Moderate cervical dysplasia: degrees and how to treat it

Moderate cervical dysplasia is a type of intraepithelial neoplasia. This is a very common gynecological disease, characterized by the occurrence of atypical cells in the deep cellular structures of the cervix. The main danger of such pathology is the high probability of developing cancer with the progression of the disease and the absence of treatment. According to statistics, women of childbearing age (from 25 years) are most often subject to the development of dysplasia.

According to the WHO classification (1995), three degrees of cervical intraepithelial neoplasia (CIN) are distinguished in medicine, which differ depending on the growth of atypical cells and have corresponding designations:

• CIN I (weak);
• CIN II (moderate);
• CIN III (severe) is the most dangerous degree of severity.

"Moderate" is considered to be grade II dysplasia, when detected, lesions are observed up to 2/3 of the thickness of the squamous epithelium. In this case, the cell nuclei increase in size, the mutual arrangement of cells is disrupted, the nuclear-cytoplasmic ratio changes significantly, pathological mitoses occur. In approximately 40% of cases, the disease regresses, but under certain unfavorable conditions and reduced immunity, the disease passes to the last (III) stage. The progression of the process is characterized by extensive damage to the multilayered epithelium of the cervical canal, which indicates the development of intraepithelial cancer. According to medical statistics, the probability of diagnosing intraepithelial cancer in patients with severe cervical dysplasia is approximately 20 times higher than in women with a healthy (undamaged) cervix.

Moderate cervical dysplasia is a rather serious but completely curable disease if detected in time. This pathology is expressed in the rapid proliferation of mutated cells located in the epithelial layers of the cervix. Today in medicine, any stage between a healthy state of the female body and cancer is usually called "cervical intraepithelial neoplasia".

The diagnosis of “Moderate cervical dysplasia” has the ICD-10 code N87.1 and belongs to class 14 - “Diseases of the genitourinary system” in the International Classification of Diseases, 10th revision.

The degree of dysplasia is determined based on the complexity of the disease, i.e. depending on the pathological changes in each of the layers: superficial, intermediate, basal. When the pathology moves to the basal layer, the patient is given the most dangerous diagnosis - "cervical cancer". Due to untimely diagnosis of cervical cancer, about 4-5 thousand out of 100 thousand women die annually in the world.

The concept of precancerous diseases of the cervix first appeared in 1947 and united pathologies that are characterized by atypia of the epithelium of the cervix without invasion. Studying the influence of dysplasia of any severity on the development of cervical cancer, Richart first introduced the term "cervical intraepithelial neoplasia" into medical practice. In the research works of the scientist, it was indicated that with a mild degree of dysplasia is completely reversible and does not require intensive therapy. However, in modern medicine, dysplasia of any severity is considered a "precancerous condition".

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Causes moderate cervical dysplasia

Moderate cervical dysplasia is a second-degree lesion of the mucous membrane structure, which is “intermediate” between the first and third. Therefore, for positive treatment results, pathological changes in the cervix must be detected as early as possible. Therapy will be aimed at suppressing the papillomavirus, and therefore at preventing carcinoma, a malignant tumor that can develop in a woman with grade II dysplasia within 3 years.

What are the main causes of moderate cervical dysplasia? It is generally accepted that this pathology can be provoked by the following factors:

• exogenous (external) – infection of the woman’s body with various viruses (herpes, chlamydia, papilloma, HIV), as well as the development of gonorrhea, trichomoniasis, urea- or mycoplasmosis;
• endogenous (internal) – immunodeficiency and various hormonal imbalances;
• bacterial vaginosis;
• starting sexual activity too early and frequently changing sexual partners;
• hereditary predisposition;
• inflammatory diseases of the pelvic organs (chronic);
• long-term use of contraceptives;
• abortions and early births (before 18 years of age) with trauma to the cervix;
• large family;
• history of advanced erosion, vaginal/vulvar dysplasia;
• diseases of the endocrine glands;
• alcohol and smoking abuse;
• folate deficiency;
• regular neglect of personal hygiene.

The hypothesis of a direct impact of the human papillomavirus (HPV) on the development of cervical cancer was put forward by Hausen in the 1970s. The main route of transmission of this virus is sexual. Oncogenic genotypes of the papillomavirus include: 16, 18 (cause 2/3 of all cases of carcinoma development), as well as 31, 33, 45, etc.

