What is Cervical Intraepithelial Neoplasia?
The number of cervical cancer cases and deaths have dropped mainly due to screening programs using the pap smear test. As more results from these programs have become available, the methods for screening and treating cervical precancerous conditions, also known as Cervical intraepithelial neoplasia (CIN), have improved. It’s crucial to catch the disease early, keep a close watch on it, and treat it to prevent it from turning into cervical cancer.
The screening process for cervical cancer involves taking a small sample from the cervix with a procedure called a Pap smear, along with testing for human papillomavirus (HPV) in certain situations. HPV is a type of virus that can cause cervical cancer.
What Causes Cervical Intraepithelial Neoplasia?
Human papillomavirus (HPV) is a sexually transmitted infection that can affect the cervix, and it significantly raises the risk of developing unhealthy changes to cervical cells. But it’s important to know that just a small number of women who get HPV will progress to severe cell changes or cervical cancer. Several things affect whether the infection will lead to these cell changes or cancer, and the biggest one is the specific type of HPV causing the infection.
There are about 100 types of HPV, but only a few are linked to changes in cervical cells and cancer. Some types of HPV are considered cancer-causing, while others aren’t. If the virus stays in the body for a long time, it increases the risk of developing these cell changes and eventually, cancer.
HPV type 16 is the most harmful and is responsible for 55 to 60% of cervical cancers worldwide. HPV 18 is the second most harmful and accounts for 10 to 15% of cervical cancer cases. Other risk factors like smoking or having a weakened immune system due to conditions like HIV can cause HPV to linger in the body and increase the risk for cell changes.
Typically, if there’s an abnormal result on a Pap smear, it’s often described as “squamous intraepithelial lesions”, which are then categorized as either “low-grade” or “high-grade.” Low-grade means changes are minor, while high-grade means changes are more serious and could become cancerous if not treated.
Risk Factors and Frequency for Cervical Intraepithelial Neoplasia
HPV, or human papillomavirus, infection often occurs in sexually active women of all ages, but it is most common in teens and women under 30. The group with the highest rate of HPV is women between the ages of 20 and 24. Interestingly, these younger women are also the most likely to naturally get rid of the infection, usually in about 8 months. This is a key reason why doctors recommend getting the first Pap smear, a test for cervical cancer, at 21.
For women over 30 who have HPV, there’s a higher chance that the infection will persist. For these women, it’s important to have more rigorous follow-up tests to discount the chance of having a cervical condition known as cervical intraepithelial neoplasia, a precursor to cervical cancer.
Signs and Symptoms of Cervical Intraepithelial Neoplasia
Usually, abnormal growths on the cervix, known as dysplastic lesions, can’t be seen without a microscope. These are typically found during a routine Pap smear, which is a test that identifies any abnormal changes in the cells of the cervix before they turn into cancer. Some of these growths might look like outward or plaque-like growths on the cervix. The human papillomavirus (HPV) can cause warts in the genital and anal regions, which could also indicate other abnormalities caused by HPV.
Testing for Cervical Intraepithelial Neoplasia
If you have abnormal results on a Pap smear test, one common method to further evaluate it is through a procedure known as colposcopy with directed biopsy. “Co-testing” is another method which uses both cell (cytology) and high-risk HPV testing, but it’s still mainly a screening process. In order to make a definite diagnosis, a tissue sample is needed.
However, there are certain cases where this standard procedure doesn’t apply:
For example, if a woman is aged between 21 to 24 and has a mild form of abnormal cells (LGSIL cytology) on her test results, no immediate biopsy is necessary because these cell changes often resolve on their own. Instead, the Pap smear test is simply repeated every 12 months. However, if this same age-group of women has more severe or uncertain results (ASC-H, atypical glandular cells, or HGSIL) on repeat cytology, the recommended next step is colposcopy. If the follow-up Pap smears show ASCUS (atypical cells of undetermined significance), LGSIL, or turn out negative, the test should be repeated in another 12 months. If the repeated tests at 24 months still show ASCUS or LGSIL, then they should proceed to a colposcopy.
