The Cervix SN Tripathy
INDEX
Page numbers followed by f refer to figure, and t refer to table
A
Abdomen, lower 117
Acetic acid 134, 142, 168
role of 142
Acetowhite epithelium 138, 139f, 143f, 144f, 147
Acquired ectopy 113
Adenocarcinoma 170
in situ 145, 148, 170
Amenorrhea 120
American College of Obstetricians and Gynecologists 9, 29, 36, 53, 54, 75, 128
American Society for Colposcopy and
Cervical Pathology 96
Androgens 35
Anteflexion 16
angle of 17f
Anteversion 16
angle of 17f
Anti-Müllerian hormone 13
Arbor vitae 16, 17f
Arias-Stella phenomena 96
Assisted reproduction technology 13
B
Balloon devices 37
Basal layer 136
Binocular colposcope 134f
Biopsies 98, 145
Bishop scoring system, modified 7t
Bleeding per vagina 117
Blood vessels 29
C
Cancer 145f
cervix 8, 10, 95, 153
glandular cells 8
Human papillomavirus-associated 172f
signs of 158
squamous cells 128
symptoms of 158
Canine visceral leishmaniasis 82
Carcinoma
cervix 153
invasive 100, 103, 134
Cells, epithelial 26
Cerclage 57
operations 60
stitches 67
techniques 60
Cervical
agenesis 13
anatomy 72, 135
architecture 84
barrier method 73
biomechanics 46
canal 50f
cancer 8, 97, 117, 127, 128, 133, 134, 153, 164, 166, 168
management of 95
screening recommendations 129t
treatment of 102
caps 73, 74
carcinoma 8
colposcopy 148f
consistency index 51
cycle 26
cysts 118
defects 58
dilatation 23, 62
phases of 48
dystocia 62
ectopic pregnancy 69f
ectopy 73, 75, 113, 113f
ectropion 118, 118f
endometriosis 116
epithelium 19,49,50
erosion 113f
fibroid 117, 117f, 118
glands 66, 78
hyaluron synthase 37
hydration 46
infection, persistent 134
insufficiency 6, 53, 54, 55f, 59
intraepithelial neoplasia 71, 72, 80, 96, 111, 127-129, 131, 134, 140f, 167-169, 172
laceration 62
length 9
ligament, transverse 17
maturation 28, 29
mucus 21,28,71,77, 78f, 79, 81
fern test 46f
plug 28,29
myomas 117
pessary 56
physiology 72
polyp 115, 115f, 116f
pregnancy 65, 66
remodeling 44, 85,86, 88f, 90t, 91
rings 15
ripening 46
physiology of 29
techniques 33
signs 44
softening 22
stenosis 12, 15, 116, 117f
stroma 87f
stromal cells 29
tissue 35, 46
trauma 53
tuberculosis 119, 120t, 121t
Cervicitis 72, 114, 114f
infectious 114
noninfectious 114
Cervicovaginal fluid 56
Cervix 3-5, 6f, 7, 17f, 18, 21f-24f, 26, 43, 44f, 48, 48f, 66, 71, 73, 74, 113f, 129f, 134, 134f
abnormal 133
acquired diseases of 113
adenocarcinomas of 33
anatomy of 112f, 135, 135f
aspects of 3
benign diseases of 111
composition of 6
congenital
absence of 112
anomalies of 112
elongation of 112f
functions of 43
funneling of 55f
healed 122f
healthy 134
hypoplasia of 112
imaging of 8, 49
inflammation of 72
invasive carcinoma of 71,72
length of 19f
ligament support of 17f
menopausal 137f
molecular biology of 84
normal 113f, 133
pathology of 72
physiology of 26
sparing hysterectomy 7
strawberry 115f, 138
supravaginal part of 112
surgical anatomy of 12
tuberculosis of 8
ultrasonography of 8
visual inspection of 134
Chadwick's sign 44
Chlamydia trachomatis 114,165
Chlamydial cervicitis 115f
Chorioamnionitis 59
Chorionic villi 69f
Collagen 85
Colposcope check report 147f
Colposcopy 98,133,148
advantages of 148
basic instruments of 140, 141f
basis of 135
contraindications of 135
indications of 134
limitations of 148
steps of 140
transformation zone 144f
Columnar epithelium 135, 136, 137f, 148
Oral contraceptive pills, combined 74
Cone biopsy 98
Contraception 71, 73, 74
hormonal 73
long-acting reversible 71
Contraceptive
adverse effects of 74t
counselling, protocol for 75
method, types of 73
Cryosurgery 114
Cryptomenorrhea 15
Cusco's speculum 140
Cysts 21
Cytokine 81
D
Dehydroepiandrosterone sulfate 35
Dendritic cells 172
Depot medroxy-progesterone acetate 73, 74
Diathermy cauterization 114
Didelphic uterus 15, 16f
Diethylstilbestrol 12, 15,33, 54, 112
Dinoprostone 36
Double cervix 14,72,75
Dyspareunia 115, 159
Dysuria 115
E
Ectopy 72
congenital 113
Ehlers-Danlos syndrome 53, 54
Electron microscopy 19
Endocervical
canal 20f, 135, 136
curettage 145
epithelium 50
glands 20f, 21
speculum 141, 146f, 147f
Endocervix 21f, 65, 137f
Endometriosis 116
Endoplasmic reticulum 85
Enzyme hyaluronidase 89
Epithelia 87f
Epithelioid histiocytes 121f
Epithelium 87
Estrogen 34, 46
receptor 30
Ethambutol 121
Exocervix 15
Extracellular matrix 3,6, 10,29, 43, 84
F
Fallopian tubes 8
Fascia around cervix 17
Female pelvis
lymphatic drainage of 23f
vessels of 23f
Female reproductive
system, autonomic innervations of 24f
tract 14f
Fern patterns 27f
Fertility 103
Fetal
fibronectin 56
membrane
properties 46
stripping of 48
Fluorodeoxyglucose positron emission tomography 99
Foley's catheter 37
Folic acid antagonist 67
Fothergill's operation 17
Foul smelling vaginal discharge 120
Friedman's curve 48f
Fusion anomalies 112
G
Gartner's duct cysts 118
Gestational sac 66
Gland openings 148
Glandular cells 127
atypical 145, 148
Glycosaminoglycan 89
Gonadotropin-releasing hormone 33
Goodell's sign 44
Granulocyte colony stimulating factor 30
Granulomas containing Langerhans’ giant cells 121f
H
Halban technique 18
Healed transformation zone 141f
Hegar's sign 44
Hegar's dilator, passage of 56
Hematometra 15
Hemorrhage 62
antepartum 114
severe 59
High-grade squamous intraepithelial
lesion 96, 128, 145, 148
Hormone 85
metabolism 89
Human immunodeficiency virus 169
infection 8, 132
Human papillomavirus 8, 127, 134, 164, 166-168, 172, 173
genotypes 166
infection 8, 122, 131f, 134, 165, 165f
natural history 165
testing 131, 167
vaccine 164, 169
Human uterine cervix 6
Hyaluronan
functions 88f
role of 89
Hyaluronic acid 30, 46
Hyaluronidase 37
synthases 87f
Hydroxyeicosatetraenoic acid 30
