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A Pap test should not be done when a woman is menstruating. However, Pap smears can be performed during a woman’s menstrual period, especially if the physician is using a liquid-based test; if bleeding is extremely heavy, endometrial cells can obscure cervical cells, and it is therefore inadvisable to have a Pap smear if bleeding is excessive.
The patient’s perception of the procedure ranges from no discomfort at all to severe discomfort (especially in women with cervical stenosis). Many women experience spotting or mild cramping afterward.
The physician or operator collecting a sample for the test inserts a speculum into the patient’s vagina, to allow access to the cervix. Samples are collected from the outer opening or Os of the cervix using an Aylesbury spatula and an endocervical brush, or (more frequently with the advent of liquid-based cytology) a plastic-fronded broom. The broom is not as good a collection device, since it is much less effective at collecting endocervical material than the spatula and brush. The cells are placed on a glass slide and checked for abnormalities in the laboratory.
The sample is stained using the Papanicolou technique, in which tinctorial dyes and acids are selectively retained by cells. Unstained cells cannot be visualized with light microscopy. The stains chosen by Papanicolou were selected to highlight cytoplasmic keratinization, which actually has almost nothing to do with the nuclear features used to make diagnoses now.
Guidelines on whom to screen vary from country to country. In general, screening starts at age 20 or 25 and continues until about age 50 or 60. There is probably no benefit screening women aged 60 or over whose previous tests have been negative.
There is little or no benefit to screening women who have not had sexual contact. HPV can be transmitted in sex between women, so women who have only had sex with other women should be screened, although they are at somewhat lower risk for cervical cancer.
Guidelines on frequency of screening vary – typically every one to three years for those who have not had previous abnormal smears. Women should wait no more than three years after the first time they have intercourse to start screening since most women contract HPV soon after becoming sexually active. It takes an average of a year, but can take up to four years, for a woman’s immune system to control the initial infection. Screening during this period may show this immune reaction and repair as mild abnormalities, which are usually not associated with cervical cancer, but could cause the woman stress and result in further tests and possible treatment. Cervical cancer usually takes time to develop, so delaying the start of screening a few years does not pose much risk of missing a potentially precancerous lesion.
Pap smear screening is still recommended for those who have been vaccinated against HPV, since the vaccines do not cover all of the HPV types that can cause cervical cancer. Also, the vaccine does not protect against HPV exposure before vaccination.
14.3. Other Prevention Measures for Cancer of Cervix
Full – thickness involvement of the epithelium; without invasion into the stroma (carcinoma in situ).
IA – Diagnosed only by microscopy; no visible lesions
IA1 – Stromal invasion less than 3 mm in depth and 7 mm or less in horizontal spread
IA2 – Stromal invasion between 3 and 5 mm with horizontal spread of 7 mm or less
IB – Visible lesion or a microscopic lesion with more than 5 mm of depth or horizontal spread of more than 7 mm
IB1 – Visible lesion 4 cm or less in greatest dimension
IB2 – Visible lesion more than 4 cm
IIA – Without parametrial invasion, but involve upper 2/3 of vagina
IIB – With parametrial invasion
IIIA – Involves lower third of vagina
IIIB – Extends to pelvic wall and/or causes hydronephrosis or non-functioning kidney
IVA – Invades mucosa of bladder or rectum and/or extends beyond true pelvis
IVB – Distant metastasis
Vaccination is the recent advance in the treatment of Cervix. Vaccination option becomes more of a prevention treatment and studies are going on to test the usability and advantage in women who are vaccinated against the Cancer of Cervix compared to those women who are not vaccinated against Cancer of Cervix. The report below is a news article from the United States of America Food and Drug Administration Department regarding the launching of the Cervarix Vaccine. Other vaccine present is the Gardasil.
As the saying goes, Prevention is better than cure, and the prevention steps towards being affected by Cancer of Cervix by which one can get known early about whether they are affected by Cancer of Cervix.
Prevention measures are taken up by screening suspected women for Cancer of Cervix. Screening is carried out Pap test, also known as Pap smear or Papanicolou Smear Test.
