Cervical leukoplakia is a limited pathological change in the exocervix, characterized by the processes of proliferation and keratinization of the multilayer epithelium. Leukoplakia of the cervix as a whole is asymptomatic; it may be accompanied by significant whites and contact secretions. It is diagnosed by examining the cervix in mirrors, extended colposcopy, examination of cervical scrapings, biopsy with histological examination of the material. In the treatment of cervical leukoplakia, cryodestruction, radio wave coagulation, CO2 laser vaporization, argon plasma coagulation methods are used; in some cases, conization or amputation of the cervix is indicated.
N88.0 Cervical leukoplakia
Leukoplakia (Greek – leucos; plax – white plaque) is a zone of keratinization and thickening of the integumentary epithelium of the cervix of varying severity (by the type of hyperkeratosis, parakeratosis, acanthosis). Macroscopically, the picture of leukoplakia looks like whitish plaques rising above the mucous membrane of the vaginal part of the cervix, sometimes these formations are localized in the cervical canal.
The prevalence of leukoplakia is 5.2% among all cervical pathology. Women of reproductive age are more prone to the disease. The insidiousness of leukoplakia lies in the high risk of malignant transformation of the cervical epithelium, which develops in 31.6% of patients. Therefore, the issues of timely diagnosis and treatment of cervical leukoplakia are closely related to the problem of prevention of cervical cancer.
The etiology of cervical leukoplakia is characterized by the influence of endogenous factors (hormonal and immune regulation disorders), as well as exogenous causes (infectious, chemical, traumatic). In changing hormonal homeostasis, a violation of the functional relationship in the hypothalamus – pituitary – ovaries – uterus chain is important, leading to anovulation, relative or absolute hyperestrogenism, progesterone deficiency and, as a consequence, hyperplastic processes in target organs.
The occurrence of cervical leukoplakia is often preceded by infectious and inflammatory processes (endometritis, adnexitis), menstrual cycle disorders (amenorrhea, oligomenorrhea). Background factors include papillomavirus infection, ureaplasmosis, chlamydia, mycoplasmosis, herpes, cytomegalovirus infection, nonspecific colpitis and cervicitis, recurrent ectopias; reduced general and local reactivity; promiscuous sex life. The development of leukoplakia is promoted by traumatic and chemical damage to the cervix during surgical termination of pregnancy, diagnostic curettage, drug cauterization or diathermocoagulation of cervical erosion, and other aggressive interventions.
Against the background of etiological factors, mechanisms are triggered that cause keratinization of exocervix multilayer epithelium cells (normally not keratinizing). Due to the gradual restructuring of epithelial cells (disintegration of nuclei and intracellular organoids), horny scales that do not contain glycogen are formed. Foci of cervical leukoplakia can be single or multiple.
According to morphological criteria, gynecology distinguishes simple and proliferative leukoplakia of the cervix. Simple leukoplakia of the cervix is attributed to background changes (hyper- or parakeratosis). It is characterized by thickening and keratinization of the surface layers of the epithelium; at the same time, the cells of the basal and parabasal layers do not undergo changes.
With proliferative transformation, differentiation, proliferation of cells of all layers is disrupted, atypical structural elements appear. This form of cervical leukoplakia is regarded as a precancerous process – cervical intraepithelial neoplasia (CIN, cervical dysplasia).
The disease is not accompanied by a specific clinical picture and subjective complaints. More often, cervical leukoplakia is detected during the next examination by a gynecologist. In some cases, indirect signs of cervical leukoplakia may be present – significant white spots with an unpleasant odor, contact discharge of a small volume of blood after sexual intercourse.
During gynecological examination with the help of mirrors on the cervix, whitish areas in the form of spots or plaques are determined, more often oval in shape, with clear boundaries, variable sizes. Foci of leukoplakia, as a rule, slightly rise above the surface of the unchanged epithelial cover of the cervix. The surface of the plaques may be covered with keratinized epithelial scales.
Cytological examination of cervical scraping reveals clusters of surface epithelial cells with signs of hyperkeratosis or parakeratosis. In the case of hyperkeratosis, nuclear-free keratinized scales are detected in large numbers. With parakeratosis, the density and color of the cytoplasm of small cells with pyknotic nuclei increases.
The processes of hyper- and parakeratosis prevent the cells of the deep layers of the epithelium from getting into the scraping, in which proliferation, differentiation disorders and atypia are possible. Therefore, in the diagnosis of leukoplakia, the leading method is a targeted knife biopsy of the cervix and histological examination of exocervix tissues, which make it possible to exclude or confirm tumor processes, as well as cervical intraepithelial neoplasia (CIN). In order to exclude cervical cancer, the cervical canal is scraped.
With the help of extended colposcopy (video colposcopy), the nature and size of the lesion are clarified. Colposcopic imaging shows white plaques with a fine-grained surface, clear and even edges, and the absence of blood vessels. The magnitude and prevalence of cervical leukoplakia can vary from a single point plaque to multiple and extensive zones covering the entire exocervix and extending to the vaginal arches. Conducting a Schiller test reveals iodonegative areas.
Clinical and laboratory tests include microscopic, bacteriological examination of smears, PCR detection and typing of HPV, hormonal and immunological studies (according to indications). In the process of diagnosis, cervical leukoplakia is differentiated from cervical cancer, cervical erosion. Patients with cervical leukoplakia may need to consult an oncogynecologist, gynecologist-endocrinologist.
The treatment strategy is determined by the form of detected cervical leukoplakia (simple or proliferative). The goals of treatment are the elimination of background diseases and the complete removal of pathological foci.
According to the indications, antibacterial, antiviral, anti-inflammatory therapy is carried out. To remove foci of cervical leukoplakia in gynecology, methods of cryogenic exposure, radio wave destruction, argon plasma coagulation, CO2 laser vaporization, diathermocoagulation, chemical coagulation are used. Minimally invasive destruction of cervical leukoplakia foci is performed on an outpatient basis; tissue healing may require a period of 2 weeks to 2 months, taking into account the extent of the lesion, concomitant diseases, and the method of destruction.
For the period of treatment of cervical leukoplakia, sexual activity and the use of any contraception are excluded. In the case of cervical intraepithelial neoplasia, a combination of leukoplakia with hypertrophy, kraurosis, scar deformities of the cervix, the scope of intervention may include conization of the cervix or amputation of the cervix.
In order to prevent the development of cervical leukoplakia, early treatment of erosions, inflammatory and infectious processes in the reproductive organs is necessary; exclusion of abortions, cervical injuries during childbirth and gynecological manipulations; prevention of STIs, the use of barrier contraception.
Women suffering from menstrual disorders should be monitored by a gynecologist-endocrinologist in order to correct hormonal disorders. Screening and explanatory work, regular gynecological examinations are important in the prevention of cervical leukoplakia. An essential preventive point is vaccination against HPV.
After the destruction of leukoplakia foci without atypia, the patient is performed colposcopy, smear examination for oncocytology, HPV tests every six months. After 2 years and in the absence of relapses, the woman is transferred to the usual monitoring mode.
In the absence of atypia, papillomavirus infection, elimination of unfavorable background factors, the prognosis after the cure of cervical leukoplakia is favorable. With the preservation of the root cause of the disease, a manifest course and the transition of leukoplakia to cervical cancer is possible.
With simple leukoplakia in women planning childbirth, in order to avoid scarring of the cervix, it is preferable to use gentle methods of destruction – cryodestruction, laser vaporization, radiosurgical treatment, chemical coagulation. Pregnancy management in this group of patients requires increased monitoring of the state of the cervix.