WHAT WILL HAPPEN DURING MY CERVICAL SCREENING?

Having your cervical screening sample taken should only take minutes. If it is the first time you are attending your screening it can be helpful to find out as much as possible about what will happen beforehand. You can bring a relative or friend with you if you need support and you can request a female nurse or doctor to take the sample.

Before the procedure starts, the doctor or nurse should explain what is going to happen and answer any questions or concerns you may have. If they don’t, feel free to share your concerns and ask questions.

You will be asked to undress from the waist down and to lie on an examination bed either on your back with your legs bent up or ankles together. Some examination beds may have stirrups on them. If yours does, you will need to place your feet in the stirrups. A paper sheet will be placed over the lower half of your body. Your doctor/nurse will then insert an instrument called a speculum into your vagina. Some clinicians may use a lubricant on the speculum which will make it easier to insert into the vagina. The speculum gently opens your vagina allowing the doctor/nurse to see the cervix. The majority of speculums used for screening are made from plastic, but occasionally metal ones are used. A specially designed brush is used to take cells from the cervix. The doctor/nurse will collect cells from the area of the cervix called the transformation zone. The sampled cells are immersed in a vial of preservative fluid and looked at under a microscope in the laboratory.

Usually, cervical screening is not painful but it may feel a little uncomfortable. Therefore, if you experience any pain or other problems, let the doctor or nurse know. You may have some spotting (very light bleeding) for a day after the procedure.

The best time (if possible) for a cervical screening is in the middle of your menstrual cycle, halfway between one period and the next. This enables the cytologist to examine the best possible specimen to achieve the best possible report. Most healthcare professionals will ask that you book the test so take your menstrual cycle into account before your book your screening test.

HELPFUL TIPS BEFORE YOUR CERVICAL SCREENING

For many, the thought of going for cervical screening is often worse than the reality of it. Do not worry if you feel anxious about having your screening test; it is normal to feel like this. It can help to be as informed as possible about what having a cervical screening is like. Make sure you discuss any concerns with your doctor or practice nurse.

A few points to remember before going for your screening:

• Do not have sexual intercourse 24 hours before your screening, as sperm, spermicidal gel, and lubricants may make it difficult to get a good sample of cells from the cervix.
• If vaginal pessaries have been prescribed to treat an infection, then postpone your screening for at least a week after the treatment has finished.
• If you are using vaginal estrogen cream for menopause symptoms, do not apply it on the day of your screening.
• Do not douche or use a tampon for at least two days before your screening.
• The sample taker should cover you with a paper towel – However, you can always wear a skirt or bring a scarf if you want to cover yourself up.
• The more relaxed you are, the less discomfort you will feel.
• You can bring a family member or friend with you for moral support.

If there is an abnormality, the colposcopist should be able to estimate whether or not treatment will be needed according to:

• How white the tissue becomes after using acetic acid;
• How quickly the tissue turns white;
• How smooth or irregular the surface is.

TAKING A BIOPSY

To be sure of the diagnosis, a biopsy is often required – this means taking a sample of tissue from your cervix. Depending on the results of this biopsy the colposcopist will decide whether you need treatment or not. There are 2 types of biopsies that could be offered. A diagnostic or punch biopsy is a small biopsy which often doesn’t require local analgesia and two or three of these may be taken at the first visit. The second is a loop excision which is slightly larger and does require local anaesthetic. This type of biopsy is usually a treatment biopsy and under certain circumstances can be performed at the first visit in some clinics.

If it is obvious that you will need treatment, this can be done during the same visit – in this case all of the abnormal area is removed, and this constitutes the biopsy. Other more invasive types of treatment require a separate appointment.

Sometimes taking the biopsy can be uncomfortable but the person performing the colposcopy will warn you before the biopsy is to be taken. Your colposcopy shouldn’t be painful and if you have any difficulty, you should discuss this with the colposcopist.

RESULTS OF BIOPSY

When your biopsy is analysed in the laboratory, they will be looking for different changes in the cells.

If your biopsy comes back positive, it is because you have abnormal cells or cervical intraepithelial neoplasia (CIN). Abnormal cells may develop into cancer, so the quantity of these cells is important. The grading of CIN is established according to the number of immature cells within the sample taken. This means that:

• If you have CIN 1, the lining of your cervix has fully normal cells at the surface and the lower 1/3 has immature abnormal cells.
• CIN 2: the lining of your cervix has normal cells at the surface and the lower 2/3 has abnormal cells.
• CIN 3: the lining of your cervix has abnormal cells throughout its entire thickness

All the results above mean that you have cervical abnormalities. This does not mean that you have or will get cancer. It just means that the laboratory has detected some changes to your cells that are abnormal and, if they are not treated, they may develop into cervical cancer in the future.