Various examinations have been developed and devised to confirm the probabilities of Cancer of the Cervix. The investigation procedures are as follows:
10.1. The Pap smear
10.2. Colposcopy Exam
10.3. Cervical Biopsy and Endocervical Curettage
10.4. Cone Biopsy and loop electrical excision procedure (LEEP)
The Pap smear plays a vital role in diagnosing cervical cancer. It is how most women discover they suffer from cervical dysplasia or cervical cancer. The Pap smear is a simple test that can reveal cervical abnormalities long before they progress into cancer.
If Pap smear results reveal cervical abnormalities, a Colposcopy is then scheduled. A Colposcopy is an in-office exam that allows the doctor to view the cervix more closely with a colposcope. A colposcope is a lighted instrument that magnifies the cervix. It rests externally, outside of the vagina, during the exam. The images seen from the colposcope may be projected on a computer or television screen. You are not obligated to watch, but it may help you understand the exam better.
During the Colposcopy, the doctor may perform a cervical biopsy depending on what is found during the exam. A cervical biopsy involves removing small amount of cervical tissue to be examined under a microscope. It takes only seconds for the doctor to gain a tissue sample and is only momentarily uncomfortable. Depending on the findings during the Colposcopy, a few areas of the cervix may be biopsied.
Along with a cervical biopsy, an endocervical curettage (ECC) may also be done. During an ECC, the doctor uses a small brush to remove tissue from the endocervical canal, the narrow area between the uterus and cervix. An ECC can be moderately painful, but the pain disappears when the ECC is done.
Biopsy and ECC results usually take less than two weeks to return. Your doctor may have you schedule another visit to go over the results with you or he/she may call you by phone to inform you of the results.
There are times when a larger biopsy needs to be done to diagnose cervical cancer. In these cases, a cone biopsy may be performed. During a cone biopsy, a cone shaped piece of tissue is removed under general anesthesia. A cone biopsy is also used to remove pre-cancerous tissue from the cervix.
A loop electro surgical excision procedure (LEEP) is a procedure done under local anesthesia to remove tissue from the cervix. A LEEP uses an electrically charged wire loop to remove a tissue sample. This method is more commonly used to treat high grade cervical dysplasia, rather than diagnose cervical cancer.
Limited non invasive methods of treatment of Cervical Cancer are used when only the outside layers of the cervix require removal to treat the Cancer of Cervix. As such no additional treatments are required for women after non invasive cancer.
The various limited non invasive treatments of cancer are:
11.1.1. Cone Biopsy (Conization)
11.1.2. Laser Surgery
11.1.3. Loop electrosurgical excision procedure (LEEP)
When the Cancer of Cervix invades deep than the superficial layers of the Cervix, then the Cancer of the cervix is labeled as the Invasive type of cancer. The treatment of such Cancer depends on various factors such as the stage of cancer, other related health problem associated with the person.
11.2.2. Complete Hysterectomy
The symptoms of the Cancer of Cervix are often going unnoticed as they have the ability to impersonate the symptomatology of other ailments and diseases. Many a times the symptoms of Cancer of Cervix go away without any warning signs as a part of Post Menopausal Syndrome or as a part of the pains during ovulation. Still many a times, Cervical Cancer pains show no symptoms at all.
The symptoms of Cancer of Cervix when do show, they appear when the Cancer has advanced to its later stages. These shows up of the symptoms vary from woman to woman regarding the intensity of presentation.
Abnormal vaginal bleeding is the foremost sign of Cancer of Cervix. This bleeding can be light or very heavy and is irregular and does not follow the pattern of normal menstrual periods and menstrual flow.
The woman experiences a heavy discharge from the Vagina. Normally there is a discharge from the vagina of a woman which keeps the Vagina wet and also the wetness can increase slightly when there is discharge of Leucorrhea. But apart from the above mentioned causes, when the discharge is very heavy, foul smelling, watery and thick with mucus (though not present all the time), can be indicative of Cancer of Cervix.
A woman during normal menstruation cycle will experience slight pain in the pelvis because of the stretching of the Cervix to allow the menstrual flow. Other types of Pelvic pain can occur in anemic women where the muscles in spite of having less energy supply and nutrition from the blood try to stretch which causes pain in the Pelvis.
