Dr H.K.Cheema Professor-OBG PIMS, Jalandhar

2. .
Second most
common cancer among
Indian women
96,922
New cases detected
every year
60,078/year
Deaths due to cervical
cancer in India:
Cervical cancer is
a preventable
disease

3. 5 years
10 years
10-20years

10. Study published First by The Lancet
Indian Women
Breast, cervical and stomach cancers
Indian men.
Lung, oral and stomach cancers

12. 4.5 cm
0.5cm
2.5 cm.

13. Columnar
Epithelium
Stratified
Squamous
Epithelium

14. v
v
Superior Lumber
Lymphatic
drainage of
cervix

16. 1) BASAL LAYER – is a single row of immature cells with large nuclei & small amounts
of cytoplasm.
2) PARABASAL LAYER – includes 2 or 4 rows of immature calls that have normal
mitotic figures & provide the replacement cells for the overlying epithelium.
3) INTERMEDIATE LAYER – includes 4 to 6 rows of cells with larger amounts of
cytoplasm in a polyhedral shape separated by intercellular space.
Intercellular bridges where glycogen production differentiation
occurs, can be seen on light microscopy.
4) SUPERFICIAL LAYER – includes 5 to 6 rows of flattened cells with small uniform
nuclei & cytoplasm filled with glycogen. Nucleus is pyknotic, & cells undergo
exfoliation.
These cells for the basis of Pap Smear Testing.
CIN occurs
at SQJ or TZ.

18. Metaplasia is a normal process & occurs in all young
females –most active during
Menarche, Pregnancy, After delivery
Normal cells , no atypia, no change to malignant
cells
Metaplasia is a normal process
where subcolumnar cells are
changed to squamous cells

19. TZ-dynamic area (1-10mm)
Most sensitive to
ph changes, hormonal changes, trauma(
early coitus, multiple partners),viral
infections,mutations with cellular atypia

20. The junction between metaplastic
squamous and columnar epithelium
The junction between squamous and
columnar epithelium
The
distance
between
original &
new SQJ
(1-10 mm)

21. Following menopause it is drawn back inwards.
SQJ Usually lies
at level of
external os.

22. Pre-puberty, Ecto-cervix is covered with squamous epithelium.

23. Heightened estrogen exposes the columnar epithelium onto the ectocervix

28. Cervical Intra-epithelial Neoplasia (CIN)
Pre-malignant condition involving uterine cervix where cellular
abnormalities (Dysplasia) are limited to the surface epithelium and don’t
extend beyond the basement membrane.

29. Dysplasia is a change in which alteration in cell
morphology with dis-orderly arrangement of stratified
squamous epithelium is seen. It is Pre-malignant
condition.
• Vary in size, shape & polarity
• Large, irregular, hyperchromatic
nucleus
• Increased nucleo-cytoplasmic ratio
• Condensation of chromatin material
• Several mitotic figures +
• However, Basement membrane is
intact.

30. • WHO in 1975 classified, the CIN into three
categories correlating with former grading of
dysplasia – CIN 1,2,3 & CIS.
• Grading to be done according to the thickness
occupied by the undifferentiated cells.

31. CIN
• Cervical intraepithelial neoplasia refers to the
histopathological description in which a part or the full
thickness of stratified squamus epithelium is replaced by
cell showing dysplasia with intact basement membrane.
• MILD DYSPLASIA/ CIN 1
• Undifferentiated cells are confined to the lower one-third of the
epithelium
• Often due to infection in young women

32. CIN
• MODERATE DYSPLASIA/CIN 2
» Undifferentiated cells occupy the lower 50-75% of
epithelial thickness
» The cells are mostly intermediate with moderate nuclear
enlargement , hyperchromasia , irregular chromatin and
multiple nucleation.
• SEVERE DYSPLASIA/CIN 3
» The entire thickness of epithelium is replaced by abnormal
cells.

34. HSILLSIL

36. CIN 1 - only mild dysplasia, or abnormal cell growth.
It is confined to the basal 1/3 of the epithelium. This corresponds
to infection with HPV, and typically will be cleared by immune
response in a year or so, though can take several years to clear.
CIN 2 - moderate dysplasia confined to the basal 2/3 of
the epithelium
CIN 3 - Severe dysplasia that spans more than 2/3 of the
epithelium, and may involve the full thickness.

