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A. During prepuberty, the ectocervix protrudes into the vagina and is covered by a nonkeratinized, stratified squamous epithelium that is continuous with the vaginal epithelium.

B. The endocervical canal connects the uterine cavity with the vaginal cavity and is lined by deep crypts of mucous-secreting simple columnar epithelium.

1. At puberty, the simple columnar epithelium of the endocervical canal extends onto the ectocervix. However, exposure of the simple columnar epithelium to the acidic (pH = 3) environment of the vagina induces a squamous metaplasia and the formation of a transformation zone.

2. The transformation zone is the site of Nabothian cysts, which develop as stratified squamous epithelium grows over the mucous-sccreting simple columnar epithelium and entraps large amounts of mucus.

a. The transformation zone is the most common site of squamous cell carcinoma of the cervix, which is usually preceded by epithelial changes called cervical intraepithelial neoplasia, which can be diagnosed by a Papanicolaou (Pap) smear.

b. The Pap smear also may be used to evaluate hormonally a woman in many different clinical situations by establishing a maturation index based on the morphology of 100 cells (Tible 24-3).

(1) Superficial squamous cells form under the influence of estrogen.

(2) Intermediate squamous cells form under the influence of progesterone.

(3) Parabasal cells imply the absence of estrogen or progesterone influence.

VI. VAGINA is lined by nonkeratinized stratified squamous epithelium.

A. The superficial cells are continuously exfoliated during the menstrual cycle, but exfoliation increases during the late secretory phase and menstrual phase.

B. The exfoliated cells contain glycogen, which is metabolized by commensal lacto-bacilli to lactic acid, which forms an acidic (pH = 3) environment. The acidic environment deters the invasion of bacterial pathogens and fungi (e.g., Candida albicans, which causes vaginal thrush).

C. The labia major and clitoris may be sites of metastasis of a malignant melanoma.

D. Trichomonas vaginalis is a flagellated protozoan that is sexually transmitted. It produces a vaginitis characterized by an inflammatory Pap smear with numerous neutrophils, strawberry-colored mucosa, and discharge (leukorrhea). Postcoital bleeding is a common complaint. In a wet preparation of the vaginal discharge, the tumbling motility of the organism can be observed.

Table 24-3

Maturation Indices in Various Clinical Situations

Table 24-3

Maturation Indices in Various Clinical Situations

ISC

PBC

SSC

Normal nonpregnant adult woman

30

0

70

Estrogen tumor or therapy; polycystic ovarian syndrome

0

0

100

Pregnant woman; prepubescent girl

100

0

0

Menopausal woman

0

100

0

ISC = intermediate squamous cells; PBC = parabasal cells; SSC = superficial squamous cells.

ISC = intermediate squamous cells; PBC = parabasal cells; SSC = superficial squamous cells.

E. Ciardnerella vaginalis is a bacterial infection often associated with Mobiluncus or Bac-lernides. It is not sexually transmitted. It produces a vaginitis characterized by no inflammatory Pap smear, no changes in the mucosa, and discharge. In the "sniff test" of the vaginal discharge, a drop of potassium hydroxide produces a noticeable fishy, amine-likc smell.

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