The cervix

The cervix is part of the female reproductive system, which also includes the fallopian tubes, uterus (womb), ovaries, vagina (birth canal) and vulva (external genitals).

Also called the neck of the uterus, the cervix connects the uterus to the vagina. The cervix:

  • produces moisture to lubricate the vagina, which keeps the vagina healthy
  • opens to let menstrual blood pass from the uterus into the vagina
  • produces mucus that helps sperm travel up the uterus and fallopian tubes to fertilise an egg that has been released from the ovary
  • holds a developing baby in the uterus during pregnancy by remaining closed, then widens to let a baby be born through the vagina.

The cervix has an outer surface that opens into the vagina (ectocervix) and an inner surface that lines the cervical canal (endocervix). These two surfaces are covered by two types of cells:

Squamous cells – flat, thin cells that cover the outer surface of the cervix (ectocervix). Cancer of the squamous cells is called squamous cell carcinoma.

Glandular cells – column-shaped cells that cover the inner surface of the cervix (cervical canal or endocervix). Cancer of the glandular cells is called adenocarcinoma.

The area where the squamous cells and glandular cells meet is known as the transformation zone. This is where most cervical cancers start.

What is cervical cancer?

Cervical cancer begins when abnormal cells in the lining of the cervix grow uncontrollably. Cancer most commonly starts in the area of the cervix called the transformation zone, but it may spread to tissues around the cervix, such as the vagina, or to other parts of the body, such as the lymph nodes, lungs or liver.

What types are there?

There are two main types of cervical cancer, which are named after the cells they start in:

Squamous cell carcinoma (SCC) – the most common type, starts in the squamous cells of the cervix. It accounts for about 7 out of 10 cases (70%).

Adenocarcinoma – a less common type (about 25% of cases), starts in the glandular cells of the cervix. Adenocarcinoma is more difficult to diagnose because it occurs higher up in the cervix and the abnormal glandular cells are harder to find.

A small number of cervical cancers feature both squamous cells and glandular cells. These cancers are known as adenosquamous carcinomas or mixed carcinomas.

Other rarer types of cancer that can start in the cervix include small cell carcinoma and cervical sarcoma.

How common is cervical cancer?

About 850 women in Australia are diagnosed with cervical cancer every year. Cervical cancer is most commonly diagnosed in women over 30, but it can occur at any age. About one in 195 women will develop cervical cancer before the age of 75.3

The incidence of cervical cancer in Australia has decreased significantly since a national screening program was introduced in the 1990s and a national HPV vaccination program was introduced in 2007.

What are the symptoms of cervical cancer?

In its early stages, cervical cancer usually has no symptoms. The only way to know if there are abnormal cells in the cervix that may develop into cervical cancer is to have a cervical screening test (see below). If symptoms occur, they usually include:

  • vaginal bleeding between periods, after menopause, or during or after sexual intercourse
  • pelvic pain
  • pain during sexual intercourse
  • an unusual vaginal discharge
  • heavier periods or periods that last longer than usual.

Although these symptoms can also be caused by other conditions or medicines, it is very important to rule out cervical cancer. See your general practitioner (GP) if you are worried or the symptoms are ongoing. This is important for anyone with a cervix, whether straight, lesbian, gay, bisexual, transgender or intersex.

What are precancerous cervical cell changes?

Sometimes the squamous cells and glandular cells in the cervix start to change. They no longer appear normal when they are examined under a microscope.

These early cervical cell changes may be precancerous. This means there is an area of abnormal tissue (a lesion) that is not cancer, but may lead to cancer. Only some women with precancerous changes of the cervix will develop cervical cancer.

Precancerous cervical cell changes are caused by certain types of the human papillomavirus (HPV). These cervical cell changes don’t have symptoms but can be found during a routine cervical screening test (see below).

