For medical students

1. Diseases of female lower reproductive tract
The lower reproductive tract,
comprising the vulva, vagina,
and cervix, exhibits a wide
spectrum of benign and
neoplastic diseases
The external vulva includes:
 Mons pubis
 Clitoris
 Vestibular bulbs
 Lesser vestibular glands
 Urethral and vaginal openings
 Labia majora and minora
 Vestibule
 Bartholin glands
 Paraurethral glands
Lateral margins of the vulva are
the labiocrural folds
Deep to the external vulva are
 Superficial and deep urogenital
triangle compartments

5. Benign diseases of the vulva
• Developmental abnormalities
• Infectious conditions

6. Developmental abnormalities
Congenital
 Vulvar hypoplasia, hyperplasia or duplication
 Clitoral enlargement
o Clitoromegally noted at birth is suggestive of fetal exposure to excessive adrogens
 It is defined as a clitoral index greater than 10mm2.
 Labial fusion
Acquired
 Labial hypertrophy
 Labial fusion
 Female genital mutilation
 Epidermal inclusion cysts

7. Labial hypertrophy
• Labial width — Labia minora hypertrophy
is generally described as protuberant labial
tissue that projects beyond the labia majora.
• In current practice, a stretch width of greater
than 6 cm is generally felt to be consistent
with hypertrophy

8. Labial fusion
Also termed labial agglutination or adhesion
Prevalence
 Prepubertal girls→1-5%
 Female infants→10%
Cause is unknown
 Hypoestrogenism
 It is seen in infants and young girls and
tends to undergo spontaneous resolution at puberty
The diagnosis is made visually
Treatment
1. Expectant management
 If the patient is asymptomatic, no intervention is necessary
2. Medical management
 Estrogen cream therapy
3. Manual separation
4. Surgical separation

9. Infectious conditions
Bacterial
 Syphilis
 Granuloma Inguinale
 Lymphogranuloma Venereum (LGV)
 Chancroid
 Tuberculosis
Viral
 Condyloma Acuminatum
 Herpesvirus
 Molluscum Contagiosum
 Varicella (Herpes Zoster)
 Cytomegalovirus
Fungal
 Vulvar candidiasis
 Pityriasis versicolor
Parasitic
 Pediculosis pubis, or pubic lice

10. Tuberculosis
It most commonly affects the fallopian tubes and endometrium
 Fallopian tubes are involved in 90–100 % of cases
 Endometrium in 50-70% of cases
Vulvar or vaginal TB
 Exceedingly rare(1–2 %)
 Lesions can be ulcerative or hyperplastic

11. Condyloma Acuminatum
It is an exophytic lesion caused by infection with HPV
 Most commonly types 6 and 11
It is sexually transmitted disease
 When it is detected in a child, sexual abuse must be considered
The lesions are usually asymptomatic and frequently multiple and multifocal
It is not considered premalignant and do not progress to HSILs or carcinoma
Management
 Topical agents
 Application of dilute podophyllin,imiquimod, or concentrated halogenated acetic acid (trichloroacetic
acid)
 Electrosurgery, cryosurgery, laser ablation, or surgical excision
 Larger lesions and those refractory to topical treatments
 The overall recurrence rate is reported as 20–30%

12. Condyloma Acuminatum

13. Molluscum Contagiosum
It is a viral infection of the skin
 Caused by a poxvirus (molluscum contagiosum
virus)
The lesions are small, raised, and usually
white, pink, or flesh-colored with a dimple or
pit in the center
 They’re usually smooth and firm
Treatment options
 Curettage
 Cryosurgery
 Topical agents

14. Herpesvirus
HSV type 2 is more common in vulvar infection
Painful, erythematous swelling of the vulva, followed by the eruption
of clusters of papules and vesicles which evolve into exquisitely painful
ulcers
 Untreated, the ulcers of the initial episode heal in approximately 2–6 weeks,
after which the virus lies dormant in regional sensory and autonomic ganglia
Antiviral agents (acyclovir, valacyclovir,or famcyclovir)
 Speed healing
 Decrease viral shedding
 Decrease the incidence of new lesions

15. Herpesvirus lesion

16. Inflammatory dermatoses
Lichen simplex chronicus
Lichen sclerosus
Lichen planus
Allergic or irritant contact dermatitis
Atopic dermatitis
Psoriasis
Crohn’s disease

17. Primary skin lesion Size Description
1 Macules Lesions ≤1 cm They are nonpalpable lesions that vary in pigmentation from the
surrounding skin and they have no depression or elevations
2 Patches Lesions > 1 cm
3 Papules Lesions ≤5 mm They are palpable, discrete lesions
4 Plaques Lesions >5 mm Superficial slightly raised lesions, often formed by a confluence of papules
5 Pustules Papules containing purulent material
6 Vesicles Lesions <5 mm
Circumscribed skin lesions containing serous material
7 Bullae Lesions ≥ 5 mm
Secondary skin lesion
1 Excoriation Superficial, often linear skin erosion caused by scratching
2 Lichenification Increased skin markings and thickening with induration
3 Scale Superficial epidermal cells that are dead and cast off from the skin
4 Crust A dried exudate on the skin surface, either serum, blood or pus or a
combination
5 Fissure Deep skin split extending into the dermis
6 Erosion Superficial, focal loss of part of the epidermis
7 Ulceration Focal loss of the epidermis extending into the dermis

18. Lichen simplex chronicus
It originates from an itch-scratch cycle that leads to chronic trauma
It is often the end stage of other dermatologic conditions or irritants
 Lichen sclerosus, atopic dermatitis, or psoriasis
 Tight clothing,heat,sweating, or products like antiseptics,body fluids,body
soaps,condoms,emollients etc
The skin responds by thickening with exaggerated gray, leathery-appearing
skin markings termed lichenfication
Treatment involves halting the itch-scratch cycle
 Topical corticosteroid ointments help reduce inflammation
 Lubricants, such as plain petrolatum or vegetable oil, and cool sitz baths help
to restore the skin's barrier function
 Oral antihistamine use, trimmed fingernails, and cotton gloves worn at night can help
decrease scratching during sleep
 If symptoms fail to resolve, biopsy is indicated to exclude other pathology

19. LSC
Thickened skin,
Exaggerated skin markings

20. Lichen Sclerosus (LS)
LS classically presents in postmenopausal women and prepubertal girls
LS is more common in the premenarchal and postmenopausal years
 About 1–2% of patients in general gynecologic practice
It is currently considered to be an autoimmune condition, occurring in
genetically predisposed patients
 Approximately 20 to 30 % of pts with LS have other autoimmune disorders, such as
Graves disease, Diabetes mellitus and SLE

21. Diagnosis
The characteristic clinical picture and histologic findings typically
confirm the diagnosis
1. Symptoms often worsen at night
 Pruritus-the most common
 LS with erosions or fissures:
 Pain
 Dysuria
 Dyspareunia
2. Physical examination
 Excoriations and vulvar skin thickening
 White atrophic papules
 The skin generally appears thinned and crinkled
 Thickened white plaques, areas of erythema, or nodularity should prompt biopsy to exclude
preinvasive and malignant lesions

22. Vulvar LS
1. The skin is thin,shiny, pale,
and wrinkled (parchment-
like), with focal ecchymosis
2. There is loss of distinction
between the labia majora and
minora

23. Vulvar LS
Note the thin and pale vulvar skin, loss of
labia minora architecture, labia minora
fusion beneath the clitoris, and hourglass
distribution around vulva and anus

24. Treatment and surveillance
Curative therapies are not available for lichen sclerosus
 Rx goals are symptom control and prevention of anatomic distortion
1. Vulvar Hygiene
2. Ultrapotent topical corticosteroids
3. Surgery
o Reserved for complicated cases
 Introital stenosis
 Symptomatic clitoral adhesions
Malignant transformation develops in 5% of pts
Surveillance
 Every 6 to 12 months for life time
 Persistently symptomatic, new, or changing lesions are biopsied

25. Treatment
1. Vulvar Hygiene
 Avoid using gels, perfumed bath products, moisturizing wipes, and soaps, as they may contain irritants
 Avoid douching
 Use aqueous creams to clean the vulva and thoroughly rinse with tepid water
 Avoid using a harsh washcloth to clean the vulva
 After bathing, sparingly apply an emollient, such as plain petrolatum, to moist vulva epithelium
 Dab the vulva gently to dry
 Avoid wearing tight-fitting pants
 Select white cotton underwear
 Avoid washing undergarments in commercial washing detergents. Wash and rinse these items separately
and Consider using a multirinse process with cold water to remove any remaining detergent residue
 Consider wearing skirts and no underwear at home and at night to avoid friction and aid drying
2. Ultrapotent topical corticosteroids
 First-line therapy
3. Surgery
 Reserved for complicated cases
 Introital stenosis
 Symptomatic clitoral adhesions

26. Lichen planus
Involves both cutaneous and mucosal surfaces
It affects 1-2 % of general population
Symptoms
 Chronic vaginal discharge with intense vulvovaginal pruritus
 Burning pain
 Dyspareunia
 Postcoital bleeding
Physical examination
 Papules classically are brightly erythematous or violaceous,flat-topped, shiny
polygons
 Vaginal erosions can produce adhesions and synechiae, which may lead to vaginal
obliteration
Diagnosis
 Confirmed by biopsy

27. Vulvar erosive lichen planus
Erythema and erosions on the vulvar labial
mucosa

28. Lichen planus
Thick, violaceous, hyperkeratotic plaque with a
white, lacelike pattern on the surface

29. Treatment
Vulvar hygiene
Pharmacotherapy
 Ultrapotent topical corticosteroid ointments
 Systemic steroids
Failed topical steroids
Surgical adhesiolysis is a last resort