ABNORMAL CERVICAL CELLS: CIN and CGIN

The cervix is covered with a layer of skin-like cells on its outer surface. There are also glandular cells usually lining the inside of the cervix. These cells produce mucus. The skin-like cells can become cancerous, leading to a squamous cell cervical cancer. The glandular cells can also become cancerous, leading to an adenocarcinoma of the cervix. Changes to these different areas are categorized differently: Cervical Intraepithelial Neoplasia (CIN) are cellular changes to the skin-like cells and Glandular Cervical Intraepithelial Neoplasia (CGIN) represent abnormal changes to the glandular cells.

If your cervical screening result shows abnormal cells you may be asked to attend a colposcopy appointment. Remember testing positive for CIN or CGIN means that you have abnormal cervical cells that may lead to cancer if untreated, but CIN and CGIN are not themselves cancerous. Treatment for abnormal cellular changes is usually very successful.

The cervix is covered with a layer of skin-like cells on its outer surface. The results of your cervical screening test are based on the examination of these cells. The test detects whether abnormal cells are present. Rarely, these cells that may be abnormal, and these abnormal areas are called glandular changes.

THE RESULTS OF THE CERVICAL SCREENING TEST

Depending on the results of your screening, you may be referred to a specialist clinic in the hospital (colposcopy) in order to get a more accurate diagnosis and have treatment if needed. You may need to have a small sample taken from your cervix to analyze the cells, this is called a biopsy. Usually, biopsies are only a few millimetres in size.

HOW IT FEELS TO HAVE CERVICAL ABNORMALITIES

Every year, almost 400,000 Canadian women receive a call that their Pap test result is abnormal (.).

Following a diagnosis of cervical abnormalities, it is possible and normal to feel a range of different emotions, and this is perfectly normal. It is quite common to question why this has happened to you and whether or not it could have been prevented. You may feel angry that the abnormal cells weren’t detected earlier or find it difficult to digest a diagnosis of HPV alongside this.

You may feel absolutely fine and aren’t unduly concerned, or feel anxious, scared and overwhelmed, or worry about what will happen¹((Lacey CJ et al., 2006. Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease. Vaccine, 24 (3), S3/35-41)). It is common for emotions to rollercoaster – with you feeling calm and untroubled one day, but scared or angry the next.

We have seen that some people’s feelings often change over time, as they gradually learn more about what having cervical abnormalities actually means for them. Understanding your situation and the treatment options that are available to you often helps relieve the anxiety and fear that often accompany diagnosis.

Our community tells us that when they were told they had cervical abnormalities, they wanted information and support to help them understand what cervical abnormalities are, cope with the diagnosis and make decisions about any subsequent treatment.

You might find that you want to know more about cervical abnormalities, cervical cancer and its prevention, HPV testing, and the different treatment options available to you (including what to expect if you need to have treatment). We have a wealth of information on these topics on this website. You can also submit questions to us online here.

Being able to speak with someone who understands what you’re going through can be invaluable. This could be one of the medical professionals responsible for your care, such as your colposcopist or practice nurse or your doctor.

YOUR FEELINGS MAY CHANGE OVER TIME

Most women and people with a cervix gradually find ways that help them deal with what’s happening to them, and their feelings about their diagnosis changes over time¹((Lacey CJ et al., 2006. Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease. Vaccine, 24 (3), S3/35-41)).

Information can be key to how you move on from your diagnosis. The realization that having abnormal cells does not mean that you have cervical cancer is a milestone, as is finding out that cervical abnormalities are common.

It is common for many with a diagnosis to find that being better informed. For example, it may help regain control of your situation and reduce anxiety to understand what the treatment procedures will be and the benefits and possible side effects.

Some come to accept the diagnosis as just ‘something that happens to women’, while others remain scared about the future. It’s perfectly normal if you continue to have mixed emotions – feeling anxious, overwhelmed and sad one minute, and calm and untroubled the next.

HPV TRIAGE

HPV Triage is used when a cervical screening result is borderline or mild dyskaryosis (or low grade squamous dyskaryosis). The HPV test is important because it allows earlier identification of the need for treatment. For minor cervical abnormalities (either borderline or low grade squamous dyskaryosis), there is only around a 15-20% chance of having a significant abnormality that requires treatment¹.

If you do not have high-risk HPV even though your screening result showed slightly abnormal cells, the risk of these abnormalities turning into cancer are extremely low, thus, you can return to normal routine screening. To find out more about routine screening in Canada, click here for the guidelines in each province and territory in Canada.