Moderate dysplasia can only be diagnosed in a medical facility, under the supervision of a gynecologist, using special instruments. Early diagnosis of cervical dysplasia is based on a cytological examination of smears developed by Papanicolaou. This examination allows for the precise location of altered areas of the cervical mucosa.

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Pathogenesis

Moderate dysplasia of the cervix develops as a result of hyperplasia (increase in size and active proliferation) of the basal cells of the squamous epithelium. This process leads to disruption of maturation and atypia – abnormal structure of cells, especially nuclei. At this stage, 1/2-1/3 of the epithelium thickness is affected, on which mitoses are visible. The affected part is represented by oval, elongated, modified cells (having large nuclei with nucleoli and a rough chromatin structure).

The pathogenesis of moderate dysplasia is often associated with HPV infection (mainly strains 16 or 18). There are two main stages of HPV development: reproductive infection (this stage is reversible) and integrative infection (the DNA of the papillomavirus is integrated into the genome of infected cells, which leads to tumor transformation). Due to active reproduction of HPV, the "aggressive" estrogen 16α-hydroxyestrone is formed in infected cells, creating favorable conditions for the development of the tumor process. Reliable criteria by which the prognosis of the disease can be most accurately determined have not yet been studied.

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Symptoms moderate cervical dysplasia

Moderate cervical dysplasia has no specific symptoms, and this feature significantly aggravates the course of the pathological process. Approximately 10% of women have a completely hidden course of the disease at all stages, up to its malignant degeneration. Therefore, a large role in the timely detection of pathology is given to regular visits to a gynecologist and scheduled PAP tests.

Symptoms of moderate cervical dysplasia are vague and usually come down to pain during sexual intercourse, bloody discharge or leucorrhoea after intercourse. Symptoms may also include nagging pain in the lower back and abdomen. Body temperature does not increase, except in cases of inflammatory processes and secondary infections.

When a microbial infection occurs against the background of moderate dysplasia, the following symptoms may occur:

• itching and irritation of the mucous membrane;
• burning sensation in the vagina;
• bloody (sometimes purulent) discharge with a characteristic odor;
• heavy and prolonged bleeding during menstruation;
• occurrence of bleeding outside of menstruation;
• pulling pain in the lower abdomen.

First signs

Moderate cervical dysplasia is almost asymptomatic, the clinical picture is blurred. Women with dysplasia in 90% of cases do not even suspect such health problems.

The first signs of dysplasia appear only at later stages of the disease. Most often, this is discomfort and nagging pain in the lower abdomen. If any infection occurs, symptoms may be observed in the form of vaginal bloody discharge after intercourse or the use of tampons, which is perhaps the only clear sign of a pathological process.

Sometimes burning and itching are observed (especially with a microbial infection of the vagina), similar to the symptoms of colpitis/cervicitis. The patient may experience profuse discharge (leucorrhoea) from the genital tract of different colors and odors.

If the above symptoms or discomfort in the lower abdomen, nagging pain, burning, itching, etc. appear, a woman should immediately be examined by a gynecologist. Timely diagnosis of dysplasia will help the doctor apply effective therapeutic methods to treat the insidious disease and eliminate its consequences.

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Complications and consequences

Since moderate cervical dysplasia is a type of precancerous condition, the consequences of the pathology are predictable: the second stage of the disease can develop into the third. This means that the most dangerous consequence of dysplasia will be the development of a malignant tumor.

According to medical statistics, in 43% of cases, grade II dysplasia goes away on its own after the patient’s body is “liberated” from HPV. In approximately 35% of cases, a long-term stable course of the pathological process is observed. In 70% of women, recovery occurs approximately 2 years after the diagnosis.

Timely diagnosis of dysplasia, complex treatment in combination with the exclusion of provoking factors leads to positive results. Inadequate treatment or complete lack of therapy can cause the development of formidable complications, i.e. the transformation of dysplasia into cancer. With grade II dysplasia, the probability of developing a tumor process is 5-7%. Viral infections (papilloma or cytomegalovirus, herpes, etc.), chronic inflammatory processes, as well as immunodeficiency states (for example, HIV infection) can contribute to the degeneration of pathology into a malignant tumor.

