Metaplasia of the cervix

Metaplasia of the cervix is one of the precancerous diseases, which has serious consequences, in the absence of treatment or incorrect diagnostic and therapeutic tactics. This pathology is frequent in women after 50 years, although it happens even earlier. But not all women have the concept of what is at issue, in the case of establishing this diagnosis. Due to the fact that cervical metaplasia with late diagnosis tends to one hundred percent malignancy in the future, this pathology is better prevented at the stage of initial changes. To this end, all women at the stage of an ordinary regular routine examination of a gynecologist are screened for metaplasia.

[1], [2], [3], [4], [5], [6]

Causes of the cervical metaplasia

Speaking about the development of cervical dysplasia, it is very important to identify the main risk factors and the etiological causes of the development of this process.

Among the etiological factors, that is, the probable causes of the development of pathology, infection control agents are in the first place. Among the possible pathogens can be both viruses and bacteria. Among the viral agents - it is most often the infection of a woman with human papillomavirus. This virus has a tropism for the female genital organs and causes the development of another disease - condyloma or cervical papilloma. But the infection can not be felt for a long time, and its course can be asymptomatic, and in some cases dysplasia of the cervix can develop. Other possible agents are herpes viruses of all types. These viruses also have a tropism for the epithelium of the cervix and a sufficiently high oncogeneity, so they can be a trigger mechanism for the development of dysplastic processes in the cell.

Bacteria less often play a role in the development of this disease, because they do not penetrate into the nuclear apparatus of the cell and do not induce changes in genetic material. But among the possible bacterial infections, only intracellular ones are of more importance: ureoplasmas, toxoplasma, chlamydia, gonococci. These microorganisms penetrate the cell and remain there for a very long time, while protecting themselves from immune cells and supporting a chronic inflammation focus. This is not the true cause of dysplasia, but similar changes may develop on its background, which will lead to dysplasia in the future.

Causes of metaplasia of the cervix are definitely difficult to establish, but to date, one of the proven etiological factors is infection with the human papillomavirus, which plays a key role in the further progression of changes within the cell.

[7], [8], [9]

Risk factors

Risk factors can be divided into general and local. Common include bad habits, smoking, drinking alcohol, eating disorders and the use of carcinogenic products, the influence of environmental factors. All these changes are accompanied primarily by a decrease in the reactivity of the whole organism, and against this background, functional and then morphological changes in organs and systems develop.

Among the risk factors for cervical dysplasia, local - early onset of sexual activity, frequent changes in sexual partners, and infectious and inflammatory diseases of female genital organs, frequent surgical interventions - abortions, hormonal disorders, traumatic injuries.

[10], [11], [12], [13]

Pathogenesis

Speaking about the process of development of dysplastic processes, it is very difficult to single out the period when they develop and the duration of the course of such changes. Since pathology can occur in women under 40 years of age, it is important to be cautious about suspicion of metaplasia.

The structure of the cervix in a healthy woman is an alternation of the epithelial cover:

• flat multilayer non-coring epithelium - located in the endocervix closer to the vaginal canal and is a continuation of it;
• the intermediate zone is located farther and is the border on the way to the cervix, both types of epithelium are absent here;
• Cylindrical epithelium - lining the cavity of the cervix and the cervical canal.

Normally, these balls do not mix and there is a clear boundary between them.

The pathogenesis of the development of cervical metaplasia begins with a trigger factor, which can be a viral agent. In this case, the virus penetrates into the cell, where its nucleic acid enters the nucleus by disrupting the integrity of the nuclear envelope.

Because of this, the genetic apparatus of a normal cell is broken and the virus initiates the synthesis of its own proteins, which are necessary for it to live. This disrupts the normal life cycle of the epithelial cell and its fission and multiplication processes. This is how abnormal cell division is formed, which contributes to the appearance of epithelial cells with atypia of the nucleus. That is, the process of cell division can stop at a certain phase of mitosis, and then the development of numerical cells with an incorrect set of chromosomes can be initiated. Such cells can not provide normal protein synthesis and metabolism in the cytoplasm, which is the cause of the appearance of dysplastic processes in the cell. Such cells multiply and can move from the main site - for example, the cylindrical epithelium goes beyond the intermediate zone and zones of cylindrical epithelium appear among the normal flat epithelium of endocervix, which is the phenomenon of metaplasia. This disruption of the normal structure of the epithelial cover does not reach the basal membrane.

To date, the definition of metaplasia or dysplasia is obsolete, and use a new term - CIN - cervical intraepithelial neoplasia. This concept allows us to clarify that this process is not so much dysplastic as peredrakovym.