HPV triage is done using the same sample of cells that were taken during your cervical screening test and it will look for any high-risk HPV infections. If the test is HPV positive, you will be invited to a colposcopy clinic. If the test is HPV negative, you will be returned to routine screening every three or five years, the frequency of which depends on your age and where you live.

TREATMENT OF ABNORMAL CERVICAL CELLS

If screening shows that you have abnormal cells in your cervix, the doctor or nurse you see in the colposcopy clinic (colposcopist) may recommend that you have them treated. The aim of treatment is to remove or destroy the abnormal cells in your cervix. However, the first step is to be sent for a colposcopy. Treatment can be offered after a first colposcopy visit. If this is a possibility, you will be advised beforehand.

TYPES OF TREATMENT FOR CERVICAL ABNORMALITIES

The treatment you will be offered depends on the type of abnormal cells you have in your cervix and how advanced the changes are. Your colposcopist will advise you on the specific treatment you will require during your colposcopy appointment.

LARGE LOOP EXCISION OF THE TRANSFORMATION ZONE (LLETZ)

Also known as LEEP or diathermy loop biopsy or just a loop, this procedure uses a small wire loop and an electrical current to cut away the affected area of tissue and seal the wound at the same time. The advantage of this treatment is that the cells are removed rather than destroyed, so the tissue can be sent for further tests to confirm the extent of the cell changes and make sure the area of your cervix that contains the cells has been removed.

CONE BIOPSY

A cone of tissue is cut away from your cervix to remove all the abnormal cells. It allows the doctor to remove a slightly larger part of the cervix than with a loop (LLETZ) biopsy. A cone biopsy allows for the cells at the edges of the specimen to be seen clearly through a microscope ensuring that all of the biopsy can be examined by a histopathologist.

A cone biopsy is usually carried out under a general anaesthetic (very small cone biopsies can be performed under local anaesthetic). A vaginal pack will sometimes be put in place while you are under anaesthetic. This looks like a long bandage that puts pressure on the biopsy site and helps stop any bleeding (a bit like putting pressure on a cut to stop the bleeding). It will be removed before you go home. It is advisable to have some painkillers at home as you may experience a deep ache and/or tenderness in the pelvis. It is not unusual to feel tired for a few days or even a week or so following a general anaesthetic.

STRAIGHT WIRE EXCISION OF THE TRANSFORMATION ZONE (SWETZ) OR NEEDLEPOINT EXCISION OF THE TRANSFORMATION ZONE (NETZ)

Similar to a cone biopsy, these procedures remove a piece of tissue but use a straight wire or needle diathermy with electricity to cut and seal the tissue like a LLETZ treatment. The procedures are done in a clinic with local anaesthetic (like a LLETZ) or under general anaesthetic (like a cone biopsy). These treatments are usually done if the abnormal cells are inside the cervical canal or are glandular abnormal cells.

CRYOTHERAPY

A cold probe is used to freeze away the abnormal cells in the cervix. This is sometimes used to treat CIN1.

LASER TREATMENTS

This is sometimes called laser ablation. Lasers pinpoint and destroy abnormal cells in the cervix. If necessary, a laser can also be used to remove a small piece of the cervix itself. This is called laser excision or laser cone biopsy.

COLD COAGULATION

Despite the name of this treatment this procedure involves applying a hot probe to the cervix, which, like laser, destroys the abnormal cells. A local anaesthetic (where the area is numbed but you are still awake) is given before any of the treatments described above. A cone biopsy may require a general anaesthetic (where you are asleep).

SUMMARY

Your colposcopist should provide you with additional information on the treatment that you will be having. Remember to ask if you have questions.

Bleeding (at the time of treatment or in the two to three weeks afterwards) or infection (more often 10-14 days after) can occur after treatment for abnormal cells of the cervix. You may experience vaginal discharge or bleeding for two to three weeks after your treatment. However, this does vary a lot. For example, some will have no bleeding at all and some will be bleeding for up to six weeks. After your treatment you may feel some pain, this is because the local anaesthetic used during your treatment will wear off after two to three hours. This pain often feels like cramps. Some women notice pain more the day after the treatment. Sometimes periods can be irregular or more painful for two to three months after treatment. Always contact your healthcare professional or colposcopist if you are experiencing any problems after treatment. There is no reason to put up with discomfort that can easily be treated.

If you are working, you might be advised to take a day or two off from work (your colposcopist will let you know if this is necessary).

Generally, a single, straightforward treatment to the cervix is very unlikely to adversely affect fertility or the ability to have a normal pregnancy.

