The cervix
The cervix is:
- part of the female reproductive system
- the lower part of the uterus (womb) that connects to the vagina
- sometimes called the neck of the uterus
The cervix has many functions, including:
- producing some of the moistness that lubricates the vagina
- producing the mucus that helps sperm travel up to the Fallopian tube to fertilise an egg from the ovary
- holding the developing baby in the uterus during pregnancy. During childbirth, the cervix widens to allow the baby to pass down into the birth canal (vagina).
The cervix is covered by two kinds of cells:
- Squamous -- flat thin cells found in the outer layer of the cervix (ectocervix).
- Glandular -- glandular cells are found in the cervical canal (endocervix).
Precancerous changes of the cervix
Abnormal cell changes in the cervix can be found with a Pap smear. This test does not diagnose cancer but finds early changes. These changes are the first step in a series of slow changes that may develop into cancer if left untreated.
Pap test
Most abnormal changes in cervical cells are detected with a Papanicolaou test (Pap test or Pap smear).
For a Pap test:
- the doctor uses a brush or small spatula to scrape some cells from the surface of the cervix
- may feel slightly uncomfortable, but usually only takes a few minutes
- cells are examined for abnormalities.
A woman should have a Pap test once every two years, but some women have them more often.
About 5-7% of Pap tests produce abnormal results, which may include dysplasia. Your doctor will talk to you if you have an abnormal result
There are several types of early cellular changes, including:
- Atypia
- the cervical cells have changed slightly
- cells may return to normal or changes may worsen
- doesn't mean you have cancer -- can be caused by infection or irritation
- may be a precancerous condition.
Dysplasia
- also called cervical intraepithelial neoplasia (CIN)
- type of unusual change in the cells of the cervix
- doesn't mean you have cancer -- it is a precancerous condition.
- CIN1 or low-grade dysplasia -- early changes that usually disappear without treatment.
- CIN2 or CIN3, high-grade dysplasia -- cells continue to change and treatment will be needed.
If a Pap smear detects changes, more tests will be needed to confirm the diagnosis.
Managing precancerous changes of the cervix
Colopsocopy
- Can help identify where abnormal cells are.
- Done using an instrument called a colposcope, which is like binoculars on a stand. The colposcope doesn't enter the body -- the doctor inserts an instrument called a speculum and views the magnified picture through the colposcope.
- Beforehand, the vagina and cervix may be coated with a special solution to highlight abnormalities.
- Takes 10-15 minutes.
- Can be slightly uncomfortable.
- An examination that allows the doctor to see a magnified view of the cervix, vagina and vulva.
Biopsy
- A small sample of tissue may be taken from an abnormal area on the cervix and sent to a laboratory for examination.
- A colposcope will be used to see what area needs to be removed.
- May be uncomfortable for a brief period.
- Taken in the doctor's rooms or in a clinic.
- Results are usually back within about a week.
Large loop excision of the transformation zone
- A loop of wire carrying an electric current is used to cut out tissue from the cervix.
- Removes a large tissue sample for examination under a microscope.
- Also called a LLETZ.
- Takes about 10 minutes.
- May be performed under a local anaesthetic in the doctor's office or in hospital under general anaesthetic.
Cone biopsy
- A procedure used to see if the abnormal cells have spread to tissue beneath the surface of the cervix.
- A cone-shaped piece of tissue containing abnormal cells is removed.
- Done under general anaesthetic.
- May involve day or overnight admission to hospital.
- Results are usually back within about a week.
Cervical cancer explained
Cervical cancer is a malignant tumour in the tissues of the cervix.
The two main types of cervical cancer are named after the type of cell from which they originate:
- Squamous cell carcinoma -- the most common, accounting for 80% of all cervical cancers. It starts in the squamous or skin-like cells of the cervix.
- Adenocarcinoma -- a less common type of cervical cancer, which develops from the glandular cells. This type is more difficult to diagnose because it starts higher in the endocervical canal and is more difficult to reach with the brush or spatula used in taking a Pap test.
Cervical cancer can be microinvasive or invasive:
- Microinvasive cancer -- cancer cells have broken through the boundary between the epithelium and stroma. Cells haven't spread more than 5mm into the cervix tissue.
- Invasive cancer -- cancer cells have spread into the stroma to a depth of more than 5mm.
How common is it?
- In NSW, about 200 women are diagnosed with cervical cancer each year.
- Cervical cancer accounts for 1.4% of all cancers in females.
Causes
The causes of cervical cancer are largely unknown. However, some factors increase a woman's risk:
Human Papillomavirus (HPV) infection
- the name for a group of wart viruses
- common infection affecting the surface of any part of the body, including the skin, vagina and cervix
- more than 100 types of the virus have been identified but only some affect the genital area
- around eight out of 10 women will become infected with the genital HPV at some time in their lives and, for most, it will clear up on its own
- women only find out they have the HPV if it shows up on a Pap smear -- it causes no symptoms.
