Young woman’s cancer and colposcopy

Kiss. Dr. Kenan Ertopcu
Every year, 493,000 women in the world are diagnosed with cervical cancer, and 274000 of them cannot overcome this disease and die. 85% of cervical cancer occurs in underdeveloped countries and 15% in developed countries.
Cervical cancer, which causes the death of 726 women every year in our country, is an absolutely preventable type of cancer when diagnosed early. Cervical cancer is the cancer of young women and every year 1364 women are diagnosed with this cancer in Turkey. Precursor lesions of cervical cancer show symptoms at an early age. Cancer usually develops slowly over 8-9 years. The highest incidence of cervical cancer is around 38 years of age.
Women who smoke, women who start sexual intercourse at an early age, and women who encounter sexually risky HPV (Human Papilloma Virus) types are in the risk group.
(HPV viruses are transmitted sexually. There are more than a hundred models. 7-8 models such as 16,18, 31,45 cause cervical cancer, models such as 6-11 cause non-cancerous genital warts. Since HPV can also be transmitted by skin friction, it can also infect virgins. . Condom is only 70-80% protective against HPV transmission).
Cervical cancer may not show any symptoms for years in the early stages. Sometimes there may be discharges, bloody discharge and bleeding after sexual intercourse. Unfortunately, it is often too late when it starts to show symptoms. Cancer, which has reached a depth of 3 mm, set out between the cells to spread to the lymph nodes.
When detected at an early stage, the suspicious area in the cervix is ​​removed with a simple operation called Leep, and early cervical cancer can be treated without leaving a trace. Moreover, this procedure is applied in an emergency, even in early pregnancy, without harming the pregnancy.
For all these reasons, early diagnosis of cervical cancer is very important. When cervical cancer occurs, despite all kinds of treatment (operation, radiotherapy, chemotherapy), it recurs in 10-20% in its early stages and 50-70% in advanced stages (it reoccurs despite treatment).
In cervical cancer, taking a swab sample from the cells spilled from the cervix, called the smear test, is an early diagnosis method for cancer that every woman should have at least once a year from a young age. In the smear test, thousands of cells are stained with special dyes and then evaluated with a microscope by the pathologist. Here, the pathologist’s knowledge, experience and time to evaluate thousands of cells one by one are very important.
For this reason, the success of the smear test can vary from 60% to 95%.
What is important in the correct performance and success of the smear test is not the hospital or clinic where the smear is taken, but the doctor who takes the smear knowing the necessary technique and documents the careful examination findings in detail to guide the pathologist, and the pathologist who will make the diagnosis by scanning the cells one by one with his knowledge and experience, by dedicating enough time and effort. .
It is also not true for women who have cancer precursor lesions as a result of smear test or pathology to panic and force their doctors for more radical treatments. In smear tests, ASCUS is the most common pathology with a rate of 4.4%. The chance of ASCUS turning into cervical cancer is 0.1-0.2%. ASC-H will be converted to 20-50% CIN 2,3%. CIN 1s that we see frequently may disappear spontaneously in a few years, but they can progress and turn into CIN 2 and CIN 3. There is a possibility that 5% of CIN 2 and 12% of CIN 3 will develop into cervical cancer years later.

