CERVICAL INTRAEPITHELIAL NEOPLASIA

Cervical Intraepithelial Neoplasia

Cervical intraepithelial neoplasia refers to a pre-cancer stage of cervical cancer which can be easily detected and treated. Over 50,000 new cases of carcinoma cervix are diagnosed annually.

Stages

Cervical intraepithelial neoplasia (CIN) divides the epithelial thickness into thirds.

1. CIN I refers to problematic cells (cellular dysplasia) over lower one third of epithelium.

2. CIN II refers to lesions confined to the lower two thirds of the epithelium.

3. CIN III refers to problematic cells are more than two thirds

Epidemiology and pathogenesis

A. CIN is typically detected at an age 10 to 15 years before the invasive cervical carcinoma actually occurs.

B. Human papillomavirus (HPV) infection is the leading cause of malignant transformation. HPV is found in 70-78 percent of patients with CIN I and in 83-89 percent of CIN II/III. Risk factors for CIN include sexual activity at an early age, history of sexually transmitted diseases, multiple sexual partners, or sexual activity with promiscuous men. Other risk factors include cigarette smoking, multiparity, and immunodeficiency.

 Diagnosis A. Women are typically screened for CIN by cervical cytology PAP smear.

B. Abnormal cytology results should be further evaluated.

Evaluation of the cervix following abnormal cytology results includes visual inspection, repeat cytology, colposcopy, directed biopsy, and endocervical curettage.

Specific therapeutic techniques

1. Common techniques for treatment of CIN:

a. Cryotherapy (nitrous oxide or carbon dioxide)

b. Loop electrosurgical excision procedure (LEEP, LLETZ).

c. Carbon dioxide (CO2) laser ablation

d. Excisional (cold knife) conization

e. Carbon dioxide laser cone excision

2. Cryotherapy

a. Cryotherapy consists of the application of a super-cooled probe directly to the cervical lesion using two cooling and thawing cycles. The probe must be able to cover the entire lesion and the lesion cannot extend into the endocervical canal.

b. The multiple cycle freeze-thaw-freeze technique should be used, and the blanching should extend at least 7 to 8 mm beyond the edge of the cryo-probe to reach the full depth of the cervical crypts. Mild cramping accompanies the procedure.

c. The advantages of this approach include low cost and a low complication rate. Disadvantages are a copious vaginal discharge lasting for weeks and a lack of tissue for histology.

3. Loop electrosurgical excision procedure

a. The loop electrosurgical excision procedure (LEEP or LLETZ) has become the approach of choice for treating CIN II and III because of its ease of use, low cost, and high rate of success. It can be performed in the office using local anesthesia.

b. The procedure uses a wire loop through which an electrical current is passed. The transformation zone and lesion are excised to a variable depth, which should be at least 8 mm, and extending 4 to 5 mm beyond the lesion. An additional endocervical specimen is frequently removed to allow histologic evaluation.

 Follow-up

1. Patients with positive margins after LEEP or cold knife conization are at increased risk for residual disease.

2. Careful clinical follow-up with cytology and colposcopy/biopsy (when indicated) in women with positive margins, instead of immediate retreatment, is appropriate in patients who are compliant with frequent monitoring. Cytologic assessment should be continued at three month intervals until normal for one year after therapy and yearly thereafter.

Bartholin gland abscess

Bartholin's glands are two glands located at the left and right of the opening of the vagina. They secrete mucus to lubricate the vagina. Two percent of women develop a Bartholin's duct cyst or gland abscess at some time in life.
   Obstruction of the Bartholin's duct may result in the retention of secretions, with resultant dilation of the duct and formation of a cyst. The cyst may become infected, and an abscess may develop in the gland.
  
   Organisms involved are Chlamydia trachomatis E coli, Streptococcus faecalis, pyococci, gonococcus.
  
   Clinical presentation: Soft, less than 2 cm in diameter, smooth surface, associated with and aggravated by pregnancy;and trauma.

   Treatment:  An asymptomatic cyst may require no treatment, but symptomatic Bartholin's duct cysts and gland abscesses require drainage.

   Incision and drainage, Excision,  Marsupialization are modalities of treatment.

   Cultures for N. gonorrhoeae and C. trachomatis may be obtained. However, Bartholin's gland abscesses tend to be polymicrobial, and empiric broad-spectrum antibiotic therapy should be used.

Normal Vaginal flora

Vaginal wall is lined by stratified squamous epithelium that is several layers thick. These layers contain glycogen, this glycogen is converted into lactic acid which keeps the pH level low and thus protect against the infections.
Lactobacilli accounts for  90% of the total organisms. They are actually useful as the check the growth of other organisms by maintaining the low pH by producing hydrogen peroxide, which inhibits bacteria. Other organisms are Staphylococcus epidermidis, hemolytic streptococci and coliforms.

Trichomonas Vaginalis

This is one of the commonest sexually transmitted disease in women. Nearly 20% of men partners with Urethritis are infected with Trichomonas Vaginalis (TV) and a co-infection with gonorrhea is very common. TV is an important cause of persistent or recurrent urethritis. Golden role:" a patient whose symptoms of urethritis persists after adequate treatment for gonorrhea and Chlamydia should be investigated for TV infection".
       Investigation are Wet mount studies, Culture and sensitivity, PCR is gold standard.
       Treatment options: First Regimen- Metronidazole as single dose of 2 g orally.
       Second Regimen- Metronidazole 500mg twice a day for 7 days.

Obesity

According to World Health Organization, when the body weights over and above 20% excess over the standard weight in relation to age and sex of that individual, its called as obesity.
Normally we call a person obese if BMI is more than 30.
BMI is measured as Wt of person in kgs divided by ht in meter square. Kg/m2. For example, an adult male weighing 60 kgs with a height of 1.70 meters has a BMI of 60/ 1.70*1.70 = 20.7.
Systemic hypertension, diabetes mellitus, ischaemic heart disease may be associated with Obesity.


Common causes of Obesity:
1. Physical inactivity
2. Hypothyroidism
3. Genetics
4. Drugs- Steroids, estrogen
5. Fatty foods

Hirsutism, Virilistion and Defeminisation

Hirsutism- It is the growth of hair in women in a pattern characteristic of men.
Causes of Hirsutism:
1. Cushing's Syndrome
2. Polycystic ovarian disease
3. Tumours affecting Adrenal glands, causing secretion of androgen.
4. Acromegaly
5. Hyperprolactinaemia
6. Drug Induced- Phenytoin, Oral Contraceptive pills, androgens, psoralens, minoxidil
7. Idiopathic or simple hirsutism: menopause

Virilisation- The characteristic features are:
1. Frontal Baldness
2. Coarsening of voice
3. Acne and seborrhoea
4. Hirsutism
5. Increase in size of Clitoris
6. Increase in size of shoulder girdle muscle

Defeminisation:
1. Decrease in Breast size
2. Loss of female body contours
3. Amenorrhoea