- Having HPV does not mean you will get cervical cancer. Most women who have the HPV infection never get cervical cancer. Only a few types of the HPV result in cervical cancer.
Smoking
- produces chemicals that may damage the cells of the cervix and make cancer more likely to develop.
Signs and symptoms
Early changes in the cells of the cervix (epithelial abnormalities) rarely cause symptoms, which is why doctors encourage women to have regular Pap tests.
If early cell changes develop into cervical cancer, the most common signs include:
- vaginal bleeding between periods
- bleeding after intercourse
- pain during intercourse
- unusual vaginal discharge
- vaginal bleeding after menopause
- excessive tiredness
- leg pain or swelling
- low back pain.
All these symptoms are common to many conditions and may not mean you have cervical cancer. However, if you have these symptoms you should have them checked by your doctor.
Diagnosis
Tests to determine the extent of the cancer and if it has spread
Your cancer may have been diagnosed following investigations for an abnormal pap smear or following investigations into abnormal bleeding or other symptoms. Further tests are required to determine the stage of the cancer
Stages of cervical cancer
If the biopsy and the results of these tests find cervical cancer, one of the following stages will be used to describe your cancer:
- Stage I - The tumour is found only in the tissues of the cervix.
- Stage II - The tumour has spread beyond the cervix to the vagina and tissues next to the cervix.
- Stage III - The tumour has spread throughout the pelvic area.
- Stage IV - The tumour has spread beyond the pelvic area to nearby organs such as the bladder or rectum. The tumour may also spread to the lung, liver or bones, although this is uncommon.
Which health professionals will I see?
Most centres treating gynaecological cancer work with a multidisciplinary team. Health professionals who may be involved in your treatment for cervical cancer include:
- gynaecological oncologist -- doctor with specialist training in cancer of the female reproductive system and its treatment
- medical oncologist -- responsible for chemotherapy
- radiation oncologist -- responsible for radiotherapy
- nurses iincluding gynaecological cancer nurse coordinator-- support and assist you through all stages of your treatment
- social worker, psychologist, physiotherapist and occupational therapist -- help you to get back to normal activities and link you to support services.
Treatment
Surgery is common for small tumours found only within the cervix. The extent of the cancer in the cervix will determine the type of surgery needed.
Cone biopsy
If your tumour is very small, a cone biopsy may be the only treatment you need. See Cone biopsy for more information.
Hysterectomy
The surgical removal of the uterus and cervix.
Two main types:
- Total hysterectomy -- removal of uterus and cervix, with about five days in hospital.
- Radical hysterectomy -- removal of uterus and about two centimetres of upper vagina and tissues around the cervix. May affect continence.
Trachelectomy
A type of surgery that may preserve fertility.
Radical trachelectomy - common for small cancers in young women.
Side effects are similar to those of a hysterectomy, however you will still have periods after surgery.
Unless your cervical cancer is a very early stage you will require a pelvic lymphadenectomy which is the removal of lymph nodes in the pelvis This may cause leg swelling (lymphoedema) particularly if surgery occurs in combination with radiotherapy. For this reason investigations such as PET and MRI scan are carried out to assess whether the lymph nodes have cancer in them. If the lymph nodes appear to be affected chemoradiation will be given even for early cancers and surgery will not be required.
Radiotherapy
Radiotherapy uses x-rays to kill cancer cells or injure them so they cannot multiply.
Radiotherapy can be given in two ways:
- From outside the body (external). A machine directs radiation at the cancer and surrounding tissue.
- From inside the body (internal). Radioactive material is put in thin tubes and implanted into your body on or near the cancer. This is called brachytherapy.
Usually both external and internal radiotherapy is used to treat cervical cancer.
Radiotherapy is usually given if the tumour has spread into the tissues surrounding the cervix, including the lymph nodes as the primary treatment as it is just as effective as curing cancer. If surgery occurs too it does not increase the likelihood of cure but significantly increases the risk of treatment related side effects. Radiotherapy may be used after surgery if pathology results show the cancer involves the lymh nodes or the surrounding normal tissue.
Radiotherapy is increasingly being used in combination with chemotherapy – this is known as chemoradiation.
Chemotherapy
Chemotherapy uses drugs to kill or slow the growth of cancer cells. These drugs are called cytotoxins.
Chemotherapy is usually combined with radiotherapy to make the radiotherapy more effective. Chemotherapy is given once each week whilst you are receiving radiotherapy.
Chemotherapy may also be used on its own for advanced cervical cancer.
Palliative treatment
Palliative treatment helps improves people's quality of life by alleviating symptoms of cancer. It is particularly important for people with advanced cancer.
Treatment may be concerned with pain relief and management of physical and emotional problems.