Most common cancer of women in India is Ca Breast, while the most common gynecological cancer of women in India is Ca cervix
HPV infection is associated with around 99% of cervical cancer
It is done for asymptomatic women and is done by:
It is taken by Ayre’s spatula. It has a sensitivity of about 47 to 62%.
Screening has brought down the incidence of Ca Cervix by 75 – 80 % & incidence of death by Ca cervix by around 70%
Use of cytobrush and cytobroom has increased sensitivity upto 90%, by prevention of drying artefacts prevented. This method washes the smear in fixative and filters out cells.
A routine paps smear is taken with Ayre spatula, placed on a slide and fixed with 95% ethanol by immediately placing the slide in the Coplin jar.
This method is also called as Liquid based cytology
Site of taking paps smear
Cervical smear is taken from the Transformation zone or the are between old and new squamo-columnar junction. The endometrium is composed of columnar cells while vagina & ectocervix is made of squamous cells, the junction of the two is known as the squamocolumnar junction.
TZ is more prone to infection by HPV (and thus cancer) as the cells are continuously dividing here.
Etiology and risk factors
HPV infection (Human Papilloma Virus)
Elaborate E6, E7 onco-proteins at transformation zone
18: Most malignant
HIV 1 & 2
HSV 1 & 2
Commercial sex worker
Women with many partners
Partner with STD
Low socio Economic status
Early intercourse [<16 yrs]
TZ is Located at 1.7 to 2.3 cm from the external Os changes location with age group. Early intercourse increases no of years of exposure of TZ to HPV as TZ gets externalized earlier
Post partum/puerperal time
HPV infection is self limiting (in most cases) in 9-15 months.
Time to do Pap Smear
Any woman > 21 yrs of age
Any women 3 yrs after 1st sexual exposure (in India)
From 21 to 29 years, sexually active women should have cytology every 3 years
From 30-65 yrs: Co-TEST [PAP + HPV]: if negative then 5 yearly if only cytology done, then once in 3 years if cytology is negative
After 65 yrs: No more PAP, if 3 cytology are negative or 2 Co-TEST are negative
Classification of cervical dysplasia
CIN I- < 1/3rd abnormal
Low Grade Lesion
CIN II- > 1/3rd to <2/3rd abnormal
CIN III- > 2/3rd abnormal
CIS- All cells are abnormal
High Grade Lesion
Management of CIN I
CIN I 5 yrs → CIN III 10 yrs → Ca CERVIX, CIN I not a precursor of Ca cevix. In case of CIN I & CIN II, 65-80% will regress spontaneously, however high grade lesions are precursor of Ca Cervix
CIN I can be followed up with 6 monthly PAP smear along with antivirals & antibiotics. HPV DNA must be done.
If CIN I persists for > 2 yrs, we must continue surveillance and an ablative or therapeutic procedure must be planned
Management of CIN II & CIN III (HSIL/ High Grade Intrepithelial Lesion)
First step is a colposcopy biopsy as the cervix is normal looking, so we need to use some agents and magnification
First step after CIN III is seen on paps smear is confirmation of diagnosis by COLPOSCOPIC [Vagino Scopic] BIOPSY
Colposcopy biopsy procedure
Acetic acid application to coagulate the proteins of the rapidly dividing areas which appear Acetowhite. Biopsy is now taken from acetowhite areas
Schiller iodine [LUGOL IODINE] application stains the glycogen rich areas which appear Mahogany Brown, biopsy is now taken from unstained areas or lugol’s negative areas.
In the absence of availability of colposcopy VIAA (Visual Inspection under Acetic Acid) or VILI (Visual inspection under lugol’s iodine) may be done
Results of Colposcopic Biopsy
Invasive cancer Cx: Rx by Radical hysterectomy
Biopsy proven CIN III is treated by LLETZ (Large Loop Excision of Transformation Zone) or LEEP (Loop Electro surgical Excision Procedure)
Conization: not usually done
Problem with conization: It leads to a short cervix which causes cervical incompetence leading to recurrent abortions. It may cause stenosis of cervix which may lead to infertility
Can be done if colposcopic Biopsy is inconclusive
Surgical Conization (If > 35 yrs)
Hysterectomy (If > 40 yrs)
Laser ablation: However requires training & experience
Symptoms of CA Cervix
Post coital bleeding, is most common, (Note: in newly married couple post coital bleeding can be due to a post coital tear most commonly located in Posterior Vaginal fornix)
Foul smelling discharge
Pyometra: Dirty vaginal discharge
Mx of Post Coital Bleeding
Do a local examination, rule out any lesion, take biopsy if any obvious growth is seen. If the cervix appears normal, do Colposcopic Biopsy (not a paps smear)
Q. Which of the following procedures is done using following
Dilatation and curettage
Q. A 30 year old woman who is P2L2 underwent a screening PAP smear. The cytology report came out to be carcinoma in situ. What is the next step in management? (AIIMS 2020)
Follow up after 6 months
Q. Young female, multigravida, presenting with post coital bleeding on examination shows a normal vagina with normal endometrial cavity on USG. Next step in management?
Per vaginal examination
Q. A 25 year woman presents with h/o post coital bleeding. Speculum examination showed following appearance. What is the diagnosis? (FMGE 2020)
Q. Which of the following types of HPV is least associated with cervical malignancy?
Q. 16 year old girl, not sexually active, came for vaccination against cervical cancer. Which vaccine to be given? (AIIMS 2019)
Screening for cervical cancer is done by __
____ bleeding is the most common symptom of ca cervix
The most common histological type of cervical cancer is ___cell
The bivalent vaccine against ca cervix available in India is ___
And that is it! That is everything you need to know about cervical carcinoma for your Obstetrics and Gynaecology preparation. For more interesting and informative posts like these, keep reading PrepLadder blogs!
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