causes of leucorrhoea:
term leucorrhoea is used to denote a simple increase in normal
vaginal secretions, but currently it is used to describe every white
discharge of a non-purulent nature.
The physiological causes of leucorrhoea are
Ovulation: when the high peak of estrogen provokes the
endocervical glands into excessive secretions.
b) As a result of sexual stimulation.
d) During pregnancy.
in the premenarchal age group:
Any foreign body should be looked for and removed.
infective leucorrhoea, a course of anti-infective agents could be
proper cleaning of the vulval region followed by application of
estrogen cream helps to increase the thickness of the vaginal
epithelium and reduces the vulnerability of the vulval region to
dose estrogen tablets of Estriol (Evalon)1mg for 10 days or
estradiol (Lynoral) 0.01mg daily for 3-4 days is also helpful.
of leucorrhoea in the reproductive age group:
the causes of vaginal discharge could be classified into
Infectious causes: These include bacterial vaginosis,
vulvovaginal candidiasis, trichomonas vaginitis, mucopurulent
cervicitis, gonorrhea, condyloma accuminata, herpes type2 virus and
Normal discharge secondary to hormonal changes: These could
occur due to physiologic leukorrhea (midcycle cervical mucus/postintercourse)
or atrophic vaginitis.
Other causes: There may be chemical/allergic vaginitis,
foreign body, desquamative inflammatory vaginitis, chronic
cervicitis, cervical ectropion, cervical polyps, cervical and
endometrial cancer and collagen disorders.
discharge in a postmenopausal woman:
In women who are not on estrogen replacement therapy, there
is relative lack of estrogen effect in postmenopausal women. Hence
in postmenopausal women, most cases of vulvo- vaginitis are due to
atrophic vaginitis. This is changing with an increasing trend to use
estrogens in postmenopausal women for the prevention of osteoporosis
and general sexual well being.
In senile vaginitis, or atrophic vaginitis, a purulent and
often slightly bloodstained discharge is evident.
The vagina is inflamed and oedematous.
Vulva is inflamed, tender and excoriated.
The raw inflamed areas may become adherent and produce an
obliteration of the canal, causing the infection to spread upwards
into the cervix and endometrium, leading to pyometra.
Senile vaginitis can mask a hidden cancer of the endocervix
or endometrium. Hence it must be investigated by doing a diagnostic
curettage.Mainstay of treatment in senile vaginitis is to improve
the resistance of the vaginal epithelium by giving estrogen.
Estrogen also raises the glycogen content of the vagina and
lowers the vaginal pH, making it more acidic and inhibits the growth
of organisms. Estrogen
creams applied locally twice is effective in these cases.
vaginosis is the most common cause of vaginal discharge.
In this condition, there is bacterial overgrowth, primarily
anaerobes, without signs of inflammation.
The patient may present with a fishy-smelling increased vaginal
discharge not accompanied by leukorrhea, vulvar burning, or pruritis.
presence represents a change in the vaginal ecosystem, specifically
a decrease in lactobacilli, which is part of the normalflora; a
proliferation of pathogenic inhabitants of the vagina; and an
elevation of pH (>4.5).
transmission:Whether BV is sexually transmitted remains unsettled.
The majority of observations, suggests that BV is probably not
The diagnosis of BV requires the presence of at least 3 of
the following 4 criteria: 1.A homogenous noninflammatory discharge
(not many WBCs).
The various modalities are:
2g PO as single dose or 500mg PO twice daily for 7 days.
2..Metronidazole gel given as suppository b.i. d for 7 days.
300mg PO b.i.d for 7 days.
clindamycin cream b.i.d for 7 days.
Ampicillin had been suggested in the past for bacterial vaginosis,
but is not effective.
In pregnancy, the recommended regimen is metrondazole in the dose of
250mg three times daily for 7 days.