30. Contact dermatitis
This condition is common and affects all ages
 It affects approximately 15–54% of women
It is classified as allergic or irritant contact dermatitis
 ACD results from a T cell-mediated, delayed type hypersensitivity (DTH) reaction elicited by the
contact of the skin with the offending chemical in individuals who have been previously sensitized to
the same chemical
 ICD is a localized inflammatory skin response that results from direct cytotoxic effect of irritants
The presentation of ICD and ACD is variable
 Acute ICD develops within minutes to hours of the exposure, while those of ACD take 24–48 hours to
develop
 The lesions of ICD tend to be well circumscribed, confined to the area of contact, more likely to be
painful, and less likely to develop vesicles and bullae, while those of ACD are more poorly
demarcated, more likely to be pruritic, and more likely to develop vesicles and bullae
Diagnosis
 Patch test
 To identify possible allergen
 Culture
 Biopsy

31. Treatment of vulvar contact dermatitis
1. Stop offending agents and/or
practices
2. Correct vulvar skin barrier
function
 Sitz bath twice daily with plain water
 Application of plain petrolatum
3. Treat any underlying infection
 Oral antifungal therapy
 Oral antibiotic administration
1. Reduce inflammation
 Topical corticosteroids twice daily for
1-3 weeks
 0.05% clobetasol propionate ointment
 0.1% triamcinolone ointment
 Systemic corticosteroids for severe
irritation
2. Break the itch-scratch cycle
 Cool packs(avoid ice packs,which
may injure skin)
 Plain,cold yogurt on a sanitary napkin
for 5-10 minutes
 Consider an SSRI or an antihistamine

32. Vulvar contact dermatitis
 Reaction to povidone-iodine
solution
 Contact sites show symmetric
erythema and edema on the vulva,
inner thighs, and buttock

33. Atopic Dermatitis
It is predominantly a disease of childhood
 With 85% of patients presenting before age 5 with severe pruritic eruption
 70% of children show spontaneous remission before they reach adulthood
 The disease first manifests in adulthood in only 2–8% of patients
The frequency of vulvar involvement is unknown
Scaly patches with fissuring are evident
Diagnosis
 It is usually established by clinical findings and the appearance on the nongenital skin
There is no cure for the disease
 Symptom control
 Emollients
 Topical corticosteroids

35. Psoriasis
It is a chronic immune-mediated disease
Its prevalence is 3.2%
 Involves the genitalia in 30–40% of patients
The median age of onset in women is 25 years
Symptoms of vulvar psoriasis
 Itching
 Burning
 Pain
Physical examination
 Classic form
 Sharply demarcated erythematous papules and plaques covered with silvery scale
Treatments are none curative
 Topical agents for mild disease
 Immunosuppressive therapy
 Methotrexate or Cyclosporine
 Phototherapy

36. Psoriasis
Raised plaques are seen on the vulva

37. Crohn’s disease
In vulvar disease concomitant gastrointestinal involvement is present
Vulvar Crohn disease is typically asymptomatic
 Only a minority of patients complain of symptoms
 Pain
 Pruritus
 Discharge
 Dyspareunia
 Dysuria
Physical examination
 Swelling of the labia minora and/or majora
 Deep, linear, “knife-like” ulcerations
Treatment
 Systemic therapy with steroids
 Topical antibiotics and steroids
 Surgical resection
 Refractory lesions

38. Vulvar Crohn disease
 Linear "knife-cut" ulcerations
and other lesions often affect
inguinal, labiocrural, and
interlabial folds

39. Vulvar cysts
Epithelial inclusion cyst
Bartholin cyst and abscess
Mucous cyst
Gartner duct cyst

40. Epithelial inclusion cyst
Frequently develop on the vulva
 More common on the labia majora and clitoris
They are benign lesions
Treatment
 Rx is not usually necessary for asymptomatic small cysts
 Surgical excision
 If cyst is enlarging, symptomatic, or secondarily infected

41. Multiple, mobile, knotty epidermal inclusion cysts line the inner labia majora

42. Urethral Diverticulum
Classic symptoms associated with
urethral diverticula are known as the
"3D's"
1) Dysuria
2) Dyspareunia
3) Dribbling(Postvoid)
Women may also note recurrent
UTI, vaginal wall tenderness,
frequency, urgency, and chronic
pelvic or urethral pain.

43. Urethral diverticulum seen in the anterior vaginal wall

44. Bartholin gland duct cyst and abscess
Bartholin gland
 Secrete mucus to provide vaginal and vulvar lubrication
 Each gland is approximately 0.5 cm in size and drains tiny drops of mucous into a
2.5 cm long duct
 It open into the vulvar vestibule at about the 5 and 7 o’clock position, distal to the
hymenal ring
The most common large cyst of the vulva is a cystic dilation of an
obstructed Bartholin duct
 Noninflamed cysts contain sterile, clear, mucinous fluid
 The underlying cause for obstruction is often unclear
It may follow infection, trauma, mucus changes, or congenitally narrowed ducts
Bartholin duct cysts and abscesses are fairly common, with a lifetime risk
estimated to be 2%

45. Bartholin gland duct cyst
An asymmetric bulge in the left lower vestibule

46. Diagnosis
The diagnosis of both Bartholin cyst and abscesses are clinical
 Cyst
It is typically painless, and may be asymptomatic
Most are detected during a routine pelvic examination or by the woman herself
Larger ones may cause discomfort, typically during sexual intercourse, sitting, or
ambulating
There is a soft, unilateral,round or ovoid ,painless mass in the posterior aspect of the
vaginal introitus, at the site of the gland
 Abscesses
Typically present with severe pain and swelling and patients are unable to walk, sit, or
have sexual intercourse
There is a large, tender, soft, or fluctuant mass at the site of the gland
Abscess cultures
Biopsy

47. Biopsy…
Bartholin gland duct cysts and abscesses
 Uncommon after menopause and should raise concern for possible neoplasia
Bartholin gland carcinoma is rare
 The median age at diagnosis is 57 years
Cyst wall biopsy following cavity drainage to exclude rare Bartholin
gland carcinoma is considered for at-risk cases
 Cysts in women older than 40 years, with solid components, fixation of the
cyst or abscess wall to surrounding tissue, or with multiple recurrences are
candidates

48. Microbiology
Bartholin gland abscesses are polymicrobial infections ???
 According to recent studies fewer abscesses are polymicrobial
MRSA is increasing
 The single most common pathogen is Escherichia coli
 Bacteroides,peptostreptococcus species and staphylococcus faecalis are common
 N.gonorrhoeae and C.trachomatis may also be identified

49. Management
No intervention is necessary for asymptomatic Bartholin cysts
 Cysts that are disfiguring or symptomatic are treated
Procedures:
1. Incision and drainage
The mainstay of treatment is I & D with placement of a Word catheter, under local
anesthesia
2. Marsupialization
It refers to a procedure whereby a new ductal orifice is created
3. Bartholin gland excision is a definitive treatment
Antibiotic therapy
 Trimethoprim-sulfamethoxazole
 Amoxicillin-clavulanate + clindamycin
 Cefixime + clindamycin

50. Bartholin gland duct incision and drainage
I & D with Word catheter placement
 I & D is easy to perform
 It is performed in an outpatient setting
 It has high risk of recurrence →2 -18 %

51. The goal of Bartholin gland duct I and D is to
empty the cystic cavity and create a new
epithelialized tract(Word catheter ) for gland
drainage
A 1 cm incision is made using a scalpel with a
no. 11 blade to pierce the skin and underlying
cyst or abscess wall
The incision is placed on the cyst bulge,just
outside and parallel to the hymen at 5 or 7
o’clock and medial to the Hart line
A deflated Word catheter tip is placed into the
empty cyst cavity. A syringe is wed to inject 2
to 3 mL of sterile saline through the catheter
hub to inflate the balloon. Inflation should
reach a diameter sufficient to keep the catheter
from falling out of the incision
Word catheter in place
Abscess or cyst incision
Word catheter

52. Bartholin gland duct marsupialization
• A vertical or elliptical incision measuring
2 cm is made across the skin overlying
the cystic bulge using a scalpel no. 15
blade
• The incision is placed just outside and
parallel to the hymen at 5 or 7 o‘clock
and is positioned medial to Hart line
Skin incision.

53. Marsupialization
• It is performed in the operating room
• It takes longer time and is more invasive
• It has recurrence rates of 2 to 13 %

54. Wound closure
The edges of the cyst wall are sutured to adjacent
skin edges with interrupted sutures using 2-0 or 3-0
gauge delayed-absorbable sutures
Cyst wall sutured open

55. Bartholin gland duct excision
It is definitive procedure for treatment of both cysts and abscesses
Excision must be performed in an operating room
Candidates:
 Symptomatic cysts which repeatedly recur and refill
 Cysts with solid component
Raise concern for malignancy
 Multilocular cysts
Excision carries a high risk of complications
Excessive bleeding
Hematoma formation
Cellulitis
Scarring
Disfigurement
Dyspareunia

56. Bartholin abscess management algorithm

57. Vulvar mucous cyst
• Most commonly seen in the vestibule or labia minora
• Excision is curative

58. Benign lesions of the urethra
• Urethral Prolapse
• Urethral Caruncles
• Urethral diverticulum

59. Urethral prolapse
It is the circular eversion of the urethral mucosa through the urethral
meatus with vascular congestion and possible strangulation
It may occur at any age
 It is most common in premenarchal children and postmenopausal women
It may be related to relative lack of estrogen.
Physical examination
 Large red polypoid mass covered with urethral mucosa with edematous
vascular submucosa, protruding from the urethra
Histologic examination
Cryosurgery is an effective method of treatment

