Written by Category Archives Articles, Drug of the month archives, Periodic Features.

A Question of Aesthetics

Take a look at the pictures shown below :

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Which one do you think is a picture of a “normal” street?

Now, take a look at the pictures of the uterine cervix below :

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Which one do you think is “normal”?

If you thought the 1st street picture (above) is normal, I’d agree with you. If you thought that the cervix on the top is normal. Well, that’s good! You are already half the way to becoming a colposcopist. The other half of becoming a colposcopist probably is co-ordinating with your pathologist!

I shall proceed to relate to you the reason for making the last statement. The colpophoto of the first cervix, is one of a 50 year old lady in whom smears have on and off since the year 2003 shown ‘LSIL'(low-grade squamous intraepithelial lesion). Her PCR of a cervical swab for HPV DNA even showed positive in 2009. In between, her Pap smear was normal. Colposcopically, the squamo-columnar junction was within the endocervix, and so the colposcopy was deemed inadequate. But consider, the cervix looked the same in 2009, as it did in 2003. Her PV examinations, and sonography of the pelvis were absolutely normal in 2003 as they were in 2009 (no bulkiness of the cervix, if you presume a growth was occurring in the endocervix).

In contrast, the second cervix, is one of a 30 year old lady who had a bad erosion during her second pregnancy. Her Pap smear following delivery (3 months after) was labeled as ‘chronic cervicitis’. 4 years later, the erosion had become even more florid and appeared as shown above. Have a look at the same cervix stained with acetic acid :

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Biopsy of the acetowhite area showed ‘Polypoidal endocervical hyperplasia’. Now, how do you deal with such a pathology?

I have the following comments to make :

  1. If we are to understand that dysplasias (LSIL, HSIL, CIN, call it what you may!) are precursors of malignancy, they should progressively look worse, as the years go by. (I hope everyone agrees with me!) In the case of cervix no. 1, no change has occurred over 6 years, so I refuse to be alarmed in her case, inspite of the bogie of ‘+ve for HPV DNA’ and LSIL being applied to her.

    Whereas, in the case of cervix no. 2, the erosion has worsened over just 4 years, acetowhite areas are seen. This cervix will have to be monitored more closely, inspite of the Pap showing just ‘chronic cervicitis’ and even a biopsy saying ‘Polypoidal endocervical hyperplasia’ (which doesn’t fall in any accepted system of nomenclature at all). I have already cauterized the suspicious areas.

  2. If I did not have documentation of what the cervix looked in 2003, I would be none the wiser, and unable to opine whether the lesion is going from bad to worse or remaining the same.

    So, I recommend to all my gynaecologist friends , try and document what you are seeing, either verbally, or by pictorial representation, or by photography. In the matter of colposcopy, we have video-colposcopes and photographic attachments to colposcopes, by which we can, today, very easily document permanently what the cervix looks like, at any one examination. This will certainly help us to keep our head on our shoulders, and not get ‘unhinged’ when faced with an odd pathology report. How many photos of your face (identity card) and yourself with family and friends do you make in a lifetime? I have a sideboard cupboard filled with them! And we can’t make the time, or take the expense of one photo of the cervix every 3 years? (Let’s say a total of 15 photos over 40 years?)

    Would you like to live in a city with streets like the 1st picture? Or, would you like to live in the 2nd picture? Living in the first picture takes its toll – you have to be vigilant, form ‘ALMs’ (in Mumbai that means citizen’s committees or ‘advanced locality management’ bodies) take pictures from time to time and see that nothing amiss occurs. Or, you can just not bother, and live in the second picture. Similarly, you can see a cervix, and just ignore it (or worse still – just take a Pap smear without even seeing the cervix!). Or, you can decide to try and describe it, try and map it, take a Pap smear, do a colposcopy, take a colpophoto, try and follow-up. It’s a question of aesthetics!