37. Dysplasia CIN Limit Of histological
changes
Bethesda system
Mild CIN I Basal one third LSIL
Moderate CIN II Basal half to two third HSIL
Severe CIN III Whole thickness except
one or 2 superficial
layers
HSIL
CIS Whole thickness HSIL

38. CIN 1 CIN II CIN III
Regression to normal 60% 40% 30%
Persistence 30% 35% 50%
Progression to CIN III 10% 20% ---
Progression to Cancer <1% 5% 20%
Duration of disease
progression(years)
5 years 5 years 10 years
Invasive ca-20yrs.
Age of patient 25-30 yrs 30-35yrs. 40-45 yrs.

40. The role of this virus in the genesis of essentially all cervical neoplasia and a
significant portion of vulvar, vaginal, and anal neoplasia is firmly
established.
Human papilloma virus is a non-enveloped DNA virus with a protein
capsid.
It infects epithelial cells exclusively and approximately 30 to 40 HPV types
have an affinity for infecting the lower anogenital tract.

44. NATURAL HISTORY
1. Can spontaneously regress to normal.
2. Mostly within 2 years, immune system clears HPV infection.
3. Remain stable for long period.
4. Or progress to higher degree of dysplasia
5. Neoplastic potential increase with CIN grade

45. HPV Infection -- >50% women in life time. Age=15-25 yrs.
HPV Persistence—Millions get infected but persistence in few.
Progression to pre-cancerous lesions-about 10 years after
infection.
Virus may enter latent phase, may become active in years later.

47. Koilocyte
is a squamous epithelial cell that has undergone a number of structural changes, which
occur as a result of infection of the cell by HPV.
Peri-nuclear
halo

48. CIN M/C in 20-30 yrs.
Ca In Situ 30-35 yrs.
Ca Cervix Bi modal peak
Ist peak -35-39 yrs.
2nd peak 55-60 yrs.

49. Age =30yrs.
 Early coitus
 Multiple sexual partners
 Partner with multiple partners
 Poor personal hygeine (20x)(G&B)-jews
 Delivery of 1st baby <20 yrs.
 Mutiple child births in quick succession
 Poor socio-economic status(20x)
 Women with chronic PID,STD,HIV,HPV(16,18,31,33,condylomata70-80%)
 smoking, drug abuse (13x),
 on OC pills >8yrs(2x)
 Women exposed to di-ethyl-stillbestrol drug-at birth ca cx ,ca vagina=(5x)
Incidence with
High risk HPV=10-
12%
Average
age=30-65
yrs.
CIN 1=3%
CIN 2=0.6%
CIN 3=0.4%
Younger
women

50. Immuno suppression=Transplant surgery
Inadequate screening
No regular health checkups
Pre-invasive carcinoma

51. CIN is most likely to develop during menarche or after pregnancy,
when metaplasia is most active.
Young age, early coitus, multiple partners
Infection with High risk stains of HPV virus
Persistence of infection
Smoking
Compromised host-immune system

52. How do I Know if I am at risk for HPV?
• Anyone who has ever had sex is at risk for HPV

53. Who is at risk for cervical cancer?
• Women who do not have Pap tests
• Women who do not follow up with testing or treatment
after an abnormal Pap test, as told by their health care
provider
• Women who have persistent HPV
• Women who smoke

54. Who is at higher risk for HPV?
• Anyone who has had more than one sex partner
• Anyone whose sex partner(s) has had more than
one sex partner

55. How do I know if I have HPV?
• Abnormal Pap test results are often a sign of HPV
• HPV DNA test can find high-risk HPV types

56. If I have HPV, does it mean I will get cancer?
• No! Most people get HPV infection, but very few get
cervical cancer
• In most cases, HPV infection goes away on its own
• Sometimes, the HPV infection does not go away after
many years. This type is called “persistent”. It can lead
to cervical cancer

57. If I have HPV, does it mean my partner has
been unfaithful?
• No! HPV is not a sign of unfaithfulness
• It is not possible to know when you got HPV or who
gave it to you
• You may have had HPV for many years before it shows
up

58. Sexual History
• A woman has a higher-than-average risk of developing cervical
if she:
• Has had multiple sexual partners
• Began having sexual relations before the age of 18
• Has a partner who has had sexual contact with a woman with
already suffering from Human Papilloma virus infection by
virulent strain.