60.  Urethral prolapse in a young girl

61. Urethral Caruncles
Caruncles are fleshy, friable, sessile,
or polypoid masses that arise in the
posterior urethra near the meatus
Most patients are postmenopausal
 Average age of 68 years
The etiology is unknown
 Reduced estrogenisation of urethral
smooth muscle
 Other possible factors include irritation,
trauma, and local congestion
Caruncles often are asymptomatic
 Bleeding or dysuria
 Superficial ulceration
Histologic examination
 Distinguish a caruncle from urethral
prolapse
Treatment
 Conservative approach-First line
 Sitz-baths
 Topical oestrogens
 Topical anti-inflammatories or steroids
 Surgery
 Severe symptoms after failed
conservative management
 Uncertain diagnosis

62. Urethral Caruncles

63. Vulvodynia
It is vulvar pain of at least three
months duration, without a clear
identifiable cause, which may have
potential associated factors
The prevalence is 3–7%
The median age of onset is 28 years
Treatments:
 Symptom relief
 Sitz baths
 Topical emollients
 Topical anesthetics
 Topical and oral antidepressants
 Oral neuropathic pain medications such as
gabapentin
Treatments…
 Symptom relief….
 Elimination of possible irritants and allergens
 Adjunctive psychotherapy
 Vestibulectomy
 It is undertaken in some women with localized
vestibulodynia, and short-term follow-up
shows 60–85% of patients so treated
experience significant relief

64. Precursor lesions and malignant tumors of the vulva
Vulvar Intraepithelial Neoplasia (VIN)
Vulvar cancer

65. Vulvar Intraepithelial Neoplasia-VIN
HPV DNA has been found in up to 80% of VIN lesions
Classification:
 VIN has three categories of squamous intraepithelial lesions (SIL):
1. Vulvar low-grade SIL (vulvar LSIL,flat condyloma, or HPV effect)
2. Vulvar high-grade SIL (vulvar HSIL, VIN usual type)
 They are commonly associated with oncogenic HPV infection
o Particularly HPV 16
3. Differentiated VIN
 It tend to be unifocal and are typically found in older, nonsmoking, postmenopausal women in
their sixth and seventh decade

66. VIN type Clinical presentation Risk factors
Vulvar LSIL
 Formerly VIN 1
1. Flat lesions with basal atypia and koilocytic
changes such as condyloma
2. Self-limited ,not precancerous
HPV effect
Vulvar HSIL
 Formerly VIN
ususal type(VIN
2,VIN 3,Vulvar CIS)
1. Multicentric and multifocal disease 1. Younger women
2. Oncogenic HPV infection
common
3. Cigarette smoking
4. Immunosuppression
Differentiated VIN 1. Unproven but likely precursor to most vulvar
SCC
2. Unicentric and unifocal disease .
3. A lesion may appear as an ulcer, warty papule,
or hyperkeratotic plaque
1. Older postmenopausal women
2. Oncogenic HPV infection
uncommon
3. Associated with vulvar
dermatoses such as lichen
sclerosus or LSC
Vulvar squamous intraepithelial lesions

67. Diagnosis
No screening strategies are available for vulvar HSIL detection
VIN may be asymptomatic
 Symptoms
Itching
Burning
Pain
Clinially significant vulvar HSIL lesions are often visible without the
aid of special techniques
Vulvar biopsy
 Suspicious focal vulvar lesions
Ulceration, surrounding induration, or inguinal adenopathy raises suspicion for invasive
cancer

68. Extensive perineal and perianal extension of
vulvar HSIL

69. Bulky lesion of differentiated VIN

70. Vulvoscopy
It is microscopic examination of the vulva
 Selection of the best location for biopsy is usually aided by magnification with
a colposcope
Apply 3-5% acetic acid soaked gauze pad for 5 minutes
o Acetic acid accentuates surface topography and may reveal acetowhite lesions not seen grossly
The most abnormal-appearing areas are biopsied
Careful documentation, mapping of vulvar biopsy sites, and photographs can aid future
management

71. Management
Objectives
 Excluding and preventing invasive
disease
 Preserving vulvar appearance and
function
 Improving patient symptoms
Vulvar LSIL
 Self-limited and is not treated unless
symptomatic
Vulvar HSIL
 87% of untreated high-grade VIN
patients progresses to vulvar cancer,
whereas only 3.8% of treated patients
progresses to invasive cancer
 All vulvar HSIL must be treated
1. Laser ablation
 It requires full epithelial thickness cellular
destruction
2. Wide local excision (WLE)
 With a gross surgical margin of 0.5 to 1 cm
of normal tissue is preferred for large
lesions
3. Cavitational ultrasonic surgical
aspiration (CUSA)
4. Topical therapy
 It can be considered if there is no concern
for invasive cancer

72. Prognosis and prevention
Recurrence rates up to 50% are common
 Multifocal disease
 Immunocompromised status
Prevention
 HPV vaccination
 Smoking cessation and improving compromised immune status
 Treat vulvar dermatosis
 Indefinite surveillance for multifocal LAGT disease is recommended

73. Vulvar cancer
It constitutes only 6 % of all gynecologic malignancies
Vulvar squamous neoplasia arise predominantly along the Hart line
Approximately 90% of vulvar cancers are SCC
Malignant melanoma is the second most common
Vulvar cancer may involve any of the external vulvar structures
 Mons pubis
 Labia majora and minora
 Clitoris
 Vestibule
 Vestibular bulbs
 Bartholin glands
 Paraurethral glands
 Urethral and vaginal openings

74. Risk factors
Age
 The average age at diagnosis is 65
years
HPV infection
 50 to 75 % of invasive vulvar
cancers are associated with high
risk HPV serotype
 HPV become a stronger
contributor when combined with
other cofactors
Smoking-35 fold greater risk
HSV infection
Vulvar intraepithelial neoplasia
(VIN)
 Approximately 4% of women with
a history of high grade VIN
subsequently develop vulvar
cancer
Chronic immunosuppression
 HIV
 Transplant patients
Lichen sclerosus
 Affected keratinocytes show a
proliferative phenotype

75. Diagnosis
History and physical
examination
 Women commonly present with
pruritus and visible lesion
 They may also have pain, bleeding
,ulceration and inguinal mass
 Evaluate the entire vulva and
perineal skin systematically
Measure the primary tumor
Evaluate cancer extension into other
genitourinary compartments, the anal
canal, the bony pelvis and inguinal
lymph nodes
Histopathology
 Specimen taken with a keyes punch
should be approximately 4mm thick to
include the surface epithelial lesion and
the underlying stroma
This permits evaluation for depth of
invasion
Imaging
 Abdomen, chest and pelvis
CT
MRI
PET

76. Vulvar biopsy steps
1. A Keyes punch biopsy is placed against
the biopsy site and gentle downward
pressure is exerted as the punch is
rotated
2. A core biopsy is created that extends
through the epidermis and into the
dermis
3. The tip of a fine needle is used to
elevate the core, while fine scissors
incise its base

77. Management
Surgery
 Surgery is often an integral part of vulvar cancer treatment
Wide local excision
Vulvectomy
Inguinofemoral lymphadenectomy
Neoadjuvant chemoradiation
Surveillance

78. Disease of the vagina
Developmental disorders
 Imperforate hymen
 Vaginal agenesis
 Transverse vaginal septum
Infectious inflammatory disorders
 Vaginitis
 Candidiasis
 Bacterial vaginosis
 Trichomonas vaginalis
 Acquired immunodeficiency syndrome
 Group B streptococcus
 Actinomycetes
 Tuberculosis
Noninfectious inflammatory diseases
 Crohn disease
Lesions that follow trauma, surgery, and
radiation
 Atrophic vaginitis
 Vaginal prolapse
 Fallopian tube prolapse

79. Imperforate hymen

80. Imperforate hymen…
Failure of the inferior end of the
vaginal plate to canalize
Incidence:
 1 in 1000 to 2000 females
Clinical features
1. In neonatal period
o Hydro/mucocolpos
 Most cases are asymptomatic
 Bulging translucent yellow-gray mass
 It resolves as estrogen levels decline
2. Adolescents after menarche
o Hematocolpos,hematometra and
hematosalpinx
 The vaginal canal greatly distends, and the
cervix may dilate with cyclic menstruation
 Cyclic pain, amenorrhea, abdominal pain,
and difficulty with urination or defecation
 The trapped menstrual blood creates a
bluish bulge at the introitus
Treatment
 Many advocate repair either in infancy or after
thelarche, but before menarche
o Presence of estrogen improves tissue healing
o Avoids formation of hematocolpometra
 Hymenectomy
o Cruciate incision is made anteroposteriorly from
10 to 4 and from 2 to 8 o'clock positions
o The hymenal leaflet are excised and then over
sewn with interrupted stitches using 3-0 or 4-0
vicryl or chromic suture
o The vagina is copiously irrigated with sterile
saline solution
o Local wound care includes twice-daily sitz baths
o Assess patency of introitus and healing 1-2 weeks
after surgery

81. The hymenal leaflet are excised and then over sewn with interrupted
stitches using 3-0 or 4-0 vicryl or chromic suture

82. Hymenectomy
The indication for hymenectomy may
include complain of amenorrhea, pain,
abdominal mass, and urinary and
defecation dysfunction
Hymen Incision
 To avoid injury to the urethra anteriorly
and to the rectum posteriorly, the surgeon
avoids creating pure vertical and horizontal
incisions. Instead, a cruciate incision is
made anteroposteriorly from 10 to
4 and from 2 to 8 o'clock into the hymeneal
membrane
Hymenal leaflet trimming

83. Transverse vaginal septum
It results when there is failure of fusion and/or
canalization of the urogenital sinus and mullerian
ducts
Incidence
 1 in 70,000 females
It can develop at any level within the vagina
 Approximately 46 % are found in the upper vagina, 35 to
40 % in the middle portion, and 15 to 20% in the lower
vagina

84. Transverse vaginal septum…
Diagnosis:
 Patients usually present with symptoms similar to those of imperforate hymen
 Symptoms and signs
o Primary amenorrhea and pelvic pain
o Abdominal or pelvic mass
o Foreshortened vagina and inability to identify the cervix
 Imaging
o Sonography or MRI confirms the diagnosis
o MRI
 It is most helpful prior to surgery to determine the septal thickness and depth
 It also help to differentiate a high vaginal septum from cervical agenesis

