Porth's Essentials of Pathophysiology, 4e

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Disorders of the Female Genitourinary System

C h a p t e r 4 0

The classification of cervical precancerous lesions has changed over time, and terms from different clas- sification systems are currently used interchangeably. 6,7 Precancerous cell epithelial lesions are often described as either atypical squamous cells (ASCs), low-grade intraep- ithelial lesions (LSILs), or high-grade intraepithelial lesions (HSILs), and cancerous lesions are termed inva- sive squamous carcinoma. Atypical squamous cells can be further divided into “ASC of underdetermined sig- nificance” (ASC-US) and “ASC, cannot exclude HSIL.” Precancerous glandular lesions are classified in a similar manner as atypical glandular cells (AGC). Cancerous glandular lesions are classified as adenocarcinoma. 6,11,22 The atypical cellular changes that precede frank neo- plastic changes consistent with cancer of the cervix can be recognized by a number of direct and microscopic techniques, including the cytology (Pap smear), colpos- copy, and cervicography. The appropriate use of Pap smear cytology in cervical screening programs has been controversial. The American Cancer Society (ACS), the American College of Obstetricians and Gynecologists (ACOG), and the U.S. Preventative Services Task Force (USPSTF) have developed evidence-based guidelines for cancer screening. 21–23 The ACOG guidelines recommend that screening begin at age 21 regardless of sexual his- tory and be done every 3 years between the ages of 21 and 29 years. For women ages 30 to 65 the preferred approach is to be screened every 5 years with the com- bination HPV and Pap smear cytology. Women who prefer may continue to be screened every 3 years with Pap smear cytology. It is recommended that women discontinue screening after the age of 65 if they have had negative cytology results in the previous 10 years. Women who have had a total hysterectomy (removal of the uterus and cervix) for noncancerous reasons should discontinue cytology and HPV testing. For women who have had a total hysterectomy because of a cancer diag- nosis, cytology and HPV testing may still be warranted. Women who have had a supra-cervical hysterectomy (the uterus is removed, but the cervix remains) should continue cytology and HPV testing as recommended by cervical cancer screening guidelines. Diagnosis and Treatment. In its early stages, cervical cancer often manifests as a poorly defined lesion of the endocervix. Frequently, women with cervical cancer pres- ent with abnormal vaginal bleeding, spotting, and dis- charge. Although bleeding may assume any course, it is reported most frequently after intercourse. Women with more advanced disease may present with pelvic or back pain that may radiate down the leg, hematuria, fistulas (rectovaginal or vesicovaginal), or evidence of metastatic disease to supraclavicular or inguinal lymph node areas. Diagnosis of cervical cancer requires pathologic con- firmation. Pap smear cytology results demonstrating squamous intraepithelial lesions often require further evaluation by colposcopy, during which a biopsy sam- ple may be obtained from suspect areas and examined microscopically. 7,24 Diagnostic endocervical currettage may also be done to determine the extent of endocervi- cal involvement. 7

Early treatment of cervical cancer involves removal of the lesion by one of various techniques. Biopsy or local destruction of the affected cervical tissue may be therapeutic in and of itself. Electrocautery, cryosurgery, or carbon dioxide laser therapy may be used to treat moderate to severe dysplasia that is limited to the exo- cervix (i.e., squamocolumnar junction clearly visible). Therapeutic conization becomes necessary if the lesion extends into the endocervical canal and can be done surgically or with a large loop electrocautery procedure (LEEP) in the physician’s office. 18 Depending on the stage of involvement of the cer- vix, invasive cancer is treated with surgery, radiation therapy, chemoradiation, or chemotherapy. 18 External- beam irradiation and intracavitary irradiation or brachytherapy (i.e., insertion of radioactive materials into the body) can be used in the treatment of cervical cancer. Intracavitary radiation provides direct access to the central lesion and increases the tolerance of the cer- vix and surrounding tissues, permitting curative levels of radiation to be used. External-beam radiation elimi- nates metastatic disease in pelvic lymph nodes and other structures, as well as shrinking the cervical lesion to optimize the effects of intracavitary radiation. Surgery can include extended hysterectomy (i.e., removal of the uterus, fallopian tubes, ovaries, and upper portion of the vagina) without pelvic lymph node dissection, and radical hysterectomy with pelvic lymph node dissection. The choice of treatment is influenced by the stage of the disease as well as the woman’s age and health. Disorders of the Uterus The uterus is subject to a number of disorders, the most common being infectious processes, endocrine imbal- ances, neoplasms, and defects in uterine support. Infectious Disorders of the Uterus and Pelvic Structures The uterus and pelvic structures are subject to infections by a number of agents, including the sexually transmit- ted organisms N. gonorrhoeae and C. trachomatis , as well as endogenous microorganisms such as anaerobes, Haemophilus influenzae , enteric gram-negative rods, and streptococci. Tuberculosis salpingitis is rare in the United States but more common in developing countries. Endometritis. The endometrium and myometrium are relatively resistant to infections, primarily because the endocervix normally forms a barrier to ascending infections. Acute endometritis is uncommon and usually occurs after the cervical barrier is compromised by abor- tion, delivery, or instrumentation. 6,7 Curettage (scraping of the uterine cavity) is diagnostic and often curative because it removes the necrotic tissue that has served as a site for microbial growth. Chronic inflammation of the endometrium is asso- ciated with intrauterine devices (IUDs), pelvic inflam- matory disease, and retained products of conception after delivery or abortion. The presence of plasma cells