It is contraindicated in first trimester. Alternative
regimens in pregnancy are with 2g single dose orally, or local
regimens in pregnancy are with 2g single dosing orally, local cream
applications or Clindamycin 300mg b.i.d for 7 days. The cost of
therapy for Clindamycin comes to about Rs.160/day in India.It is
safe in pregnancy.
Infection with BV has been associated with an increased risk of
septic abortion, premature rupture of amniotic membranes, preterm
labor, preterm delivery, post-Cesarean endomyometritis, and
post-hysterectomy pelvic cellulitis.
Trichomonal vaginitis is caused by the protozoan Trichomonas
vaginalis, a motile organism with four flagella,It accounts for 10
to 25 percent of vaginal infections.It is sexually transmitted and
may be identified in 30 to 80 percent of the male sexual partners of
infected women. Trichomoniasis is associated with and may act as a
vector for other venereal diseases. Studies indicate that this
infection increases the transmission rate of the human
immunodeficiency (AIDs) virus.
There is copious, malodorous, yellow-green (or discolored)
discharge,pruritus and vaginal irritation.
There may be no symptoms in 20 to 50 percent of affected
women. On examination there may be vulvar and vaginal edema and
erythema. The cervix
may have a strawberry appearance in 25% of women. The vaginal pH is
elevated (>4.5) Microscopic examination will show many
trichomonads and many polymorphonuclear cells.
2g orally in a single dose.
Metronidazole could be given in the the dose of 500mg twice daily
for 7 daily as an alternative.
Clotrimazole, another nitro-imidazole compound similar to
metronidazole, has been reported to attain nearly a 50% cure rate
when given as an intravaginal cream.
partners should be treated simultaneously even if they are
Recurrences should be treated with 2gm daily for 3-5 days.
candidiasis is a common cause of vaginitis in women. In 80-90% of
cases, the causative organism is Candida albicans.
factors: Risk of this infection is increased in women who use oral
contraceptive pills, a diaphragm and spermicide, or an IUD. Other
risk factors include young age at first intercourse, intercourse
more than four times per month and receptive oral sex. The risk of
vulvovaginal candidiasis is also increased in some women who have
diabetes, are pregnant or are taking antibiotics.
Women with vulvovaginal candidiasis frequently complain of pruritus,
vaginal irritation and dysuria. In vulvovaginal candidiasis, the
discharge is usually white and thick, with no odor and a normal pH.
Women with candidiasis can have vulvar and vaginal erythema and,
occasionally, scaling and fissures of vulvar tissue.
Microscopy of the discharge with 10% KOH will often reveal
hyphae or budding yeast in 50%-70% of cases C albicans organisms are
easiest to identify, as they have long hyphae with blastospores
along their length and a terminal cluster of chlamydia spores.
candidiasis could be treated with intravaginal creams or pessaries
or oral drugs. Recommended
intravaginal agents are:
Butoconazole 2% cream, 5 g intravaginally for 3 days.
Clotrimazole 1% cream, 5 g intravaginally for 7 to 14 days.
Clotrimazole 100 mg vaginal tablet daily for 7-10 days.
Clotrimazole 100 mg vaginal tablet, two tablets daily for 3
. Clotrimazole 500 mg
vaginal tablet, one tablet in a single application.
Miconazole 2% cream, 5 g intravaginally for 7 days
Miconazole 200-mg vaginal suppository, one daily for 3 days.
Miconazole 100-mg vaginal suppository, one daily for 7 days.
vaginal tablet, one daily
for 14 days
Tioconazole 6.5% ointment, 5 g intravaginally in a single
Terconazole (Terazole) 0.4% cream, 5 g intravaginally for 7 days
Terconazole 0.8% cream, 5 g
intravaginally for 3 days
Terconazole 80-mg vaginal suppository, one daily for 3 days.