59. How do I lower my risk of getting cervical
cancer?
• Get regular Pap tests and follow up, if necessary
• Limit your number of sex partners
• Choose a sex partner who has had no or few prior sex partners
• Do not smoke cigarettes
• Keep a healthy diet and lifestyle
• Use condoms consistently and correctly during sexual activity

62. Abnormal cell growth Healthy Cervix

63. • Screening means looking for cancer when the patient is
not having any symptoms at all.
• It helps find cancer at early stage with only small
abnormal tissue.
• It helps to start treatment at any early stage of cancer.

64.  Pap smear
 Liquid Cytology
 HPV – DNA detection (PCR, Southern Blot Assay, Hybrid
Capture)

65.  Colposcopy
 Colposcopy directed Biopsy
 Visual inspection with Acetic acid, Lugol iodine
 Cervical biopsy

66. SCREENING
PAP Smear

67. History
Initially using vaginal pool smears to study
hormonal status
Dr. George Papanicolaou reported
the usefulness of the technique for
detecting neoplastic cervical cells in
1941.
late 1940s to early 1950s, Pap smear became
widely used as a screening technique

68. Aim of taking Pap Smear
To obtain well preserved cellular smear from Ectocervix, Endocervix & the
Transformation Zone
Correct timing
Correct instruments
Correct sampling technique
Correct spreading technique
Correct fixation

69. Guidelines – When to do Pap Smear
• After menses preferably mid-cycle.
• When there is no signs of inflammation or infections
• No prior vaginal douching or contraceptive cream/ jelly
• No sexual intercourse for 24 hours prior to pap smear.
• Pregnancy is NOT a contraindication for pap smear.
• Postpartum smear should be taken only after 6 - 8 weeks of delivery

70. Sampling Instruments
• Ayer’s Saptula Cyto-Brush
Cervical Broom/Brush

71. How to take Pap Smear
Patient in dorsal position
 Good illumination is necessary
 Cusco’s speculum is inserted to visualise &
fix the cervix
 Inspection of cervix done & findings are
noted
 Ayres spatula is inserted first. It is placed at
cervical os so that longer end goes into
cervical canal and smaller end rests on
ectocervix

72. Sampling Technique
 Spatula is rotated through 360
degrees maintaining contact
with ectocervix
 Do not use too much force [bleeding
/pain]
 Do not use too less force [inadequate
sample]
 Sample is smeared evenly on the slide
and fixed immediately
 Both sides of spatula are to be smeared

74. Spreading Options
• .

75. Fixation of smear
 Fixation is done immediately with fixative like 95%
alcohol or cytofix spray to avoid air drying
 Spray should be kept at 10 inches, to avoid destruction
of cells by propellent in the spray
 Smear should monolayer for proper penetration of cell
surface by fixative

76. Significance of Pap smear
Detect precancerous & invasive cancer cervix cases in
early stages
Positive screeners can be selected for selective tests and
management
With treatment, progression of disease is halted. Thus
morbidity associated with advanced cancer decreases
Mortality reduces by 20-60 %.
Helps us to study natural history of disease.

77. New Guidelines
ACOG Guidelines-(Aug2003),
American Cancer Society (Nov 2002) and
U.S. Preventative Services Task Force (Jan 2003)
Target group –
All women aged 18-70 yrs who have ever had sex
Timing of Initial Screening –
Initial screening at age of 21 years or within 3 years of
sexual activity

78. Pap smear - Guidelines
• In high risk group after treatment for CIN
• every 3 monthly for 2 years
 every 6 monthly for 3yrs
 Yearly thereafter
 Women who had hysterectomy for CIN,
 it is necessary to do vault smears
 In women who received vaccination against HPV, it is necessary to
continue screening

79. Pap smear - Guidelines
Screening interval - yearly till the age of 30 then 3 yearly
High Risk cases --Guidelines
When to End Screening
-After 70 yrs
-Post Hysterectomy(done for benign lesions)
-HPE confirmed complete removal of cervical epithelium
-previous 3 normal PAP reports

80. PAP SMEAR SCREENING GUIDELINES
• INITIATION OF SCREENING
» Screening begins at the age of 21 yrs.
» Or 3 yrs after the first sex.
• SCREENING INTERVEL
» 21 – 30yrs. – every year
» >30 yrs – every 3 years
» ( if 3 previous consecutive pap test -negative.)
» HIV women – every year screening for Life
» Prior Rx for CIN 2,3 – Atleast for 20 years
• DISCONTINUATION OF SCREENING
» 65 or 70 yrs. (after three consecutive negative pap resulting
during the previous 10 years.)

