O Cervical dysplasia refers to the presence
of precancerous changes of the cells that
make up the inner lining of the cervix, the
opening to the womb (uterus).
O The term dysplasia refers to the abnormal
appearance of the cells when viewed
under the microscope. The degree and
extent of abnormality seen on a tissue
sample (such as a Pap smear) was
formerly referred to as mild, moderate, or
The 2 new systems for studying the cervical dysplasia :.
O (cytological system ): Squamous
intraepithelial lesion is the pathology
terminology for cervical dysplasia observed in
smears of cells taken from the cervix.
Squamous refers to the type of cell that lines
the cervix. intraepithelial refers to the fact that
these cells are present in the lining tissue of
O (histological system ): Cervical intraepithelial
neoplasia is cervical dysplasia that is
observed on a cervical biopsy or surgically
The causes :
O Cervical dysplasia is caused by infection of the cervix
with the human papillomavirus (HPV). Although there
are over 100 HPV types, a subgroup of HPVs have been
found to infect the lining cells of the genital and
reproductive tract in women. HPV is a very common
infection and is transmitted through sexual contact; , it is
possible to become re-infected with a different HPV
O Factors that may influence persistence of the infection
O advancing age,
O duration of the infection, being infected with a "high-
risk" HPV type).
O Among the HPVs that infect the genital tract,
certain types typically cause warts or mild
dysplasia ("low-risk" types; HPV-6, HPV-11),
while other types (known as "high-risk" HPV
types) are more strongly associated with
severe dysplasia and cervical cancer (HPV-
16, HPV-18). Cigarette smoking and
suppression of the immune system (such as
with concurrent HIV infection) have been
shown to increase the risk for HPV-induced
dysplasia and cancer of the cervix.
O The HPV types that cause cervical cancer
also have been linked with both anal and
penile cancer in men as well as a subgroup of
head and neck cancers in both women and
Risk factor :
O In women, an increased risk of a
persistent HPV infection is associated
O Early initiation of sexual activity.
O Having multiple sex partners.
O Having a partner who has had multiple
O Having sex with an uncircumcised man.
Signs or symptoms :
O Typically, cervical dysplasia does not
produce any signs or symptoms. So
regular screening is important for early
diagnosis and treatmen
O Because a pelvic exam is usually normal in women with cervical dysplasia, a
Pap test is necessary to diagnose the condition.
O Although a Pap test alone can identify mild, moderate, or severe cervical
dysplasia, further tests are often required to determine appropriate follow-up
and treatment. These include:
O Repeat Pap tests.
O Colposcopy, a magnified exam of the cervix to detect abnormal cells so that
biopsies can be taken.
O Endocervical curettage, a procedure to check for abnormal cells in the
O Cone biopsy or loop electrosurgical excision procedure (LEEP), which are
performed to rule out invasive cancer. During a cone biopsy, the doctor
removes a cone-shaped piece of tissue for lab examination. During LEEP, the
doctor cuts out abnormal tissue with a thin, low-voltage electrified wire loop.
O HPV DNA test, which can identify the HPV strains which are known to
cause cervical cancer.
Classification / cytologic
O Cytological analysis : by pap smear
O ASC-US: This abbreviation stands for atypical squamous cells of
undetermined significance. The word "squamous" describes the thin, flat
cells that lie on the surface of the cervix. One of two choices are added
at the end of ASC: ASC-US, which means undetermined significance, or
ASC-H, which means cannot exclude HSIL
O LSIL: This abbreviation stands for low-grade squamous intraepithelial
lesion. This means changes characteristic of mild dysplasia are observed
in the cervical cells.
O HSIL: This abbreviation stands for high-grade squamous intraepithelial
lesion. And refers to the fact that cells with a severe degree of dysplasia
Classification / histological
O Histologic analysis (cervical biopsies):
O CIN 1 refers to the presence of dysplasia confined to the
basal third of the cervical lining, or epithelium (formerly
called mild dysplasia). This is considered to be a low-grade
O CIN 2 is considered to be a high-grade lesion. It refers to
dysplastic cellular changes confined to the basal two-thirds
of the lining tissue (formerly called moderate dysplasia).
O CIN 3 is also a high grade lesion. It refers to
precancerous changes in the cells encompassing greater
than two-thirds of the cervical lining thickness, including full-
thickness lesions that were formerly referred to as severe
dysplasia and carcinoma in situ.
O CIN (cervical intraepithelial neoplasia )
O Most women with low grade (mild) dysplasia (LGSIL, CIN1) (when
the diagnosis is confirmed and all abnormal areas have been
visualized), will undergo spontaneous regression of the mild
dysplasia without treatment. Therefore, monitoring without specific
treatment is often indicated in this group. Treatment is appropriate
for women with high-grade cervical dysplasia.
O Treatments for cervical dysplasia fall into two general categories:
destruction (ablation) of the abnormal area and removal (resection).