But when the pain is excruciating and abnormal, it is very different than that which is present in women otherwise and is indicative of Cancer of Cervix as the causative reason for Cancer of Cervix. The pain is often a dull ache which can change over to sharp pains which can last for many hours together.
Pain during urination is a rare symptom which arises only in advanced cancers. Of the cancers when the Cancer of Cervix spreads to the Urinary bladder which in near vicinity to the Uterus.
A healthy Cervix does have small amount of bleeding during examinations, intercourse. Irritation caused to the cervix in a woman with Cancer of Cervix can cause excessive bleeding during regular menstrual periods, sexual intercourse, douching or pelvic examinations. An exception to this is
While considering the above symptoms and signs to be because of Cancer of Cervix, one must always remember that these signs and symptoms are also a part of presentations of other illnesses and ailments. Thus these symptoms and signs cannot decide that the underlying disease is only Cancer of Cervix and thus to rule out other causes of the symptoms, one must carry out the other investigations necessary to find out the exact cause of the disease.
The Risk Factors which involve in making a woman susceptible to develop Cancer of Cervix are as follows:
Transmission of HPV occurs primarily by skin-to-skin contact. Basal cells of stratified squamous epithelium may be infected by HPV. Other cells types appear to be relatively resistant. It is assumed that the HPV replication cycle begins with entry of the virus into the cells of the basal layer of the epithelium.
It is likely that HPV infection of the basal layer requires mild abrasion or micro trauma of the epidermis.
Once inside the host cell, HPV DNA replicates progress to the surface of the epithelium. In the basal layer, viral replication is considered to be non-productive, and the virus establishes itself as a low-copy number episome by using the host DNA replication machinery to synthesize its DNA on average once per cell cycle. In the differentiated keratinocytes of the suprabasal layer of the epithelium, the virus switches to a rolling-circle mode of DNA replication, amplifies its DNA to high copy number, synthesizes capsid proteins, and causes viral assembly.
Recent studies and research propose the usage of the vaccination therapy for the prevention of the Cancer of Cervix. While sexually transmitted viruses have been found to be as cofactors, which along with the co-infection of the herpes viruses increasing the chances of formation of Cancer of Cervix, Cytomegalovirus, Human Herpes Virus (HHV) -6 and HHV – 7 have been also found to be the excitement causes of the Cancer of Cervix. Chlamydia Trachomatis has also been found as a super infection on high risk Human Papilloma Virus infections to result into Cancer of Cervix.
But behind all these viruses and their infections, lies the basic cause, the predisposition of which leads to the activation of the infections caused by the above mentioned viruses and bacteria – the Genetic Factor. As nearly as 27% of Genetic predisposition has been found to be the underlying causes, which aid to, decide upon the susceptibility of a woman towards the viruses and bacteria mentioned above to result into Cancer of Cervix. The effect of Family Environment towards a genetic cause to result into Cancer of Cervix was found to be up to 2% which was common in between the sisters and not in between Mother and Daughter.
Another cause for Cancer of Cervix is the low immunity of a woman. The inner linings of the Cervix and the surrounding areas remain a house of the viruses and bacteria which can live in the environment of the Vagina and the Cervix and can cause harm every now and then when the resistances offered by the Immunity cells in the areas are low in their ability, infections arise.
Many a times, the immunity is able to resist the further development of the infections of the secondary causative organisms by expressions of various signs and symptoms, which or without the aid of medicinal support, get relieved, cured, suppressed or palliated. According to the level of treatment done for the infection, it can arise again in the presence of favorable conditions for the cervical infections to cultivate.
If the infection gets promoted repeatedly, the risk of alteration in the genes of the cervical cells gets high and thus these altered genes can become the focus of the root of the Cancer of Cervix.
The nature of the warts on the basis of virulence was shown by using a filtrate, which was free of cells. Papilloma viruses stayed out of hand to the studies in standard virology because the main problem lied in the methods of propagating the papillomaviruses in standard conditions of Temperature and pressure and related conditions were difficult.
