Diseases of The Cervix

The cervix, or neck of the uterus, (Fig. 1) is considered separately from the main body of the organ for it suffers from diseases different from those of the uterus proper. This may well be because of its more external position, half of it being in the vagina where the secretions are different from those inside the uterus itself.

Abnormalities of Structure

The developmental abnormalities are dealt with on p. 150 but, in addition, the cervix may be very long (hypertrophy) or very small (hypoplasia). The first is usually part of a process of prolapse and is best treated with operative removal. The small cervix is often part of a general smallness of all the genital organs and may be associated with poor sexual development.

Lacerations and Erosions of The Cervix

When a baby is delivered, the baby's head is usually about four to four and a half inches in diameter. This has to pass through the cervix which usually dilates in labour to accommodate such a passenger.

Despite the dilatation there are often small tears in the cervix after delivery (Fig. 2: compare a with b and c) and these tears are permanent. To a lesser extent this can happen after a miscarriage.

The resulting exposure of the delicate lining of the cervical canal to the vagina with its germs, often causes a low-grade, mild, chronic infection. This process goes on and causes much reddening of and discharge from the cervix.

The condition is known as an erosion of the cervix although in actual fact no real erosion of tissue occurs, rather a heaping-up. Sometimes this process goes on inside the canal of the cervix so that the heaping-up process makes a cervical polyp protrude (Fig. 2d).

Both these conditions can give rise to bleeding from the vagina at any time, but especially after intercourse.

They commonly lead to infection so that the periods are heavier and may become painful. Intercourse is often painful and conception may be difficult.

Treatment is Operative

A polyp can be twisted off but this process should be accom-panied by a full uterine curettage in case other polyps, which cannot be seen at the entrance to the canal, exist higher up.

Cervical erosion is best treated by cautery to destroy the unhealthy tissue and to allow healthy re-growth of the lining of the cervix. Both operations necessitate an anxsthetic and a short stay in hospital, but they give good results.

Cancer of the Cervix

This is the most common of all gynaecological cancers and is about the fifth com-monest of all malignant growths that develop in women.

Since it usually occurs in fairly young women it is important that treatment starts early in order to give patients the best chance of cure.

The growth seems to develop more commonly in women aged 35 to 50 who have had children. The number of children does not seem greatly to increase the risk, but some doctors believe that the younger the mother when her first children are born, the greater the likelihood of cancer of the cervix.

No one knows yet what causes this or any other cancer, but until we do, treatment must be aimed at destroying all new growths as soon as they are found. As has been affirmed above, this means that early treatment is the best treatment.

Early Cell Changes

Over the last few years, doctors have been finding that cancer of the cervix is sometimes preceded by a state of instability of the cells of the cervix.

While not producing a frank cancer, the cells show rapid growth and other marked changes. If the disorder is ignored, a certain number of such women develop a true cervical cancer.

These early cell changes have been called ‘carcinoma in situ', that is, cancer-like changes that are well localised and have not spread to neighbouring cells. Throughout life, the cells of the cervix are growing and the outer layers are shed.

They peel away just as the outer layers of the skin flake off.

Cervical Smears

A small wooden spoon lightly rubbed across the cervix will remove a lot of cells. These cell scrapes can be put on a microscope slide, stained, and examined.

Experts trained in this special field can some-times find groups of cells which show ‘carcinoma in situ’ changes.

If found, the patient should have a small operation to remove a little of the cervix tissue. This can be further examined microscopically and the diagnosis confirmed or not.

Should ‘in situ’ changes be found in the tissue, it is possible that all the affected cells have already been removed in the small piece of tissue and experts can sometimes tell this too.

If the patient has had these potential cancer cells excised, she needs no further operation although she should be seen regularly at an out-patient clinic for some time. Should however, all cells not be removed, and the patient be finished with childbearing, it may be wise to remove the uterus to prevent the onset of cancer.

Thus there is a possible means of detecting cancer of the cervix before it is at a spreading stage. The test is simple, painless, and takes ten minutes of the woman's time. Many hospitals and clinics will do this easy test freely for women who wish it in order to try to prevent cervical cancer.

Symptoms

The symptoms of cancer of the cervix should be well known. Irregular bleeding or spotting of blood is often noticed first. It may occur between the periods or even after the menopause. It may come after intercourse or after having the bowels open.

This symptom demands proper investigation by a doctor and must not be ignored. If neglected, the growth may go on to cause a foul discharge. Pain is a late symptom as are bladder troubles such as increased frequency of passing urine or pain when voiding. Examination by a doctor may show a suspicious ulcer or nodule. This should be removed under an anaesthetic and examined with a microscope. If it confirms the presence of cancer, treatment should be started.

Treatment

Some growths of the cervix may respond to radiation and so treatment is given by radium pellets or by external penetrating rays beamed on to the pelvis.

Other growths can be removed by operation and this means removing the cervix and uterus plus the Fallopian tubes, ovaries and lymph nodes coming from these regions. Thus potential cancer-bearing tissue is excised. Sometimes the two types of treatment, radiation and surgery, are combined one after the other to give the best chance to the patient.

If treated early, there is a good chance of full recovery but early treatment depends on early diagnosis.

This in turn depends on the patient seeing her doctor as soon as any irregular bleeding occurs. Delay may allow cancer cells to spread to areas where they cannot be destroyed and this may be fatal.

Dr. Sitara Choudhury
The author is a gynaecologist practising at New York, USA.

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