Hygroscopic dilators 37
Hypertrophic columnar epithelium 142
Hysterectomy 7, 67
radical 157
sub-total 7
Hysterocervicography, premenstrual 56
Hysterosalpingography 8
I
Iliac fossae 5
Immune cells 90
role of 85, 89
In vitro fertilization 81
Infertility 120
Inflammation 90
Insler score 21
modified 15t
Interconceptional period 56
Internal iliac vessels 67
International Agency for Research on Cancer 33, 74
International Federation of Cervical Pathology and Colposcopy 148
International Federation of Gynecology and Obstetrics 96
Intracorporeal surgeon's knot 58f
Intracytoplasmic sperm injection 82
Intrauterine
contraceptive devices 74
infection 62
insemination 81
Invasive cervical cancer 8, 170
Ipsilateral renal anomaly syndrome 15
Ischial tuberosity 5
Isoniazid 121
J
Junctional proteins 89
K
Kegel exercises 160
Khanna's sling operation 18
Killer cells, cytokine-induced 172
L
Labor, stages of 47f
Ladin's sign 44
Laminaria japonica 7,37
Langhans’ giant cells 122
Laparoscopic cerclage 58
placement 59
Laparoscopy 15f
Laparotomy 67
Lea's shield 73
Leukoplakia 142f, 148
Levonorgestrel 73
Lipopolysaccharide 91
Liquor amnii 50f
Loop electrosurgical excision procedure 80, 134f, 147, 168, 169
Lower uterine
endometrium 69f
segment 46, 59
Low-grade
intraepithelial lesions 166
squamous intraepithelial lesion 128, 145, 148
Lugol's iodine 134, 136, 145, 145, 146f
application of 136f
Lymphatic drainage 22
M
Mackenrodt's ligament 17
Macrophage
colony stimulating factor 82
inflammatory protein 81
Magnetic resonance imaging 27, 56, 98
Malignant cells 134
Manchester operation 17
Maschowitz technique 18
Matrix metalloproteinases 30, 47,84
Mayer -Rokitansky-Kuster-Hauser
syndrome 12, 13, 15f
McCall culdoplasty 18
McDonald approach 60, 61
McDonald cerclage 60
McDonald cervical cerclage procedure 61f
McDonald techniques 60
Membranes, premature rupture of 62
Menometrorrhagia 120
Menstrual cycle 27
Mersilene tape suture, erosion of 59
Metaplastic epithelium 136
reproductive age 137f
Methotrexate 67
Microinvasive carcinoma 100
Microphthalmia associated transcription
factor 45
Microscopy 18
Misoprostol 36
Mosaic epithelium 140f
Mucinous retention cysts 21
Mucins 79
Müllerian development 13
Müllierian duct 13, 13f, 14, 112
Mullerian hypoplasia 15
Müllierian malformation 13-15
Müllierian structure 13
Myometrial contractions 50
N
Nabothian cysts 5, 21, 131f, 138f, 148
Nabothian follicle 5, 21
N-acetylneuraminic acid 79
Nasal
forceps 141
speculum 146f
National Cervical Cancer Coalition 127
National Comprehensive Cancer Network 131
Natural contraception, Billing's method 73
Neisseria gonorrhoeae 114
Neoadjuvant chemotherapy 95, 101, 104
O
Oral contraceptive pills 32
Organogenesis 95
Ovulatory disorders 33
P
Pain, abdominal 120
Papanicolaou smear 74, 75, 97, 120, 128, 134
Papillomatosis 172f
Paracervical node 22
Pelvic
computed tomography 99
examination 97
lymph node assessment 98
pain 115
Periodic acid-Schiff 19
Pink squamocolumnar epithelium 136f
Policresulen 114
Polyp 142f
Polypoidal endometrium 142
Portio vaginalis 15, 135
Post-coital bleeding 115, 120
Post-coital test 80
Post-menopausal bleeding 120
Pouch of Douglas 5,18
Preinvasive disease 96
Preterm premature rupture of membranes 53, 56, 59
Prevotella intermedia 35
Progesterone 34, 46
only pill 73,74
only preparations 73
Prostaglandin 30, 33, 35
inhibitor 30
Proteins, noncollagenous 85
Proteoglycans 6
Pubocervical ligament 17
Puerperal pyrexia 62
Purandare's operation 18
Pyrizinamide 121
Q
Quasi-static elastography 51
R
Radiation 117
therapy 158
Radiotherapy 156
Rapid mechanical cervical dilation 53
Rectum 15f
Reddish columnar epithelium 136f
Renal unilateral agenesis’ 16f
Rifampicin 121
Royal College of Obstetricians and Gynaecologists 9, 57
Rubin's criteria for histological diagnosis of cervical pregnancy 66
S
Sacral nodes 23f
Secretory leukocyte protease inhibitor 28
Sepsis 62
Sexually transmitted infections 71
Shirodkar dissected uterosacral ligaments 17
Shirodkar's cervical cerclage procedure 61f
Shirodkar's sling operation 18
Shirodkar's technique of transvaginal cerclage 60
Sliding sign 66
Society for Maternal Fetal Medicine 9
Sperm 78
glycocalyx 79
Spermatozoa 21, 78
Spermicides 74
Spiritual crisis 10
Spontaneous preterm birth 9
Squamocolumnar junction 15, 20f, 72, 130, 139f, 141f
Squamous cell 127
carcinoma 128, 170
Squamous epithelium 135, 136, 148
Squamous metaplasia 147
Strawberry trichomonas infection 138f
Streptomycin 121
Sturmdorf suture 113
Subcolumnar reserve cells 72
T
Thromboembolism 59
Transabdominal cerclage 57
Transformation zone 19
large loop excision of 80
normal 136
Transvaginal ultrasound 9, 55
Traumatic epithelial lesions 50
True pelvis 4
Tuberculosis, global burden of 119
Tuberculous lesion
Schirous type of 121f
ulcerative type of 120f
Tumor markers 99
Two-day method 73
U
Upsuck theory 22
Urinary tract infection 117
Uterine
activity 45f
artery 22f
embolization 67
bleeding 66
cervix 12
transformation zone of 20f
fundus, endometrium of 69f
procidentia, reduction of 4f
vessel
bleeding 59
ligation of 67
Uterosacral ligament 17, 18, 23f
Uterus 6f, 17f, 66
anteflexion of 19f
embryology of 14f
ligament support of 17f
lower part of 17f
nature of 4
V
Vaccines, types of 170
Vagina 134
adenocarcinomas of 33
part of 17f
Vaginal
aplasia 13
bleeding 62
delivery 50
diaphragm 73,74
discharge 115
ecosystem 78
infection, persistent 134
pessaries 4
progesterone 9
sponge 73
Valethamate bromide 37
Vessels 138
atypical 147, 148
normal arborization of 138f
Video colposcope 134f
Vulva 134
W
Warts, human papillomavirus-associated 172f
Wolffian duct 13f
Z
Zygote intrafallopian transfer 13
×
Chapter Notes