150-mg tablet taken orally in a single dose or itraconazole 200 mg
orally in a single dose.
sexual transmission: Complications of vulvovaginal candidiasis are
rare. Chorioamnionitis in pregnancy and vulvar vestibulitis syndrome
have been reported. Candidal
organisms are not transmitted sexually, and episodes of vulvovaginal
candidiasis do not appear to be related to the number of sexual
partners. Treating the
male partner is unnecessary unless he is uncircumcised or has
inflammation of the glans of the penis.
Recurrent infections may be treated with a weekly
administration of fluconazole 150mg for up to 12 consecutive weeks.
An alternative topical maintenance regimen consists of clotrimazole
vaginal suppositories 500 mg weekly. When infection is related to
menstruation, 100-mg clotrimazole vaginal suppositories nightly for
several days preceding menstruation may be effective. But it must be
remembered that 15% of women harbour yeast organisms in their GI
tract and for these women, local treatments may not be effective and
oral preparations may be the only solution.
It is important to avoid douching and wearing tight
underclothings to prevent recurrences. Tight undergarments tend to
retain moisture in the vaginal secretions.Immunosuppressive factors
like diabetes should be looked for and treated.
a preventive measure, it has been found useful to give two
additional doses of Fluconazole on days 14 and 35 to women having
severe infections with Candida Albicans.
Cytolytic Vaginosis is a condition thought to be caused by an
overgrowth of lactobacilli and possibly other bacteria, which causes
cytolysis of vaginal epithelium and a frothy white discharge.
Symptoms, which usually increase during the second half of the
menstrual cycle, include dyspareunia, vulvar pruritus, and dysuria.
Physical examination is remarkable for the presence of white frothy
discharge and a pH level between 3.5 and 4.5.
four diagnostic criteria observed on wet mount are:
of Trichomonas, bacterial vaginosis, and Candida;
Cytolysis of vaginal epithelial cell.
with cytolytic vaginosis are frequently misdiagnosed as having
chronic yeast infections and treated unsuccessfully with various
antifungal medications, especially when the health care provider
relies on the patient’s symptoms and not on a thorough examination
of the wet mount. This is treated with sodium bicarbonate douches two to
three times a week and then once or twice a week as needed to
increase the pH of the vagina and decrease the amount of
lactobacilli. The recommended douching solution should include 30 to
60 g of sodium bicarbonate to 1 L of warm water.
ectropion is the new terminology for what was previously known as
erosion of the cervix. It
indicates migration of endocervical epithelium over the surface of
the cervix. This lesion is usually symmetric about the os and is not
particularly friable. It is accompanied by a mucoid cervical
discharge. Ectropion is more common in women taking oral
contraceptives, and the increased amount of exposed columnar
epithelium may contribute to the greater risk of chlamydial
infection among women taking oral contraceptives. It is often
impossible on clinical grounds alone to differentiate ectropion from
true infection. Levofloxacin once-a-day therapy can be useful for
What are the causes, presentation and treatment of mucopurulent
Normal cervical discharge is clear and mucoid. Purulent or
mucopurulent discharge is associated with gonococcal or chlamydial
infection. Chlamydial infection of the cervix is usually associated
with hypertrophic cervicitis. On
examination the cervix may appear normal or exhibit edema, erythema,
and hypertrophy with a mucopurulent discharge from the os .
Mucopurulent cervicitis caused by Chlamydia trachomatis is
characterized by a thick yellow-white discharge coming from the
cervical os in conjunction with 10 or more leukocytes per
microscopic field (high-power oil immersion) on Gram’s stain
examination. Because the diagnostic tests and treatments for
cervicitis are different from those for vaginitis, it is important
to differentiate these conditions. Several clues can help to rule
out cervical infection as the cause of a vaginal discharge. Almost
90 percent of symptomatic or asymptomatic women with chlamydial
cervicitis meet at least two of the following criteria: (1) younger
than 24 years, (2) sexual intercourse with a new partner in the
previous two months, (3) presence of mucopurulent cervicitis, (4)
cervical bleeding induced by swabbing the endocervical mucosa and
(5) no form of contraception.
