|Terminology: Cervical dysplasia is also called cervical intraepithelial neoplasia (CIN); squamous intraepithelial lesion (SIL) and precancerous changes of the cervix.
What Is Cervical Dysplasia?
If your doctor tells you that you have cervical dysplasia it means the cells that line your cervix have undergone abnormal changes. The cervix is positioned at the top of the vagina and is the opening into the lower part of the womb (uterus). Cervical dysplasia affects nearly 50,000 American women a year. For some, it will turn into cervical cancer, for others it will not. There is no way of telling who will develop cancer or in what time frame it will occur. Cervical dysplasia can take a few years to turn to cancer or it can do so in less than a year (if the dysplasia is severe). Although being diagnosed with dysplasia may be scary, going through the correct diagnosis procedure and getting the right treatment as soon as you can is important. The sooner it is treated, the less likely it is to turn into cancer.
What Are The Symptoms?
Cervical dysplasia produces no symptoms. Very occasional signs/symptoms may include:-
• Genital warts.
• Spotting after intercourse.
• Abnormal bleeding.
• Vaginal discharge.
• Lower back pain.
What Causes It?
Dysplasia of the cervix is most often seen in women between the ages of 25 and 35, but it can develop at any age. It is widely accepted that 95 percent of all cervical cancers (and by definition dysplasia) are caused by a virus called the human papillomavirus (HPV). HPV is a common sexually transmitted disease (STD). There are over 100 different types of HPV (genital warts is one form of HPV). Types 16, 18, 31, 33 and 45 specifically increase the risk of dysplasia and cervical cancer. It is estimated that one third of American college women are infected with HPV and about 1 in 10 men between the ages of 15 and 49. Scientists believe that the HPV virus weakens cervical cells so that they mutate and make abnormal changes. As to why these changes eventually turn into cancer in some women but not in others is still not understood. The risk seems to increase in young female smokers - it may be smoking introduces toxic chemicals into the body which makes cells more vulnerable to damage by the HPV virus.
How Is It Diagnosed?
The first you are likely to hear of your condition is when your doctor phones to say your 'Pap smear test result isn't quite normal'. See Pap test to find out more about this test. You will need to return to your doctor to discuss the results. The smear (or a repeat smear) should reveal what stage of dysplasia is present. The categories are:
Possibly cancerous (malignant).
Atypical glandular cells (AGUS).
Next your doctor will perform a colposcopy directed biopsy. The purpose of this biopsy is twofold:
1. To pinpoint the exact grade of dysplasia present.
2. To check for cancerous cells which may have been missed by the smear test.
No single test can determine for sure if there are cancer cells present, but several tests used together can reduce the chance of missing it. This is why an accurate diagnosis involves a step by step process that includes colposcopy-directed biopsy, endocervical curettage (EEC) or loop electrocautery excision procedure (LEEP).
Colposcopy Directed Biopsy
During this exam you lie on the table in the same way you would for a pelvic examination. A speculum is inserted; this is, an instrument which stretches the vaginal opening so that the doctor can look more easily inside. A special lighted magnifying instrument called a colposcope is used to magnify the cervix. The cervix is rinsed with a solution of acetic acid (similar to vinegar) to clear away any mucus. This may cause a burning feeling but it helps to highlight any area of suspicious cells. The most abnormal part is selected for biopsy. The collected biopsy tissue is sent to a pathologist for examination.
Your doctor may perform a further type of biopsy (either an EEC or LEEP). In an EEC a large speculum is inserted into the vagina to gain access deep into the cervical canal. The whole surface is scraped with a cutting tool called a curette. Next a punch biopsy can be done. All collected tissue is sent to the lab for examination by a pathologist.
Some diagnostic centers routinely use LEEP with ECC, others use one or the other. During this procedure suspicious cells are removed for biopsy and the area is cauterized (burned). LEEP is both a diagnostic test and treatment.