81. BETHESDA 2001-REPORTING SYSTEM
• . Normal cervical cytology Infection/Inflammation
Dysplastic Changes
 1. Squamous cells
• ASCUS
• ASCUS-H - suggestive of high
grade lesion
• LSIL - changes associated with
HPV, atypical changes, mild
dysplasia/ CIN1
• HSIL – moderate to severe
dysplasia / CIN2, 3 and Ca In Situ
HSIL – where invasion cannot be
ruled out
Squamous cell carcinoma
 Glandular cells – AGUS
(Endocervical, endometrial)
AdenocarcinomaeOther malignant
neoplasms

82. PAP Descriptive CIN Bethesda
Class-1 negative negative WNL
Class 2
Inflammatory,
squamous, koilocytic
atypia
Reactive, reparatative
changes, ASCUS,
LSIL(HPV)
Class 3
Mild dysplasia
Moderate dysplasia
Severe dysplasia
CIN1
CIN2 CIN3
LSIL(HPV)
HSIL
Class 4 Ca In Situ CIN3 HSIL
Class 5 Invasive Invasive Invasive

83. Abnormal
due to
Inadequacy
Abnormal
due to
Inflammation
Abnormal
due to
Infection
Abnormal
due to
Dysplasia

84. BETHESDA SYSTEM 2001

85. GENERAL CONSIDERATION
Report of Pap Smear
1. Negative for intraepithelial lesion or malignancy
2. Inflammatory smear
– EPITHELIAL CELL ABNORMALITY
• SQUAMOUS CELL ABNORMALITY
1. Atypical squamous cells
1. ASCUS (Atypical squmous cells of undetermined significance)
2. ASC-H (Atypical squmous cells where HSIL can’t be ruled out)
2. LSIL-- Low grade intra epithelial lesion
3. HSIL--High grade intra epithelial lesion
4. Squamous cell carcinoma

86. Unsatisfactory/Inadequate smear
Reactive cellular changes due to radiation, repair or IUCD
ASCUS with Low Risk HPV type or no facility for HPV typing
Selected LSIL--- repeat in 6 months, if persistent, do
colposcopy

87. 1. INFECTIONS
Trichomonas vaginalis ( Metronidazole 400mg &
Doxycyline 100mg bd for 1 week)
Fungal infection : Antifungal
Bacterial vaginosis (Metronidazole, Clindamycin) Actinomyces species :
Penicillin
Herpes simplex : Acyclovir
Repeat smear in 6-8 weeks, if persistent in 3 occasion, refer
for colposcopy.
2 ATROPHIC SMEAR
Local oestrogen cream/tab (1 gm nighty for 2 weeks then twice weekly) 6-8
weeks and repeat pap smear in 3-4 months.
Treatment of Infections

88. • Follow any method;
• HPV DNA testing—Best method
• Immediate colposcopy
• Repeat cytology after 6 months

89. Low grade lesions
• .

90. High Grade lesions

91. Abnormal Pap smear- HPV
 Peripherial condensation of cytoplasm - wire looping effect
 Koilocyte

92. PAP Smears - Limitations
Low sensitivity 51% (Have high specificity 95-98%)
False negative rates(49%) are due to faulty sampling,
improper fixation or interpretation problems
Large group population & high risk group screening not
possible
 Other methods of screening can also be used.