(100 mg twice a day for 7 days)
(500 mg four times a day for 7 days), with treatment of the partner
and follow-up culture 1 week after completed treatment.
Azithromycin 1gm as a single dose is as effective as Doxycycline
100mg /day for seven days, but is more expensive.
Levofloxacin 250mg once -a-day for 7 days can also be useful on
typical cases of gonococcal cervicitis the cervical os is reddened
and produces a purulent discharge.
detection: Polymorphonuclear cells are normally present in the
endocervix, but abnormally increased numbers are suggestive of
gonococcal cervicitis. This
can be detected crudely on a Gram stain of the endocervical
material. After the endocervixhas been cleaned off, a swab is
inserted into the cervix and gently rotated, and therecovered
material is applied to a microscope slide by rolling the swab over
an areaabout 1 × 2 cm. The specimen is then Gram stained.
Observation of 10 to 30 PMNs
oil-immersion field in the densest portion of the slide correlates
statistically with the presence of gonococci or chlamydiae.
One of four initial regimens-are recommended as initial therapy:
Ceftriaxone, 125 mg IM.(this drug probably aborts incubating
Cefixime, 400 mg orally.
Ciprofloxacin, 500 mg orally.
Ofloxacin, 400 mg orally.
major drawback of Ceftriaxone is the necessity for intramuscular
administration. Ciprofloxacin and Ofloxacin should be avoided in
pregnant women, and because they lack activity against Treponema
pallidum, these drugs will not abort incubating syphilis. The
efficacy of cefixime against incubating syphilis is uncertain.
Although cross-reactions between penicillin and the
cephalosporins appear to be uncommon in persons treated for
gonorrhea and although many clinics routinely use ceftriaxone,
cefixime, or other cephalosporins to treat gonorrhea in patients
with histories of penicillin allergy, the safest approach in such
circumstances would be to use an oral fluoroquinolone. Regardless of
the single-dose regimen chosen, the initial treatment should be
followed by a regimen active against C. trachomatis. In addition to
treating chlamydial infection, along with an attendant reduction in
the risk of postgonococcal urethritis and salpingitis, giving a
second drug may reduce the potential for selection of gonococci with
increased antimicrobial resistance. The recommended regimens are
doxycycline, 100 mg orally twice daily for 7 days, or a single oral
dose of azithromycin 1.0-g. The
latter is highly effective against genital chlamydial infection.
A single dose of 2.0 g azithromycin is effective against both
gonorrhea and chlamydial infection, but cost and gastrointestinal
intolerance limit its utility. Erythromycin, in a divided-dose
regimen totaling 2.0 g/day orally, is acceptable as follow-up
therapy if neither azithromycin nor a tetracycline can be given.
women with uncomplicated gonorrhea should not be treated with
quinolones or tetracyclines.
is effective and safe but is less acceptable because of the
increased likelihood of pharyngeal gonorrhea during pregnancy. The efficacy of azithromycin in eradicating chlamydial
infection has not been determined in pregnant women, and most
authorities recommend following ceftriaxone with a 7- to 10-day
course of erythromycin.
vaginal discharge: Treatment:
A: In most centers in India, gynaecology health providers do not
take endocervical swabs for gram staining or do tests to detect
chlamydia. Treatment is
essentially empirical. In
this scenario it is useful to remember that all fluoroquinolones are
active against N. gonorrhoeae, and ofloxacin (but not ciprofloxacin)
is active against C. trachomatis. Neither ciprofloxacin nor ofloxacin is highly active against
anaerobic bacteria. A regimen consisting of 14 days of treatment
with oral ofloxacin plus metronidazole provides comprehensive
coverage for all likely pathogens. Several studies have demonstrated
good short-term outcomes in women with mild to moderate PID treated
with ofloxacin alone, and
some investigators believe that most outpatients with acute PID can
be safely treated without providing coverage for anaerobic
bacteria(i.e, there is no need to add metronidazole to the
most authorities agree that it is prudent to routinely add
metronidazole (or clindamycin) to improve coverage for anaerobic
Herpetic cervicitis may be present without external lesions.