Cone Biopsy (Conization)
Women with positive EECs need conization. This procedure requires surgery to remove a sample of tissue from the cervix. You will be given general anesthesia (so you are asleep). A cone biopsy will help find how far cancer cells have invaded the cervix. This allows for the most suitable treatment plan to be put in place. Conization is nearly always necessary for postmenopausal women (women who have gone through menopause) with abnormal Pap smears because cancer cells are usually located deep in the cervix in this age group. Your doctor may ask you to put an estrogen cream inside your vagina for several days before the operation to help highlight cervical tissue changes.
After your tests your doctor will refer to your dysplasia as cervical intraepithelial neoplasia (or CIN for short!). There are 3 categories of CIN, your biopsy result will show which one you have:
CIN I: Mild dysplasia.
CIN II: Moderate to marked dysplasia.
CIN III: Severe dysplasia to carcinoma in situ. Without treatment 30 to 50 percent of CIN III cases turn into cancer. The risk is much lower for milder dysplasia. The next stage after CIN III is cervical cancer (see stages of cervical cancer).
Internal picture: Shows the cervix of a woman
who was diagnosed with CIN III.
How Is It Treated?
The type of treatment you receive depends on the type of CIN present, the exact location of the abnormal cells, your age and future desire for children. In all cases treatment involves removing or destroying all abnormal cells.
CIN I Treatment
One option may be just to monitor cell changes with regular Pap smears or colposcopies. Because many low grade CIN revert to normal without treatment, this wait and see option is reasonable. Repeat exams every 3 to 6 months should be expected. If a biopsy was performed it may have removed any abnormal cells and considered a cure. If however the changes do not go away, or worsen, then treatment will be necessary.
CIN II and CIN III Treatment
The aim of treatment is to stop abnormal cells turning into cancer. Some centers will be more aggressive in their treatment than others. They will select from a variety of outpatient treatments including laser treatment (vaporization), electrocautery, LEEP and cryosurgery. A more aggressive approach is to opt for cone biopsy or cervical conization.
Electrocautery has been used as a local treatment for CIN for years. An electric current is passed through a metal rod that touches, burns and destroys suspicious cells. It is effective for CIN I and CIN II but less effective for CIN III. The main disadvantage is that it can cause cervical scaring which reduces the ability of the cervix to stretch during childbirth. For this reason it has fallen out of favor in recent years.
Cryosurgery involves freezing suspicious cells which then die and fall away. A probe called a cryoprobe is inserted through the vagina into the cervix and a liquid is squirted through the probe which freezes the cells. It is just as effective as electrocautery but does not cause as much scarring. On the downside the cryoprobe may be too large or too small for the area to be treated with the consequence that some women are over treated and others are undertreated. The failure rate to cure by cryosurgery is 5 percent for CIN 1, 7 percent for CIN II and 12 percent for CIN III.
This is a popular treatment for all grades of CIN. It is just as effective as cryosurgery and electrocautery, but is more expensive. However it offers precise destruction of cells in small areas and minimizes scarring. Furthermore it can reach parts of the cervix that other treatments cannot. For these reasons, it may be reserved for cases where suspicious cells are found deep within the cervix or where large areas need to be destroyed.
Once the most common treatment for CIN, hysterectomy (removal of the womb and cervix), is still offered to women who are past childbearing years.
Follow Up After Treatment: Cervical Screening
Follow up treatment starts between 6 and 9 months after treatment. The follow up is called cervical cytology - cytology is just a fancy word which means study of cells. Which method of 'study' is used depends on the extent of dysplasia you were treated for.
CIN 1: You will be offered a Pap test screening at 6, 12 and 24 months after treatment. If your test results are negative, you return to a normal Pap test screening process.
CIN 2 and 3: You will be offered a Pap test 6 and 12 months after treatment and then every year for 9 years (that's a total of 10 years follow up). If you have a positive result at any time, you should be offered a colposcopy and cervical biopsy.
As cervical dysplasia can come back, following your doctor's follow-up recommendation is very important. Women treated for CIN have a lifetime risk of a recurrence. However, while the incidence of dysplasia is on the rise, the rates of cervical cancer are declining dramatically. This is due to better Pap test screenings which identifies dysplasia in the early stages before it has a chance to develop into cancer.
Can It Be Prevented?
There are several steps which can be taken to reduce your risk of dysplasia. See cervical cancer prevention, the advice is the same.