93. When do I need my first Pap test?
• No more than 3 years after you first have sex
• No later than age 21

94. How often do I need a Pap test?
• Every year until age 30
• After age 30, if you have had only normal results,
you may have them every 2 to 3 years (after
talking with your health care provider about your
level of risk)

95. Why do I need to keep getting tested?
• Just like mammogram screening, Pap testing is not a one-time test
• The test is not perfect
• New changes (abnormalities) can occur after you get tested, even if
you have not had new partners
• It could take many years for changes to develop or to be noticed
• Your risk changes if you have new partners, or if your partner has
other partners

96. When can I stop having Pap tests?
• Around the age of 65 or 70, if you are not otherwise
at high risk for cervical cancer

97. Do I need a Pap test if I had a hysterectomy?
1. If you had treatment for precancer or cancer of the
cervix, you may still need a Pap test
2. If the cervix was left in place at the time of your
hysterectomy, you will still need Pap tests
3. Preventive health care is still important, even if
you do not need a Pap test

98. What is new in cervical cancer screening and
prevention?
1. Liquid-based Pap cytology
2. Combination of HPV test and Pap test for women 30 years of age and
older –HPV Co-testing
3. HPV test for women with ASCUS
4. Vaccines for HPV currently being used.

99. Other Diagnostic Tests
1. Liquid Cytology
2. Colposcopy
3. Colposcopy directed Biopsy
4. HPV – DNA detection
(PCR, Southern Blot Assay, Hybrid Capture)
5. Visual inspection with Acetic acid, lugol iodine
6.Cervical biopsy

100. Liquid Based Cytology
To improve results of PAP newer techniques like liquid based
cytology are recommended
Cells are obtained with a broom, then the head is broken off in
to a vial containing preservative fluid
In the laboratory the sample is spun to remove obscuring
material
It gives clearer image, no cell clumps
It will assist in future automated reading

101. .
• LIQUID BASED TEST COLLECTION
» Improved cell collection and preparation quality
» Produce even monolayer of cells
» Random distribution of abnormal cells.
» Fixative—Buffered Menthol solution

102. Liquid Based Cytology
Several slides can be prepared from one smear
Chlamydia, HPV testing can be done at later date
Reduces the incidence of inadequate and repeat smears

103. • An HPV DNA test can detect the presence of oncogenic strains of the virus in
cervical cells.
• Positive test means that patient is suffering from High risk HPV strain that can
cause cervical cancer. It can be done with Pap smear test .
• This test is being offered for Rs 900.
• Method to test=PCR, Southern Blot Assay, Hybrid Capture
• Hybrid capture 2 test for HR-HPV in combination with cytology for primary cervical
screening in women aged 30yrs & older.-every 5 yrs.
• Co-testing increases the sensitivity of single PAP testing for high grade neoplasia
for 85% to 100%
• If cytology is negative and HPV testing is positive, Cytology and HPV DNA testing
are repeated 1yr later.
• Persistent positive HPV DNA testing needs colposcopy.
• HPV testing alone twice as sensitive as pap test but lacks specificity

104.  Test from cervical cells to check DNA or
RNA for virulent strains of HPV virus.
 If Pap smear test is abnormal. Proceed
with this test.
 When both, Pap smear & HPV DNA test are
done from same sample, it is called Co-
testing.
 > 30 yrs woman, Both Papa smear and HPV
DNA co-testing is preferred. Then it is
repeated after 5 years.

105. • CLINICAL INDICATION
• Abnormal Pap smear
• To locate abnormal areas
• To obtain directed biopsy
• Conservative therapy under colposcopic guidance
• For follow up of treated cases
1. CONTRAINDICATION
1. upper and lower reproductive track infection.
2. Uncontrolled severe hypertension.
• SOLUTION USED
– Normal saline
» Saline remove cervical muscus and allows initial assessment of vascular
pattern and surface contours.

106. .
• VIA- Acetic acid
– Applying acetic acid to abnormal epithelium result in the aceto
white change characteristic of neoplasm
– It exerts its effect by reversibly clamping nuclear chromatin.
– 3-5% is a mucolytic agent.

107. .
– LUGOL SOLUTION
• stains normal mature squamous epithelial cells a dark
mahogany brown colour as a result of high glycogen
content.
• Due to poor cell differentiation, dysplastic cells have lower
glycogen level, fails to fully stain

108. COLPOSCOPIC GRADING OF LESION
COLPOSCOPIC SIGN ZERO POINT ONE POINT TWO POINT
MARGIN Condylomatous
Micropapillary
Fearthery
Satellite lesion
Smooth
straight
Polled
Peeling
Internal border
COLOUR AND
ACETOWHITING
Shinny
Snowy
Transulucent
Transient
Duller white Dull white gray
VESSELS Fine pattern
Uniform caliber
absent Coarse pattern
Variable caliber

109. VASCULAR PATTERN
PUNCTATION MOSAICISM

110. CERVICAL BIOPSY
• ECTOCERVICAL BIOPSY
– under direct colposcopic visualization suspicious lesion on the ectocervix are
biopsied using sharp instrument such as tischler biopsy forceps
– Thickened Monsel solution or silver nitrate applied
– Extreme case of bleeding can be controlled with direct pressure or vaginal
packing.

