Causes, symptoms and treatment of cervical dysplasia
- What is cervical dysplasia?
- Dysplasia from a doctor's point of view
- Causes of cervical dysplasia
- Symptoms of cervical dysplasia
- Consequences of cervical dysplasia
- Cervical dysplasia and pregnancy
- Diagnostics of the cervical dysplasia
- Treatment of cervical dysplasia
What is cervical dysplasia?
Dysplasia of the cervix (cervical dysplasia) is a condition of the epithelium covering the cervix, which is characterized by a change in the number of layers and the structure of the cells that form it. At the same time, the basement membrane and the uppermost cell layers are not involved in the process. Dysplasia refers to diseases that, under the coincidence of circumstances, can cause the development of a malignant tumor of the cervix.
Dysplasia of the cervix is an extremely dangerous pathology and the most common precancerous form that changes the structure of the mucous membrane of the cervix and vagina. Dysplasia can have a different origin, but it is always accompanied by a violation of the cellular structure of the epithelium. It affects not only the upper layers, but can penetrate much deeper.
Often, cervical dysplasia is called erosion, but this term does not fully convey the essence of the phenomenon. The main difference between these two processes is that erosion occurs due to mechanical damage to tissues, and dysplasia is characterized by a violation of the cellular structure of tissues.
Depending on the depth of the lesion of the mucous membrane of the cervix, there are:
- a weak (mild) form of dysplasia (up to a third of the thickness of the layers of squamous epithelium is affected; the cells of the intermediate layer may swell);
- moderately pronounced (medium) form of dysplasia (affected from one third to two thirds of the thickness; the polarity of the location of the epithelium is disturbed);
- pronounced (severe) form of dysplasia (all layers of the epithelium are affected).
Every year in the world about 40 million women are diagnosed for the first time or confirmed with cervical dysplasia. This disease accounts for approximately 15-18% of cases of identified pathologies of the cervix. It is characteristic of women of reproductive age 34-35 years old. The average incidence of the transition of severe forms of cervical dysplasia to cancer is approximately 10-30% according to various studies.
Most patients, not understanding the essence of the pathological mechanisms, confuse cervical dysplasia with erosion or cancer. Neither statement is correct. To understand what the difference is, you need to turn to anatomy.
Dysplasia from a doctor's point of view
The cervix is the border between the vagina and the uterus itself. It consists of 3 types of fabrics:
A feature of its epithelium is that it is heterogeneous in its structure. The cervix is the meeting point for 2 types of integumentary epithelium: cylindrical, the cells of which are located in one layer, have a rectangular shape and line the uterine cavity and cervical canal, and multilayer flat, characteristic of the vagina and represented by several rows of flattened cells. Both the one and the other epithelium are located on a thin basement membrane, consisting of collagen fibers and playing the role of a solid base and limiter.
It is because of such a complex structure of the cervix in this zone that various pathological processes often arise associated with changes in cell characteristics.
The most basic ones are:
Erosion is the displacement of the columnar epithelium towards the vagina. The structure, functions, features of cell growth are not violated. Due to the difference in conditions in the cervical canal and in the vagina, cylindrical cells are damaged by the acidic environment, waste products of the normal microflora of the female genital tract, trauma during intercourse, forming poorly healing wounds - erosion. During a gynecological examination on a chair, she looks like a patch of juicy red color against a pale pink background.
Read more: Causes, symptoms and treatment of cervical erosion
Cervical cancer is a process of changes in the structure and functions of epithelial cells, which have acquired the ability to grow indefinitely. If the overgrown cells have not gone beyond the basement membrane, then they speak of "cancer in situ" (CIS carcinoma in situ), it is the initial stage of the development of malignant neoplasms of any internal organs. If a cancerous tumor has grown over the basement membrane, then from a medical point of view, we are talking about invasive cancer (this is cancer in the common sense).