It is extremely important that you attend your follow up appointment as advised by your local service. Six months after your treatment, you will be called back to have a repeat cervical screening test. Between 5-10% of women continue to have cervical abnormalities after treatment. Occasionally, second and third treatments are required. It is very important that you attend treatment if further treatment is advised.

TEST OF CURE

These follow up tests help to identify that, if the treatment has been successful, the abnormal cervical cells have been removed and the area is now normal.

It will test for high-risk HPV, which can cause cervical cancer. Test of Cure will only be given to you if you have undergone treatment for cervical abnormalities. The test is used in combination with cervical screening cytology (looking at how the cells look under the microscope).

If HPV is not found and your screening test comes back negative (that means the cells appear normal under the microscope), then you have been successfully treated by removing the abnormal cells and you will be returned to your regular screening schedules. Click here to find out what the guidelines are for screening in Canada. You do not need to have another cervical screening test for three or five years depending on your age or where you live. The HPV test helps to confirm that there is no longer a higher-than-average risk of developing further cervical abnormalities.

If HPV infection is found (HPV positive) or the screening test shows an abnormality you will again be referred to colposcopy for further investigation. If this happens, try not to be alarmed, it is better to get things checked out. Occasionally, cervical abnormalities are not all removed at the first treatment. This is because the treatment is a balance between removing all the abnormal cells, without removing too much normal cervix. Put simply – it is always easier to take a bit more away in the future, than it is to stick a bit back on later! If there are still abnormal cells left at the follow up, then another treatment can be done. Using both a cervical screening test and HPV test, this provides a more effective way of assessing the success of treatment than a cervical screening test on its own. Many who come back to the colposcopy clinic do not need further treatment.

There is also a small chance that cervical abnormalities may come back in the future. It is therefore important to keep going for your cervical screening when invited, so that you can have further treatment if necessary.

Remember if you have been found positive for abnormal cervical cells this is unlikely to be cervical cancer. Treatment for abnormal cervical cells is usually very effective and it is estimated that early detection and treatment can prevent up to 75% of cervical cancers from developing.

Upon being diagnosed, it can feel as though the world is collapsing in around you, but it’s important to remember that you are not alone. Cervical abnormalities are a lot more common that you may think, and if you speak with friends and colleagues, you will probably find someone who has been through a similar experience. 400,000 Canadian women receive a call telling them that their Pap test result is abnormal²

It may be helpful to talk about your feelings, rather than bottling up anxieties and worries. Having a strong support network, including your partner, family and friends around you can make your diagnosis easier to come to terms with. And if you can speak anyone who has been through the same procedures or hear some of their stories, it may help reduce your anxiety about what lies ahead. There are many online support groups, especially on Facebook. You can reach out to us here for some suggestions.

When first receiving a diagnosis of a cervical abnormality, it is understandable that you may want to carry out your own research to find out as much information as possible. We would always encourage you to look up information on trusted websites such as HPV Global Action, the Public Health Agency of Canada, The Canadian Cancer Society, the Society of Obstetricians and Gynaecologists of Canada, the Society of Gynaecologic Oncology of Canada, so that you know you will be accessing reliable information.

FOLLOWING DIAGNOSIS:

• Try to focus on the fact that having a cervical abnormality does not mean that you have cancer.
• Ask questions at every step along the way to make sure you understand what is happening to you – fear of the unknown can be debilitating.
• Ensure that you attend further tests or treatment – they could prevent developing cancer in the future.

Cervical Cancer

Cervical cancer forms in the tissues of the cervix. The cervix is an organ that connects the uterus and vagina. It is usually a slow-growing cancer that may or may not have symptoms but can be prevented through regular screening (a procedure in which cells are taken from the cervix and looked at under a microscope).

Cervical cancer is not thought to be hereditary.³((Lacey CJ et al., 2006. Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease. Vaccine, 24 (3), S3/35-41))((Giuliano AR et al., 2008. Epidemiology of human papillomavirus infection in men, cancers other than cervical and benign conditions. Vaccine, 26 (10), K17-28))

99.7% of cervical cancers are caused by the persistent high-risk human papillomavirus (HPV) infection which causes changes to the cervical cells. HPV is an extremely common virus; around 4 out of 5 people are exposed to the virus. A person comes into contact with this virus through any skin-to-skin sexual contact below the waistline with fingers, mouth, or other body parts – even without penetration. Condoms give good protection against sexually transmitted infections (STIs), unwanted pregnancies and HPV in general BUT do not fully protect people from this virus because there is still direct skin -to – skin contact.