There are two main types of cervical cell changes:

Abnormal squamous cells

These are called squamous intraepithelial lesions (SIL). They can be classified as either low grade (LSIL) or high grade (HSIL). SIL used to be called cervical intraepithelial neoplasia (CIN), which was graded according to how deep the abnormal cells were within the surface of the cervix:

  • LSIL, previously graded as CIN 1, usually disappear without treatment.
  • HSIL, previously graded as CIN 2 or 3, are precancerous. High-grade abnormalities have the potential to develop into early cervical cancer over 10–15 years if they are not found and treated. They can often be treated without affecting fertility.

Abnormal glandular cells

These are called adenocarcinoma in situ. They will need treatment to reduce the chance they develop into adenocarcinoma. Anyone with abnormal glandular cells in the cervix should be referred to a gynaecologist for a colposcopy.

Treating precancerous cervical cell changes will prevent them developing into cervical cancer.

What are the causes of cervical cancer?

Almost all cases of cervical cancer are caused by an infection called human papillomavirus (HPV). There are also other known risk factors.

Infection with HPV

HPV is the name for a group of viruses. It is a common infection that affects the surface of different
areas of the body, such as the cervix, vagina and skin.

There are more than 100 different types of HPV, including over 40 types that affect the genitals. Genital HPV is usually spread via the skin during sexual contact. About four out of five people will become infected with at least one type of genital HPV at some time in their lives. Some other types of HPV cause common warts on the hands and feet.

Most people will not know they have HPV as it is usually harmless and doesn’t cause symptoms. In most people, the virus is cleared quickly by the immune system and no treatment is needed. In some women, the infection doesn’t go away and they have an increased risk of developing changes in the cervix. These changes usually develop slowly over many years.

Approximately 15 types of genital HPV cause cervical cancer. Screening tests are used to detect most of these types of HPV or the precancerous cell changes caused by the virus. See pages 15–16 for more information on screening tests. There is also a vaccine that protects people from some types of HPV.

National HPV vaccination program

  • The HPV vaccine used in Australia protects against nine strains of HPV known to cause around 90% of cervical cancers.
  • The HPV vaccine also offers some protection against other less common cancers associated with HPV, including vaginal, vulvar, anal and oropharyngeal cancers.
  • As part of the national HPV vaccination program, the vaccine is free for girls and boys aged 12–13. (The vaccine helps to protect males against penile, anal and oropharyngeal cancers.)
  • People who are already sexually active may still benefit from the HPV vaccine. Ask your GP for more information.
  • The HPV vaccine does not treat precancerous cell changes or cervical cancer.
  • If you’ve been vaccinated, you will still need regular screening tests as the HPV vaccine does not provide protection against all types of HPV. For more information, visit hpvvaccine.org.au.

What are the risk factors?

Smoking and passive smoking

Chemicals in tobacco can damage the cells of the cervix, making cancer more likely to develop in women with HPV.

Long-term use of oral contraceptive (the pill)

Research has shown that women who have taken the pill for five years or more are at increased risk of developing cervical cancer. The reason for this is not clear. However, the risk is small and the pill can also help protect against other types of cancer, such as uterine and ovarian cancers. Talk to your doctor if you are concerned.

Having a weakened immune system

The immune system helps rid the body of HPV. Women with a weakened immune system have an increased risk of developing cervical cancer and need to have more frequent cervical screening tests. This includes women with the human immunodeficiency virus (HIV) and women who take medicines that lower their immunity. Ask your doctor if this applies to you and how often you should have a screening test.

Exposure to diethylstilbestrol (DES)

This is a synthetic (artificial) form of the female hormone oestrogen. DES was prescribed to pregnant women from the 1940s to the early 1970s to prevent miscarriage. Studies have shown that the daughters of women who took DES have a small but increased risk of developing a rare type of cervical adenocarcinoma.

Which health professionals will I see?

Your GP will arrange the first tests to assess your symptoms. If these tests do not rule out cancer, you will usually be referred to a specialist, such as a gynaecologist or gynaecological oncologist. The specialist will arrange further tests.

