Cervical dysplasia

Definition

Cervical dysplasia is the existence of abnormal cells on the uterine cervix.

Description

The cervix is an organ in the female reproductive system. It is narrow and located at the lower end of the uterus. The cervix serves as a tubular passageway between the uterus and vagina. When a woman is pregnant, the cervix closes and seals off the uterus for the developing fetus. During childbirth , the cervix expands to allow the baby to pass through. When a woman is not pregnant, the lining of the uterus passes through the cervix each month during the menstrual cycle. The cervix also secretes mucus during ovulation, which assists in the fertilization of the egg by sperm cells. Women can usually feel the cervix by inserting a finger toward the back of the vagina. The cervix resembles a small mound with a dimple in the middle.

The cervix has two types of cells. The outer part of the cervix near the vagina is covered with cells called squamous epithelial cells. The cervix canal is lined with epithelial cells that secrete mucus during ovulation. The border between these two types of cells is called the transformation zone, which changes shape and position with age. Doctors may closely examine the transformation zone to watch for problems in both types of cells.

Cervical dysplasia occurs when cells on the cervix have abnormalities. The condition is technically called cervical intraepithelial neoplasia (CIN) or squamous intraepithelial lesions (SIL), depending on the affected cells. The cervix is also susceptible to other problems, including cervicitis (inflammation), sexually transmitted diseases (STDs), infections , and cancer (dysplasia is a precursor to cancer).

Causes & symptoms

The two factors that create the highest risks for cervical dysplasia are smoking and sexual behavior. Cervical dysplasia is two to three times more likely to occur in women who smoke than in those who do not. One study showed that the risk of dysplasia increases directly with the number of cigarettes a woman smokes per day. A second study published in the late fall of 2002 showed that smokers infected with HPV had infections that lasted longer and were more difficult to eradicate than women who were infected but had never smoked. Nicotine, a toxin in cigarette smoke, can be found in the cervical cells of smokers.

Sexual behavior is another major risk factor. Studies have shown that the presence of sexually transmitted diseases are strongly correlated with the occurrence of cervical dysplasia. Women who have human papillomavirus (HPV), which causes genital warts , have higher occurrences of cervical dysplasia. Other STDs are believed to influence cervical dysplasia as well, including herpes, hepatitis B and C, and HIV. Risky behaviors for contracting STDs and cervical dysplasia include having many sexual partners, having intercourse at a young age, and having unprotected sex.

As of late 2002, there is a clear need to educate women more effectively about the link between human papillomavirus infections and cervical cancer. A recent study found that even women who understand the importance of early cervical cancer detection are much less well informed about the risk factors for cervical cancer.

Other factors that influence the development of cervical dysplasia are a high number of pregnancies; long-term use of birth control pills; use of immunosuppressive drugs (drugs which weaken the immune system); and deficiencies of folic acid, vitamin A , and vitamin C . Folic acid deficiency is often observed with heavy alcohol consumption, which may indirectly pose a risk as well, as may drug abuse. Cervical dysplasia has also been observed to have higher incidence in women in low income groups.

Cervical dysplasia is generally asymptomatic, which means that most women are not alerted to the condition by detectable symptoms. To detect cervical dysplasia, women must rely on diagnostic tests.

Diagnosis

The most common method for diagnosing cervical dysplasia is the Pap smear, which was invented by the American researcher George Papanicolaou in the 1950s. Due to the effectiveness of the Pap smear in detecting cervical problems, the incidence of cervical cancer has decreased by as much as 50% since 1960. Deaths from cervical cancer have decreased by as much as 70% in groups of women who get frequent Pap tests.

The Pap test is a simple procedure. A doctor inserts a small brush and obtains a sample of cervical cells that are then analyzed under a microscope. Cell abnormalities, or cervical dysplasia, can be classified as low grade or high grade, or ranked numerically. A Class 1 Pap result is normal, Class 5 represents cervical cancer, and the numbers in between indicate relative severity. It should be noted that the Pap smear is not perfectly accurate. In 20% or more of tests, the Pap smear can fail to find problems. The Pap smear may also overestimate the severity of abnormalities. Thus, if dysplasia is found for the first time, it is a good idea to have follow-up Pap tests to confirm the diagnosis. To increase the accuracy of Pap tests, women should not douche or use a tampon for three days before an exam, should abstain from intercourse for two days, and should allow a week after menstrual periods or vaginal infections before having the exam performed.

Since women exposed to the HPV virus are also more susceptible to cervical dysplasia and cervical cancer, in 2002, a Food and Drug Administration (FDA) panel backed an HPV test as an accompaniment to the Pap smear. The test could help separate women at high or low risk for cervical disease.