111. .
• ENDOCERVICAL SAMPLING
» Endocervical curettage is performed by introducing an endocervical
curette 1 to 2 cm into cervical canal
» The entire length and circumference is firmly curetted carefully avoiding
sampling of ectocervix or uterine cavity

112. Colposcopy Cone Biopsy Punch Biopsy
Done when Pap smear
–abnormal
Lesion-not visible.
Done to confirm
colposcopic findings if
discripancy in Pap
smear & colposcopy
Doen when Pap smear-
abnormal
Lesion-visible.

114. MANAGEMENT
• TREATMENT OF PREINVASIVE LESION
• LOCAL DESTRUCTION
 cauterization
Cryosurgery
Laser ablation
• LOCAL EXCISION
 LEEP,( loop electro-excisional procedure)
LLETZ(large loop excision of transformation zone)
Conisation with knife , laser
• RADICAL EXCISION
Hysterectomy

115. .Observation contd.---Adolescents.
Treat –if > 2yrs. Persistence
Observation in adolescent& young.
 Excision or ablation in adult.
 Excision or abalation at any age.

116. ABLATION TREATMENT MODALITIES
• Effective for non invasive ecto cervical disease.
• Evidence of glandular or invasive carcinoma should be
excluded.
1. Cryotherapy
2. Carbondioxide laser
3. Electro diathermy

117. .
CRYOTHERAPY
– Principle is crystallizing intracellular water.
– Usually nitrous oxide is used.(-80 degree)Freon(-60 degree)Co2 -
60degree---Freeze 3min– thaw 5 min--- Freeze 3 min-technique-.
– Ideal for ectocervical lesion associated with satisfactory
colposcopy, destoys 3-4 mm depth .Not used for CIN 3
– Disadvatage— Only for ectocervix lesion
– No tissue left for HPE for follow up.

118. .
CO2 LASER ABALATION
– laser is delivered using colposcopic guidance with a micro
manupulator
– Is used to vaporize tissue to a depth of 7mm.
– Best method in CIN I & II where it extends to vaginal fornices.
– Ideal for biopsy proven SIL associated with satisfactory
colposcopy,condylomatous and dysplastic lesion.

119. .ELECTRO -DIATHERMY
– Uses unipolar electrode
– 8-10 mm depth can be destroyed.

120. .
ADVANTAGE DISADVANTAGE
Favorable safty profile No tissue specimen for histopathological
examination
Out patient procedure Cannot treat lesion with unfavorable size
or shape
No anaesthetic requirments Uterine cramping
Low cost equipment Potential for vasovagal reaction
Bleeding complication rare Profuse vaginal discharge, post procedure
No proven adverse reproductive effect migration of squamo-columar junction
inwards

121. EXCISION TREATMENT MODALITIES
• Indicated for unsatisfactory colposcopy with histological
CIN, recurrent AGC cytology.
• MODALITIES
1. LEEP
2. Cold knife conization.
3. Laser conization.

122. .
L E E P (Method of choice)
(Loop Electro surgical Excision Procedure)
• Method of choice in CIN II & CIN III at any age.
• simultaneously cuts and coagulate the tissue with blended current.
• Can be used for high grade cervical lesion including those that extend into
endocervical canal, minimal complications
• Done under local anaesthesia. 10 mm depth removed.
• 2 cm loop of stainless steel wire is used to excise transformation zone.