Save Clear


1General
  • ▸ An Overview
  • ▸ Surgical Anatomy of Cervix
  • ▸ Physiology of Cervix
  • ▸ Effects of Drugs on Cervix2

An OverviewCHAPTER 1

SN Tripathy,
GN Dash

ABSTRACT

The cervix is a mystic organ of the body. Though it is a very small, not even an organ by itself, just part of the uterus, it plays a very big role in reproductive health of women in disease and childbirth. Whatever and whenever we desire a function from it, it complies. In normal pregnancy, despite progressive softening, the cervix keeps the uterus closed until term, and then softens/dilates further to allow for delivery of the fetus. Within minutes after birth, this remarkable structure reconstitutes to close the uterus. The entire complex process involves an elegant concert of molecular and microstructural events. On the other hand, we expect it should not allow any organisms to pass through it, but allow only the sperm so that it can fertilize the ovum. Strangely, it complies to this wishes too. What a strange organ !!!. The role of cervix in fertility and infertility is getting clearer day by day. The cause of the most dreaded disease cancer cervix is now known. I believe, very soon we will unravel all the mysteries surrounding the cervix.
 
INTRODUCTION
I always wonder about the cervix, how an organ can function so diametrically oppositely in pregnancy and later in life becomes the woo of millions of women. Cervix fascinated me from the very beginning of my carrier and still I go on wondering about it. It is the most mystic organ of the body, whatever and whenever we desire a function from it, it complies. In normal pregnancy, despite progressive softening, the cervix keeps the uterus closed until term, and then softens/dilates further to allow for delivery of the fetus. Within minutes after birth, this remarkable structure reconstitutes to close the uterus. The entire complex process involves an elegant concert of molecular and micro- structural events, including precisely timed activation of biochemical pathways and interactions between resident and immune cells and the extracellular matrix (ECM). On the other hand, we expect it should not allow any organisms to pass through it, but allow only the sperm so that it can fertilize the ovum. Strangely, it complies to our wishes. What a strange organ !!!.
The name of the cervix comes from Latin word cervix (neck) from the Proto-Indo-European root ker-, referring to a “structure that projects”. Thus, the word cervix is linguistically related to the English word “horn”, the Persian word for “head” (sar), the Greek word for “head” (Greek: koryphe), and the Welsh word for “deer” (Welsh: carw).1
 