85. Management
Antibiotic prophylaxis is usually
administered
Vaginal septum excision is best
performed in a post pubertal
adolescent or young adult
 Thin septum
 Excision followed by end-to end
anastomosis
 Thick septum
 Excision followed by skin or buccal
mucosal grafts
 Intercourse is delayed for 6 weeks
post surgery
 Mold advice
 Soft stent for 7 days
 Plastic dilator for 12 weeks
 Intercourse at least twice each week

86. Vaginal septum excision
• Enema bowel preparation aids rectal decompression to
permit greater vaginal traction for visualization
• The septum is then incised transversely at its center to
avoid laceration of the urethra, bladder, or rectum.
• A finger is placed through the transverse incision and
is centered cephalad to delineate the upper vaginal wall
and the circumferential margins of the septum
• Once the septum's perimeter and thickness is defined,
the initial transverse incision is extended laterally to
the vaginal
wall margins. The septum is widely excised
circumferentially along its base to minimize
postoperative stricture
• Others surgeons prefer to create cruciate incisions
similar to those with hymenectomy
• The four wedges are then trimmed close to the vaginal
wall
If the septum was thin, a simple
circumferential ring of interrupted
stitches is constructed using 2-0
gauge delayed-absorbable suture
to reapproximate vaginal mucosal
edges

87. Atrophic vaginitis
Physiologic events in
postmenopausal women
 Reflect estrogen deprivation
o Atrophy of the squamous epithelium of the vagina
 A minor trauma may facilitate a transition from simple
atrophy to atrophic vaginitis
o A loss of glycogen and an increase in pH
o A change in the vaginal flora
 Reduction in the lactobacilli
Symptoms
 Many patients are asymptomatic
 There may be minor vaginal bleeding,
pruritus, dysuria, or dyspareunia
Physical examination
 A pale-appearing mucosa, with
petechiae and loss of rugal folds
Treatment
 There usually is a good response to estrogen replacement
 Antibiotic therapy rarely is necessary

88. Vaginal agenesis
Lack of the lower portion of the vagina
with otherwise normal pubertal maturation
and external genitalia
 The urogenital sinus fails to contribute its
expected caudal portion of the vagina
As a result, the lower portion of the vagina,
usually one-fifth to one-third of the total length, is
replaced by 2 to 3 cm of fibrous tissue
It does not often become apparent until
menarche

89. Vaginal Agenesis…
Symptoms
 Cyclic pelvic pain due to
hematocolpos or hematometra
Physical examination
 The hymeneal ring is normal, and no
bulging membrane is seen
 Proximal to the ring, only a vaginal
dimple or small pouch is found
 A rectoabdominal examination
confirms midline organs
Imaging
 Sonography or MRI will display
upper reproductive tract organs
 MRI is the most accurate diagnostic tool
o Length of the atresia
o Amount of upper vaginal dilation
o Presence of a cervix
 A cervix in such cases distinguishes vaginal atresia
from mullerian agenesis
Treatment follows that for mullerian
agenesis

90. Vaginal cysts and neoplasms
Squamous inclusion cyst
 Cysts of the vagina are relatively
uncommon
Gartner’s duct cysts
Mullerian cyst
Benign neoplasms
 Squamous papilloma
 Condyloma acuminatum
 Müllerian papilloma
 Leiomyoma
 Rhabdomyoma
Malignant neoplasms
 Vaginal intraepithelial neoplasia
 Vaginal cancer
Primary vaginal cancer is rare,
constituting only 1%–2% of all female
genital tract malignancies and only 10% of
all vaginal malignant neoplasms

91. Gartner duct cyst
It is derived from remnants of the mesonephric
(Wolffian) ducts
They are typically asymptomatic
Symptoms
 Dyspareunia
 Vaginal pain, and
 Difficulty inserting tampons
Physical examination
 Reveals a tense cyst that is palpable or seen to bulge
beneath the vaginal wall
 They are thin walled, translucent, and contain clear fluid
 They are most often located along the anterolateral
wall of the vagina
 Observation is reasonable in most cases
Marsupialization or excision may be appropriate
for symptomatic Gartner duct cysts

92. Benign disease of the cervix
Cervicitis
 Noninfectious cervicitis
 Infectious cervicitis
Benign tumors
 Endocervical polyps
 Mesodermal stromal polyp
Cysts
 Nabothian cyst
 Inclusion cyst

93. Endocervical polyp
These lesions represent overgrowths of benign
endocervical
stroma covered by mucinous columnar epithelium
They typically appear as single, red, smooth, elongated
masses extending
from the endocervical canal
It is found more frequently in multiparas
They are usually asymptomatic, but they can cause
intermenstrual or postcoital bleeding or symptomatic
vaginal discharge
Many of them are identified by visual inspection during
pelvic examination
They are typically benign, and premalignant or malignant
transformation develops in less than 1 %
Most recommend removal and histologic evaluation of all
polypoid lesions

94. Nabothian Cyst
• Nabothian cysts are the most common type of
cyst of the cervix and develop within the transformation zone secondary to
squamous metaplasia covering over and obstructing endocervical
glands. Grossly, these lesions appear as yellow
white cysts that are frequently multiple and can
measure up to 1.5 cm in diameter. Microscopically, they are lined by a
somewhat flattened,
single layer of mucin-producing endocervical
epithelium (Fig. 50). In some cases, squamous
metaplasia of the lining epithelium occurs. The
lining epithelium is almost always at least
focally positive with mucicarimine stains allowing these lesions to be
distinguished from

95. Cervical Stenosis
This narrowing of the cervical canal or opening may be congenital or acquired.
Diagnosis is based on symptoms and physical findings
Symptoms of stenosis in menstruating women include dysmenorrhea,
amenorrhea and infertility
Postmenopausal women are usually asymptomatic until fluid,
exudates, or blood accumulates behind the obstruction
If the obstruction is complete, a soft, enlarged uterus from trapped
intracavitary fluid is sometimes palpable
An inability to introduce a dilator into the endocervical canal is generally considered diagnostic
Cervical stenosis is relived by introduction of dilators
Preprocedural misoprostol may aid by softening the cervix
In postmenopausal women, pretreatment for several weeks with vaginal estrogen cream may
also assist dilation.

96. Precancerous and cancerous lesions of the cervix

102. Preinvasive Lesions of the Lower Genital Tract

103. Introduction
• The introduction of Pap test has reduced the incidence and mortality
rate from invasive cervical cancer by more than 70 percent

104. Terminology and histology of cervical
intraepithelial neoplasia
LAST: lower anogenital squamous
terminology; LSIL: low-grade squamous
intraepithelial lesions; HSIL: high-grade
squamous intraepithelial lesions; CIN:
cervical intraepithelial neoplasia.
* CIN 2 that is p16-positive is classified
as HSIL. CIN 2 that is p16-negative is
classified as LSIL.
Squamous neoplasia of the vagina, vulva,
perianal,and anal squamous epithelia (VaIN,
VIN, PAIN, and AIN, respectively) are graded
similarly with the caveat that VIN 1 is no longer
recognized

105. Anatomic considerations
External Genitalia
o Micropapillomatosis labialis
Minute epithelial projections on the inner labia minora
Uniform in size and shape and arise singly from
their base attachments
 Often shows spontaneous regression, and
treatment is not indicated
o HPV lesions
Multifocal and asymmetric, and to have
multiple papillations arising from a single base

106. SCJ everts outward on to ectocervix SCJ regresses into endocervical canal
Adolescence Squamous metaplasia
Pregnancy Menopause
COC use Prolonged lactation
Cervix
Squamocolumnar Junction
• The original squamocolumnar junction (SCJ) marks the terminal site of the upward
migration of squamous epithelium during embryonic development
• When visible on the ectocervix, the SCJ is a pink, smooth squamous epithelium
juxtaposed against the red, velvety columnar epithelium surrounding the external
cervical os
• The location of the SCJ varies with age and hormonal status
Long term pop use

107. Squamous Metaplasia
 the normal replacement of columnar by squamous epithelium on the cervix
 Squamous metaplasia is most active during adolescence and pregnancy
 This normal process creates a progressively
widening band of metaplastic and maturing
squamous epithelium, termed the transformation
zone ( Z), between the congenital (original)
columnar epithelium and the squamous
epithelium

108. Transformation Zone and Cervical Neoplasia
• The transformation zone consists of the band of squamous
metaplasia lying between the original SCJ and new (current) SCJ
• Nearly all cervical neoplasia, both squamous and columnar,
develops within the Z, usually adjacent to the new or current
SCJ

109. Human papillomavirus
• HPV primarily infects squamous or metaplastic epithelial cells.
• Intact virus is shed during normal desquamation of superficial
squames.
• Late genes are not strongly expressed in high-grade neoplastic lesions
• Completion of the viral life cycle takes place only within an intact,
fully differentiating squamous epithelium.
• HPV is a nonlytic virus, and therefore infectiousness depends on
normal desquamation of infected epithelial cells.