Read more: Causes, symptoms, stages, consequences and treatment of cervical cancer
- Dysplasia is a change in the structure of the stratified squamous epithelium that covers the cervix, while cells with an “abnormal” nucleus, multinucleate, irregularly shaped cells appear in it, anatomical division into layers is lost. However, at the same time, the altered cells do not have the ability to grow indefinitely and do not penetrate beyond the basement membrane. The cylindrical epithelium in the transition zone on the cervix remains unchanged.
Modern medicine has not used the term "dysplasia" for a long time, instead of it, both in the diagnosis and in the scientific literature, the following definition can be found: cervical intraepithelial neoplasia (CIN, or CIN), which means the formation of new cellular elements of the cervical epithelium that are not characteristic of this tissue.
Causes of cervical dysplasia
The appearance of cervical dysplasia, like any other precancerous disease, does not occur under the influence of any one factor. It is always a complex combination of many provoking components.
The main reasons for the formation of foci of dysplasia are:
- infection with certain types of human papillomavirus (HPV);
- hormonal contraceptive pills with prolonged use (from 5 years);
- early onset of sexual activity (14-15 years old);
- a large number of sexual partners;
- bad habits (smoking).
Also, their role in the development of dysplastic processes can be played by:
- monotonous diet with a lack of vitamins C, A;
- immunity disorders;
- genetic predisposition to any kind of cancer;
- genital infections;
- low level of education, life, antisocial behavior;
- a large number of genera.
The discovery of the dominant role of the HPV virus in the development of dysplasia and malignant tumors of the cervix was a breakthrough in the development of effective methods for combating cancer of the female reproductive system.
Cervical dysplasia most often develops due to the human papillomavirus (HPV). This disease is most often asymptomatic; it usually takes about 10 years from the onset of dysplasia to the onset of cervical cancer.
Human papillomavirus infection can occur in everyone, but women who are sexually active and have multiple sex partners are at risk. Neglect of contraception and untreated inflammation of the reproductive system also increase the likelihood of contracting HPV. Injury to the cervix can also occur due to abortion or frequent childbirth.
There are many types of HPV virus, each of which can cause specific lesions. For example: common warts on the arms and legs, genital warts; dysplasia and cancers of the cervix.
According to the degree of oncological "danger", all types of HPV can be divided into 3 categories:
- Non-oncogenic and types of low oncogenic risk are found in warts and genital warts, these are types 1, 2, 3, 5, 6, 11, 42, 43, 44.
- Low oncogenic risk. Viruses belonging to highly oncogenic serotypes are found in 90% of all cases of dysplasia and malignant neoplasms of the cervix. These are 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 types.
- High oncogenic risk. Particularly aggressive of them are 16 and 18, which are more common than others and in half of the cases lead to the development of cervical cancer.
Read more: HPV Causes, Symptoms and Treatment
How does HPV cause cellular changes?
In a healthy body, any damaged cell is immediately destroyed by the immune system and internal antitumor mechanisms, which prevent it from entering the process of division and reproducing similar defective cells. In addition, the number of divisions of each cell type is strictly limited by the genetic program. This determines the aging process in the body, with all the desire, a person cannot live forever.
When the HPV virus, which has a high oncogenic activity, enters the body, it is carried by the blood to the genitals, and is embedded in the cells of the squamous cervical epithelium. Viral particles produce special proteins that block the "safety system" of the epithelial cell and damage DNA. As a result, atypical cells are formed, which do not die off, are not removed by the immune system, they are capable of division and reproduce similar "abnormal" specimens. Thus, there is a change in the structure of the layers of the cervical epithelium, which, when analyzed, is defined as cervical intraepithelial neoplasia (CIN, or CIN). However, in dysplasia, unlike cancer, atypical cells do not have the property of unlimited unrestrained growth.
The effect of long-term use of hormonal combined oral contraceptives (COCs) on the occurrence of dysplastic processes in the cervix has been well studied.
In this case, there are 2 separate effects (COC):
The indirect effect is that women who constantly take COCs, as a rule, are young aged 20-40 years, are sexually active, often change sexual partners, they suffer from sexually transmitted diseases more often than others in the population, and smoke. The combination of these factors increases the risk of developing dysplastic processes in the cervix.
