chapter 17. , contraception, menopause, and CHAPTER 1 CHAPTER

This chapter discusses with the if not, it may be the only opportunity often be necessary to hold back the management of CIN during preg- to do so. vaginal walls (Fig. 5.11b). Engorged nancy, use of contraception and The pregnant is both easi- vulvovaginal varices may add to the replacement therapy, and er and more difficult to examine than difficulty. hysterectomy. the non-pregnant one. It is usually However, there are times when easier to see the entire TZ because colposcopy will be necessary during 17.1 Management of CIN of eversion of the cervical epithelium, pregnancy. If so, it is wise to refer the during pregnancy whereby there is a relatively large to a colleague who is experi- ectropion, which inverts postpartum. enced with colposcopy during preg- The management of CIN during However, the extra mucus, increased nancy. If a woman meets the criteria pregnancy is dealt with comprehen- vascularity, stromal hypertrophy, and for colposcopy, pregnancy should sively elsewhere (Freeman-Wang decidual changes induced by preg- not defer it, but biopsy and treatment and Walker, 2006). nancy are more difficult to interpret in thresholds will be different. The pri- Inevitably, CIN will sometimes be the presence of an abnormal screen- mary ambition of a colposcopic ex- first recognized during pregnancy, ing test, and this is one of the few amination during pregnancy is to particularly if the population has not times that cancer may be mistakenly recognize or rule out malignancy. been systematically screened. CIN suspected when the tissue is actual- Precancerous lesions are usually left is also the most common gynaeco- ly normal. As pregnancy progresses, untreated until about 3 months post- logical cancer of pregnancy (Yoon- the vaginal walls may become highly partum (NHS, 2010). However, it is essi et al., 1982). Opinions vary as patulous and the cervix more diffi- often prudent to monitor suspected to whether it is wise to perform a cult to visualize. The use of lateral HSIL colposcopically and cytologi- CHAPTER 17 CHAPTER smear during pregnancy. If a com- vaginal wall specula or, more com- cally as pregnancy progresses. prehensive screening programme fortably, a condom (with its end cut Although the evidence is not is in place, it is not necessary, but off) placed around a speculum will conclusive, several observational

Chapter 17. Pregnancy, contraception, menopause, and hysterectomy 135 studies have reported the safety of biopsy needs to be taken. Punch oral contraceptive pill, but no study delaying treatment during pregnan- biopsies are inadequate in this has shown an advantage to discon- cy (Coppola et al., 1997; Palle et al., situation. Several alternative means tinuing use. Also, in a large meta-an- 2000; Paraskevaidis et al., 2002; of taking a biopsy are available. An alytical review, Smith et al. (2003) Woodrow et al., 1998). In the report adequate biopsy sufficient to allow found no association between use of of Paraskevaidis et al. of 98 pregnant the pathologist to rule out or recog- the combined oral contraceptive pill women with CIN followed up until nize cancer will be achieved using a and CIN in women who had used the postnatal treatment by LLETZ, re- small loop biopsy or a wedge biop- combined oral contraceptive pill for gression occurred in 36% of women sy. Occasionally, it may be neces- up to a decade (Ylitalo et al., 1999). with the antenatal suspicion of CIN1 sary to take larger pieces of tissue and in 48% of women with suspect- or even to perform an excision of 17.2.2 Intrauterine contra- ed CIN2/CIN3. Of seven women with the TZ. If so, these procedures are ceptive device suspected microinvasion, only one better performed in hospital, usual- had histological evidence (early stro- ly under general anaesthesia with a There is no need to remove an IUCD mal invasion < 1 mm), but there was suture set to hand and sometimes in women who are being investigat- one case of microinvasion (< 1.5 mm) with a prophylactic cerclage in place. ed for suspected CIN. It does not ap- not suspected antenatally. The oppo- Haemorrhage is a real risk (Robin- pear to have any effect on CIN pro- site view was taken by Siegler et al. son et al., 1997). gression or regression. Colposcopy (2014), who reported safe treatment Either way, it is crucial that wom- is unaffected by the presence of an of precancer during pregnancy and en in whom CIN is first recognized IUCD. However, there are implica- suggested high rates of HSIL pro- during pregnancy are at least fol- tions for women who are undergoing gression to cancer in women not lowed up and managed at 3 months excisional treatment. It is quite easy treated during pregnancy. In their postpartum, because the untreated to resect the threads of an IUCD dur- observational study of 31 pregnant disease usually persists (LaPolla et ing excision of any kind. To prevent women with HSIL, 18 were conser- al., 1988). this, it is often possible to push the vatively followed up and 13 under- In summary, colposcopy should threads up above the field of resec- went LLETZ during the first 14 weeks be performed at the same thresh- tion under colposcopic guidance. of pregnancy. Four women (12.9%) old during pregnancy as for women It is thus possible to resect the TZ in the study group were diagnosed who are not pregnant. For women without disturbing the IUCD, and the with invasive cervical cancer. Of the with suspected LSIL, management threads (and not the IUCD) may then women who underwent LLETZ, nine may be deferred until 3 months post- be gently pulled back down into their continued their , of which partum. A large biopsy must be per- correct position. seven had full-term normal deliveries formed for women with suspected However, sometimes it is not and two had late preterm deliveries. microinvasive or invasive disease. possible to ensure that the threads No complications of severe Endocervical curettage is contrain- stay out of the field of resection. If or miscarriage were reported in any dicated during pregnancy. Women the threads are resected, the woman of the treated patients. Siegler et al. with suspected HSIL should have should be informed about this, be- advocate treatment of HSIL during a follow-up examination in the sec- cause she may need to attend a gy- pregnancy. However, most authori- ond half of pregnancy and again naecologist to achieve removal of the ties recommend a conservative ap- 3 months postpartum. IUCD when it is due for removal or proach to the management of CIN replacement. This is usually not diffi- during pregnancy, for two reasons: 17.2 Contraception and CIN cult using a Nelson-Roberts forceps, because of the risks of treatment particularly if the examination is per- during pregnancy, and because pro- 17.2.1 Combined oral contra- formed in the and gression to cancer is thought to be ceptive pill with exogenous taken for a uncommon (Massad et al., 2013; few days up to and including the day NHS, 2010). Women should not be advised to of the examination. With exogenous The optimal management of CIN change their method of contracep- estrogen and in the follicular phase, during pregnancy is uncertain at this tion because of the recognition of the cervix is more likely to be relaxed, time. What is universally agreed is CIN at screening. Some studies open, and amenable to forceps ex- that where a suspicion of microin- have shown a slight increase in CIN ploration of the endocervical canal vasive disease is present, a large among women using the combined and lower uterine cavity, whereby

