Before we start talking about pathologies related to the cervix, let's talk about its morphology and its tasks. This is the part of the uterus that we see with a speculum during a gynecological examination and together with the body of the uterus and the fallopian tubes, it creates this beautiful organ. Its appearance changes throughout our lives: initially, it is associated with maturation and changes in the proportions of length between the cervix and the body, and after reaching puberty, it changes further depending on our fertility. On the vaginal side, there is the vaginal part of the cervix, also called the cervical shield, on which the external opening is located and from which we take a cytological test. On the uterine side, there is the internal opening and the isthmus, i.e. the place where the cervix passes into the body of the uterus. What is it actually needed for? It is a tunnel through which the uterus communicates with the outside world, which is why the cervix has an external and internal opening, i.e. places that are usually closed, and in certain situations, they open or open completely - depending on the need. When? During menstruation, blood needs to escape from the uterus and our cervix is responsible for this. An incredible thing happens during childbirth, when the cervix, which has an opening the size of a pinhead, "opens" to 10 cm and practically disappears, gradually shortening (you can hear more about the extraordinary extensibility of the cervical tissue in this film ). And let someone tell me that childbirth is not a miracle :) Unfortunately, despite its incredible beauty, the cervix is not free from diseases and pathologies, which I will try to explain to you below.
The first contact with the cervix usually takes place during a cytology test. As a standard, we take a smear from the disc and external opening with a rubber brush, spread it on a glass plate, and then the cytologist evaluates it under a microscope. There is also a second option, liquid cytology. The method of collection is the same, but the material is not spread on a plate, but in a liquid, which also allows for additional tests, e.g. for the presence of the HPV virus or additional immunohistochemical staining. Cytology is a test that allows for the prevention of cervical cancer and we should do it once a year - this is my opinion and I repeat it to my patients. Unfortunately, this is one of the cases in my practice when I do not fully follow the guidelines. The National Health Fund recommends performing a cytology test once every 3 years in women aged 25-59 who do not have risk factors for cervical cancer. The Polish Gynecological Society allows cytology to be taken even every 5 years (in women without risk factors, with a normal previous cytology result and an additional negative HPV test result - we will talk about it later). Why did I pick on this year? For two reasons: firstly, I believe that it is a minimally invasive and low-cost test, giving us information about the presence of cancerous changes in our body. Secondly, the sensitivity of classic cytology is, according to various sources, from 50 to 70%. This means that in the case of 10 women who actually have pre-cancerous or cancerous changes on the cervix, 3 to 5 of them will not have any changes in the cytology. It is worth doing this test every year, increasing your chances of detecting a cancerous process.
Okay, but what if the cytology is bad... Don't worry, we just keep diagnosing. It's a screening test, so its purpose is to simply "screen out" people at risk of cancer. We have to remember that between "good cytology" and cancer there is a whole range of intermediate results. Of course, we won't discuss all of them, but we will briefly discuss the diagnostic and therapeutic possibilities associated with them.
The first option for expanding diagnostics after cytology is colposcopy. This is nothing more than viewing the cervix under a microscope. Is it painful? The discomfort is mainly related to inserting the speculum. During the examination, we assess the appearance of the cervix with and without reagents (here, a strange sensation related to pouring fluid into the vagina and a slight burning sensation may appear). Based on the colposcopic image, we assess not only "there is cancer" or "there is no cancer", but also the severity of the changes and the possibility of possible observation of the patient.
If cancerous changes are suspected during colposcopy, the next step is to take samples from the cervix. This procedure is performed differently in different centers. And I don't mean the technique itself, because here everything is quite simple - we take samples under the control of the colposcope or after colposcopy, where the result clearly indicates where the suspicious places are. The differences mainly consist in the type of anesthesia: local, short intravenous, and I have seen both when taking samples and in the operating theater. These differences are not only due to the place (clinic, hospital), but also to the technical conditions in your vagina ;) If we care about time, we go to the clinic and after an hour we return home with a smile. If we are panicky - we choose the hospital. The procedure itself is not complicated and burdensome, the main factor causing the above differences is the patient's acceptance of the method of performance - you have a choice :) What next? Depending on the histopathological result, which will describe in black and white the changes in your cervix, you either move on to the observation stage or surgical treatment should be applied. Ok, but I started with the worse scenario. Colposcopy can also rule out changes in the cervix. The cytologist only evaluates the smear of cells, the colposcopist sees the entire organ and this is after using various reagents or light filters that allow him to differentiate the changes in our cervix. It may be necessary to repeat cytology after anti-inflammatory treatment ( I wrote about inflammation in the first post ) or we will return to basic screening altogether.