Patients who are older than 24 years with ASCUS and positive high-risk HPV and LGSIL or higher are recommended to undergo colposcopy. Regardless of the age, women with HGSIL (higher grade abnormal cells) or ASCUS-H (atypical cells that can’t exclude high-grade cells) should have a colposcopy. If the diagnosis is CIN II (moderate to high degree of abnormal cells) or more severe, the standard course of treatment is to remove the abnormal tissue. In the case of younger women, it might be more appropriate to closely monitor the situation with colposcopy as long as they are compliant with their follow-up care.
Treatment Options for Cervical Intraepithelial Neoplasia
CIN-1 is a condition where abnormal cells are noted on the surface of the cervix – these changes are usually mild and often get better by themselves. Therefore, doctors usually monitor the condition rather than treating it immediately. If this condition does not improve in two years or if it gets worse over time, then treatment is typically recommended.
However, for more serious conditions such as CIN-2 or higher, treatment is usually needed as soon as it is detected. Treatment may also be necessary when there’s a big difference between the Pap smear results and the biopsy results. For example, if the Pap smear shows severe changes but the biopsy does not show these changes, doctors might suggest a diagnostic excisional procedure. This means they’ll remove a part of the cervix to both diagnose and treat the condition. After this procedure, the removed tissue is checked closely to see if all the abnormal cells were removed.
There are several ways to get rid of abnormal cells on the cervix. One way is to destroy, or “ablate,” these cells, which can be done through cryosurgery (freezing) or laser ablation (using a laser). These techniques were more commonly used before LEEP, which stands for loop electrosurgical excision procedure, was developed. Ablation techniques might be used when there are no abnormal cells in the cervical canal, no glandular abnormalities, the whole area of abnormal cells can be seen, and the patient has not failed other treatments. However, these methods may not work as well for more severe conditions compared to LEEP.
Excisional procedures, which involve cutting out the abnormal cells, include LEEP, cold knife conization, and laser conization. These procedures might increase the risk for preterm labor, but this isn’t certain. It’s also important to note that close observation might be an alternative to surgery for women younger than 25 with CIN-2 or CIN-3. However, this is not usually the preferred option and treatment is generally delayed until after pregnancy, unless it’s found that the condition is getting worse during regular check-ups.
Women who were treated for CIN-2 or higher should get a Pap smear and HPV testing once a year and two years after the procedure. Even if not all the abnormal cells are removed during the procedure, it’s usually successful for about 70-80% of the people. When the test suggests that there are still abnormal cells present, doctors usually recommend a repeat cytology testing in 4-6 months along with a procedure to scrape off cells from the inside of the cervical canal. They may also suggest repeating the excisional procedure or a hysterectomy, especially in recurrent cases of CIN. However, the decision ultimately depends on the patient’s preference and health circumstances.
What else can Cervical Intraepithelial Neoplasia be?
When trying to diagnose a medical condition, doctors must consider quite a few possibilities. They have to rule out:
- Normal squamous cells
- Cervical warty lesions
- Inflammation
- Infection
- Carcinoma (a type of cancer)
This ensures that they arrive at the correct diagnosis.
What to expect with Cervical Intraepithelial Neoplasia
The future health outlook for Cervical Intraepithelial Neoplasia, a condition that affects the cells in the lining of a woman’s cervix, can vary based on how severe the condition is. By following the guidelines set by the American Society for Colposcopy and Cervical Pathology (ASCCP), the chance of the condition transitioning into cancer is reduced.
However, the risk for noticeable cervical cancer becomes significantly higher for women who haven’t undergone checks or screening for more than 10 years.
Possible Complications When Diagnosed with Cervical Intraepithelial Neoplasia
Potential complications can occur from a cervical biopsy, such as excessive bleeding or infections, but these are rare. Surgical treatments, like a cold knife cone or LEEP, may have increased risks, including anesthesia risks. Among those undergoing surgical procedures, concerns have been raised about possible pregnancy complications, such as preterm delivery or a weak cervix. However, it’s hard to determine the real impact of the surgical procedure on early delivery, because the risk factors for these complications are the same as those for cervical dysplasia.
Possible Risks and Complications:
- Excessive bleeding
- Infection
- Increased risks associated with surgical treatments
- Anesthesia risks
- Potential pregnancy complications for women undergoing surgical procedures
- Preterm delivery
- Weak cervix