September is over and so too is Gynaecological Cancer Awareness month...says the calendars! We want to stress the importance of understanding and preventing gynaecological cancers all year round. Gynaecological cancers encompass a range of cancers, including:
- Cervical cancer
- Endometrial cancer
- Ovarian cancer
- Vulvar cancer
- Vaginal cancer
- Uterine cancer
We will be focusing on cervical cancer: what it is, who it affects, the symptoms and the progress in the areas of prevention and treatment.
Cervical cancer is a cancer that affects the cervix, the tissue that connects the vagina to the uterus. Data from Cancer Research UK estimates that there are 3,197 new diagnoses of cervical cancer a year and 99.8% of cases are preventable. When cervical cancer does develop, the survival rate is 51% over 10 or more years (1).
Cervix: The lower part of the uterus, the cylinder-shaped bottleneck of tissue that connects the vagina to the uterus.
Pap smear: A way to collect cells from the cervix, a small brush is inserted into the vagina and used to sweep the walls of the cervix to collect cells
HPV (human papillomavirus): A very common type of virus. People who have HPV usually do not have symptoms however some people develop genital warts. HPV infection can increase the chance of developing cervical cancer.
Early stage cervical cancer does not normally show symptoms, but some symptoms that can appear in individuals include (2):
- Unusual vaginal bleeding, such as in between periods, during, or after penetrative sex or after menopause.
- Pain/discomfort during penetrative sex.
- Vaginal discharge.
- Pelvic pain (pain in between your hips).
Many of you reading this will probably be thinking, ‘but all these symptoms seem fairly common!’ And you’re right. There are many reasons that could explain these symptoms, such as STI infection, endometriosis or even stress (3,4). This highlights the importance of attending your cervical screenings to get your smear test and discussing any changes that are unusual for you with your GP.
What causes cervical cancer?
The most common cause of cervical cancer is Human Papillomavirus (HPV) infection. HPV is the name for a large group of common viruses that affect the skin, and not all of these cause cancer (5).
There are 12 strains of HPV that can increase risk of cervical cancer. The strains that most commonly cause cervical cancer are HPV16 and HPV18, making up about 70% of cervical cancer cases (6). HPV is a common virus and, for most of us, our immune systems do the legwork to clear it up quickly before cancer develops. It's like “the common cold that you get in your cervix”. By the age of 50, at least 90% of people with a cervix will come into contact with HPV and only 1% of cases will develop into cervical cancer (7).
The HPV Vaccine
Two HPV vaccine programmes are running in the UK, one which is offered to all children aged 12 to 13, and the other is for men who have sex with other men (8).
The first version of this programme used a vaccine called Gardasil which protects against HPV types 16, 18, 6 and 11, which protects against the two most common HPVs that cause cervical cancer, HPV 16 and 18. (9)
The new vaccine Gardasil 9 protects against all of the same HPVs as the Gardasil, but also HPV types 31, 33, 45, 52 and 58. (9)
There are also risk factors (things that increase your chance of developing a disease) for cervical cancer. For example, smoking tobacco is associated with 21% of cervical cancer cases (10). HIV infection is also associated with cervical cancer in roughly 5% of cases (11).
What is cervical screening?
Cervical screening is a screening test that can pick up the presence of a high-risk HPV strain and abnormal cellular changes on your cervix. Abnormal cellular changes means that some of the cells on your cervix didn't develop the way they were expected to. Cervical intraepithelial neoplasia (or "CIN") is the term that tells your doctor that these cellular changes on your cervix have occurred. Now hold up! This doesn't mean straight away that you have cervical cancer but it does mean that these cells have the potential to turn into cancerous cells in the future. Another pause for the importance of screenings.
By detecting these cells at the early stage, your doctor can help you get the treatment option that you need.
Who needs to get cervical screenings?
Anyone who has a cervix should get regular cervical screenings. This includes women who have not had a hysterectomy (removal of the reproductive organs, including the cervix), transgender men, non-binary people, and intersex people who have a cervix. All individuals meeting these criteria between the ages of 25 and 64 years will be invited for a screening by the NHS, and this is an invitation you don't want to turn down. A common misconception is that “I’ve never had a sex with a man so I don’t need a smear test”. The virus is everywhere in our environment, so if you ever had any type of sex/intercourse/genital contact, it's recommended that you attend a screening. If you're still uncertain about whether you should book a screening, you can use the flowchart below to help:
Jo's Cervical Cancer Trust, the NHS and Cancer Research UK have a wealth of resources for anyone who needs testing no matter your gender identity, as well as resources to cope with anxiety.
Does the screening hurt?
During a test, you will be laid on your back with your legs elevated. A smooth tool called a speculum will be inserted into the vagina, which allows a good view of the cervix. Some people find that part of the examination uncomfortable, but the speculum comes in a variety of sizes, and the one most appropriate for your body will be chosen to reduce discomfort as much as possible. Once there is a good view of the cervix, a small brush is inserted and sweeps the walls of the cervix to collect cells, the brush and speculum are removed, and the procedure is done. Once the doctor visualises your cervix, it normally only takes a few seconds to use the brush and collect the sample, and the entire test itself is usually over in 5 minutes.