The mechanism of the direct effect has not been fully understood, however, based on statistical data, it was concluded that prolonged use of COCs (5 years or more) increases the risk of developing cervical dysplasia by almost 2 times.
Women who use progestin-only drugs for contraception (birth control pills for pregnant women) do not fall into the risk category, since this type of contraceptive does not affect the cervical epithelium. The same applies to women in menopause or with removed ovaries, who receive hormone replacement therapy, their risk of developing dysplastic processes does not increase.
The causes of cervical dysplasia can be both an improper lifestyle and bad habits (especially smoking), since reduced immunity and hypoxia increase the likelihood of microtrauma of the cervical epithelium.
Other reasons, such as early sexual activity, a large number of sexual partners, a low social level - all of them are directly related to the frequent infection of this category of women with various types of HPV.
Lack of vitamins A and C, immunodeficiency states, genetic predisposition lead to disruption of the body's defense system and disruptions in the program for destroying damaged cellular elements, which also contributes to the development of dysplastic processes.
In general, the development of cervical dysplasia can be explained using the theory of "weeds", which was proposed in 1995 by a professor at the University of California, gynecologist Michael Policar (Michael Policar). In his opinion, the cervical epithelium is the soil where the "seeds" of cellular changes in the form of HPV enter, but in order for them to germinate, "water, light, heat" is needed, the role of which is played by other factors in the development of dysplastic processes - smoking, decreased immunity, vitamin deficiency, genetic predisposition. Without them, even in the presence of HPV, the development of cervical dysplasia does not occur.
To date, it has not been possible to confirm this theory clinically and laboratory. However, the combination of HPV with other risk factors in most women supports this scientific hypothesis.
Symptoms of cervical dysplasia
In the initial forms, the disease is often asymptomatic. The disease manifests itself only in neglected conditions: a woman has pains in the lower abdomen, there may be an abundant vaginal bleeding. To avoid this and start treatment on time, it is necessary to undergo regular gynecological examinations, including instrumental, laboratory and clinical studies.
Signs of dysplasia can be detected only if the symptoms are accompanied by other diseases. According to gynecologists, in most cases, in the presence of cervical dysplasia, there is cervical erosion. Therefore, a competent doctor will certainly refer the patient to an SMEAR analysis if erosion is detected in her.
Dysplasia symptoms can be:
- profuse leucorrhoea, without an unpleasant odor, milky white;
- streaks of blood in vaginal discharge after intimacy;
- soreness during sexual intercourse.
It must be repeated again: these symptoms are not specific for cervical dysplasia, cannot be used for diagnosis, but are only a reminder to a woman that her women's health needs a thorough examination.
Depending on how deeply the cervical epithelium is affected, there are 3 degrees of cervical dysplasia:
- 1 degree (weak);
- Grade 2 (moderate);
- 3 degree severe.
If we imagine a section of the epithelium in the form of a rectangle, the lower side of which is represented by the basement membrane, and the upper side is the surface row of cells, then various degrees of dysplasia will look like this.
Grade 1 cervical dysplasia (mild)
In medical records (analysis results or discharge), it is designated as follows: CIN I (cervical intraepithelial neoplasia I). It is placed in the event that only the lower 1/3 of the epithelial layer, adjacent to the basement membrane, has undergone pathological changes.
Grade 2 cervical dysplasia (moderate)
In the diagnosis, it is designated as CIN II (cervical intraepithelial neoplasia II). It is established when the pathological process spreads to 2/3 of the depth of the epithelium, while the upper 1/3 remains unaffected.
Grade 3 cervical dysplasia (severe)
It is designated as CIN III (cervical intraepithelial neoplasia III). It is the most severe form of cervical dysplasia, when the structure of all layers of the epithelium is disrupted. This grade is a fine line between dysplasia itself and the initial stage of cancer ("cancer in situ", or carcinoma in situ). In neither case, the basement membrane remains intact. All the difference is only in the function of cells, which acquire the ability to divide indefinitely. Histological examination can help establish the severity of the pathological process.
