This is the part of the uterus below the internal os. The endocervical canal is lined with mucous columnar epithelium, the vaginal cervix with squamous epithelium. The transition zone between them the squamo columnar junction is the area which is predisposed to malignant change.
Cervical ectropion
This is often called erosion, an alarming term for a normal phenomenon. There is a red ring around the os because the endocervical epithelium has extended its territory over the paler epithelium of the ectocervix. Ectropions extend temporarily under hormonal influence during puberty, with the combined Pill, and during pregnancy. As columnar epithelium is soft and glandular, ectropion is prone to bleeding, to excess mucus production, and to infection.
Treatment
Cryocautery will treat these if they are a nuisance; otherwise no treatment is required.
Nabothian cysts
These mucus retention cysts found on the cervix are harmless.
Treatment
Cryocautery if they are discharging.
Cervical polyps
These pedunculated benign tumours of endocervical epithelium may cause increased mucus discharge or postcoital bleeding.
Treatment
In young women they may be simply avulsed, but in older women treatment usually includes D&C to exclude intrauterine pathology.
Cervicitis
This may be follicular or mucopurulent, presenting with discharge.
Causes
Chlamydia (up to 50%), gonococci, or herpes (look for vesicles). Chronic cervicitis is usually a mixed infection and may respond to antibacterial cream. Cervicitis may mask neoplasia on a smear.
Cervical screening
Cervical cancer has a pre-invasive phase: cervical intraepithelial neoplasia (CIN not to be pronounced sin'). Papanicolaou smears collect cervical cells for microscopy for dyskaryosis (abnormalities which reflect CIN). A smear therefore identifies women who need cervical biopsy. The degree of dyskaryosis approximates to the severity of CIN (Table, p 273). ~50% of CIN I lesions return to normal but most CIN III lesions progress to invasive carcinoma. This may take ~10yrs, but may happen much faster in young women.
In the UK from 2005 it is recommended that 1st smear be taken at aged 25, then 3 yearly until 49 years, 5 yearly from 50 to 64 years and only to screen after 65 years if one of the last 3 included an abnormal result. Those most at risk are the hardest to trace and persuade to have screening, eg older women, smokers, and those in inner cities. 83% of the eligible UK population is now screened, and mortality here is starting to fall; this depends critically on being able to retain skilled lab staff.
Taking a smear
Explain the nature and purpose of the test, and how results will be conveyed. Warn that results are not always unequivocal.
The cervix is visualized with a speculum (p 242). Are there any suspicious areas? If so, carry on with the smear and indicate this on the referral form, but do not wait for its results before arranging further care.
Cells are scraped from the squamo-columnar transformation zone with a special spatula or brush, then transferred to a slide and fixed at once. Liquid based cytology (LBC)1 involves rinsing the sampler or detaching its head into a vial of liquid creating a cell suspension from which slides are prepared which are quicker and easier to screen than conventional smears. The suspensions can also be tested for herpes virus and chlamydia. Inadequate smear rates are reduced with LBC. Good technique is needed (make sure that all 4 quadrants of the cervix are sampled); it is best to learn by instruction from an expert at the bedside.
Advertisements