HISTORICAL ASPECTS OF CERVIX
“No group should ever neglect to honor the work of forebears upon which their contributions are based. Great is the loss to anyone who neglects to study the lives of those he follows.”
—Kelly
Gynecology in antiquity finds its roots in the Ebers Papyrus (1500 BC) which portrayed the uterus as an independent animal, usually a tortoise, newt or crocodile, 4capable of movement within its host and the cervix was recognized as an organ in entity as early as 4500 BC. During the third Egyptian dynasty, about 1500 BC, the sacred Vedas were written. They practised dissection, but the knowledge of anatomy was fanciful. The sacred code of Manu describes conception occurring during menstrual epoch when the cervix opens like flowers of the water lily to the beams of the sun. They have described many skilled operations and devised many instruments (Figs 1.1 and 1.2).
Hippocrates perpetuated the animalistic concept stating that the uterus often went wild when deprived of male semen. He gives us the earliest description of a pessary employing a pomegranate to reduce uterine prolapse and he used catheters of tin and lead to irrigate the uterus. The seven cells doctrine of the Common Era replaced the animalistic concept, depicting the uterine cavity as being divided into seven compartments whereby male embryos developed on the right, females on the left and hermaphrodites in the center. Such notions remained popular until the middle ages.
zoom view
Fig. 1.1: Early gynecological instruments
zoom view
Fig. 1.2: Reduction of uterine procidentia with vaginal pessaries
Soranus of Ephesus (AD 98–138) is commonly considered the foremost gynecologic authority of antiquity. He described the uterus based on human dissection. It was Soranus, who gave the first accurate description of the cervix uteri as a separate portion of the uterus. On his treatise ‘On the Nature of the Uterus and Female Pudende,’ he described the cervix in detail. The os uteri, lies in the center of the female genital organs, for the cervix is closed by the labia, the os is moved from those in some more, in some less according to the age. In adults generally 3.5–4 cm, in those who have borne children it comes to the nearer through elongation of the cervix. The size of the os uterus varies and in most persons as large as the outer end of the auditory meatus. It opens at certain times as in the orgasm of the coitus to receive the semen, during menstruation that the blood may escape, in pregnancy according to the growth of the embryos and in labor to the greatest extent until it will admit the full sized head. In texture, it is soft and fleshy in pregnancy. How accurate he was !!
The Renaissance (1453–1600) with the rise of universities, printing and self-education provided a clear understanding of female anatomy. Leonardo Da Vinci (1452–1519), founder of iconographic and physiologic anatomy, provided the format for modern anatomical illustration. His work included pelvic anatomy and provides the earliest accurate description of the fetus in utero. Unfortunately, his sketches were seen by only a few of his contemporaries and were not published until the end of the nineteenth century. Jacob Rueff (1500–1558) provided the first illustration of a vaginal speculum, which appeared little changed from Greco-Roman times. His contemporary, Ambrose Pare’ (1510–1590) was the first to suggest amputation of the cervix in cases of malignancy.
Andreas Vesalius (1514–1564) produced the most famous anatomical illustrations of all time revolutionizing the science of anatomy and the manner in which it was taught. Vesalius provided the first accurate description of the entire female genital tract and its vasculature, depicting the left ovarian vein entering the left renal vein for the first time. Distinguished pupils of Vesalius include Gabriele Falloppio (1523–1562) who produced the earliest clear description of the human oviduct and described the clitoris as a vasomuscular structure. Bartolomeo Eustachi (1520–1574) provided the earliest accurate delineation of the uterine cavity and cervical canal.1
The cervix is located within the ‘true pelvis’, posterior to the bladder base and directly anterior to the rectum. Separating the bladder from the upper portion of the cervix 5is the perimetrium, which is reflected on to the base of the bladder to form the vesicouterine pouch. A lateral extension of this tissue passes towards the pelvic walls and encloses a number of important structures, including the uterine vessels and ureters, surrounded by areolar tissues. Posteriorly, the rectouterine pouch (of Douglas) is formed as a result of the peritoneal reflection from the cervix inferiorly to the posterior vaginal fornix and onto the rectum.
The portion of the cervix exposed to vagina is the exocervix or portio vaginalis. It has a convex round surface with a circular (in nulliparous) or slit like (in multiparous) opening, i.e. the external os that opens into endocervical canal. The endocervical canal is about 2.5–3.5 cm in length and opens proximally into the endometrial cavity at the internal os. Anatomical internal os remains above the histological internal os and the distance between the two is approximately 0.1–0.5 cm (isthmus) in nonpregnant state which is lengthened to 7.5–10 cm in the advanced labor as the lower uterine segment. Anatomical internal os is demarcated as obvious constriction between the uterine cavity and cervical canal but histological internal os is recognized microscopically by abrupt changes of the epithelia and stroma. The use of the terms anatomic and histologic “internal os” seems arbitrary as no convincing morphologic evidence is offered to support such a geographic subdivision.
The vault of the vagina is divided into four areas according to their relation to the cervix: the posterior fornix which is capacious, the anterior fornix which is shallow and two lateral fornices. Because the cervix is inserted below the vault, the posterior vaginal wall is approximately 10 cm in length whereas the anterior wall is 8 cm. The cervical canal varies greatly in length and width between women and over the course of a woman's life, and can measure 8 mm (0.3 inch) at its widest diameter in premenopausal adults. It is wider in the middle and narrower at each end. The anterior and posterior walls of the canal each have a vertical fold, from which ridges run diagonally upwards and laterally. These are known as palmate folds due to their resemblance to a palm leaf. It is also called arbor vitae because of the resemblance of tree trunk and branches. It is most obvious in young nulliparous women. The anterior and posterior ridges are arranged in such a way that they interlock with each other and close the canal. They are often effaced after pregnancy. Nabothian cysts (or nabothian follicles) form in the transformation zone where the lining of metaplastic epithelium has replaced mucous epithelium and caused a strangulation of the outlet of some of the mucous glands. A build up of mucus in the glands forms nabothian cysts, usually less than about 5 mm (0.20 in) in diameter, which are considered physiological rather than pathological. Both gland openings and nabothian cysts are helpful to identify the transformation zone.
The cervix is held in place by paired ligaments on either side: The uterosacral and cardinal (transverse cervical) ligaments. The uterosacral ligaments run from the posterior and lateral supravaginal portions of the cervix to the middle three sacral vertebrae. Near the most distal attachment at the cervix, the uterosacral ligaments interlace with their respective cardinal transverse ligaments for approximately 2 cm, before running to their proximal attachments. It is thought that the uterosacral ligaments help maintain the uterus in its typically anteverted state. The cardinal ligaments are the principal supports of the cervix. The attachments and positioning of the cardinal ligaments have been researched extensively, with great variation being observed. Although there remains controversy over whether these structures represent true ligaments or fascial condensations, a recent literature review has identified a variety of attachment sites on or running toward the pelvic side wall, including both iliac fossae, ischial tuberosity, etc.2,3
The venous drainage parallels the arterial system, with communication between the cervical plexus and neck of the urinary bladder. The lymphatics of the cervix have a dual origin beneath the mucosa and deep in the fibrous stroma. Both systems collect into two lateral plexuses in the region of the isthmus and give origin to four efferent channels running toward: (1) the external iliac and obturator nodes, (2) the hypogastric and common iliac nodes, (3) the sacral nodes, and (4) the nodes of the posterior wall of the urinary bladder. The innervation of the cervix is chiefly limited to the endocervix and peripheral deep portion of the exocervix. This distribution is responsible for the relative insensitivity to pain of the portio vaginalis. The cervical nerves derive from the pelvic autonomic system, the superior, middle, and inferior hypogastric plexuses.
The relationship of cervix with uterus changes with the age (Fig. 1.3).
In prepubertal girls, the functional squamocolumnar junction is present just within the cervical canal. Entering puberty, due to hormonal influence, and during pregnancy, the columnar epithelium extends outward over the ectocervix as the cervix everts. This also causes the squamocolumnar junction to move outwards onto the vaginal portion of the cervix. The exposed columnar epithelium can undergo physiological metaplasia and change to tougher metaplastic squamous epithelium in days or weeks, which when mature is very similar to the original squamous epithelium. The new squamocolumnar junction is therefore internal to the original squamocolumnar junction, and the zone of unstable epithelium between the two junctions is called the transformation zone of the cervix.6
zoom view
Fig. 1.3: Relationship of cervix with the uterus in different age groups
After menopause, the uterine structures involute and the functional squamocolumnar junction moves into the cervical canal.
 