[14], [15], [16], [17]

Symptoms of the cervical metaplasia

Considering that this pathology often passes without symptoms, it is necessary to know the basic symptoms that allow you to pay attention and suspect this problem.

Metaplasia of the cervix is a dangerous condition for the very reason that often the morphological changes that develop are much faster than the development of at least a minimal clinical symptomatology. This is one of the reasons for introducing mandatory screening for this pathology.

Symptoms of metaplasia of the cervix can be manifested most often with any provoking factor. It can be with accompanying condylomata, erosions, infectious lesions. Rarely, the clinical picture occurs without such conditions and is characterized by soreness in sexual intercourse, a violation of the normal menstrual cycle, if there are hormonal failures, secretions from the vagina. Excretions can be in the form of whites - curdled, plentiful, white or milky discharge with an unpleasant odor, and also in the form of bloody discharge before menstruation, after or after sexual intercourse. Local pain with metaplasia is not characteristic if it is purely a dysplastic process.

The first signs that appear most often and are not specific, but should alert - this is a painful sexual act. Unpleasant sensations arise due to trauma to the dysplastic epithelium, which can also be accompanied by bloody discharge. This does not happen so often, but it can be one of the first manifestations. As for older women, their first symptoms of metaplasia may often not be expressed due to involuntary processes in the uterus and cervix, which suggests pre-menopausal changes. So the symptoms that appear in a woman, she explains by the beginning of menopause and does not address the doctor.

Given that the clinical symptomatology is not sufficiently expressed, it is necessary to take very seriously any changes in the state of health, especially for older women.

[18], [19]

Forms

Since the epithelium of the cervix has several types of cells, metaplasia can also be different. The histological pattern of changes in the smear is studied to establish the correct diagnosis and choice of treatment tactics. This indicates not only the extent of the spread of atypical cells, but also the nature of these changes and the morphological features of the smear.

There are several types of dysplasia:

1. immature metaplasia of the cervix;
2. squamous metaplasia of the cervix with dyskaryosis;
3. squamous cell metaplasia of the cervix.

With regard to immature metaplasia, this is considered the most unfavorable option, since the lower the level of cell differentiation, the greater the risk of malignancy. The picture of immature dysplasia is characterized by the appearance in the smear of cells that are small in size, fuzzy unequal boundaries, and also placed chaotically in the smear itself. As for the internal structure of the cells, the cytoplasm has been altered in violation of the arrangement and structure of the structural elements of the cell. There are various changes in mitosis in the nucleus. Sometimes it is difficult to attribute such cells to any kind of epithelium, since they do not have characteristic distinctive features.

Squamous cell metaplasia of the cervix with dyskaryosis is a more differentiated species, compared with immature forms. Such cells already have a certain shape, the same size and sufficient size. Within the cell, the cytoplasm is not altered, and the structural elements are located correctly, in sufficient quantity, which characterizes the cytoplasm of the normal epithelial cell. The only differences from normal cells are abnormal fission in the nucleus in the form of pathological mitoses. This is what characterizes the term "dyskaryosis".

Squamous cell metaplasia of the cervix is the most differentiated variant, since the epithelium has all the characteristics of normal cells, with the exception of location. Thus, in squamous cell metaplasia of the cervix, the flat multilayered epithelium is determined beyond the intermediate zone in the region of the cervical canal among the cylindrical epithelium.

These histological types do not affect the course of the disease, but have a different prognosis, so this classification is mandatory in the cytological study.

[20], [21], [22]

Diagnostics of the cervical metaplasia

Since the course of this pathology is often asymptomatic, an important element of timely diagnosis and prevention of complications are preventive examinations at the gynecologist, which the woman must undergo annually. When examined, the doctor examines the cervix of the woman in the mirrors, which makes it possible to see changes that can be seen without additional methods. Several cells of metaplastic epithelium among the normal cover, as a rule, can not be seen, therefore the obligatory stage of the examination is taking a smear with a special brush for histological examination and detection of dysplasia.

Be sure to observe the right technology - a swab is taken from three zones of the cervix - endocervix, intermediate zone and cervical canal, that is, all three types of epithelium should be present. This ends the objective examination. Then all the smears are sent to the laboratory for cytology and histology.

Analyzes, which the doctor receives from the laboratory, allow one to suspect dysplastic changes. There are six basic types of smears:

1. histological picture of a healthy woman;
2. inflammatory and benign changes in the smear;
3. cervical intraepithelial neoplasia
   1. mild metaplasia (CIN-I) - altered dysplastic cells extend deep into not more than one-third of the epithelial cover;
   2. Moderate metaplasia (CIN-ІІ) - altered dysplastic cells extend deeper into not more than two-thirds;
   3. severe metaplasia (CIN-III), altered dysplastic cells extend inward by two-thirds or more, but without invasion of the basal membrane;
4. suspected cancer;
5. cancer;
6. a non-informative smear (not all types of epithelium are represented).