If cervical cancer is diagnosed, the specialist will consider treatment options. Often these will be discussed with other health professionals at what is known as a multidisciplinary team (MDT) meeting. During and after treatment, you will see a range of health professionals who specialise in different aspects of your care.

Health professionals you may see to treat cervical cancer:

Gynaecologist a specialist who specialises in diseases of the female reproductive system; may diagnose cervical cancer and then refer you to a gynaecological oncologist
Gynaecological oncologist a specialist who diagnoses and performs surgery for cancers of the female reproductive system (gynaecological cancers), such as cervical cancer
Radiation oncologist a specialist who treats cancer by prescribing and overseeing a course of radiation therapy
Medical oncologist a specialist who treats cancer with drug therapies such as targeted therapy, chemotherapy and immunotherapy
Radiologist a specialist who analyses x-rays and scans; an interventional radiologist may also perform a biopsy under ultrasound or CT, and deliver some treatments
Cancer care coordinator coordinates your care, liaises with MDT members, and supports you and your family throughout treatment; may be a clinical nurse consultant (CNC) or clinical nurse specialist (CNS)
Nurse administers drugs and provides care, information and support throughout treatment
Dietitian recommends an eating plan to follow during treatment and recovery
Social worker, psychologist link you to support services; help with emotional and practical problems associated with cancer and treatment
Women’s health physiotherapist treats physical problems associated with treatment for gynaecological cancers, such as bladder and bowel issues, sexual issues and pelvic pain

Diagnosis

You may have tests for cervical cancer because you have symptoms or because your cervical screening test results suggest that you have a higher risk of developing cervical cancer.

Some tests allow your doctor to see the tissue in your cervix and surrounding areas more clearly. Other tests tell the doctor about your general health and whether the cancer has spread. You probably won’t need to have all the tests described in this chapter.

Screening test for cervical cancer

Cervical screening is the process of looking for cancer or precancerous changes in women who don’t have any symptoms. The cervical screening test detects cancer-causing types of HPV in a sample of cells taken from the cervix.

The National Cervical Screening Program recommends that women aged 25–74 have a cervical screening test two years after their last Pap test, and then once every five years. Whether you identify as straight, lesbian, gay, bisexual, transgender or intersex, if you have a cervix you should have regular cervical screening tests.

During both the old Pap test and the new cervical screening test the doctor gently inserts an instrument called a speculum into the vagina to get a clear view of the cervix. The doctor uses a brush or spatula to remove some cells from the surface of the cervix. This can feel slightly uncomfortable, but it usually takes only a minute or two. The sample is placed into liquid in a small container and sent to a laboratory to check for HPV.

If HPV is found, a specialist doctor called a pathologist will do an additional test on the sample to check for cell abnormalities. This is called liquid-based cytology (LBC).

The results of the cervical screening test are used to predict your level of risk for significant cervical changes. If the results show:

  • a higher risk – your GP will refer you to a specialist (gynaecologist) for colposcopy (see below)
  • an intermediate risk – you will be monitored by having a follow-up test (usually for HPV) in 12 months and more frequent screening tests in the future
  • a low risk – you will be due for your next cervical screening test in five years.

A small number of women are diagnosed with cervical cancer because of an abnormal cervical screening test. For more information about screening tests, call Cancer Council 13 11 20 or visit cervicalscreening.org.au.

Colposcopy and biopsy

If the cervical screening test results show that you have a higher risk of significant cervical changes, you will usually be referred for a colposcopy. A colposcopy lets your doctor look closely at the cervix to see where any abnormal or changed cells are and what they look like.

The colposcope is a magnifying instrument that has a light and looks like a pair of binoculars on a large stand. It is placed near your vulva but does not enter your body.

A colposcopy usually takes 10–15 minutes. You will be advised not to have sex or put anything in your vagina (e.g. tampons) for 24 hours before the procedure.

