ANATOMY OF THE CERVIX,

SQUAMOCOLUMNAR
JUNCTION, METAPLASTIC
CHANGE AND
TRANSFORMATION ZONE
 Recognize the anatomical and histological landmarks of
cervix the
.
Define the squamocolumnar junction (SCJ)
Learnin and transformation zone (TZ).

objective
g Understand the changes that occur during the
reproductive life and the metaplastic process
s (transformation process).
Consider SCJ and TZ as fundamental dynamic landmarks of
the transformation process and origin of precancerous
lesions
(CIN) and
cancer.

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 The cervix represents the lower cylindrical distal portion
of the uterus and is divided into:

ectocervix endocervix
/
Anatomy The portion of the cervix projecting into the vagina is
called portio vaginalis (3cm length).
the
of
The ectocervix - portio vaginalis - is visible during a
cervix speculum examination (fig.1).

The cervix opens onto the vagina through an orifice called

the external os (fig.1).

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 Anatomy of the cervix
Fig. 1
Fallopian tube
Ectocervix – portio vaginalis
and external os (EO)
during
the vaginal
ovar uteru ovar examination
y s y

IO
Endocervix
SCJ

EO
Vagina
EO: external os,
IO: internal
os, 4

SCJ:
squamocolumn
 The endocervix (endocervical canal) is a luminal cavity
within
the cervix forming a passageway between the external os
and the internal os.

Anatomy The upper limit of the endocervical canal called the internal
the
of os
or isthmus, marks the transition from the endocervix to
the
endometrium (uterine cavity) (fig.1).
cervix
The endocervical canal has a fusiform shape and measures
7 to 8 mm at its widest in reproductive-aged women.

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Anatomy of the cervix
Fig. 2

The size and shape of the cervix vary widely with

age, hormonal state, and parity.
A nulliparous
In the nulliparous female it is barrel shaped with a
small circular external os at the center of the
cervix. (fig. 2a).

In parous women, cervix is bulky and the external

os becomes slit-like (fig. 2b).

B parous

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 The ectocervix is covered by non-keratinizing, stratified
squamous epithelium, either native or metaplastic
in
continuity with the vaginal
epithelium.
Histology of The squamous epithelium is composed by multiple layers:
basal, parabasal, intermediate and superficial layer (fig.
the normal 3).

cervix The endocervix is lined by a simple columnar epithelium that

secretes mucus.
Mucinous columnar epithelium lines the surface and
the underlying glands (fig. 4).

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Histology of the normal cervix:
Ectocervix
Fig. 3

Structure of the ectocervix: CT=connective tissue, BM=basement membrane, L1=basal cells (1 layer), L2=parabasal
cells (2 layers), L3=intermediate cells (around 8 layers), L4=superficial cells (5 or 6 layers) and L5=exfoliating cells.
Courtesy of IARC: http://screening.iarc.fr
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Histology of the normal cervix:
Endocervix
Fig. 4

A B

Normal endocervix: the columnar epithelium is composed of one layer of mucin secreting cells with few reserve cells
(black arrow) – fig. 4a. Ectropion allowing the visualization of columnar epithelium – fig. 4b
Courtesy of IARC: http://screening.iarc.fr
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 The squamocolumnar junction (SCJ) (fig.5) is defined as
Histology of the junction between the squamous epithelium and the
the columnar
epithelium. Its location on the cervix is variable.

normal cervix: The SCJ is the result of a continuous remodeling

process resulting from uterine growth, cervical
Squamo- enlargement and hormonal status.

columnar During this process the original SCJ everts along with large
junction portions of columnar epithelium from their initial position
onto the ectocervix.

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Histology of the normal cervix:
Squamocolumnar junction
Fig. 5

The squamocolumnar junction: marks the boundary between the squamous-lined ectocervix and the columnar-
lined endocervix (arrows)
Pathological and histological images: Courtesy of Ed Uthman at Flickr
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 Age hormonal are the most important
influencing
and location of SCJ.
status factors
Histology of
the At birth and during premenarchal years, the SCJ is located
at or very close to the external os (original SCJ).
normal cervix:
Squamo- During reproductive age, the SCJ is located at variable
distances from the external os.
columnar
junction In a postmenopausal woman, the new SCJ not visiblean
has
is receded into the d
endocervix.

