<unk>  seen on a T2-weighted sagittal MR image of the pelvis. Biopsy The Pap test can be used as a screening test, but produces a false negative in up to 50% of cases of<unk> . Other concerns is the cost of doing Pap tests, which make them unaffordable in many areas of the world. Confirmation of the diagnosis of<unk>  or precancer requires a biopsy of the cervix. This is often done through colposcopy, a magnified visual inspection of the cervix aided by using a dilute acetic acid (e.g. vinegar) solution to highlight abnormal cells on the surface of the cervix, with visual contrast provided by staining the normal tissues a mahogany brown with Lugol's iodine. Medical devices used for biopsy of the cervix include punch forceps. Colposcopic impression, the estimate of disease severity based on the visual inspection, forms part of the diagnosis. Further diagnostic and treatment procedures are loop electrical excision procedure and<unk>  conization, in which the inner lining of the cervix is removed to be examined pathologically. These are carried out if the biopsy confirms severe<unk>  intraepithelial neoplasia. This large squamous carcinoma (bottom of picture) has obliterated the cervix and invaded the lower uterine segment. The uterus also has a round leiomyoma up higher. Often before the biopsy, the doctor asks for medical imaging to rule out other causes of woman's symptoms. Imaging modalities such as ultrasound, CT scan, and MRI have been used to look for alternating disease, spread of the tumor, and effect on adjacent structures. Typically, they appear as heterogeneous mass on the cervix. Interventions such as playing music during the procedure and viewing the procedure on a monitor can reduce the anxiety associated with the examination. Precancerous lesions IMage:Ca in situ, cervix 2.Histopathologic image (H&E stain) of carcinoma in situ (also called CIN3), stage 0: The normal architecture of stratified squamous epithelium is replaced by irregular cells that extend throughout its full thickness. Normal columnar epithelium is also seen.<unk>  intraepithelial neoplasia, the potential precursor to<unk> , is often diagnosed on examination of<unk>  biopsies by a pathologist. For premalignant dysplastic changes,<unk>  intraepithelial neoplasia grading is used. The naming and histologic classification of<unk>  carcinoma precursor lesions has changed many times over the 20th century. The World Health Organization classification system was descriptive of the lesions, naming them mild, moderate, or severe dysplasia or carcinoma in situ (CIS). The term<unk>  intraepithelial neoplasia (CIN) was developed to place emphasis on the spectrum of abnormality in these lesions, and to help standardize treatment. It classifies mild dysplasia as CIN1, moderate dysplasia as CIN2, and severe dysplasia and CIS as CIN3. More recently, CIN2 and CIN3 have been combined into CIN2/3. These results are what a pathologist might report from a biopsy. These should not be confused with the Bethesda system terms for Pap test (cytopathology) results. Among the Bethesda results: Low-grade squamous intraepithelial lesion (LSIL) and high-grade squamous intraepithelial lesion (HSIL). An LSIL Pap may correspond to CIN1, and HSIL may correspond to CIN2 and CIN3, but they are results of different tests, and the Pap test results need not match the histologic findings. Cancer subtypes The location of<unk>  can be described in terms of quadrants, or corresponding to a clock face when the subject is in supine position. Histologic subtypes of invasive<unk>  carcinoma include: Though squamous cell carcinoma is the<unk>  with the most incidence, the incidence of adenocarcinoma of the cervix has been increasing in recent decades. Endocervical adenocarcinoma represents 20–25% of the histological types of<unk>  carcinoma. Gastric-type mucinous adenocarcinoma of the cervix is a rare type of cancer with aggressive behavior. This type of malignancy is not related to high-risk human papillomavirus (HPV). * Squamous cell carcinoma (about 80–85%) * adenocarcinoma (about 15% of<unk> s in the UK) * Adenosquamous carcinoma * Small cell carcinoma * Neuroendocrine tumour * Glassy cell carcinoma * Villoglandular adenocarcinoma Noncarcinoma malignancies which can rarely occur in the cervix include melanoma and lymphoma. The International Federation of Gynecology and Obstetrics (FIGO) stage does not incorporate lymph node involvement in contrast to the TNM staging for most other cancers. For cases treated surgically, information obtained from the pathologist can be used in assigning a separate pathologic stage, but is not to replace the original clinical stage. Staging<unk>  is staged by the FIGO system, which is based on clinical examination rather than surgical findings. Prior to the 2018 revisions to FIGO