123. .
ADVANTAGE DISADVANTAGE
Favarable safty profile Thermal damage may obsure specimen
margin
Ease of procedure Special training required
Out patient procedure using L.A Risk of post procedure bleeding
Tissue specimen for histopathological
examination
Possible increased risk of adverse
reproductive outcomes
Low cost equpiment

124. .COLD KNIFE CONIZATION
– surgical procedure to remove the cervical transformation zone including
cevical lesion
– Requier G.A or reginal anaesthesia.
– Prefered for high grade CIN extending deep into the endocervical canal, for
endocervical glandular disease.
– Patient selection, Ideal for patient older than 35yrs with CIN3 & CIS and
patient with risk of invasive cancer.

125. RADICAL EXCISION
• HYSTRECTOMY
1. Prefered for older & parous women.
2. When women cannot comply with follow up.
3. If CIN lesion is associated with fibroid, DUB or prolapse
4. If microinvasion excits.
5. Cancer phobia.

126. PROPHYLAXIS
• .

127. .
• CERVARIX-
• bivalent vaccine against HPV 16,18
• GARDSIL -
• Quadravalent vaccine against HPV 6,11,16,18
• FIRST DOSE – At elected time before exposure to sexual activity(0.5ml)
• SECOND DOSE – 2 month after first injection.
• THIRD DOSE - 6 month after first injection
• CONTRAINDICATION- pregnancy
• SIDE EFFECTS- fever ,local pain & erythema.

129. Rs 2200/-
Bivalent
vaccine
6,11
Girls

130. Details of Vaccine----
• Age
• 9-14 yrs.
• Max up to 45 yrs.
• Dosage
• <15 years= 2 doses 0,6 months
• >15 yrs-45 years– 3 doses 0,2,6 months
• HiV patients--- 3 doses
• How to give?
• I/M 0.5 ml, upper deltoid
• Prefer same brand for vaccination
• 158 countries-part of National Immunisation programme.

131. Efficacy Of Vaccine Against Ca Cx
• Is usually 9.4 yrs with slow long term antibody response for 20 yrs..
• Immuno-compromised patients should be given 3 doses… 0,1,6months
• Presently no booster dose is recommended
• It cannot be given in pregnancy..
• Efficacy is 85% against persistent infections and 93% against cytological
abnormalities.
•

132. With HPV vaccine, is screening still necessary?
• Yes! HPV vaccines should be part of a comprehensive strategy to eliminate
cervical cancer.
• Screening will still be needed to target cervical cancers caused by HPV
types not covered by the vaccine and for women who have already been
exposed to HPV types 16 and 18.
• In regions where cervical cancer screening is not possible, vaccination is the
best way to protect the next generation of women from cervical cancer.

133. Imp. Points To Remember
• Age
• 10-14 yrs, max 45 yrs.
• Y the need for vaccination, when natural infection with HPV
is available?
• After vaccination, is there any need for screening?
• Can HPV vaccine be given in women suffering from HPV
virus?
• Can this vaccine be given to women, already sexually active?
• Can Condom use prevent HPV virus transmission?

134. Is vaccinating Men necessary
• Cervical carcinoma—93.6%
• Anal, vaginal, vulval, oro-pharyangeal ca –6.5%
• In men, Vaccine use will drop the rate by only –2%
• And cost will increase 2 fold.
• Hence , Not cost-effective.
• Efficacy of Vaccine=
• 85%-persistent infections
• 93%-cytological abnormalities

135. Research In PIMS
Cytological examination N Percentage
Normal 458 91.6%
ASCUS 27 5.4%
LSIL 07 1.4%
HSIL 04 0.8%
SCC 04 0.8%
Total 500 100 %

136. Research In PIMS
• Distribution Of Dysplasia—Age wise
AGE GROUP NORMAL ASCUS LSIL HSIL SCC TOTAL
<18 10 0 0 0 0 10
18-25 80 4 0 0 0 84
26-30 54 4 01 0 0 58
31-35 65 3 01 01 2 71
36-40 62 3 02 01 1 67
>40 194 13 03 02 1 210
Total 465 27 07 04 04 500

137. Research In PIMS
0%
10%
20%
30%
40%
50%
60%
70%
80%
NORMAL ASCUS LSIL HSIL SCC
Different types of dysplasia as per clinical findings
NORMAL
EROSION
HYPERTROPHY
ATROPHY

138. Take Control of Your Health
• Make an appointment
• To get a Pap test today
• Get Vaccination done at the earliest.

139. Cervical Cancer is preventable.
Take a Pledge today
Spread
Awareness

140. .