Even though some advances have been made in the standard methods of propagating Papilloma viruses in a laboratory by using organotypic raft cultures of epithelial cells, the study and research will go on.
Most of the knowledge currently acquired regarding the biology of papillomaviruses at molecular level and the genetics of the Papilloma viruses has been an outcome from the advances in basic research and also by the application of reverse genetics by using cloned viral DNAs.
The Papilloma virus families are icosahedral in shape and are circular. They have a double stranded DNA genome and thus, on these characteristics the Papilloma virus families were previously classified under the papovavirus families.
Now, a clear difference has been noted in the Papilloma virus families and the papovavirus families. On the basis of the different characteristics of biologic and genetic grounds, the Papilloma viruses and the Papova viruses like the Polyoma and the Simian virus 40 (SV40) are noted to be different.
While the Polyomaviruses have 5000 base pairs in their double stranded circular DNA genome, the Papilloma viruses have 8000 base pairs in their double stranded circular DNA genome.
Correspondingly, the capsid diameter of Polyomaviruses is 40 nanometers while the capsid diameter of papillomaviruses is 55 nanometers.
The Polyomaviruses can be propagated in the tissue culture under standard conditions; the Papillomaviruses cannot be propagated in the tissue culture under standard conditions.
More than 150 types of HPV are known to exist of which some sources indicate that there are more than 200 subtypes of Human Papilloma Viruses. Of the total of nearly 200 HPVs, 15 papillomaviruses are classified as high-risk types, namely 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82., Other 3 types which come under probable high-risk are HPVs 26, 53, and 66 while 12 other HPVs are classified as low-risk, namely, 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and CP6108. Although the low risk do not have strong evidence for causing Cancer of Cervix, but even those may cause cancer. Types 16 and 18 are generally acknowledged to cause about 70% of cervical cancer cases. Together with type 31, they are the prime risk factors for cervical cancer.
Histological analysis of the Cervix is an important aspect from the point of this study as this study us related to the changes in the tissue and cellular level of that of the Cervix and thus is worth mentioning in the Thesis. Also histological study is worth in effective cytological screening, Colposcopy and biopsy results in the management of Cervical Neoplasia. The epithelium is variable in different areas of the Cervix.
Histological studies of the epithelium of the Ectocervix show that the cellular layers are composed of nonkeratinized stratified squamous epithelium. The epithelium of the Endocervix is composed of simple columnar epithelium.
The area around the Ectocervix and Endocervix is known as the transformation zone. This transformation zone undergoes metaplasia for a number of times during the normal and healthy span of life of a female. Thus when the epithelium of the transformation zone is exposed to the acidic medium of the Vagina, it undergoes metaplasia to squamous epithelium and when the epithelium of the transformation zone enters the less acidic environment of the Uterus, it undergoes metaplasia to columnar epithelium.
There are certain significant stages of life in a woman related to the metaplasia of the transformation when it should occur; other than the otherwise normal changes in the transformation zone.
The first significant metaplasia occurs at puberty when the Endocervix everts out of the Uterus.
The second significant metaplasia occurs with the changes occur in the cervix with every normal menstrual cycle.
The third significant change occurs with the post menopause phase when the Uterus shrinks thus moving the Transformation zone upwards.
The Mucus of the Cervix also undergoes variable changes and also changes its property from being fertile to infertile and vice versa.
When the menses of a woman stop after the menstrual period, the external Os of the cervix is blocked by mucus which is thick and prevents the sperm from entering into the Uterus. This infertile block gets changed by a fertile type of mucus which is sperm friendly and also helps in nourishing the Sperm and allowing it to stay in the crypts of the cervix for a few days.
The cervix develops a special mucosal plug which prevents bacteria from invading the Uterus and the growing fetus inside it. This plug of mucus comes out as the cervix dilates in labor.
The Cervix dilates slightly during menstruation which allows the loosened endometrium to be shed. The same cervix stretches or rather contracts up to 10 centimeter in diameter to allow the head of the fetus to come out of it. This stretching and contractions of the Cervix is the reason behind the pains during menstruation and labor.