staging, the system allowed only these diagnostic tests to be used in determining the stage: palpation, inspection, colposcopy, endocervical curettage, hysteroscopy, cystoscopy, proctoscopy, intravenous urography, and X-ray examination of the lungs and skeleton, and<unk>  conization. However, the current system allows use of any imaging or pathological methods for staging. File:Diagram showing stage 1A<unk>  CRUK 200.Stage 1A<unk>  File:Diagram showing stage 1B<unk>  CRUK 203.Stage 1B<unk>  File:Diagram showing stage 2A<unk>  CRUK 212.Stage 2A<unk>  File:Diagram showing stage 2B<unk>  CRUK 216.Stage 2B<unk>  File:Diagram showing stage 3B<unk>  CRUK 226.Stage 3B<unk>  File:Diagram showing stage 4A<unk>  CRUK 236.Stage 4A<unk>  File:Diagram showing stage 4B<unk>  CRUK 239.Stage 4B<unk>  Prevention Screening<unk>  screening test vehicle in Taiwan. Negative visual inspection with acetic acid of the cervix. Positive visual inspection with acetic acid of the cervix for CIN-1. Checking<unk>  cells with the Papanicolaou test (Pap test) for<unk>  pre-cancer has dramatically reduced the number of cases of, and mortality from,<unk> . Liquid-based cytology may reduce the number of inadequate samples. Pap test screening every three to five years with appropriate follow-up can reduce<unk>  incidence up to 80%. Abnormal results may suggest the presence of precancerous changes, allowing examination and possible preventive treatment, known as colposcopy. The treatment of low-grade lesions may adversely affect subsequent fertility and pregnancy. Personal invitations encouraging women to get screened are effective at increasing the likelihood they will do so. Educational materials also help increase the likelihood women will go for screening, but they are not as effective as invitations. According to the 2010 European guidelines, the age at which to start screening ranges between 20 and 30 years of age, but preferentially not before age 25 or 30 years, and depends on burden of the disease in the population and the available resources. In the United States, screening is recommended to begin at age 21, regardless of age at which a woman began having sex or other risk factors. Pap tests should be done every three years between the ages of 21 and 65. In women over the age of 65, screening may be discontinued if no abnormal screening results were seen within the previous 10 years and no history of CIN2 or higher exists. HPV vaccination status does not change screening rates. A number of recommended options exist for screening those 30 to 65. This includes<unk>  cytology every 3 years, HPV testing every 5 years, or HPV testing together with cytology every 5 years. Screening is not beneficial before age 25, as the rate of disease is low. Screening is not beneficial in women older than 60 years if they have a history of negative results. The American Society of Clinical Oncology guideline has recommend for different levels of resource availability. Pap tests have not been as effective in developing countries. This is in part because many of these countries have an impoverished health care infrastructure, too few trained and skilled professionals to obtain and interpret Pap tests, uninformed women who get lost to follow-up, and a lengthy turn-around time to get results. Visual inspection with acetic acid and HPV DNA testing have been tried, though with mixed success. Barrier protection Barrier protection or spermicidal gel use during sexual intercourse decreases, but does not eliminate risk of transmitting the infection, though condoms may protect against genital warts. They also provide protection against other sexually transmitted infections, such as HIV and Chlamydia, which are associated with greater risks of developing<unk> . Vaccination Three HPV vaccines (Gardasil, Gardasil 9, and Cervarix) reduce the risk of cancerous or precancerous changes of the cervix and perineum by about 93% and 62%, respectively. The vaccines are between 92% and 100% effective against HPV 16 and 18 up to at least 8 years. HPV vaccines are typically given to age 9 to 26, as the vaccine is most effective if given before infection occurs. The duration of effectiveness and whether a booster will be needed is unknown. The high cost of this vaccine has been a cause for concern. Several countries have considered (or are considering) programs to fund HPV vaccination. The American Society of Clinical Oncology guideline has recommendations for different levels of resource availability. Since 2010, young women in Japan have been eligible to receive the<unk>  vaccination for free. In June 2013, the Japanese Ministry of Health, Labor and Welfare mandated that, before administering the
Cervical cancer
Vaginal cancer
Endometrial cancer
Uterine cancer
Ovarian cancer
Breast cancer
Ovarian disease
Breast disease