If a smear comes and the woman is healthy - everything is fine, but in all other cases - a woman is called for a second consultation and preobsleduyut.

If there is a suspicion of metaplasia, that is, if a third type of smear is used, then instrumental methods of investigation are conducted.

Colposcopy is the diagnosis of the cervix by a special device that has a magnifying power of 2 to 32 times, depending on the power. This increase allows you to see those areas of metaplasia, which are not determined by routine examination in the mirrors. In addition to simple colposcopy, an extended one is also performed. In this case, the site of the examined epithelium of the cervix is colored with trichloroacetic acid, iodine or Lugol solution, and look at the degree of coloration. The sites of metaplastic epithelium will be pale against a normally colored epithelium. Such a diagnosis can confirm the presence of metaplasia, even if visually nothing can be found.

In case of doubtful diagnosis, a repeated histological examination is performed in colposcopy with a targeted aspiration biopsy, and also possible - diagnostic scraping of the cavity and canal of the cervix.

These are the main research methods that allow you to establish a diagnosis.

[23], [24]

Differential diagnosis

Since metaplasia is often asymptomatic, the main diagnosis is histological verification, which allows you to accurately establish the diagnosis. But also it is necessary to differentiate metaplasia with other precancerous conditions and benign cervical structures: polyps or condylomas, erosion, leukoplakia without atypia, adenomatosis.

Polyps or condylomata of the cervix are benign neoplasms of the viral etiology. The cause of development of cervical polyps, as in some cases and metaplasia, is the human papillomavirus. This neoplasm is characterized, as well as metaplasia, by the multiplication and proliferation of cells. But with polyps these formations are visible to the naked eye and rise above the surface of the epithelial cover. There are flat warts - similar to build-up by the type of warts on the skin, and pointed condylomas on the stem in the form of cauliflower.

Erosion of the cervix in colposcopy has a characteristic appearance - it is a mucosal defect. Also distinguish pseudo-erosions, which are in girls under 25 years, as a consequence of a violation of the hormonal background. In any case, they have a bright red color, a small swelling due to an inflammatory component.

Leukoplakia is the appearance of the horny epithelium in those areas where it should not be. This is a form of dysplasia, but in this case, it is not intraepithelial neoplasia. These areas look like whitish islets among the epithelial cover. Establish the presence of atypia cells and accurately distinguish leukoplakia from neoplasia allows a histological examination.

Considering all possible changes in the epithelium of the cervix, the morphological examination of the epithelial smear comes to the fore for precise diagnosis, which also allows differential diagnosis with other precancerous diseases.

Treatment of the cervical metaplasia

Treatment of cervical metaplasia is mandatory and it is necessary to carry it out at the earliest and timely time, as this is a precancerous disease and the likelihood of malignancy is high. Regarding the method of treatment, the choice depends on the degree of CIN and type of smear. In the second type of smear, a woman is given an etiological therapy, symptomatic anti-inflammatory therapy. In the third type of stroke (CIN-I), when dysplastic cells occupy up to one-third of the epithelial cover, treatment can be conservative with the use of medications and local medications. In the case of CIN-ІІ, CIN-ІІІ or fourth and fifth types of smears, treatment is only prompt, as conservative increases the risk of malignancy.

Conservative treatment of metaplasia of the cervix provides for a comprehensive treatment using different directions.

The regime with this disease is common, dietary recommendations are without special features, healthy food is recommended. For the period of treatment it is necessary to keep from sexual activity.

As for medicines, for carrying out etiological treatment it is necessary to determine the human papilloma virus, which is most often metaplasia, and to use antiviral drugs. To date, there are two main drugs that are used to influence the virus - "Genferon" and "Panovir". These drugs inhibit the activity of the virus by affecting the nucleic acid and disrupt the process of reproduction of viral particles.

In the case of the definition of a concomitant bacterial flora in the smear - antibiotic therapy is mandatory. Preference is given to complex preparations that have in their composition not only an antibiotic, but a corticosteroid, and an antifungal drug. Such complex preparations include Neotrizol, Terzhinan. Use the course doses with further additional study after the treatment.

Also, symptomatic anti-inflammatory therapy is performed in the form of vaginal anti-inflammatory suppositories.

Immunomodulating drugs are also included in the treatment package.