Cervicitis is seen on physical examination in about 90% of women
whose cervical cultures are positive for herpes simplex virus.
The cervix usually displays diffuse friability and, less
frequently,frank ulcers or necrosis.
Cervical discharge is usually mucoid, but it is occasionally
mucopurulent, and in one series herpetic cervical infection caused
8% of cases of mucopurulent cervicitis.
Affected patients may have lower abdominal pain, but inguinal
adenopathy is rare unless the disease is accompanied by lesions of
the external genitalia because lymphatic drainage of the cervix
involves the external iliac rather than the inguinofemoral nodes.
First-episode primary genital herpes is characterized by fever,
headache, malaise, and myalgias. Pain, itching, dysuria, vaginal and
urethral discharge, and tender inguinal lymphadenopathy are the
predominant local symptoms. Widely spaced bilateral lesions of the
external genitalia are characteristic Lesions may be present in
varying stages, including vesicles, pustules, or painful
erythematous ulcers. The cervix and urethra are involved in more
than 80% of women with first-episode infection.
diagnosis: The diagnosis of herpetic cervicitis may be made
cytologically by observing multinucleated giant cells, often with
of genital herpes:
Acyclovir, Famcyclovir and Valacyclovir are useful in the
treatment of genital herpes The dosage schedule for Acyclovir is
PO 200 mg 5 times daily for 7 days or 400mg tid for 10 days.
PO 200 mg 5 times daily or 400 mg tid for 5 d.
PO 400-mg bid or 200 mg tid for up to 5 y.
papillomavirus, particularly certain subtypes, frequently infects
the cervix. It has been observed since 1837 that cancer of the cervix
behaves epidemiologically as if it were a sexually transmitted
disease. The strongest infectious association with cancer of the
cervix has been established for some types of human papillomavirus.
Other organisms occasionally considered causes of cervicitis include
adenovirus, measles virus, cytomegalovirus, Enterobius vermicularis,
amoebae,M. tuberculosis, group B streptococci, N. meningitidis, and
actinomycetes, the last usually in association with the use of
intrauterine contraceptive devices. The chancre of syphilis
sometimes manifests as a cervical lesion.
general, the clinical manifestations of recurrent genital herpes,
including the frequency of subclinical versus clinical infection and
the duration of lesions, pain, and constitutional symptoms are
similar in pregnant and nonpregnant women. Recurrences appear to
increase in frequency over the course of pregnancy. Among women who
are HSV-2 seropositive entering pregnancy, several clinical series
and a recent study indicates that there is no effect of recurrent
clinical infection on neonatal outcome, including birth weight and
gestational age. First-episode infections in pregnancy have more
severe consequences to mother and infant.
Visceral dissemination during the third trimester
occasionally occurs and prematurity or intrauterine growth
retardation, or both, may be seen. The acquisition of primary
disease in pregnancy carries the risk of potential transplacental
transmission of virus to the neonate.Primary
infection in pregnancy can result in spontaneous abortion, albeit
this appears to be relatively uncommon.
cervicitis is one of the common disorders encountered in daily
practice. To overcome this problem,the first step should be
antibiotic therapy in the acute phase. If this fails, the infection
becomes chronic and may spread to internal genital organs leading to
pelvic inflammatory disease and eventually to infertility. Chronic
form of infection may lead to the
development of dysplasia and neoplasm. Hence if the patient does not
improve after 2-3 months, minor surgical therapy is indicated.
