with N. gonorrhoeae frequently are coinfected with C. trachomatis;
Azithromycin
1 g
Orally
Once or
Doxycycline
100 mg
Twice a day for 7 days
Sexual abstinence for 7 days 30