Both types of treatment are equally effective. Generally, destruction
(ablation) procedures are used for milder dysplasia and removal
(resection) is recommended for more severe dysplasia or cancer.
O The destruction (ablation) procedures are carbon dioxide laser
photoablation and cryocautery. The removal (resection) procedures
are loop electrosurgical excision procedure (LEEP), cold knife
conization, and hysterectomy. Treatment for dysplasia or cancer is
not usually done at the time of the initial colposcopy, since the
treatment depends on the analysis of the biopsies done during
Carbon dioxide laser
O This procedure, which is also known as CO2 laser,
uses an invisible beam of infrared light to
essentially vaporize the abnormal area. A local
anesthetic is given to numb the area prior to the
laser treatment. A substantial amount of clear
vaginal discharge and spotting of blood can occur
for a few weeks after the procedure. The
complication rate of this procedure is very low,
about 1%. The most common complications are
narrowing (stenosis) of the cervical opening and
delayed bleeding. Disadvantages of this treatment
include that this procedure does not allow
sampling of the abnormal area and is not
satisfactory for treating cervical cancer. It is useful,
however, for milder dysplasia
O Like the laser treatment, cryocautery is an ablation therapy.
It uses nitrous oxide to freeze the abnormal area. This
technique, however, is not optimal for large areas or areas
where abnormalities are already advanced or severe. After
the procedure, women may experience a significant watery
vaginal discharge for several weeks. As with laser ablation,
significant complications of this procedure are rare and
occur in about 1% of patients. They include narrowing
(stenosis) of the cervix and delayed bleeding. Cryocautery
also does not allow sampling of the abnormal area and is
generally felt to be inappropriate for women with advanced
cervical disease. Thus, this procedure is not satisfactory for
treating cervical cancer, but is useful for milder dysplasia.
Loop electrosurgical excision
O Loop electrosurgical excision procedure, also
known as LEEP, is an inexpensive, simple
technique that uses a radio-frequency current
to remove abnormal areas. It has an
advantage over the destructive techniques in
that an intact tissue sample for analysis can
be obtained. Vaginal discharge and spotting
commonly occur after this procedure.
Complications occur in about 1% to 2% of
women undergoing LEEP, and include
cervical narrowing (stenosis) and bleeding.
This procedure is used most commonly for
treating dysplasia, including severe dysplasia.
Cold knife cone biopsy
O Cone biopsy (conization) was once the primary
procedure used to treat cervical dysplasia, but the
other methods have now replaced it for this
purpose. However, when a physician cannot view
the entire area that needs to be seen during
colposcopy, a cone biopsy is typically
recommended. It is also recommended if
additional tissue sampling is needed to obtain
more information regarding the diagnosis. This
technique allows the size and shape of the
sampling to be tailored. Cone biopsy has a slightly
higher risk of cervical complications than the other
treatments, and these can include postoperative
bleeding in 5% of women and narrowing of the
O Hysterectomy is the surgical removal of
the uterus. This operation is used to treat
virtually all cases of invasive cervical
cancer. Sometimes, a hysterectomy is
done to treat severe dysplasia. It may also
be used if dysplasia recurs after any of the
other treatment procedures
O Low-grade cervical dysplasia (LGSIL and/or CIN1)
often spontaneously resolves without treatment,
but careful monitoring and follow-up testing is
required. Both ablation and resection of areas of
cervical dysplasia cure approximately 90% of
women with dysplasia, meaning that 10% of
women will have a recurrence of their abnormality
after treatment, requiring additional treatment.
When untreated, high grade cervical dysplasia
may progress to cervical cancer over time.
Resection and ablation therapies have been
shown to reduce the risk of developing cervical
cancer by 95% in the first eight years after
treatment in women with high grade dysplasia.
O A vaccine is available against four common HPV types associated with the
development of dysplasia and cervical cancer. This vaccine (Gardasil) has
received FDA approval for use in women between 9 and 26 years of age and
confers immunity against HPV types 6, 11, 16 and 18.
O Abstinence from sexual activity can prevent the spread of HPVs that are
transmitted via sexual contact. However, some researchers believe that HPV
infection might be transmitted from the mother to infant in the birth canal,
since some studies have identified genital HPV infection in populations of
young children and cloistered nuns. Hand-genital and oral-genital
transmission of HPV has also been documented and is another means of
O HPV is transmitted by direct genital contact. The virus is not found in or
spread by bodily fluids, and HPV is not found in blood or organs harvested for
transplantation. Condom use seems to decrease the risk of transmission of
HPV during sexual activity but does not completely prevent HPV infection.
Spermicides and hormonal birth control methods do not prevent the spread of
The patient said that she had abnormal Pap
tests, dysplasia and cancer
.she was 24 years when she received a post
card in the mail saying she needed to call the
office, They did a repeat PAP test that came
back as Class 3 dysplasia, then she had a D&C.
They decided to follow it for a few months. Then
she married and have 2 babies
What is the possible treatment for her now ?