Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 18-19: Cervical Intraepithelial Neoplasia (CIN) (Dysplasia of the Cervix) + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ The presumptive diagnosis is made by an abnormal Papanicolaou smear from an asymptomatic woman with no grossly visible cervical changes Diagnosed by colposcopically directed biopsy +++ General Considerations ++ The squamocolumnar junction of the cervix is an area of active squamous cell proliferation This junction is located on the exposed vaginal portion of the cervix in childhood An area of metaplasia (transformation zone) is created during puberty when the squamous margin begins to encroach on the single-layered, mucus-secreting epithelium Infection by the human papillomavirus (HPV) may lead to cellular abnormalities, which over time may develop into squamous cell dysplasia or cancer There are varying degrees of dysplasia, defined by the degree of cellular atypia; all atypia must be observed and treated if persistent or worsening + Clinical Findings Download Section PDF Listen +++ ++ There are no specific symptoms or signs of CIN + Diagnosis Download Section PDF Listen +++ ++ The presumptive diagnosis is made by cytologic screening (Papanicolaou smear) of an asymptomatic patient with no grossly visible cervical changes All visible abnormal cervical lesions should be biopsied Colposcopy is indicated when HPV screen is positive + Treatment Download Section PDF Listen +++ ++ Treatment varies depending on the degree and extent of CIN Biopsies should precede treatment, except in cases of HSIL where it may be appropriate to proceed directly to a loop electrosurgical excision procedure (LEEP) Cryosurgery is effective for noninvasive small lesions visible on the cervix without endocervical extension CO2 laser Minimizes tissue destruction May be used with large visible lesions Involves the vaporization of the transformation zone on the cervix and the distal 5–7 mm of endocervical canal Loop excision (ie, LEEP) When the CIN is clearly visible in its entirety, a wire loop can be used for excisional biopsy Cutting and hemostasis are achieved with a low-voltage electrosurgical machine Conization of the cervix Surgical removal of the entire transformation zone and endocervical canal Should be reserved for cases of severe dysplasia (CIN III) or carcinoma in situ, particularly those with endocervical extension Can be performed with scalpel, CO2 laser, needle electrode, or large-loop excision + Outcomes Download Section PDF Listen +++ +++ Follow-Up ++ Because recurrence is possible—especially in the first 2 years after treatment—and because the false-negative rate of a single cervical cytologic test is 20%, close follow-up after colposcopy and biopsy is imperative Following any excisional or ablative procedure, co-testing (cytology and HPV DNA) should be repeated at 12-month intervals for 2 years If CIN II or III is identified at the margins of an endocervical curettage procedure, however, repeat cytology with endocervical curettage is preferred at 4–6 months If follow-up testing is normal, routine cytologic screening can be resumed Colposcopy and endocervical sampling should be performed for any abnormality +++ Prevention ++ HPV 9-valent (Gardasil-9) recombinant vaccine (9vHPV) Indicated for the prevention of Cervical, vaginal, and vulvar cancers (in women) Anal cancers (in women and men) caused by HPV types 16, 18, 31, 33, 45, 52, and 58 Genital warts (in women and men) caused by HPV types 6 and 11 Precancerous/dysplastic lesions of cervix, vagina, vulva (in women), and anus (in women and men) caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 Recommended for vaccination of females and males ages 9–45 years old Now that HPV 9-valent (Gardasil-9) is available, the earlier HPV 4-valent vaccine known as Gardasil (for prevention of HPV types 6, 11, 16, and 18) has been discontinued in the United States In addition to vaccination, preventive measures include Limiting the number of sexual partners Using a diaphragm or condom for coitus Smoking cessation and avoiding exposure to secondhand smoke +++ When to Refer ++ Patients with CIN II/III should be referred to an experienced colposcopist Patients requiring conization biopsy should be referred to a gynecologist + References Download Section PDF Listen +++ + +Arbyn M et al. Prophylactic vaccination against human papillomaviruses to prevent cervical cancer and its precursors. Cochrane Database Syst Rev. 2018 May 9;5:CD009069. [PubMed: 29740819] + +Castle PE et al. Treatment of cervical intraepithelial lesions. Int J Gynaecol Obstet. 2017 Jul;138(Suppl 1):20–5. [PubMed: 28691333] + +Harper DM et al. HPV vaccines—a review of the first decade. Gynecol Oncol. 2017 Jul;146(1):196–204. [PubMed: 28442134] + +Melnikow J et al. Screening for cervical cancer with high-risk human papillomavirus testing: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018 Aug 21;320(7):687–705. [PubMed: 30140883] + +Ogilvie GS et al. Effect of screening with primary cervical HPV testing vs cytology testing on high-grade cervical intraepithelial neoplasia at 48 months: the HPV FOCAL randomized clinical trial. JAMA. 2018 Jul 3;320(1):43–52. [PubMed: 29971397] + +Smith RA et al. Cancer screening in the United States, 2019: a review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin. 2019 May;69(3):184–210. [PubMed: 30875085] + +Stumbar SE et al. Cervical cancer and its precursors: a preventative approach to screening, diagnosis, and management. Prim Care. 2019 Mar;46(1):117–34. [PubMed: 30704652] + +US Preventive Services Task Force; Curry SJ et al. Screening for cervical cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018 Aug 21;320(7):674–86. [PubMed: 30140884] + +Vegunta S et al. Screening women at high risk for cervical cancer: special groups of women who require more frequent screening. Mayo Clin Proc. 2017 Aug;92(8):1272–7. [PubMed: 28778260]