Consequences of cervical dysplasia
What a woman can face with cervical dysplasia directly depends on its degree:
Cervical dysplasia of the 1st degree in 57% of cases goes away on its own after the virus is removed from the woman's body. In a healthy person, in 9 cases out of 10, the virus ceases to be detected in blood tests after six months or a year from the moment it enters the body. There is an independent destruction of viral particles by the immune system.
In 32% of cases, there is a long course of the disease without progress, either for the worse or for the better. In 11% of patients, there is a transition from 1 degree to the second.
Cervical dysplasia of the 2nd degree in 43% of cases also goes away on its own after the body is free from HPV. Its long-term stable course is observed in 35%. Thus, 70% of women recover in 2 years from the moment of diagnosis.
In 22% of sick women, grade 2 dysplasia becomes grade 3.
According to studies conducted among various categories of women, the probability of the transition of grade 3 cervical dysplasia to cancer is 10-30%. The reason for such a scatter of results is the presence of a different number of individual risk factors for different categories of women (by age, methods of coception, bad habits, lifestyle, number of sexual partners).
Cervical dysplasia and pregnancy
Dysplasia of the cervix is not a contraindication for bearing a fetus in women who were first diagnosed during pregnancy. The presence of this pathological process does not affect the development of the unborn child, does not inhibit the function of the placenta. At the same time, pregnancy itself does not in any way affect the cervical dysplasia, does not worsen its course and does not contribute to the transition to a more severe form.
In addition, under the influence of hormonal changes occurring in a pregnant woman, physiological changes can develop on the cervix, which can be mistaken for cervical dysplasia. We are talking about extrapion (pseudo-erosion), in which the cells characteristic of the cervical canal are shifted towards the vagina. On examination, this condition is defined as a red corolla on the cervix.
Therefore, if a woman was examined for 1-3 years before pregnancy and has a negative cytological test result, then repeated control is not prescribed.
If the pregnant woman has never been examined for either HPV carriage or atypical cells, then when changes are first detected on the cervix at any time, a smear is taken for a Pap smear test (smear-test).
Further tactics depend on the result. If it is negative, then no further action is taken and control is assigned 12 months after birth. If the test is positive and a mild degree of dysplasia is found, then a colposcopy and control is performed 12 months after delivery.
With an average degree of cervical dysplasia, colposcopy and re-examination after childbirth are prescribed.
If a grade 3 dysplasia is suspected, a targeted biopsy is performed - taking a piece of altered tissue for analysis. If severe dysplasia is confirmed, colposcopy is required every 3 months until delivery and the first 1.5 months from the moment of delivery.
If cancer is detected, further tactics of patient management are agreed with the oncologist and depends on the specific situation.
Diagnostics of the cervical dysplasia
Since dysplasia can turn into cancer under a number of conditions, the most important thing in preventing complications is its early diagnosis. All women over 21 years of age who are sexually active must visit a gynecologist once a year for examination and undergo a cytological examination once every 3 years.
The following common methods are used to diagnose this disease:
- cytological examination of a smear (Papanicolaou, or smear-test);
- taking a piece of tissue (targeted biopsy).
When viewed in mirrors, areas of dysplasia look like areas of irregular shape (plaques) of a whitish color. When conducting a Schiller test - staining of the cervical epithelium with Lugol's solution - uneven staining is determined. Areas of dysplasia remain lighter than healthy tissue.
Cytological examination is able to determine the presence of cervical dysplasia with an accuracy of 60-90%. The sensitivity of the method increases with an increase in the degree of dysplasia.
Colposcopy is an instrumental method of examining the vaginal part of the cervix with a special magnifying device - a colposcope. On examination, irregularly located branched blood vessels in the dysplasia zone, mosaicism, pale coloration of the altered epithelium will be visible. When the cervix is treated with an acetic acid solution, the altered areas will be white.
