Histo-physiological characteristics of the cervix in different periods of age icon

Histo-physiological characteristics of the cervix in different periods of age

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Histo-physiological characteristics of the cervix in different periods of age

The portion of the cervix that projects into vagina is covered with stratified squamous epithelium, which resembles the vagina epithelium. This portion is called exocervix. It is very easy to examine it in a speculum. Exocervix is co­vered by mucous membrane of pink colour with smooth shining surface. Endocervical portion is situated above vaginal portion of cervix and is called endocervix. Cervical canal is covered by single columnar epithelium, which is placed on lamina propria. Epithelium forms the crypts that form cervical glands. Mucous membrane of the cervical canal is bordered from the side of isthmus by histological internal uterine os, and outside by the region of external cervical os.

The cervix is covered by two genetically different types of epithelium. The squamous epithelium changes to a simple columnar epithelium in the transition zone. In infant squamocolumnar junction is situated on the ectocervix surface. This zone is found at about the level of the external cervical os in the juvenile period and puberty. In the majority of them in adolescence it is situated on the level of external os of cervical canal, however, approximately in 30 % of young women the junction zone is found outside the external os. Although, it is found higher from the endocervical canal in menopausal and postmenopausal women. This zone comes to lie upward into the endocervical canal, often out of direct visual contact.

So, presence of the "garland" of columnar epithelium around the external cervical os in women before 20-21 years, that is interpreted by some authors as «congenital erosion», is not a pathological phenomenon. It does not require treat­ment, especially electrocoagulation.

However, if ectopic epithelium undergoes harmful influences, especially me­chanical traumatization (early begining of sexual life, induced abortions), infection, caused by associations of microorganisms and viruses (which happens at frequent change of sexual partners), the part of exocervical epithelium can be transformed into metaplastic flat one with formation of new junction zone. Metaplastic changes take place in this zone. This region is called transformation zone. In some patients carcinogen exposure may cause the abnormal maturation process at the trans­formation zone and begin the process of intraepithelial neoplasia.


True cervical erosion

True cervical erosion is a pathological process,which is a result of damage and following exfoliation of original stratified squamous epithelium. Absence of epithelium on cervical vaginal part appears. Most frequently endocervicitis and endometritis are the causes of true erosions. The area of epithelial defect is exposed to purulent secretions and irritants which are common in endocervicitis and endo­metritis, cause secondary inflammation and exfoliation of epithelium from cervical surface. Harmful examination can cause traumatization of the cervical epithelium.

Clinic. Main clinical signs are chiefly the features of the basic disease. Pa­tients complain on purulent discharge which is common after gynecological exa­mination and sexual intercourse (contact bleeding).

Diagnosis is based on data of clinical picture, colposcopy, and cytological examination. Erosion is revealed during speculum examination. The fleshy red­dened tissue area on the posterior (more rarely than on anterior) cervical lip and concomitant bleeding are common. Erosion fundum is swollen by the connective tissue with subepithelial vessels. Colposcopic criteria such as inflammatory chan­ges, abnormal vascular patterns, vessel dilation, edema, and fibrin precipitation on erosion surface help to identify such areas.

This disease is referred to the short-term processes, true erosion exists no longer than for 2-3 weeks. There is the epithelium defect owing to neogenic squa­mous columnar epithelium. Due to the fact that columnar epithelium has higher regenerative ability, than the squamous one, predominate part of true erosion is replaced by single columnar epithelium thanks to growing on its surface from the cervical canal. The process transforms into the following stage called pseudoerosion.

Treatment Treatment of diseases which cause the formation of true cervical erosion. Doctor determines the pathogenic organism and prescribes treatment directed on its elimination and decreasing of inflammatory reaction in tissues. Optimal conditions for erosion elimination are created. Tampons with cod-liver oil, dog-rose and sea-buckthorn oil should be used. Laser therapy for increasing the regenerative ability of the cervical tissue and improving the organic specificity of neogenic epithelium is indicated. Helium-neon or semi-conductor lasers are applied for this purpose. Each region is exposed to rays during 1-2 minutes, general exposition is 6-8 minutes. Treatment course takes 6-8 days.

^ Cervical pseudoerosion

Cervical pseudoerosion is a benign pathological process, which is characte­rised by presence of original columnar endocervical tissue on exocervical surface.

The disease is polyetiologic. Hormonal correlation in female organism play role in appearing of cervical pseudoerosion. Autoimmune theory of cervical pathology pathogenesis has proved the connection between local humoral immu­nity with the degree of morphological changes in cervix. It confirms possible effect of immunoglobulins of different classes on appearing and progressing of benign lesions.