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 An eversion onto the ectocervix of the SCJ along with
portions
large of columnar epithelium is referred to as an
ectropion
(fig. 6 and animation).
Progressively through a process called metaplasia
Ectropion the
ectropion is replaced by metaplastic squamous
epithelium
(fig. 7 - 8 and
animation).
Metaplasia is a reaction of the exposed everted
columnar
epithelium (ectropion) to irritation by acidic
vaginal
environment
.

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SCJ and TZ: Fundamental dynamic
landmarks of the transformation process

Surgical specimen: courtesy of Dr C. Achtari (CHUV), Lausanne

Pictures: Pierre Vassilakos, GFMER, Geneva / Dominique Ricard-Gauthier, medical student HUG,
Geneva
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Ectropion:
Eversion of the columnar epithelium
Fig. 6

Ectropion: the columnar Large ectropion: with cervical

endocervical epithelium is visible on polype covering the external os
the surface of the cervix
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 Metaplasia is a non-neoplastic transformation of one mature
cell type to another mature cell type that is not normally
Histology of present at that location.

the normal The metaplastic process of the cervix starts with the
cervix: appearance of subcolumnar reserve cells of the endocervical
epithelium (fig. 4a).
Squamous
These cells proliferate and form a thin layer of
metaplasia immature squamous cells without stratification or
glycogen
(immature squamous metaplasia) (fig. 7a).

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Histology of The immature metaplasia then differentiates into
mature stratified squamous epithelium (mature

the normal squamous metaplasia).

cervix: The mature squamous metaplasia is similar to the normal

glycogen containing original squamous epithelium (fig.
Squamous 7b).

metaplasia Both mature and immature metaplasia might be observed

on the cervix at the same time.

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 Histology of the normal cervix:
Squamous metaplasia

Fig. 7A 7A
Immature squamous
after proliferation of reserve cells.
metaplasia
Remaining endocervical cells on
the surface.

Fig. 7B 7B a
Mature squamous metaplasia
(a) identical to the native
b
squamous epithelium (b)

Courtesy of IARC:
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http://screening.iarc.fr
 Transformation zone (TZ) (fig. 7, 8 and animation):
The Area between the original SCJ and the new SCJ where
the
columnar epithelium (ectropion) has been replaced and/or is
transformation being replaced by the new metaplastic squamous
epithelium.
zone The TZ may be either wide or narrow depending on age,
(TZ) parity, prior infections and exposure to female
hormones.

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 As a result of the metaplastic process a new SCJ is formed.
It is visible as a distinct white line after the application of 3
to acetic
5%
The new acid.
The white aspect after acetic acid application (fig.7a,
squamocolum- fig.8a)
is due to the presence of immature squamous
nar jonction metaplastic
epithelium adjacent to the new
SCJ.
The cervical area between the old SCJ and the new SCJ
is referred to as the transformation zone (TZ fig.8b).

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 Transformation zone (TZ)

Squamous epithelium
oSC
J Squamocolumnar junction
T (SCJ)
Z Columnar epithelium
nSC
J
Transformation zone

Fig. 8A Fig. 8B
Observe the immature metaplasia Once the metaplasic epithelium is
present in the transformation mature, its aspect will be identical
zone to the original squamous
oSCJ – old squamocolumnar junction epithelium
nSCJ – new squamocolumnar 21
junction
 Nabothian cysts and glandular orifices
Nabothian cysts and fine glandular orifices are normal findings in a
transformation zone. They appear when metaplasia fails to progress into the
glandular crypts.

A B

Nabothian cysts (a): the metaplastic process The fine glandular orifices (b): the
fails to enter the crypts covering them only at metaplastic process fails to descend or cover
the surface. The mucus of endocervical crypts the crypts of the columnar epithelium.
accumulates creating a typical cyst aspect. Therefore the orifices of the crypts remain
visible.
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 Recent studies indicate SCJ to be a site of “embryonic cell
population”, with a «top-down» pattern of
differentiation.
Why are SCJ In this model, the reserve cells are the progeny of
and TZ cells with different susceptibilities to infection by HPV
embryonic
therefore
and involved in malignant
important ? transformation.
The TZ is the site of origin for > 90% of precancerous
lesions also called squamous intraepithelial lesions (CIN) and
cancers.

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 The SCJ and TZ are fundamental dynamic landmarks of
transformation process
the
(metaplasia).
Age hormonal status are the most important
and factors
influencing the location of SCJ on the
Conclusion cervix.
HPV infections affecting the transformation zone may
lead
malignant transformation (CIN) and
cancer.
Identification of the SCJ and TZ is crucial when performing
a VIA/VILI examination.

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