When the smear test gives a suspicious result or there is a risk of encountering the sexually transmitted HPV virus, a special technique can be applied to detect HPV viruses by taking a swab sample from the cervix. This technique, which is applied in special cases, is expensive and can be performed in few pathology laboratories. When viruses or virus groups that trigger cervical cancer are detected in the HPV test, it may be recommended to repeat this test after 2 years.
It has been stated that 60% of HPV virus types are destroyed by the immune system within 2 years without making any negative changes in the cervix.
According to the joint recommendations of the American Cancer Society and the organization, which accepts many scientific views on the subject, in 2011; Women aged 30 and over should have an HPV test every three years along with a regular smear test.
According to the joint recommendations of the ACS (American Cancer Society), ACOG (American Obstetricians and Gynecologists) association and many other organizations mentioned in 2011, the smear test should be applied at the earliest 21 years of age. In young women, the cervix is ​​more sensitive to carcinogens such as smoking and HPV, and smear test should be started 3 years after the first sexual intercourse. Smear test can be applied safely during pregnancy. Since HPV vaccine also provides protection against 70% of virus models that cause cervical cancer, those who are vaccinated should not neglect regular smear tests.
Generally, the upper limit is accepted in the 2011 proposals of the above-mentioned organizations aged 65 years. However, no suspicious cells should have been detected in the smear test in the last three years.
It was stated in the 2011 proposals of the mentioned institutions that those who do not have cancer or suspicious cells (dysplasia) in the post-operative pathological examination of the uterus do not need to have a smear test anymore.
The process of examining the cervix and external genitalia by magnifying 10-40 times with a device called colposcope, which looks like a binocular, is called colposcopy. Small pathologies or precancerous diseases that cannot be clearly observed with the naked eye can be easily and painlessly detected. Particularly in the case of detecting suspicious cells in the smear test, a definitive diagnosis can be made by taking biopsy from the areas deemed necessary with the help of colposcopy. There is usually no need for anesthesia even with local anesthesia during colposcopy and biopsy.
1- Women with suspicious cells as a result of the smear (ASCUS, ASC- H, CIN-1, 2, 3),
2- Those with HPV suspicious cellular change (koilocytosis) detected in the smear,
3- Those with unexplained inflammation in recurrent smears,
4- Abnormal appearance of the cervix on examination,
5- Colposcopy can be used in suspicious images of external genital organs (such as genital warts).
During the procedure, the colposcope does not enter the vagina. After the patient lies on the gynecological examination table, a speculum is placed to examine the vagina and cervix, then the colposcope is approached 25-30 cm and the tissues are examined by magnifying them approximately 15 times. The main area evaluated in this examination is the area where the cell layer forming the outer part of the cervix and the cell layer forming the canal extending into the uterus meet. This area is called the transformation zone. The transformation zone is more common and reddened in young women, pregnant women, and those who use birth control pills. This rash is misinterpreted by some doctors and there is a wound in the mouth of the uterus! It is interpreted as This redness is a natural, physiological appearance. If the woman does not have severe complaints, if the smear test and colposcopy are normal, there is NO NEED FOR INVASIVE TREATMENTS SUCH AS BURNING, FREEZING. It may correct itself and reappear spontaneously.
Cervical cancers start from the transformation area and if this area cannot be evaluated fully, colposcopy is considered unsuccessful. Because superficial vascularization in the cervix gives important clues about cervical cancer, they should be evaluated by an experienced colposcopist.
Then, 5% acetic acid is applied to the mouth of the uterus with a small cotton swab. Some patients may feel a slight burning, but not severe pain. After the application of acetic acid, the proteins in the cells will be denatured and the areas containing abnormal cells will turn white. These areas are called aceto-white areas. If the borders of the aceto-white areas are sharp and distinct, appear more dense and white, it is possible to see cervical cancer precursor tissues and biopsy should be taken from these areas. Acetic acid will whiten the areas within 20-30 seconds, and after 5 minutes the effect will disappear. If the colposcopy will take a long time, it may be necessary to apply acetic acid again.
Some gynecologists who perform colposcopy apply an iodine solution called Lugol’s solution to the cervix. This is called the Schiller test and the yellow areas that are not stained brown are considered suspicious areas and biopsy can be taken from these areas when necessary.
Colposcopy and direct biopsy can also be performed during pregnancy.
In the early diagnosis of cervical cancer, smear test, HPV screening and colposcopy are indispensable methods.
Colposcopy is an excellent diagnostic tool in the evaluation of genital warts. It is not always possible to detect very small genital warts with the naked eye, and these warts, which are virus storage, can become widespread despite treatment and require re-application of the necessary treatment procedures. Enlarged observation of suspicious areas will increase the success of the treatment.
Finally, the need for an experienced colposcopist is inevitable in the evaluation and differential diagnosis of vulvar cancer (external genital organ cancer) precursor lesions, which are mostly seen in elderly women and are more common in HPV carriers.
As a result, smear test, HPV test and colposcopy applied in the early diagnosis of cervical cancer are the early diagnosis methods applied without hurting. .When changes leading to cancer in the cervix are detected, it can be easily treated at an early stage without leaving a trace.
We wish you to benefit from the early diagnosis methods of cancer required for a healthy life in a timely manner.

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