Some people may get some spotting after the smear. People who have cervical ectropian (this is when the cells from inside the cervical canal grow on the outside of the cervix) may be more likely to experience discomfort or cramps from the stimulation of the cervix.
There are a few factors that may cause screening to be more uncomfortable than usual, such as:
- Vaginismus: sudden tightening of the vagina during any insertion (13)
- FGM: Female genital mutilation (13)
- Endometriosis: chronic scarring and inflammation can make the procedure more painful (14)
- Cervical erosion: where cells from the cervix grow beyond the cervix (13)
- Having a tilted cervix (15)
During any test, you are in control. You can ask the test to be stopped at any time, you can lie in a more comfortable position, and you can ask for a different size speculum. You can also ask for a longer appointment if you’re particularly anxious, and have someone accompany you to the appointment (16).
The results take a few weeks to come back. In the UK, around 95% of women attending cervical screening will have a normal result. Abnormal results means that there may be some cells on your cervix that need to be investigated further. Those with abnormal results may be invited for a colposcopy appointment. During that appointment, if the doctor sees any abnormal areas, they may take a biopsy (tiny piece of tissue) to be sent to a lab for analysis.
Looking to the future
There have been incredible strides in cervical cancer research and treatment and prevention. The introduction of the HPV vaccine has been invaluable in prevention, with a study funded by Cancer Research UK stating that ‘the HPV immunisation programme has successfully almost eliminated cervical cancer in women born since Sept 1, 1995.’ (17). Attending your smear test is currently the single most effective way of preventing cervical cancer.
There have also been breakthroughs in treatment of late stage, treatment-resistant cervical cancer. The HARE-40 clinical trial is currently underway, which is testing a vaccine that activates the immune system to kill cancers caused by HPV. If this trial is successful, it will give patients who have already tried every treatment option new hope in treating their cancer (18).
The proverb ‘an ounce of prevention is worth a pound of cure’ is used a lot when discussing medical conditions, and cervical cancer is one of the most applicable to this. The early stages typically show no symptoms, or symptoms which many may brush off, and, again, approximately 98.9% of cases are preventable. Attending cervical screenings is the best defence you have against cervical cancer.
Anyone with a cervix from the age of 25 is entitled to cervical screening, during which you should be respected, in control and comfortable. There is a lot of hope for the future, the HPV vaccine will drastically reduce future cases. However, you should still attend screenings, as HPV is not the only cause of cervical cancer!
- Cervical Cancer Statistics, Cancer Research UK https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer
- Cervical Cancer Symptoms, Cancer Research UK https://www.cancerresearchuk.org/about-cancer/cervical-cancer/symptoms
- What’s causing my spotting in between periods? https://www.livi.co.uk/your-health/whats-causing-my-spotting-in-between-periods/
- What causes heavy or irregular periods? A doctor’s guide https://www.livi.co.uk/your-health/what-causes-heavy-or-irregular-periods-a-doctors-guide/
- Human papillomavirus (HPV), NHS. https://www.nhs.uk/conditions/human-papilloma-virus-hpv/
- Risks and causes - cervical cancer, Cancer Research UK https://www.cancerresearchuk.org/about-cancer/cervical-cancer/risks-causes
- Your guide to HPV, The Royal Mardson https://www.royalmarsden.nhs.uk/your-guide-hpv
- HPV vaccine overview https://www.nhs.uk/conditions/vaccinations/hpv-human-papillomavirus-vaccine/
- Having the HPV vaccine in school, Jo’s cervical cancer trust https://www.jostrust.org.uk/information/hpv-vaccine/school
- Cervical cancer, risks and causes, Cancer Research UK https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/cervical-cancer/risk-factors#ref-4
- Estimates of the global burden of cervical cancer associated with HIV, Stelze et al, The Lancet. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30459-9/fulltext#:~:text=Women%20living%20with%20HIV%20have%20a%20substantially%20increased%20risk%20for,cancer%20are%20attributable%20to%20HIV.
- Oral Human Papillomavirus Infection in Children during the First 6 Years of Life, Finland. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920652/
- Let’s talk about it… sometimes smear tests are painful https://www.jostrust.org.uk/about-us/news-and-blog/blog/sometimes-smear-tests-are-painful
- Let's talk about...smear tests when you have endometriosis https://www.jostrust.org.uk/about-us/news-and-blog/blog/lets-talk-about-smear-tests-when-you-have-endometriosis
- Let's talk about... smear tests when you have a tilted cervix https://www.jostrust.org.uk/about-us/news-and-blog/blog/lets-talk-about-smear-tests-when-you-have-tilted-cervix
- Our cervical screening tips https://www.jostrust.org.uk/information/cervical-screening/cervical-screening-tips
- The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: a register-based observational study https://www.sciencedirect.com/science/article/pii/S0140673621021784
- Trial of a new vaccine to treat incurable cancer expands to more UK sites https://www.southampton.ac.uk/ctu/news/2022/07/14-trial-of-vaccine-to-treat-incurable-cancer-expands-to-manchester.page
Article edited by Fiona Kennedy, MSc
Medically reviewed by Dr.Paulina Cecula