Another test that helps us diagnose the cervix is the HPV DNA test. And here I would like to introduce you to our villain - the human papillomavirus. The test consists of taking a smear from the cervix (exactly the same as during cytology) and marking the DNA of the virus in it. What are the differences between the individual tests (because there are many of them in the offer of different clinics). The number of virus types that are marked - we always offer genotypes with the highest oncogenicity. But now maybe a little more about the virus itself. According to various sources, from 100 to 200 of its types have been identified, which are divided into oncogenic and non-oncogenic. How do we get infected? Mainly through sexual intercourse, which is why this virus is mainly widespread in the population of young adults. It is possible to be infected through a towel, underwear, in a public toilet or at a swimming pool, but let's face it - it is ultra rare, in most cases it is sexual intercourse.
Oncogenic types are those with numbers 16, 18, 31, 33, 35, 39, 40, 43, 51, 52, 53, 54, 55, 56, 58. Their DNA is found in almost 100% of cervical cancers, so it is a virus closely related to this disease (but also often to head and neck cancers). But don't be scared - most HPV infections are self-healed by our immune system. Infections that carry a risk of developing cervical cancer are persistent infections. How to differentiate them? You can simply do a repeat test with colposcopy in a few months, but you can also do an HPV mRNA test, which detects the proteins of the basic oncogenic types (usually fourteen) responsible for persistent infection and oncogenesis.
We also have non-oncogenic types (1, 2, 6, 11, 42, 43, 44), which in most cases are asymptomatic. However, sometimes they cause the formation of warts on the skin or condyloma acuminata (genital warts) in the area of the genitals and anus. It does not look too good, but fortunately we have many treatment options, which should be carried out under the watchful eye of a doctor. There is also a large selection of ointments (whether of a cytostatic nature or increasing the immune response of our body) or procedures (such as electrocoagulation, cryotherapy, laser therapy, and in extreme cases surgical treatment). Remember that untreated condylomas can lead to the formation of Buschke-Loewenstein condyloma or squamous cell carcinoma, but these are extremely rare cases today.
Fortunately, we can get vaccinated against this virus. There are 2, 4 and 9-valent vaccines, and these numbers indicate how many types of the virus it works against (each protects against the most oncogenic types 16 and 18). Unfortunately, the availability of these vaccines varies (this is a global problem), but we must remember that one dose does not change anything. From 9 to 14 years of age, we take two doses of the vaccine, and after 14 - three. Of course, it is best to get vaccinated before starting sexual intercourse, but starting to have sex does not exclude taking the vaccine.
The change I would like to discuss about the cervix is the erosion known to everyone, which was burned and frozen with great passion some time ago. What is this erosion? Erosion is divided into two groups: true and pseudo. True erosion is a defect of the epithelium on the cervix. In such cases, we can see in the speculums the cervical stroma, which is bright red and bleeds on contact. It can develop on the basis of pre-cancerous changes, but also after mechanical or chemical injuries. It requires cytological diagnostics and further treatment. However, this is a very rare condition, most often we deal with the second type, i.e. pseudoerosion, also known as glandular ectopy. It looks very similar and macroscopically is very often indistinguishable from true erosion. It also causes contact bleeding (e.g. after taking a cytology or intercourse). How is it formed? The epithelium present in the cervical canal "comes out" onto its shield. Just as each of us has a different nose, we can also have different necks ;) What are the indications for treatment? Abnormal cytology, recurrent inflammation, intermenstrual bleeding.
The cervix is a very broad and very interesting subject. It is affected by many diseases, but at the same time it has a pinch of magic because of its extreme ability to open during labor. Unfortunately, most of us will not have the pleasure of getting to know it, but we can be proud to consider it our superpower ;)
Created at: 13/08/2022
Updated at: 13/08/2022
