Cervical procedures
Cervical procedures encompass various surgical interventions targeting the cervix, primarily to diagnose and treat abnormalities identified during routine gynecological examinations, such as abnormal Pap tests. Common procedures include biopsy, conization, cryosurgery, and electrocauterization. Biopsies are often the first step in diagnosing cervical issues, utilizing a colposcope for detailed examination and tissue sampling. If abnormalities such as dysplasia or localized cancer are detected, treatments like cryotherapy and electrocauterization may be employed to destroy problematic tissue.
For more severe cases, conization removes a cone-shaped section of cervical tissue for further analysis, while cervical cerclage may be performed on pregnant women to prevent miscarriage due to cervical incompetence. Although many procedures are minimally invasive and performed on an outpatient basis, they may carry risks such as infection, scarring, and potential impacts on fertility. Advances in cervical cancer detection and prevention, including the HPV vaccine and improved surgical techniques, have significantly reduced the incidence of cervical cancer. Regular screening and early intervention remain crucial in maintaining cervical health and preventing serious complications.
Cervical procedures
Anatomy or system affected: Genitals, reproductive system, uterus
Definition: Such procedures as biopsy, conization, cryosurgery, and electrocauterization, which are performed to analyze cervical tissue for abnormal cell development and/or remove abnormal or cancerous tissue from the cervix.
Indications and Procedures
Surgical procedures performed on the cervix (the opening of the uterus into the vagina), such as biopsy, conization, cryosurgery, and electrocauterization, are used to diagnose and treat cervical abnormalities. The first indication of a potential problem is usually a routine gynecological examination that reveals inflammation of the cervix or an abnormal Pap test. In Pap testing, a cell sample is scraped from the surface of the cervix and analyzed microscopically. Abnormal results range from slightly abnormal cell growth (dysplasia) to invasive cancer. If the Pap testing results indicate a condition more serious than dysplasia, further tests are conducted.
The first step in the diagnosis of a cervical abnormality is colposcopy and cervical biopsy. The colposcope is a lighted magnifying instrument similar to a pair of binoculars. When placed at the vaginal opening, it permits detailed viewing of the cervix. The cervix is treated with vinegar to produce an aceto-whitening reaction, abnormal areas are visualized, and small tissue samples of cervical cell layers are punched out for further analysis. Cervical biopsy is performed in an outpatient setting by physicians and, in some cases, by nurse practitioners and certified nurse midwives, and anesthesia is not required, though a local anesthetic may be applied.
In cases of severe dysplasia or cancer localized to the cervix, a cone biopsy may be performed. Conization is conducted in an outpatient setting with local anesthesia or in a hospital under general anesthesia. A circular incision is made around the cervical opening with a knife or laser and is extended up at an angle to obtain a cone of tissue, including some from the cervical canal. The edges of the incision are sutured or cauterized. Examination of the cone can determine the severity and extent of cancer. In some cases, excision of the cone may have eliminated all the cancerous cells from the cervix.
Cryosurgery, also known as "cryotherapy," freezes and destroys abnormal tissue with liquid nitrogen. This procedure can be done in an outpatient setting and takes only a few minutes to perform. It can be used successfully to treat dysplasia, localized cancer cells, and reddened areas that sometimes develop around the cervical opening, called "cervical erosions."
Dysplasia, cancer, and cervical erosions are also treated with electrocauterization, in which an electrically heated instrument is used to destroy abnormal cells. This procedure is performed in a doctor’s office, without anesthesia, just after a woman’s menstrual period. A speculum is used to open the vagina, and the tip of the electrocautery device is applied to the abnormal tissue. A scab forms and allows new healthy tissue to grow. Healing is complete in seven to eight weeks.
Pregnant women who have a history of miscarriage during the second trimester of pregnancy due to cervical incompetence may undergo a cervical cerclage, a procedure used to temporarily stitch the cervix closed. A cervical cerclage will help keep the cervix closed as the baby grows. The stitches are generally removed at the thirty-seventh week of pregnancy, allowing normal delivery. The procedure successfully prevents miscarriage or premature delivery due to cervical incompetence in 85 to 90 percent of cases.
Uses and Complications
Mild dysplasia typically reverts to a normal state spontaneously and is merely monitored for possible slow progression to a more serious state. When Pap testing, punch biopsies, or both indicate more serious development of abnormal cells, cryotherapy or electrocauterization is used to destroy the suspicious tissue. While colposcopy is nearly painless, a punch biopsy may cause some cramping. Side effects of electrocauterization include cervical swelling, discharge for up to three weeks, and, rarely, infection or infertility caused by the removal of too many cervical mucous glands. Scarring may occur, making future Pap tests difficult to interpret. Cryotherapy causes much less damage to the cervical opening than electrocauterization does, but it may produce a temporary watery discharge and changes in cervical mucus.
If repeated colposcopies or Pap tests confirm severe dysplasia or localized cancer, and if the abnormal tissue extends into the cervical canal, a cone biopsy is performed. If analysis of the cone reveals that the abnormal tissue extends beyond the borders of the biopsied tissue, a second, larger conization may be performed. This conization is major surgery performed under general anesthesia, and bleeding and infection are common complications. Removal of too many cervical mucous glands may lead to infertility. Removal of cervical muscle may lead to an incompetent cervix, an inability of the cervix to maintain a pregnancy to term. There are surgical interventions, however, that can eliminate this problem.
If tests indicate that the cancer has become invasive and has spread beyond the borders of the cervix, a hysterectomy and possible removal of the lymph nodes is performed. This serious surgery renders the woman infertile and carries the same risks as any major surgery.
Perspective and Prospects
In the 1940s, George Papanicolaou discovered that premalignant as well as malignant changes caused the cervix to shed cells that could be analyzed microscopically. Simultaneously, the colposcope was developed. Together, the Pap test and colposcopies caused a revolution in the early detection and prevention of cervical cancer.
Cervical cancer has become a more preventable and easily monitored disorder as a result of advances in the classification of abnormalities from mild to severe and the discovery that human papillomaviruses (HPV), genital herpes virus, multiple sexual partners or mates with a history of multiple partners, smoking, and environmental toxins can all contribute to the development of cervical malignancies. The HPV vaccine is recommended for female patients aged nine to twenty-six, as well as boys and young men, to reduce the transmission of HPV infection and the incidence of cervical cancer, among other genital malignancies. Public education and public awareness campaigns regarding the vaccine led to a decrease in the incidence of this disease.
New surgical techniques have improved the efficiency of abnormal tissue destruction with fewer side effects. The loop electrosurgical excision procedure (LEEP) uses a low-voltage electrical current that runs through a thin wire loop to scoop out abnormal tissue from the cervix in a matter of seconds. Carbon dioxide laser treatment uses a laser beam to destroy cells in a small area without damaging healthy tissue. Little bleeding occurs, and healing is rapid. Future advances in deoxyribonucleic acid (DNA) analysis may help to identify those who may be at risk for developing cervical cancer so that they may take preventive action and be closely monitored for early, successful treatment. Early detection, however, remained the best preventative action. The American College of Obstetricians and Gynecologists recommended that women under the age of thirty get a Pap test every three years. Women aged thirty through sixty should either get a Pap test every three years or a Pap and HPV test every five years. Women over the age of sixty-five who have never had an abnormal Pap test no longer need a screen for abnormal cervical cells.
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