COMPOSITION OF THE CERVIX
The corpus uterus is composed of smooth muscle bundles embedded in extracellular matrix (ECM). On the other hand, ECM dominates the cervix and the smooth muscle component is 4% in the distal part and about 10% at the inner meatus. The compositions indicate their different functions during pregnancy and parturition. A normal parturition is established when cervical ripening is accomplished before the onset of labor.
The components of the subepithelial stroma of the cervix have been well documented. The firmness of the cervix is a result of the presence of collagen (70% type I and 30% type II), which is the predominant protein of its extracellular matrix. Collagen and the associated ground substance account for up to 80% of the subepithelial stroma. It is thought that the directionality of the collagen fibers may determine their ability to withstand forces encountered in pregnancy: circumferentially around the cervical canal to prevent dilation of the cervix and longitudinally to resist those associated with cervical effacement. The proportion of smooth muscle is variable. The distribution of smooth muscle is scattered at random throughout the stroma, with very few bundles being formed. They are unlikely to be functional due to fiber immaturity and fiber positioning within densely tangled collagen.47
Elastin has consistently been reported as comprising a small percentage of the stromal substance. The majority of elastin fibers are found in vessel walls, but a few are scattered throughout the cervical stroma. Elastin is presumed to be important in cervical remodeling during and after pregnancy.811
The human uterine cervix is a passive organ whose mechanical response during gestation has a critical influence on the outcome of the pregnancy. It has a dual structural function: prior to term, the cervix must stay closed to allow the fetus normal development; and at term, the cervix must dilate under the influence of uterine contractions to allow the fetus passage. This dual mechanical functionality is reflected in the changing mechanical properties of the cervical stroma. Firm and rigid at the beginning of pregnancy, the cervix undergoes progressive remodeling during gestation until it is noticeably soft at term. This drastic change in tissue properties is the physical manifestation of a complex biochemical process commonly referred to as cervical maturation (or ripening). The clinical implications of an impaired cervical function are well known.
Cervical insufficiency is a condition in which the cervix softens and dilates prematurely in the absence of apparent uterine contractions which can lead to preterm delivery and, in many cases, causes extremely premature birth. At the other end of the biomechanical spectrum, a cervix that fails to dilate at term can result in substantial maternal and fetal morbidity. Biochemical mechanisms of cervical softening have intrigued the obstetricians for many years. The extracellular matrix (ECM) of the cervical stroma is the load-bearing component of the cervical tissue. The ECM of the stroma is similar to other fibrous connective tissues. The primary constituents are type I and type III collagens, hyaluronan (HA) and proteoglycans (PGs), elastin and water. In current clinical practice, the biomechanical status of the cervix is assessed in terms of a subjective scoring system introduced by Bishop.12
 
CERVICAL RIPENING
The goal of cervical ripening is to facilitate softening, thinning, and dilation of an unfavorable cervix so as to reduce the time to delivery and the incidence of failed induction. In addition to uterine contractility, cervical change is an essential component of normal labor. Originally described by EH Bishop in 1964, the status of the cervix is routinely determined by the Bishop pelvic scoring system. The scoring system was subsequently modified for easier clinical use and the inclusion of cervical length as a substitute for cervical effacement (Table 1.1). A Bishop score of 6 or less is generally accepted as an unfavorable cervix and has been used for inclusion criteria in most clinical trials of labor induction.7
Table 1.1   Modified Bishop scoring system
Score
0
1
2
3
Dilation
<1 cm
1–2 cm
2–4 cm
> 4 cm
Station
–3
–2
1 or 0
+ 1 or 2
Consistency
Firm
Average
Soft
Position
Posterior
Mid to anterior—
Cervical length
>4 cm
>2–4 cm
>1–2 cm
<1 cm
A Bishop score of 8 generally confers the same likelihood of vaginal delivery as that of spontaneous labor. If labor induction is planned in the setting of an unfavorable cervix, a cervical ripening agent is indicated. Currently available approaches to cervical ripening include mechanical methods and synthetic prostaglandins. Hygroscopic and osmotic dilators, such as synthetic Dilapan and naturally occurring Laminaria japonica, are effective methods of mechanical cervical dilation. However, these methods have been associated with an increase in peripartum infection and are not commonly used in the setting of third trimester labor induction. The most commonly used mechanical device for labor induction is the Foley catheter. The device causes not only mechanical dilation of the cervix but also a release of endogenous prostaglandins from the fetal membranes, thus stimulating uterine contractility. Overall, the use of a Foley catheter is associated with a decreased risk of cesarean delivery when compared with oxytocin alone.
 
CERVIX AND PRETERM LABOR
Premature cervical remodeling is one of the factors of preterm birth. But there are limitations to study the same. As challenges of obtaining human cervical tissue in pregnancy is there at present, we depend on rodent models to study the same. Now some studies are being done with anatomically correct computer simulation models of the pregnant human pelvis, uterus and cervix for studying human cervical remodeling in pregnancy. Recent studies utilizing these anatomically correct computer simulation models have shown that the angle of the cervix in the pelvis influences the amount of stretch exerted on the area of the internal os. In addition, simulations show that the strength of the fetal membranes influences the degree of stretch at the internal os.
Studies evaluating the utility of these computer models (which incorporate patient-specific tissue properties and ultrasound derived parameters) to predict and/or identify which women with premature cervical remodeling will actually deliver preterm are currently ongoing.
 