You will lie on your back in an examination chair with your knees up and apart. The doctor will use a speculum to spread the walls of your vagina apart, and then apply a vinegar-like liquid or iodine to your cervix and vagina. This makes it easier to see abnormal cells through the colposcope. You may feel a mild stinging or burning sensation, and you may have a brown discharge from the vagina afterwards.

If the doctor sees any suspicious-looking areas, they will usually take a tissue sample (biopsy) from the surface of the cervix for examination. You may feel uncomfortable for a short time while the tissue sample is taken. You will be able to go home once the colposcopy and biopsy are done. The doctor will send the tissue sample to a laboratory, and a pathologist will examine the cells under a microscope to see if they are cancerous. The results are usually available in about a week.

Side effects of a colposcopy with biopsy

After the procedure it is common to experience cramping that feels similar to menstrual pain. Pain is usually short-lived and you can take mild pain medicines such as paracetamol or non-steroidal anti-inflammatory drugs. You may also have some light bleeding or other vaginal discharge for a few hours.

To allow the cervix to heal and to reduce the risk of infection, your doctor will probably advise you not to have sexual intercourse or use tampons for 2–3 days after a biopsy.

Treating precancerous abnormalities

If any of the tests show precancerous cell changes, you may have one of the following treatments to prevent you developing cervical cancer.

Large loop excision of the transformation zone (LLETZ)

Also called loop electrosurgical excision procedure (LEEP), this is the most common way of removing cervical tissue to treat precancerous changes of the cervix. The abnormal tissue is removed using a thin wire loop that is heated electrically. The doctor aims to remove all the abnormal cells from the surface of the cervix.

A LLETZ or LEEP is done under local anaesthetic in your doctor’s office or under general anaesthetic in hospital. It takes about 10–20 minutes. The tissue sample is sent to a laboratory for examination under a microscope. Results are usually available within a week.

Side effects of a LLETZ or LEEP

After a LLETZ or LEEP, you may have some vaginal bleeding and cramping. This will usually ease in a few days, but you may notice some spotting for 3–4 weeks. If the bleeding lasts longer than 3–4 weeks, becomes heavy or smells bad, see your doctor. To allow your cervix to heal and to prevent infection, you should not have sexual intercourse or use tampons for 4–6 weeks after the procedure.

After a LLETZ or LEEP you can still become pregnant, however you may have a slightly higher risk of having the baby prematurely. Talk to your doctor before the procedure if you are concerned.

Cone biopsy

This procedure is similar to a LLETZ. It is used when the abnormal cells are found in the cervical canal, when early-stage cancer is suspected, or for older women needing a larger excision. In some cases, it is also used to treat very small, early-stage cancers, particularly for young women who would like to have children in the future (see page 30).

The cone biopsy is usually done as day surgery in hospital under general anaesthetic. A surgical knife (scalpel) is used to remove a cone-shaped piece of tissue from the cervix. The tissue is examined to make sure that all the abnormal cells have been removed. Results are usually available within a week.

Side effects of a cone biopsy

You may have some light bleeding or cramping for a few days after the cone biopsy. Avoid doing any heavy lifting for a few weeks, as the bleeding could become heavier or start again. If the bleeding lasts longer than 3–4 weeks, becomes heavy or has a bad smell, see your doctor. Some women notice a dark brown discharge for a few weeks, but this will ease.

To allow your cervix time to heal and to prevent infection, you should not have sexual intercourse or use tampons for 4–6 weeks after the procedure.

A cone biopsy may weaken the cervix. You can still become pregnant after a cone biopsy, but you may be at a higher risk of having a miscarriage or having the baby prematurely. If you would like to become pregnant in the future, talk to your doctor before the procedure.

Laser surgery

This procedure uses a laser beam instead of a knife to remove the abnormal cells or pieces of tissue for further study.

