1. Abnormal papsmear and colposcopy

2. Cervical anatomy

3. Squamocolumnar junction
epithelium. Its location on the cervix is variable.
The squamocolumnar junction (SCJ) .is defined as the
junction between the squamous epithelium and the columnar
Age and hormonal status are the most important factors
influencing location of SCJ.
At birth and during premenarchal years, the SCJ is located ator very close to the external os (original SCJ).
During reproductive age, the SCJ is located at variable
distances from the external os.
In a postmenopausal woman, the new SCJ is not visible and
has receded into the endocervix.

4. The transformation zone(TZ)
Area between the original SCJ and the new SCJ where the columnar epithelium (ectropion) has been replaced and/or is
being replaced by the new metaplastic squamous epithelium.
The TZ may be either wide or narrow depending on age,
parity, prior infections and exposure to female hormones.

5. As a result of the metaplastic process a new SCJ is formed. It
is visible as a distinct white line after the application of 3 to
5% acetic acid.

6. 27y NG cc:PCB (دو بار در دو ماه اخیر) and Cervical appearance
Case 1
27y NG cc:PCB (دو بار در دو ماه اخیر) and Cervical appearance

7. What is the DX?
Ectropion
What is the next step?

8. ECTROPION 
Ectropion occurs when eversion of the endocervix exposes columnar epithelium to the vaginal milieu. The everted epithelium has a reddish appearance similar to granulation tissue, and may be covered by a yellow turbid discharge.
Ectropion is common in :
Adolescence
women who are pregnant
who taking estrogen-progestin contraceptives
who had a cervical laceration during labor and delivery.
Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971; 284:878.

10. Many years ago before development of medicine,ectropion seemed a wound on the cervix and it was named erosion ,at that time because of high incidance of cervical cancer many doctors made treatment and sed if not treated cervical cancer may occur , later with progress medical tecnology with colposcopy and histologic exam found the doctor made a big mistake to types of epithelium.
Treatment of cervical erosion …

11. Ectropion should not be treated
except in the rare occurrence of excessive mucous discharge or spotting that is very bothersome to the woman. In such cases, malignancy should be excluded before undertaking any treatment.
Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971; 284:878.

12. Ectropion /ablative procedure
An ablative procedure using cryocautery or electrocautery
Is invasive
copious vaginal discharge until healing is completed, which may take weeks.
cervical stenosis, which can adversely affect future fertility and, if pregnancy is achieved, labor and delivery
Herbst AL, Ulfelder H, Poskanzer DC. Adenocarcinoma of the vagina. Association of maternal stilbestrol therapy with tumor appearance in young women. N Engl J Med 1971; 284:878.

13. Ectropion/Medical treatment
a two-week trial of an acidifying agent, such as boric acid suppositories 600 mg vaginally at bedtime, which may be effective
Use of deoxyribonucleic acid 5 mg vaginal suppositories has also been reported

14. 34Y G2P2 CC:ارجاع به علت ظاهر سرویکس

15. Nabothian cysts =also called mucinous retention cysts
form when a cleft of columnar epithelium becomes covered with squamous cells and the columnar cells continue to secrete mucoid material.
The cysts vary from microscopic to several centimeters in size;
They may appear translucent or opaque . Nabothian cysts may occur following minor trauma or childbirth.
Comprehensive Visual Inspection of the Cervix with Acetic Acid (VIA) and Lugol’s Iodine (VILI)

16. indication for treatment is
relief from pain
a bothersome feeling of fullness in the vagina.
Ablation of the cyst using electrocautery is the usual approach;
if the diagnosis is uncertain, excision to evaluate histopathology is advised.
The main disadvantage to surgical treatment is the possibility of causing scar tissue, which itself can lead to dyspareunia.
Comprehensive Visual Inspection of the Cervix with Acetic Acid (VIA) and Lugol’s Iodine (VILI)

18. Colposcopy

19. Abnormalities that should be noted during cervical colposcopy include:
Acetowhite epithelium
●Abnormal vascular patterns:
•Mosaicism
•Punctation
•Atypical vessels

21. Features suggestive of high-grade disease: dense acetowhite epithelium, rapid appearance of acetowhitening, cuffed crypt (gland openings), coarse mosaic, coarse punctation, sharp border, inner border sign, ridge sign

22. Features suggestive of invasive cancer: atypical vessels, fragile vessels, irregular surface, exophytic lesion, necrosis, ulceration (necrotic), tumor/gross neoplasm

23. Case 3

24. معاینه با اسپکولوم - شرح حال بیمار -
معاینه با اسپکولوم - شرح حال بیمار -

26. Biopsy: CIN I -thin acetowhite epithelium -geographic border
-fine mosaic
- fine punctation

28. Case4
36y G2L2 Papsmear:LSIL

30. Focal mild dysplasia(CIN I)
Colposcopy aw/ Punctation /Mosaicism
biopsy
بیوپسی:
Focal mild dysplasia(CIN I)

31. Case 5
34y G3P2Ab1 Papsmear:LSIL
Colposcopy /Biopsy
Biopsy:CIN I

32. 28y NG Pap smear :LSIL
HPV testing : Positive
Biopsy:CIN I

34. Case 7
36yG3L2Ab1 Papsmear:HSIL
what is the next step?

36. بیوپسی:
CIN II

38. 36yG3l1Ab2 Papsmear :HSIL Colposcopy and Biopsy Was done
بیوپسی:
CIN2 with endocervical invasion
What is the next step?

40. 21yNG Papsmear: ASC H
What is the next step?

44. 27yNG Papsmear:ASC H
What is the next step?

46. Squamous metaplasia + focal erosion
بیوپسی:
Squamous metaplasia + focal erosion

47. توصیه به: -بازخوانی لام پاپ اسمیر - conization

49. Case 10 61yG3L3 Papsmear:AGC What is the next step?
Cervical colposcopy with directed cervical biopsies and sampling of the endocervical canal
2.Endometrial sampling is performed for all women ≥35 years old and for younger women at risk for endometrial neoplasia

51. Sonography: ET=2mm EMC
Biopsy: chronic cervicitis

53. 16y Virgin cc: ضایعات زگیلی در ناحیه ران
Case 11
16y Virgin cc: ضایعات زگیلی در ناحیه ران

55. Biopsy?

56. Indications for pretreatment biopsy
The diagnosis is uncertain.
●The lesion has any suspicious features, such as fixation (infiltration of dermis)
●The patient is postmenopausal or immunocompromised.
●The lesion is refractory to medical therapy.

57. -Treatment: Medical therapy :Podophyllotoxin/Trichloroacetic acid  (TCA)/5-Fluorouracil and …. APPLIED THERAPIES :exision-Cryotherapy — Electrosurgery (Risk for transmission of human papillomavirus (HPV) to oral or nasal mucosa of health care workers during electrosurgery or laser treatment of anogenital warts )
Silvera RJ, Smith CK, Swedish KA, Goldstone SE. Anal condyloma treatment and recurrence in HIV-negative men who have sex with men. Dis Colon Rectum 2014; 57:752.

58. Is vaccination necessary?
Is it necessary to check other STD?
The presence of genital warts alone is not an indication for screening for additional sexuality transmitted disease
Is HPV typing necessary?
Determining the human papillomavirus (HPV) type of the warts is unnecessary
Is vaccination necessary?
HPV vaccines are effective in the primary prevention of HPV infection. prevention of recurrent disease is investigational

60. . Follow-up? How can we manage Recurrence?
are based on patient symptoms and satisfaction with treatment results.
How can we manage Recurrence?
most are within three to six months of therapy.
We can treat her with previuos treatment

61. با تشکر