The main danger of dysplasia turning into cancer is the unnoticeable, almost asymptomatic course of this process. Arising from atypical cells, cancer cells begin to divide repeatedly and spread into the deep layers of the mucous membrane of the cervix, as well as to nearby tissue areas. The progression of the tumor process leads to the spread of cancer cells through the systemic bloodstream into bone tissue and internal organs. With this process, the appearance of distant metastases throughout the body is observed.

Moderate cervical dysplasia is an insidious disease that requires effective therapeutic measures, including the use of the most radical methods, including surgical ones (in the last stages – removal of the uterus due to the high risk of malignant cells).

Complications of this pathology are associated, first of all, with the possibility of the second stage of the disease degenerating into the third, which is fraught with oncological processes. As a result of failure to eliminate provoking factors, a relapse is possible - i.e. repeated development of dysplasia, which most often occurs against the background of secondary pathologies. In this case, therapy should be more active than in the primary treatment of dysplasia.

Infectious complications occur during surgical treatment of dysplasia, as a result of which the local protective properties of the mucous membrane are reduced. To prevent infections, a woman must carefully observe the rules of personal hygiene, as well as abstain from sexual intercourse for at least a month after the course of treatment.

After surgical intervention, bleeding may be a complication. It is necessary to note the possibility of scar formation and subsequent complications during childbirth due to poor stretchability of scar tissue. Due to obstruction of the cervical canal against the background of ascending infection (endometritis or chronic salpingitis), hormonal problems (in particular, menstrual irregularities) and the development of infertility may be observed.

Complications occur when dysplasia is not detected in a timely manner, there is no comprehensive treatment and annual preventive examinations, as well as when the female body has a genetic predisposition to oncology, a combination of STDs, and severe immunodeficiency.

Modern gynecology has effective methods for diagnosing and treating grade II dysplasia, which make it possible to detect the pathology in time and prevent the degeneration of the disease into grade III and cancer.

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Diagnostics moderate cervical dysplasia

Moderate cervical dysplasia is diagnosed annually in 10 million women worldwide. With a traditional gynecological examination using speculums, grade II dysplasia can only be diagnosed preliminarily: visually, it manifests itself in the form of changes in the color of the mucous membrane and peculiar white spots on it.

Accurate diagnostics of moderate cervical dysplasia is performed based on gynecological smear sampling for the PAP test and a special analysis of cells for oncocytology. Such diagnostic methods allow one hundred percent detection of the so-called "atypical" cells - multinucleated, large in size and without a clear shape.

Other methods for diagnosing dysplasia include:

• colposcopy (allows for better visualization of cervical tissue to identify abnormal areas);
• taking a smear to determine the presence and typing of HPV;
• biopsy with histological examination (considered the most effective method for diagnosing dysplasia).

The most informative can be considered a histological examination of tissue samples as a result of conization and biopsy of the cervix with curettage of the cervical canal.

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Tests

The diagnosis of "moderate cervical dysplasia" can only be established based on the results of the tests. It is important to note that with dysplasia, no significant changes are observed in blood and urine tests. Therefore, other types of tests will be more effective, in particular, studies aimed at identifying HPV.

Tests for diagnosing moderate dysplasia:

• The Pap test (Papanicolaou smear) is considered the “gold” standard for diagnosing dysplasia; the reliability of this test reaches 80%;
• analysis of the surface layer of the cervix for HPV;
• enzyme immunoassay (allows to determine the oncoprotein E7);
• additional bacteriological studies.

If a tumor process is suspected, a woman may be prescribed immunohistochemistry with tumor markers.

The results of the Pap test reveal intraepithelial changes in the cytological material. Latin letters denote obvious deviations from the norm: for example, the abbreviation LSIL means that the epithelial lesions are insignificant, and the HSIL indicator indicates a moderate degree of CIN II and the development of carcinoma at an early stage.

More indicative are medical studies of histology (the so-called "cervical tissue biopsy") and conization (cone biopsy).

The doctor may prescribe tests to the patient to determine the concentration of various hormones in the blood (hormonal homeostasis), since one of the key factors that provoke the development of cervical dysplasia is long-term use of birth control pills. Some oral contraceptives cause hormonal imbalances and thus are a kind of prerequisite for the development of precancerous pathology. Hormonal imbalance is assessed based on a blood test to determine the concentration of progesterone, estrogen and free testosterone. Excretion analysis (hormonal excretion through urine) allows for a more specific assessment of hormonal imbalances in the body.