A laser beam is a strong, hot beam of light. The laser beam is pointed at the cervix through the vagina. The procedure is done under local anaesthetic. Laser surgery takes about 10–15 minutes, and you can go home as soon as the treatment is over.

Laser surgery works just as well as LLETZ and may be a better option if the precancerous cells extend from the cervix into the vagina or if the lesion on the cervix is very large.

Side effects of laser surgery

These are similar to those of LLETZ. Most women are able to return to normal activity 2–3 days after having laser surgery, but will need to avoid sexual intercourse for 4–6 weeks.

Further tests

If any of the tests or procedures described above show that you have cervical cancer, you may need further tests to find out whether the cancer has spread to other parts of your body. This is called staging (see page 24). You may have one or more of the tests described on the following pages.

Blood test

You may have a blood test to check your general health, and how well your kidneys and liver are working.

Before having scans, tell the doctor if you have any allergies or have had a reaction to contrast during previous scans. You should also let them know if you have diabetes or kidney disease or are pregnant.

Imaging scans

You may have one or more of the following imaging scans to find out if the cancer has spread to lymph nodes in the pelvis or abdomen or to other organs in the body.

CT scan

A CT (computerised tomography) scan uses x-rays to take pictures of the inside of your body and then compiles them into a detailed, three-dimensional picture.

Before the scan, you may be given a drink or an injection of a dye (called contrast) into one of your veins. The contrast may make you feel hot all over for a few minutes. You may also be asked to insert a tampon into your vagina. The dye and the tampon make the pictures clearer and easier to read.

During the scan, you will need to lie still on a table that moves in and out of the CT scanner, which is large and round like a doughnut. The scan is painless and takes 5–10 minutes.

MRI scan

An MRI (magnetic resonance imaging) scan uses a powerful magnet and radio waves to build up detailed cross-sectional pictures of the inside of your body. Let your medical team know if you have a pacemaker or any other metal implant as some may affect how an MRI works.

During the scan, you will lie on a treatment table that slides into a large metal cylinder that is open at both ends. The noisy, narrow machine can make some people feel anxious or claustrophobic. If you think you may become distressed, mention it to your medical team before the scan. You may be given medicine to help you relax, and you will usually be offered headphones or earplugs. Most MRI scans take 30–90 minutes.

PET scan

Before a PET (positron emission tomography) scan, you will be injected with a glucose (sugar) solution containing some radioactive material. You will be asked to lie still for 30–60 minutes while the solution spreads throughout your body.

Cancer cells show up brighter on the scan because they absorb more of the glucose solution than normal cells do. It may take a few hours to prepare for a PET scan, but the scan itself usually takes about 30 minutes.

PET–CT scan

A PET scan combined with a CT scan is a specialised test available at many major metropolitan hospitals. It produces a three-dimensional colour image. The CT helps pinpoint the location of any abnormalities revealed by the PET scan.

Before having scans, tell the doctor if you have any allergies or have had a reaction to contrast during previous scans. You should also let them know if you have diabetes or kidney disease or are pregnant.

Examination under anaesthetic

Another way to check whether the cancer has spread is for the doctor to examine your cervix, vagina, uterus, bladder and rectum. This is done in hospital under general anaesthetic. If the doctor sees any abnormal areas of tissue during the procedure, they will take a biopsy (see pages 16–17) and send the sample to a laboratory for examination.

Pelvic examination

The doctor will put a speculum into your vagina and spread the walls of the vagina apart so they can check your cervix and vagina for cancer.

Uterus

The cervix will be dilated (gently opened) and some of the cells in the lining of the uterus (endometrium) will be removed and sent to a laboratory for examination under a microscope. This is called a dilation and curettage (D&C).

Bladder

A thin tube with a lens and a light called a cystoscope will be inserted into your urethra (the tube that drains urine from the bladder to the outside of the body) to examine your bladder.

Rectum

The doctor will use a gloved finger to feel for any abnormal growths inside your rectum. To examine your rectum more closely, the doctor may insert an instrument called a sigmoidoscope, which is a tube with an attached camera.