Congenital, posttraumatic and dyshormonal ectopia are distinguished. Pseudoerosion is formed from the true one when the columnar epithelium spreads on the devoided of stratified squamous epithelium exocervical surface canal. The reserve cells, which are situated under epithelium of cervical canal and its glands (crypts) are the source of ectopic (placed outside the borders of its usual localization) epithelium. Cervical epithelium regeneration passes from these un­differentiated elements. Having biopotential properties reserve cells can trans­form both into columnar and into squamous epithelium. Columnar epithelium penetrates deep in, forming ramified glandular passages, reminding the glands of mucous membrane of cervical canal. The glands produce mucus that is exuded by excretory ducts. As a result of ducts closing during epidermization process mucus accumulates inside the glands. Retention cysts, so-called Nabothian cysts are formed. Their dimensions are different, they shine through cervical epithelium as yellow humps.

Papillary, follicular, glandular and mixed pseudoerosions are distinguished according to morphological signs.

Clinic. Usually patients have no complaints. There can be complaints on vaginal discharge, pain in lower abdomen, sometimes contact bleeding as a result of presence of concomitant diseases (inflammatory processes of the uterus, adnexa, vagina). Speculum examination reveals on its back lip a spot of red colour, from 3-5 to 30-50 mm in size with "velvet" surface. In touch it slightly bleeds around external cervical os.

Diagnosis is based on the data of speculum cervical examination, simple and broadened colposcopy and biopsy. During the simple colposcopy one can see acinar accumulation of scarlet and long papillae. The papillae become more relief, pale and acquire clear appearance, reminding a bunch of grapes, as a result of momentary vessels' constriction and epithelium edema during broadened (after applying on erosion surface 3% solution of acetic acid) colposcopy

The erosion has lightly-pink colour during the Shiller's test (applying on the cervix 3% Lugol's iodine solution or 5% spirit iodine solution). This test gives a possibility to find the most altered epithelium areas for taking biopsy by scalpel or special instruments. The biopsy material is fixed in 5-10% formalin solution and is sent to laboratory.

Treatment. The underlying concept in the treatment of benign cervical lesions is in excision or removal of the superficial precursor lesion avoiding progression to carcinoma:

  • women with congenital epithelial ectopy are subject to supervision till 23 years. They need no treatment

  • treatment of erosions begins from the treatment of diseases, such as endocer-vicitis, endometritis, salpingoophoritis, ectropion, vaginitis, endocrine disor­ders. Etiotropic treatment should be prescribed after authentication of the pathogenic organism. It depends on its species (trichomoniasis, chlamidiosis, gonorrhoea).

  • stimulation of regenerative process of stratified squamous epithelium by application tampons, moistened with cod-liver oil, dog-rose and sea-buckthorn oil to the cervix after elimination of inflammatory process in vagina, and laser therapy by Helium-Neon or semiconductor lasers — ANP-2, Lika-3 should be used. Treatment course takes 6-8 days

  • medical destruction of pathological substratum by the following remedies such as Solcovagyn (Solcogyn), Vagotyle, or electrocoagulation, cryodestruction of erosive surface should be performed if after concervative therapy erosion doesn't heel over. The biopsy is recommended before electrocoa­gulation or cryodestruction

  • radical surgical intervention is recommended (cone-biopsy or cer­vical amputation)

^ The polyps of mucous membrane of cervical canal

The polyps of mucous membrane of cervical canal are created from the mucous of the external os, middle or upper third part of endocervix. They can have a pedicle or wide base. Depending on the dominance in their structure of glandular or connective tissue glandular, glandular-fibrose and adenomatous polyps morphologically are distinguished. Their consistency also depends on the tissue presence (dense in fibrous polyps and soft in glandular ones). A polyp colour depends on its blood supply. At sufficient blood supply polyp has pink or pale pink colour. Polyp can be changed from red to cyanotic in such complications as hemorrhage, necrosis and inflammation.

Clinic. Polyps are common in 40 aged women. The uncomplicated polyps have no symptoms, they are found mostly during monitoring. Mucous or in­significant bloody discharge from vagina can appear in some women.

Diagnosis. During speculum examination the rounded formation, that is situated in the cervical canal is visualized. The colposcopy should be performed for specification of diagnosis. If polyp is covered with columnar epithelium, then during the broadened colposcopy it has a typical papillary surface; if polyp is covered by stratified squamous epithelium (epidermal polyp) then its surface is smooth with divaricated vessels. The polyps, originating from mucous mem­brane of endocervix aren't tinctured by Lugol's iodine solution.