CERVIX-SPARING HYSTERECTOMY (SUB-TOTAL HYSTERECTOMY)
Early hysterectomies were all subtotal; the first ever recorded having been performed by Charles Clay in 1843.13 he first total hysterectomy is attributed to Richardson in 1929. From then on, there was a gradual increase in the rates of total hysterectomy, until the 1940s, when the advent of antibiotics, blood transfusion, modern anesthesia and improved surgical techniques emboldened surgeons to the point where total hysterectomy became the mainstay procedure. Hysterectomy remains the number one surgery in gynecology. The total versus subtotal hysterectomy debate has largely been resolved. In terms of counseling women needing a hysterectomy for a benign indication, they can now be reassured that neither total nor subtotal abdominal hysterectomy adversely affects pelvic organ function. Subtotal abdominal hysterectomy is easier to perform, with less risk of ureteric damage but requires that women have regular cervical smears, and may result in cyclical bleeding in a small proportion of women.
Hysterectomy disrupts the anatomical relationships and local nerve supply, and it has seemed reasonable to suppose that pelvic organ functions might be adversely affected. Because subtotal hysterectomy minimizes the anatomic and nervous disruption, some have argued that it may ameliorate the potential adverse effects of total hysterectomy. The issue simmered in the background until a real debate was sparked off by a series of publications from Scandinavia in the early 1980s. Kilkku et al.14 concluded that subtotal hysterectomy conferred significant advantages over total hysterectomy with respect to bladder and sexual function.
However, subsequent studies by Virtanen et al.15 from the same institute did not concur with Kilkku et al. findings. Thakar et al.16 found no significant differences between the two groups pre- and postoperatively in the important parameters of urinary, bowel and sexual function. However, the changing perspective of the risk of cancer in the cervical stump, the risk of bladder and ureteric injury and the prevailing litigious climate in medical practice, as well as patient demand and media interest, have forced gynecologists to re-examine their negative attitude to subtotal hysterectomy. Women should be provided with as much information as possible, and invited to participate in the decision-making about the type of hysterectomy they should have. Such empowerment may well improve satisfaction rates after surgery.178
 
CANCER CERVIX
Cervical carcinoma, though is a preventable disease, remains the third most common malignancies among women in the world. The estimated number of new cases every year amounts to 3,81,000, and three-quarter was diagnosed in the developing countries. It is a leading cause of mortality and morbidity, which comprises approximately 12% of all cancers in women worldwide according to World Health Organization (WHO). It is now known that cancer of the cervix is commonly caused by a virus named human papillomavirus (HPV). The virus can damage cells in the cervix, namely squamous cells and glandular cells that may develop into squamous cell carcinoma (cancer of the squamous cells) and adenocarcinoma (cancer of the glandular cells), respectively. Squamous cell carcinoma can be thought of as similar to skin cancer because it begins on the surface of the ectocervix. Adenocarcinoma begins further inside the uterus, in the mucus-producing gland cells of the endocervix. For patients with early stage disease, the 5-year survival rate is 80–90% after radical hysterectomy and pelvic lymphadenectomy. Radiotherapy is the alternative treatment and achieves similar survival rate. As ovarian and vaginal functions can be preserved with radical surgery but not radiotherapy, radical hysterectomy is the treatment of choice for young and low surgical risk patients. Adjuvant radiotherapy is often given to patients found to have poor prognostic factors pathologically after surgery, and the percentage of patients requiring postoperative radiotherapy ranges from 30 to 50%. A combination of radical hysterectomy and radiotherapy is undesirable as it produces higher complication rate than both treatment given alone and might not improve survival. It is therefore important to identify patients who carry these poor prognostic factors and treat them with primary radiotherapy.
 
SCREENING FOR CERVICAL CANCER
Screening for cervical cancer in women is minimum essential health measure for reproductive health of women. Various method of screening are available and can be used in all resource setting.18 Visual inspection of cervix with naked eye during routine gynecological examination added with acetic acid application is an effective screening tool and can be performed by paramedical person. Cytology still is basic tool for screening for cervical cancer irrespective of HPV vaccination status. Liquid-based cytology and HPV screening add to sensitivity and specificity of cancer screening yet it adds to cost and might not be available to all women and health facilities in country like India. Creating awareness for women and people for significance of regular cervical cancer screening is the foundation stone of all cervical cancer screening program. Cotesting is the best. Cervical cancer screening with Pap (Papanicolaou) cytology has been effective at decreasing the incidence of cervical cancer in countries with established screening programs. The use of cotesting has been suggested by some to be the preferred screening option and is included in the current recommendations. However, some have also suggested that human papillomavirus (HPV) testing alone might serve as the referred primary screening modality and such a scenario appears closer to reality given the recent US Food and Drug Administration (FDA) approval of the Roche cobas HPV test as a primary screening modality.
 
HUMAN PAPILLOMA VIRUS INFECTION AND CERVICAL CANCER
Almost all cases of cervical cancer can be linked to a persistent infection with cancerogenic HPV transmitted via sexual contact.1921 Prevalence of HPV correlates with cytological abnormalities and reaches >99% in invasive cervical cancer.22 The majority of HPV infections regress spontaneously. More than 100 different genotypes have been identified. The most prevalent genotypes are HPV 16, 18, and 45. Other carcinogenic genotypes are HPV 31, 33, 35, 39, 51, 52, 56, 58, and 59, plus the potentially carcinogenic genotype 68. Cofactors increasing the risk of development of cancer include smoking, long-term use of hormonal contraceptives, multiparity, and human immunodeficiency virus (HIV) infection. HPV-negative women past the peak of HPV infection (i.e. 30 years or older), or women who converted from HPV-positive to HPV-negative, have a very low risk for precancerous lesions or invasive cancer.22
 
IMAGING OF CERVIX
Various imaging tools have been used for evaluation of the cervix. Hysterosalpingography (HSG) is a quick and minimally invasive tool for evaluation of infertility that facilitates visualization of the inner surfaces of the uterine cavity and fallopian tubes, as well as the cervical canal and isthmus. The lesions of the uterine cervix show various imaging manifestations on HSG, such as narrowing, dilatation, filling defects, irregularities and diverticular projections. Tuberculosis of the cervix shows distinctive features on X-rays.23 Accurate diagnosis of such cases is considered essential for optimal treatment.
 
