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Cervical Dysplasia and Carcinoma

• Neoplasia is an abnormal growth of cells
• Dysplasia is an abnormal development typically with an excess of immature cells
• Cervical dysplasia and carcinoma have been linked to human papillomavirus (HPV)

Risk factors

• Sexual activity increases risk for exposure to HPV
  • The younger the age of first intercourse the greater the risk
  • Risk increases with the number of sexual partners
  • Risk increases with sexual partners who have multiple sexual partners
  • Use of condoms or a diaphragm decreases risk
  • HPV exposed patient should be monitored closely
• Low socioeconomic status
• Smoking

Clinical Presentation

• Routine pap smear. Unless very advanced invasive disease there will be no symptoms

Labs and Studies

• Papanicolaou Smear
  • Normal
  • Mild cervical intraepithelial neoplasia (CIN-1)
  • Moderate cervical intraepithelial neoplasia (CIN-2)
  • Severe cervical intraepithelial neoplasia (CIN-3)
  • Carcinoma in situ (CIS), about one third of CIN-3 will progress to CIS
• Colposcopy
  • Schiller test
  • Paint the cervix with Lugol’s iodine. Cells that do not stain should be biopsied
• Biopsy
  • Punch biopsy
  • Endocervical curettage
  • Conization
    • For CIN-3 or CIS – The removal of a cone shaped area of the cervix including the entire transformation zone. This can be done with a scalpel, laser or as a loop electrosurgical excision procedure (LEEP)

Treatment

• Gardasil and Cervarix
  • HPV vaccines for patients not previously exposed to HPV
  • Recommended for women age 9-26
• Conization may be used to treat pre-invasive CIN
• Hysterectomy with pelvic lymphadenectomy for more advanced disease
• Radiation treatment may be necessary

Cervical Incompetence

• The Cervix dilates and effaces before labor. This becomes a concern when it threatens the viability of the pregnancy.

Clinical Presentation

• Routine prenatal exam

Labs and studies

• Bimanual physical exam
• U/S vaginal

Treatment

• Surgical cerclage
  • Using suture to reinforce the cervix in the operating room

Cervicitis

• An infection of the cervix which is similar to urethritis in men

Clinical Presentation

• Pelvic discomfort
• Mucopurulent discharge

Labs, Studies and Physical Exam Findings

• Friable cervix
• Mucopurulent discharge
• Gram stain
  • Difficult to isolate an organism
  • Chlamydia and Neisseria gonorrhoeae make up 40% of cases
  • Trichomonas vaginalis is also common

Treatment

• Chlamydia
  • Azithromycin 1 g oral (PO) in a single dose
  • Doxycycline 100 mg PO twice daily (bid) for 7 days
• Neisseria
  -Ceftriaxone 250 mg administered intramuscularly (IM) in a single dose, PLUS
  Azithromycin 1 g PO in a single dose

Vulvar and Vaginal Neoplasms

• Malignancies are most commonly squamous cell carcinomas
• Vaginal cancer is rare
• Vulvar intraepithelial neoplasms (VIN)
  • VIN-1 = mild
  • VIN-2 = moderate
  • VIN-3 = severe
  • Vulvar carcinoma in situ

Risk factors

• HPV Infection
• History of VIN
• History of CIN
• History of cervical cancer
• HIV infection
• Smoking

Clinical Presentation

• Routine office visit
• Vulvar itching is the most common complaint
• Vaginal bleeding
• Vaginal mass

Labs, Studies and Physical Exam Findings

• Acetic acid
• Toluidine blue staining
• Lugol staining
• Colposcopy
• Biopsy

Treatment

• Vulvar neoplasm
  • Local excision – vulvectomy
  • Radiation and chemotherapy
• Vaginal cancer
  • Radical hysterectomy
  • Upper vaginectomy
  • Pelvic lymphadenectomy
  • Intracavity or external beam radiation

Vaginitis

• There are three main classes of vaginitis
  • Yeast Infection
  • Trichomonas
  • Bacterial vaginosis (BV)

Clinical Presentation

• Vaginal irritation
• Pruritus
• Pain and/or burning
• Unusual discharge either profuse or foul smelling

Labs, Studies and Physical Exam Findings

• Culture of cervix (not really helpful to culture the vagina)
• Vaginal pH – normal is 4.5 or less
• Microscopic examination of discharge
• Careful inspection of vulva, vagina and cervix

Candida albicans (yeast infection)

Risk Factors

• Use of antibiotics
• Use of Corticosteroids
• DM`
• Pregnancy
• Moisture and heat

Clinical Presentation

• Pruritus
• Burning
• Dyspareunia
• White cottage cheese like discharge

Labs and Studies

• Microscopic exam with 10% potassium hydroxide shows hyphae and spores
• Vaginal pH > 4.5

Treatment

• Topical azoles
• Oral fluconazole 150 mg oral tablet single dose may be repeated if infection is not cleared

Trichomonas vaginosis

• Flagellated protozoan that is sexually transmitted

Clinical Presentation

• Pruritus
• Malodorous frothy, yellow-green discharge
• Severe vaginal erythema

Labs and studies

• Wet mount – motile flagellates

Treatment

• Metronidazole 2 grams one time may be repeated if not cleared
• All partners should be treated

Bacterial Vaginosis

• Polymicrobial infection, not sexually transmitted

Clinical Presentation

• Grey, frothy, malodorous discharge

Labs and studies

• Wet mount
  • Clue cells – epithelial cells covered in bacteria
• Whiff test – KOH will enhance the oder

Treatment

• Metronidazole 500 mg po BID x 7 days
• Clindamycin

Condylomata acuminata

• HPV 6 and 11 virus, sexually transmitted

Presentation

• Warty growths

Labs and Studies

• Acetic acid – warts turn white
• Colposcopy

Treatment

• Cryotherapy with liquid nitrogen
• Trichloroacetic acid
• CO2 laser
• Surgical removal

Review Questions

Q) Clue cells should make you think of what diagnosis?
A) Bacterial vaginosis

Q) How do you treat a yeast infection?
A) Fluconazole 150 mg one tablet

Q) How is cervical dysplasia initially diagnosed?
A) Routine yearly pap smear

Q) What three organisms cause the majority of cervicitis?
A) Chlamydia and Neisseria gonorrhoeae make up 40% of cases Trichomonas