111. L1 and L2 are two “late” genes of the human
papillomavirus (HPV) genome. These genes encode
proteins
responsible for which of the following?
a. Capsid construction
b. Regulatory functions
c. DNA synthesis and replication
d. Conformational changes aiding entry into the host
cell

112.  HPV16,18,31
,33,35,45,58
• 95% of
cervical ca
 HPV 6,11
• Genital wart
• laryngeal
papillomas
HPV TYPES
High risk
(HR)
Low
risk
 HPV 16 is the most oncogenic type
 45% of CIN3
 55% of cervical ca
 Anogenital and oropharyngeal ca
 HPV 18
 13% of SCC
 40% of adenocarcinoma
 HPV 16 and 18
 70% of cervical ca
 68 % of SCC
 85% of Adenocarcinoma
 HPV 45
 3rd most common type for cervical ca
 HR HPV infection does not cause
neoplasia in most infected women,
and additional host, viral, and
environmental factors determine
progression to LG neoplasia
Genital HPV Infection=It is the most common STD(USA)

114. Clinically, human papillomavirus (HPV) types are
classified as high risk (HR) or low risk (LR) based
upon their oncogenic potential. Which two HR HPV
types together account for approximately 70 percent
of cervical cancers worldwide?
a. 6 and 11
b. 11 and 45
c. 16 and 18
d. 18 and 31

115. Transmission
Risk factors
 the number of sexual partners
Both life time and recent
early coitarche
Cervical HR HPV infection generally requires penetrative intercourse
All women who are sexually active should undergo cervical cancer
screening regardless of sexual orientation
Infection with HPV, predominantly HR types, is very common
soon after initiation of sexual activity

116. Transmission…
Genital warts that develop in children after infancy(1-3years)
o Possibilities are:
 Sexual abuse
 Nonsexual contact
 Autoinoculation
 Fomite transfer
Congenital HPV infection from vertical transmission beyond transient skin
colonization is rare
 Infection is not linked to maternal genital warts or route of delivery
Indication for cesarean delivery :Large genital wart that may obstruct
delivery or Avulse and bleed

117. Infection Outcomes
 Most infections are subclinical.
 Spontaneous resolution is the most common outcome.
 Neoplasia is the least common manifestation of HPV
infection, developing as the result of persistent infection
with integration of HPV DNA
 The natural history of genital HPV infection varies between
individuals and over time
Latent infection refers to that in which cells are infected, but
HPV remains quiescent
Productive infections are characterized by viral life-cycle
completion and plentiful production of infectious viral particles
Subclinical infections may be indirectly identified as low-
grade cytologic, colposcopic, or histologic abnormalities

118. HPV Infection Diagnosis
• HPV infection is suspected based on clinical lesions or results
of cytology, histology, and colposcopy, all of which are subjective and often inaccurate.
• Moreover, serology is unreliable and cannot distinguish past from current infection
• culture of HPV is not feasible
• Thus, diagnosis is confirmed only by the direct detection of HPV nucleic acids by
methods that include in situ hybridization, nucleic acid amplication testing (NAA ),
polymerase chain reaction (PCR),or others
• Tests are not indicated or useful for routine STD screening
• Appropriate clinical uses or HR HPV testing include: cotesting with cervical cytology
screening in women aged 30 years or older, triage or surveillance of certain
abnormal cytology results and untreated CIN, and posttreatment surveillance
• One HR HPV test (cobas HPV test) was recently FDA approved as a stand-alone screening
test for cervical cancer for women 25 years of age and older

119. Infection Treatment
• The indications to treat HPV-related LG disease are symptomatic warts,
high-grade neoplasia, or invasive cancer.
• Treatment of cervical LSIL (HPV changes or CIN 1) is not
necessary and is considered only after observation for at least
2 years.
• Mechanical removal or destruction, topical immunomodulators, and
chemical or thermal coagulation can be used
• Examination of a male partner does not benefit a female partner either by
in influencing reinfection or by altering the clinical course or treatment
outcome or genital warts for LG neoplasia

120. Infection Prevention
Behavior
• Sexual abstinence, delaying coitarche, and limiting the number
of sexual partners are logical strategies to avoid genital HPV
infection and its adverse effects.
Vaccines
• Prophylactic vaccines elicit type-specific humoral antibody production
that prevents new HPV infection by blocking its entry into host cells
• They do not prevent transient HPV positivity or resolve preexistent
infection
• HPV vaccines have the potential to prevent malignancies at least six body
sites that include cervix, vulva, vagina, penis, anal canal, and oropharynx

121. Vaccines
• There are three HPV vaccines (FDA approved)
• All three vaccines contain adjuvants that boost the
immune response to vaccine antigens.
• Testing for HPV is not recommended prior to vaccination
• ACIP target group:Girls aged 11 to 12 years (as early as age 9
years)
Vaccine type HPV type covered Remark % of Cx prevented
Cervarix (HPV2) HPV 16,18 bivalent vaccine
Gardasil (HPV4) HPV 6, 11, 16, and
18
quadrivalent
vaccine
65
Gardasil 9 (HPV9) 6,11,16,18, 31, 33,
45, 52, and 58
nonavalent vaccine 80

122. HPV vaccine
• They are administered in three intramuscular doses during a 6-month period.
• Specifically, the second dose is given 1 to 2 months after the first dose, and the
third dose is given 6 months after the first dose.
• Immune compromised women are candidates to receive the vaccine
• All three vaccines show nearly 100-percent efficacy in preventing incident
infection and high-grade cervical neoplasia from HPV types included in the
vaccines
• HPV4 and HPV9 are approved for genital wart prevention in both males and
females
• HPV vaccines are highly immunogenic with maintenance of protection for at least
5 to 8 years after vaccination
• No evidence supports the need for later booster dosing
• Because HPV vaccines prevent most, but not all, HPV related cervical cancers,
cervical cancer screening should continue per current guidelines

123. • Catch-up vaccination is also recommended for
all 13- to 26-year-old persons
• ACOG recommends shared decision-making with persons aged 27 to 45
years who
have not previously received the HPV vaccine and are at risk of
acquiring HPV.
• IfHPV vaccination is initiated before age
15 years, only 2 doses are needed. This is because the vaccine is
more immunogenic at an earlier age. The second dose is given
6 to 12 months following the first

124. • HPVvaccines have excellent safety profiles, are well-tolerated,
and can be administered along with other recommended vaccinations. Injection-
site erythema, pain, and sweling are common. These can increase in severity
following subsequent doses
but are usually mild to moderate. HPV vaccination is avoided
during pregnancy, but pregnancy testing is not recommended
prior to administration (American College of Obstetricians and
Gynecologists, 2017). If inadvertently given during pregnancy,
no action is needed. Vaccination can be given during lactation.
Immunocompromised persons are candidates to receive the
vaccine and show high seroconversion rates despite concerns
for a blunted immune response. 9vHPV should be given with
caution to persons who experienced an allergic reaction to a
prior dose, have an allergy to yeast, or have had a recent febrile
illness

125. CIN
• CIN is most strongly related to
persistent genital hrHPV
infection and aging
• Inadequate screening is a strong
cervical neoplasia risk factor.

126. Natural History
• Preinvasive lesions can
spontaneously regress, remain
stable, or
progress
• The risk of progression to
invasive cancer rises with
CIN severity

127. CIN diagnosis
• Cervical Cytology
• HPV testing
• Current Cervical Cancer Screening
Guidelines
• Colposcopy
• Biopsy

128. Which of the following is true regarding the clinical
performance of the Pap test?
a. Higher sensitivity than specificity
b. Higher specificity than sensitivity
c. Equally low sensitivity and specificity
d. Equally high sensitivity and specificity

129. Cervical cytology
oThe preventive power of Pap testing lies in
regular serial screening
oThe Papanicolaou (Pap) test
Specificity→98%
Sensitivity→45-65%
Sampling of the transformation zone at the SCJ adds substantial sensitivity of
the Pap test

130. How can we optimize the pap test?
oSchedule to avoid menstruation
oPatients should abstain from vaginal intercourse, douching, vaginal tampon
use, and intravaginal medicinal or contraceptive creams
for a minimum of 24 to 48 hours before tested
oTreatment of cervicitis or vaginitis prior to Pap testing is optimal
oAdd the following clinical information to pathology requisition forms
LNMP
Pregnancy or menopausal status
Exogenous hormone use
Abnormal bleeding, and
Prior abnormal Pap test findings
IUCD

131. Cytology Collection
• Three types of plastic devices are commonly used to sample
the cervix: the spatula, broom, and endocervical brush (cytobrush)
• Wooden collection
devices and cotton swabs are no longer recommended due to
their inferior collection and release of cells

132. Devices
1. Plastic spatula
 Predominantly samples the ectocervix
 distal endocervical canal
 It firmly scrapes the cervical surface while completing
at least one full rotation
2. Endocervlcal brush
 samples the endocervical canal
 To minimize bleeding, the brush
is used after the ectoccrvix has been sampled and is
rotated only one-quarter to one-half turn
3. Plastic broom
 Samples
both endo- and ectocervical epithelium simultaneously
 Five rotations in the same direction are recommended.
 Broom devices are favored for
liquid-based Pap testing.

133. HPV Testing
Indications
• cervical cancer screening
• triage of lesser cytologic abnormalities to later repeat
testing or immediate colposcopy
• surveillance after colposcopy,
or surveillance after treatment

134. Co-testing
o Pap test plus HPV test
o Raises the sensitivity of a single screening test for high-grade
neoplasia and leads to earlier detection and management of
HSIL
o It offers a nearly 100-percent negative predictive value for high-grade neoplasia.
o Result can be:
Both negative
• Repeat after 5 years
Cytology positive but HPV negative
• ???
Cytology negative but HPV positive
• Occur in 10% of the cases
• co-testing is repeated 12 months later
• A reflex test specifically for HPVs 16 and 18
 If positive immediate colposcopy recommended

135. Primary HPV Testing
oHPV testing alone is approximately twice as sensitive (>90%) as
a single Pap test and leads to earlier detection of high-grade
disease.
oTo counter the lower specificity:
Genotyping is part of primary HPV screening
for cervical disease and allows the triage of women who test
positive for HPV 16 or 18 to immediate colposcopy
If positive for non HPV 16 and 18→Reflex cytology is proposed
• Colposcopy for abnormal cytology
oApproved by FDA for primary cervical cancer screening in women aged ≥25
years

136. Appropriate clinical uses for high-risk human
papillomavirus (HPV) testing include which of the
following?
a. Surveillance after treatment of cervical neoplasia
b. Cotesting (cytology plus HPV testing) as screening
for women 30 years or older
c. Triage or surveillance of certain abnormal cervical
cytology results or untreated cervical intraepithelial
neoplasia (CIN)
d. All o the above

137. Current cervical cancer screening guidelines
 The choice of screening strategy should be a shared decision by the provider and patient.