ULTRASONOGRAPHY OF CERVIX
A vaginal ultrasography is the best way to measure the cervix because it can be seen much more clearly this way. The 9cervix looks like a tube on the ultrasound, between 3 cm and 5 cm long, with one end at the top of the vagina (the external os), and the other end inside the uterus (the internal os). It is the internal os that can begin to open first, and this will look like a V shape on the scan. As the os opens further it becomes U shaped. This is called funneling. 2.5 cm lengh of the cevix is taken as the cutoff point.
In 1968, Wilson and Jungner18 set a public health milestone by outlining the principles for using a screening test for early disease detection. Since 1968, the application of these screening test criteria has become a main pillar of preventive medicine by improving public health and contributing to society's well-being. Spontaneous preterm birth (PTB) is a major public health challenge. A short cervical length (CL) detected by transvaginal ultrasound (TVU) in the second trimester is one of the best current predictors of subsequent PTB. TVU CL screening of singleton gestations with previous PTB already has been recommended by American College of Obstetricians and Gynecologists (ACOG), Society for Maternal Fetal Medicine (SMFM), and Royal College of Obstetricians and Gynaecologists. TVU CL is a good screening test for PTB prevention because it meets the screening test criteria.24
They are as follows:
  1. The condition sought should be an important health problem. Preterm birth is associated with 1 million neonatal deaths worldwide.
  2. There should be an accepted treatment for patients with recognized disease. Vaginal progesterone is a proven treatment for preterm birth prevention in singleton gestations with a short cervix.
  3. Facilities for diagnosis and treatment should be available. All pregnant women are offered ultrasound at 18–24 weeks of gestation and can be offered transvaginal ultrasound cervical length measurement.
  4. There should be a recognizable latent or early symptomatic stage. A short transvaginal ultrasound cervical length is an early predictor of preterm birth.
  5. There should be a suitable test or examination. Transvaginal ultrasound is a validated reliable test for cervical length measurement.
  6. The test should be acceptable to the population. Transvaginal ultrasound cervical length is acceptable by more than approximately 75% of women with singleton gestations and no previous spontaneous preterm birth.
  7. The natural history of the condition, including development from latent to declared disease, should be understood adequately. Transvaginal ultrasound cervical length shortening precedes by weeks or months, digitally detected cervical changes, symptomatic uterine contractions, and eventual preterm birth.
  8. There should be an agreed policy on whom to treat as patients. Transvaginal ultrasound cervical length 20 mm at <24 weeks of gestation is the currently accepted indication for treatment in singleton gestations without previous preterm birth.
  9. The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be balanced economically in relation to possible expenditure on medical care as a whole. Several studies have confirmed the cost-effectiveness of universal transvaginal ultrasound cervical length screening.
  10. Case-finding should be a continuing process and not a “once and for all” project.
CT and MRI are rarely used in nonpregnant and pregnant condition of the cervix. But it is of superb value in assessment of cervical malignancy. It is superior to clinical (FIGO) staging for tumors greater than stage 1 disease.
Cervical cancer possesses a typical and fairly invariable appearance on MRI. T2W images show a high intensity lesion in contrast to the usual very low-intensity normal cervical stroma. Small foci of low intensity within the higher intensity tumor represent areas of necrosis. Invasion of paracervical tissues can be ruled out with 100% specificity if a low signal intensity rim surrounds the tumor around its entire circumference. Vaginal invasion is usually obvious clinically; however, lateral spread at the fornices can be assessed on MRI. The vaginal tunica muscularis usually appears as a low signal wall on T2W images. Focal disruption of this layer or of the bladder or rectal wall suggests local infiltration by tumor. Complete disruption of the stromal ring with focal nodular or irregular tumor signal intensity extending into the parametrium is a reliable sign of invasion. Lymph nodes greater than 1 cm in short axis diameter are positive for disease in 88%25 of cases. Contrast enhanced sequences are of value in detecting or confirming invasion of adjacent organs and identifying fistulous tracts.26 MRI and CT have comparable specificities for parametrial invasion, rectal invasion and lymph node involvement. MRI has a higher specificity for bladder invasion compared to CT, making MRI more accurate than CT in the overall staging of cervical cancer.27 In differentiating operable from advanced disease, MRI imaging has been reported to have an accuracy of 93%.28 In cervical cancer, it has been shown that the tumor volume determines outcome rather than invasion beyond the margins of the uterus. MRI assessment of tumor volume using both an endovaginal coil and an external coil provides an accurate prediction of prognosis in cervical cancer.29 MRI is of value in the follow up of cervical cancer posttherapy in detecting recurrent tumor.3010
 
PSYCHOSOCIAL PROBLEMS OF CANCER CERVIX
The National Cancer Institute defines psychological distress as “an unpleasant experience of an emotional, psychological, social, or spiritual nature that interferes with the ability to cope with cancer treatment. It extends along a continuum, from common normal feelings of vulnerability, sadness, and fears, to problems that are disabling, such as true depression, anxiety, panic, and feeling isolated or in a “spiritual crisis” In the case of cervical cancer, women may experience a unique emotional and psychological burden for three main reasons: cervical cancer is largely a preventable cancer; there is an effective screening test, and it is associated with a sexually transmitted virus, raising the spectre of guilt and blame, at least in the minds of many women and families if not in the minds of health care providers . Common psychosocial stressors for persons with cancer, financial, physical, and Interpersonal. Psychosocial Counseling helps these patients a lot. While counseling, the family members are also to be included in the sessions.
 