Treatment The polyp is removed by screwing it off with the following coagulation of its pedicle, if its base is visible. If polyp pedicle's base is situated inside the cervical canal, endocervical curettage with the following histological examination is performed. Cryodestruction of polyp's base is indicated. Patients need consultation of oncogynecologist in the case of polyp's recurrence.

^ Cervical papilloma

This disease is caused by human papillomavirus (HPV). There are 18 types of papillomavirus, but only some of them are able to cause lesion of female sexual organs. The HPV-infections most frequently occur in young women which are relating to early sexual life and neglecting the rules of personal hygiene.

There are three types of HPV-lesions of the cervix:

  • condyloma acuminata (exophytic type)

  • condyloma lata

  • inverted ones (endophytic type)

There are no clinical signs specific for HPV-infection. It is manifested by signs of vaginitis such as discharge from genital tract and itching. Papillomas are found during pelvic examination or during speculum examination of the cervix. Typical cytological sign of viral invasion are the phenomena of koilocytosis, that is found as enlightening of the cytoplasm around the nucleus.

Treatment. Papillomatous growth of large sizes requires the biopsy. Laser coagulation by high-intensive laser or cryodestruction by liquid Nitrogen should be performed after this. Small excrescences on the pedicle are treated by means of electrocoagulation of papilloma's pedicle with the following histological re­search of the tissue taken. Conservative methods include powdering by Resorcin, processing with Podophillin, Condylin or Pherisol.


The ectropion is an inversion of cervical mucous as a result of badly renewed cervix after labour trauma. These traumas rarely occur after abortion.

A surface, that is formed in the result of rupture, heals over thanks to the columnar epithelium of the cervical canal.

Clinic. In some cases patients have no complaints. At complicated forms of the ectropion patients complain on aching pain in the lower abdomen, discharge from genitals, of menstrual dysfunction in the form of hypermenstrual syndrome and menorrhagias.

Diagnosis. Presence of old rupture of the cervix, its deformation, the erosive edges are found during the speculum examination. Unlike the erosion the ectropion "disappears" when they draw together the edges of rupture. It can be seen only during breeding of the anterior and posterior lip of the cervix.

Colposcopy diagnoses the atypical picture caused by the chronic inflammatory process. Dysplasia may be present frequently in strong deformation coexisting with considerable histological changes. Complex examination of the patient, except the broadened colposcopy, includes cytological research, cervical biopsy, and endocervical curettage. The question about the volume of treatment is decided after taking into account the received data.

Treatment. Medical arrangements, directed on the renewing of cervical structure start from vaginal flora normalisation. At small dimensions of the rupture, after elimination of inflammatory process in vagina and cervix, electro­coagulation of the eroded surface of the ectropion is performed. Growing of connective tissue leads to constriction of the external os and formation of the exocervix. Reconstructive-plastic surgeries, specifically Emmet's operation is performed at considerable deformation of the cervix and deep lacerations. Presence of the dysplasia is an indication for more radical treatment — cone- or wedge-shaped amputation of the cervix.

^ Cervical leukoplakia

Leukoplakias belong to hyperkeratoses. Leukoplakia is a pathological state of epithelium that is characterized by its thickness and comification. Etiology of this disease is connected with hormonal insufficiency, the involutional changes in the female organism, and vitamin A deficiency.

Clinic. The disease does not have typical clinical picture. Patients have no complaints Leukoplakia is found during the medical monitoring or during the gynecological examination. In some cases patients complain on the great amount of discharge from the genital tract and contact bleeding (this is a sign of possible malignization).

Diagnosis. Leukoplakia, located on the cervix and vaginal walls, is found m the result of speculum cervical examination It looks like a white film or plague, sometimes with pearl colour, that can be flat or slightly prominent over the level of cervical epithelium . The film can be removed from the cervix, and the base of leukoplakia in the initial stages of the process becomes visible. In colposcopy it looks like Iodine-negative region with crimson dots, that is re­presented by connective tissue papillae in stratified squamous epithelium with loops of capillary vessels. The fields of leukoplakia during colposcopy look like multiangular areas, divided by threads of capillaries that create the mosaic drawing.

Layers of polygonal keratinized cells with picnotic nucleus of irregular form — dyskeratocytes are presented during cytological research in smears-imprints

Biopsy is the basic method of diagnostics. It is made under control of colpo­scopy from the most altered areas of the cervix. The regions of squamous metaplasia can be situated also in the cervical canal. That's why it is necessary to perform the endocervical curettage.

Treatment. It is necessary to normalise the vaginal flora, taking into account the pathogenic organism's species if leukoplakia is combined with the inflam­matory diseases of vagina and cervix. Application of methods influencing on tissue exchange and regeneration (dog-rose and sea-buckthorn oil, aloe, etc.) is not recommended because of stimulation of the proliferative processes of these medecines. It causes dysplastic changes in the cervix.