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Instrumental diagnostics

To diagnose “moderate cervical dysplasia” (CIN II), it is necessary to conduct studies that would confirm the spread of the pathological process to 2/3 of the depth of the epithelial layer, i.e. would help to establish the second degree of severity of the disease.

In addition to collecting anamnesis, instrumental diagnostics is one of the primary methods of determining the disease. General examination of the patient (screening method) consists of cytological examination of the cervix using gynecological mirrors (Pap test).

If the patient has suspected pathological changes in the structure of the cervix, the doctor prescribes further observation (in-depth diagnostics). The next stage of the examination involves colposcopy together with a targeted biopsy of the cervix and a biopsy of the endocervix.

Colposcopy is a visual method that accurately determines pathology in 80-90% of cases. The advantages of this type of research include ease of use, while the disadvantages include low specificity, which makes it impossible to predict the development of the process and thereby reduce the mortality rate from invasive forms of cervical cancer.

It should be noted that it is also impossible to predict the progression of cervical dysplasia using the histological method of examination. The most informative method is the histology of the preparation, carried out as a result of conization with curettage of the cervical canal.

Differential diagnosis

Moderate cervical dysplasia requires differential diagnostics with other pathologies and female diseases.

Differential diagnostics of dysplasia, in particular, is carried out with true erosion of the cervix and cancer. Thus, with erosion, destruction of the mucous layer is observed under the influence of certain factors. The growth of a cancerous tumor is associated with the proliferation of atypical cells in the tissues.

Differential diagnostics of dysplasia is also carried out with cervicitis, dystrophic processes, leukoplakia without atypia, decidual tissue during pregnancy. In this regard, establishing an accurate diagnosis requires consultation with other medical specialists, such as a gynecologist-endocrinologist, oncogynecologist, immunologist, so that the doctor can determine the best treatment tactics.

Differential diagnostics of dysplasia is carried out with various diseases and pathological processes, such as:

• herpetic cervicitis;
• syphilis;
• tuberculosis of the genital organs;
• protozoal and parasitic infections;
• venereal lymphogranulomas;
• sarcoidosis;
• cervical ectopia;
• cervical polyps;
• microglandular hyperplasia;
• hyperkeratosis and parakeratosis;
• squamous cell papilloma;
• leiomyoma;
• cervical atrophy;
• papillary adenofibroma;
• endometriosis of the cervix, etc.

Pathological changes in squamous epithelium can be caused by various pathogens: papilloma virus, type 2 herpes simplex, syphilis pathogen, etc. Isolation of culture is considered the most effective method of diagnosing the pathological process and determining the type of pathogen.

Each type of pathogen specifically affects the cervical epithelium. For example, the pathogens of chlamydia or gonorrhea affect exclusively the cylindrical epithelium. Other pathogens can cause tumors (condylomas) and ulcers of various sizes on the surface of the cervix.

The symptoms of dysplasia are similar to those of trichomonas and the herpes virus, in which there is abundant discharge of cloudy mucus, and the presence of atypical cells in a cytological smear is also possible.

Treatment moderate cervical dysplasia

Moderate cervical dysplasia requires a specific treatment strategy, which is determined by the severity of the disease. After establishing the diagnosis, the doctor will select the optimal treatment regimen aimed at the most positive result.

Treatment of moderate cervical dysplasia is based on the achievements of world medicine in recent years. Patients under 40 are prescribed laser treatment, radio wave conization, and electroconization. Women over 40 are preferably treated with radio wave conization and electroconization. Patients under 23 are not prescribed treatment in most cases, especially if the pathology does not affect the cervical canal, or only point areas of cervical dysplasia are detected.

Often, a gynecologist is forced to choose a wait-and-see approach to determine the most effective method of therapy. Sometimes, with moderate dysplasia, general strengthening drugs can be used, since in 70% of women the pathology is cured on its own. It is imperative to carry out treatment if HPV is detected in the patient.

In case of second degree dysplasia or recurrent pathology, conservative medications may be prescribed:

• antibiotics and anti-inflammatory drugs;
• immunomodulators and interferon preparations;
• medications (most often suppositories) to restore the structure of the cervical epithelium and vaginal microflora;
• vitamin complex preparations.