You will most likely be able to go home from hospital on the same day after one of these examinations under anaesthetic. You may have some light bleeding and cramping for a few days afterwards. Your doctor will talk to you about the side effects you may experience.

Staging cervical cancer

The tests described above help the doctors decide how far the cancer has spread. This is called staging. Knowing the stage of the cancer helps your health care team recommend the best treatment for you.

In Australia, cervical cancer is usually staged using the International Federation of Gynecology and Obstetrics (FIGO) staging system. This is also often used for other cancers of the female reproductive organs. FIGO divides cervical cancer into four stages. Each stage is further divided into several sub-stages.

Stage I, early of localised cancer: Cancer is found only in the tissue of the cervix.

Stage II, locally advanced cancer: Cancer has spread outside the cervix to the upper two-thirds of the vagina or other tissue next to the cervix.

Stage III, locally advanced cancer: Cancer has spread to the lower third of the vagina and/or the tissue on the side of the pelvis (pelvic wall). The cancer may also have spread to lymph nodes in the pelvis or abdomen, or caused a kidney to stop working.

Stage IV, metastatic or advanced cancer: Cancer has spread to the bladder or rectum (stage IVA) or beyond the pelvis to the lungs, liver or bones (stage IVB).

Prognosis

Prognosis means the expected outcome of a disease. You may wish to discuss your prognosis and treatment options with your doctor, but it is not possible for anyone to predict the exact course of the disease. Instead your doctor can give you an idea about the general prognosis for people with the same type and stage of cancer.

To work out your prognosis, your doctor will consider:

  • your test results
  • the type of cervical cancer
  • the size of the cancer and how far it has grown into other tissue
  • whether the cancer has spread to the lymph nodes
  • other factors such as your age, fitness and overall health.

In general, the earlier cervical cancer is diagnosed and treated, the better the outcome. Most early-stage cervical cancers have a good prognosis with high survival rates. If cancer is found after it has spread to other parts of the body (referred to as an advanced stage), the prognosis is worse and there is a higher chance of the cancer coming back after treatment (recurrence).

Question checklist

Asking your doctor questions will help you make an informed choice. You may want to include some of the questions below in your own list.

Diagnosis

  • What type of cervical cancer do I have?
  • Has the cancer spread? If so, where has it spread? How fast is it growing?
  • Are the latest tests and treatments for this cancer available in this hospital?
  • Will a multidisciplinary team be involved in my care?
  • Are there clinical guidelines for this type of cancer?

Treatment

  • What treatment do you recommend? What is the aim of the treatment?
  • Are there other treatment choices for me? If not, why not?
  • If I don’t have the treatment, what should I expect?
  • How long do I have to make a decision?
  • I’m thinking of getting a second opinion. Can you recommend anyone?
  • How long will treatment take? Will I have to stay in hospital?
  • Are there any out-of-pocket expenses not covered by Medicare or my
    private health cover? Can the cost be reduced if I can’t afford it?
  • How will we know if the treatment is working?
  • Are there any clinical trials or research studies I could join?

Side effects

  • What are the risks and possible side effects of each treatment?
  • Are the side effects immediate, temporary or long-lasting?
  • Will I have a lot of pain? What will be done about this?
  • Can I work, drive and do my normal activities while having treatment?
  • Will the treatment affect my sex life?
  • Will the treatment affect my ability to have children? What options do I have to preserve my fertility?
  • Should I change my diet or physical activity during or after treatment?

After treatment

  • How often will I need check-ups after treatment? Who should I go to?
  • If the cancer returns, how will I know? What treatments could I have?

Last Reviewed: 30/09/2019

Anti-Cancer Council of Victoria



References

Cancer Council Victoria. Understanding Cervical Cancer. Last Updated September 2019. https://www.cancervic.org.au/downloads/resources/booklets/Understanding-Cervical-Cancer.pdf