It should be remembered that none of the listed methods can differentiate severe dysplasia from cancer. This is possible only with the help of a histological examination of a piece of epithelium. The method by which this is done is called targeted biopsy with curettage of the cervical canal. The tissues obtained as a result of the procedure are thoroughly examined. This method is 100% accurate.
Treatment of cervical dysplasia
Before treating cervical dysplasia, the doctor detects and eliminates its cause (hormonal disorders, infections or inflammation). This should stop the development of dysplasia in unreleased forms and promote tissue scarring. In the opposite cases, patients are recommended surgical treatment.
A common treatment for dysplasia is an electric knife, which is used to excise the affected tissue. Healing after such an operation takes three months, but scars and bleeding are possible, which creates the risk of an unfavorable course of pregnancy.
Also, dysplasia of the cervix is treated with laser surgery. Depending on the neglect of the pathological process, healing can last about two months, but this treatment is safe and takes place with practically no consequences.
Another method of surgical treatment for dysplasia is cryotherapy. Affected tissue is frozen with liquid nitrogen. In addition, there is also a chemical method of treatment, which consists in applying a special chemical preparation to the foci of dysplasia that cauterizes the tissue. After a couple of days, they fall off in the form of a thin crust.
The severity of the pathological process affects the tactics of treatment:
Since there is scientifically proven evidence that in most cases, cervical dysplasia of the 1st degree goes away on its own after 1-2 years, provided that the body is free from HPV, modern doctors do not recommend using any treatment at this stage.
Therapeutic tactics are as follows:
- dynamic observation up to 2 years from the date of diagnosis;
- analysis for cytology and colposcopy every year;
- treatment of diseases of the reproductive system (vaginitis, venereal infections);
- fight against bad habits (smoking cessation);
- selection of alternative methods of contraception;
- correction of disorders from the endocrine system.
Since antiviral drugs for the treatment of HPV have not yet been created, proper nutrition and vitamin support are of great help to the body in the fight against the virus. It is recommended to take multivitamin complexes containing vitamins E, B 12, B 6, A, C, folic acid, selenium.
If, during the follow-up examination, carried out 2 years after the diagnosis was established, there is no tendency of grade 1 dysplasia to decrease or, conversely, there are signs of its transition to grade 2, then it becomes necessary to use more aggressive treatment methods.
Small areas of grade 1 cervical dysplasia are successfully treated by treating them with a chemical coagulation drug such as solcogin, vagotide.
2nd and 3rd degree
For the treatment of 2 and 3 degrees of cervical dysplasia, surgical methods are used:
- Laser treatment
- Radio wave treatment
- Electroconization (excision)
- Photodynamic therapy
Surgical treatment should be carried out immediately after the end of menstruation, this prevents the development of endometriosis and improves the healing process. Before the procedure, it is imperative to take a smear for cytological examination, colposcopy and biopsy.
- The principle of action of cauterization is based on the fact that pathologically altered cells are destroyed under the influence of a low voltage current. The procedure is performed using a special apparatus with electrodes in the form of a loop.
- The advantages of the method are its low cost, availability of equipment, and technical simplicity of implementation.
- Disadvantages of the technique: inability to control the depth of exposure, rough scars after healing, there is a high risk of complications in the form of endometriosis.
- With this method, the removal of altered epithelial cells is performed by instant freezing them with liquid nitrogen. The temperature of liquid nitrogen is -196 C%, the water contained in the epithelial cells instantly turns into ice, thus the altered tissue areas die.
- The advantages of the method are that it does not leave behind rough scars, therefore it can be recommended for nulliparous women if it is impossible to use more technological methods.
- The disadvantages include abundant transparent discharge after the freezing procedure, which can bother a woman for up to 1 month, the need to refrain from sexual intercourse for up to 2 months from the moment of treatment, the inability to adequately control the depth of treatment.
- This method is based on the "evaporation" of the affected tissue under the action of laser energy.
