01. the normal cervix

cervix normal

1. The normal cervix: cytology,
colposcopy, and histology

Michelle Szymanowski, RNC, MSN, WHNP
OB/GYN Nurse Practitioner
Southwest Contemporary Women's Care
Gilbert, AZ

| | ASEP | A > Comprehensive Colposcopy

2. Disclosures

As an accredited provider of CME credit, ASCCP has implemented a process to ensure that anyone who is in a position to affect the
content of an educational activity has disclosed all relevant financial relationships with any commercial interest. Any conflicts of interest
have been resolved by ASCCP prior to the activity.

‘The following person(s) disclosed relevant financial relationships:

‘Sarah Feldman, MD, MPH - Faculy - UptoDate (Author and Peer Editor)

Michele Szymanowski, WHNP — Faculty - Myriad Genetics (Speaker)

Alan Waxman, MD, MP - Faculy — Loktal Medical Electronics (Speaker)

‘The following person(s) disclosed no relevant financial relationships:

Christine Conageski, MD - Facuty

Nancy Joste, MD — Facuty

Michele Khan, MD, MPH- Faculty

Megan Huchko, MD, MPH - Content Reviewer
Edward J. Mayeaux, MD - Content Reviewer
Colleen Stockdale, MD, MSc — Content Reviewer
Kerry Curtis — Stat

Cate Langley = Staff

Car Price = Staff

Lies Robinson - Staff

‘Aisha Yocum - Staff

Images used with permission:
+ Apgar B, Brotzman G, Spitzer M. Integrated Colposcopy: À Text and Allas. Elsevier, 2002, 2008. (ABS)
+ Ferris D, Cox T, O'Connor D, Wright C. Modern Colposcopy. Wolters Kluwer, ASCCP, 2002
= Personal coleclions as noted on slides

Comprehensive Colposcopy

3. Objectives

+ Review the epithelial features of the normal
transformation zone

+ Discuss the process of squamous metaplasia

+ Explain the normal features of the transformation zone
according to age

+ Describe features that define a satisfactory colposcopy

| | ASEP | A > Comprehensive Colposcopy

4. Origin of cervical epithelium

« Vagina is originally lined by columnar epithelium derived
from fusion of the Mullerian ducts
+ Lines the endocervix and is continuous with the endometrium

+ Gradually replaced by a core of stratified squamous
epithelium originating in the urogenital sinus
+ Lines the vagina, portio vaginalis of the cervix

« Rudimentary cervix by 16 weeks gestation

| | ASEP | A > Comprehensive Colposcopy

5. Types of cervical epithelia

Stratified squamous Metaplasia: immature
+ Covers the ectocervix and vagina and mature
+ Multilayered epithelium, rests on + Lies between columnar and
basement membrane squamous epithelium

+ “Smooth pink color + *"Faintacetowhite color after

vinegar application
Tall columnar
+ Lines the endocervix

+ One cell layer thick, mucin-secreting,
numerous folds

« **Brightred irregular color

| b Comprehensive Colposcopy

6. 2 types of epithelium

Squamous
Columnar

7

| Com sive Colposcopy

7. Be

x
Columnar 7

(Irregular Red).

8. Columnar epithelium

Infolding of epithelium Columnar

> .

epithelium

Glandcleft [i

9. Columnar epithelium

« Single layer tall columnar cells lining endocervical canal
+ Course proximally from SCJ through endocervical canal to internal os
+ Majority secrete mucus; may have cilia

+ Covers villi that contain central loop capillaries
+ *Vessels are poorly concealed: epithelium is “red” compared to
squamous “pink”
+ Endocervical cells invaginate into the stroma to depth of 5-8mm
+ Are called “glands” but are technically crypts
+ Infolding of epithelium creates texture on surface

| b Comprehensive Colposcopy

10. Columnar epithelium

\

Stroma with blood vessels

11. Columnar
epithelium

*redder**

than squamous

12. er

13. Superficial

Stratified =
squamous à a Intermediate
epithelium
divided

into 4 layers

Parabasal

Comprehensive Colposcopy

14. Stratified squamous epithelium

« Estrogen continuously remodels squamous epithelium in
premenopausal women
+» Epithelial proliferation
+ Epithelial maturation
+ Epithelial desquamation

« Divided into layers

+ Basal / parabasal / intermediate / superficial
+ Regeneration from the basal layer under influence of estrogen

| PASE P| À . Comprehensive Colposcopy

15. Stratified squamous ~
epithelium (PINKER th

columnar) à 30-year-old
À woman

16. squamous

ere

17. 65-year-old
postmenopausal
woman

Stratified squamous
epithelium

No columnar epithelium visible

18. Squamocolumnar junction (SCJ)

Interface between the columnar epithelium and
squamous epithelium

+» Original SCJ is defined at birth

+ Separates the original glycogenated squamous epithelium from the
original columnar epithelium

+ Embryologically determined caudal extent of columnar epithelium
* Cervical “transformation” begins here

| b Comprehensive Colposcopy

19. Life cycle of the SCJ

Adolescence Reproductive years Postmenopause

Comprehensive Colposcopy

20. Mayeaux, EJ, & Cox, J.T. (2012). Modem colposcopy:
textbook & allas. Philadelphia: Wolters Kluwer
HeattLippincott Wiliams & Wilkins.