Cervical abnormalities are caused by persistent high-risk HPV infection. These abnormal cells found through cervical screening are not cancerous but, given time, they may go on to develop into cancer. 

The most effective method of preventing cervical cancer is through regular cervical screening. Cervical cancer is the most preventable cancer, if caught early, survival rates are high. Click here to know where you can get the HPV vaccine in Canada for free.

Causes of Cervical Cancer

Almost all cases of cervical cancer are caused by persistent high-risk HPV. HPV is a very common infection, over 80% of Canadians will have one form or another of this virus in their lifetime. This is why it is so important to get the HPV vaccine and to attend your regular cervical screening.

See our section on HPV 

Cervical cancer is not caused by promiscuity or infidelity; however, it makes sense that the more sexual partners you have and the younger you are when you have your first sexual encounter, the more likely you are to come into contact with the more dangerous types of HPV – called high-risk types. Whilst these factors are considered to increase your risk of developing cervical cancer, you can become infected with high-risk HPV and may go on to develop abnormal cell changes/CIN or cervical cancer even if you have only had one sexual partner in your lifetime.

Similarly, as with most cancers, smoking can also pose an increased risk. Smoking stops your body’s immune system from working properly, leaving you more likely to get infections and therefore can cause abnormalities in the cells of your cervix.

Other risk factors involved with cervical cancer:

• Weakened immune system
• Having children at a very young age
• Giving birth to many children
• If your mother was given DES (infertility drug) when pregnant with you
• Long-term use of the contraceptive pill (more than 10 years) can slightly increase the risk of developing cervical cancer but the benefits of the pill outweigh the risks for most women.

Types of Stages of Cervical Cancer

If, after receiving the results of your biopsy, you are diagnosed with cervical cancer, your consultant will order more tests to find out to what type of cervical cancer you have, the extent the cancer has progressed and if the cancer cells have spread to other parts of the body. 

There are two main types of cervical cancer:

• Squamous cell – eight out of 10 (80%) cervical cancers are diagnosed as squamous cells. Squamous cell cancers are composed of the flat cells that cover the surface of the cervix and often begin where the ectocervix joins the endocervix.
• Adenocarcinoma – more than one in 10 cervical cancers are diagnosed as adenocarcinoma (15 – 20%). The cancer develops in the glandular cells which line the cervical canal. This type of cancer can be more difficult to detect with cervical screening tests because it develops within the cervical canal.

Adenosquamous cancers are tumours that contain both squamous and glandular cancer cells. Other rare types of cervical cancer can include clear cells, small cells undifferentiated, lymphomas and sarcomas.

Cervical cancer staging

You may be asked to have various diagnostic tests which help understand your cancer better. These could include

• a pelvic examination
• MRI or PET-CT
• Chest x-ray or blood tests
  

Your healthcare professionals need information to understand the extent to which your cancer has progressed and if the cancer cells have spread to other parts of your body. This process is called staging. Knowing the stage of the disease helps your consultant plan treatment.

The following stages are used to describe cancer of the cervix:

• Stage 1a: Cancer involves the cervix but has not spread to nearby tissue. A very small amount of cancer that is only visible under a microscope is found deeper in the tissues of the cervix.
• Stage 1b: Cancer involves the cervix but has not spread nearby. A larger amount of cancer is found in the tissues of the cervix.
• Stage 2a: Cancer has spread to nearby areas but is still inside the pelvic area. Cancer has spread beyond the cervix to the upper two-thirds of the vagina.
• Stage 2b: Cancer has spread to nearby areas but is still inside the pelvic area. Cancer has spread to the tissue around the cervix.
• Stage 3: Cancer has spread throughout the pelvic area. Cancer cells may have spread to the lower part of the vagina. The cells also may have spread to block the tubes that connect the kidneys to the bladder (the ureters).
• Stage 4a: Cancer has spread to other parts of the body, such as the bladder or rectum (organs close to the cervix).
• Stage 4b: Cancer has spread to distant organs such as the lungs.

Cervical Cancer Treatments

In most hospitals, a team of specialists will work together to decide which treatment is best for you. This multidisciplinary team (MDT) will include:

• a surgeon who specializes in gynaecological cancers (gynaecologist or gynae-oncologist)
• a clinical oncologist (chemotherapy and radiotherapy specialist)
• a pathologist
• a radiologist

and may include a number of other healthcare professionals such as:

• a nurse specialist
• dietician
• physiotherapist
• psychologist or counsellor
• sexologist

Depending on what stage your cancer is and your specific needs, your team will consider the following treatments. In order to fully understand which treatment will be right for you, you will need to discuss this with your consultant at your next appointment.