138. ACS/ASCCP/ASCP/ACOG
deem co-testing
preferable to cytology
alone in women ≥30
years

139. Screening Discontinuation
• Screening may be stopped at age 65 years in those at average risk for
cervical cancer and who have undergone adequate
screening, regardless of past or current sexual history.
• Adequate
screening is defined as three consecutive, negative cytology
results or two consecutive, negative co-test results in the prior
10 years, with the most recent result occurring within the past
5 years

140. If all Pap tests to date have been negative and performed
at recommended intervals, cervical cancer
screening discontinuation would be acceptable for
which fo the following women?
a. A 42-year-old woman with prior hysterectomy for
leiomyomas
b. A 72-year-old woman in good health with one
prior sexual partner and one new sexual partner
or 6 months
c. A 55-year-old woman with metastatic breast cancer
refusing further therapeutic cancer interventions
d. All o the above are reasonable candidates or
discontinuation o cervical cancer screening.

141. Post hysterectomy
• All guidelines
recommend against Pap test screening for women who have
undergone total hysterectomy (cervix removed) for a benign disease indication
and who lack a prior high-grade CIN or
cervical cancer diagnosis.
• Women who have undergone supracervical hysterectomy
should continue routine screening.
• The American College of Obstetricians
and Gynecologists (2018b) recommends Pap testing of the vaginal cuff every 3
years for 20 years after initial posttreatrment
surveillance, which is traditionally a schedule of three Pap tests
in the first 2 years posthysterectomy

142. Immunocompromised Patients
• With HIV infection, screening should commence within 1
year of sexual activity onset and no later than age 21 years.
• Women aged 21 to 29 years should receive Pap testing at
the time of HIV diagnosis
• If an initial Pap test result is negative, testing should be repeated 6 or
12 months later and then continued every 12 months. After
three consecutive, negative Pap test results, the interval of Pap
testing can be extended to 3 years. For women aged ≥30 years,
cytology screening can be followed as just described, or cotesting every 3 years can begin. This co-
testing interval is shorter
than for immune competent women. Cervical cancer screening
is continued indefinitely even in those aged 65 years or older
who have been adequately screened.
• After hysterectomy for
benign disease, vaginal cuff cytology is not recommended.

143. A 55-year-old patient undergoes a conization procedure
for cervical intraepithelial neoplasia (CIN 3)/
carcinoma in situ (CIS). Appropriate postexcision
surveillance over the subsequent 2 to 3 years reveals
no recurrence. Which of the following screening
schedules is most appropriate for her beyond this
posttreatment surveillance?
a. Discontinue screening
b. Annual screening until age 75 then may
discontinue
c. Routine screening until age 65 then may
discontinue
d. Routine screening for at least 20 years even if
screening extends beyond age 65

144. Immunocompromised Patients…
• Those
with prior high-grade cervical neoplasia or cancer should have
annual vaginal cuff cytology

145. The Bethesda System
• Cervical cytology reporting is
standardized by the Bethesda
System nomenclature.

146. Epithelial Cell Abnormality Management
• A cytology report interprets a screening test and does not provide a
final diagnosis.

147. Atypical Squamous Cells of Undetermined
Significance ASC -US
Positive Negative
Reflex HPV testing
Colposcopy
Cotest every 3 years
No HPV test
Repeat cytology in 1 year
 Risk of CIN 2 or 3 is 5-10%
 Risk of cancer is 1-2%
 Rate of HPV positivity is app 50%

148. Low-Grade Squamous intraepithelial Lesion.
• Colposcopy is generally indicated for LSIL cytology.

149. Atypical Squamous Cells, Cannot Exclude HSIL
• Colposcopy is indicated regardless of age or HPV test
result
• If SCJ is not visualized ,do diagnostic excision

150. High-Grade Squamous lntraepithelial Lesion.
• Colposcopic evaluation is warranted regardless of age or HPV status
• If SCJ not visualized ,do diagnostic excision
• Altenatively, immediate excision is
acceptable in some nonpregnant patients depending on other
factors such as age and concerns regarding future pregnancy

151. Glandular Cell Abnormalities
• Initial evaluation of a cytologic glandular cell
abnormality includes colposcopy and endocervical sampling,
regardless of HPV status.
• It also includes endometrial sampling in patients aged ≥35 years or in
younger women with risk factors for endometrial disease
• Reflex HPV testing is not recommended for the triage of
glandular cytologic abnormalities for fear that a negative result
will dissuade appropriate evaluation.

152. Carcinoma.
• Cytology results suspicious for squamous cell
carcinoma or adenocarcinoma are rare and carry the highest
risk of invasive cancer.
• If initial evaluation fails to reveal invasive cancer, a diagnostic excision
procedure is indicated

153. Colposcopy
• The colposcope provides a bright light
source and variable magnification
through an optical lens system or high
resolution digital imaging.
• Sensitivity estimates range
between 50 and 80 percent
• Colposcopic examination is optimally
timed to avoid
menses but is not delayed if there is a
visible cervical lesion
or abnormal bleeding, or if the patient is
unlikely to return.
• Solutions used during colposcopy are
normal saline, 3-
to 5-percent acetic acid, and Lugol iodine

154. Solutions used
• To begin, normal saline helps remove discharge and cervical
mucus and allows initial assessment of vascular patterns and
surface contours. A green (red-free) light filter adds contrast to
aid vascular pattern visualization (Fig. 29-9).
Acetic acid 3- to 5-percent solution is mucolytic and exerts its
whitening effects, termed acetowhitening, presumably by reversibly
denaturing cellular proteins. This causes neoplastic areas to
appear denser compared with the normal surrounding epithelium, and
lesions assume varying hues of transient whiteness. Lugol iodine solution
stains mature, glycogen-rich squamous
epithelium a dark purple-brown color in reproductive-aged
women with normal serum estrogen levels. Due to incomplete
maturation, dysplastic epithelium has a lower glycogen content, fails to
fully stain, and appears yellow

155. Lesion Grading
• With colposcopy, normal squamous
epithelium of the cervix
appears featureless, pale-pink and
smooth. Blood vessels lie
below this layer and therefore are not
visible or are seen as a
fine capillary network
• The mucin-secreting columnar
epithelium appears red due to its
thinness and close proximity of
underlying blood vessels. Its villous
appearance derives from
epithelial peaks and crypts

156. Biopsy
Ectocervical Biopsy
oAll acetowhite lesions and other
abnormalities are biopsied using
cervical biopsy forceps under direct
colposcopic visualization
Recomendations encourage biopsy
of all acctowhite areas; two to four
biopsies of abnormalities
are recommended for optimal
sensitivity
Endocervical Sampling
oEndocervical curettage is
performed by introducing an
endocervical curette 1 to 2 cm into
the cervical canal
oIndications
The SCJ is not fully visualized.
The SCJ is fully visualized, but no
lesion is identified.
 Initial evaluation of ASC-H, HSIL,
AGC, or AIS cytology test results
Tissue from endocervical sampling is always sent
separately from ectocervical biopsies for histologic
evaluation

157. Pregnancy
oPregnancy does not alter the natural history of cervical disease
oPregnancy is an opportunity to screen patients aged ≥21
years as indicated
oWhen colposcopy is indicated, its primary goal during
pregnancy is to exclude invasive cancer
oColposcopy and biopsy
are safe and accurate during pregnancy
oEndocervical and endometrial sampling are never performed
during pregnancy to avoid amnionic membrane rupture, infection, or other
harm to the pregnancy
oCIN is reevaluated postpanum since lesion grade frequently changes after
delivery and puerperal remodeling

158. CERVICAL INTRAEPITHELIAL
NEOPLASIA MANAGEMENT
• CIN management may be surveillance or treatment
• CIN severity, colposcopic findings, age,
and reproductive plans play key roles in cervical disease management.

159. CIN 1
oHistologic LSIL (HPV changes or CIN 1)
oCIN 1 is no longer treated immediately
periodic cytology or co-testing.
oTreatment is acceptable only if CIN 1 persists for more than 2 years
Ablation
• Criteria require that the SCJ and all lesions are fully seen during colposcopy and that the
endocervical sampling lacks HSIL (CIN 2/3) or ungraded CIN
Excision
• If the above criteria are not met and treatment is indicated, excision is recommended
and ablation is unacceptable

160. HSIL: CIN 2 and CIN 3
• Generally, treatment is recommended for CIN 2 or CIN 3
because of the significant malignant potential and
the efficacy of treatment to eradicate precancers.
• Treatment modalities include either ablation or excision of the entire TZ
• Recurrent or persist HSIL after treatment
is managed with repeat excision, not ablation
• Hysterectomy may be indicated if repeat excision is needed but not anatomically feasible
or if high-grade CIN recurs or persists and invasive cancer has
been thoroughly excluded
• Hysterectomy as
primary therapy is unacceptable
• For young women, particularly of low parity, with CIN 2 or HSIL (CIN 2/3, not otherwise
specified) surveillance or treatment is acceptable, if the SCJ and all lesions are fully seen
during colposcopy

161. Adenocarcinoma in Situ
• Exclusion of coexistent invasive cancer and
removal of all affected tissue are primary goals
• AIS can
be multifocal, lie deep within endocervical crypts, and extend
high into the endocervical canal
• Thus, diagnostic excision is recommended to exclude invasive cancer with maximum certainty
• cold-knife conization is favored over loop electrosurgical excision procedure (LEEP) to get an intact specimen
with the most interpretable
margins
• Ifthe excised specimen
shows no invasive cancer, hysterectomy is recommended in
women who have completed childbearing