If dysplasia is detected for a long time after multiple Pap tests, the woman is prescribed surgical treatment. The choice of the surgical method will depend on the severity of the disease. Young nulliparous patients are most often prescribed operations using a radio knife or laser, as well as low-trauma methods in the form of multiple cryodestruction (using liquid nitrogen in the form of extreme cold to cauterize the altered tissues of the cervix) and electrocoagulation. Each of these treatment methods has its own advantages and disadvantages, but they help in more than 90% of cases.

Laser therapy and radio wave cauterization are suitable for the treatment of dysplasia of all degrees and guarantee the absence of scars in 94-95% of cases.

Medicines

Moderate cervical dysplasia requires treatment with medication. However, this disease of this degree cannot be cured with medication alone - more radical measures, in particular, surgical intervention, will be needed.

Medicines are used before and after the manipulation to remove the modified areas in dysplasia. At the same time, it is necessary to conduct therapy aimed at eliminating the pathological conditions due to which this disease developed. This primarily concerns papillomavirus infection, so the patient is prescribed specific treatment when the diagnosis is confirmed. The same tactics are needed when determining other infections in a woman's body - trichomonas, chlamydia, etc.

The following are medications that are used in the treatment of grade 2 dysplasia:

• Biologically active additives (Indinol) - help restore estrogens and suppress hyperplastic processes.
• Immunomodulators (Genferon, Viferon, Isoprinosine) – have antibacterial and immunomodulatory effects, promote rapid tissue healing, have an analgesic effect, and also destroy papillomavirus and cytomegalovirus infections, genital herpes and other viruses.
• Vitamin complexes.
• Antibiotics (for concomitant infectious diseases): Ceftriaxone, Azithromycin, Doxycycline.
• Terzhinan (eliminates symptoms of vaginosis).
• Malavit (eliminates unpleasant symptoms such as itching, etc.).

Vaginal suppositories are prescribed to normalize the vaginal microflora and destroy bacteria and pathogenic microorganisms (Betadine, sea buckthorn suppositories, Livarol, Hexicon).

Folk remedies

Moderate cervical dysplasia is not treated with medications or folk remedies alone. Complex therapy should be used, in which surgery to remove atypical areas of the cervical mucosa plays a primary role.

Traditional medicine is only an auxiliary method and is used only after consultation with a gynecologist.

The patient is recommended a rational diet, which includes the following products: cabbage of all kinds, carrots, citrus fruits, tomatoes, legumes, peppers, dairy products. In addition, she should drink green tea more often, which helps restore epithelial cells.

You can use douching (green tea + calendula - 1 spoon each, brew 1 liter of boiling water) for a month. In case of an inflammatory process accompanying dysplasia, baths with a decoction of pine (5 tbsp. per 1 liter of boiling water) will help. The extract of the rhizome of bergenia, which has an astringent effect, can be purchased at the pharmacy and also used for douching according to the instructions for the drug.

Tampons with propolis or sea buckthorn oil accelerate healing processes and have a general strengthening effect. The course of treatment is usually 10-20 days.

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Herbal treatment

Moderate cervical dysplasia requires a special approach to treatment. As for the use of herbs, this issue must be discussed with the attending physician, in no case allowing self-medication.

Herbal treatment is not a basic therapy, but only additional measures that include the use of medicinal herbs with anti-inflammatory, astringent and wound-healing effects.

Tamponing is one of the main methods used in folk therapy. You can use aloe juice, soaking a tampon and inserting it deeper into the vagina. This procedure is carried out twice a day for a month.

After surgical manipulations (cryodestruction, cauterization, conization), pine buds can be used, which are rich in essential compounds and have a good antibacterial effect. Several tablespoons of raw materials should be poured into 1 liter of cold water and boiled for 5 minutes. After cooling, the decoction is used for washing and douching (2 times a day for 2 weeks).

A decoction of Vitexagnus castus has an effective effect; it has hemostatic properties and normalizes the state of the hormonal system.

A decoction of milk thistle and burdock root cleanses the blood and helps to activate the blood supply to the epithelial tissue. Raw materials in equal proportions (1 tbsp each) should be poured with boiling water (250 g) and infused for 30 minutes. Then strain and use warm for irrigation twice a day.