As proposed by Robin Baker and Mark A. Bellis, from the University of Manchester, the cervix convulses and the external Os dilates during sexual intercourse and orgasm to draw the semen into the Uterus to increase the chances of conception which was called as the upsuck theory of female orgasm which was also supported by Komisaruk, Whipple, and Beyer-Flores, in their book, The Science of Orgasm but then this theory has been found to be badly flawed as many of the experiments were found to be inconsistent and not meeting to the requite standards of research.
The narrow and lower portion of the Uterus which continues the Uterus with the upper end of Vagina is known as the Cervix (Neck in Latin) of the Uterus. The shape of the Cervix is Cylindrical or conical which projects through the anterior wall of the Vagina.
When inspected by the medical instruments, half of the length of Cervix is visible and the remaining half which is present above the Vagina is not visible by the external scopes as it lies in the Uterus and thus is called as the Cervix uteri.
Ectocervix is that part of the Cervix which protrudes into the Vagina and thus is also known as Portio vaginalis. The Ectocervix is about 3 centimeters long and 2.5 centimeters wide, on an average. The surface of the cervix is convex and elliptical and is divided into two lips – The Anterior and Posterior lips.
The external opening or orifice of the Uterus is known as the External Os and is also known as the Ostium of Uterus or the External opening of the Cervix. This External Os is a depressed, small and not perfectly but somewhat circular aperture on the vaginal portion of the Cervix which is a rounded opening.
Through this opening, the internal cavity of the Cervix communicates with the cavity of the Vagina.
The External Ostium of the Cervix is bounded by two lips – The Anterior lip and the Posterior lip.
The Anterior lip of External Os of Cervix is short and thick, while the Posterior lip of External Os of Cervix is log and thin. Even then, the anterior lip projects lower than the posterior lip because of the slope and angle of the cervix and thus in normal Anatomical and Physiological conditions, both the lips are in contact of the Posterior Wall of Vagina. Before the first pregnancy, the external Os of Cervix is round in shape when viewed through the Canal of Vagina using a speculum, which after the parturition of the first (Primi-) pregnancy, becomes transverse slit shaped (H Shaped).
The canal of the cervix is also known as the endocervical canal, cervical canal, cervical canal of uterus, or the cavity of cervix. The canal of Cervix is spindle shaped and flattened antero-posteriorly which forms the neck of the Uterus of the Female Reproductive System.
The Canal of the Cervix serves as a communication channel in between the Vagina and the Uterus via the External orifice and the internal orifice, respectively.
The Cervical Canal wall has two longitudinal ridges; the anterior longitudinal ridge and the posterior ridge. From each of the ridges, numerous columns which are small and oblique give out palmate folds which appear like the branches from the stem of a tree which is known as the arbor vitæ uteri. The folds arising from the longitudinal ridges are arranged in such a manner that they fit in between each other so that the canal is closed.
The internal opening or orifice of the uterus is known as the internal orifice of the cervix uteri or internal Os. The internal Os is a change in the anatomy of the walls of the lower 1/3rd of the Uterus where there is an interior narrowing of the uterine cavity. It is known as the isthmus which can be observed on the surface of the uterus about midway between the apex and base.
The pockets in the cervix linings are known as the crypts of the Cervix. The function of the crypts of the Cervix is to produce Cervical Fluid. The Crypts also aid in holding the sperms after the initial stage of locomotion into the vagina. The sperms which are on hold are then later moved forwards thus increasing the time span which can be utilized for fertilizing the Ovum after one intercourse.
The arterial or Oxygenated blood supply of the Cervix of the Uterus is accomplished by the Vaginal Artery and the Uterine Artery which arise from the Internal Iliac Arteries with the descend of the arteries along the lateral aspect of the Cervix along the 3 and 9’o clock positions.
The venous drainage is carried out by venules and its tributaries running along the path of the arteries and arterioles and then finally draining into the Hypogastric Venous Plexus.
The Lymphatic drainage of the Cervix is carried out by multiple groups of Lymph nodes and Lymphatic vessels including the common, internal, external iliac nodes, the Obturator lymph nodes and the parametrial nodes.