Various methods such as electrocautery, loop diathermy,
cryotherapy or laser are used to destroy the inflamed area if the
chronic cervicitis is accompanied by ectropion.
procedure should be done in the first half of the cycle, as there is
the danger of ascending infection and postoperative infection in the
premenstrual period. But
puncture biopsy of nabothian cysts may be done at any time during
A vaginal cytology, and if possible a colposcopy should be done to
know if there is cervical intraepithelial neoplasia. Carcinoma of
the cervix or endometrium is a contraindication.
should be ruled out.
Any acute inflammation of the cervix should be treated, as doing the
procedure on the cervix in the acutely inflammed state would produce
spread of infection into the parametrial tissues.
Electocauterisation is done with either a thermal or a spark-type
electrocautery n a radial strip fashion.
Because there are very few nerve endings carrying pain
sensation from the cervix, this can be done in the office without
anesthesia. After the procedure, the patient should be administered
local creams or vaginal suppositories to aid healing.
Cryosurgery destroys tissue by freezing.
The refrigerants (carbondioxide, Freon,nitrous oxide, or
nitrogen- all in liquid state) are passed through a hollow probe
placed in the cervical canal and against the external os.
The advantages are the ease of administration and lack of
discomfort as compared with thermal or electrocauterization.
This tratment method has the disadvantage of causing a
profuse vaginal discharge for 2-3 weeks following its application.
In laser (light amplification by stimulated emission of radiation)
therapy, a high-energy beam of light in the infrared spectrum is
directed to the cervix, resulting in complete vaporization of cells.
As a result, there is no necrotic tissue slough and no resulting
are the relatively large size and high cost of the equipment as well
as the special training required.
The aim of these methods is destruction of infected tissues with
subsequent healing by fibroblastic proliferation and
healing may take up to 6 weeks.
The cervix should be inspected again at the end of this time
to be certain that healing is satisfactory.
If cauterization must be repeated, it should be done 1-2
months after the initial tratment to encourage healing.
Reactivation of salpingitis may occur if treatment is done in
the presence of acute cervicitis.
Cervical stricture may follow deep cauterization carried high
into the endocervical canal. Cauterization
or freezing of a cervix that contains an unrecognized malignant
tumour will mask the neoplastic process, resulting in further delay
in its recognition and perhaps serious consequences.
intraepithelial neoplasia is a premalignant lesion of the
cervix.There is abnormality of cervical epithelium displaying
proliferation of parabasal cells with disordered polarity, loss of
cellular junctions, coarse nuclear chromatin clumping, abnormal
nuclear cytoplasmic ratio, and high mitotic index. Reported as
grades I (low grade) to Ill (high grade, including carcinoma in situ)
dysplasia It remains asymptomatic and can be diagnosed only on routine
screening. McIndoe (1984) concluded that women with cytological
evidence of continuing neoplasia afer initial diagnosis of carcinoma
in situ of the cervix had an 18% chance of developing invasive
cancer of the cervix or vaginal vault at 10 years and a 36% chance
at 20 years. Routinely
screening women with vaginal cytology and coloposcopy can pick up
these women and prevent them from progressing to carcinoma cervix.
Pap smear is vaginal cytology, where exfoliated cells from the
vagina are examined for various purposes. It was introduced by
Papanicolou and can be used to screen women for premalignant lesions
of the cervix. It is
important to remember that it is only a screening procedure and not
a diagnostic procedure. Suspicious cases found on Pap smear need further evaluation
with colposcopy, simple biopsy or cone biopsy. The physician cannot
rely on the Pap smear alone to be diagnostic for that particular
precautions: The Pap smear is best performed during midcycle. The
patient should avoid douching, vaginal medications, and intercourse
for 24 hours prior to the procedure. Reschedule the examination if
the patient is actively menstruating.
1.Clarify the patient’s risk factors for cervical dysplasia by
Label the end of a glass slide with the patient’s name and other
identifying data as necessary.
Insert speculum and adjust it to obtain adequate visualization of
Determine whether the vagina or cervix appears inflamed or infected.