Homeopathy

Moderate cervical dysplasia and the use of homeopathic remedies is a question that requires clarification. It should be emphasized that homeopathic remedies are allowed as an adjunctive therapy, most often to restore ovarian function and support immunity.

Homeopathy is an additional method of treating dysplasia if the patient has papillomavirus infection. In this case, the drug Acidum nitricum is indicated (promotes rapid healing of ulcerative and erosive surfaces).

Papillokan suppositories with thuja extract are prescribed when HPV is detected, and the action of the drug Ovarium compositum is aimed at normalizing hormonal balance.

Gynecoheel is one of the most popular homeopathic medicines that reduces tissue swelling, fights inflammatory processes and improves the condition of the nervous system.

Lycopodium is a drug that activates blood supply in the cervix and also affects the processes of regeneration and metabolism.

The use of any homeopathic medicine should be accompanied by the recommendation of the attending physician, who will determine the dosage and duration of the course of treatment.

Surgical treatment

Moderate cervical dysplasia requires surgical intervention, that is, manipulations aimed at removing damaged tissue.

Surgical treatment is indicated for the patient in the absence of inflammatory processes and is performed in the first (6-10 day) phase of the menstrual cycle. Tests that must be taken before surgery: a smear to determine the degree of purity of the vagina, a cytological smear, tests for STIs.

Surgical methods for treating stage II dysplasia are as follows:

• Diathermocoagulation (cauterization/excision of a damaged tissue area with electric current).
• Laser vaporization (exposure of the damaged area to a low-intensity laser beam to destroy pathological tissue).
• Ultrasonic destruction.
• Cryotherapy (use of liquid nitrogen to destroy the pathological focus).
• Knife electroconization (removal of a cone-shaped section of the cervix) is performed using a diathermocoagulator loop.
• Conization using a scalpel.
• Amputation of the cervix.

The postoperative recovery period lasts from 4 to 6 weeks. Contraindications to surgical treatment are: pregnancy, vaginal and cervical infections, adenocarcinoma, inflammatory processes in the pelvic organs.

In the first days after the operation, women may experience pain, abundant mucous discharge with blood, fever, and menstrual irregularities. In case of bleeding, you should immediately seek medical help. Complications in the form of relapse of the disease, exacerbation of chronic inflammatory processes, cicatricial deformation of the cervix, and infertility are possible.

Prevention

Moderate cervical dysplasia is not a death sentence, but it is easier to prevent the disease than to treat it.

Prevention of dysplasia primarily consists of regular visits to the gynecologist (at least 1-2 times a year) and taking a Pap smear. Vaccination is also considered an effective method of specific HPV prevention.

Women should monitor their intimate life, avoiding promiscuous sexual relations and using reliable barrier methods of contraception when frequently changing sexual partners. Both partners, both the woman and the man, should be examined before starting sexual relations to detect possible viral infections, trichomoniasis, chlamydia, HPV. An important factor is to quit smoking, normalize nutrition with the inclusion of vitamin complexes and folic acid.

A preventive method is also the sanitation of infectious foci in the body. Loss of control over the state of women's health can lead to the development of dysplasia into cancer, even after treatment, since the disease can recur.

It is necessary to promptly treat infectious and inflammatory diseases of the genital area and background diseases of the cervix, since in 90% of situations dysplasia develops against the background of already altered epithelium.

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Forecast

Moderate cervical dysplasia is completely curable in most situations.

The prognosis is determined by the time and timeliness of diagnosis of the disease, as well as the adequacy of the therapy. The frequency of the reverse development of the pathological process depends on the degree of its expression and the age of the woman: in young patients, regression of cervical dysplasia is more likely. Moderate dysplasia in 40-70% of cases can develop spontaneously after treatment.

We can talk about a favorable prognosis for dysplasia, provided that the HPV virus is completely eliminated from the body. Otherwise, if the immune system is quite weak and no attempts have been made to diagnose and treat the disease, stage II dysplasia develops into stage III dysplasia, and then (in more than 12% of cases) into invasive cancer.

Moderate cervical dysplasia is a serious enough issue that requires a special approach to its solution. With complex treatment, the probability of recovery is very high and reaches 90-100%. Complex therapy should include destructive methods and antiviral treatment. When dysplasia of stage 2-3 is detected, it is recommended to immediately begin therapy for both the pathology itself and the predisposing factors.

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