sive Colposcopy

22. The evolution of the SCJ

Squamous

Columnar

23. The SCJ “moves” centrally byt! the esse of
squamous metaplasia

+ Metaplasia: transformation of
one cell type into another

« Squamous metaplasia is the
process of transformation of
columnar into squamous
epithelium

« Squamous metaplasia is a
normal process of cervical
maturation

sive Colposcopy

24. Mechanism of squamous metaplasia

+ Columnar cells changed into immature metaplastic cells
« Become indistinguishable from squamous cells as they mature

« Transformation zone thought to arise from transformation
of columnar epithelium through subcolumnar reserve cell
hyperplasia

+ These reserve cells become metaplastic cells that then
become the new squamous epithelium

| PASE P| À . Comprehensive Colposcopy

25. Active squamous metaplasia

Comprehensive Colposcopy

26. Metaplasia

Comprehensive Colposcopy

27. Metaplasia

28. How squamous metaplasia occurs
Mechanism of reserve cell hyperplasia

Estrogen lowers vaginal pH
+ Estrogen levels increase in neonatal period and at puberty

* Cervical eversion mediated by estrogen

« Exposes endocervical columnar epithelium to more acidic
vaginal environment

- “Acid burn” stimulates metaplasia of columnar epithelium

| PASE P| À . Comprehensive Colposcopy

29. How squamous metaplasia occurs

Reserve cells below columnar cells

30. Factors inducing squamous metaplasia

+ Etiologic factors
+ Mechanical irritation
+ Chronic inflammation
+ pH changes
« Environmental conditions

+ Probably begins when the original SCJ moves out of the os
+ Exposes delicate columnar cells to acidic vaginal environment

| | ASEP | A > Comprehensive Colposcopy

31. | Proliferation of reserve cells - immature squamous
| cells directly below the remaining columnar cells

32. Mature stratified squamous epithelium

33. Squamous metaplasia

* Tips of columnar villi are traumatized by acidity of the vagina
+ Immature cells gradually mature and the cells begin to
produce glycogen

+ Can be a random distribution on the cervix
+ Patchy, uneven areas of metaplasia
+ Immature tips have acetowhite appearance

| | ASEP | A > Comprehensive Colposcopy

35. Normal transformation zone

Mayeaux, E, & Cox, J.T. (2012) Modem colposcopy: textbook & atlas.
Philadelphia: Wolters Kluwer HeallvLippincott Willams & Wikins,

Comp sive Colposcopy

38. pink squamous

epithelium
acetowhite immature 4

squamous metaplasia

red columnar
epithelium

AS à A”

39. What is the transformation zone?

« Physical zone or area on the cervix
» Area between the original SCJ and the new SCJ

+ TZ gets larger as the woman ages and remodeling or
transformation occurs

* The new SCJ appears to “move” closer to the external
os and then inside the endocervical canal
« Process completed following menopause

| | ASEP | A > Comprehensive Colposcopy

40. Transformation zone
; al ER Last gland
opening

41. Transformation zone

Lesion in
transformation
zone

42. Components of the TZ

Nabothian cysts:

« Formed when the opening of the endocervical infoldings
become blocked by metaplasia

+ Accumulated mucus forms “cysts”
+ Vessels accentuated over the cyst
+ No treatment is necessary

| | ASEP | 2 . Comprehensive Colposcopy

43. What happens to those mucus secreting “glands” when
they become blocked by squamous cells?

Nabothian
_— follicle
Answer: land
opening immature
2 metaplasia

| Comprehensive Colposcopy

44. Bu

Nabothian cyst

45. Nabothian cyst:
good place to
learn normal
vessels

Branching vessels
Usually yellow

46. Nabothian cyst
branching
vessels

47. Multiple
nabothian
cysts

Compre

48. Components of the TZ

Islands of columnar epithelium
+ Result from uneven process of squamous metaplasia

+ Mini SCJ's

+ If obliterate, may produce Nabothian cyst

| | ASEP | 2 . Comprehensive Colposcopy

50. Components of the TZ

“Gland” openings with mucin secretion
+» Not true glands

+ Infoldings of columnar epithelium

| | ASEP | A > Comprehensive Colposcopy

52. Image from Greenwald, Spitzer, Sedis. ACOG Basic Colposcopy

Comprehensive Colposcopy

53. Immature
metaplasia
with multiple
gland openings

54. Components of the TZ

+ Mature squamous epithelium

« Final result of squamous metaplasia

+ Original SCJ and squamous epithelium interface becomes
a squamous-squamous junction

| | ASEP | 2 . Comprehensive Colposcopy

56. General assessment of the cervix and SCJ at the
colposcopic exam: if fully visualized

+ The entire new SCJ on the cervix can be visualized
(360° of columnar epithelium)

« If any lesion is visible, must see it entirely

+ May require manipulation or endocervical speculum for
complete visualization

| | ASEP | A > Comprehensive Colposcopy

57. Is the general assessment of the SCJ and lesions fully visualized?

Not Fully Visualized

-

e Colposcopy

58. Summary

» Reviewed the epithelial features of the normal
transformation zone

« Discussed the process of squamous metaplasia

+ Explained the normal features of the transformation
zone according to age

» Described features that define a fully visualized cervix
and SCJ at colposcopy

| | ASEP | A > Comprehensive Colposcopy