Editing Cervix (section)

==Clinical significance==
===Cancer===
{{Main|Cervical cancer}}
In 2008, cervical cancer was the third-most common cancer in women worldwide, with rates varying geographically from less than one to more than 50 cases per 100,000 women.{{Update after|2021|3|17}}<ref name=ARBYN2011>{{cite journal | vauthors = Arbyn M, Castellsagué X, de Sanjosé S, Bruni L, Saraiya M, Bray F, Ferlay J | title = Worldwide burden of cervical cancer in 2008 | journal = Annals of Oncology | volume = 22 | issue = 12 | pages = 2675–2686 | date = December 2011 | pmid = 21471563 | doi = 10.1093/annonc/mdr015 | doi-access = free }}</ref> It is a leading cause of cancer-related death in poor countries, where delayed diagnosis leading to poor outcomes is common.<ref name="who fact sheet">{{cite web |author=World Health Organization |date=February 2014 |title=Fact sheet No. 297: Cancer |url=https://www.who.int/mediacentre/factsheets/fs297/en/index.html |access-date=23 July 2014|author-link=World Health Organization }}</ref> The introduction of routine screening has resulted in fewer cases of (and deaths from) cervical cancer, however this has mainly taken place in developed countries. Most developing countries have limited or no screening, and 85% of the global burden occurs there.<ref name="Vaccarella13">{{cite journal | vauthors = Vaccarella S, Lortet-Tieulent J, Plummer M, Franceschi S, Bray F | title = Worldwide trends in cervical cancer incidence: impact of screening against changes in disease risk factors | journal = European Journal of Cancer | volume = 49 | issue = 15 | pages = 3262–3273 | date = October 2013 | pmid = 23751569 | doi = 10.1016/j.ejca.2013.04.024 }}</ref>

Cervical cancer nearly always involves human papillomavirus (HPV) infection.<ref name=WAHL2007>{{cite book| vauthors = Wahl CE |title=Hardcore pathology|date=2007|publisher=Lippincott Williams & Wilkins|location=Philadelphia, PA |isbn=9781405104982|page=72|url=https://books.google.com/books?id=JZtr6cmJhvgC&q=transformation+zone+vaginal+pH&pg=PA72}}</ref><ref name=ROBBINS2007/> HPV is a virus with numerous strains, several of which predispose to precancerous changes in the cervical epithelium, particularly in the transformation zone, which is the most common area for cervical cancer to start.<ref name=LOWE2005>{{cite book| vauthors = Lowe A, Stevens JS |title=Human histology|year=2005|publisher=Elsevier Mosby|location=Philadelphia, PA; Toronto, ON|isbn=0-323-03663-5|edition=3rd|pages=350–51}}</ref> [[HPV vaccines]], such as [[Gardasil]] and [[Cervarix]], reduce the incidence of cervical cancer, by inoculating against the viral strains involved in cancer development.<ref name=HARRISONS2010B>{{cite book| veditors = Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J |title=Harrison's Principles of Internal Medicine|url=https://archive.org/details/harrisonsprincip00asfa |url-access=limited |date=2008|publisher=McGraw-Hill Medical|location=New York [etc.]|isbn=978-0-07-147692-8|pages=[https://archive.org/details/harrisonsprincip00asfa/page/n646 608]–09|edition=17th}}</ref>

Potentially precancerous changes in the cervix can be detected by [[cervical screening]], using methods including a [[Pap smear]] (also called a cervical smear), in which [[epithelium|epithelial]] cells are scraped from the surface of the cervix and [[cytopathology|examined under a microscope]].<ref name=HARRISONS2010B/> The [[Colposcopy|colposcope]], an instrument used to see a magnified view of the cervix, was invented in 1925. The Pap smear was developed by [[Georgios Papanikolaou]] in 1928.<ref name=GASPARINI2009 /> A [[loop electrical excision procedure|LEEP procedure]] using a heated loop of [[platinum]] to excise a patch of cervical tissue was developed by [[Aurel Babes]] in 1927.<ref>{{cite journal | vauthors = Diamantis A, Magiorkinis E, Androutsos G | title = Different strokes: Pap-test and Babes method are not one and the same | journal = Diagnostic Cytopathology | volume = 38 | issue = 11 | pages = 857–859 | date = November 2010 | pmid = 20973044 | doi = 10.1002/dc.21347 | s2cid = 823546 }}</ref> In some parts of the developed world, including the UK, the Pap test has been superseded with [[liquid-based cytology]].<ref>{{cite book |url= https://books.google.com/books?id=eqC-0qjzl_AC&q=nice+lbc&pg=PA614 |title= Diagnostic Cytopathology | veditors = Gray W, Kocjan G |year=2010 |page=613 |publisher= Churchill Livingstone|isbn= 9780702048951 }}</ref>

