🩺 Cervical Lesions

Course Overview

Cervical lesions encompass a variety of abnormal changes of the cervical epithelium or stroma, which may be benign, premalignant, or malignant. Early recognition and intervention are critical in preventing progression to cervical cancer, especially in women at high risk due to HPV infection, immunosuppression, or chronic inflammation.

This module provides a structured approach to understanding the types, risk factors, clinical features, diagnostic evaluation, and management of cervical lesions.

Learning Objectives

By the end of this module, learners should be able to:

1. Describe the types and pathophysiology of cervical lesions.

2. Identify risk factors associated with cervical dysplasia and malignancy.

3. Recognize clinical signs and symptoms of cervical lesions.

4. Outline diagnostic investigations including cytology, histology, and imaging.

5. Formulate management strategies based on lesion type and severity.

6. Understand preventive measures including HPV vaccination and screening protocols.

 Types of Cervical Lesions

Cervical lesions can be classified as:

1. Benign lesions

   • Nabothian cysts

   • Cervical polyps

   • Ectropion (ectopy)

   • Inflammatory lesions

2. Premalignant lesions (Cervical Intraepithelial Neoplasia, CIN)

   • CIN I (mild dysplasia)

   • CIN II (moderate dysplasia)

   • CIN III (severe dysplasia/carcinoma in situ)

3. Malignant lesions

   • Squamous cell carcinoma (most common)

   • Adenocarcinoma

   • Rare types: small cell, neuroendocrine, or adenosquamous carcinoma

 Risk Factors

Key risk factors for cervical lesions include:

• Human Papillomavirus (HPV) infection, particularly high-risk types (16, 18).

• Early onset of sexual activity and multiple sexual partners.

• Immunosuppression, including HIV infection.

• Smoking and exposure to carcinogens.

• Chronic cervical inflammation or history of STIs.

• Low socioeconomic status and limited access to screening.

 Clinical Features

Cervical lesions may be asymptomatic (detected via screening) or present with:

• Abnormal vaginal bleeding: intermenstrual, postcoital, or postmenopausal.

• Vaginal discharge: watery, mucopurulent, or foul-smelling.

• Pelvic pain (less common, usually in advanced disease).

• Visible lesion on speculum examination: erythematous, exophytic, ulcerated, or friable tissue.

• Occasionally, obstruction or irregularity of the cervical canal.

 Diagnostic Investigations

A stepwise approach is recommended:

1. Cytology (Pap smear)

   • Screening for premalignant or malignant changes.

   • Reported using Bethesda system: ASCUS, LSIL, HSIL, or malignancy.

2. HPV Testing

   • High-risk HPV DNA testing to identify oncogenic virus presence.

3. Colposcopy

   • Visualization of abnormal epithelium using acetic acid or Lugol’s iodine.

   • Targeted biopsies for histopathology.

4. Histopathology

   • Confirms diagnosis and guides management (CIN grading, invasive carcinoma).

5. Imaging (if invasive disease suspected)

   • MRI or CT to assess local invasion or metastasis.

 Management

Management depends on lesion type, severity, and patient factors:

A. Benign Lesions

• Nabothian cysts: usually no treatment unless symptomatic.

• Cervical polyps: polypectomy under local anesthesia.

• Cervical ectropion: observation; ablation if persistent bleeding.

• Inflammatory lesions: treat underlying infection.

B. Premalignant Lesions (CIN)

• CIN I: observation or ablative therapy (cryotherapy, laser) if persistent.

• CIN II/III: excisional procedures (LEEP, cold knife conization) to remove abnormal epithelium.

• Follow-up: cytology and HPV testing at defined intervals to ensure complete resolution.

C. Malignant Lesions

• Early-stage carcinoma: radical hysterectomy or fertility-sparing trachelectomy.

• Locally advanced: chemoradiation.

• Palliative care: for metastatic disease, symptom control with chemotherapy, radiotherapy, or surgery.

D. Supportive Care

• Pain management, psychological support, and counseling regarding fertility and sexual health.

• Vaccination of high-risk individuals with HPV vaccine to prevent new infections.

 Preventive Strategies

• Cervical cancer screening: Pap smear or HPV testing starting from age 21 or per local guidelines.

• HPV vaccination: ideally before sexual debut (ages 9–14), with catch-up programs up to 26 years.

• Safe sexual practices: condom use and limiting partners.

• Regular follow-up: for women with previous cervical lesions or high-risk HPV.

 Key Summary Points

• Cervical lesions range from benign to premalignant and malignant.

• HPV infection is the leading cause of premalignant and malignant lesions.

• Many lesions are asymptomatic, emphasizing the importance of screening.

• Management is lesion-specific, from observation to excision or radical surgery.

• Prevention includes HPV vaccination and routine screening.

Recommended References

• Williams Obstetrics, 27th Edition, Cunningham FG et al.

• American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin: Cervical Cancer Screening and Management, 2023.

• WHO Guidelines on Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention, 2021.

• Ministry of Health Zambia: National Cervical Cancer Control Guidelines.