- Advantages: does not leave rough scars, modern equipment allows you to control the depth of penetration of the laser beam, which allows you to completely remove all pathological tissue.
- Disadvantages: burns of adjacent healthy areas of the cervix may occur, short-term anesthesia may be required, since the effectiveness directly depends on the patient's immobility.
Radio wave treatment: Refers to a relatively new technique, based on the removal of the focus of dysplasia under the influence of high frequency waves. Performed on the Surgitron apparatus.
The advantages of the method are:
- low invasiveness;
- the ability to control the depth of the impact;
- short rehabilitation period;
- absence of rough scars after the healing period;
- a small percentage of recurrence of areas of dysplasia;
- the ability to use in nulliparous women.
Disadvantages: a very expensive method that is only available in private clinics.
Excision (conization): removal of areas of dysplasia with a scalpel or Surgitron apparatus. Due to the high trauma and a large number of complications after the procedure, it is not used in women of childbearing age. Currently, instead of conization with a scalpel, conization with a laser beam is used. With such an operation, the likelihood of bleeding decreases both during the procedure and during the rehabilitation period, which is associated with the cauterizing effect of the laser.
- Read more: Electroconization of the cervix with dysplasia
Photodynamic therapy: is one of the newest methods of cancer treatment. Its essence boils down to the selective accumulation of a photosensitizer by a tumor after intravenous or local administration. Subsequently, the cancer is irradiated with a light source (laser or non-laser). As a result, a reaction with the release of singlet oxygen occurs in the affected tissues. This leads to the death of cancer cells.
- Read more: Photodynamic therapy of the cervix
With any method of treatment in the postoperative period, it is necessary to adhere to a certain regimen during the first month:
- Sexual rest;
- Do not lift weights;
- Do not play sports;
- Do not visit the pool, sauna, beach;
- Do not sunbathe or go to a solarium, especially in women with HPV;
- Do not take a bath, only showers are allowed;
- Do not inject any drugs or solutions into the vagina, except as prescribed by a doctor;
- It is imperative to conduct a control gynecological examination after the next menstrual cycle after treatment.
Many women, fearing to hear the diagnosis, postpone the visit to the gynecologist, but this is a false fear. Dysplasia of the cervix is perfectly treatable if done on time and in the right way.
If the diagnosis of cervical dysplasia was carried out early, then getting rid of the disease in most cases is successful. Taking medications is prescribed as an auxiliary therapeutic measure, and surgery is considered to be the main method of treatment. In the course of its implementation, pathological areas are removed. However, medical correction is still required. First of all, it is necessary to neutralize HPV, which very often leads to the development of dysplasia. The choice of drugs should be based on the individual characteristics of the course of the disease, and should also be based on the patient's age and her desire to have children in the future.
The objectives of the therapy are as follows:
- Relieve inflammation (anti-inflammatory drugs).
- Restore the functioning of epithelial tissue (hormonal drugs are prescribed).
- Increase the body's resistance (immunomodulators).
- Restore the microflora of the vagina.
So, at the stage of drug correction, immunomodulators, vitamin and mineral complexes (vitamins A, C, E, folic acid) are prescribed.
Drugs for the treatment of cervical dysplasia
Preparations for stimulating immunity
Vitamins and minerals
Read more: HPV vaccination, why is it needed?
Doctors, if possible, try to postpone surgery for as long as possible. However, it is not always possible to cope with cervical dysplasia with the help of medications. Therefore, in 65-70% of cases, you still have to resort to the help of a surgeon. In the future, medical correction is prescribed.
Antibiotics and antiviral agents are prescribed only when dysplasia is severe. In general, drug therapy for neoplastic processes is ineffective.
The author of the article: Lapikova Valentina Vladimirovna | Gynecologist, reproductologist
Education: Diploma in Obstetrics and Gynecology received at the Russian State Medical University of the Federal Agency for Healthcare and Social Development (2010). In 2013 completed postgraduate studies at N. N. N. I. Pirogova.