An inexpensive, cost-effective and practical alternative in poorer countries is [[Cervical screening#Visual inspection to detect pre-cancer or cancer|visual inspection with acetic acid]] (VIA).<ref name="who fact sheet"/> Instituting and sustaining cytology-based programs in these regions can be difficult, due to the need for trained personnel, equipment and facilities and difficulties in follow-up. With VIA, results and treatment can be available on the same day. As a screening test, VIA is comparable to cervical cytology in accurately identifying precancerous lesions.<ref name=sherris>{{cite journal | vauthors = Sherris J, Wittet S, Kleine A, Sellors J, Luciani S, Sankaranarayanan R, Barone MA | title = Evidence-based, alternative cervical cancer screening approaches in low-resource settings | journal = International Perspectives on Sexual and Reproductive Health | volume = 35 | issue = 3 | pages = 147–154 | date = September 2009 | pmid = 19805020 | doi = 10.1363/3514709 | doi-access = free }}</ref>

A result of [[dysplasia]] is usually further investigated, such as by taking a [[cone biopsy]], which may also remove the cancerous lesion.<ref name=HARRISONS2010B/> [[Cervical intraepithelial neoplasia]] is a possible result of the biopsy and represents dysplastic changes that may eventually progress to invasive cancer.<ref name=NEJM1996>{{cite journal | vauthors = Cannistra SA, Niloff JM | title = Cancer of the uterine cervix | journal = The New England Journal of Medicine | volume = 334 | issue = 16 | pages = 1030–1038 | date = April 1996 | pmid = 8598842 | doi = 10.1056/NEJM199604183341606 }}</ref> Most cases of cervical cancer are detected in this way, without having caused any symptoms. When symptoms occur, they may include vaginal bleeding, discharge, or discomfort.<ref name=DAVIDSONS2010>{{cite book | veditors = Colledge NR, Walker BR, Ralston SH |others= Illustrated by Britton R |title= Davidson's Principles and Practice of Medicine |url= https://archive.org/details/davidsonsprincip00frcp |url-access= limited |year=2010 |publisher= Churchill Livingstone/Elsevier |location= Edinburgh |isbn=978-0-7020-3084-0 |edition= 21st |page=[https://archive.org/details/davidsonsprincip00frcp/page/n292 276] }}</ref>

===Inflammation===
{{Main|Cervicitis}}
Inflammation of the cervix is referred to as [[cervicitis]]. This inflammation may be of the endocervix or ectocervix.<ref name=STAMM2013>{{cite book | vauthors = Stamm W |title=The Practitioner's Handbook for the Management of Sexually Transmitted Diseases |date=2013 |publisher= Seattle STD/HIV Prevention Training Center |pages= Chapter 7: Cervicitis |url= http://depts.washington.edu/handbook/syndromesFemale/ch7_cervicitis.html|archive-url= https://web.archive.org/web/20130622033953/http://depts.washington.edu/handbook/syndromesFemale/ch7_cervicitis.html |url-status= dead |archive-date= 2013-06-22  }}</ref> When associated with the endocervix, it is associated with a mucous vaginal discharge and [[sexually transmitted infection]]s such as [[chlamydia infection|chlamydia]] and [[gonorrhoea]].<ref name=HARRISONS2010 /> As many as half of pregnant women having a gonorrheal infection of the cervix are asymptomatic.<ref name=Kenner2014>{{cite book | vauthors = Kenner C |title= Comprehensive neonatal nursing care | publisher= Springer Publishing Company, LLC |place= New York |edition=5th |year= 2014 | isbn= 9780826109750}} Access provided by the University of Pittsburgh.</ref> Other causes include overgrowth of the [[commensal flora]] of the vagina.<ref name=ROBBINS2007>{{cite book | vauthors = Mitchell RS, Kumar V, Robbins SL, Abbas AK, Fausto N |title= Robbins basic pathology |publisher= Saunders/Elsevier |year=2007 |edition=8th | pages=716–21 |isbn=978-1-4160-2973-1 }}</ref> When associated with the ectocervix, inflammation may be caused by the [[herpes simplex]] virus. Inflammation is often investigated through directly visualising the cervix using a [[Speculum (medical)|speculum]], which may appear whiteish due to exudate, and by taking a Pap smear and examining for causal bacteria. Special tests may be used to identify particular bacteria. If the inflammation is due to a bacterium, then antibiotics may be given as treatment.<ref name=HARRISONS2010>{{cite book | veditors = Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J  |title= Harrison's Principles of Internal Medicine |url= https://archive.org/details/harrisonsprincip00asfa |url-access= limited |date=2008 |publisher= McGraw-Hill Medical |location= New York [etc.] |isbn= 978-0-07-147692-8 |pages=[https://archive.org/details/harrisonsprincip00asfa/page/n866 828]–29 |edition=17th }}</ref>