136 the IUCD may be grasped and gently 17.4 Hysterectomy and is difficult to evaluate or treat (see removed. It is rarely necessary to re- treatment of CIN Chapter 16). sort to general anaesthesia. For women who have no other It is prudent to take a smear or per- pathology, hysterectomy is gross 17.3 Hormone replacement form another screening test for any overtreatment of CIN, which is better therapy and CIN woman who is having a hysterectomy treated locally (by excision or abla- for benign pathology. Every woman tion). Hysterectomy is associated with Use of hormone replacement ther- who is due to have a hysterectomy far greater morbidity than local treat- apy does not increase or decrease and who has an abnormal screening ment. Finally, simple hysterectomy is the risk of CIN development or test should have a preliminary col- an inadequate treatment for invasive progression. There is no reason poscopic examination (NHS, 2010). cancer (Roman et al., 1992). Where to advise cessation of hormone re- The inadvertent undertreatment or coexisting benign pathology exists or placement therapy use because of overtreatment of CIN at hysterec- where unexplained endocervical pa- a suspicion of CIN (Sawaya et al., tomy is a preventable error. Where thology persists, it may be justifiable 2000). In women who are not using HSIL is present, if the TZ is not com- to perform hysterectomy, providing hormone replacement therapy, it is pletely excised at hysterectomy, the that all reasonable efforts have been sometimes useful to prescribe it for risk of subsequent cancer develop- made to rule out cancer and provid- several weeks, when estrogen-relat- ing will be increased and monitoring ing that iodine is applied just before ed atrophic change confuses the col- the vaginal vault is difficult. Some hysterectomy to ensure excision of poscopic appearances or to increase dysplastic epithelium may be buried any vaginal intraepithelial neoplasia the chance of successfully examin- in the scar of a hysterectomy, and (Mohamed-Noor et al., 1997). ing the endocervical canal. this vaginal intraepithelial neoplasia

Key points

• Colposcopy should be performed at the same threshold during pregnancy as for women who are not pregnant, but for women with suspected LSIL, management may usually be deferred until 3 months postpartum.

• A large biopsy must be performed for women with suspected microinvasive or invasive disease, and endocer- vical curettage is contraindicated during pregnancy.

• Women with suspected HSIL should have a follow-up examination in the second half of pregnancy and again 3 months postpartum.

• The investigation of abnormal bleeding after menopause must include direct visual inspection of the cervix.

• All patients in the cervical screening age range undergoing a hysterectomy for other gynaecological reasons should have a negative test result within the screening interval or as part of their preoperative investigations.

• All patients being considered for hysterectomy who have an undiagnosed abnormal sample or symptoms attributable to cervical cancer should have diagnostic colposcopy and an appropriate biopsy. CHAPTER 17 CHAPTER

Chapter 17. Pregnancy, contraception, menopause, and hysterectomy 137