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.
The area of cervix between the old and new squamo-
It is the area of risk of developing premalignant and
malignant disease of the cervix.
-Associated cervicitis may produce
backache, pelvic pain
p/s bright red area extending beyond
Neither tender nor bleeds on touch.
Outer edge clearly demarcated
The feel is soft, granular and gives rise
to grating sensation
It can be confused with
-early carcinoma (indurated, friable and bleeds to touch)
-primary chancre (ulcer has a punched out appearance.
-tubercular ulcer (indurated with caseation at base)
All cases should be subjected to cytological examination to
exclude dysplasia and malignancy
In symptomatic cases
-Pill should be stopped and barrier method is advised.
-persistent ectopy with troublesome discharge
In chronic cervicitis there is marked thickening of
cervical mucosa with underlying tissue edema. These
thickened tissue tend to push out through the ex. Os
along direction of least resistance.
More marked if cx already lacerated
As a result lips of cx curl upwards and outwards
exposing red looking endocervix
It frequently occurs during vaginal delivery.
One or both sides of cx may be torn, or it may b irregular
If these is no infection the torn surfaces approximate
and heal leaving a notch if infection persists it causes
Non obstetric causes include lacerations due to operative
procedures of DNC
Postmenopausal atrophy or chronic cervicitis also
predisposes to tear.
1. Nabothian cyst
2. Endometriotic cyst
3. Mesonephric cyst
Endocervical glands in the transformational zone become
covered with squamous cells and forms mucus filled
As this benign process continues, smooth, clear or yellow
glandular elevations are visible during routine
Nabothian cyst warrants no further therapy..
Situated in portio vaginalis part of
It is small reddish and <1cm dia.
Implantaion of endometrium due
to surgery or during labour
occurs giving rise to cyst
-PCB, intermenstrual bleeding
Destruction by cauterisation
Usually situated in outer side of
Seldom increase 2.5cm.
Lined by cuboidal epithelium.
They are asymptomatic .
Warrants no further treatment
It is one of the most common neoplasms
It is a hyperplastic projection of the endocervical folds.
These lesions are commonly found and may be associated
with leukorrhea and post coital spotting
If it has a slender stalk it is removed my continuous
twisting using a ring forceps. Twisting leads to occlusion of
supporting vessels and avulsion of mass
A thick pedicled polyp needs surgical excision
Excised cervical polyps require pathologic
evaluation to rule out malignancy
Usually follows child birth, abortion or any
operative procedure on cervix.
Responsible organisms aregonococcal,
chlamydia, thrichomonal vaginosis,
mycoplasma and HPV.
-Painful vaginal examination
-Tender, Oedematous and congested cx
-Muco purulent discharge seen at os
-infection spreads to adjacent structures.
-high vaginal endocervical swab to be taken for
-treat with appropriate antibiotics.
Follows attack of acute cervicitis
Endocervix ia a potential reservoir of infection
with N. gonorrhoeae, chlamydia, HPV,
-excessive mucoid discharge might be present
-h/o contact bleeding might be there
-Cx is tender
On p/s mucopurulent discharge escaping ex. Os
1) No role of antimicrobial therapy except in
2) Diseased tissue destroyed by electo or
diathermy cauterisation or laser
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
Factors that increase risk of transmission:
Early age of intercourse.
Oral contraceptive pills.
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
(severe dysplasia/CIS) Invasive cancer
Low grade squamous intraepithelial lesion (LSIL); HPV
infection, CIN I.
High grade squamous intraepithelial lesion (HSIL); CIN
II, CIN III.
Squamous cell Glandular cell
Atypical squamous cell (ASC) Atypical glandular cells (AGC) Endocervical,
endometrial, or not otherwise specified
ACS of undetermined significance(ASCUS)
Atypical glandular cells, favour neoplastic or not
ACSH cannot exclude HSIL
Low grade sq. intraepithelial lesion(LSIL) Endocervical adenocarcinoma in situ
Sq cell carcinoma
Outcome of CIN
Progression to invasive cancer.
Progression from one stage to another takes years.
Detection and treatment of CIN prevents cancer cervix.
Screening for dyskariosis by obtaining cervical cytology.
Cervical screening should be carried out every 3-5 years
in all sexually active women from 20-60 years of age.
There is a 10-15 % chance of false positive or false
Smear Risk of
Management If next smear is negative
Normal 0.1% Repeat in 3-5 years Routine
Inflammatory <6% Repeat in 3-5 years Routine
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
Repeat 1 year then 2 then routine.
Colposcopy if 3 borderline.
moderate dyskaryosis 50-70% Colposcopy Repeat after treatment
Severe dyskaryosis 80-90% Colposcopy Repeat after treatment
Invasion suspected 50% invasion Urgent colposcopy
Is the inspection of the cervix with a low powered
Magnifies the cervix 4-20 times.
The patient is put in lithotomy position.
Passing a bivalve speculum gently into the vagina.
Inspection of the cervix and its vasculature.
Green filter may help studying vasculature.
Abnormal vascular structure includes punctuation and
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
CIN II,CIN III. ?CIN I.
Techniques for treatment:
Excisional: LEEP (loop electrosurgical excision
procedure) CO2 laser cone, knife cone, hysterectomy.
Ablative: radical electrodiathermy, cold coagulation,
90-95% cure rate
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.
The first vaccine that intends to prevent cancer.
2 forms of vaccine are available
Bivalent 16, 18 (cervarix)
Quadrevalent 6, 11, 16, 18.(gardasil)
Now licensed in a number of countries.
Benign diseases of cervix are harmless but malignancy
should be excluded.
Cervical intraepithelial neoplasia proceedes cancer cervix
by years. (CIN 1 to CIN 3 twenty years)
Screening for CIN reduces mortality from cancer cervix.
Those with positive screening test should be referred to
colposcopy for diagnosis and treatment.