162. Postcolposcopy Surveillance
without Treatment
• When colposcopy following abnormal screening tests fails to
diagnose a high-grade precancer or there is spontaneous regression ofhigh-
grade CIN in younger women, further surveillance
is indicated.
• Surveillance involves repeat cytology, HPV testing, or colposcopy alone or
in combination at specific intervals
depending on the original abnormal cytology result, patient
age, and current guidelines.
• Exceptions are AGC, favor neoplasia and AIS Pap test results. These are
always followed by
excision unless invasive cancer is diagnosed during initial colposcopic
examination and biopsy

163. CERVICAL INTRAEPITHELIAL
NEOPLASIA TREATMENT
• Current treatment of CIN is limited to ablation or excision
procedures targeting the entire TZ
• Thus, individual cervical
lesions are not treated. Any treatment ideally should reach a
depth of 5 to 7 mm from the surface to treat CIN adequately. Surgical
treatments have an approximate 90-percent
success rate

164. Ablation
• This involves physical destruction of tissue and is generally
effective for noninvasive ectocervical disease
• Before ablation,
glandular neoplasia or invasive cancer are excluded with the
greatest possible certainty.
• Ablation should
not be used after previous therapy, after glandular cytologic
abnormalities, or for AIS
• The most commonly used ablative treatment modalities are
cryosurgery and carbon dioxide (C02) laser

165. Excision
• Excision procedures are favored when
the risk of invasive cancer is significant
• Excision is also indicated for
persistence
or recurrence ofhigh-grade CIN after
treatment
• Excisional modalities include LEEP,
also known as LLETZ
(large loop excision of the
transformation zone}; cold-knife
conization (CKC); and laser conization.

167. Surveillance after Treatment or Regression
• Post-treatment surveillance with cytology, HPV testing, and/or
colposcopy is required to confirm treatment success
• After excision, surveillance will be influenced by margin status.
• After treatment for high-grade cervical dysplasia or
invasive cancer, screening continues for at least 20 years, even ifscreening
extends beyond age 65.
• If an excision margin or endocervical curettage performed
immediatdy after an excision is positive for HSIL {CIN 2 or
CIN 3), repeat excision may be indicated. Repeat excision is
indicated for special circumstances such as AIS or microinvasive carcinoma
at the excision margins.

168. Hysterectomy
• Hysterectomy is unacceptable as primary therapy for CIN
• However, it may be considered when treating
recurrent high-grade cervical disease if childbearing has been
completed or if a repeat cervical excision is strongly indicated
but not technically feasible.
• Hysterectomy is the preferred
treatment of AIS, if future fertility is not desired and excision
has excluded invasive cancer.
Even with negative cervical margins, hysterectomy performed for CIN
2 or worse is not completely protective.

169. Cervical Cancer
oCervical cancer is the most common gynecologic cancer in
women worldwide
oWomen have 1 in 132 lifetime risk of developing this cancer
oThe median age at diagnosis of cervical cancer is 50 years
oHPV is the primary etiologic infectious agent associated
with cervical cancer
99.7 percent of cervical cancers are associated with an oncogenic HPV subtype

170. Risk factors
o Lack of regular cervical screening
o HPV infection
o Lower education attainment,older
age,neighborhood poverty
Related to lower rate of cervical
screening
o Cigarette smoking
2-3 fold increased risk for HSIL or invasive
cancer
Reduced clearance of hr HPV infection
Modify viral oncoprotein expression
o Parity
7-four fold
1 or 2-two fold
oLong term COC use
o HPV positive +COC user-4 fold
o Relative risk decrease after 10 years of
cessation
oMultiple sexual partner
> 6 life time sexual partner
oEarly coitarche
Before 20 years
oImmunosupression
Cervical ca is AIDS defining illness
Transplant recipients on azathioprine

171. PATHOPHYSIOLOGY
o Tumorigenesis
Unlike low-risk serotypes,
oncogenic HPV serotypes can integrate
into human DNA
Amplification of viral replication and
subsequent transformation of normal
cells into tumor cells may follow
E7 oncoprotein binds to the
retinoblastoma (Rb) tumor suppressor
protein, whereas E6 binds to the p53
tumor suppressor protein
• In both instances, binding leads to
degradation of these suppressor proteins.
• The E6 effect of p53 degradation is well
studied and linked with the proliferation
and immortalization of cervical cells

172. Spectrum of cervical dysplasia
• A. This initial point shows the cell at risk
due to active HPV
infection. The HPV genome (blue ring)
exists as a plasmid, separate from the
host DNA.
• B. The clinically relevant preinvasive
lesion, cervical intraepithelial neoplasia 3
(CIN 3) or carcinoma in situ (CIS), is an
intermediate stage in cervical cancer
development. The HPV genome has
become integrated into the host DNA,
resulting in increased proliferative ability.
• C. Interactive effects between
environmental insults, host immunity, and
somatic cell genomic variations lead to
invasive cervical cancer

173. Tumor Spread
Lymphatic Spread
o The cervix has a rich network of
lymphatics, which follow
the course of the uterine artery
o The pattern of tumor spread typically
follows cervical lymphatic drainage
o In contrast, lymphatic channels from
the posterior cervix course through the
rectal pillars and the uterosacral
ligaments to the rectal lymph nodes.
Lymph Node Groups
Paracervical and
parametrial lymph node
Obtrator lymph node
Paraaortic lymph node
Internal,external and
common iliac lymph nodes

174. Lymphatic drainage of the cervix
The parametrial
lymph nodes are removed
during radical hysterectomy.
Pelvic and
paraaortic nodes also may be
removed by lymphadenectomy

175. Lymphovascular Space Involvement
• LVSI is poor prognostic indicator but not included in the clinical
staging of cervical cancer

176. Local and Distant Tumor Extension
• With extension through the parametria to the pelvic sidewall, ureteral
blockage frequently develops, resulting in hydronephrosis
• Additionally the bladder may be invaded by direct tumor extension
through the vesicouterine ligaments (bladder
pillars). The rectum is invaded less often because it is anatomically
separated from cervix by the posterior cul-de-sac. Distant
metastasis results from hematogenous dissemination, and the
lungs, ovaries, liver, and bone are the most frequently affected.

177. HISTOLOGIC TYPES
o Squamous cell carcinomas represent 70% of all cervical
cancer, and adenocarcinomas account for 25% of cervical
cancers.
o The other cell types are rare
o SCC-arise from the ectocervix
o Adenocarcinoma-arise from the endocervical
mucus-producing columnar cells.
o Mucinous adenocarcinomas are the most common
o Endometeroidadenocarcinomas are the second most
frequently identified and display glands resembling those of
the endometrium
o Women with Peutz-Jegher syndrome are at higher risk of
developing adenoma malignum(Minimal deviation)
 contain a greater number of glands positioned at a deeper level
than normal endocervical glands.

178. Prognosis Comparison
• Women with adenocarcinomas
have worse overall survival rates
at every stage compared with
those with squamous cell
carcinoma(FIGO)
Other Tumor Types
oThe following has poor prognosis
Neuroendocrine tumors of the
cervix are highly aggressive
Cervical sarcoma
• leiomyosarcomas
• stromal sarcomas
Melanomas

179. DIAGNOSIS
Symptoms
• Some women diagnosed with this
cancer are asymptomatic.
In others, early-stage cervical cancer
may create a watery,
blood-tinged vaginal discharge.
Intermittent vaginal bleeding that
follows coitus or douching also can be
noted. As
a malignancy enlarges, bleeding
typically intensifies, and
occasionally, a woman presents with
uncontrolled hemorrhage from a
tumor bed

180. Physical examination
o Most have normal general physical
examination
o External genitalia and vaginal
examination
o Inspect anogenital area
o Speculum examination
o Bimanual examination
The proximal posterior vaginal wall is
most commonly involved
o Rectovaginal examination
Thick hard irregular rectovaginal septum
oDigital rectal examination
Appreciate the parametrial,uterosacral
and pelvic side wall involvement
Thick irregular firm and less mobile
A fixed mass indicates that tumor has
poorly extended to the pelvic side walls
• Lower extremity edema
• Low back pain radiating to legs
• Hydronephrosis
oLymphatic tumor spread to
supraclavicular and inguinal
lymphadenopathy
oHematuria or Vesicovaginal or
rectovaginal fistula

181. Papanicolaou Test and Cervical Biopsy
oHistologic evaluation of cervical biopsy is the primary tool to
diagnose cervical cancer
oPap testing alone for evaluation of a suspicious lesion is discouraged
Due to low single test sensitivity(53-80%)
• Thus, the preventive power of Pap testing lies in regular serial screening
Take biopsy for diagnosis
• Biopsies are taken from the tumor periphery and include underlying stroma
oCervical punch biopsies or conization specimens are the most accurate for
allowing assessment of cervical cancer invasion

182. STAGING
o Historically, cervical cancer has been
staged clinically.
o The current staging system now
incorporates radiologic and surgical
evaluation
 Lymph node metastases worsen patient
prognosis and may be identified with
imaging.
o early-stage disease refers to FIGO stages
I through IIA.
o The term advanced-stage disease
describes stages IIB and higher
o Accurate evaluation is critical to
appropriate treatment planning

185. Which of the following tests is NOT used for staging
cervical cancer per the International Federation of
Gynecology and Obstetrics (FIGO)?
a. Cystoscopy
b. Chest radiograph
c. Intravenous pyelogram
d. Computed tomography scan

186. Imaging
• Imaging results can tailor treatment for an individual.

187. MRI
• Measures tumor size, delineates cervical
tumor boundaries, and identifies surrounding bladder, rectal, or
parametrial invasion.
• Offers superior contrast resolution at soft tissue interface
• Less accurate for diagnosing microscopic or deep cervical stromal
invasion or identifying minimal parametrial extension
• For primary cervical cancer, MR imaging is superior to CT
for determining carcinoma size, local tumor extension, and
lymph node involvement

188. Computed Tomography
• for the assessment of nodal involvement and distant metastatic
disease
• CT can also aid detection of ureteral obstruction
• CT is not accurate for assessing subtle parametrial invasion or deep
cervical stromal invasion
• CT is also limited by its inability to detect small volume metastatic
involvement in normal-size lymph nodes.