CONCLUSION
Though the cervix is a very small, not even an organ by itself, just part of the uterus hardly measuring from 2.5 to 3 cm, it plays a very big role in reproductive health of women in disease and childbirth. To know about the organ you have to search many books and journals. The entire complex process of remodeling of cervix involves an elegant concert of molecular and microstructural events, including precisely timed activation of biochemical pathways and interactions between resident and immune cells and the extracellular matrix (ECM). Our understanding of this multifaceted process is rapidly changing as an explosion of molecular and microstructural information is adding to the body of knowledge about cervical remodeling in pregnancy. The role of cervix in fertility and infertility is getting clearer day by day. The cause of the most dreaded disease cancer cervix is now known. I believe, very soon we will unravel all the mysteries surrounding the cervix.
REFERENCES
  1. Harper, Douglas. “Cervix”. Etymology Online. Retrieved 19 March 2014;1.
  1. D Vu, BT Haylen, K Tse, A Farnsworth. Surgical anatomy of the uterosacral ligament. Int Urogynecol J. 2010; 21 1123e1128, http://dx.doi.org/10.1007/s00192-010-1147-8.
  1. Ramanah MB, Berger BM, Parratte JOL, DeLancey. Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments, Int. Urogynecol. J. 2012;23:1483–94 http://dx.doi.org/10.1007/s00192-012-1819-7
  1. Danforth DN. The fibrous nature of the human cervix, and its relation to the isthmic segment in gravid and nongravid uteri. Am J Obstet Gynecol. 1947; 53 541e560.
  1. Danforth DN. The distribution and functional activity of the cervical musculature. Am J Obstet Gynecol. 1954; 68 1261e1271. http://europepmc.org/abstract/MED/13207218 (accessed 11.12.14)., j jbiomech. 2015.02.060.
  1. Danforth DN. The morphology of the human cervix. Clin. Obstet. Gynecol. 26(1983)7e13. http://journals.lww.com/clinicalobgyn/Abstract/1983/03000/The_Morphology_of_the_Human_Cervix.5.aspx (accessed 11.12.14).
  1. Schwalm H, Dubrauszky. The structure of the musculature of the human uterus-muscles and connective tissue. Am J Obstet Gynecol. 1966;94:391–404.
  1. Leppert P, Keller S. Conclusive evidence for the presence of elastin in human and monkey cervix. Am J Obstet Gynecol. 142 (1982) 179e182. http://www.ncbi.nlm.nih.gov/pubmed/7055182 (accessed 11.12.14).
  1. Leppert PC, Keller S, Cerreta J, et al. The content of elastin in the uterine cervix, Arch. Biochem. Biophys. 1983;222:53e58, http://dx.doi.org/10.1016/0003-9861(83)90501-5.
  1. Leppert P, Cerreta J, Mandl I, Orientation of elastic fibers in the human cervix, Am. J. Obstet. Gynecol. 1986;155:219e224. http://www.sciencedirect.com/science/article/pii/0002937886901158 (accessed 11.12.14).
  1. Rotten D, Gavignet C, Colin MC, et al. Evolution of the elastic fiber network of the human uterine cervix before, during and after pregnancy. A quantitative evaluation by automated image analysis, Clin. Physiol. Biochem. 1988;6:285e292. http://www.ncbi.nlm.nih.gov/pubmed/3229071 (accessed 05.12.14).
  1. Bishop, Edward H. “Pelvic Scoring for Elective Induction”. Obstetrics & Gynecology. 1964;24(2):266–268. PMID 14199536.
  1. Sutton C. Hysterectomy: A historical perspective. Baillieres Clin Obstet Gynaecol. 1997;11(1):1–22.
  1. Kilkku P, Gronoos M, Hirovnen T, Rauramo L. Supravaginal uterine amputations vs hysterectomy: effects on libido and orgasm. Acta Obstet Gynecol Scand. 1983;62:147–52.
  1. Virtanen HS, Makinen JI, Tenho T, Kiiholma P, Hirvonen T. Effects of abdominal hysterectomy on urinary and sexual symptoms. Br J Urol. 1993;72:868–72.
  1. Thakar R, Ayers S, Clarkson P, et al. Outcomes after total versus subtotal abdominal hysterectomy. N Engl J Med. 2002;347:1318–25.
  1. Sahana Gupta, Isaac Manyonda, Total and subtotal abdominal hysterectomy for benign gynaecological disease Obstetrics, Gynaecology and Reproductive Medicine. 2010;21:2–36.
  1. Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva: World Health Organization;  1968.
  1. Schiffman M, Castle PE, Jeronimo J, et al. Human papillomavirus and cervical cancer. Lancet. 2007;370:890–907.
  1. Bosch FX, Broker TR, Forman D, et al. Comprehensive control of human papillomavirus infections and related diseases. Vaccine. 2013;315:H1–H31.
  1. Crosbie EJ, Einstein MH, Franceschi S, et al. Human papillomavirus and cervical cancer. Lancet. 2013;382:889–99.

  1. 11 Guan P, Howell-Jones R, Li N, et al. Human papillomavirus types in 115,789 HPV-positive women: A meta-analysis from cervical infection to cancer. Int J Cancer. 2012;131:2349–59.
  1. Tripathy SN, Tripathy SN. Cervical tuberculosis, Tuberculosis Manual for Obstreticians and Gynaecologists. Jaypee Brothers. 
  1. Khalifeh A, Berghella V, Universal CL screening for the prediction and prevention of PTB. Am J Obstet Gynecol. 2016.
  1. Roy C, Le Bras Y, Mangold L, Saussine C, Tuchmann C, Pfleger D, et al. Small pelvic lymph node metastases: evaluation with MR imaging. Clin Radiol. 1997;52:437–40.
  1. Nicolet V, Carignan L, Bourdon F, Prosmanne O. MR imaging of cervical carcinoma: a practical staging approach. Radiographics. 2000;20:1539–49.
  1. Bipat S, Glas AS, van d V, Zwinderman AH, Bossuyt PM, Stoker J. Computed tomography and magnetic resonance imaging in staging of uterine cervical carcinoma: a systematic review. Gynecol Oncol. 2003;91:59–66.
  1. Sheu MH, Chang CY, Wang JH, Yen MS. Preoperative staging of cervical carcinoma with MR imaging: a reappraisal of diagnostic accuracy and pitfalls. Eur Radiol. 2001;11:1828–33.
  1. Soutter WP, Hanoch J, D'Arcy T, Dina R, McIndoe GA, deSouza NM. Pretreatment tumour volume measurement on high-resolution magnetic resonance imaging as a predictor of survival in cervical cancer. BJOG. 2004;111:741–7.
  1. Jeong YY, Kang HK, Chung TW, et al. Uterine cervical carcinoma after therapy: CT and MR imaging findings. Radiographics. 2003;23:969–81.