If Pap tests continue to detect cervical dysplasia, other diagnostic tests may be ordered. A cervigram is a photograph of the cervix that can be performed alongside a Pap test. A colposcopy is a procedure in which a tiny camera allows the physician to view the cervix and the interior of the vagina. If cancer or severe problems are suspected after a colposcopy, a biopsy may be used, in which tissue from the cervix, vagina, and uterus is surgically

removed in order to be analyzed. In a cone biopsy, a surgeon removes a cone-shaped section of the cervix to check for cancerous cells. Cone biopsies can cause permanent internal scarring, so women should carefully consider this procedure, particularly in cases where dysplasia is not severe.

Treatment

There are several alternative therapies that can be utilized for cervical dysplasia. During and after alternative treatment, cervical dysplasia should still be monitored by Pap smears from standard physicians, particularly for severe cases.

Dietary and nutritional therapies seek to balance the hormonal system and support the immune system. Diets for cervical dysplasia should be predominately vegetarian and low in fat, emphasizing fresh fruits, vegetables, grains, nuts, and legumes (beans and lentils). Alcohol, caffeine , fried foods, and sugar should be avoided, as should foods that may contain artificial hormones and estrogen, such as dairy and meat products that are not organically produced. Women should eat plenty of yellow and leafy green vegetables. Tomatoes contain a substance called lycopene that may protect against dysplasia. Soy products should also be frequently added to the diet for their estrogen balancing effects.

Nutritional support includes the supplementation of B-complex vitamins, particularly folic acid, vitamin B₆, and vitamin B ₁₂. Vitamins A, C, and E are recommended, as are the minerals selenium and zinc . Grape seed extract and pine bark extract are recommended antioxidants to assist healing, and nutritional yeast and spirulina are natural supplements for B vitamins and minerals.

Recommended herbs include vitex berries (also called chasteberries, or chasteberry tree ) and black cohosh to balance hormones and stimulate healing in the reproductive system. Herbs to stimulate and support the immune system include echinacea, goldenseal , burdock, milk thistle , shiitake mushrooms, yarrow, ginger , and astragalus . Herbs that may balance hormones include red clover, kudzu root, licorice root, and Siberian ginseng . Aromatherapy baths may also help, utilizing the essential oils of geranium, rose, lavender , bitter orange, rosemary , or tea tree oil . Herbal douches and herbal vaginal suppositories are available that utilize herbs and essential oils to stimulate internal healing.

Exercise is recommended to stimulate the immune system and reduce stress . Yoga has exercises specifically designed to stimulate circulation in the lower abdomen and reproductive organs. Plenty of fresh air during the day is also beneficial for those trying to improve their health and energy.

Stress and emotional problems may also play a significant role in cervical dysplasia and in problems with the reproductive system in general. Mind/body techniques such as psychotherapy, meditation , progressive relaxation , breath work, and visualization may help reduce stress, remove emotional blockages, and stimulate healing. Detoxification therapies may also be recommended, including fasting , sweating, and other techniques, particularly for women who may have accumulated toxins in the body from smoking, drug abuse, or poor dietary and lifestyle habits.

Allopathic treatment

For mild cases of cervical dysplasia, physicians may choose to monitor a patient with Pap smears every three months, to determine if the condition can improve on its own. For severe or chronic cases of dysplasia, allopathic treatment seeks to remove or destroy abnormal cells on the cervix. Cryosurgery destroys dysplastic cells by freezing them. Abnormal cervical cells can be burned off with a solution of trichloroacetic acid. Laser surgery may also be employed, as well as the loop electroexcision procedure (LOOP), a surgery in which a small wire loop with an electrical charge is used to destroy abnormal cervical cells. Conventional surgery may be used for severe cases of dysplasia. Women with high-risk HPV infection are typically treated by conization, which is a procedure in which the surgeon excises, or cuts out, a cone-shaped piece of the cervix. Conization is reported to be about 73% effective in eliminating the HPV infection. Partial hysterectomies remove the uterus and cervix.

Expected results

Several outcomes are possible with cervical dysplasia. In some cases, dysplasia may clear up completely without medical intervention. Some statistics have shown that moderate to severe cervical dyplasias (Class 3) improve on their own in 50% of cases. Mild dysplasia may progress to severe dysplasia in up to 25% of cases. A 2002 study found that HIV-infected women were more likely than women not infected with HIV to have a recurrence of cervical dysplasia even after treatment for it. Hysterectomy was the most effective method to preventing recurrence.

As of late 2002, there is still no completely satisfactory treatment for cervical dysplasia associated with HPV infection. None of the present therapies are 100% effective in eradicating HPV infection.