Solkovagyn deserves special attention from group of the chemical coagulants. This remedy is a mixture of organic and inorganic acids and has coagulative action on columnar epithelium. It penetrates into the tissue on 2,5 mm, that is sufficient for destruction of pathologically altered epithelium, and does not cause rough scar changes.

Surgical diathermy should be applied in leucoplakia treatment, but numerous disadvantages of this method (implantative endometriosis, bleeding during scab exfoliating, rough changes in the cervix at extremely deep coagulation) can occur. They limit the usage of this method. Electroexcision should be performed in the limited areas of leukoplakia. Progesterone in tampons is also used. Such methods as cryodestruction and high-intensive action of Carbon laser have higher effecti­veness. There are the methods of combination of cryodestruction with the follo­wing irradiation by low-intensive semiconductor laser. Maximum organo-specificy of the renewed after cryodestruction tissue, decreasing of relapses is reached.



According to the degree of epithelium stinging, cultural atypia and saving of epithelial layer architectonics three degrees of dysplasia have been distingui­shed. There are:

  • mild (CIN I)

  • moderate (CIN II)

  • severe (CIN III)

Hyperplasia and basal cell atypia occupies 1/3 of epithelium layer at CIN 1, at CIN II the changes take about the half of mucous layer, and at CIN III all the epithelium or not less than 2/3 of its layer is altered. The expressed atypia of the superficial layers is considered to be the severe dysplasia.

The following types of epithelium changes are distinguished at colpo­scopy. They are:

• areas of dysplasia:

areas of stratified squamous epithelium

areas of columnar epithelium metaplasia

• papillary zone of dysplasia:

papillary zone of stratified squamous epithelium hyperplasia

papillary zone of columnar epithelium metaplasia

precancer transformation zone

Diagnosis. Cytological research of smears allows to find the cells of basal and parabasal layers with signs of dyskariosis.

Histochemical research in patients with dysplasia show a drastic lowering of glycogen in cells up to full its absence and changes of tissue enzymes activity.

Cytogenetic researches testify that under this pathology the cells with tetraploid and pentaploid number of chromosomes appeared.

Transition of dysplasia into cancer in situ is observed in 40-60 % of patients. CIN 1 precedes the invasive carcinoma by approximately 5-6 years and CIN 3 — about one year.

^ Leukoplakia with atypia

Clinically it does not differ from the simple leukoplakia. The processes of keratinization of the cells in this disease are mistologicaly marked to be reinforced as compared with leukoplakia. Cytological research of the stratified squamous epithelium reveals cells without nucleus at simple leukoplakia. Basal and parabasal cells without nucleoses are also present in the patients with leukoplakia and atypia.


It is a prettily heterogeneous form of dyskeratoses. The changes of cervical mucous membrane are in thinning and keratinizing of epithelium. It looks like scarlet area in the result of translucence of the basal membrane cells through thinned epithelial layer. It easily bleeds at contact. The seats are single or plural with transition on fornices and vaginal walls. Thinning of epithelial layer to 1-2 layers with nuclear atypia and cellular polymorphism is revealed during the histo­logical research.

^ Glandular hyperplasia with atypia

Local hyperplasy of the glands that looks like a clew, similar to endometrial glands at histological research are found. The glands which have different form and size are covered by epithelium, that is unlike the cervical one. It frequently occurs in the first trimester of pregnancy, and disappears after delivery. The adeno­matosis frequently transforms into cancer in situ outside the pregnancy.

Treatment of precancer lesions is made by diathermic excision, cryosurgical and laser destruction. The most radical and less traumatic method is laser coagulation. It is bloodless, painless, and can be performed without anaesthesia in outpatient conditions.

Patients who are treated for benign cervical lesions need to be followed more frequently than the patients presenting for annual health examination.

The patients with benign cervical lesions after 2 months of appropriate treat­ment should be encouraged to avail themselves of annual health care checkups to include the Pap smear.

The patients with precancerous lesions after radical therapy usually receive repeates Pap smear and colposcopic assessment at 1, 5, 6 and 12 months. If Pap smears and colposcopic findings remain normal, patients may resume having annual Pap smear assessments at the beginning of the third year.

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Histo-physiological characteristics of the cervix in different periods of age iconMinistry of the public health of ukraine bukovinian state medical university
ПН. 015 To determine critical periods of embryogenesis, abnormalities of the human development
Histo-physiological characteristics of the cervix in different periods of age iconMinistry of the public health of ukraine bukovinian state medical university
ПН. 015 To determine critical periods of embryogenesis, abnormalities of the human development
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