Acute and chronic cervicitis

At the onset of menarche, the production of estrogens by the ovary stimulates maturation of the cervical and vaginal squamous mucosa and formation of intracellular glycogen vacuoles in the squamous cells. As these cells are shed, the glycogen provides a substrate for endogenous vaginal aerobes and anaerobes, including streptococci, enterococci, Escherichia coli, and staphylococci; however, the normal vaginal and cervical flora is largely dominated by lactobacilli. Lactobacilli produce lactic acid that maintains the vaginal pH below 4.5, suppressing the growth of other saprophytic and pathogenic organisms. In addition, at low pH, lactobacilli produce bacteriotoxic hydrogen peroxide (H2O2).21 At higher, more alkaline pH caused by bleeding, sexual intercourse, vaginal douching as well as during antibiotic treatment, lactobacilli decrease H2O2 production, permitting the overgrowth of other microorganisms, which may result in clinically apparent cervicitis or vaginitis. Some degree of cervical inflammation may be found in virtually all women, and it is usually of little clinical consequence. However, infections by gonococci, chlamydiae, mycoplasmas, and herpes simplex virus may produce significant acute or chronic cervicitis and are important to identify due to their association with upper genital tract disease, complications during pregnancy, and sexual transmission. Marked cervical inflammation produces reparative and reactive changes of the epithelium and shedding of atypical-appearing squamous cells, and therefore may cause a nonspecific, abnormal Pap test result.

Endocervical Polyps

Endocervical polyps are benign exophytic growths that occur in 2% to 5% of adult women. Perhaps the major significance of polyps lies in their production of irregular vaginal "spotting" or bleeding that arouses suspicion of some more ominous lesion. Most polyps arise within the endocervical canal and vary from small and sessile to large, 5-cm masses that may protrude through the cervical os. All are soft, almost mucoid, lesions composed of a loose fibromyxomatous stroma harboring dilated, mucus-secreting endocervical glands, often accompanied by inflammation (Fig. 22-14). Simple curettage or surgical excision effects a cure.

Premalignant and Malignant Neoplasms

No form of cancer better documents the remarkable effects of screening, early diagnosis, and curative therapy on the mortality rate than does cancer of the cervix. Fifty years ago, carcinoma of the cervix was the leading cause of cancer deaths in women in the United States, but the death rate has declined by two thirds to its present rank as the eighth leading cause of cancer mortality. In sharp contrast to this reduced mortality, the detection frequency of early cancers and precancerous lesions is high. Much credit for these dramatic gains belongs to the effectiveness of the Pap test in detecting cervical precancers and to the accessibility of the cervix to colposcopy (visual examination of the cervix with a magnifying glass) and biopsy. While there are an estimated 11,000 new cases of invasive cervical cancer in the United States annually, there are nearly 1 million precancerous lesions of varying grade that are discovered yearly by cytologic examinations. Thus, it is evident that Pap smear screening not only has increased the detection of potentially curable, low-stage cancers but has also allowed the detection and eradication of preinvasive lesions, some of which would have progressed to cancer if not discovered and treated.