Avoid rubbing or otherwise traumatizing the cervix.
Identify cervical landmarks, including the transformation zone with
its squamocolumnar junction. Note the nature of the cervical mucus.
Excess mucus or discharge may be gently blotted, not rubbed, from
view. Note any gross cervical lesions such as erosions, leukoplakia,
nabothian cysts, or condylomata
the vaginal fornices for obvious abnormalities
Obtain the Pap smear by using an endocervical sampling
device(Cytobrush,Papette,or Cervexbrush). If the two-sample method
of obtaining cells is used,first insert the Cytobrush into the canal
and rotate 90 to 180 degrees. Follow this by a gentle smear of the
entire transformation zone with a spatula device, fitting the
contour of the patient’s remaining transformation zone.Sampling
the vaginal pool has little advantage during Pap smear screening
unless the patient has had a hysterectomy. In this instance, be sure
to sample the vaginal cuff. If vaginal abnormalities are seen,
another Pap smear of these areas (using a spatula) may be submitted
on a separate slide. Areas that appear abnormal on visualization
ultimately require colposcopy and biopsy.
preparation is evenly applied to its appropriate slide immediately
after sampling and then the slide is sprayed or dipped in
preservative within 5 seconds and sent to the
Make sure the Pap smear requisition form includes all pertinent data
regarding the patient. Be sure to include clinical findings, patient
risk factors, or yourconcerns as part of this “referral”.
and further management: All Pap smears reported as abnormal require
some form of intervention. A report of dysplasia warrants colposcopy.
Many clinicians recommend colposcopy for reports of atypia also,
especially in patients with numerous risk factors.
classification and Approximate Comparative Nomenclature of Cervical
Smears with CIN class;
I: normal smear; no abnormal cells (CIN Class- normal)
II: atypical cells; no neoplasia (CIN class-reparative or atypical)
III: smear contains abnormal cells consistent with dysplasia
class- CIN I or II mild,moderate dysplasia)
IV: smear contains abnormal cells consistent with carcinoma in situ
(CIN class- CIN III, CIS)
V: smear contains abnormal cells consistent with carcinoma of
CIN = cervical intraepithelial neoplasia.
CIS = carcinoma in situ.
American College of Obstetricians and Gynecologists (ACOG)
recommends that all women who have been sexually active or are at
least 18 years old undergo an annual Papanicolaou test (vaginal
cytology) and pelvic examination. The ACOG and the US
PreventativeService Task Force agree that if three annual
Papanicolaou screens are normal,screening may be performed less
frequently than yearly at the discretion of the physician based on
the woman’s risk factors. Some clinicians will screen a subset of
women with low risk factors every 3 years providing that there are
three negative yearly Pap smears and the risk factors do not change.
groups for CIN are as follows: Genital HPV infection, Positive HIV
status, Multiple sexual partners,Early age of intercourse,High
parity,Cigarette smoking,Low socioeconomic status and History of
prior sexually transmitted disease other than HPV.
Any visible or palpable lesion of the cervix. Follow precaution that
Pap smear is not diagnostic and further assessment may be necessary.
abnormal vaginal bleeding or discharge.
Posthysterectomy (hysterectomy for benign disease): Every 3 years if
patient’s risk for cancer remains low.
Posthysterectomy (hysterectomy for dysplasia, carcinoma): annually
after three to four normal Pap smears at 4- to 6-month intervals.
Posttreatment for cervical dysplasia, malignancy: Every 4 months for
three visits; every 6 months for two visits; annually thereafter.
Victims of rape, incest, abuse: As part of initial work-up. Repeat
in 6 to 12 months.
Currently it is not considered necessary to continue screening
beyond the age of 64 years, provided that: the woman has had three
consecutive negative smears,the most recent one was done no more
than three years previously.