===Anatomical abnormalities===
[[Stenosis of uterine cervix|Cervical stenosis]] is an abnormally narrow cervical canal, typically associated with trauma caused by removal of tissue for investigation or treatment of cancer, or [[cervical cancer]] itself.<ref name=ROBBINS2007 /><ref>{{cite journal | vauthors = Valle RF, Sankpal R, Marlow JL, Cohen L |title= Cervical Stenosis: A Challenging Clinical Entity |journal= Journal of Gynecologic Surgery |volume=18 |issue=4 |pages=129–43 |doi= 10.1089/104240602762555939 |year=2002 }}</ref> [[Diethylstilbestrol]], used from 1938 to 1971 to prevent preterm labour and miscarriage, is also strongly associated with the development of cervical stenosis and other abnormalities in the daughters of the exposed women. Other abnormalities include: [[vaginal adenosis]], in which the squamous epithelium of the ectocervix becomes columnar; cancers such as [[clear cell adenocarcinoma]]s; cervical ridges and hoods; and development of a cockscomb cervix appearance,<ref name="CaseyLong2011"/> which is the condition wherein, as the name suggests, the cervix of the [[uterus]] is shaped like a [[comb (anatomy)|cockscomb]]. About one-third of women born to [[diethylstilbestrol]]-treated mothers (i.e., in-utero exposure) develop a cockscomb cervix.<ref name="CaseyLong2011">{{cite journal | vauthors = Casey PM, Long ME, Marnach ML | title = Abnormal cervical appearance: what to do, when to worry? | journal = Mayo Clinic Proceedings | volume = 86 | issue = 2 | pages = 147–50; quiz 151 | date = February 2011 | pmid = 21270291 | pmc = 3031439 | doi = 10.4065/mcp.2010.0512 }}</ref>

Enlarged folds or ridges of cervical [[Stroma (animal tissue)|stroma]] (fibrous tissues) and [[epithelium]] constitute a cockscomb cervix.<ref name=NCI>{{cite web|title=Diethylstilbestrol (DES) Cervix|url=https://visualsonline.cancer.gov/details.cfm?imageid=7590|website=National Cancer Institute Visuals|publisher=National Cancer Institute|access-date=14 May 2015}}</ref> Similarly, cockscomb [[polyp (medicine)|polyp]]s lining the cervix are usually considered or grouped into the same overarching description. It is in and of itself considered a [[benign]] abnormality; its presence, however, is usually indicative of DES exposure, and as such, women who experience these abnormalities should be aware of their increased risk of associated pathologies.<ref name="Wingfield1991">{{cite journal | vauthors = Wingfield M | title = The daughters of stilboestrol | journal = BMJ | volume = 302 | issue = 6790 | pages = 1414–1415 | date = June 1991 | pmid = 2070103 | pmc = 1670127 | doi = 10.1136/bmj.302.6790.1414 }}</ref><ref name="Mittendorf1995">{{cite journal | vauthors = Mittendorf R | title = Teratogen update: carcinogenesis and teratogenesis associated with exposure to diethylstilbestrol (DES) in utero | journal = Teratology | volume = 51 | issue = 6 | pages = 435–445 | date = June 1995 | pmid = 7502243 | doi = 10.1002/tera.1420510609 }}</ref><ref name="HerbstPoskanzer1975">{{cite journal | vauthors = Herbst AL, Poskanzer DC, Robboy SJ, Friedlander L, Scully RE | title = Prenatal exposure to stilbestrol. A prospective comparison of exposed female offspring with unexposed controls | journal = The New England Journal of Medicine | volume = 292 | issue = 7 | pages = 334–339 | date = February 1975 | pmid = 1117962 | doi = 10.1056/NEJM197502132920704 }}</ref>

[[Cervical agenesis]] is a rare congenital condition in which the cervix completely fails to develop, often associated with the concurrent failure of the vagina to develop.<ref>{{cite journal | vauthors = Fujimoto VY, Miller JH, Klein NA, Soules MR | title = Congenital cervical atresia: report of seven cases and review of the literature | journal = American Journal of Obstetrics and Gynecology | volume = 177 | issue = 6 | pages = 1419–1425 | date = December 1997 | pmid = 9423745 | doi = 10.1016/S0002-9378(97)70085-1 }}</ref> Other congenital cervical abnormalities exist, often associated with abnormalities of the vagina and [[uterus]]. The cervix may be duplicated in situations such as [[bicornuate uterus]] and [[uterine didelphys]].<ref>{{cite journal | vauthors = Patton PE, Novy MJ, Lee DM, Hickok LR | title = The diagnosis and reproductive outcome after surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum | journal = American Journal of Obstetrics and Gynecology | volume = 190 | issue = 6 | pages = 1669–75; discussion p.1675–78 | date = June 2004 | pmid = 15284765 | doi = 10.1016/j.ajog.2004.02.046 }}</ref>

[[Cervical polyp]]s, which are benign overgrowths of endocervical tissue, if present, may cause bleeding, or a benign overgrowth may be present in the cervical canal.<ref name=ROBBINS2007 /> [[Cervical ectropion]] refers to the horizontal overgrowth of the endocervical columnar lining in a one-cell-thick layer over the ectocervix.<ref name=HARRISONS2010 />