Cervical dysplasia does not directly progress to cervical cancer, especially when it is detected early and treated. In some studies, cervical dysplasia progressed to cervical cancer in approximately 15% of cases that were not diagnosed and treated properly. Cervical cancer is the second most common malignancy in women between the ages of 15 and 34; about 1% of cervical cancers occur in pregnant or recently pregnant women. When detected early by frequent Pap smears and other tests, however, cervical cancer is very treatable. One study estimated that cervical cancer is fatal for 1 in 30,000 women.

Prevention

The most important recent development related to prevention of cervical dysplasia is the positive outcome of clinical trials of a vaccine against HPV. According to an article published in the New England Journal of Medicine in November 2002, a vaccine against HPV type 16 was effective in reducing the incidence of cervical dysplasia as well as HPV infection in the study subjects. Similar findings have been reported by Australian researchers.

Until a vaccine against HPV is approved for general use, however, women should eliminate risky sexual behaviors and should immediately quit smoking. Healthy dietary and lifestyle habits should be adopted, and birth control pills should be avoided. Pap tests and gynecological exams should be performed once a year or more to monitor for recurring dysplasia. In fact, regular Pap tests are critical to early detection of cervical disease. A 2002 report by the College of American Pathologists said that of those women who die of cervical cancer, 80 percent had not seen their doctors for a Pap test in the five years preceding their diagnoses.

Resources

BOOKS

"Gynecologic Neoplasms." Section 18, Chapter 241 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Hobbs, Christopher and Kathi Keville. Women's Herbs, Women's Health. Loveland, CO: Interweave Press, 1998.

Morgan, Peggy and the Editors of Prevention Magazine. The Female Body: An Owner's Manual. Emmaus, PA: Rodale, 1996.

PERIODICALS

Bodner, K., B. Bodner-Adler, F. Wierrani, et al. "Is Therapeutic Conization Sufficient to Eliminate a High-Risk HPV Infection of the Uterine Cervix? A Clinicopathological Analysis." Anticancer Research 22 (November-December 2002) (6B): 3733–3736.

Castellsague, X., F. X. Bosch, and N. Munoz. "Environmental Co-Factors in HPV Carcinogenesis." Virus Research 89 (November 2002): 191–199.

"College of American Pathologists Applauds New Pap Test Guidelines." Women's Health Weekly (May 30, 2002): 12.

Frazer, I. "Vaccines for Papillomavirus Infection." Virus Research 89 (November 2002): 271–274.

Frieden, Joyce. "FDA Advisory Panel; Backs HPV Test as Pap Smear Adjunct (Identifies High-Risk Strains)." Family Practice News (June 15, 2002): 30–31.

Giulian, A. R., R. L. Sedjo, D. J. Roe, et al. "Clearance of Oncogenic Human Papillomavirus (HPV) Infection: Effect of Smoking (United States)." Cancer Causes and Control 13 (November 2002): 839–846.

Koutsky, L. A., K. A. Ault, C. M. Wheeler, et al. "A Controlled Trial of a Human Papillomavirus Type 16 Vaccine." New England Journal of Medicine 347 (November 21, 2002): 1645–1651.

Pitts, M., and T. Clarke. "Human Papillomavirus Infections and Risks of Cervical Cancer: What Do Women Know?" Health Education Research 17 (December 2002): 706–714.

Tate, Darren R. and Ralph J. Anderson. "Recrudescence of Cervical Dysplasia Among Women Who are Infected with the Human Immunodeficiency Virus: A Case-Control Analysis." American Journal of Obstetrics and Gynecology (May 2002): 880–883.

Tewari, K. S., and P. J. DiSaia. "Primary Prevention of Uterine Cervix Cancer: Focus on Vaccine History and Current Strategy." Obstetrics and Gynecology Clinics of North America 29 (December 2002): 843–868.

Zanotti, K. M., and J. Belinson. "Update on the Diagnosis and Treatment of Human Papillomavirus Infection." Cleveland Clinic Journal of Medicine 69 (December 2002): 948–956.

ORGANIZATIONS

American College of Obstetricians and Gynecologists (ACOG). 409 12th Street, SW, P. O. Box 96920, Washington, DC 20090-6920. <http://www.acog.com>.

Centers for Disease Control and Prevention. 1600 Clifton Road NE, Atlanta, GA, 30333. (404) 639-3534.

The Health Resource. 209 Katherine Drive, Conway, AR 72032. (501) 329–5272.

OTHER

Health Wisdom for Women. 7811 Montrose Road, Potomac, MD 20854.(800) 804–0935.

Douglas Dupler

Rebecca J. Frey, PhD