189. Positron Emission Tomography
• Enable an imaging of functional processes within the body
• FDG-PET is superior to CT or MR imaging for lymph node
metastasis identification
• However, PET is insensitive for lymphatic metastasis <5 mm

190. LYMPH NODE DISSECTION
• It offers accurate metastasis detection and may
modify a patient's primary treatment strategy
• Potential candidates include patients with positive or suspected
positive pelvic nodes undergoing chemoradiation treatment
• During lymphadenectomy, most experts recommend lymph
node dissection in the common iliac and paraaortic region
and resection of macroscopic lymph nodes

191. PROGNOSIS
• FIGO stage is the most
significant prognostic factor
• Lymph node involvement is an
important prognostic feature
• In addition, the number of nodal
metastases is predictive
• In general, microscopic nodal
involvement has a better
prognosis than macroscopic
nodal disease

192. EARLY-STAGE PRIMARY
DISEASE TREATMENT
• Early stage disease includes stage I to IIA
• Stage IA is a microinvasive cervical cancer that carries a minor risk of
lymph node involvement and excellent prognosis following treatment.

193. Stage IA1
oRisk of nodal metastasis-1.5%
oOption of treatment
Cervical conization
Total extrafascial hysterectomy (type I hysterectomy) is preferred
for women who have completed childbearing
oWhen LVSI present in Stage IA1,the risk of lymph node metastasis is app 5%
Modified radical hysterectomy (type II hysterectomy) and pelvic lymphadenectomy.
Radical trachelectomy with pelvic lymph node dissection can be considered in those
patients desiring fertility preservation

194. What is the most appropriate treatment for a 30-year old
woman who has stage IA1 adenocarcinoma of
the cervix, negative lymphovascular space invasion
(LVSI), and strongly desires future fertility?
a. trachelectomy
b. Cold-knife conization
c. Extra fascial hysterectomy
d. Modifed ( type II) radical hysterectomy

195. Stage IA2
o These cancers have a 7-percent risk of lymph node metastasis and carry a >4-
percent risk of disease recurrence
o Radical (or modified radical) hysterectomy and pevic
lymphadenectomy is recommended.
o For fertility preservation, stage IA2 squamous cervical lesions
may be treated with radical trachelectomy and lymphadenectomy.
o A nonabsorbable cerclage may be placed concurrently
with radical trachelectomy to improve cervical competence
during pregnancy
o Preoperative MR imaging to evaluate the
parametria and/or CT scan to evaluate extracervical disease is
recommended in these cases.

196. IA1 and IA2
• Alternatively, patients with stage IAl and IA2 cervical cancer can be
treated with intracavitary brachytherapy alone with
excellent results
• Potential
candidates for vaginal brachytherapy include women who are
elderly or who are not surgical candidates due to comorbid
medical disease

198. Which of the following statements about radical
trachelectomy is FALSE?
a. Cesarean delivery is required if pregnancy
achieved.
b. Preterm birth rates are increased after radical
trachelectomy.
c. At least 1 cm of endocervix must remain attached
to the uterus.
d. If the shave margin is positive, hysterectomy is
completed

200. Stage 1B to IIA
• Stage IB to IIA cancers do not extend into the parametria and
thus can be managed with either surgery or chemoradiation
• In general, radical hysterectomy for stage IB through IIA
tumors is usually selected for premenopausal women who wish
to preserve ovarian function and for women who have concerns
about altered sexual functioning following radiotherapy.
• Age and weight are not contraindications to surgery.
• Surgery is contraindicated in patients with severe cardiac or
pulmonary disease

201. Weighing Surgical and
Radiotherapy Complications
Early-stage cervical cancer radical surgery
• Ureteral stricture
• Vaginal fistulas, bladder
dysfunction,constipation, wound
breakdown, lymphocyst, and
lymphedema
• VTE
Radiation therapy
• altered sexual function secondary to a
shortened vagina
• Dyspareunia
• psychologic factors
• vaginal stenosis
• Late urinary and bowel complications
such as fistula formation,
enteritis, proctitis, and bowel
obstruction

202. Positive Pelvic Lymph Nodes
• Approximately 15 percent of
patients with clinical stage I
through IIA cervical cancers will
have positive pelvic nodes.
oRisk factors for lymph node
involvement include
Histologic grade
Depth of invasion
Stromal invasion
Parametrial extension
LVSI

203. Recurrence Risk
For women who have completed radical surgery for early-
stage cervical cancer, the GOG has defined risk factors to
help identify women for tumor recurrence

204. ADVANCED-STAGE PRIMARY
DISEASE TREATMENT
• Radiation Therapy
• Both external beam pelvic radiation
and brachytherapy are typically delivered
• During evaluation, if paraaortic nodal
metastases are found, extended field radiation can be added to
treat these affected lymph nodes

205. Chemoradiation
• Chemotherapy given concurrently
with radiation therapy significantly
improves overall and disease free
survival rates in women with
cervical cancer
• It is now recommended that
cisplatin based chemotherapy
should
be considered in women
undergoing radiation for cervical
cancer

206. Pelvic Exenteration for Primary Disease
• Stage IVA without distant spread

207. StagelVB
• poor prognosis
• palliation

208. SURVEILLANCE
Following Radiotherapy
o In general, patients are seen at 3month
intervals for 2 years,
then every 6 months until 5 years have
passed from treatment,
and then annually
o Vaginal dilator or have vaginal intercourse
o Pelvic examination and/or radiologic
scanning
 shrinkage of the mass
o Rectovaginal examination
 Nodularity in the ligaments and parametria
o Manual nodal survey
 neck, supraclavicular, axillary, and inguinal
lymph nodes
o A cervical or vaginal cuff Pap test also is
collected annually for 20 years after
treatment completion
o Colposcopy ,biopsy ,CT or CT/PET as
needed

209. SURVEILLANCE …
• Following Surgery
• After a radical hysterectomy, 80
percent of recurrences are
detected within the subsequent 2
years
• During patient surveillance, an
abnormal pelvic mass or abnormal
pelvic examination finding typically
prompts CT scanning of the abdomen
and pelvis.
• Clinical findings include cervical or
vaginal lesion, rectovaginal nodularity,
pain radiating down the posterior
thigh,
or new-onset lower extremity edema.
Pelvic recurrences after
radical hysterectomy, if diagnosed
early, can be treated with
radiation therapy
• The same schedule of visits and Pap
tests as
outlined above for surveillance
following radiotherapy is then
recommended

210. SURVEILLANCE …
• Hormone Therapy
• Cervical cancer is not estrogen-dependent and thus hormone
therapy is not contraindicated to treat menopausal symptoms
• Either systemic
or vaginal forms of estrogen are suitable.

211. SECONDARY DISEASE
• This is defined as either
persistent or recurrent cancer
• usually palliative Rx
• pelvic radiation if not received
before
• Metastatic cervical cancer is not
curable
• Pelvic Exenteration for
Secondary Disease
• Radiotherapy or Chemotherapy
for Secondary Disease
chemoradiation for radiotherapy
naive pts

212. PALLIATIVE CARE
• Pain management forms the basis of palliation
• Many will require narcotics
• Treat constipation
• Home hospice

213. MANAGEMENT DURING PREGNANCY
• A greater proportion of patients have stage I disease
• A Pap test is recommended for all pregnant patients older than
21 at the initial prenatal visit.
• Additionally, clinically suspicious lesions are directly biopsied
• If Pap test results reveal HSIL,
adenocarcinoma in situ (AIS), or suspected malignancy, colposcopy is performed
and biopsies are obtained.
• endocervical curettage is excluded to prevent amnionic sac rupture
• IfPap testing indicates malignant cells and colposcopy-directed
biopsy fails to confirm malignancy, diagnostic conization may be
necessary

214. Stages I and II Cancer in Pregnancy
• Women with positive nodes may elect to
be
treated with definitive treatment, rather
than delay.
• Given the
outcomes, a planned treatment delay is
generally acceptable for
women who are 20 or more weeks'
gestational age at diagnosis
• For patients with stage IA2
through IIAI, a cesarean section via a
classical uterine incision
may be performed at term, followed
immediately by radical
hysterectomy and lymph node dissection.
Notably, a classical
cesarean incision minimizes the risk of
cutting through tumor
in the lower uterine segment, which can
cause serious blood
loss and result in tumor spread
• (stage IAl) may deliver vaginally and he
reevaluated
6 weeks postpartwn

215. Advanced Cervical Cancer in Pregnancy
• Women with advanced cervical cancer diagnosed prior to fetal
viability are offered primary chemoradiation.
• Spontaneous
abortion of the fetus tends to follow whole-pelvic radiation
therapy.
• For women who decline pregnancy termination, systemic chemotherapy can be administered.
Cisplatin with vincristine or paclitaxel can be administered in pregnancy.
• If cancer is
diagnosed after fetal viability is reached and a delay until fetal
pulmonary maturity is elected, then a classical cesarean delivery is performed. Chemoradiation is
administered after uterine
involution.
• For patients with advanced disease and treatment
delay, pregnancy may impair prognosis. A woman who elects
to delay treatment, to provide quantifiable benefit to her fetus,
will need to accept an undefined risk of disease progression.

216. A 29-year-old primigravida at 10 weeks’ gestation
has a Pap test result of adenocarcinoma in situ (AIS).
Colposcopy and biopsies performed are concerning for
invasive adenocarcinoma. What is the best next step?
a. Pregnancy termination
b. Conization at 6 weeks’ postpartum
c. Cesarean radical hysterectomy at term
d. Conization early in the second trimester