Operative treatment of dysplasia of the epithelium of the cervix is carried out at CIN-ІІ and CIN-ІІІ. This tactic is due to the fact that conservative treatment with such a degree is ineffective, and during this time, malignancy is possible.

There are several methods of surgical treatment: laser vaporization, cone excision, scraping of the cervical canal, electrocoagulation.

Scraping of the cervical canal is the most "crude" method and can be used if there are no technological possibilities of other methods of treatment or there are concomitant conditions requiring such a method.

Cone excision is the excision of the cervical epithelium in the form of a cone, depending on the depth of the lesion. This method has its advantages, since the risk that any cells will remain deeper is minimal, since the site is cut to the basement membrane or even deeper if necessary. But this method is more invasive and traumatic than the rest. After the excision the material is sent for histological examination and it is possible to exclude atypical cells again.

Electrocoagulation is the use of an electric charge to create a high temperature that is able to coagulate a protein and thus destroy dysplastic cells.

Laser vaporization works on the same principle as electrocoagulation, but laser energy is used here.

The choice of treatment methodology depends mainly on the technological capabilities of the hospital and is not a priority one method over another. It is necessary to be guided also by the volume of the affected tissues and the depth of the changes.

Alternative treatment of cervical metaplasia

The people have many methods of treating this pathology, and they all have some justification. But it must be remembered that this disease is serious enough and requires the same approach to treatment, so alternative treatment can be carried out only with CIN-I and in combination with medications.

There are many prescriptions for the treatment of cervical metaplasia by alternative means. Main methods:

1. Treatment of pine - need half a glass of pine buds pour hot water, insist, and then boil for five minutes, after which a warm solution can be syringed twice a day. Such treatment can be done for a long time until complete recovery.
2. The juice from the leaves of the nettle should be squeezed into a glass, then soak a tampon in this juice and enter into the vagina for a few minutes, this procedure should be repeated throughout the month once a day.
3. The leaves of aloe, which has a pronounced anti-inflammatory and regenerating effect, are squeezed into a glass and dipped in a tampon, inserted into the vagina, repeating the procedure once a day for a whole month.
4. Propolis - use propolis ointment, which is prepared by welding ten grams of propolis in a hundred grams of olive oil, then cool and make vaginal tampons.

Particular attention should be paid to the treatment of cervical metaplasia with celandine. Use infusion celandine: half a glass of dry leaves celandine pour a liter of boiling water and take inside two teaspoons twice a day.

You can also make an alcoholic tincture and take 10 drops for ten days.

Boiled solution can be used for syringing.

Homeopathic preparations that are used in the treatment of cervical metaplasia act mainly on the possible etiologic factor, and also stimulate the regeneration of the epithelium and reduce inflammatory manifestations. These drugs include Allokin-alpha, vaginal suppositories "Papillocan" and "Immunovita." The latter also has a local immunomodulatory effect.

[25], [26], [27], [28], [29], [30], [31]

Prevention

Prevention of metaplasia may be specific and nonspecific. Nonspecific prevention is a modification of the way of life with the exception of risk factors. Such risk factors that are subject to modification are the exclusion of bad habits, proper nutrition, exclusion of the work of women in industry with hazardous substances. It is also necessary to monitor the hygiene of sexual activity, because its early onset and frequent change of sexual partners is a risk factor not only for metaplasia of the cervix, but for cervical cancer and breast cancer. Sexual life should be safe in terms of possible infections - avoid infection with the human papilloma virus as much as possible.

As for specific prevention, this is the use of vaccines. Since the only proven etiologic factor in the development of cervical metaplasia in women can be considered HPV, the timely vaccination against this virus reduces the risk of developing both metaplasia and malignant oncological diseases of the cervix. There is a vaccine against the human papillomavirus that is used for girls 9-14 years before the onset of sexual activity. It provides immunity for a long time, which is already at least some preventive remedy.

[32], [33], [34]

Forecast

The consequences of cervical metaplasia can be very serious in case of untimely diagnosis and lack of treatment. Metaplasia is a precancerous condition that has the ability to rapidly malignantize, since there is a predisposition in the form of cell dysplasia. Therefore, the prognosis in the absence of treatment is unfavorable. In the case of timely diagnosis - a complete reduction is possible, both conservative and surgical, and then the prognosis is positive.

Cervical metaplasia is a serious disease that requires treatment to prevent future complications, since there is a direct risk of malignancy. It is better to prevent this condition through periodic medical examinations, as well as the elimination of risk factors. In the case of establishing this diagnosis, you should not worry, because it is well amenable to therapy, the main thing is not to delay this. Treatment depends on the stage, but, in any case, is mandatory. We need to monitor our health and start worrying in time.

[35], [36], [37], [38], [39], [40]