There are no absolute contraindications to obtaining a Pap smear.
include clinical circumstances where sample collection is difficult
to obtain or difficult to interpret (e.g., active vaginitis or
cervicitis, pelvic inflammatory disease [PID], or menses). The
clinician must weigh the benefits versus the risk of obtaining the
screening Pap smear under these circumstances. For instance, if a
woman presents with abnormal vaginal bleeding, a Pap smear is
advised, despite the presence of blood. This contrasts with a
patient who comes in for a routine Pap smear screening and has begun
to menstruate. In the later instance, the Pap smear can be deferred
premalignant lesions of the
following treatment modalities are useful in patients with CI N.
Chemical :Topical concentrated trichloroacetic acid (TCA 50% to 85%)
or bichloracetic acids are desiccant acids that have been used to
Cold Coagulation: Cold coagulation is also a highly effective
ablative treatment for CIS. The name iscounterintuitive: that is,
this method involves heat destruction of tissue, although the amount
of heat is less than that used with other coagulation methods. A 100°C
Teflon probe is applied directly to the cervical tissue.
Cryotherapy: Cryotherapy is a relatively safe, easy, and inexpensive
ablative treatment for CIN. As is true in any method of treatment
for cervical dysplasia, the goal is destruction of the lesion,
including the abnormal transformation zone.
Electrocoagulation: Cervical lesions have been treated with
monopolar electrocoagulation for years with good success reported.
With this method, there is a continuous flow of electrons from the
generator to the handpiece tip back to the generator via the
grounding pad and the patient. The electron flow is highly
“channeled” through the small surface area of the handpiece tip
and spread over a large-area grounding pad as the electrons make the
circuit. The result is a concentrated thermal effect at the
handpiece tip and no thermal effect at the grounding pad. At 45°C,
irreversible tissue damage occurs that is notusually visible to the
naked eye. At 100°C, desiccation occurs. At greater than 100°C,
vaporization and carbonization occur. The most efficient way to
obtain deep thermal damage at the tissue level is a low continuous
current (e.g., cutting current) with a large-surface-area handpiece
tip (e.g., a ball electrode). The ball should be used in contact
mode (placed directly on the tissue) and held in place long enough
to obtain deep penetration into the cervical glands. Firm pressure
on the tip against the surface is essential to achieve the broad
Vaporization :Carbon dioxide laser vaporization continues to be used
widely, with excellent success rates for treating CIN.
techniques: Excisional techniques have been an effective treatment
for CIN for many years.
Hysterectomy :Historically, hysterectomy was a mainstay of
excisional therapy for CIS. With theadvent of more sensitive
outpatient diagnostic modalities and less invasive
treatmentmodalities, hysterectomy is now rarely indicated for CIN.
Hysterectomy might beconsidered for (1) patients who have high-grade
lesions who have failed conservativetreatments, (2) patients who
have high-grade lesions who desire sterilization, (3) patientswho
have high-grade lesions who cannot be treated adequately with local
therapies, and(4) patients who have high-grade lesions who have no
access for follow-up diagnosticprocedures after a conservative
therapy. Disadvantages of hysterectomy are the
for hospitalization, the requirement for regional or general
anesthesia, theincreased surgical risk, and the risk for
complications. It is sometimes more difficult diagnostically to
follow-up vaginal neoplasia that occurs posthysterectomy.
Conization :Excisional conization is the treatment of choice for
patients with CIN and an unsatisfactory colposcopic examination. The
cold-knife procedure involves surgical excision with a scalpel and
requires an operating room and regional or general anesthesia.
Cold-knife conization is largely being replaced with LEEP conization.
LEEP/LLETZ : Loop electrical excision procedure and large loop
excision of the transformation zone
are relatively simple outpatient treatments for CIN. Indications for
LLETZ are as follows: Unsatisfactory colposcopic examination
of biopsy-proven CIN 2, CIN 3, and CIS
of squamous microinvasive disease or adenocarcinoma in situ
CIN 1 for 1 year or noncompliant patient.
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