Cervical Dysplasia

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Overview

Cervical dysplasia is a term used to describe the appearance of abnormal cells on the surface of the cervix, the lowest part of the uterus. These changes in cervical tissue are classified as mild, moderate, or severe. While dysplasia itself does not cause health problems, it is considered to be a precancerous condition. Left untreated, dysplasia sometimes progresses to an early form of cancer known as cervical carcinoma in situ, and eventually to invasive cervical cancer.

It can take 10 years or longer for cervical dysplasia to develop into cancer. Dysplasia can be detected from a Pap smear, the single most important step that a woman can take to prevent cervical cancer.

Mild dysplasia is the most common form, and up to 70% of these cases regress on their own (i.e., the cervical tissue returns to normal without treatment). Moderate and severe dysplasia are less likely to self-resolve and have a higher rate of progression to cancer. The greater the abnormality, the higher the risk for developing cervical cancer.

Cervical dysplasia does not cause symptoms; therefore, regular screening and early diagnosis are important. Detecting and treating dysplasia early is essential to prevent cancer. For this reason, most physicians quickly remove suspicious cervical lesions and require frequent Pap smears to monitor for recurrences.

Incidence and Prevalence
Every year, between 250,000 and 1 million women in the United States are diagnosed with cervical dysplasia. While it can occur at any age, the peak incidence is in women between the ages of 25 to 35. Most dysplasia cases can be cured with proper treatment and follow-up. Without treatment, 30% to 50% may progress to invasive cancer.

Risk Factors

Risk factors increase the frequency of occurrence. Several risk factors have been linked to dysplasia including multiple sexual partners, early onset of sexual activity, cigarette smoking, and sexually transmitted diseases, especially human papillomavirus (HPV) and HIV infection.

HPV Infection
Eighty to ninety percent of women with cervical dysplasia have an HPV infection. Human papillomavirus (HPV) is a group of more than 80 different viral strains. About one-third are sexually transmitted, and some types cause genital warts. HPV infects about 25 million people in the United States, and most of the viral strains are harmless.

However, the NIH Consensus Conference on Cancer of the Cervix and the World Health Organization (WHO) have concluded that several strains of HPV cause cervical cancer. The strains found most frequently in precancerous lesions and in cervical cancer are types 16 and 18. Other strains with high malignant potential include 31, 33, 35, 39, 45, 51, 52, 56, 58, and 68, and together, they account for almost 90% of cancerous lesions and dysplasia in HPV infections.

Most HPV infections resolve within 6 months and many women develop immunity. HPV often does not cause symptoms. One study found that nearly one-half of the women infected with HPV had no symptoms and a person may not even know that they are infected. Untreated HPV can result in recurrent and persistent cervical dysplasia and many experts believe that HPV is the main cause for changes in cervical cells that result in dysplasia.

HIV Infection
Women who are infected with HIV are at a greater risk for developing dysplasia. The risk appears to increase as the number of CD4 cells (cells that play a critical role in immune responses) decreases. HIV-positive women also have a higher rate of persistent HPV infections and may be infected with the strains that are associated with severe dysplasia and cervical cancer. Women whose immune systems are suppressed for other reasons, such as by drugs that prevent rejection of organ transplants, are also at greater risk. This suggests that women with weakened immunity are more likely to be infected with HPV and to have a persistent infection that does not resolve on its own.

Smoking
Nicotine and cotinine, chemicals produced from tobacco, have been found in the cervical cells of women who smoke. Men who smoke also excrete these chemicals in their semen, which comes in contact with the cervix during sexual intercourse. Tobacco chemicals may cause alterations in the cells that lead to dysplasia. (See also: women and smoking, and smoking cessation options)

High-risk sexual behavior
Having multiple sex partners, having sex with a man who has had multiple sex partners, and engaging in sexual intercourse before the age of 18 are linked to cervical dysplasia. Women in these categories have a greater chance of being infected with HPV or HIV, especially if they do not use a barrier contraceptive such as a condom. These infections put them at higher risk for developing cervical dysplasia.

DES Exposure
Between 1938 and 1971, approximately 5 million pregnant women were prescribed diethylstilbestrol (DES), a synthetic estrogen thought to help prevent miscarriage. Its use was discontinued when researchers found it to be ineffective and dangerous. The daughters of women who took DES have a higher risk for developing rare cancer of the vagina or cervix, called clear cell adenocarcinoma, and abnormalities of the cervix, vagina, and uterus.

Poor Nutrition
There is growing evidence that certain vitamins, such as folic acid, play a role in cervical health. A poor diet may also cause the immune system to weaken, decreasing the body's ability to fight viruses such as HPV.

Oral Contraceptives
Some research shows that women who use oral contraceptives may be at a higher risk for developing cervical dysplasia. However, it is not clear if the risk is directly attributable to the contraceptives themselves. One reason may be that oral contraceptives interfere with folic acid metabolism in the cells around the cervix, and folic acid may help prevent or improve cervical dysplasia. Another reason may be that women using this method of birth control may have increased exposure to sexually transmitted diseases, compared to those who rely on a barrier method such as a condom.

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